Vast menu of options (starters, mains and sides outlined by @FarberMichaela) for labour analgesia. DPE PIEB potentially faster onset, medication sparing, no increased S/E. Caveats not compared to every option, changing mix changes results? #OAA3dc2022
Next from @FarberMichaela, Chloroprocaine vs Lidocaine for activation of labour epidural for cesareans section - similar results but not non-inferior. #OBAnes#OAA3dc2022
@FarberMichaela asks whether non-inferiority studies are the wave of the future in #OBAnes? Maybe… but with some serious caveats: good article from EHJ. #OAA3dc2022
Degree of uterine tilt vs phenylephrine requirements - 30 degree tilt required less. Now we use phenylephrine infusions all the time in #OBAnes, and surgeons, patients and providers dislike tilt, so why worry? #OAA3dc2022
Prophylactic second uterotonics in #OBAnes? More nausea for no real benefit? And it doesn’t matter which agent you use (ergometrine or carboprost) #OAA3dc2022
@FarberMichaela continues with PDPH: 22k PDPH a year in USA alone, that’s a significant disease burden, especially if 1/7 to 1/2 of PDPH develop chronic headache. Well powered study: 58.4% of ADP patients have chronic headache at 18months! #OAA3dc2022
Interesting that EBP at time of ADP had less frequent less severe chronic headache - evidence for earlier intervention? No evidence of intracranial hypotension on MRI in 25 patients with chronic headache - what’s the mechanism? Trigeminal sensitization? #OAA3dc2022
Take home message on PDPH from @FarberMichaela - it is NOT always self limiting. We need to follow patients longitudinally. NB we MUST include chronicity as part of informed consent. #OAA3dc2022
What of PPH? TXA is very topical (WOMAN trial- lower mortality if TXA within 3h; TRAAP-1 TXA no difference QBL > 500mL), latest iteration is 2021 TRAAP-2 trial (EBL >1000, transfusion at 48h Decreased PPH, but other parameters not different. #OAA3dc2022
TXA prophylaxis for cesarean has no effect on clinical morbidity from hemorrhage, not warranted as PPx, should not be prioritized over other treatments. Must be carefully stored - drug errors. ?VTE risk. PPH preventable, cycle of too little too late. Enter REACT trial.#OAA3dc2022
We arrive at the REACT study: QBL can be abandoned unless clinical cues concerning. @FarberMichaela respectfully disagrees with the passive “balanced” approach in favour of a more proactive stance. #OAA3dc2022
@FarberMichaela concludes with an invitation to #OBAnes to join her and others in providing excellent peri-delivery care (not just needle jockeys) #OAA3dc2022
Next up at #CASAM2023 - fittingly keeping the most important academic session to last: #OBAnes @ValZaph moderating the Maternal Experience and Outcomes: Improving the care we provide. @DrWesleyEdwards
Dr Christina Lamontagne kicks off the session with: Use of Dexmedetomidine in improving maternal experience and outcomes. Nothing to disclose. Then an important disclosure: All indications discussed are OFF LABEL in Canada. Objectives. #OBAnes#CASAM2023
Why does Dr Lamontagne use a lot of dexmedetomidine (not only in #OBAnes mind)? Clinical pharmacology of dexmedetomidine (1): highly selective alpha-2 agonist; sedation WITHOUT amnesia at locus coeruleus. #CASAM2023
Dr Ning Nan Wang introduces @harshamd5 to open the chronic pain session: Perioperative use of opioid in the context of Opioid Epidemic. #CASAM2023
The opioid crisis isn’t new - China probably remembers the Opium wars that helped establish a British foothold on the continent. Opioids and OUR crisis. Is what we fear the real crisis? Are opioid-related deaths due to surgical prescriptions? No, mostly due to street fentanyl.… twitter.com/i/web/status/1…
Opioid use around the time of surgery. Understanding nociception vs pain. Does eliminating opioids during surgery make a difference - no definitive conclusions. #CASAM2023
PPH: a focus on coagulation is kicked off by Dr Karine Doyon (a hematologist). Objectives. Canada ranked 39th in world in maternal mortality - not sure if that’s good. We’re doing better than USA. #OBAnes#CASAM2023
Causes of coagulopathy in pregnancy - Dr Doyon won’t be discussing inherited disorders. The focus will be on the acquired hemorrhagic disorders. #OBAnes#CASAM2023
Pregnancy-associated mortality ≈ maternal mortality. #OBAnes 0.2% - doing well (wonder what the denominator is?), so Elmo could ask why are we worried? #SOAPAM2023