Case of acute and evolving intrinsic cord lesion in pregnancy presenting as unusually bizarre, but evolving neurology, referred as ‘cauda equina?’
When faced with an unusual presentation, particularly if it does not fit with anything ever seen before, and even if on probability it is very unlikely to be pathalogical, need to exclude the relevant and not be biased towards preliminary diagnosis planted by others. Consider Bayesian modelling.
Have an open mind and think broader than the problem presented. Is this something that we have neither yet considered nor ever seen before? How to prove/disprove this? Consider safety nets and worst case scenario. Accept uncertainty in an uncommon, undeclared situation rather than over-confidence. Observe evolution over time with multiple snap shots and opinions.
Wash in large sterile basin gently, like a ‘delicates wash’. Then suck into cell salvage and process.
e.g. in severe hypertensive PET
spinal 1-1.5ml 0.5% heavy bupivicaine + 300mcg diamorphine in 0.3ml
Top up epidural as necessary
Cause of metabolic acidosis in pregnancy.
- Metabolic acidosis
- Normal lactate
- High ketones
10% dextrose +/- insulin +/- HCO3
– deliver if no response
Mnemonic for causes of maternal collapse:
Bleeding / DIC
Embolism – coronary, pulmonary, amniotic fluid
Cardiac disease – MI, ischaemia, aortic dissection, cardiomyopathy
Hypertension, pre-eclampsia, eclampsia
Other (4 Hs & Ts from ALS)
Pregnant women have lower oncotic pressure so have a lower threshold for pulmonary oedema.
TTP. Do not give platelets. Femoral vascath & plasma exchange.
Placental abruption. Causes DIC so give blood products early and aggressively.
To do regional in bleeding diathesis? If diathesis is corrected then its fine.
Renal disease in pregnancy:
- In pregnancy normal values are Cr 50/Ur 3.3 (compared to 70/4)
- Treat the cause
- Avoid NSAIDs/toxins
- Keep on dry side (as pul oedema is worse than AKI)
- Talk to nephrologist
- Hypertensives do worse than normotensives
Cannot bronchi down a size 7.0 ETT so use a larger size if possible.
Have at least 2 anaesthetists present for KTS/delivery of placenta.
RCOG guidelines require presence of consultant anaesthetist.
High risk if:
Previous cardiac event
Severe degree of disease (LVF, sever AS)
Most cadiac morbidity is acquired disease.
High index of suspicion if:
Cardiac risk factors (FHx, smoking, age, HTN, DM)
Chest pain requiring opioids
Ix: ECG, CXR, Serial troponin, echo, CTPA
From Obstetric Revalidation Day