Placenta Percreta: A Report On Surviving Death From The Bleeding Disaster!

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Methylergometrine-Induced Myocardial Infarction in the Setting of a Cesarean Delivery

A 30-year-old female with no significant past medical history presented to our labor and delivery ward for induction of labor. Due to failure to progress, she was proceeded to cesarean delivery. Intraoperatively, it was noted that her uterus was hypotonic; she required supplemental methylergometrine to control the bleeding from the uterine atony. However, within three minutes of intramuscular (IM) administration, she complained of chest pain. She then subsequently developed pulmonary edema in the postoperative care unit, which required supplemental oxygen. She was found to have elevated troponin and brain natriuretic peptide (BNP), along with radiologic features of fluid overload suggestive of congestive cardiac failure, which all lead to the diagnosis of non-ST myocardial infarction. The patient had a normal computed tomography (CT) pulmonary angiogram, echocardiogram, and serial electrocardiograms (ECGs). She was successfully discharged from the hospital on postoperative day 4 with resolution of her symptoms and improving cardiac enzymes. Cardiology outpatient follow-up was arranged

Placenta Percreta; A Report On Surviving Death From The Bleeding Disaster!

A 34 year old G6P5 diagnosed with placenta previa percreta (fig 1) in her 2nd trimester was reviewed by a multidisciplinary team. Baby delivery was planned at 34 weeks gestation by cesarean hysterectomy(CH) immediately preceded by bilateral ureteral stents for anticipated surgical complexity. Patient received combined spinal and epidural (not activated) for the ureteric stenting with an aim to use the epidural for post-operative analgesia followed by general anesthesia and establishment of invasive lines and monitoring prior to start of CH. Soon after baby delivery, patient became hypotensive from severe hemorrhage. Massive transfusion protocol was instituted. After completion of hysterectomy, patient continued to bleed from multiple intraabdominal sites. While surgical hemostasis remained a challenge, patient developed PEA arrest. CPR was started with return of spontaneous circulation (ROSC) after chest compression for 2 minutes and 1mg of epinephrine. Following this, abdomen was packed with a decision to close secondarily after interventional radiology (IR) assisted intervention if necessary and hemodynamic stabilization. Intraoperatively, patient received a total of 29pRBCs, 22FFP, 4platelet & 3Cryo units with 21 L of crystalloids, 3.25 L of 5% albumin and 1.8L of cell saver with an estimated blood loss of 25L. Tranexamic acid and prothrombin complex concentrate was given. Thromboelastogram (TEG) and lab based coagulation profile was used intraoperatively to guide blood component transfusion. Serial blood gas analyses guided volume and electrolyte correction. In the ICU patient improved with no neurological insult or DIC. On postop day 1 IR found no active extravasations and surgical abdominal closure was performed. Epidural catheter was used for postoperative pain control and was removed on day 4. Patient was discharged on postop day 10.https://scholarlycommons.henryford.com/merf2020caserpt/1124/thumbnail.jp

Emergent Cesarean Delivery in a Patient With Freeman-Sheldon Syndrome Complicated by Preeclampsia, Acute Pulmonary Embolism, and Pulmonary Edema: A Case Report

Freeman-Sheldon syndrome (FSS) is an exceedingly rare congenital disorder with an unspecified prevalence. FSS is caused by a mutation in the embryonic skeletal muscle myosin heavy chain 3 gene. Patients may have facial abnormalities that put them at risk of difficult airway intubation. These facial abnormalities include micrognathia, macroglossia, high-arched palate, prominent forehead, and mid-face hypoplasia. Additionally, skeletal abnormalities such as joint contractures, scoliosis with resultant restrictive lung disease, and camptodactyly (bent fingers) can be noted. These features played an important role in the anesthetic management of our FSS patient. Perioperative planning and optimization were crucial in her anesthetic management as she underwent an urgent cesarean section due to preeclampsia with severe features

Sleep apnea screening: An overlooked aspect of routine prenatal care.

Introduction: Obstructive sleep apnea (OSA) in pregnancy can lead to adverse maternal and neonatal outcomes such as pre-eclampsia, intrauterine growth restriction (IUGR), gestational diabetes (GDMA) and preterm birth. Polysomnography screening is gold standard for OSA but can be logistically challenging and not cost-effective. In this study, we will investigate simple screening tools such as the Berlin (BQ) and STOP-BANG questionnaires (SBQ) for OSA in pregnancy. Methods: We screened 169 pregnant women using the BQ and SBQ in the third trimester. A chart review was performed for primary outcomes: pre-eclampsia, IUGR and GDMA. Secondary outcomes were gestational age at time of delivery, Apgars, and birth weight. Demographics such as age, race, BMI, gravidity and smoking history were also reviewed. Results: Of the 169 women who participated in the study, 58 women(34.3%) were screened as high risk on the SBQ. Of these, 34.5% were subsequently diagnosed with pre-eclampsia(p5,0.01), 22.4% with GDMA(p=0.098), and 8.6% with IUGR(p=0.743). Of the 80 women(47.3%) who screened high risk on the BQ, 30% were diagnosed with pre-eclampsia(p5,0.01), 21.3% with GDMA(p5,0.01) and 7.5% with IUGR(p=0.929). Rate of preterm births were significantly higher in both BSQ and BQ high risk group at 29.3% and 26.3%, respectively(p5,0.01). No significant difference was noted in demographics. Conclusion: Obstructive sleep apnea is a modifiable risk factor that can be screened at time of first prenatal care visit, using the STOPBANG and Berlin questionnaires. Identifying and treating those with OSA early in pregnancy may lead to a decreased risk of pre-eclampsia, gestational diabetes and subsequent preterm deliveries

Obstructive Sleep Apnea Screening: An Overlooked Aspect of Routine Prenatal Care

Introduction: There is no single screening measure developed to measure the severity of OSAS in pregnancy. Furthermore, the parturient population usually bypasses the pre-operative optimization clinic further decimating the chances of providing optimum intervention for OSAS. Pregnancy and the physiological changes that accompany it may precipitate or at least exacerbate the co-existing OSAS and there may be a correlation between OSAS and development of pre-eclampsia, gestational diabetes, intra-uterine growth retardation, etc. Besides the intrapartum effects of OSAS, there are anesthetic implications such as increased sensitivity to all central nervous system depressant drugs and the potential for upper airway obstruction or apnea with even minimal drug doses, difficult mask ventilation, difficult intubation, arterial hypoxemia, pulmonary hypertension and cardiac failure. Study design: Retrospective cohort analysis. Objectives: Primary: The prevalence of pre-eclampsia between a high & low risk of OSAS patient based on Berlin questionnaire. Secondary: The prevalence of gestational diabetes and other maternal and neonatal outcomes between a high and low risk of OSAS patient, based on Berlin Questionnaire and Stop-Bang screening test. Results: A total of 699 charts were analyzed retrospectively, the prevalence of high- risk for OSAS was 35.5% and it was significantly associated with high maternal BMI (p=0.003). High-risk OSA subjects were associated with a higher likelihood of pregnancy-induced hypertension and pre-eclampsia (adjusted OR 2.3, 95% CI 1.4-4.0), gestational diabetes (adjusted OR 2.1, 95% CI 1.3-3.4) and unplanned Caesarean deliveries (adjusted OR 2.1, 95% CI 1.4-3.2) after multivariable regression analysis. Conclusions: OSAS is associated with adverse perinatal outcomes. Our long-term objective is to provide a safe workflow to identify, diagnose and provide optimum intervention for high-risk OSA patients, in order to avoid adverse outcome.https://scholarlycommons.henryford.com/merf2019hvc/1000/thumbnail.jp