194
International Journal of Obstetric Anesthesia
Table 1 Impact of structured research curriculum on obstetric anesthesiology fellow research productivity and pursuit of academic career Structured research curriculum (n=19) Programs with >20% graduating fellows with peer-reviewed publication in two years preceding study Peer-reviewed manuscripts published with a fellow as an author in two years preceding study Months spent pursuing research during fellowship year Programs sending >40% of fellows onto academic career
No structured research P value curriculum (n=17)
95% CI of difference
10 (53%); [31, 75]
7 (41%); [18, 64]
0.53
20, 40 (%)
3.2 ± 2.6
3.0 ± 2.4
0.89
1.5, 1.9
2.3 ± 1.3 8 (42%)
2.8 ± 1.6 10 (59%)
0.28 0.51
1.5, 0.5 10, 40 (%)
Data are n (%); [95% CI] or mean ± standard deviation.
We did not stratify data to evaluate research productivity in programs that are ACGME accredited. As more programs in the USA achieve accreditation status it will be interesting to evaluate the impact of the research education requirements on fellow scholarly productivity. Additionally, we did not assess when research curricula were initiated, so we do not know if or how productivity increased within a program following implementation. In summary, we found no correlation between a structured fellow research curriculum and increased research productivity for obstetric anesthesiology fellowship programs. As healthcare evolves, clinical productivity pressure will continue to mount, limiting the time available for academic pursuits for both faculty and trainees. There is continued need to improve research education for obstetric anesthesiology fellows in order for the subspecialty to keep and further advance our status as a respected academic anesthesiology subspecialty. R.M. Kacmar, G.S. De Oliveira Jr., R.J. McCarthy, C.A. Wong Department of Anesthesiology Northwestern University Feinberg School of Medicine Chicago, IL, USA E-mail address: [email protected]
References 1. Ahmad S, De Oliveira Jr GS, McCarthy RJ. Status of anesthesiology resident research education in the United States: structured education programs increase resident research productivity. Anesth Analg 2013;116:205–10. 2. Alguire PC, Anderson WA, Albrecht RR, Poland GA. Resident research in internal medicine training programs. Ann Int Med 1996;124:321–8. 3. Levine RB, Hebert RS, Wright SM. Resident research and scholarly activity in internal medicine residency training programs. J Gen Int Med 2005;20:155–9. 4. Andropoulos DB, Walker SG, Kurth CD, Clark RM, Henry DB. Advanced second year fellowship training in pediatric anesthesiology in the United States. Anesth Analg 2014;118:800–8.
5. Steiner JW, Pop RB, You J, et al. Anesthesiology residents’ medical school debt influence on moonlighting activities, work environment choice, and debt repayment programs: a nationwide survey. Anesth Analg 2012;115:170–5. 0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.01.002
Rectus sheath haematoma: a rare cause of abdominal pain in pregnancy Rectus sheath haematoma is caused by rupture of the superior or inferior epigastric arteries or their branches, which lie between the rectus muscle and the posterior rectus sheath, or by rupture of the muscle itself.1,2 We describe the management of a parturient who presented with a rectus sheath haematoma. A 40-year-old, G3P2 (both normal vaginal deliveries) woman presented to hospital at 38 weeks of gestation with sudden onset severe abdominal pain after a bout of coughing. Her pregnancy had been uncomplicated apart from a lower respiratory tract infection in the past week, which was treated with antibiotics. Her initial blood pressure at home was 80/50 mmHg which improved to 120/70 mmHg on arrival to the delivery unit after fluid resuscitation by paramedics. Her heart rate was 120 beats/min but a full blood count, coagulation profile, renal function tests, amylase and liver function tests were unremarkable. The anaesthetic team was informed and analgesia instituted with intravenous paracetamol and intramuscular diamorphine. Intra-uterine fetal resuscitation was commenced using maternal oxygen, fluids and left lateral tilt. The fetal heart rate which was initially reassuring rapidly deteriorated into a pathological trace. A provisional diagnosis of placental abruption was made after an abdominal ultrasound, and a decision was made to deliver the baby by category 1 caesarean section under general anaesthesia. A male infant was delivered
International Journal of Obstetric Anesthesia Table 1
195
Clinical features of rectus sheath haematoma in pregnancy
Symptoms and signs
Risk factors
Diagnosis and investigations
Maternal management
Effect on fetus and management
Abdominal pain/cramping with rigidity that may mimic placental abruption Abdominal wall mass Fever, nausea and vomiting Tachycardia with hypotension mimicking haemorrhagic shock Abdominal wall ecchymosis: in flanks (Grey Turner’s sign) or periumbilical region (Cullen’s sign) Multiparity, obesity, coagulation disorders Strenuous exercise, coughing or sneezing Amniocentesis Fothergill’s sign: mass does not cross midline, remains palpable when patient tenses rectal muscle by touching chin to chest Carnett’s sign: exacerbation of pain by contraction of rectus muscles by sitting up from a supine position Anaemia (possible coagulopathy if massive bleed) Ultrasound: sensitivity and specificity 70–90% MRI: differentiates sub-acute and chronic haematoma from palpable abdominal masses CT scan: sensitivity and specificity 100% Conservative: bed rest, analgesia, fluid resuscitation, correction of anaemia and coagulopathy Surgical: epigastric artery embolisation or surgical evacuation of haematoma FHR abnormalities may follow maternal haemodynamic instability. Initiate intra-uterine resuscitation using maternal oxygen, fluid therapy, left lateral tilt and maintaining maternal blood pressure. If FHR abnormal may need emergency caesarean section
MRI: magnetic resonance imagining; CT: computerised tomography; FHR: fetal heart rate.
10 min later. Umbilical arterial pH was 6.95 and Apgar scores were 3 and 5 at 1 and 5 min, respectively. There was no evidence of placental abruption or intra-abdominal bleeding, but the right rectus sheath was found ruptured with large clots between the rectus muscle and posterior sheath. The woman required significant intravenous fluid resuscitation with crystalloid 2000 mL and two units of blood. The neonate required a brief period of respiratory support in the neonatal intensive care unit, but subsequently made an uneventful recovery. Mother and baby were discharged on the fifth postoperative day. Rectus sheath haematoma is a rare cause of abdominal pain that can occur spontaneously in pregnancy. The exact incidence is unknown. The main clinical features of rectus sheath haematoma in pregnancy are highlighted in Table 1. It poses a significant diagnostic challenge as it mimics placental abruption, especially when accompanied by fetal heart rate abnormalities. Misdiagnosis is extremely common as is seen in our case. Rectus sheath haematoma should be considered in the differential diagnosis of women presenting with abdominal pain, especially after a recent respiratory tract infection. Awareness of clinical features, such as Carnett’s and Fothergill’s sign, and close cooperation between anaesthetists, obstetricians and radiologists, can ensure correct diagnosis and
appropriate management thereby decreasing maternal and fetal morbidity. C. Wai, K. Bhatia Department of Anaesthesia Central Manchester University Hospitals & St Mary’s Hospital Manchester, UK E-mail address: [email protected] I. Clegg Department of Anaesthesia Royal Blackburn Hospital Blackburn, UK
References 1. Tolcher MC, Nitsche JF, Arendt KW, Rose CH. Spontaneous rectus sheath hematoma pregnancy: case report and review of the literature. Obstet Gynaecol Surv 2010;65:517–22. 2. Chang WW, Knight WA, Weredehoff SG, Blomkains AL. Rectus sheath haematoma. http://reference.medscape.com/article/776871overview [accessed August 2014]. 0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.01.002
International Journal of Obstetric Anesthesia
Table 1 Impact of structured research curriculum on obstetric anesthesiology fellow research productivity and pursuit of academic career Structured research curriculum (n=19) Programs with >20% graduating fellows with peer-reviewed publication in two years preceding study Peer-reviewed manuscripts published with a fellow as an author in two years preceding study Months spent pursuing research during fellowship year Programs sending >40% of fellows onto academic career
No structured research P value curriculum (n=17)
95% CI of difference
10 (53%); [31, 75]
7 (41%); [18, 64]
0.53
20, 40 (%)
3.2 ± 2.6
3.0 ± 2.4
0.89
1.5, 1.9
2.3 ± 1.3 8 (42%)
2.8 ± 1.6 10 (59%)
0.28 0.51
1.5, 0.5 10, 40 (%)
Data are n (%); [95% CI] or mean ± standard deviation.
We did not stratify data to evaluate research productivity in programs that are ACGME accredited. As more programs in the USA achieve accreditation status it will be interesting to evaluate the impact of the research education requirements on fellow scholarly productivity. Additionally, we did not assess when research curricula were initiated, so we do not know if or how productivity increased within a program following implementation. In summary, we found no correlation between a structured fellow research curriculum and increased research productivity for obstetric anesthesiology fellowship programs. As healthcare evolves, clinical productivity pressure will continue to mount, limiting the time available for academic pursuits for both faculty and trainees. There is continued need to improve research education for obstetric anesthesiology fellows in order for the subspecialty to keep and further advance our status as a respected academic anesthesiology subspecialty. R.M. Kacmar, G.S. De Oliveira Jr., R.J. McCarthy, C.A. Wong Department of Anesthesiology Northwestern University Feinberg School of Medicine Chicago, IL, USA E-mail address: [email protected]
References 1. Ahmad S, De Oliveira Jr GS, McCarthy RJ. Status of anesthesiology resident research education in the United States: structured education programs increase resident research productivity. Anesth Analg 2013;116:205–10. 2. Alguire PC, Anderson WA, Albrecht RR, Poland GA. Resident research in internal medicine training programs. Ann Int Med 1996;124:321–8. 3. Levine RB, Hebert RS, Wright SM. Resident research and scholarly activity in internal medicine residency training programs. J Gen Int Med 2005;20:155–9. 4. Andropoulos DB, Walker SG, Kurth CD, Clark RM, Henry DB. Advanced second year fellowship training in pediatric anesthesiology in the United States. Anesth Analg 2014;118:800–8.
5. Steiner JW, Pop RB, You J, et al. Anesthesiology residents’ medical school debt influence on moonlighting activities, work environment choice, and debt repayment programs: a nationwide survey. Anesth Analg 2012;115:170–5. 0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.01.002
Rectus sheath haematoma: a rare cause of abdominal pain in pregnancy Rectus sheath haematoma is caused by rupture of the superior or inferior epigastric arteries or their branches, which lie between the rectus muscle and the posterior rectus sheath, or by rupture of the muscle itself.1,2 We describe the management of a parturient who presented with a rectus sheath haematoma. A 40-year-old, G3P2 (both normal vaginal deliveries) woman presented to hospital at 38 weeks of gestation with sudden onset severe abdominal pain after a bout of coughing. Her pregnancy had been uncomplicated apart from a lower respiratory tract infection in the past week, which was treated with antibiotics. Her initial blood pressure at home was 80/50 mmHg which improved to 120/70 mmHg on arrival to the delivery unit after fluid resuscitation by paramedics. Her heart rate was 120 beats/min but a full blood count, coagulation profile, renal function tests, amylase and liver function tests were unremarkable. The anaesthetic team was informed and analgesia instituted with intravenous paracetamol and intramuscular diamorphine. Intra-uterine fetal resuscitation was commenced using maternal oxygen, fluids and left lateral tilt. The fetal heart rate which was initially reassuring rapidly deteriorated into a pathological trace. A provisional diagnosis of placental abruption was made after an abdominal ultrasound, and a decision was made to deliver the baby by category 1 caesarean section under general anaesthesia. A male infant was delivered
International Journal of Obstetric Anesthesia Table 1
195
Clinical features of rectus sheath haematoma in pregnancy
Symptoms and signs
Risk factors
Diagnosis and investigations
Maternal management
Effect on fetus and management
Abdominal pain/cramping with rigidity that may mimic placental abruption Abdominal wall mass Fever, nausea and vomiting Tachycardia with hypotension mimicking haemorrhagic shock Abdominal wall ecchymosis: in flanks (Grey Turner’s sign) or periumbilical region (Cullen’s sign) Multiparity, obesity, coagulation disorders Strenuous exercise, coughing or sneezing Amniocentesis Fothergill’s sign: mass does not cross midline, remains palpable when patient tenses rectal muscle by touching chin to chest Carnett’s sign: exacerbation of pain by contraction of rectus muscles by sitting up from a supine position Anaemia (possible coagulopathy if massive bleed) Ultrasound: sensitivity and specificity 70–90% MRI: differentiates sub-acute and chronic haematoma from palpable abdominal masses CT scan: sensitivity and specificity 100% Conservative: bed rest, analgesia, fluid resuscitation, correction of anaemia and coagulopathy Surgical: epigastric artery embolisation or surgical evacuation of haematoma FHR abnormalities may follow maternal haemodynamic instability. Initiate intra-uterine resuscitation using maternal oxygen, fluid therapy, left lateral tilt and maintaining maternal blood pressure. If FHR abnormal may need emergency caesarean section
MRI: magnetic resonance imagining; CT: computerised tomography; FHR: fetal heart rate.
10 min later. Umbilical arterial pH was 6.95 and Apgar scores were 3 and 5 at 1 and 5 min, respectively. There was no evidence of placental abruption or intra-abdominal bleeding, but the right rectus sheath was found ruptured with large clots between the rectus muscle and posterior sheath. The woman required significant intravenous fluid resuscitation with crystalloid 2000 mL and two units of blood. The neonate required a brief period of respiratory support in the neonatal intensive care unit, but subsequently made an uneventful recovery. Mother and baby were discharged on the fifth postoperative day. Rectus sheath haematoma is a rare cause of abdominal pain that can occur spontaneously in pregnancy. The exact incidence is unknown. The main clinical features of rectus sheath haematoma in pregnancy are highlighted in Table 1. It poses a significant diagnostic challenge as it mimics placental abruption, especially when accompanied by fetal heart rate abnormalities. Misdiagnosis is extremely common as is seen in our case. Rectus sheath haematoma should be considered in the differential diagnosis of women presenting with abdominal pain, especially after a recent respiratory tract infection. Awareness of clinical features, such as Carnett’s and Fothergill’s sign, and close cooperation between anaesthetists, obstetricians and radiologists, can ensure correct diagnosis and
appropriate management thereby decreasing maternal and fetal morbidity. C. Wai, K. Bhatia Department of Anaesthesia Central Manchester University Hospitals & St Mary’s Hospital Manchester, UK E-mail address: [email protected] I. Clegg Department of Anaesthesia Royal Blackburn Hospital Blackburn, UK
References 1. Tolcher MC, Nitsche JF, Arendt KW, Rose CH. Spontaneous rectus sheath hematoma pregnancy: case report and review of the literature. Obstet Gynaecol Surv 2010;65:517–22. 2. Chang WW, Knight WA, Weredehoff SG, Blomkains AL. Rectus sheath haematoma. http://reference.medscape.com/article/776871overview [accessed August 2014]. 0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.01.002
