M J Douglas

University of British Columbia - Vancouver, Vancouver, British Columbia, Canada

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Publications (67)142.53 Total impact

  • 06/2014; 36(6):527-553.
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    ABSTRACT: Objective: This executive summary presents in brief the current evidence assessed in the clinical practice guideline prepared by the Canadian Hypertensive Disorders of Pregnancy Working Group and published by Pregnancy Hypertension (http://www.pregnancyhypertension.org/article/S2210-7789(14)00004-X/fulltext) to provide a reasonable approach to the diagnosis, evaluation, and treatment of the hypertensive disorders of pregnancy. Evidence: Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library in March 2012 using appropriate controlled vocabulary (e.g., pregnancy, hypertension, pre-eclampsia, pregnancy toxemias) and key words (e.g., diagnosis, evaluation, classification, prediction, prevention, prognosis, treatment, postpartum follow-up). Results were restricted to systematic reviews, randomized control trials, controlled clinical trials, and observational studies published in French or English between January 2006 and February 2012. Searches were updated on a regular basis and incorporated in the guideline to September 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values: The quality of evidence in the guideline summarized here was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). Recommendations Chapter 1: Diagnosis and classification of the measurement of BP for HDPs ● BP Measurement: 1-10 ● Diagnosis of Hypertension: 11-17 ● Measurement of Proteinuria: 18-24 ● Classification of HDPs: 25-31 ● Investigations to Classify HDPs: 32-37 Chapter 2: Prediction and prevention ● Predicting Preeclampsia: 38-40 ● Preventing Preeclampsia and its Complications in Women at Low Risk: 41-46 ● Preventing Preeclampsia and its Complications in Women at Increased Risk: 47-54 Chapter 3: Treatment of the HDPs ● Dietary and Lifestyle Changes: 55-59 ● Place of Care: 60, 61 ● Antihypertensive Therapy for Severe Hypertension: 62-68 ● Antihypertensive Therapy for Non-Severe Hypertension Without Comorbid Conditions: 69-73 ● For Non-Severe Hypertension (BP of 140-159/90-109 mmHg) With Comorbid Conditions: 74-76 ● Corticosteroids for Acceleration of Fetal Pulmonary Maturity: 77-80 ● Timing of Delivery for Women With Preeclampsia: 81-88 ● Timing of Delivery for Women With Gestational Hypertension: 89, 90 ● Timing of Delivery for Women with Pre-existing Hypertension: 91 ● Mode of Delivery: 92-97 ● Anaesthesia: General Principles: 98-101 ● Anaesthesia: Fluid Administration: 102-105 ● Monitoring: 106-108 ● Coagulation: 109, 110 ● Aspects of Care Specific to Women Wth Pre-Existing Hypertension: 111-115 ● Aspects of Care for Women With Preeclampsia: Magnesium Sulphate for Preventing or Treating Eclampsia: 116-123 ● Aspects of Care for Women With Preeclampsia: Plasma Volume Expansion: 124 ● Therapies for HELLP Syndrome: 125-131 ● Care in the 6 Weeks Postpartum: 132-142 ● Care Beyond 6 Weeks Postpartum: 143-148 ● Effects of Maternal Hypertension and its Therapies on Child Neurobehavioural Development: 149, 150 Chapter 4: Patient Perspective: 151-153.
    Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 05/2014; 36(5):416-438.
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    ABSTRACT: Controversy exists as to whether effective spinal anaesthesia can be achieved as quickly as general anaesthesia for a category-1 caesarean section. Sixteen consultants and three fellows in obstetric anaesthesia were timed performing spinal and general anaesthesia for category-1 caesarean section on a simulator. The simulation time commenced upon entry of the anaesthetist into the operating theatre and finished for the spinal anaesthetic at the end of intrathecal injection and for the general anaesthetic when the anaesthetist was happy for surgery to start. In the second clinical part of the study, the time from intrathecal administration to 'adequate surgical anaesthesia' (defined as adequate for start of a category-1 caesarean section) was estimated in 100 elective (category-4) caesarean sections. The median (IQR [range]) times (min:s) for spinal procedure, onset of spinal block and general anaesthesia were 2:56 (2:32 - 3:32 [1:22 - 3:50]), 5:56 (4:23 - 7:39 [2:9 - 13:32]) and 1:56 (1:39 - 2:9 [1:13 - 3:12]), respectively. The limiting factor in urgent spinal anaesthesia is the unpredictable time needed for adequate surgical block to develop.
    Anaesthesia 05/2013; · 3.49 Impact Factor
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    ABSTRACT: Intrathecal morphine is an effective analgesic post-cesarean delivery; however, it may be contraindicated or unsuitable in some patients. We compared the efficacy and side effects of intrathecal morphine with an ultrasound-guided transversus abdominis plane (TAP) block in a randomized, controlled, double-blinded trial. The primary outcome was the morphine equivalents dose used in the first 24 h post-surgery. Secondary outcomes were pain scores and side effects, including pruritus, sedation, nausea and vomiting. Planned recruitment was for 90 women; however, the study was terminated early. Sixty-nine women undergoing elective cesarean delivery under spinal anesthesia were enrolled. They were randomized to receive either intrathecal morphine 100 μg plus a sham TAP block or a TAP block with 0.5% ropivacaine 1.5 mg/kg, to each side to a maximum of 20 mL. Women were assessed at 2, 6, 10, 24 h and 3 months post-spinal. Sixty-six women completed the trial. The morphine equivalents dose used in the TAP block group was greater at 24 h compared with the intrathecal morphine group (7.5 mg (95% CI 4.8-10.2) vs. 2.7 mg (95% CI 1.0-4.3), F [1, 64]=9.62, P=0.003). There was no difference at 2, 6, or 10 h. Pain scores on rest and movement were higher in the TAP block group at all times although this only reached statistical significance at 10 h (P=0.001). Nausea and vomiting (P=0.02) and pruritus (P=0.007) were lower in the TAP block group. In this trial, the TAP block was associated with greater supplemental morphine requirements and higher pain scores than intrathecal morphine but fewer opioid-related side effects. The TAP block may be a reasonable alternative when intrathecal morphine is contraindicated or not appropriate.
    International journal of obstetric anesthesia 03/2012; 21(2):112-8. · 1.85 Impact Factor
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    ABSTRACT: Platelet count has been proposed as a screening test for generalized coagulopathy in women with preeclampsia. We performed this study to determine the relationship between platelet counts and the risk of abnormal coagulation and adverse maternal outcomes in women with preeclampsia. We used data from women in the PIERS (Pre-eclampsia Integrated Estimate of RiSk) database. Abnormal coagulation was defined as either an international normalized ratio result greater than and/or a serum fibrinogen level less than the BC Women's Hospital laboratory's pregnancy-specific normal range. The relationship between platelet counts and adverse maternal outcomes was explored using a logistic regression analysis. The sensitivity, specificity, positive predictive value, and negative predictive value of platelet counts in identifying abnormal coagulation or adverse maternal outcomes were calculated. Abnormal coagulation occurred in 105 of 1405 eligible women (7.5%). The odds of having abnormal coagulation were increased for women with platelet counts < 50 × 10(9)/L (OR 7.78; 95% CI 3.36 to 18.03) and between 50 and 99 × 10(9)/L (OR 2.69; 95% CI 1.44 to 5.01) compared with women who had platelet counts above 150 × 10(9)/L. Platelet counts < 100 × 10(9)/L were associated with significantly increased odds of adverse maternal outcomes, most specifically blood transfusion. A platelet count of < 100 × 10(9)/L had good specificity in identifying abnormal coagulation and adverse maternal outcomes (92% [95% CI 91% to 94%] and 92% [95% CI 91% to 94%], respectively), but poor sensitivity (22% [95% CI 15% to 31%] and 16% [95% CI 11% to 23%], respectively). A platelet count < 100 × 10(9)/L is associated with an increased risk of abnormal coagulation and maternal adverse outcomes in women with preeclampsia. However, the platelet count should not be used in isolation to guide care because of its poor sensitivity. Whether or not a platelet count is normal should not be used to determine whether further coagulation tests are needed.
    Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 09/2011; 33(9):900-8.
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    ABSTRACT: We sought to determine the role of respiratory assessment by cardiorespiratory symptoms and/or oxygen saturation by pulse oximetry (SpO2) in predicting adverse maternal outcomes in women admitted to hospital with preeclampsia. These data derive from an international, prospective multicentre cohort study, PIERS (Pre-eclampsia Integrated Estimate of RiSk), which assesses predictors of adverse outcomes in women admitted to tertiary perinatal units with preeclampsia. Univariate and multivariate analyses of cardiorespiratory symptoms and pulse oximetry were performed to assess their ability to predict a combined adverse maternal outcome developed through international Delphi consensus. SpO2 successfully predicted adverse maternal outcomes; the area under the receiver-operator characteristic curve (AUC ROC) was 0.71 (95% CI 0.65 to 0.77). Combining the symptoms of chest pain and/or dyspnea with pulse oximetry improved this predictive ability (AUC ROC 0.73; 95% CI 0.67 to 0.78). When SpO2 was stratified into risk groups using inflection points on the ROC curve, the highest risk group (SpO2 90% to 93%) had an odds ratio of 18.1 (95% CI 8.2 to 40.2) for all outcomes within 48 hours when compared with the baseline group (SpO2 98% to 100%). Assessing SpO2 aids in the assessment of maternal risk in women admitted to hospital with preeclampsia. An SpO2 value of ≤ 93% confers particular risk. The symptom complex of chest pain and/or dyspnea adds to the association.
    Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 07/2011; 33(7):705-14.
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    ABSTRACT: Many aspects of hypertension care outside pregnancy may be applied in pregnancy, but little information is available on which to base decision-making. It would seem reasonable to continue previous dietary salt restriction and physical activity in women with pre-existing (and controlled) hypertension, encourage a heart-healthy diet in all women with a hypertension disorder of pregnancy, and take patient preference into account when deciding on place of care. Although bed rest has become a key part of obstetric practice and for care of women with a hypertension disorder of pregnancy, in particular, the evidence is lacking to support this practice. This may also increase thromboembolic risk. Antihypertensive treatment is strongly advised for women with severe hypertension. The most common agents are parenteral labetalol, hydralazine, or oral nifedipine capsules. Clinicians should familiarise themselves with multiple agents. Until the role of antihypertensive treatment for non-severe hypertension in pregnancy is clarified by ongoing research, clinicians should explicitly state an individual patient's blood pressure goal, which could reasonably be anywhere between 130/80 and 155/105 mmHg. Labetalol and methyldopa are used most commonly. Breastfeeding should be encouraged. Many risk factors for hypertension (e.g. obesity), as well as hospitalisation and pre-eclampsia, all increase the thromboembolic risk for pregnant women, and care providers should consider thromboprophylaxis in the appropriate setting. Finally, anaesthetists play a critical role in the management of women with a hypertension disorder of pregnancy, and should be involved earlier rather than later in the course of their care.
    Best practice & research. Clinical obstetrics & gynaecology 04/2011; 25(4):477-90. · 1.87 Impact Factor
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    M Joanne Douglas, Roanne L Preston
    Canadian Anaesthetists? Society Journal 04/2011; 58(6):494-8. · 2.31 Impact Factor
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    ABSTRACT: Pre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder. We developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting. 261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility. The fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia. Canadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute.
    The Lancet 01/2011; 377(9761):219-27. · 39.06 Impact Factor
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    ABSTRACT: To reduce maternal and perinatal morbidity and mortality associated with the hypertensive disorders of pregnancy by using an active model of guideline implementation. This study used a preintervention and postintervention cohort comparison design. We interrogated the British Columbia Perinatal Database Registry for 6 years of existing prospectively gathered data (fiscal years 2000-2001 to 2005-2006), introduced the hypertensive disorders of pregnancy guidelines, and assessed the incidence of the combined adverse maternal and perinatal outcomes for the next 2 years (fiscal years 2006-2007 and 2007-2008). The combined adverse maternal outcome was maternal death, life-threatening, or life-altering complications. The combined perinatal outcome included the severe complications of prematurity and hypoxic-ischemic encephalopathy. Eighteen thousand seventy-six women were diagnosed with hypertensive disorder of pregnancy in British Columbia from 2000-2001 to 2007-2008. Outcomes were compared preguideline (n=13,150 deliveries) and postguideline (n=4,926 deliveries) implementation. The incidence of the combined adverse maternal outcome decreased from 3.1% to 1.9% (relative risk 0.60, 95% confidence interval 0.48-0.75). There was a concomitant fall in the incidence of the combined adverse perinatal outcome. The active introduction of standardized management of women with a hypertensive disorder of pregnancy is associated with reduced maternal and perinatal risk. II.
    Obstetrics and Gynecology 09/2010; 116(3):659-66. · 4.80 Impact Factor
  • Cancer Letters - CANCER LETT. 01/2010; 1.
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    ABSTRACT: To determine the association between adverse maternal/perinatal outcomes and Canadian and U.S. preeclampsia severity criteria. Using PIERS data (Preeclampsia Integrated Estimate of RiSk), an international continuous quality improvement project for women hospitalized with preeclampsia, we examined the association between preeclampsia severity criteria and adverse maternal and perinatal outcomes (univariable analysis, Fisher's exact test). Not evaluated were variables performed in <80% of pregnancies (e.g., 24-hour proteinuria). Few of the evaluated variables were associated with adverse maternal (chest pain/dyspnea, thrombocytopenia, 'elevated liver enzymes', HELLP syndrome, and creatinine >110 microM) or perinatal outcomes (dBP >110 mm Hg and suspected abruption) (at p < 0.01). In the PIERS cohort, most factors used in the Canadian or American classifications of severe preeclampsia do not predict adverse maternal and/or perinatal outcomes. Future classification systems should take this into account.
    Hypertension in Pregnancy 02/2007; 26(4):447-62. · 0.93 Impact Factor
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    ABSTRACT: This review reflects both the variable presentation and the systemic nature of preeclampsia. Recommendations for the comprehensive evaluation and management of organ dysfunction associated with pre-eclampsia are included. The main points in the review are that: (1) Preeclampsia is a systemic disorder that may affect many organ systems. (2) For preeclampsia remote from term (<34 weeks), expectant management improves perinatal outcomes, but requires obsessive surveillance to mitigate maternal risks and is a "package." (3) Initial assessment and ongoing surveillance of women with preeclampsia should include assessment of all vulnerable maternal organs as well as of the fetus. (4) Initiate antihypertensive drug treatment immediately if sBP >160 mmHg or dBP more than 110 mmHg, or if sBP 140-159 mmHg and/or dBP 85-109 mmHg (prepregnancy renal disease or diabetes). (5) The treatment of nonsevere pregnancy hypertension should include a treatment goal of dBP 80-105 mmHg (depending on practitioner preference), with one of the following agents, Methyldopa, Labetalol, Nifedipine, or, with special indications (renal or cardiac diseases), diuretics. (6) Drugs to avoid: angiotensin-converting enzyme inhibitors; angiotensin II receptor antagonists; and atenolol. (7) For the acute management of severe hypertension, initially reduce dBP by 10 mmHg and maintain the blood pressure at or below that level with either Nifedipine or Labetalol. (8) For both prophylaxis against and treatment of eclampsia, MgSO4 (4 g IV stat, then 1 g/hr). (9) For recurrent seizures, MgSO4 (2g IV stat, then increase to 1.5 g/hr). (10) Total fluid intake should not exceed 80 ml/hr; tolerate urine outputs as low as 10 ml/hr. (11) Early-onset and/or severe preeclampsia predict later cardiovascular morbidity and mortality; it would seem prudent to offer such women screening and lipid lowering interventions.
    Frontiers in Bioscience 02/2007; 12:2876-89. · 3.29 Impact Factor
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    M Joanne Douglas
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    ABSTRACT: HIS issue of the Journal contains the report of an investigation examining the gender ratio of practicing Canadian anesthesiologists and residents, to determine whether or not the current gender balance in medical schools is reflected in the specialty of anesthesia. 1 The results indicate that more practicing anesthesiologists are male than female, but the proportion of women has increased since 1998, especially in the younger age groups. These two findings are in keeping with the relatively recent feminization of medical schools in Canada. What may be surprising to some is that the number of women in anesthesia residency programs in the 2004–2005 year continues to lag significantly behind the number of men (201 women to 316 men). In considering these findings, one may question the reasons for a gender imbalance in the number of residents, and whether this might be due to overt or covert discrimination during the residency selection process. Data from the Canadian Resident Matching Service for the period 1993 to 2005 show that more men than women consistently selected anesthesia as their first specialty choice. 1 Thus, it appears that the gender gap is due to a difference in application rates. To address the question regarding fairness of the residency selection process, a previous study by the same authors shows that males and females were equally likely to be accepted or rejected when anesthesia was their first residency choice. 2 This finding suggests that the selection process for anesthesia residency is fair with respect to gender, and the problem is failure of more women to select anesthesia as a career path. Why might anesthesia be less attractive to female medical students? One possibility is lack of exposure to anesthesia during medical school, but as male and female medical students receive the same exposure to anesthesia clinical rotations, this is unlikely to be a factor in the gender gap. Another possibility is that anesthesiologists have limited opportunity to form relationships with patients due to their perceived relatively brief contact. The desire for a more traditional physician-patient relationship may be a reason why more women choose a specialty such as pediatrics. 3 A third possibility is that, as most anesthesiologists are male, there are fewer female anesthesiologists to serve as role models for female medical students. A study from Australia found that women commented that role models encountered during internship and residency were instrumental in their decision to enter or continue in anesthesia. 4
    Canadian Journal of Anaesthesia 06/2006; 53(5):427-31. · 2.13 Impact Factor
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    M Joanne Douglas, Stephanie Ensworth
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    ABSTRACT: To present the anesthetic management of a parturient with relapsing polychondritis (RP) and to discuss the anesthetic implications of RP. A 28-yr-old primiparous woman with known RP, spondyloarthropathy and fibromyalgia presented for urgent Cesarean delivery for breech presentation and prodromal labour. Her pregnancy had been complicated by a hospital admission for an exacerbation of her RP as manifested by hoarseness, increased pain and tenderness of her left ear and nasal bridge cartilages, sinusitis with bloody nasal discharge and increased pain and tenderness of the anterior tracheal rings. Epidural anesthesia was administered for the Cesarean delivery. Her intraoperative and postoperative course was uneventful. Close cooperation among obstetricians, anesthesiologists and rheumatologists resulted in a successful outcome. Relapsing polychondritis is a syndrome with important anesthetic implications. Multidisciplinary cooperation is essential in managing these high risk parturients.
    Canadian Journal of Anaesthesia 12/2005; 52(9):967-70. · 2.13 Impact Factor
  • M. Joanne Douglas, Stephanie Ensworth
    Canadian Journal of Anaesthesia-journal Canadien D Anesthesie - CAN J ANAESTH. 01/2005; 52(9):967-970.
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    D M A Choi, A P Kliffer, M J Douglas
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    ABSTRACT: Dextromethorphan is an N-methyl-D-aspartic acid antagonist which can attenuate acute pain with few side-effects. In this prospective, randomized, double-blind study of dextromethorphan and intrathecal morphine, we investigated postoperative pain, pruritus, nausea and vomiting in women undergoing Caesarean section under spinal anaesthesia. Women were allocated randomly to one of six groups, to receive intrathecal morphine 0.05, 0.1 or 0.2 mg plus oral dextromethorphan 60 mg or placebo. The addition of dextromethorphan did not reduce postoperative pain scores (P=0.83). Compared with women receiving intrathecal morphine 0.05 mg, women receiving higher doses had a significantly higher incidence of nausea and vomiting [odds ratio for intrathecal morphine 0.1 mg, 4.0 (95% confidence interval 1.2-14.1); for intrathecal morphine 0.2 mg, 7.9 (2.3-27.1)]. Compared with women receiving intrathecal morphine 0.05 mg, women receiving higher doses also had a significantly higher incidence of pruritus [odds ratio for intrathecal morphine 0.1 mg, 3.2 (95% confidence interval 1.3-8.2); for intrathecal morphine 0.2 mg, 3.7 (1.4-9.5)]. Women receiving dextromethorphan had a lower incidence of nausea and vomiting [odds ratio 2.6 (1.1-6.3)]. Postoperative pain after Caesarean section under spinal anaesthesia was not reduced by the addition of oral dextromethorphan to a multimodal approach including intrathecal morphine.
    BJA British Journal of Anaesthesia 06/2003; 90(5):653-8. · 4.24 Impact Factor
  • Rakesh B. Vadhera, M.Joanne Douglas
    Anesthesiology Clinics of North America 03/2003; 21(1):xiii–xv.
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    M J Douglas, V B Gunka, P von Dadelszen
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    ABSTRACT: We present our experience in the anesthetic management of two parturients with pseudoxanthoma elasticum. The first had an epidural catheter inserted for labor analgesia and ultimately had a forceps delivery. The second had a cesarean section under epidural anesthesia and had a complicated postoperative course. There were no untoward effects of regional anesthesia in either of these two women. The anesthetic implications for parturients with pseudoxanthoma elasticum are discussed.
    International Journal of Obstetric Anesthesia 02/2003; 12(1):45-7. · 1.80 Impact Factor

Publication Stats

830 Citations
142.53 Total Impact Points

Institutions

  • 1985–2011
    • University of British Columbia - Vancouver
      • • Department of Obstetrics and Gynaecology
      • • Faculty of Medicine
      • • Faculty of Pharmaceutical Sciences
      Vancouver, British Columbia, Canada
  • 2003
    • Children's & Women's Health Centre of British Columbia
      Vancouver, British Columbia, Canada
  • 1988–1993
    • Grace Hospital
      Winnipeg, Manitoba, Canada