Obsgynaecritcare

Hypothetical Case: You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service) She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight. The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea. Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1 Her bloods are relatively normal except for an unexpected high BNP. You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension.  The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia………………… Hi Everyone, This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia. This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them. Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below: References Australasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End” Oral vaccine could prevent rheumatic heart disease in NZ VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease

Hypothetical Case: You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service) She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight. The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea. Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1 Her bloods are relatively normal except for an unexpected high BNP. You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension.  The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia………………… Hi Everyone, This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia. This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them. Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below: References Australasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End” Oral vaccine could prevent rheumatic heart disease in NZ VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease

Hi everyone, Pain during caesarean is a very challenging and distressing event – for the patient, their partner, the anaesthetist and all the staff present in theatre. This week we catch up with Matt Rucklidge, who recently gave a presentation on this topic at the obstetric anaesthesia meeting in London. We discuss why this has become a “hot topic” in the anaesthesia world in recent times, what is the true incidence, and many other aspects of this difficult topic. References The following is a first person narrative story from a patient with commentary from an uninvolved obstetric anaesthetist. Disappointingly from elselvier this article is unfortunately not open access but is well worth a read: Stanford SE, Bogod DG. Failure of communication: a patient’s story. Int J Obstet Anesth. 2016 Dec;28:70-75. doi: 10.1016/j.ijoa.2016.08.001. Epub 2016 Aug 23. PMID: 27717633. Podcast: The Retrievals Season 2 from NY Times Prevention and management of intraoperative pain during Caesarean sectionOrbach-Zinger, S. et al.BJA Education, Volume 25, Issue 2, 50 – 56

Hi everyone, Sepsis is an important cause of mortality and morbidity in our patients. It is common but can be difficult to diagnose, challenging to manage and sometimes downright scary. After being inspired by listening to an episode from “The Critical Care Commute Podcast” (with Dr Mervyn Singer a UK intensivist involved in sepsis 3.0), Graeme and I sit down to discuss some of these thought provoking areas of sepsis which are controversial and are still actively being researched. Thanks again Graeme! References The Critical Care Commute Podcast

Hi Everyone, This week I am joined by Dr Jen Kielty to discuss ERAS – Enhanced Recovery After Surgery. Jen has been helping us with the introduction of ERAS here at our hospital and also shares her experience with the introduction of ERAS into obstetrics at two hospitals back in Ireland. What is ERAS? Why is ERAS good for patients and good for the hospital? What are the components of an ERAS program? A big shout out to Dr Chloe Ayres here at KEMH as the champion for this initiative. Chloe has done a huge amount of work to make this a success here in our gynae-oncology patients and without her enthusiasm it probably would never have happened. Another big acknowledgement to my wife Andrea, who as the inaugural ERAS nurse has also had to do an amazing amount of work with staff and patients to make it a success! References ERAS Society guidelines for Obstetrics and Gynaecology

Hi everyone, This week Declan and I sit down to discuss a novel non opioid analgesic drug recently approved for use by the FDA, suzetrigine. What is it? How does it work? Why should we be interested in this new class of drugs and most importantly will it live up to it’s hype? References Suzetrigine: First in a New Class of Nonopioid Analgesics for Acute Pain. Anesthesiology 142(6):p 989-991, June 2025. | DOI: 10.1097/ALN.0000000000005465 – Unfortunately this is not a free article but well worth a read if you can get to it through your hospital or college library. The accompanying podcast of this editorial is open access – follow the following link. podcast Suzetrigine Drug-Drug Interactions: Perioperative Anesthesia Considerations to Enhance Patient Safety

Hi Everyone, This week I sat down with Declan to discuss a fascinating therapy which is used in many areas of medicine. This podcast has a bit of everything, a quiz, a part one viva, dubious animal experimentation, discussions about laxatives, and even some references to cosmology and the Big Bang. Thanks Declan for another entertaining episode.

You are called to assess a pregnant woman who presents to your hospital complaining of shortness of breath. She is 36 weeks pregnant with twins and tells you she had been getting progressively short of breath over the last month but put it down to the physical effects of the twin pregnancy in her abdomen. However last night she couldn’t get her breath lying flat, had to sleep sitting up on 3-4 pillows and feels that “it is much worse”. On examination she has a respiratory rate of 24/min, SpO2 = 92%, HR 105/min, BP 95/45 and you can hear crepitations in both lung fields. Her initial blood tests come back showing a raised plasma BNP and a bedside ECHO is done by a helpful colleague – who says “subjectively her LV isn’t contracting very well”. Hi everyone, This week I sit down with Dr Faith Njue the most qualified person here in WA to discuss the rare but important disease – peripartum cardiomyopathy. (See Faith’s Bio below). Join us in our wide ranging discussion which touches on the diagnostic challenges, demographics, proposed mechanisms and general principles involved in managing these complex patients. Thanks Faith for a great discussion! Dr Faith Njue – Bio Faith Njue graduated from the University of Western Australia and completed cardiology training in Perth. She undertook further subspeciality training in advanced heart failure/ heart transplantation at Fiona Stanley Hospital and the University of Ottawa Heart Institute in Canada. Thereafter, she undertook further fellowship in cardio-obstetrics at the John Radcliffe hospital in Oxford (UK). She has special interest in women’s cardiovascular health, heart disease in pregnancy and heart failure. Faith runs the dedicated Western Cardiology cardio-obstetrics clinic, designed to support women at risk of or with pre-existing heart conditions, through preconception counselling, pregnancy and into the post-partum period. Cardio-obstetrics is an expanding subspecialty that focuses on prevention, early detection, and appropriate management of cardiovascular disease in pregnancy. She holds public consultant positions at Sir Charles Gairdner and Fiona Stanley hospitals. She is part of the Advanced heart Failure and Cardiac Transplant team at FSH. She is the cardiology clinical lead for High Risk pregnancy at FSH. References Anaesthesia and peripartum cardiomyopathy Chapman, K. Njue F, Rucklidge M. BJA Education, Volume 23, Issue 12, 464 – 472 Melanie Ricke-Hoch, Tobias J. Pfeffer, and Denise Hilfiker-Kleiner. Peripartumcardiomyopathy: basic mechanisms and hope for new therapies. Cardiovascular Research (2020) 116, 520–531. doi:10.1093/cvr/cvz252​ Bauersachs J, König T, van der Meer P, et al. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail. 2019 Jul;21(7):827-843. doi: 10.1002/ejhf.1493. Epub 2019 Jun 27. PMID: 31243866​ 2018 ESC Guidelines for the Management of Cardiovascular Disease During Pregnancy. European Heart Journal 2018. Vol 39;3165-3241​ Bromocriptine: Koenig T, Bauersachs J, Hilfiker-Kleiner D. Bromocriptine for the Treatment of Peripartum Cardiomyopathy. Card Fail Rev. 2018 May;4(1):46-49. doi: 10.15420/cfr.2018:2:2. PMID: 29892477; PMCID: PMC5971672 Hilfiker-Kleiner D, Haghikia A, Berliner D, Vogel-Claussen J, Schwab J, Franke A, Schwarzkopf M, Ehlermann P, Pfister R, Michels G, Westenfeld R, Stangl V, Kindermann I, Kühl U, Angermann CE, Schlitt A, Fischer D, Podewski E, Böhm M, Sliwa K, Bauersachs J. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J. 2017 Sep 14;38(35):2671-2679. doi: 10.1093/eurheartj/ehx355. PMID: 28934837; PMCID: PMC5837241.

Hi everyone, This week I am joined again by Dr David Owen an obstetrician here at KEMH. We sit down to discuss uterine inversion – an acute obstetric emergency. Luckily this condition is relatively rare – however because of this there can be challenges in recognising and treating this condition even amongst experienced individuals. Should you be unlucky enough to encounter this rare condition, now having listened to our discussion you will be better prepared and confident you know what is required! Thanks again David for your research and preparation for this episode! References Uterine inversionPararajasingam, S.S. et al.BJA Education, Volume 24, Issue 4, 109 – 112 Unfortunately (as of Feb 2025) this article is not yet open access – but it is very good if you can get it through your hospital or college library.. Uterine Inversion for the layperson – Cleveland Clinic https://youtu.be/bYIPkNfPDUI

Hi Everyone, Welcome to Part Two of our discussion with two of the founding members of the Placenta Accreta Spectrum Team here at KEMH Dr Matt Epee-Bekima and Dr David Owen. This team was conceived in 2017 and began operating in 2018 – and has now cared for over 75 women with PAS – including 24 alone this year (2024). In this episode we continue our initial discussion with a more detailed dive into: Surgical management – team members, techniques and approach Techniques for catastophic bleeding – manual aortic compression, vascular clamping, interventional radiology Postpartum issues Controversies (ICU vs HDU, leaving placenta in -situ) Thoughts for the future Thanks Matt & David for sharing the experiences and knowledge learnt by the PAS team over the last 7 years. References https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Placenta-Accreta.pdf?thn=0

Hi Everyone, This week I had the privilege of sitting down and recording two fascinating episodes with two of the founding members of the Placenta Accreta Spectrum Team from here at KEMH, Dr Matt Epee-Bekima and Dr David Owen. In this first episode we discuss the following: Definitions and pathology of placenta accreta spectrum What is the story behind the formation of the PAS team? Screening / Identification / Diagnosis and referral The optimisation and planning of the patient’s journey. References King Edward Memorial Hospital website – The Placenta Accreta Spectrum guideline

Hi Everyone, Join Graeme and I as we discuss two articles chosen from last months edition of IJOA (International Journal of Obstetric Anesthesia). In the first we discuss an article exploring whether the use of intermittent calf compression can reduce hypotension and vasopressor use in women undergoing caesarean section under spinal anaesthesia. The second article looks at the utility of preoperative electrical stimulation of acupressure points prior to caesarean section reduces postoperative pain and improves the quality of maternal recovery. There’s a sprinkling of our usual dad jokes at the end. For regular listeners to the show join us again later this month when we hopefully will have a couple of episodes dedicated to the management of placenta accreta spectrum and an interview with the founders of the placenta accreta service setup 7 years ago here at KEMH – see you then! References International Journal of Obstetric Anesthesia Effect of pneumatic leg compression on phenylephrine dose for hypotension prophylaxis via variable rate infusion at cesarean delivery: an unblinded randomized controlled trial Transcutaneous electrical acupuncture point stimulation and quality of recovery following cesarean delivery: A randomized controlled trial

The next patient on your elective list arrives in theatre. She is a 35 year old woman booked for hysteroscopy to investigate her menorrhagia. She has no co-morbidities so wasn’t seen preoperatively in a clinic. She tells you that she has no medical problems but did start on Wegovy for weight loss about 4months ago and has now lost about 12kg. She hasn’t eaten anything since 9pm last night – it is now 10am. You were planning a general anaesthetic and a supra-glottic device, but now you’re not sure what you should do? Hi everyone, This week I am joined by Erin and we discuss in detail the perplexing topic of GLP1 receptor agonists. These new wonder weight loss drugs seem to be all the rage and certainly things look rosy if you have shares in Novo Nordisk (the manufacturer). However they are not so great if you provide anaesthesia…. We discuss their relationship with delayed gastric emptying and the risk of aspiration. References ANZCA GLP1 clinical practice recommendation June 2024 ASA consensus based guidance on preoperative management of GLP1 agonists Feb 2024 Gastricultrasound.org. – This is the best resource available (our humble opinion) if you want to upskill yourself to be able to assess the contents of the stomach. ANZCA clinical practice recommendation summary – June 2024 see below

Your patient arrives in the anaesthetic room next to theatre, she’s booked for a non elective caesarean for failure to progress. She has an epidural in situ and you decide try to top it up – however after 25ml of lignocaine 2% with adrenaline and around 20min of waiting the block is stuck at the umbilicus and she can still move her legs relatively freely. This is obviously not going to be adequate – she is adamant she wants to be awake to see her baby born. You sit her up, pull out the epidural and do a single shot spinal with 2.1ml of heavy bupivacaine 0.5% + fentanyl 15mcg – after all you don’t want this block to fail as well! You clean her back, lie her down and turn to talk to the midwife. When you turn back to the patient 30s later she looks a little purple and isn’t breathing……. Hi everyone join Graeme and I this week as we discuss total spinal anaesthesia – a fascinating but somewhat scary rare emergency which can occur when we use regional anaesthesia in obstetric practice. A big shout out to the team from Rotunda Hospital in Dublin who wrote the recent narrative review published in IJOA on this topic! References Total spinal anaesthesia following obstetric neuraxial blockade: a narrative review Radwan, M.A. et al.International Journal of Obstetric Anesthesia, Volume 59, 104208 Sobhy S, Zamora J, Dharmarajah K, Arroyo-Manzano D, Wilson M, Navaratnarajah R, Coomarasamy A, Khan KS, Thangaratinam S. Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health. 2016 May;4(5):e320-7. doi: 10.1016/S2214-109X(16)30003-1. PMID: 27102195.

What is the EXIT procedure? Who is it used for and how do we do it? In our institution this procedure only occurs on average every 3-4 years. It is an event where a large diverse group of individuals, who often have never met each other, come together for a brief period of time to work as a highly complex team to achieve a great result for both the mother and baby. Join Lloyd and I as we do a deep discussion on this uncommon but challenging multi-disciplinary procedure. References Maternal anesthesia for EXIT procedure: A systematic review of literature. The management of congenital upper airway anomalies and the ex-utero intrapartum treatment (EXIT) procedure

Hi Everyone, This week Matt and I agreed to get together to do another journal club episode (or more accurately I printed out an article, put it in Matt’s pigeon hole and told him to make himself available or else!). We went to one of our favourite journals IJOA (International Journal of Obstetric Anesthesia), where we chose an article from the latest edition published in May. The article is entitled “A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard Ostheimer lecture.” The background to this article is that every year the north american Society of Obstetric Anesthesia and Perinatology (SOAP) hold an annual conference. One of the highlights of these annual conferences is this lecture which is researched and then presented by a well respected obstetric anesthesiologist from the north american community. The lecture is a narrative review of the previous years published literature highlighting important papers and discussing their importance and relevance particularly in relation to current north american practice. This year’s lecture was presented by Pervez Sultan from Stanford University, and it is drawn from a review of articles published in 2022 from 66 different journals. Over 12 different themes are discussed including (but not limited to) TIVA for GA Caesareans, dexamethasone for post CS analgesia, predicting epidural blood patch success, dural puncture epidurals and a number of other interesting topics. Join Matt and I as we discuss these and muse over what relevance they may have to our current practice here in Western Australia as well as a couple terrible olympic themed dad jokes to close! References / Links A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard W. Ostheimer lecture  Int J Obstet Anesth 2024 May:58:103973. doi: 10.1016/j.ijoa.2023.103973. Epub 2024 Jan 3.

Hi everyone, This week I sit down with Jacob one of the provisional fellows in our department and we discuss the findings from the latest UK National Audit Project – NAP7 – which this time investigated Perioperative cardiac arrest. REFERENCES NAP7 – Royal College of Anaesthetists

A woman collapses with abdominal pain in a restaurant & then the initial evaluation in the ED she is diagnosed with suspected ruptured ectopic pregnancy. She is brought straight into your theatre and you perform a rapid sequence induction. You place your video laryngoscope into her mouth and all you see is vomitus and fluid, your yankauer sucker is blocked with food and doing nothing………… Hi everyone, This week I am joined by Dr Nathan Blakely one of our enthusiastic trainees to discuss an area he has taken a personal interest in —- the management of the soiled airway. Thanks Nathan! Blood in Airway: Useful Links / References https://youtu.be/Jaq-vHbcGi0 https://youtu.be/oMXkGgoRMpE Cook T, Woodall N, Frerk C, Project FNA. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. British journal of anaesthesia. 2011;106(5):617-31. Kei J, Mebust DP. Comparing the effectiveness of a novel suction set-up using an adult endotracheal tube connected to a meconium aspirator vs. a traditional Yankauer suction instrument. The Journal of emergency medicine. 2017;52(4):433-7. Andreae M, Cox R, Shy B, Wong N, Strayer R. 319 Yankauer outperformed by alternative suction devices in evacuation of simulated emesis. Annals of Emergency Medicine. 2016;68(4):S123. Cox R, Andreae M, Shy B, DuCanto J, Strayer R. Yankauer suction catheters with “safety” vent holes may impair safety in emergent airway management. The American Journal of Emergency Medicine. 2017;35(11):1762-3. Nikolla DA, King B, Heslin A, Carlson JN. Comparison of Suction Rates Between a Standard Yankauer, a Commercial Large-Bore Suction Device, and a Makeshift Large-Bore Suction Device. The Journal of Emergency Medicine. 2021;61(3):265-70. Weingart SD, Bhagwan SD. A novel set-up to allow suctioning during direct endotracheal and fiberoptic intubation. Journal of clinical anesthesia. 2011;23(6):518-9. Han S, Fisher JA. Airway Management During Persistent Flooding Of the Oropharyngeal Airway. DuCanto J, Serrano KD, Thompson RJ. Novel airway training tool that simulates vomiting: suction-assisted laryngoscopy assisted decontamination (SALAD) system. Western Journal of Emergency Medicine. 2017;18(1):117. Root CW, Mitchell OJ, Brown R, Evers CB, Boyle J, Griffin C, et al. Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A technique for improved emergency airway management. Resuscitation Plus. 2020;1:100005. Chrimes N. The Vortex: a universal ‘high-acuity implementation tool’for emergency airway management. BJA: British Journal of Anaesthesia. 2016;117(suppl_1):i20-i7. Finke S-R, Schroeder DC, Ecker H, Böttiger BW, Herff H, Wetsch WA. Comparing suction rates of novel DuCanto catheter against Yankauer and standard suction catheter using liquids of different viscosity—a technical simulation. BMC anesthesiology. 2022;22(1):285.

As the DA you are paged to come to PACU to review a patient with pre-eclampsia who has just had a PPH and a repair of a perineal tear after delivering in labour ward. The O&G team ordered a VBG because she was febrile and they want to assess her lactate and start her on some antibiotics. The O&G registrar is concerned however because her potassium / K has come back as 7.8 mmol/L…. Join Natalie and I as we discuss the issue of hyperkalaemia specifically in the context of women suffering from pre-eclampsia. Why are they at risk of this important electrolyte abnormality and what are the principles of management? We also review a recent paper addressing some of the myths surrounding the treatment of acute hyperkalaemia (thanks to Casey at Broomedocs.com for bringing this paper to our attention). Useful References Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med. 2022 Feb;52:85-91. doi: 10.1016/j.ajem.2021.11.030. PMID: 34890894 LITFL, ECG library, Hyperkalaemia https://litfl.com/hyperkalaemia-ecg-library A case of probable labetalol induced hyperkalaemia in pre-eclampsia. https://pubmed.ncbi.nlm.nih.gov/25370900 Hypocalcaemia and hyperkalaemia during magnesium infusion therapy in a pre-eclamptic patient https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4614650 Oh’s Intensive Care Manual. 7th Edition. Chapter 93 – Fluid and Electrolyte Therapy. Bersten A, Soni N et al. 2014.

You receive a page from labour ward. A woman at 35/40 weeks gestation has just arrived in the hospital very distressed in a lot of pain. A quick bedside ultrasound by the obstetric team has unfortunately demonstrated a large abruption and fetal death in utero. She is contracting strongly and beside herself in pain, the team would like you to come down and place an epidural for analgesia. The team are hoping she will deliver vaginally in the next few hours. What is your approach in this situation? Join Graeme and I as we discuss this complex and challenging clinical condition and the coagulopathy that can occasionally occur. Here is a link to cases we have had in the past here at KEMH in the ROTEM Real Cases Discussed section: Case 6 – Abruption and fetal death in utero Case 11 – Abruption and severe coagulopathy References Coagulopathy and placental abruption: changing management with ROTEM-guided fibrinogen concentrate therapy 2015 Liverpool Womens Hospital – this is not open access but available through the ANZCA library or your hospital library. It contains 4 very interesting case reports Fibrinolytic and thrombotic DIC an explanation 2023 – This paper explains how there are two types of DIC one predominantly causing microvascular thrombosis and eventually factor depletion. The second which is possibly the mechanism seen in some abruptions is massive activation of fibrinolysis and fibrinogenolysis. WARNING this paper is highly technical!