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Hi everyone, Graeme and I recorded this episode way back just before Christmas but because of technical issues here it is a little bit late! Disclaimer neither Graeme or I have any claim to being experts in exam technique but we hope that you find our opinions / advice of some use. Also my answers to these questions were easier for me than real life vivas because I knew in advance what the questions were going to be! Good luck to everyone sitting exams in 2021!

Hi Everyone, This week I am joined again by Mike and we discuss this fascinating syndrome of pregnancy, the management of which many of us have had drilled into us for many decades. Although this is a real syndrome which has been recognised for many years and has many serious potential consequences there are many controversies regarding it’s physiology and treatment. In recent years advances in imaging technology and recent studies have questioned some of practices which were taught as if they were dogma…… How far can we tilt the operating table in theatre and does it really help? Compression of the aorta – really? Thanks Mike LINKS The Aortocaval Compression Conundrum – Analgesia and Anesthesia 2017 https://youtu.be/Y2T4MLiQTrM

Hi Everyone, This week I am joined on the show with a new guest, consultant anaesthetist Dr Chris Mitchell. Chris is a colleague who also used to work with us at our women’s hospital and is already famous for his range of USS regional anaesthesia needles (now manufactured by pajunk). Today we discuss the issue of the adverse environmental effects of our profession. In particular we focus on anaesthetic gases and what we can do to make a difference. LINKS British Journal of Anaesthesia 2020 – Environmental sustainability in anaesthesia and critical care

Hi Everyone, Thanks to Mason Habel from Northern Health in Victoria, who contacted us a few months ago and suggested this topic to us. Join Graeme and I as we try to tackle this topic in a comprehensible manner. We do jump around a little bit, chasing anecdotes, interesting historical facts and the occasional dodgy dad joke but hopefully we get there in the end! LINKS 054 – Neurological injuries after childbirth and neuraxial anaesthesia. 053 – Complications after central neuraxial blocks in obstetric anaesthesia a discussion with Graeme 046 – Managing a patient with a postdural puncture headache PDPH with Dr Matt Rucklidge

Hypothetical case: You are called to a code blue medical on the gynaecology ward. A patient in her late 60s has collapsed in the bathroom. You are told she was admitted earlier that day for investigation of a probable pelvic cancer. She is conscious, has a heart rate 130/min, NIBP 90/45, SPO2 94% on hudson mask, and is mildly SOB with a respiratory rate 30/min. This patient undergoes investigation and is diagnosed with a large pulmonary embolism. She deteriorates suddenly with the following vitals: groaning, HR 145/min, NIBP 60/35, SpO2 85%, Respiratory rate 35/min. What is the physiology and what are the principles behind the resuscitation of a patient with an acute right ventricular emergency like this? Fluids? Vasopressors? Inotropes? Thrombolysis? Intubation? Pulmonary vasodilators? Join Graeme and I as we discuss this particularly challenging scenario which can be both hard to diagnose and resuscitate. There are some important and critical differences to other common causes of deterioration, and serious traps to be aware of and avoid. Whilst educating myself on this topic I realised that I wasn’t as up to speed on this as I thought I was! Thanks to the following resources which I have listed below which I strongly recommend: USEFUL LINKS EMCrit 272 – Right Heart Failure with Sara Crager PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose?

Hi everyone, This week I am joined by Matt & Graeme to discuss induction drugs and adjuncts used in general anaesthesia for caesarean delivery, with a few obligatory dad jokes thrown in at the end if you make it that far! Hypothetical cases we discuss: 1 – Healthy woman rushed to theatre with cord prolapse and fetal compromise 2 – A woman with severe preeclampsia needs urgent caesarean delivery because of fetal compromise. She has a platelet count of 18, and a BP of 210/120. 3 – A woman ruptures her uterus attempting a VBAC and arrives in theatre with a heart rate of 170/min and BP of 60/40 USEFUL LINKS The future of general anaesthesia in obstetrics BJA Education 2016

Hypothetical patient: You get called by an anaesthetic registrar to come and help them with a woman in labour ward. They tell you that they have been struggling for a number of hours now to get a woman comfortable. They have placed three epidurals and topped them up aggressively with generous doses of the usual bupivacaine and fentanyl medications but none of them seem to have been effective. The woman told them that she has had similar problems in the past with dental procedures and minor skin procedures when younger – she also states she has Ehlers-Danlos syndrome. Hi Everyone, This week I am joined by Fionn – a WA anaesthetic trainee currently working with us here. We discuss the fascinating (but distressing) syndrome of resistance to local anaesthetics. Is it real? (yes) How common is it – and what do we know about it? LINKS https://www.bbc.com/future/article/20170106-the-people-who-cant-go-numb-at-the-dentists https://www.hypermobility.org/local-anaesthetic Resistance to local anesthesia in people with the Ehlers-Danlos Syndromes presenting for dental surgery

You receive a call from an obstetrician: “I have a term patient booked for induction of labour this morning. She had an MRI of her brain 4 years ago after a car accident and was told she has an Arnold-Chiari malformation. She is very keen to have an epidural – can she have one?” Hi everyone, This week Graeme is back and we sit down to discuss Arnold – Chiari malformations and having a baby – why all the fuss and controversy? References Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study Management of parturients in active labor with Arnold Chiari malformation, tonsillar herniation, and syringomyelia https://www.orphananesthesia.eu Ghaly Chiari malformation decision guide – see article above

You are called to a code blue medical on labour ward. A woman who has been in labour attempting a VBAC has just collapsed whilst pushing during the second stage. She is unresponsive, not breathing and looks “bad”. This week I am joined by my two colleagues, also consultant anaesthetists, Dr Emelyn Lee and Dr Lip Ng. Join us for this interesting conversation where we discuss all things relating to cardiac arrest in pregnancy! Links https://resus.org.au/

Hi Everyone, This week I sit down again with Graeme. We discuss WA’s isolation & covid bubble, exchange a few crap jokes and have a go at the thorny topic of shivering under neuraxial anaesthesia. Big thanks to everyone who helped with the OSCAR trial all those years ago, Yelena for teaching me a new trick to stop shivering and to Dr Tim Pavy for giving me two weeks leave to write up my thesis on shivering! LINKS The OSCAR trial – prophylactic ondansetron does not prevent or decrease the severity of shivering under spinal for Caesarean.

Hi Everyone, This week is our first episode of our journal club to discuss interesting recent relevant research papers. We are hoping to do this on a regular basis interspersed amongst the other regular episodes where we choose a topic and explore it in detail. In this inaugural episode I am joined by a couple of colleagues who have both been on the podcast before. We have decided to choose articles from IJOA – the International Journal of Obstetric Anaesthesia – a journal devoted to obstetric anaesthesia, critical care and perinatology. Prof Mike Paech is the chief editor, has been on it’s editorial board almost since it was first started in the 1990s and Dr Matt Rucklidge has also been a reviewer for the journal for a number of years now. Mike explains the history of the journal and shares some insights of what it is like being a chief editor, and then we discuss four interesting articles from recent editions. REFERENCES International Journal of Obstetric Anaesthesia https://www.obstetanesthesia.com/ 1.Rocuronium Versus Suxamethonium for Rapid Sequence Induction of General Anaesthesia for Caesarean Section: Influence on Neonatal Outcomes 2. Lower-limb Neurologic Deficit After Vaginal Delivery: A Prospective Observational Study

Case History (*hypothetical patient) A 33yr old woman presents to a GP complaining of hair loss, cold intolerance, dizziness, extreme fatigue and weight gain. On further questioning the patient states this is her third attempt to seek help over a number of years. She initially sought help for amenorrhoea after her second delivery and was started on oestrogen / progesterone tablets. The second doctor gave her a diagnosis of postpartum depression after eliciting a history of anxiety, tachycardia and feelings of stress and started her on an antidepressant. However the medication didn't help and she tapered them off and didn't return. On close questioning she recounts that her first delivery was uncomplicated but the second was an emergency caesarean after failure to progress and fetal distress. The surgery was complicated by blood loss of 4 litres and she remembers being told by staff "that the blood was coming out as fast as it was going in". She spent a number of days in the HDU / ICU and her child was bottle fed because she had difficulty establishing breastfeeding due to the traumatic events. Join Graeme and I again as we discuss this important but rare complication of pregnancy. References Diagnosis and Treatment Challenges of Sheehan's Syndrome Sheehan's syndrome in modern times: a nationwide retrospective study in Iceland QUIZ Which of these is a doctor and which is a serial killer? - and who are they!

Hi Everyone, This week on the podcast I am joined by Dr Andi Atkinson one of the obstetric and gynaecology trainees here in WA. A few years ago Andi took time off during her training to spend time working in Africa for MSF on two separate occasions and we sat down to record an interview where she explains the processes involved in working with MSF and reflects on some of her experiences during her missions. Andi is still training here in WA but tells me she intends to work again for MSF sometime in the near future. Thanks for sharing your stories Andi! Links MSF Australia https://msf.org.au/

A 28 yr old woman at 36/40 G2P1 presents with a few days history of mild headache, nausea, anorexia, and some upper right abdominal pain. You do some observations and some blood testing and find she has a BP 150/95, mildly hyperreflexic and bloods showing a Hb107, Plts 88, schistocytes on the film, raised AST / ALT /LDH and bilirubin. Hi Everyone, Acknowledging that we are still in the midst of a world wide pandemic we hope you are all safe. This week we thought it would be nice to take a break from COVID related matters (which we are sure like us has invaded most of your minds over the last few months) and turn to a fascinating obstetric critical illness. Join Graeme and I as we discuss this interesting and serious pregnancy related condition. What causes this condition?What do they die from? What are the important differential diagnoses? How do we manage them? We also share a few sh***e dad jokes, reminisce about ANZAC Day, the COVID pandemic and have another crack at one of our quizzes! Doctor or serial killer? Is This Person a Doctor or Serial Killer?? Leave a comment below Bonus Points available if you can tell us their name!

Join Matt and I as we discuss some of the issues we have been grappling with in our planning for how to manage obstetric patients suspected of or known to have COVID-19. Is pregnancy a risk factor for worse disease severity?What is the appropriate PPE for women in active labour? Is active labour an aerosol generating procedure?What about the use of inhaled (and therefore exhaled) nitrous oxide in these women?What about the need for emergency or urgent procedures such as caesarean sections or post partum haemorrhage - how do we get them safely around the hospital? LINKS https://soap.org/education/provider-education/expert-summaries/interim-considerations-for-obstetric-anesthesia-care-related-to-covid19/ https://www.oaa-anaes.ac.uk/OAA_COVID19_Resources

(*Hypothetical Case) A woman is brought into your emergency dept by her husband at 14 weeks gestation. He tells you that she has been "really sick" for almost two months now. He states that they have seen their GP multiple times and have "tried almost everything". This is the second time they are presenting to your ED - they came 2 weeks ago where he recounts she was given some IV fluids and antiemetics before going home - but they were reluctant to come back because a member of staff was quite dismissive to them last time apparently she told them that if she ate ginger and sipped water she should be fine and "it all stops at 15 weeks anyway so not to worry it will be over soon". This time he tells you that she has practically eaten nothing in the last 4 weeks and she is now having trouble getting out of bed, because of almost 4 weeks of continuous vomiting. He thinks she has probably lost at least 8-10kg since becoming pregnant. He is "super-worried" and "she is just not herself anymore - please do something". She appears listless, drowsy and distracted when you try to question her directly, and she tells you she is thirsty, nauseated and has had enough - she even asks you as you take some bloods and place an iv whether it is permissible to get a termination for untreatable nausea. Bloods: pH 7.58 HCO3 28, PCO2 56, Na 126, K2.3, Gluc 8, LFTs normal Urinary Ketones +++, no glucose How would you approach the management of this woman? Join Graeme and I as we discuss this under appreciated & poorly understood yet potentially catastrophic condition...... USEFUL TREATMENT GUIDELINE https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf LINKS Profound Hypokalaemia Resulting in Maternal Cardiac Arrest: A Catastrophic Complication of Hyperemesis Gravidarum? Wernicke's encephalopathy in hyperemesis gravidarum: A systematic review. http://www.hyperemesis.org/ Pregnancy sickness can kill – why are doctors so uninformed about it? Why are Women Still Dying from Nausea and Vomiting of Pregnancy? http://theconversation.com/when-nausea-from-pregnancy-is-life-threatening-46709

(* Hypothetical Case) You are asked to see a pleasant 31 yr old woman in the antenatal clinic who is pregnant for the first time because as an adolescent she had an extensive scoliosis repair and now has Harrington Rods in her lumbar and thoracic spine. She tells you that she "is worried about being in a lot of pain during labour" and she wants to know what her options are. Hi everyone, This week three of us sat around our new AV equipment (thanks Trilby) to discuss the interesting and somewhat controversial topic of remifentanil PCA use for analgesia in labour. We discuss the history, the concerns regarding safety especially respiratory depression or apnoea, efficacy and some of the new evidence recently published. Links The RESPITE study in Lancet 2018 : Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial IJOA August 2019 Serious adverse events attributed to remifentanil patient-controlled analgesia during labour in The Netherlands IJOA August 2019 Remifentanil patient-controlled analgesia in labour: six-year audit of outcome data of the RemiPCA SAFE Network (2010–2015) BMC Pregnancy and Childbirth 2013 Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a “poor man’s epidural”

Hi Everyone, This week I am joined by Prof Mike Paech, Mike has dedicated most of his career to both the research and practice of obstetric anaesthesia. Join us in this podcast where we sat down to discuss the myriad of changes he has witnessed in Obstetric Anaesthesia over his career. We have now started an interactive poll where you the listeners can make suggestions to us about topics you would like to hear discussed! At this stage we are not making any guarantees but if there are certain topics that seem to be very popular and if we can find someone who feels empowered enough to talk on the topic we will see if we can make it happen! (If you can also supply someone to talk - even better - send us a separate email). Go to the home screen and scroll down to find the poll - see link below: https://www.obsgynaecritcare.org/

Hi everyone, Welcome back to part 2 of our discussion on the use of abbreviations and acronyms in healthcare. We discuss the results, go through some of the more obscure ones and then have a bit of a serious discussion about the advantages but also the dangers inherent in using these for communication in healthcare. Below are the correct answers and some "interesting" responses from the Ob / Gyn abbreviation quiz which Sneha compiled using some of the abbreviations found here in our women's hospital. If you want to have a go first - look away - and navigate back to the preceding post 060. Correct Answers "Interesting Answers" Do you have any interesting abbreviations or acronyms? Send them in!

"Where the f**k is the anaesthetist! I asked for the epidural 45min ago, those obstetric doctors took five goes to put in my drip, the midwife has turned up the hormone drip and now I am going crazy! Aaarghhhh!" Seem familiar? Hi everyone, Welcome back this week I am joined by long time listener and first time interviewee - Dr Sneha Neppali who sits down with me to discuss a couple of projects she has recently completed - epidural analgesia response times and the use of abbreviations in healthcare - specifically obs / gynae ones used during her recent time here at our women's hospital. How many of these abbreviations do you know? Want to see how Sneha faired on her recent TV appearances follow the links below: The Chase  https://www.youtube.com/watch?v=tEG7JZUTgyk&feature=youtu.be&fbclid=IwAR1DGM7uQtduFBX3kxL-DLJq4GPUf5wXV2NvmWa7m7l_4dq5HwIekNXE63A Millionaire Hot Seat https://www.youtube.com/watch?v=DcVJyd5j_9A&feature=youtu.be&fbclid=IwAR3amg4KC2CmAggv2foCplyzjXWnrwbxIODNS72VXPKZMeUevRRddDEoam0