Retrospective Review of Time to Uterotonic Administration and Maternal Outcomes After Postpartum Hemorrhage.

OBJECTIVE: Despite advances in health care and ample resources, post-partum hemorrhage (PPH) rates are increasing in high income countries. Although guidelines recommend therapeutic uterotonics, timing of administration is open to judgement and most often based on (inherently inaccurate) visual estimates of blood loss. With severe hemorrhage, every minute of delay can have significant consequences. Our objective was to examine the timing of uterotonic administration and its impact upon maternal outcomes. We hypothesized that increased time to uterotonic administration following the identification of PPH would be associated with a greater decline in hemoglobin (Hb) and higher odds of hypotension and transfusion. METHODS: We reviewed all cases of PPH that occurred at an academic centre between June 2015 and September 2017. All cases of primary PPH (i.e., those declared within 24 h of delivery with estimated blood loss [EBL] >500 mL for vaginal and >1000 mL for cesarean deliveries) were analyzed. Patient records were excluded if they were missing information regarding time of PPH declaration, uterotonic administration, and/or Hb measures, or if a pre-existing medical condition could have contributed to PPH. RESULTS: Of 4397 births, there were 259 (5.9%) cases of primary PPH, of which 128 were included in this analysis. For these patients, each 5-minute delay in uterotonic treatment was associated with 26% higher odds of hypotension following delivery of any type. For vaginal deliveries (n = 86), each 5-minute delay was associated with 31% and 34% higher odds of hypotension and transfusion, respectively. CONCLUSION: In this study, delay in administration of therapeutic uterotonics was associated with a higher incidence of hypotension and transfusion in primary PPH patients.

Expiratory Central Airway Collapse and Dynamic Hyperinflation During Peroral Endoscopic Myotomy: A Case Report.

In tracheobronchomalacia, the structural weakening of the airway results in altered ventilatory mechanics. This case report describes a patient with known tracheobronchomalacia who experienced expiratory central airway collapse and dynamic pulmonary hyperinflation during peroral endoscopic myotomy (POEM) to treat symptomatic achalasia. We discuss the physiological considerations and potential complications of a POEM procedure with superimposed tracheobronchomalacia and present perioperative strategies for the prevention and management of this potentially deleterious combination. Although tracheobronchomalacia was a known condition in our patient, it is likely an underdiagnosed condition that may first present intraoperatively.

Spontaneous dissection of the coronary and vertebral arteries post-partum: case report and review of the literature.

BACKGROUND: Spontaneous coronary and vertebral artery dissections are rare events occurring most commonly in otherwise healthy women during pregnancy or the post-partum period. CASE PRESENTATION: This report describes a 35-year-old female who presented with an acute inferior ST elevation myocardial infarction 7 months post-partum secondary to spontaneous dissection of the left obtuse marginal coronary artery. Despite appropriate medical therapy with dual anti-platelet therapy, the patient presented four weeks later with a spontaneous dissection of the right vertebral artery. CONCLUSION: We review the presentation, diagnosis, and management of spontaneous dissections of the vasculature in the peri-partum period.

Hemodynamic effects of low-dose bupivacaine spinal anesthesia for cesarean section: A randomized controlled trial.

BACKGROUND: Spinal anesthesia is the most common technique for cesarean section. The conventional local anesthetic dose has been decreasing over time to 8-12.5 mg of bupivacaine. Lower doses of bupivacaine may be associated with reduced incidence of hypotension and other complications. This low dose also may be associated with improved maternal cardiac index (CI). We hypothesized that low dose spinal anesthesia using 4.5 mg bupivacaine would result in improved maternal CI when compared with conventional dose (9 mg) intrathecal bupivacaine. METHODS: This randomized controlled trial included all healthy parturients presenting for elective cesarean section. In addition to standard monitors, an arterial line was placed for pulse contour cardiac output measurement. Due to limited data on maternal cardiac output during cesarean section, we had to power our study on recovery room length of stay. Secondary outcomes included the change in maternal CI, fluid administration, vasopressor usage, maternal satisfaction, and adequacy of surgical blockade and recovery time from motor and sensory blockade. RESULTS: The low dose group had significantly faster motor recovery times (132 [122-144] versus. 54 [48-66] min conventional versus. low-dose, respectively, P < 0.01), and a shorter recovery room stay (92 ± 21 vs 70 ± 11 min, conventional vs. low-dose, respectively, P < 0.01, 95% CI -35 to -10 min). There was no difference in CI between the conventional dose and low dose spinal groups. Both groups had a drop in CI with spinal anesthesia. The low-dose group demonstrated equivalent surgical anesthesia and block onset times compared to the conventional group. CONCLUSIONS: Low-dose spinal anesthesia provides adequate surgical anesthesia, improved recovery time, but no difference in maternal cardiac index when compared to conventional dose spinal anesthesia.NCT02046697.

Topical tacrolimus in the treatment of erosive pustular dermatosis of the scalp.

BACKGROUND: Erosive pustular dermatosis of the scalp (EPDS) is a rare condition characterized by chronic, sterile, pustular erosions leading to scarring alopecia. Although the etiology is unknown, it appears to be associated with ultraviolet light exposure and trauma. Histologic findings include nonspecific atrophy of the epidermis and chronic inflammation. CASE HISTORY: A 71-year-old female presented with a 1-year history of a boggy, erythematous, friable plaque on the vertex of her scalp. A diagnosis of EPDS was made based on presentation, negative cultures, and histologic findings. Initial therapy with intralesional and topical steroids and oral antibiotics resolved the inflamed plaques; however, steroid-induced atrophy became prominent after 5 months of use. The treatment was discontinued, resulting in recurrence of disease. Topical tacrolimus 0.1% ointment was initiated, which has been successfully controlling the lesions with reversal of skin atrophy and clinical evidence of hair growth. CONCLUSION: This is the fourth reported case of the successful treatment of EPDS with topical tacrolimus for the resolution of atrophy and the prevention of relapse of inflammation. Although its long-term use warrants close follow-up for side effects, tacrolimus may constitute a novel therapeutic option for the treatment of EPDS.