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Extrinsic compression of the heart consequent to intrapleural fluid is a rare cause of cardiac tamponade. Cases of massive hemothorax resulting in external cardiac tamponade due to injury of the internal thoracic artery (ITA) following blunt or penetrating trauma have been described in the literature. Here, we present a case of iatrogenic injury to the right ITA complicating mastectomy and deep inferior epigastric perforator flap reconstruction. It manifested as hemodynamic instability that persisted despite aggressive fluid resuscitation. Investigation with an intraoperative transesophageal echocardiogram demonstrated cardiac tamponade secondary to a massive hemothorax which resolved following surgical placement of an intercostal drain.

Postpartum haemorrhage is the commonest life-threatening obstetric emergency that justifies our professional existence. We treat it successfully most of the time, but cannot take any haemorrhage for granted, as this case shows. However, a combination of training, regular drills, and skills, clinical experience, and reflection prepare doctors for the next cases. This case describes a massive postpartum haemorrhage following the induction of labour of an obese multiparous woman. It illustrates several important points in the diagnosis and management of postpartum haemorrhage, and the typical challenges on the frontline of care. The value of early recognition, involvement of experienced staff, efficient communication, and multidisciplinary teamwork (particularly with the haematologist and anaesthetist) is central to the successful management of a sick patient such as this.

As a result of the global obesity epidemic, more women than ever are starting their pregnancy overweight or obese, putting them at greater risk of pregnancy complications. This case describes the course of a pregnancy in a woman with a BMI of 49 kg/m2. As the case progresses, the challenges associated with such pregnancies are highlighted; in particular, maternal risk such as diabetes and pre-eclampsia as well as surgical and anaesthetic complications.