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Simon Ash Profile picture
@OBsleepmerchant
May 23 • 18 tweets • 18 min read Twitter logo Read on Twitter
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@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 Beta blockers have neonatal effects, best withdrawn 24-48h prior to… twitter.com/i/web/status/1… ImageImage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

Simon Ash Profile picture
May 24
@rr_metabolicmed presents the Bruce Scott Lecture 2023 at #OAA23ASM: Obesity & diabetes in pregnancy - legacy for the child. #OBAnes Image
Study of 1.3 million pregnant women reveals global obesity crisis: 75% pregnant women fail to achieve healthy weight gain during pregnancy, leading to preventable adverse health consequences for both the women and their babies. Obesity has strong evidence for increased risk of… twitter.com/i/web/status/1… ImageImageImage
Maternal obesity and offspring cardiovascular disease: maternal obesity increases offspring cardiovascular death (Hazard ratio [all cause mortality] = 1.35). At current UK maternal obesity rates, this equates to extra 650 deaths before age 50 each year. The Hazard ratio for type… twitter.com/i/web/status/1… ImageImageImage
Read 14 tweets
Simon Ash Profile picture
May 22
@ICULone presents on Severe Maternal Morbidity (SMM) and its consequences at #OAA23ASM. #OBAnes Image
Definition of acute SMM: severe, life threatening event during pregnancy & within 6 weeks of delivery. @NPEU_UKOSS provides UK wide high quality obstetric surveillance. Deaths, while uncommon, investigated in depth.

Study Aims: operationalise definition of SMM; report incidence… twitter.com/i/web/status/1… ImageImageImage
SMM at a population level. Study population derivation. #OBAnes #OAA23ASM ImageImage
Read 11 tweets
Simon Ash Profile picture
May 22
Prof Donald Peebles on Embedding Maternal Medicine Networks at #OAA23ASM. Knowing who to call is half the solution to any problem? (Touched on by @elsmere_g during #OBAnes session at #Anaesthesia2023) Image
Direct maternal mortality rate per 100,000 maternities had been decreasing over the last 2 decades, but should a remarkable upswing since 2018, not all accounted for by #COVID19. @mbrrace outlined a case for change: most parts of UK have MDT, but make up variable most without… twitter.com/i/web/status/1… ImageImage
The Maternal Medicine Network (MMN) mandate: ensure timely access to specialist advice and care at all stages of pregnancy. Development of Maternal Medicine specialist centres as regional hub & spoke model = urgent national priority (@DOckendenLtd report)

MMN Ambition and… twitter.com/i/web/status/1… ImageImage
Read 5 tweets
Simon Ash Profile picture
May 21
Dr Katy Sheehan and @ArcBroom present the pick of the posters at #OAA23ASM. 4 criteria for selection of #OBAnes abstracts. ImageImage
A positive start, with the power of positive communication on patient satisfaction, morale & culture, and #patientsafety #OBAnes #OAA23ASM ImageImageImageImage
Barriers to care. Ethnicity, Language and Socioeconomic deprivation. @mbrrace, @TheLancet, and most recently @Anaes_Journal (@LateralTilt @noolslucas @SQuashie @Marianfknight) set the stage. #OBAnes #OAA23ASM ImageImageImageImage
Read 18 tweets
Simon Ash Profile picture
May 21
@NoelleHealy (another 🇮🇪 representative - @ISOA_Ireland well represented!) presents on #OBAnes as a team sport - how do we perform better? at #OAA23ASM. Quite an inspiring quote, then setting the stage with @Fionafionakel et al #humanfactors guidelines in @Anaes_Journal… twitter.com/i/web/status/1… ImageImageImage
Why is teamwork important in OB/ #OBAnes? @mbrrace suggests some lessons to be learned. Prompt action is arguably reliant on good communication, within & between teams. Involving consultant/ specialist care early has been a theme for over a decade. #OAA23ASM ImageImageImage
@DOckendenLtd’ final report highlighted “conflicting agendas and poor teamwork” contribute to adverse maternal & neonatal outcomes? So how do we create good teams?

The @JulieAndrews approach may have the hills alive, but for #OBAnes we may need to start at the very beginning,… twitter.com/i/web/status/1… ImageImage
Read 10 tweets
Simon Ash Profile picture
May 21
@emirakur presents an update on @NAPs_RCoA NAP7 Perioperative cardiac arrest & #OBAnes at #OAA23ASM. ImageImage
The history of @NAPs_RCoA projects and key findings for #OBAnes over the years (failed intubation NAP4 1:390, recent US data 1:808 - gotten better or different methodology?) #OAA23ASM ImageImage
Cardiac arrest in pregnancy. CAPS study @BJOGTweets (I see @Marianfknight?) looked at incidence, management & outcomes in UK. #OBAnes have a significant slice of the pie. @SOAPHQ serious complication repository project (incl. @RichSmileyMD @bscottsegal) provide US data: cardiac… twitter.com/i/web/status/1… ImageImageImageImage
Read 11 tweets

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