Diagnosis and management of a ruptured 20-week anencephalic cornual ectopic pregnancy undergoing termination: implications of interstate travel due to restrictive abortion law.

In the changing legal environment of obstetric care in the USA, with laws in many states banning termination at all stages of pregnancy with narrow exemptions, healthcare providers are encountering cases in which risk to maternal safety is increased. This report presents a case of a 28-year-old primigravida with an anencephalic fetus who was legally unable to pursue termination in her home state. She traveled to another state in order to pursue safe and legal abortion of a non-viable fetus. Due to an unrecognized cornual ectopic gestation, the delivery resulted in uterine rupture, the need for hysterectomy, and significant morbidity in a patient with a strong desire for future fertility.

A case of local anesthetic toxicity that wasn't: lipid rescue from self-administered benzodiazepine overdose in labor.

A 32-year-old G2P1 woman presented for induction of labor at term. Her past medical history included polysubstance use disorder and methadone maintenance, scant prenatal care, morbid obesity, and intimate partner violence. Her induction was progressing smoothly until the acute onset of altered mental status near to the time of delivery, several minutes after a clinician-administered epidural local anesthetic bolus for significant pain. Given concern about local anesthetic systemic toxicity, lipid emulsion was administered and resulted in an immediate and drastic clinical response. The epidural infusion bag and pump system were evaluated and found to be correct and there was no clinical suspicion of an intravascular epidural catheter. The woman remained stable and was transferred to the postpartum unit, where she experienced a similar episode of altered mental status approximately 12 h postpartum. This episode self-resolved and she was managed conservatively. Shortly after this event, it was discovered that the patient had been self-administering benzodiazepines throughout the course of her labor, in addition to her hospital staff-administered medications. Presumably, her intrapartum altered mental status was a result of self-administered benzodiazepine that was then "rescued" with lipid emulsion. This case illustrates the potential for lipid emulsion as a reversal agent for medications other than local anesthetics.

Postpartum hemoptysis as presenting sign of longstanding vasculitis.

We present the case of a 26-year-old postpartum patient who presented with an episode of desaturation and hemoptysis on postpartum day three after an uncomplicated spontaneous vaginal delivery. The patient came to our attention in the postpartum area after she experienced massive hemoptysis and we were called by the obstetric team. The patient was subsequently intubated, mechanically ventilated, and underwent bronchoscopy, demonstrating diffuse alveolar hemorrhage. She was brought to the intensive care unit, placed on high-dose steroids and plasmapheresis was initiated. Her intensive care unit course was complicated by acute respiratory distress syndrome, acute kidney injury and a pulmonary embolism, but she recovered well and was discharged on postpartum day 23. This report describes a rare case of medium vessel vasculitis diagnosed in the peripartum period, and describes the diagnostic dilemmas underlying making a rare diagnosis, and the difficulties initiating appropriate therapy in a postpartum patient.

Team-based model for non-operating room airway management: validation using a simulation-based study.

BACKGROUND: Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios. METHODS: Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group). RESULTS: Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively]. CONCLUSIONS: Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.

Effect of metoclopramide on ureteral motility.

Metoclopramide, a procainamide derivative that markedly stimulates peristalsis in a variety of gastrointestinal tissues, demonstrated a significant dose-dependent effect on rat, canine, and human ureters studied in vitro. A moderate increase in phasic activity was seen at low concentrations with striking inhibition noted at higher concentrations. In the dog, atropine 0.6 microgram/ml inhibited the former while procaine 400 micrograms/ml stimulated the latter. Surgically produced, chronically dilated canine ureters were also stimulated by metoclopramide. Metoclopramide may be useful in states of disordered ureteral motility.

The role of urinary obstruction in the genesis of renal dysplasia. A model in the chick embryo.

Although obstruction of urinary drainage is the current pathogenetic mechanism believed responsible for renal dysplasia, the results of experimental studies have not uniformly substantiated this impression. To help resolve this issue, we evaluated the effect of obstruction of the urinary drainage of the embryonic kidney upon the later development of the kidney. We developed a model which allowed us to ligate the ureter surgically of the chick embryo before and after the appearance of nephrons. Initially, the normal morphologic features of renal development were studied in 22 embryos at various stages of incubation and in 94 metanephric rudiments cultivated as chorioallantoic membrane (CAM) grafts. Then, the morphologic features of renal development were studied in 151 metanephric rudiments subjected to surgical ligation of the primitive ureter and then cultivated as CAM grafts. The ligations were performed with 9-0 silk suture, aided by the operating microscope, and induced before and after the appearance of nephrons. Renal differentiation of the non-ligated rudiments cultivated as CAM grafts resembled that which appeared in situ. Renal differentiation of 87 per cent of nonligated rudiments which survived grafting displayed normal renal development and 13 per cent displayed mild hydronephrosis. Renal differentiation of 67 per cent of the ligated rudiments which survived grafting displayed hydronephrosis and 33 per cent displayed normal development. Dysplasia was never seen in any specimen. Obstruction of the ureter of the developing kidney caused only hydronephrosis in the chick model. It appears that renal dysplasia is not solely caused by simply mechanical obstruction to urinary drainage, even when the obstruction is imposed at early stages of renal development.