Simon Ash Profile picture
May 23, 2023 18 tweets 18 min read Read on X
@TasPirani presents of Liver disease in pregnancy. A lot to cover! #OBAnes #OAA23ASM ImageImage
Physiological changes in pregnancy. Normal LFT/ laboratory changes. #OBAnes #OAA23ASM ImageImage
Causes of liver derangement in pregnancy: flare of pre-existing liver disease (known or unknown). Incidence of pregnancy in people with chronic liver disease at King’s College Hospital. Historically, cirrhotic patients have been infertile d/t anovulation. Population based data… twitter.com/i/web/status/1… ImageImageImageImage
A reminder that MELD score >10 (UKELD > 48) predicts maternal complications related to pregnancy. Relevance of pre-existing liver disease? Hemorrhage: highest risk 2nd trimester & during labour. TIPPS have been described. An algorithm for the management of variceal bleeding.… twitter.com/i/web/status/1… ImageImageImage
What about drugs used for management of variceal bleeding during pregnancy - terlipressin is relatively contraindicated (crossed out of algorithm) due to effects on uterine blood flow & uterine contractions. Beta blockers have neonatal effects, best withdrawn 24-48h prior to… twitter.com/i/web/status/1… ImageImage
Case 1. 33/40, actively bleeding variceal in splenic hilum. Massive transfusion. Fetal loss. Provisional Dx portal HTN, massive splenomegaly and varices.
Hx clarified: Child Pugh B, MELD 17, UKELD 57 (😱). Intolerant of beta blockers. CT abdomen: massive and diffuse varices.… twitter.com/i/web/status/1… ImageImageImageImage
What next? Survived. Advised against another pregnancy.

Splenic artery aneurysm: rare, 50% rupture in pregnancy (66.7% 3rd trimester, some postpartum). Materno-fetal mortality 70-90%. Rupture during labour uncommon. Mx unruptured SAA undefined. Elective Mx recommended for SAA >… twitter.com/i/web/status/1… ImageImage
Causes of liver derangement in pregnancy - unique to pregnancy: HG, ICP, AFLP, PET/HELLP. HG early, rest tend to be second trimester onwards. #OBAnes #OAA23ASM ImageImage
Case. Hyperlactatemia & distributive shock requiring exploratory lap day1 post emergency section for PET. HELLP is a leading cause of maternal & perinatal mortality worldwide. PET complicates 2-8% pregnancies, 20-30% liver involvement. 1 in 4 serious maternal complications.… twitter.com/i/web/status/1… ImageImageImageImage
Clinical picture: symptoms & labs. Mississippi & Tennessee systems for diagnosis of HELLP (Mississippi class 1 is most severe) - uniform reporting is important, but not decide clinical care. Complications of HELLP: extrahepatic & hepatic. #OBAnes #OAA23ASM ImageImageImage
Liver ischemia/subcapsular hematoma occurs in up to 1.6%. Management of HELLP: if unstable, deliver; steroid for fetus (NO role in mother); aggressive HTN Mx; Magnesium. Lab values normalize 48h to 2 weeks. Indications for imaging: hemodynamic instability, AST>1000, severe… twitter.com/i/web/status/1… ImageImage
Acute Fatty Liver of Pregnancy (AFLP) = medical and OB emergency, incidence 1 in 7,000-15,000 pregnancies. Mitochondrial cytopathy (Reye’s syndrome). Ubiquitous risk factors. 1 in 5 POSTPARTUM. 20-40% preeclampsia patients diagnosed with AFLP, up to 20% AFLP diagnosed with HELLP.… twitter.com/i/web/status/1… ImageImageImageImage
Swansea criteria for diagnosis of AFLP. Pathophysiology (mitochondrial disease, majority = no genetic defects) ImageImage
AFLP cont. Complications include acute liver failure, overwhelming sepsis, pancreatitis, DIC, etc. Maternal mortality 10% (based on recognition, timely delivery and improved ICU Mx). 10-20% fetal mortality. Management complicated by no universal diagnostic criteria/ algorithm.… twitter.com/i/web/status/1… ImageImageImage
@TasPirani now leads #OBAnes audience into #OBCritcare realm with management of liver disease in pregnancy at ICU (ITU) level (@MelissaEBauer1 @TheMillennialMD). Thankfully not often seen during pregnancy, however, peri delivery and postpartum encounters involve badness with… twitter.com/i/web/status/1… ImageImage
Acute Liver Failure. Definition. Management: 2 areas of focus - hepatic/ cause specific & extrahepatic/ general. Multiorgan Failure, cerebral oedema & herniation, and sepsis are major concerns. Prognostication has 3 end points: survive with medical management; death; and liver… twitter.com/i/web/status/1… ImageImage
Management priorities while awaiting transfer to transplant centre: MDT approach - resuscitation, neuroprotection, aggressive sepsis treatment, and vigilance for bleeding. Good history essential. How do we decide who needs a transplant? INR & bilirubin good for predicting… twitter.com/i/web/status/1… ImageImageImageImage
Interesting case report: extending the reach of emergency liver transplantation to pregnant people by bridging with ECMO. Summary slide. Got questions? Ask @TasPirani. #OBAnes #OAA23ASM ImageImageImage

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More from @OBsleepmerchant

May 9
@SQuashie presents an update on anesthesia for operative delivery. Declarations. Methodology and themes. #OAA24ASM #OBAnes

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Gastric USS. Oral rehydration has benefits over NPO wrt vasopressor use. #siptilsend safe, noting some patients have increased gastric volumes irrespective of starvation status. #OAA24ASM #OBAnes
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@SQuashie continues at a rapid pace. To DPE or not to DPE remains a question - 16min vs 19 min, is that 3 min clinically relevant? Esketamine for supplemental analgesia - >95% had psych effects, read @rjharrison79 editorial. #OAA24ASM #OBAnes
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Read 16 tweets
May 9
@Jamesocarroll presents an Update on Labour and Delivery. Disclosures #OAA24ASM #OBAnes

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How the lecture was put together. Screening. Themes. How to interpret the slides. Very Ostheimer-esque @Jamesocarroll #OAA24ASM #OBAnes


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@Jamesocarroll Clinical practice theme: intrathecal catheters & ADP. Intrathecal catheters: No decrease in PDPH, but reduction in EBP. 10mL intrathecal saline decreased PDPH & need for EBP. Of note, the percentage of epidurals requiring multiple attempts. #OAA24ASM #OBAnes

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Read 17 tweets
May 5
8am-ish in Denver and time for a much anticipated session: PDPH beyond the guidelines. Moderated by Dr Lisa Leffert, featuring @Ropivacaine, @euklaas, @sharonOzynger and @WouterSchievink at #SOAPAM2024 #OBAnes

(HT: @Ropivacaine, bless his heart, he knows I hate missing out)

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Hot off the Press? August 2023! @JAMANetworkOpen with quite an illustrious team including @Ropivacaine @robin_russell1 @KalagaraHari @LimGrapes @claralexlobo @noolslucas @NarouzeMD (please tag others if you have their handles?) #SOAPAM2024 #OBAnes

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Introduction, Methods and the 10 questions. #SOAPAM2024 #OBAnes

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Read 11 tweets
Jun 12, 2023
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

Bookends the 1st #OBAnes session, on intrapartum pain at cesarean section… twitter.com/i/web/status/1… Image
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 ImageImageImageImage
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 ImageImageImage
Read 9 tweets
Jun 11, 2023
Dr Ning Nan Wang introduces @harshamd5 to open the chronic pain session: Perioperative use of opioid in the context of Opioid Epidemic. #CASAM2023 ImageImageImage
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… ImageImageImage
Opioid use around the time of surgery. Understanding nociception vs pain. Does eliminating opioids during surgery make a difference - no definitive conclusions. #CASAM2023 ImageImageImage
Read 11 tweets
Jun 10, 2023
@DrLucieFilteau introduces @CMA_Docs president @AlikaMD for his keynote address at #CASAM2023 Image
@AlikaMD starts with the state of the 🇨🇦 health system, including a little history. #CASAM2023 ImageImage
The 🇨🇦 health system approach to problems, creating new problems as a result with a dangerous lack of interoperability. #CASAM2023 ImageImageImage
Read 12 tweets

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