Maternal collapse in pregnancy

Maternal collapse is a rare life-threatening event that can occur at any stage of pregnancy or up to 6 weeks postpartum. Prompt identification and timely intervention by a multidisciplinary team that includes an obstetrician, midwifery staff and an obstetric anaesthetist are essential to improve maternal and fetal outcomes. Standard adult resuscitation guidelines need to be followed with some modifications, taking into account the maternal-fetal physiology, which clinicians should be familiar with. During cardiac arrest, the emphasis is on advanced airway management, manual uterine displacement to relieve aortocaval compression and performing a resuscitative hysterotomy (peri-mortem caesarean delivery) swiftly in patients who are more than 20 weeks gestation to improve maternal survival. Annual multidisciplinary simulation training is recommended for all professionals involved in maternity care; this can improve teamwork, communication and emergency preparedness during maternal collapse.

Prognostic utility of left ventricular global longitudinal strain in patients with systemic amyloidosis

Background

Myocardial deposition of amyloid proteins results in restrictive cardiomyopathy. Left ventricular global longitudinal strain (GLS) has emerged as a sensitive measure for detecting subclinical cardiac dysfunction over traditional echocardiographic parameters. However, multiple studies have provided differing conclusions regarding prognostic utility of impaired GLS in patients with systemic amyloidosis.

Purpose

We conducted a systematic review and meta-analysis to evaluate whether impaired GLS was associated with increased mortality or major adverse cardiovascular events (MACE) in patients with systemic amyloidosis.

Methods

We performed a literature search of Embase, Medline and Web of Science databases to identify studies that reported the association of GLS with clinical outcomes in patients with systemic amyloidosis (light chain or TTR amyloidosis). Outcomes of interest included all-cause mortality and MACE, defined as a composite of death or heart transplant or heart failure hospitalization. Unadjusted and adjusted hazard ratio (uHR and aHR respectively) were pooled using a random effects model. Heterogeneity among the studies was assessed using the Higgins I2 value.

Results

Out of 2139 initial citations, 28 observational studies with a total of 2713 patients were included in the analysis. The mean age ranged between 58–78 years and 62% of the patients were male. Most patients had cardiac amyloidosis (83%) and light-chain amyloidosis accounted for 69% of cases. Mean follow-up ranged between 1 and 5 years. GLS was significantly higher (less negative) (mean difference (MD) −3.69 [−5.94, −1.44], I2=87, p<0.01) in non-survivors compared with survivors. Similarly, patients who experienced MACE had a significantly higher mean GLS (MD −3.22, [−5.21, −1.22,], I2=82, p<0.01]. The risk of both mortality and MACE increased significantly for every −1% increase in GLS. In unadjusted models, a GLS above the defined threshold value was associated with a significantly higher risk of mortality (uHR: 1.66 [1.22, 5.21], I2=85.2, p<0.01) and MACE (uHR: 2.24 [1.28, 3.92], I2=39, p<0.01). In multivariable models an increase in GLS by −1% was an independent predictor of mortality (aHR: 1.09 [1.01,1.16], I2=53, p=0.02) and MACE (aHR: 1.24 [1.14,1.36], I2=0, p<0.01).

Conclusion

In patient with amyloidosis, the baseline left ventricular GLS may help identify patients with a higher risk of mortality and MACE.

Funding Acknowledgement

Type of funding sources: None.

Comparing direct oral anticoagulants versus vitamin K antagonist in patients with atrial fibrillation after transcatheter aortic valve replacement: an updated meta-analysis

Background

Oral anticoagulation therapy is indicated for patients undergoing transcatheter aortic valve replacement (TAVR) with concomitant or new onset atrial fibrillation (AF). However the data on optimal anticoagulation regimen in this population remains unclear.

Purpose

To compare efficacy and safety outcomes of direct oral anticoagulants (DOACs) versus Vitamin K antagonists (VKA) in patients with AF post TAVR.

Methods

We searched electronic databases (PubMed, Embase, Scopus, Cochrane) from inception to February28th, 2022 using MeSH terms and keywords for DOACs, AF or TAVR. Primary outcome of interest was all-cause stroke or systemic embolic event. Secondary safety outcomes were major bleeding and all-cause mortality. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random-effects model. Interstudy heterogeneity was assessed using the Higgins I 2 value. All statistical analysis were performed using RevMan 5.4.1 software.

Results

We identified five eligible studies (1RCT, 4 observational) including 3694 patients (DOAC n=1581, VKA n=2113). The mean age was 81.4±0.9 years. The mean follow-up was 12.4±14.3 months. Type of DOACs included apixaban (n=394, 24.9%), rivaroxaban (n=354, 22.4%), dabigatran (n=119, 7.5%) and edoxaban (n=714, 45.2%).There was no significant difference in primary outcome of stroke or systemic embolic event (RR: 0.93; CI: 0.65–1.33; p>0.05; I2=5%), or in secondary outcomes of major bleeding (RR: 1.02; CI: 0.78–1.34; p>0.05; I2=44%) and all-cause mortality (RR: 0.87; CI: 0.59–1.27; p>0.05; I2=56%) between DOACs and VKA groups.

Conclusion

This meta-analysis shows anticoagulation therapy with DOACs has similar safety and efficacy outcomes compared to VKA in patients with AF undergoing TAVR.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular unloading with Impella versus IABP in patients on VA-ECMO for cardiogenic shock

Background

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in shock is limited by increased left ventricular afterload. Impella and intra-aortic balloon pump (IABP) can be used in conjunction with VA-ECMO to help unload the left ventricle. Data comparing the two strategies are limited.

Purpose

We performed a systematic review and meta-analysis of published data to compare outcomes of patients with shock supported by VA-ECMO in conjunction with Impella versus IABP.

Methods

We conducted a search of Medline, Embase, and Cochrane databases to identify studies comparing the use of Impella versus IABP in patients on VA-ECMO. The primary outcome of interest was all-cause mortality (in-hospital or 30-day). Secondary outcomes included transition to destination therapy with left ventricular assist device (LVAD) or transplant, stroke, need for continuous renal replacement therapy (CRRT), bleeding, and hemolysis. Risk ratios (RR) with 95% confidence interval and the heterogeneity statistic I2 were reported for each outcome.

Results

Six observational studies with a total of 629 patients were included in the analysis. Of these, 205 (33%) and 424 (67%) patients were supported by Impella and IABP respectively, in addition to VA-ECMO. All six studies reported the primary outcome. No difference was observed in all-cause mortality between VA-ECMO with Impella and VA-ECMO with IABP (RR 1.02 [0.74–1.40], I2=74%). Similar rates were observed for transition to LVAD or transplant (RR 0.75 [0.45–1.27], I2=0%), stroke (RR 1.50 [0.80–2.83], I2=0%), and need for CRRT (RR 1.04 [0.82–1.32], I2=0%). However, use of VA-ECMO with Impella was associated with a higher risk of bleeding (RR 1.91 [1.28–2.86], I2=68%) and hemolysis (RR 4.61 [1.24–17.17], I2=66%) as compared with use of VA-ECMO with IABP.

Conclusion

In patients with shock requiring VA-ECMO, concurrent use of Impella and IABP had similar risk of mortality, transition to LVAD/transplant, stroke, and need for CRRT. However, Impella use was associated with higher risk of bleeding and hemolysis. Randomized trials are needed to identify the optimal strategy for left ventricular unloading in patients with cardiogenic shock on VA-ECMO.

Funding Acknowledgement

Type of funding sources: None.

Efficacy and safety outcomes of ultrasound assisted thrombolysis versus standard catheter direct thrombolysis in patients with submassive or massive pulmonary embolism: an updated meta-analysis

Background

The use of catheter-based thrombolysis in comparison to systemic thrombolytics has emerged as a potentially lifesaving therapy for patients with sub massive or massive pulmonary embolism (PE). The addition of ultrasound waves to accelerate lytic dispersion in ultrasound assisted thrombolysis (USAT) has been proposed to improve outcomes as compared to standard catheter-directed thrombolysis (SCDT). These two modalities have been compared in small studies, but larger population data on the outcomes of these therapies is still lacking.

Purpose

To assess the efficacy and safety of USAT versus SCDT in patients with submassive or massive pulmonary embolism.

Methods

A review of electronic databases (PubMed, Scopus, Embase, and Cochrane) was performed using keywords USAT, SCDT and PE and studies were included if efficacy and safety outcomes were compared between the two types of therapies. Efficacy outcomes that were evaluated included the reduction in right ventricle/left ventricle ratio (RV/LV ratio), pulmonary artery systolic pressure (PASP) and Miller score. Safety outcomes that were evaluated included major bleeding, mortality and length of ICU stay. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for continuous variables. Risk ratio (RR) and 95% CI were reported for dichotomous variables using the random effects model in comprehensive meta-analysis and RevMan 5.4.1 softwares.

Results

Six studies with a total of 381 patients (USAT n=204; SCDT n=177) were included. No statistical difference in efficacy outcomes of USAT over SCDT was noted in the degree of RV/LV ratio reduction (SMD: −0.507; CI: −1.386–0.373; p>0.05; I2=92%), PASP reduction (SMD: 0.037; CI: −0.404–0.478; p>0.05; I2=59%), or Miller score reduction (SMD: 0.303; CI: −0.481– 1.087; p>0.05; I2=82%). Safety outcomes were also not statistically different with similar rates of major bleeding (RR: 1.44; CI: 0.54–3.85; p>0.05; I2=4%), mortality (RR: 1.46; CI: 0.35–6.05; p>0.05; I2=0%) and length of ICU stay (SMD: −0.01; CI: −0.29–0.27; p>0.05; I2=31%) in both treatment groups.

Conclusion

Our data suggest that despite the technological advancement of USAT, there is no additional benefit over SCDT in terms of efficacy and safety. Further studies are warranted for both procedures investigating financial and clinical outcomes in real world practice.

Funding Acknowledgement

Type of funding sources: None.

To compare efficacy and safety of direct oral anticoagulants in patients with concurrent atrial fibrillation and bioprosthetic heart valve repair or replacement: a systematic review and meta-analysis

Background

Use of direct oral anticoagulants (DOACs) is contraindicated in patients with mechanical valves. However data on their use in patients with atrial fibrillation (AF) and bioprosthetic valves (BV) is still limited.

Purpose

To assess the safety and efficacy of DOACs versus Vitamin K antagonist (VKA) in patients with AF after BV repair or replacement.

Methods

We performed a comprehensive review of electronic databases (PubMed, Embase, Scopus, Cochrane) using MeSH terms and keywords for DOACs, AF and BVs from inception through December 2021. Randomized clinical trials (RCT) or observational studies that reported clinical outcomes comparing DOACs versus VKA in patients with AF and BVs were eligible for inclusion. Ten articles were reviewed for full text. Primary outcome was a composite of all cause stroke or systemic embolic event.

Secondary outcomes included major bleeding and all-cause mortality. Subgroup analysis stratified by study design was performed. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using Mantel-Haenszel method with DerSimonian-Laird estimator for tau2 for random effects model.

Interstudy heterogeneity was assessed using the Higgins I 2 value. All statistical analysis was performed using RevMan 5.4.1 software.

Results

Ten studies (5 RCTs, 5 observational studies) with a total of 5,333 patients (DOACs n=2434; VKA n=2899) were included. Aortic, mitral and mixed BV repair or replacement were 74.2%, 25.6% and 0.02% respectively. The mean age was 72.6±11.9 years. The mean follow-up was 15.7±12.9 months. Type of DOACs included apixaban (n=553, 22.7%), rivaroxaban (n=893, 36.7%), dabigatran (n=151, 6.2%) and edoxaban (n=837, 34.4%). There was no significant difference in primary outcome of stroke or systemic embolic event (RR: 0.79; CI: 0.56–1.11; p>0.05; I2=12%) or secondary outcomes of major bleeding (RR: 0.84; CI: 0.64–1.11; p>0.05; I2=45%), and all-cause mortality (RR: 0.84; CI: 0.64–1.11; p>0.05; I2=29%) between DOACs compared with VKA.

Conclusion

In patients with AF and BV, DOACs are non-inferior to VKA for risk of stroke or systemic embolism, major bleeding, and all-cause mortality. Thus, DOACs can serve as a viable alternative to VKAs which have a narrow therapeutic index, multiple drug interactions, and require frequent monitoring.

Funding Acknowledgement

Type of funding sources: None.

Obstetric analgesia and anaesthesia in SARS-CoV-2-positive parturients across 10 maternity units in the north-west of England: a retrospective cohort study

Since the start of the COVID‐19 pandemic, few studies have reported anaesthetic outcomes in parturients with SARS‐CoV‐2 infection. We reviewed the labour analgesic and anaesthetic interventions utilised in symptomatic and asymptomatic parturients who had a confirmed positive test for SARS‐CoV‐2 across 10 hospitals in the north‐west of England between 1 April 2020 and 31 May 2021. Primary outcomes analysed included the analgesic/anaesthetic technique utilised for labour and caesarean birth. Secondary outcomes included a comparison of maternal characteristics, caesarean birth rate, maternal critical care admission rate along with adverse composite neonatal outcomes. A positive SARS‐CoV‐2 test was recorded in 836 parturients with 263 (31.4%) reported to have symptoms of COVID‐19. Neuraxial labour analgesia was utilised in 104 (20.4%) of the 509 parturients who went on to have a vaginal birth. No differences in epidural analgesia rates were observed between symptomatic and asymptomatic parturients (OR 1.03, 95%CI 0.64–1.67; p = 0.90). The neuraxial anaesthesia rate in 310 parturients who underwent caesarean delivery was 94.2% (95%CI 90.6–96.0%). The rates of general anaesthesia were similar in symptomatic and asymptomatic parturients (6% vs. 5.7%; p = 0.52). Symptomatic parturients were more likely to be multiparous (OR 1.64, 95%CI 1.19–2.22; p = 0.002); of Asian ethnicity (OR 1.54, 1.04–2.28; p = 0.03); to deliver prematurely (OR 2.16, 95%CI 1.47–3.19; p = 0.001); have a higher caesarean birth rate (44.5% vs. 33.7%; OR 1.57, 95%CI 1.16–2.12; p = 0.008); and a higher critical care utilisation rate both pre‐ (8% vs. 0%, p = 0.001) and post‐delivery (11% vs. 3.5%; OR 3.43, 95%CI 1.83–6.52; p = 0.001). Eight neonates tested positive for SARS‐CoV‐2 while no differences in adverse composite neonatal outcomes were observed between those born to symptomatic and asymptomatic mothers (25.8% vs. 23.8%; OR 1.11, 95%CI 0.78–1.57; p = 0.55). In women with COVID‐19, non‐neuraxial analgesic regimens were commonly utilised for labour while neuraxial anaesthesia was employed for the majority of caesarean births. Symptomatic women with COVID‐19 are at increased risk of significant maternal morbidity including preterm birth, caesarean birth and peripartum critical care admission.

1678 A Rare Example of a Simple Bone Cyst of The Ascending Ramus in A Paediatric Patient

A simple bone cyst is described as an intra-osseous pseudocyst, devoid of an epithelial lining and either empty of filled with serous or sanguineous fluid. This case presents a rare example of a simple bone cyst of the ascending ramus of the mandible in a paediatric patient. Studies have shown that less than 5% of simple bone cysts of the jaw bones are located within the mandibular ramus, with the most common site being the premolar-molar region (75%). The 14-year-old female was referred by her orthodontist to the local Oral and Maxillofacial department, for an incidental finding on her pre-orthodontic OPT of a radiolucency in the left ascending ramus. Her medical history was clear, she was asymptomatic and had no sensory deficit. A CT scan demonstrated a 22mm multilocular radiolucency centred on the left ascending ramus, extending superiorly up to the base of the coronoid process and condylar neck. Inferiorly, the radiolucency abutted but did not involve the unerupted third molar. The scan highlighted thinning of the buccal and lingual cortices putting the patient at risk of pathological fracture. The inferior alveolar nerve canal passed through the lingual aspect of the radiolucency. The patient underwent exploration of the left mandible which revealed an empty bony cavity, with no cystic lining or contents. The definitive diagnosis of a simple bone cyst was established. She experienced satisfactory healing by her review appointment 4 weeks post-surgery. Combined radiographic and clinical assessment is important in the diagnosis of simple bone cysts.

Postpartum cerebral venous sinus thrombosis following obstetric neuraxial blockade: a literature review with analysis of 58 case reports

BACKGROUND

Cerebral venous sinus thrombosis (CVST) is a rare complication of pregnancy. It usually presents with a headache and may mimic a post-dural puncture headache (PDPH) in women who receive a neuraxial block.

METHODS

Medline, CINAHL and EMBASE databases were searched to identify postpartum cases of CVST following neuraxial block. The aim was to delineate the characteristics, presentation, investigations, and outcomes of postpartum women who presented with CVST.

RESULTS

Forty-nine articles with 58 case reports were identified. Forty-two women (72.4%) had an epidural attempted whilst 16 women (27.6%) received a spinal anaesthetic. Accidental dural puncture (ADP) was reported in 17 women (40.5%). Headache was the presenting symptom in 57 women (98.3%); 26 women (44.8%) also experienced seizures. Post-dural puncture headache was reported in 46 (79.3%) and an epidural blood patch was performed in 26 women (44.8%). Superior sagittal sinus, transverse sinus, and cortical veins were the most common sites of thrombosis. The median time to diagnosis was 6.5 days from delivery. Magnetic resonance imaging was the most common diagnostic neuro-imaging modality. Full neurological recovery was reported in 48 (82.8%), whilst neurological deficits were reported in six (10.3%) women.

DISCUSSION

The diagnosis of CVST may be overlooked in women who present with headache following neuraxial block. A change in character of headache with loss of postural element, and focal neurological signs are the key clinical features that could help anaesthetists differentiate headache of CVST from PDPH. The high reported rates of ADP and PDPH lend support to their possible association with CVST.

Transradial Neuroendovascular Procedures in Adolescents: Initial Single-Center Experience

BACKGROUND AND PURPOSE

The feasibility and safety of transradial angiography is not established outside the adult literature. The objective of this study was to assess the feasibility and safety of transradial access for neuroangiography in adolescents.

MATERIALS AND METHODS

A retrospective case-control study was performed, comparing transradial neuroendovascular procedures in adolescents (age range, 10-18 years) with an age- and procedure-matched cohort of transfemoral neuroendovascular procedures. Clinical and procedural details, including type of procedure, conversion rate, fluoroscopy time, radiation dose, complications, and readmissions, were reported by descriptive statistics or measures of central tendency and compared using a t test or nonparametric equivalent. A P value < .05 was considered statistically significant.

RESULTS

Twenty adolescents (mean age, 14.6 [SD, 1.7] years, M/F ratio = 9:11) who underwent transradial neuroangiography were compared against 20 adolescents (mean age, 14.4 [SD, 2.1 ] years, M/F ratio = 12:8) who underwent transfemoral neuroangiography. We found no significant difference in procedural success (0% conversion rate), fluoroscopy times (33.7 [SD, 40.2] minutes versus 23.3 [SD, 26.2] minutes, P = .34) and radiation dose (150.9 [SD, 133.7] Gy×cm² and 122.9 [SD, 79.7] Gy×cm,² P = .43) There were 2 self-limiting postprocedural complications in the transradial group. There were no major hemorrhages, need for further interventions, or readmissions in either group.

CONCLUSIONS

The benefits of transradial angiography described for adults can likely be safely extended to adolescents. These are important data before transitioning to smaller children and should be prospectively evaluated in a larger cohort.

Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial

OBJECTIVE

To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage.

DESIGN

Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS).

SETTING

Twenty-eight UK NHS early pregnancy units.

SAMPLE

A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage.

METHODS

Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets.

MAIN OUTCOME MEASURES

Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs).

RESULTS

For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management.

CONCLUSIONS

The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage.

TWEETABLE ABSTRACT

The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.