UMEM Educational Pearls - By Michele Callahan

Spontaneous coronary artery dissection (SCAD) occurs when there is an intimal tear that develops within the wall of an epicardial coronary artery, leading to intramural hematoma and false lumen formation with compromised coronary blood flow.  This tear develops in the absence of atherosclerosis, trauma, or iatrogenic injury. SCAD is believed to account for 4% of acute coronary syndromes, and has been found to be the cause of ACS in 35% of women under the age of 50. Women comprise the majority of cases of SCAD( 87-95%). 

Patients with Pregnancy-associated SCAD (P-SCAD) will often present with higher-risk features and more severe presentations compared with non-pregnancy related SCAD. They are more likely to present with STEMI (>>NSTEMI), impaired left ventricular function, left main and multivessel disease, and shock than other cohorts of SCAD patients.

The peak timing of P-SCAD is within the first month postpartum (with the highest incidence within the first week), although cases can occur throughout all trimesters of pregnancy or many months postpartum.

Keep SCAD in your differential for patients without typical risk factors who present with signs/symptoms of ACS. A strong index of suspicion is necessary to prevent bad outcomes and improve morbidity and mortality from this disease entity.

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Category: Obstetrics & Gynecology

Title: Postpartum Depression

Keywords: postpartum depression (PubMed Search)

Posted: 5/2/2024 by Michele Callahan, MD (Updated: 7/17/2024)
Click here to contact Michele Callahan, MD

Perinatal mental health problems are unfortunately quite common: according to the World Health Organization, approximately 10% of women in high-income countries and approximately 30% in low- or middle-income countries are affected.

It's important to be able to distinguish “baby blues” from more significant mental health issues. Typical symptoms of the “baby blues” include mild and short-lived changes in mood, as well as feelings of exhaustion, worry, and unhappiness in the weeks that follow giving birth.

Symptoms that are more severe or lasting >2 weeks post-partum should prompt further investigation and discussion with a mental health professional. Symptoms of perinatal depression may include: feeling persistently sad, feelings of hopelessness, loss of interest or pleasure in hobbies/activities, trouble bonding with the infant, appetite changes, and can even become as severe as wanting to harm onself or one's child. There are specific DSM-5 Criteria used to diagnose postpartum depression.

Universal screening for all pregnant and postpartum patients is highly recommended, and can be life-saving.

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Category: Obstetrics & Gynecology

Title: Postpartum Hemorrhage

Keywords: postpartum, hemorrhage, pregnancy, maternal (PubMed Search)

Posted: 4/4/2024 by Michele Callahan, MD
Click here to contact Michele Callahan, MD

Postpartum hemorrhage (defined as >500 mL blood loss after birth by the WHO and >1000 mL blood loss within 24 hours of birth by ACOG), accounts for 27% of maternal deaths worldwide. It is the leading cause of maternal complications and death worldwide, with approximately 70,000 deaths globally.

In a randomized trial published in the NEJM in 2023, they implemented a bundle of first-response treatments including uterine massage, uterotonic medications, and tranexamic acid and compared this intervention group with a control group providing "usual care". They concluded that early detection of PPH and use of bundled treatment led to a lower risk of postpartum hemorrhage, lower need for laparotomy for bleeding, or lower risk of death from bleeding compared with usual care amongst patients having a vaginal delivery.  

This study confirms the already widely-published recommendations for prevention of PPH with active management of the third stage of labor using prophylactic uterotonic medication (most commonly Oxytocin), uterine massage for atony, early cord clamping, and controlled cord traction for delivery of the placenta. Prompt escalation to more aggressive management (including blood transfusion, TXA, and more invasive treatments such as uterine tamponade or surgical intervention) should occur when initial treatments fail.

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