Latest Updates

Physiologic and Anatomic Changes during Pregnancy

    • A recent study using MRI demonstrated that left uterine displacement of at least 30° (not 15° as previously taught) is needed to relieve aortocaval compression.
    • Pharyngeal volume decreases while airway Mallampati class increases throughout labor, which may contribute to increased risk of difficult intubation throughout labor.
    • Thrombocytopenia commonly occurs in parturients, but the risk of spinal-epidural hematoma is exceedingly low.

Gastrointestinal Diseases in Pregnancy

Jennifer X Cai, MD, MPH, Punyanganie S. de Silva, MBBS, MPH, MRCP(UK)
    • Most inflammatory bowel disease medications, including biologics are safe during pregnancy.
    • Based on recent studies, proton pump inhibitors (PPI) are generally considered to be safe in pregnant women and are usually reserved as second line treatment for GERD complications or for women who did not respond to previous treatments.
    • Polyethylene glycol PEG as a low-risk drug and the preferred drug for chronic constipation in pregnancies.

Thyroiditis, Goiter, Thyroid Nodules, and Thyroid Cancer

Paul W. Ladenson, MD
    • 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum
    • 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis.

Psychiatric Diseases in Pregnancy

    • In March 2019, the U.S. Food and Drug Administration approved Zulresso (Brexanolone) injection for intravenous (IV) use for the treatment of postpartum depression (PPD) in adult women. This is the first drug approved by the FDA specifically for treatment of PPD and is currently available only under a restricted distribution program due to concerns about serious risks including excessive sedation or sudden loss of consciousness during administration. Specific restrictions and requirements are planned to be detailed on the medication’s associated black box warning label. 
    • All women should be screened multiple times during pregnancy and in the postpartum period for depression, regardless of their risk factors or medical history. Many tools such as the Edinburgh Postnatal Depression Scale form are available to assist in screening.
    • When considering intrapartum pain management in women with opioid use disorder, it is important to avoid drugs with an opioid antagonist component, such as nalbuphine, as this can precipitate withdrawal symptoms. Use of other medications such as NSAIDs can reduce the amount of opioids required.
    • The effect of marijuana use in pregnancy is unclear, as studies are confounded due to co-existing mental health disorders, socioeconomic status, parental education, and cigarette smoking. Despite these limitations, several studies have demonstrated an association with preterm labor, low birth weight, NICU admission, and stillbirth. As with any drug of abuse, abstinence during pregnancy should be encouraged.

Thyroiditis, Goiter, Thyroid Nodules, and Thyroid Cancer

Paul W. Ladenson, MD
    • 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum
    • 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis.

Minimally Invasive Esophageal Procedures

Jon O. Wee, MD, FACS

    Approach to the Patient with Abdominal Pain

      • Point-of-care ultrasonography should be used in the patient presenting with abdominal pain 
      • Computed tomography is often used in diagnostic care of the patient with abdominal pain
      • Analgesia should be liberally used when appropriate in the patient with abdominal pain

    Traumatic Brain Injury

    Pierre Borczuk, MD, FACEP
      • Subdural hematoma and traumatic subarachnoid blood are the most common hemorrhagic computed tomographic (CT) findings in patients with head injury.
      • In the patient with signs of brain herniation and borderline or shock vital signs, the ideal hyperosmotic agent is hypertonic saline.
      • Although the incidence of traumatic findings on a cranial CT scan in patients with head injury, loss of consciousness, and a Glasgow Coma Scale score of 15 is about 6%, the need for neurosurgical intervention in this cohort is 0.4%.
      • Guidelines for ordering CT scans in adults after head trauma are the Canadian CT head rule and the New Orleans criteria. The guideline for pediatric patients is the PECARN set of rules.
      • Four-factor prothrombin complex concentrate can rapidly reverse the effects of warfarin in patients with intracranial hemorrhage.
      • For the athlete with head injury, immediate removal from play and a graded increase in activity as long as the patient is asymptomatic are the basis of concussion management.
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