Postpartum convulsions and acute hemodynamic instability in the parturient with recent amphetamine intake

Obstetric anesthesia, by definition, is a subspecialty of anesthesia dedicated (devoted) to peripartum, perioperative, pain and anesthetic management of women during pregnancy and the puerperium. Today, obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. An obstetric anesthesiologist has become an essential member of the obstetric care team, who closely works with the obstetrician, midwife, neonatologist and labor and delivery nurse to ensure the high-quality care for the parturient and her baby. Communication skills and exchange of information in ever changing environment of labor and delivery is essential for perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. The anesthesiologist’s unique skills in acute resuscitation combined with experience in critical care make members of this subspecialty of anesthesiology particularly valuable in peripartum care of the high-risk patients, extending the anesthesiologist’s role well beyond the routine provision of intrapartum anesthesia or analgesia.     

Pregnant women with prosthetic heart valves

Pregnant women with prosthetic heart valves present the same myriad of problems and challenges inherent in other patients with severe cardiac disease. Care for these patients should involve counseling to determine the advisability of attempting or continuing pregnancy. Combined team care with several specialists is necessary for the optimal management of these patients. Family planning is very important for these patients.     

Running an obstetric anesthesia training program: words of wisdom

Obstetric anesthesia, by definition, is a subspecialty of anesthesia dedicated (devoted) to peripartum, perioperative, pain and anesthetic management of women during pregnancy and the puerperium. Today, obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. An obstetric anesthesiologist has become an essential member of the obstetric care team, who closely works with the obstetrician, midwife, neonatologist and labor and delivery nurse to ensure the high-quality care for the parturient and her baby. Communication skills and exchange of information in ever changing environment of labor and delivery is essential for perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. The anesthesiologist’s unique skills in acute resuscitation combined with experience in critical care make members of this subspecialty of anesthesiology particularly valuable in peripartum care of the high-risk patients, extending the anesthesiologist’s role well beyond the routine provision of intrapartum anesthesia or analgesia.     

Postpartum hemorrhage: Anesthesia management

As major stakeholders in the labor and delivery suite, obstetric anesthesiologists are frequently called upon to provide their unique skill sets and expertise to the management of postpartum hemorrhage, whether anticipated or not. Essential contributions of the anesthesia team ideally begin in the antenatal period with referral of women at high risk of postpartum hemorrhage to an outpatient obstetric anesthesia clinic where a tailored plan for both urgent or scheduled delivery for women with an anticipated complex delivery can be formulated. Maternal safety can be greatly improved if comorbidities are identified early and strategies to address these issues are proposed and known by the obstetric anesthesia team. Participation of the obstetric anesthesiology team is crucial in the development of systematic approaches that are customized to each institution and should comprise the creation and dissemination of algorithms and guidelines that are anesthesia specific, including detailed protocols for the labor and delivery unit and operating rooms, at large. Because management of postpartum hemorrhage requires a coordinated team effort, and may not always be planned, the anesthesia team should be prepared at all times to provide the appropriate anesthetic management and advanced cardiovascular support. The involvement of the anesthesia team should not only be limited to the immediate intrapartum period, but should also extend to the postpartum period where adequate anesthetic/analgesic plans will enhance maternal safety and recovery.     

Brain abscess complicating pregnancy

Brain abscess is a potentially life-threatening complication that is only rarely associated with pregnancy. Although predispositions such as a preexisting infection, foreign body, or immunosuppression are often present, up to 30% of individuals could have no risk factors. Presenting symptoms are often nonspecific but suggestive of a central nervous system process and include headache, seizures, mental status changes, and focal neurologic deficits. Cranial imaging by computed tomography (CT) or magnetic resonance imaging (MRI) can suggest the diagnosis of abscess. Diagnosis is confirmed by aspiration of purulent material. Treatment involves antibiotics, often with surgical drainage. Vaginal delivery at term appears to be safe. Care of the affected gravida, including time and route of delivery, should be approached by a team representing perinatology, neurosurgery, infectious disease, and anesthesiology.     

Prenatal diagnosis of coarctation of the aorta with ventricular septal defect: A case report

Objective

To present an accurate prenatal diagnosis of coarctation of the aorta with ventricular septal defect and to illustrate how early diagnosis in prenatal period with proper referral and counseling can optimize management.

Undiagnosed Maternal Fallot Tetralogy Presenting in Pregnancy

EDITORIAL COMMENT : We accepted this case report for publication not only because we wish to help spread the authors' message regarding team management during pregnancy of high risk patients with cardiac disease, but also to remind readers that significant cardiac anomalies may be recognized for the first time during routine antenatal examination.     

Congenital heart disease and aneuploidy

Congenital heart disease (CHD) is one of the commonest prenatal diagnoses made on routine ultrasound screening. Overall, up to 33% of CHD are associated with fetal aneuploidy. However, some specific cardiac lesions have a significantly greater association with particular chromosomal abnormalities. The majority of fetuses with CHD and aneuploidy also have extra-cardiac anomalies and are best managed by a multidisciplinary team where the management and prognosis of the cardiac defect can be discussed in the context of the baby as a whole. It is therefore important for clinicians involved in the management of fetuses with CHD to be aware of the association of aneuploidy as well as the prognosis and management of these cases, so that they can appropriately counsel the parents. In this chapter, we review the frequency and types of aneuploidy associated with the commonly diagnosed CHD and discuss their management.     

Structural cardiac anomalies

Although it is unrealistic to expect that all major structural cardiac anomalies will be detected at the time of routine prenatal ultrasound, an increase in prenatal diagnosis is anticipated as accreditation of ultrasound practices takes place nationwide. Following the diagnosis of congenital heart disease, evaluation for extracardiac anomalies and chromosomal abnormalities is important because these are found in up to 62% and 38% of prenatally identified cases, respectively. Although the literature is limited, counseling parents based on the prenatal experience gives them realistic information about frequency, diagnosis, associated findings, and prognosis of the heart defect found in their fetus. A multidisciplinary team of perinatologists, pediatric cardiologists, geneticists, pediatric cardiac surgeons, and neonatologists should be assembled to assist patients in making informed decisions about their pregnancies and to establish a reasonable management plan for ongoing pregnancies with congenital heart disease.     

Cardiac disease and pregnancy

The pregnant state imposes a supraphysiologic strain on the pregnant woman's cardiac performance through complex biochemical, electric, and physiologic changes affecting the blood volume, myocardial contractility, and resistance of the vascular bed. In the presence of underlying heart disease, these changes can compromise the woman's hemodynamic balance, her life, and that of her unborn child. Cardiac pathology represents a heterogeneous group of disorders, each with its own hemodynamic, genetic, obstetric, and social implications. Physicians caring for these women should actively address the issue of reproduction. Ideally, pregnancy should be planned to occur after optimization of cardiac performance by medical or surgical means. Once pregnancy is achieved, the concerted effort of a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, nursing, social, and other services provides the best opportunity to carry the pregnancy to a successful outcome.     

Maternal cardiac disease in pregnancy

The 2019 MBRRACE-UK report highlighted the prevalence of cardiac disease amongst pregnant women, and its role as a driver in maternal mortality. Advancing maternal age, a rise in cardiovascular co-morbidities, and the improvements in congenital heart disease care have all contributed to this static prevalence, despite improvements in obstetric and cardiac care. In this review we consider the importance of pre-conception counselling for women with known heart disease, review the physiological changes of pregnancy which place increased demand on the cardiovascular system, and explore maternal risk, from a cardiovascular perspective. Contemporary management of women with moderate to severe heart disease during pregnancy should be delivered by the pregnancy heart team, a term coined by the European Society of Cardiology in its 2018 guidelines. Individualized care empowers trust and shared decision making and early access to multidisciplinary care is vital in optimizing maternal and fetal outcomes.     

Pregnancy after thoracic organ transplantation

A growing number of heart, heart-lung, or lung transplant recipients are women of reproductive age. Fertility and pregnancy are important issues in this group of patients and often pose complex medical, psychosocial, and ethical problems. Many successful pregnancy outcomes have been reported following heart or lung transplantation. Nevertheless, these patients are at risk of certain maternal, fetal, and neonatal complications, including hypertension, preeclampsia, infection, preterm birth, and low birth weight. The physiological changes that occur in pregnancy are generally well tolerated by patients who have undergone thoracic organ transplant(s). The risk of allograft rejection during and after pregnancy is significant, and it is important to maintain an adequate level of immunosuppression. Pregnancies among lung transplant recipients are at higher risk for certain complications. The rate for graft rejection, independent of pregnancy status, is higher in this population. The long-term graft and patient outcomes citing a 50% 5-year mortality will be critical while counseling these patients regarding the impact of pregnancy on survival, and the ability to participate in raising the child. A multi-disciplinary team, involving specialists in maternal fetal medicine, cardiology or pulmonary medicine, transplant medicine, anesthesiology, high-risk nursing, neonatology, psychology, genetics, and social service, is crucial to the care of these patients. This team approach should be initiated at the time of pretransplant and preconception counseling and be continued through the prenatal and postpartum periods. The management plan should be individualized according to the status of the mother, the fetus, and the allograft. For most cases, given the need for close collaboration and frequent monitoring, these patients are best managed at their primary transplant institution in collaboration with local or referring physicians.     

The role of palliative care in critical congenital heart disease

Patients with critical congenital heart disease are exposed to significant lifetime morbidity and mortality. Prenatal diagnosis can provide opportunities for anticipatory co-management of patients between palliative subspecialists and the cardiac care team. The benefits of palliative care include support for longitudinal decision-making and avoidance of interventions not consistent with family goals. Effectively counseling families requires an up-to-date understanding of outcomes and knowledge of provider biases. Patient-proxy reported quality of life (QOL) is highly variable in this population and healthcare providers need to be aware of limitations in their own subjective assessment of QOL.     

多学科合作救治严重产后出血

严重产后出血仍然是导致孕产妇死亡的重要原因。多学科合作在严重产后出血的救治中起着十分重要的作用。针对严重产后出血的原因,加强产科、麻醉科、影像科和输血科等多学科的协作;规范输血输液管理,提倡自体输血的应用,有利于严重产后出血的成功救治。     

Permanent pacemakers in pregnancy

Advances in cardiology and cardiovascular surgery have increased the use of permanent pacemakers in young adults such that there are more women with pacemakers becoming pregnant. This case report describes the pregnancy and delivery of a young woman with a demand pacemaker and reviews the principles of management of cardiac pacemakers in pregnancy. As part of the multidisciplinary team including cardiology, anesthesia, nursing and caring for these patients, it is important that obstetricians be informed and follow the principles of management of cardiac pacemakers in pregnancy to continue to achieve successful pregnancy outcomes.     

Management of the critically ill obstetric patient

Obstetric critical illnesses represent a small but important proportion of all intensive care unit (ICU) admissions in the UK. They are challenging to the critical care team because of the unique physiology and specific medical disorders seen in this population. Maternal mortality is fortunately rare, but devastating when it occurs, with the commonest causes of death being cardiac disease and venous thromboembolism. Massive obstetric haemorrhage, pre-eclampsia and genital tract sepsis are also important causes, and these are reflected in the reasons for ICU admission in the obstetric population. Maternal mortality may be reduced by prompt recognition of critical illness in the pregnant woman, earlier initiation of intensive care, and increased input from senior clinicians.ICU management involves resuscitation, monitoring \and assessment of deranged physiology, and the provision of safe organ support. The overall aims are to ensure adequate oxygen delivery and tissue perfusion, and to stabilise the patient while awaiting investigations which may guide further disease-specific management. The normal physiological adaptations to pregnancy and the effects of any drugs or procedures on the fetus should be taken into account.     

妊娠合并室性心律失常的管理

妊娠合并室性心律失常是一种常见的妊娠合并心血管系统疾病,严重时可致孕产妇心力衰竭、猝死以及胎儿生长受限、胎儿窘迫、早产及死胎等不良结局。该疾病的管理需要产科、心脏科、麻醉科及新生儿科等多学科共同参与,文章从妊娠合并室性心律失常的孕前咨询与评估、治疗、孕期管理及分娩期管理等方面进行阐述,以减少母儿并发症的发生,同时强调多学科协作管理对疾病预后转归的重要性。     

Nursing considerations of the neonate with congenital heart disease

Nursing care of the neonate with CHD incorporates a knowledge base of the anatomy and physiology of congenital heart defects, surgical repair, complications associated with CHD, diagnostic testing, medical therapy, and psychosocial support. The neonatal nurse is a vital member of the cardiac team in providing accurate assessments, implementing medical therapies, and supporting the family.     

Maternal mortality

The Confidential Enquiry into Maternal Deaths has provided important information about the causes of death, areas of sub-standard care, and vulnerable groups of women in the UK. The latest report has identified obesity as an important emerging theme. Thromboembolism is the most common direct cause and cardiac disease the most common indirect cause of maternal mortality. Deaths from suicide were fewer than in the previous triennium. Early recognition of serious illness and effective, multidisciplinary, team working are key to avoiding potentially avoidable maternal deaths.