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Background Liquid chromatography coupled to tandem mass spectrometry (LC–MS/MS) is the gold standard for the measurement of fentanyl and norfentanyl (NF) in urine and is favored over immunoassays due to its superior specificity. NF is the principal metabolite of fentanyl found in the urine and is typically present in higher abundance than fentanyl. Thus, the sensitivity and specificity of LC–MS/MS relies largely on the ability to identify and quantitate NF. Methods We analyzed urine specimens from women who had received bupivacaine and fentanyl for epidural analgesia during labor. We analyzed the contents of the epidural bag itself and purified bupivacaine metabolite N-desbutyl bupivacaine [or N-(2,6-dimethylphenyl)piperidine-2-carboxamide (NDB)] by LC–MS/MS. Results NDB interferes with the LC–MS/MS assay for NF. NDB passes through the Q1 mass selection filter because it is isobaric with the NF precursor ion (233 m/z). Further, it shares product ions with NF (84 m/z and 150 m/z), used as quantifier and qualifier ions, respectively, in our urine NF detection method. Baseline resolution of NDB and NF using these quantifier and qualifier ions could not be achieved. A unique product ion of NF (177 m/z) was useful for distinguishing NDB from NF. Conclusion Bupivacaine is a commonly used drug. Recognition of this interference by laboratories is critical for preventing the misidentification of NF, which can have profound effects on patient care.

Unfractionated heparin continues to be one of the main agents used for thromboprophylaxis in obstetrics, which can complicate the placement of neuraxial anesthetics. In this study, we explored the relationship between a point-of-care coagulation test (thromboelastometry) and plasma heparin concentrations in vitro.We obtained blood from consenting obstetric patients with uncomplicated pregnancies in their third trimester who were not in labour and had a specific hematocrit range. Blood was processed and analyzed. We added increasing amounts of unfractionated heparin to samples from 0 to 0.3 U·mLSeventy-seven patients were included in the study. Only one concentration of heparin was added to blood samples of each patient. At a concentration of 0.05 U·mLThe point-of-care IH CT ratio may be useful in identifying the presence of little to no heparin activity. Further research is needed to determine if this ratio can predict heparin activity in vivo.RéSUMé: OBJECTIF: L’héparine non fractionnée demeure l’un des principaux agents utilisés pour la thromboprophylaxie en obstétrique, ce qui peut compliquer la mise en place d’anesthésiques neuraxiaux. Dans cette étude, nous avons exploré la relation entre un test de coagulation au chevet de la patiente (thromboélastométrie) et les concentrations plasmatiques d’héparine in vitro. MéTHODE: Nous avons obtenu du sang de patientes obstétricales consentantes ayant des grossesses non compliquées au cours de leur troisième trimestre qui n’étaient pas en travail et dont l’hématocrite était dans une plage spécifique. Le sang a été traité et analysé. Des quantités croissantes d’héparine non fractionnée ont été ajoutées à des échantillons de 0 à 0,3 U·mL

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

A positive urine fentanyl toxicology test may have significant consequences for peripartum individuals, yet the extent to which fentanyl in a labor epidural may lead to such a positive test is poorly characterized.To quantify the extent to which neuraxial fentanyl in labor neuraxial analgesia can lead to a positive peripartum maternal or neonatal urine toxicology test.We performed a prospective cohort study of pregnant participants planning a vaginal delivery with neuraxial analgesia. Participants with a history of substance use disorder, hypertension, renal or liver disease were excluded. A urine sample was collected prior to initiation of neuraxial analgesia, each time the bladder was emptied in labor, and up to four times postpartum. Neonatal urine was collected once. Urine fentanyl testing was performed with two common toxicology testing methods: immunoassay and Liquid-Chromatography with Tandem Mass Spectrometric detection (LC-MS/MS).33 maternal-infant dyads yielded a total of 178 urine specimens. All maternal specimens were negative for fentanyl on LC-MS/MS and immunoassay prior to initiation of neuraxial analgesia. Intrapartum, 26/30 (76.7%) of participants had positive LC-MS/MS for fentanyl or its metabolites, and 12/30 (40%) participants had positive immunoassays. Postpartum, 19/21 (90.5%) participants had positive LC-MS/MS, and 13/21 (61.9%) had a positive immunoassay. Of the 13 neonatal specimens collected, 10 (76.9%) were positive on LC-MS/MS, the last of which remained positive 29 hours and 50 minutes after delivery.Neuraxial fentanyl for labor analgesia may lead to positive maternal and neonatal toxicology tests at various times after epidural initiation and cessation and at different rates depending on the testing method used. Caution should be used in interpreting toxicology test results in individuals who receive neuraxial analgesia to avoid false assumptions of non-prescribed use.

BackgroundEarly reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing.MethodsDeliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2-infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery

A narrative review of the pathophysiology, diagnosis, management, delivery implications, obstetric anesthesia care, and potential critical care needs in patients presenting with acute fatty liver of pregnancy.

This article reviews several controversial aspects of management of nonobstetric surgery during pregnancy, including the optimal timing for nonurgent surgery, when to perform intraoperative fetal monitoring, modifications to anesthetic techniques to account for the physiologic changes of pregnancy, and management of maternal cardiac arrest. There have been several advances in the management of nonobstetric surgery during pregnancy, including the increased use of laparoscopic techniques, an improved understanding of the importance of adequate pain management, and new initiatives to improve the maternal cardiac resuscitation algorithm. Traditional dogma regarding aspiration prophylaxis during pregnancy and concerns about abortifacient and teratogenic properties of diagnostic imaging and anesthetic agents have also recently been reevaluated. Urgent and emergent surgeries should proceed without delay during pregnancy in order to ensure optimal outcomes for both the mother and fetus. Anesthetic management may require several modifications to account for physiologic changes of pregnancy. In general, uteroplacental perfusion is best maintained by avoidance of maternal hypoxemia, hypotension, hyper- and hypocapnia, temperature extremes, and stress.

Postpartum hemorrhage is increasing in prevalence in the USA and continues to be an important cause of preventable maternal morbidity and mortality. This review provides the most recent epidemiologic data on postpartum hemorrhage in the USA, current nationwide initiatives for prevention, preparedness, and response to postpartum hemorrhage, and recent evidence-based advances in management. The National Partnership for Maternal Safety consensus bundle on obstetric hemorrhage serves as a resource for postpartum hemorrhage–related clinical and research initiatives. Areas of focus include standardizing postpartum hemorrhage management with protocol use, massive transfusion protocols, early and enhanced risk assessment, accurate quantitation of blood loss, and refined transfusion strategies such as early fibrinogen replacement, tranexamic acid therapy, and point of care testing to detect and treat coagulopathy. Continued focus on improving the management of postpartum hemorrhage with available resources is imperative to minimize associated risks of morbidity and mortality.

Background Severe acute post-cesarean delivery (CD) pain has been associated with an increased risk for persistent pain and postpartum depression. Identification of women at increased risk for pain can be used to optimize post-cesarean analgesia. The impact of labor prior to CD (intrapartum CD) on acute post-operative pain and opioid use is unclear. We hypothesized that intrapartum CD, which has been associated with both increased inflammation and affective distress related to an unexpected surgical procedure, would result in higher postoperative pain scores and increased opioid intake. Methods This is a secondary analysis of a prospective cohort study examining opioid use up to 2 weeks following CD. Women undergoing CD at six academic medical centers in the United States 9/2014-3/2016 were contacted by phone two weeks following discharge. Participants completed a structured interview that included questions about postoperative pain scores and opioid utilization. They were asked to retrospectively estimate their maximal pain score on an 11-point numeric rating scale at multiple time points, including day of surgery, during hospitalization, immediately after discharge, 1st week, and 2nd week following discharge. Pain scores over time were assessed utilizing a generalized linear mixed-effects model with the patient identifier being a random effect, adjusting for an a priori defined set of confounders. A multivariate negative binomial model was utilized to assess the association between intrapartum CD and opioid utilization after discharge, also adjusting for the same confounders. In the context of non-random prescription distribution, this model was constructed with an offset for the number of tablets dispensed. Results A total of 720 women were enrolled, 392 with and 328 without labor prior to CD. Patients with intrapartum CD were younger, less likely to undergo repeat CD or additional surgical procedures, and more likely to experience a complication of CD. Women with intrapartum CD consumed more opioid tablets following discharge than women without labor (median 20, IQR 10–30 versus 17, IQR 6–30; p = 0.005). This association persisted after adjustment for confounders (incidence rate ratio 1.16, 95% CI 1.05–1.29; p = 0.004). Pain scores on the day of surgery were higher in women with intrapartum CD (difference 0.91, 95% CI 0.52–1.30; adj. p = Conclusion Intrapartum CD is associated with worse pain on the day of surgery but not other time points. Opioid requirements following discharge were modestly increased following intrapartum CD.

OBJECTIVE: To assess whether a multiphase, departmental quality improvement effort decreases opioid prescribing and increases multimodal analgesic use after cesarean delivery. METHODS: This is a prospective quality improvement study. In Phase 1 of the protocol, discharge providers implemented counseling regarding expectations for pain, typical need for opioids, and importance of multimodal non-opioid analgesic use, and employed shared decision-making to determine the number of opioids prescribed. Patients could select up to a maximum of 30 tablets of oxycodone 5 mg, (or equivalent opioid), lower than the previous routine discharge prescription of 40 opioid tablets. The primary outcome was the mean (standard deviation, SD) number of opioid tablets prescribed on discharge, with secondary outcomes including opioid refill rate within 30 days of discharge and rates of non-opioid analgesic prescriptions on discharge. In Phase 2, using these results, we adjusted the protocol’s maximum opioid prescription to 25 opioid tablets, but no other aspects of the protocol were changed. All data were analyzed with t-test and chi-squared analyses. RESULTS: Data from 624 women who underwent cesarean deliveries were analyzed. Opioids, most commonly oxycodone, were prescribed after 95% of all cesarean deliveries., The mean (SD) number of opioid tablets prescribed decreased from 33.2 (9.3) to 26.5 (6.7), p

Venous thromboembolism is recognized as a leading cause of maternal death in the United States. Thromboprophylaxis has been highlighted as a key preventive measure to reduce venous thromboembolism-related maternal deaths. However, the expanded use of thromboprophylaxis in obstetrics will have a major impact on the use and timing of neuraxial analgesia and anesthesia for women undergoing vaginal or cesarean delivery and other obstetric surgeries. Experts from the Society of Obstetric Anesthesia and Perinatology, the American Society of Regional Anesthesia, and hematology have collaborated to develop this comprehensive, pregnancy-specific consensus statement on neuraxial procedures in obstetric patients receiving thromboprophylaxis or higher dose anticoagulants. To date, none of the existing anesthesia societies' recommendations have weighed the potential risks of neuraxial procedures in the presence of thromboprophylaxis, with the competing risks of general anesthesia with a potentially difficult airway, or maternal or fetal harm from avoidance or delayed neuraxial anesthesia. Furthermore, existing guidelines have not integrated the pharmacokinetics and pharmacodynamics of anticoagulants in the obstetric population. The goal of this consensus statement is to provide a practical guide of how to appropriately identify, prepare, and manage pregnant women receiving thromboprophylaxis or higher dose anticoagulants during the ante-, intra-, and postpartum periods. The tactics to facilitate multidisciplinary communication, evidence-based pharmacokinetic and spinal epidural hematoma data, and Decision Aids should help inform risk-benefit discussions with patients and facilitate shared decision making.

Pregnant people are considered to be young and healthy. However, increasingly, they are older at the time of their first delivery and are more likely to have complex comorbid conditions, including obesity, hypertension, and diabetes. In this context, the rate of many adverse pregnancy outcomes has increased.1 In particular, the rates of hypertensive disorders of pregnancy (e.g., gestational hypertension, preeclampsia/eclampsia) are on the rise in the United States and other countries.2

OBJECTIVE: To characterize risk and timing of postpartum stroke readmission after delivery hospitalization discharge. METHODS: The Healthcare Cost and Utilization Project's Nationwide Readmissions Database for calendar years 2013 and 2014 was used to perform a retrospective cohort study evaluating risk of readmission for stroke within 60 days of discharge from a delivery hospitalization. Risk was characterized as odds ratios (ORs) with 95% CIs based on whether patients had hypertensive diseases of pregnancy (gestational hypertension or preeclampsia), or chronic hypertension, or neither disorder during the index hospitalization. Adjusted models for stroke readmission risk were created. RESULTS: From January 1, 2013, to October 31, 2013, and January 1, 2014, to October 31, 2014, 6,272,136 delivery hospitalizations were included in the analysis. One thousand five hundred five cases of readmission for postpartum stroke were identified. Two hundred fourteen (14.2%) cases of stroke occurred among patients with hypertensive diseases of pregnancy, 66 (4.4%) with chronic hypertension, and 1,225 (81.4%) without hypertension. The majority of stroke readmissions occurred within 10 days of hospital discharge (58.4%), including 53.2% of patients with hypertensive diseases of pregnancy during the index hospitalization, 66.7% with chronic hypertension, and 58.9% with no hypertension. Hypertensive diseases of pregnancy and chronic hypertension were associated with increased risk of stroke readmission compared with no hypertension (OR 1.74, 95% CI 1.33–2.27 and OR 1.88, 95% CI 1.19–2.96, respectively). Median times to readmission were 8.9 days for hypertensive diseases of pregnancy, 7.8 days for chronic hypertension, and 8.3 days without either condition. CONCLUSION: Although patients with chronic hypertension and hypertensive diseases of pregnancy are at higher risk of postpartum stroke, they account for a minority of such strokes. The majority of readmissions for postpartum stroke occur within 10 days of discharge; optimal blood pressure management may be particularly important during this period.

BackgroundStroke risk is increased during pregnancy, but estimates of pregnancy-related stroke incidence vary widely.AimsA systematic review and meta-analysis was conducted to assess the incidence of stroke during pregnancy and the puerperium. Ovid Medline, EMBASE, and ISI Web of Science were searched for studies published between 1990 and January 2017 reporting stroke incidence during pregnancy and postpartum, from defined pregnancy populations. Pooled analyses were conducted using a random effects approach and expressed as an incidence rate per 100,000 pregnancies, with 95% confidence intervals. Subgroup analyses of stroke type and timing were conducted.Summary of reviewEleven studies met inclusion criteria. Variation in estimated rates was noted based on geography and study methodology. The pooled crude rate of pregnancy-related stroke was 30.0 per 100,000 pregnancies (95% confidence interval 18.8–47.9). The pooled crude rates from nonhemorrhagic stroke (arterial and cerebral venous sinus thrombosis) were 19.9 (95% confidence interval 10.7–36.9) and from hemorrhage 12.2 (95% confidence interval 6.4–23.2) per 100,000 pregnancies. For studies separately reporting cerebral venous sinus thrombosis, the rates were roughly equal between ischemic stroke (12.2, 95% confidence interval 6.7–22.2), cerebral venous sinus thrombosis (9.1, 95% confidence interval 4.3–18.9), and hemorrhage (12.2, 95% confidence interval 6.4–23.2). The crude stroke rate for antenatal/perinatal stroke was 18.3 (95% confidence interval 11.9–28.2), and for postpartum stroke was 14.7 (95% confidence interval 8.3–26.1).ConclusionsStroke affects 30.0 per 100,000 pregnancies, with ischemia, cerebral venous sinus thrombosis, and hemorrhage causing roughly equal numbers and with highest risk peripartum and postpartum. Organized approaches to the management of this high-risk population, informed by existing evidence from stroke and obstetrical care are needed.

Venous thromboembolism remains a major source of morbidity and mortality in obstetrics with an incidence of 29.8/100,000 vaginal delivery hospitalizations; cesarean delivery confers a 4-fold increased risk of thromboembolism when compared with vaginal delivery. Revised national guidelines now stipulate that the majority of women delivering via cesarean and women at risk for ante- or postpartum venous thromboembolism receive mechanical or pharmacological thromboprophylaxis. This practice change has important implications for obstetric anesthesiologists concerned about the risk of spinal epidural hematoma (SEH) among anticoagulated women receiving neuraxial anesthesia. We conducted a systematic review of published English language studies (1952-2016) and of the US Anesthesia Closed Claims Project Database (1990-2013) to identify cases of SEH associated with neuraxial anesthesia and thromboprophylaxis. We also report on SEH in obstetric patients receiving thromboprophylaxis and neuraxial anesthesia without adherence to the American Society of Regional Anesthesia (ASRA) recommendations. In our review, we initially identified 736 publications of which 10 met inclusion criteria; these were combined with the 5 cases of SEH identified in 546 obstetric Anesthesia Closed Claims reviews. None of these publications revealed SEH associated with neuraxial anesthesia and thromboprophylaxis with unfractionated heparin or low-molecular-weight heparin in obstetric patients. Based on data from 6 reports, 28 parturients had their neuraxial blockade before the minimum ASRA recommended time interval between the last anticoagulant dose and the neuraxial procedure. Based on data from 2 reports, 52 parturients received neuraxial anesthesia without their low-molecular-weight heparin dose being discontinued during the intrapartum period. Although the very low level of evidence and high heterogeneity in these reports make it difficult to draw quantitative conclusions from this systematic review, it is encouraging that this comprehensive search did not identify a single case of SEH in an obstetric patient receiving thromboprophylaxis and neuraxial anesthesia. Analysis of large-scale registries (eg, the Anesthesia Incident Reporting System of the Anesthesia Quality Institute) with more granular clinical and pharmacological data is needed to assess the impact of these practice changes on obstetric SEH incidence. In the interim, optimal care of obstetric patients depends on multidisciplinary planning of anticoagulation dosing to facilitate neuraxial anesthesia and thoughtful weighing of the relative risks and benefits of providing versus withholding neuraxial in favor of general anesthesia.

To define the amount of opioid analgesics prescribed and consumed after discharge after cesarean delivery.We conducted a survey at six academic medical centers in the United States from September 2014 to March 2016. Women who had undergone a cesarean delivery were contacted by phone 2 weeks after discharge and participated in a structured interview about the opioid prescription they received on discharge and their oral opioid intake while at home.A total of 720 women were enrolled; of these, 615 (85.4%) filled an opioid prescription. The median number of dispensed opioid tablets was 40 (interquartile range 30-40), the median number consumed was 20 (interquartile range 8-30), and leftover was 15 (interquartile range 3-26). Of those with leftover opioids, 95.3% had not disposed of the excess medication at the time of the interview. There was an association between a larger number of tablets dispensed and the number consumed independent of patient characteristics. The amount of opioids dispensed did not correlate with patient satisfaction, pain control, or the need to refill the opioid prescription.The amount of opioid prescribed after cesarean delivery generally exceeds the amount consumed by a significant margin, leading to substantial amounts of leftover opioid medication. Lower opioid prescription correlates with lower consumption without a concomitant increase in pain scores or satisfaction.

Abnormally implanted, invasive, or adherent placenta has become one of the most serious problems in obstetrics, comprising a leading cause of maternal hemorrhage, the most common cause of peripartum hysterectomy and an increasingly important contributor to cesarean delivery morbidity. Currently, up to 3 in 1000 pregnancies in the USA are complicated by placenta accreta, increta, or percreta, and the incidence is increasing in parallel with the rising cesarean delivery rate. Yet, despite the high morbidity and mortality associated with placenta accreta, consensus guidelines are lacking regarding the management of women with this condition.

The hypertensive disorders of pregnancy (HDP) encompass a spectrum of disorders, including new-onset hypertension diagnosed during pregnancy (gestational hypertension), preeclampsia, and chronic hypertension with superimposed preeclampsia. HDP are estimated to occur in ≈2% to 8% of pregnant women globally.1 The precise etiology of preeclampsia is unknown, although it is believed to be a systemic disease with widespread endothelial dysfunction2 that is either unmasked or invoked during pregnancy.

Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis.Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls.Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after1 hour.Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy.

BACKGROUND: Increased risks of cerebral cerebral venous thrombosis or subdural hematoma, bacterial meningitis, persistent headache, and persistent low back pain are suggested in obstetric patients with post-dural puncture headache (PDPH). Acute postpartum pain such as PDPH may also lead to postpartum depression. This study tested the hypothesis that PDPH in obstetric patients is associated with significantly increased postpartum risks of major neurologic and other maternal complications. METHODS: This retrospective cohort study consisted of 1,003,803 women who received neuraxial anesthesia for childbirth in New York State hospitals between January 2005 and September 2014. The primary outcome was the composite of cerebral venous thrombosis and subdural hematoma. The 4 secondary outcomes were bacterial meningitis, depression, headache, and low back pain. PDPH and complications were identified during the delivery hospitalization and up to 1 year post-delivery. Adjusted odds ratios (aORs) and 95% confidence interval (CIs) were estimated using the inverse probability of treatment weighting approach. RESULTS: Of the women studied, 4808 (0.48%; 95% CI, 0.47–0.49) developed PDPH, including 264 cases (5.2%) identified during a readmission with a median time-to-readmission of 4 days. The incidence of cerebral venous thrombosis and subdural hematoma was significantly higher in women with PDPH than in women without PDPH (3.12 per 1000 neuraxial or 1:320 versus 0.16 per 1000 or 1:6250, respectively; P < 0.001). The incidence of the 4 secondary outcomes was also significantly higher in women with PDPH than in women without PDPH. The aORs associated with PDPH were 19.0 (95% CI, 11.2–32.1) for the composite of cerebral venous thrombosis and subdural hematoma, 39.7 (95% CI, 13.6–115.5) for bacterial meningitis, 1.9 (95% CI, 1.4–2.6) for depression, 7.7 (95% CI, 6.5–9.0) for headache, and 4.6 (95% CI, 3.3–6.3) for low back pain. Seventy percent of cerebral venous thrombosis and subdural hematoma were identified during a readmission with a median time-to-readmission of 5 days. CONCLUSION: PDPH is associated with substantially increased postpartum risks of major neurologic and other maternal complications, underscoring the importance of early recognition and treatment of anesthesia-related complications in obstetrics.

The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.

Background: There is evidence that male neonates have higher incidences of ischemic stroke and associated limitations in brain repair compared to female neonates. We used data from the International Maternal Newborn Stroke Registry (IMNSR) to further explore neonatal sex differences in demographics, birth characteristics, stroke onset, and maternal factors. Methods: Eleven international sites participated; 8 entered data for this analysis. Eligible participants with newborn (28 weeks gestation to 28 postnatal days) ischemic or hemorrhagic stroke or cerebral venous thrombosis were identified prospectively and retrospectively and enrolled. Preterm infants born before 28 weeks and neonates with germinal matrix intraventricular hemorrhage were excluded. We collected APGAR scores at 1 and 5 minutes, resuscitation status, demographics, stroke type, maternal and gestational age at birth, and mother’s health conditions at birth. Descriptive statistics were performed to identify differences in female versus male neonate cases related to demographics, pregnancy-related factors, and birth-related factors. Results: We analyzed 68 cases, 38 males and 30 females. Median maternal age for all cases was 31 y (IQR 29-34). Compared to females, males were more likely to have a lower APGAR 1 score and receive resuscitation, and more likely to have a stroke onset within the first week of life. This data set did not show significant gender-related differences in stroke type, or maternal health concerns during pregnancy (Table). Conclusions: We found that males with newborn strokes had more complications at birth and were more likely to have strokes present in the first week of life than females. Further research on the reasons for these sex differences is needed.

BACKGROUND: Discharge diagnoses are used to track national trends and patterns of maternal morbidity. There are few data regarding the validity of the International Classification of Diseases (ICD) codes used for this purpose. The goal of our study was to try to better understand the validity of administrative data being used to monitor and assess trends in morbidity. METHODS: Hospital stay billing records were queried to identify all delivery admissions at the Massachusetts General Hospital for the time period 2001 to 2011 and the University of Michigan Health System for the time period 2005 to 2011. From this, we identified patients with ICD-9-Clinical Modification (CM) diagnosis and procedure codes indicative of severe maternal morbidity. Each patient was classified with 1 of 18 different medical/obstetric categories (conditions or procedures) based on the ICD-9-CM code that was recorded. Within each category, 20 patients from each institution were selected at random, and the corresponding medical charts were reviewed to determine whether the ICD-9-CM code was assigned correctly. The percentage of correct codes for each of 18 preselected clinical categories was calculated yielding a positive predictive value (PPV) and 99% confidence interval (CI). RESULTS: The overall number of correctly assigned ICD-9-CM codes, or PPV, was 218 of 255 (86%; CI, 79%–90%) and 154 of 188 (82%; CI, 74%–88%) at Massachusetts General Hospital and University of Michigan Health System, respectively (combined PPV, 372/443 [84%; CI, 79–88%]). Codes within 4 categories (Hysterectomy, Pulmonary edema, Disorders of fluid, electrolyte and acid–base balance, and Sepsis) had a 99% lower confidence limit ≥75%. Codes within 8 additional categories demonstrated a 99% lower confidence limit between 74% and 50% (Acute respiratory distress, Ventilation, Other complications of obstetric surgery, Disorders of coagulation, Cardiomonitoring, Acute renal failure, Thromboembolism, and Shock). Codes within 6 clinical categories demonstrated a 99% lower confidence limit

Introduction There is currently no consensus regarding the minimum threshold platelet count to ensure safe neuraxial procedures. Numerous reports describe the safe performance of lumbar punctures in severely thrombocytopenic patients but reports of neuraxial anesthetic procedures in thrombocytopenic patients are limited. To date, the focus on specific populations in contemporary reviews has failed to include any actual hematoma cases. This systematic review aggregates reported lumbar neuraxial procedures from diverse thrombocytopenic populations to best elucidate the risk of spinal epidural hematoma. Methods MEDLINE, Embase, Cochrane, CINAHL databases were searched for articles about thrombocytopenic patients ( Results Of 4167 articles reviewed, 131 met inclusion criteria. 7476 lumbar neuraxial procedures were performed without and 33 procedures with spinal epidural hematoma. Within the platelet count ranges of 1–25,000 × 106/L, 26–50,000 × 106/L, 51–75,000 × 106/L, and 76–99,000 × 106/L there were 14, 6, 9, and 4 spinal epidural hematomas, respectively. An infection point and narrow confidence intervals were observed near 75,000 × 106/L or above, reflecting a low probability of spinal epidural hematoma in this sample. Of the 19 spinal epidural hematoma cases for which the onset of symptoms was reported, 18 (95%) were symptomatic within 48 h of the procedure. Conclusions Spinal epidural hematoma in thrombocytopenic patients is rare. In this sample of patients, an inflection point and narrow confidence intervals are observed near a platelet count of 75,000 × 106/L or above, reflecting an estimated low spinal epidural hematoma event rate with more certainty given a larger sample size and inclusion of spinal epidural hematoma cases. Thrombocytopenic patients should be monitored, particularly in the first 48 h, and educated about symptoms concerning for spinal epidural hematoma.

The Canadian Stroke Best Practice Consensus Statement Acute Stroke Management during Pregnancy is the second of a two-part series devoted to stroke in pregnancy. The first part focused on the unique aspects of secondary stroke prevention in a woman with a prior history of stroke who is, or is planning to become, pregnant. This document focuses on the management of a woman who experiences an acute stroke during pregnancy. This consensus statement was developed in recognition of the need for a specifically tailored approach to the management of this group of patients in the absence of any broad-based, stroke-specific guidelines or consensus statements, which do not exist currently. The foundation for the development of this document was the concept that maternal health is vital for fetal well-being; therefore, management decisions should be based first on the confluence of two clinical considerations: (a) decisions that would be made if the patient wasn't pregnant and (b) decisions that would be made if the patient hadn't had a stroke, then nuanced as needed. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include initial emergency management, diagnostic imaging, acute stroke treatment, the management of hemorrhagic stroke, anesthetic management, post stroke management for women with a stroke in pregnancy, intrapartum considerations, and postpartum management. These statements are appropriate for healthcare professionals across all disciplines and system planners to ensure pregnant women who experience a stroke have timely access to both expert neurological and obstetric care.

This review summarizes the pathophysiology, peripartum treatment, and anesthetic management of parturients with cardiac disease. Valvular disease, coronary disease, and cardiomyopathy are specifically addressed in the context of the normal physiologic changes of pregnancy. We offer recommendations for anesthetic approaches, hemodynamic goals with an emphasis on interdisciplinary planning between anesthesiologists, cardiologists, cardiothoracic surgeons, obstetricians, maternal fetal medicine specialists, and neonatologists. Vaginal delivery with neuraxial analgesia can be well tolerated by many pregnant patients with cardiac disease when coordinated by an interdisciplinary team of experts. Cardiac disease in pregnancy can present a significant challenge for the interdisciplinary care team. A detailed understanding of each patient’s cardiac pathology and the physiologic changes of pregnancy are critical to ensure a safe and successful labor and delivery. Optimized medical therapy in the peripartum period and neuraxial anesthesia with the judicious use of vasoactive agents can be of great benefit for these parturients. As is generally the case, cesarean delivery should be primarily reserved for obstetric indications and maternal wellbeing, with careful consideration of the fetus to guide best practices.

As a broad and heterogeneous diagnosis, stroke stands at the intersection of many related specialties. Thus, stroke researchers have a unique opportunity to collaborate across a wide range of clinical and basic science disciplines. In addition to the more obvious collaboration opportunities (eg working with cardiologists on clinical trials with composite cardiovascular outcomes), stroke researchers may work in fields as diverse as primary care, oncology, obstetrics, cognitive neuroscience, physiology, biomedical engineering, environmental science, and health disparities. Cross-disciplinary biomedical research synthesizes expertise from diverse contributing disciplines and develops new scientific approaches to address complex problems in health.1 Cross-disciplinary approaches can be as simple as research collaborations involving several medical subspecialties. More complex endeavors, such as collaborations between clinical researchers and scientists from widely different disciplines (eg engineers or social scientists), may be termed transdisciplinary research; however, similar principles apply. For the purposes of this discussion, we refer to the entire spectrum of multidisciplinary collaborative research as cross-disciplinary research. Collaborating with investigators outside your own field requires more than just adding a coauthor to a paper or proposal. True collaborations will not always be without conflict. Navigating the challenges of cross-disciplinary research successfully can lead to significant rewards in terms of job satisfaction and career development, and most importantly, to the advancement of scientific understanding. Early career vascular neurologists interested in growing robust cross-disciplinary research collaborations might consider the following approaches. A good research question identifies a gap in knowledge about a specific problem, which, in turn, may require expertise from multiple scientific disciplines to answer. For example, a stroke neurologist investigating intracranial atherosclerosis might collaborate with a vascular surgeon studying peripheral vascular disease, a radiologist studying vessel wall imaging, or a biomedical engineer measuring arterial compliance. Alternatively, a stroke neurologist might be interested in rare causes of stroke affecting a …

(Reg Anesth Pain Med. 2018;43:263–309)The American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Fourth Consensus Conference on Regional Anesthesia and Anticoagulation in conjunction with the European Society of Anesthesiology (ESA) in response to emerging patient safety issue

BACKGROUND During pregnancy, upper airway resistance is increased, predisposing vulnerable women to pregnancy-related OSA. Elevation of the upper body increases upper airway cross-sectional area (CSA) and improves severity of OSA in a subgroup of nonpregnant patients (positional-dependent sleep apnea). We tested the hypothesis that elevated position of the upper body improves OSA early after delivery. METHODS Following institutional review board approval, we conducted a randomized, crossover study on two postpartum units of Massachusetts General Hospital. Women during the first 48 h after delivery were included. Polysomnography was performed in nonelevated and 45° elevated upper body position. Upper airway CSA was measured by acoustic pharyngometry in nonelevated, 45° elevated, and sitting body position. RESULTS Fifty-five patients were enrolled, and measurements of airway CSA obtained. Thirty patients completed polysomnography in both body positions. Elevation of the upper body significantly reduced apnea-hypopnea index (AHI) from 7.7 ± 2.2/h in nonelevated to 4.5 ± 1.4/h in 45° elevated upper body position (P = .031) during sleep. Moderate to severe OSA (AHI > 15/h) was diagnosed in 20% of postpartum patients and successfully treated by elevated body position in one-half of them. Total sleep time and sleep architecture were not affected by upper body elevation. Change from nonelevated to sitting position increased inspiratory upper airway CSA from 1.35 ± 0.1 cm 2 to 1.54 ± 0.1 cm 2 during wakefulness. Position-dependent increase in CSA and decrease in AHI were correlated ( r = 0.42, P = .022). CONCLUSIONS Among early postpartum women, 45° upper body elevation increased upper airway CSA and mitigated sleep apnea. Elevated body position might improve respiratory safety in women early after delivery. TRIAL REGISTRY ClinicalTrials.gov ; No.: NCT01719224; URL: www.clinicaltrials.gov

Recent advances in the diagnosis, pathogenesis, and understanding of preeclampsia-related morbidity provide opportunities to optimize clinical management of the mother and fetus. These discoveries are timely, as contemporary data suggest that the prevalence of preeclampsia, affecting 7.5% of pregnancies globally and 2-5% in the USA, has increased by up to 30% over the last decade. Managing pregnant patients with preeclampsia can be challenging for all members of the obstetric care team due to the disease's multi-organ system maternal and fetal effects. This review presents recent updates in the definition of preeclampsia, etiology, comorbidities and therapeutic interventions and discusses how they impact the care of these high-risk patients.

Anesthesiologists are responsible for the safe and effective provision of analgesia for labor and anesthesia for cesarean delivery and other obstetric procedures. In addition, obstetric anesthesiologists often have a unique role as the intensivists of the obstetric suite. The anesthesiologist is frequently the clinician with the greatest experience in the acute bedside management of a hemodynamically unstable patient and expertise in life-saving interventions. This review will discuss (1) risks associated with neuraxial and general anesthesia for labor and delivery, and (2) clinical scenarios in which the obstetric anesthesiologist is commonly called upon to function as a "peridelivery intensivist."

The authors conducted a prospective longitudinal study from 2009 to 2016 to assess the short and long-term impact of a formal mentorship program on junior faculty satisfaction and productivity. Junior faculty mentees enrolled in the program and junior faculty without formal mentorship were administered surveys before and after the program to assess satisfaction with their mentoring experiences. Long-term retention, promotion, and funding data were also collected. Twenty-three junior faculty mentees and 91 junior faculty controls were included in the study. Mentees came from the Departments of Radiation Oncology and Anesthesia, Critical Care, and Pain Management. After participating in the mentorship program, mentees demonstrated an increase in satisfaction from baseline in five of seven domains related to mentoring, while controls experienced no significant change in satisfaction in six of the seven domains. At long-term follow up, mentees were more likely than controls to hold senior faculty positions (percent senior faculty: 47% vs. 13%, p = 0.030) despite no difference in initial administrative rank. When comparing the subset of faculty who were Instructors at baseline, mentees were more likely to be funded and/or promoted than controls (p = 0.030). A majority of mentees reported that the program strengthened their long-term success, and many maintained their original mentoring relationships and formed new ones, highlighting the strong culture of mentorship that was instilled. Several short-term and long-term benefits were fostered from this formal mentorship program. These findings highlight the potential impact of mentorship programs in propagating a culture of mentorship and excellence.

Objective To assess whether a shared decision-making intervention decreases the quantity of oxycodone tablets prescribed after cesarean delivery. Technique A tablet computer-based decision aid formed the basis of a shared decision-making session to guide opioid prescribing after cesarean delivery. Women first received information on typical trajectories of pain resolution and expected opioid use after cesarean delivery and then chose the number of tablets of 5 mg oxycodone they would be prescribed up to the institutional standard prescription of 40 tablets. Experience From April 11, 2016, to June 10, 2016, 105 women were screened, 75 were eligible, and 51 consented to participate; one patient was excluded after enrollment as a result of prolonged hospitalization. The median number of tablets (5 mg oxycodone) women chose for their prescription was 20.0 (interquartile range 15.0-25.0), which was less than the standard 40-tablet prescription (P Conclusion A shared decision-making approach to opioid prescribing after cesarean delivery was associated with approximately a 50% decrease in the number of opioids prescribed postoperatively in this cohort compared with our institutional standard prescription. This approach is a promising strategy to reduce the amount of leftover opioid medication after treatment of acute postcesarean pain. Clinical trial registration ClinicalTrials.gov, NCT02770612.

Background and Purpose— Preeclampsia affects 3% to 8% of pregnancies and increases risk of pregnancy-associated stroke (PAS). Data are limited on which women with preeclampsia are at highest risk for PAS. Methods— Using billing data from the 2003 to 2012 New York State Department of Health inpatient database, we matched women with preeclampsia and PAS 1:3 to preeclamptic controls based on age and race/ethnicity. Pre-defined PAS risk factors included pregnancy complications, infection present on admission, vascular risk factors, prothrombotic states, and coagulopathies. We constructed multivariable conditional logistic regression models to calculate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for independent risk factors for PAS. Results— Among women aged 12 to 55 years admitted to New York State hospitals for any reason during the study period (n=3 373 114), 88 857 had preeclampsia, and 197 of whom (0.2%) had PAS. In multivariable analysis, women with preeclampsia and stroke were more likely than controls to have severe preeclampsia or eclampsia (OR, 7.2; 95% confidence interval [CI], 4.6–11.3), infections present on admission (OR, 3.0; 95% CI, 1.6–5.8), prothrombotic states (OR, 3.5; 95% CI, 1.3–9.2), coagulopathies (OR, 3.1; 95% CI, 1.3–7.1), or chronic hypertension (OR, 3.2; 95% CI, 1.8–5.5). Additional analyses matched and stratified by severity of preeclampsia confirmed these results. Conclusions— Infections, chronic hypertension, coagulopathies, and underlying prothrombotic conditions increase PAS risk in women with preeclampsia. These women may warrant closer monitoring.

In this study, we aimed to continuously measure cardiac output (CO) with the electrical velocimetry (EV) method and characterize the hemodynamic profile of patients undergoing spinal anesthesia for elective cesarean delivery (CD), and to discuss the potential benefit of using real time CO monitoring to guide patient management. Forty-two patients scheduled for elective CD under spinal anesthesia were enrolled in this observational study. A non-invasive CO monitor incorporating the electrical velocimetry algorithm, ICON(®) (Cardiotronic(®), La Jolla, California, USA), was used to measure CO and stroke volume (SV) continuously. Peripheral venous pressure was measured intermittently at pre-defined time points. Systemic vascular resistance was calculated retrospectively after completion of the study. Hemodynamic changes at pre-defined time points and caused by phenylephrine administration were analyzed. Hypotension (MAP reduction more than 20% from baseline values) occurred in 71.1% of patients after spinal anesthesia, while the coinstantaneous CO was increased ≥20% from baseline in the majority of patients (76.3%) at the same time. Significant increase in CO took place at 3-2 min before the administration of phenylephrine bolus. Treatment of hypotension with phenylephrine was associated with significant decrease in CO. Continuous CO monitoring with EV enables clinicians to determine CO and SV changes prior to onset of hypotension and to better understand patients' hemodynamics. It is an important addition to the current monitoring. The benefit of routinely using this technique remains to be determined in term of the patient outcomes.

Parturients with intracranial lesions are often assumed to have increased intracranial pressure, even in the absence of clinical and radiographic signs. The risk of herniation after an inadvertent dural puncture is frequently cited as a contraindication to neuraxial anesthesia. This article reviews the relevant literature on the use of neuraxial anesthesia in parturients with known intracranial pathology, and proposes a framework and recommendations for assessing risk of neurologic deterioration, with epidural analgesia or anesthesia, or planned or inadvertent dural puncture. The authors illustrate these concepts with numerous case examples and provide guidance for the practicing anesthesiologist in determining the safety of neuraxial anesthesia.