Ostheimer Lecture

Gerard W Ostheimer Lecture Syllabus

A. JOURNALS INCLUDED IN LITERATURE SEARCH

B. DETAILED SEARCH STRATEGY(PubMed)

Acknowledgement: search strategy designed and executed with the help of Lindsay Blake (Medical Librarian at UAMS)

Anesthesia Journals = 14

("Acta Anaesthesiol Scand"[Journal] OR "Anaesthesia"[Journal] OR "Anesth Analg"[Journal] OR "Br J Anaesth"[Journal] OR "Anesthesiology"[Journal] OR "Anaesth Intensive Care"[Journal] OR "Can J Anaesth"[Journal] OR "J Anesth"[Journal] OR "Reg Anesth Pain Med"[Journal] OR "J Clin Anesth"[Journal] OR "Int J Obstet Anesth"[Journal] OR "BMC Anesthesiol"[Journal] OR "Eur J Anaesthesiol"[Journal] OR "Curr Opin Anaesthesiol"[Journal])

AND

("Pregnancy"[Mesh] OR pregnancy OR pregnant OR maternal OR "Labor, Obstetric"[Mesh] OR labor OR "Pregnant Women"[Mesh] OR "Postpartum Period"[Mesh] OR postpartum OR antepartum OR "Mothers"[Mesh] OR maternal OR "Parturition"[Mesh] OR parturition OR "Postnatal Care"[Mesh] OR postnatal OR "Delivery, Obstetric"[Mesh] OR "Cesarean Section"[Mesh] OR cesarean OR delivery OR vaginal delivery OR "Infant, Newborn"[Mesh] OR "Fetus"[Mesh] OR fetus OR newborn OR neonatal OR obstetric OR "Obstetrics"[Mesh])

OB Journals = 10

("Acta Obstet Gynecol Scand"[Journal] OR "Am J Obstet Gynecol MFM"[Journal] OR "J Matern Fetal Neonatal Med"[Journal] OR "BJOG"[Journal] OR "Birth"[Journal] OR "Obstet Gynecol"[Journal] OR "Aust N Z J Obstet Gynaecol"[Journal] OR "Eur J Obstet Gynecol Reprod Biol"[Journal] OR "Int J Gynaecol Obstet"[Journal] OR "Pregnancy Hypertens"[Journal])

AND

("Analgesia, Epidural"[Mesh] OR "Injections, Epidural"[Mesh] OR "Anesthesia, Epidural"[Mesh] OR "Anesthesia, Spinal"[Mesh] OR "Anesthesia"[Mesh] OR "Analgesia, Obstetrical"[Mesh] OR "Anesthesia, Obstetrical"[Mesh] OR "Injections, Spinal"[Mesh] OR Epidural OR spinal OR anesthesia)

General Journals = 41

("Fertil Steril"[Journal] OR Am J Epidemiol"[Journal] OR "Am J Perinatol"[Journal] OR "BMJ"[Journal] OR "BMJ Qual Saf"[Journal] OR "Chest"[Journal] OR "Circulation"[Journal] OR "Crit Care Med"[Journal] OR "Diabetologia"[Journal] OR "Epidemiology"[Journal] OR "Early Hum Dev"[Journal] OR "Eur Heart J"[Journal] OR "Eur J Pain"[Journal] OR "Heart"[Journal] OR "Hypertension"[Journal] OR "Int J Dev Neurosci"[Journal] OR "Intensive Care Med"[Journal] OR "J Am Coll Cardiol"[Journal] OR "J Clin Epidemiol"[Journal] OR "J Pain"[Journal] OR "JAMA Pediatr"[Journal] OR "Pediatrics"[Journal] OR "J Pediatr"[Journal] OR "J Perinatol"[Journal] OR "JAMA"[Journal] OR "J Thromb Haemost"[Journal] OR "Lancet"[Journal] OR "Nature"[Journal] OR "Neurotoxicol Teratol"[Journal] OR "N Engl J Med"[Journal] OR "Pain"[Journal] "PLoS One"[Journal] OR "PLoS Med"[Journal] OR "Resuscitation"[Journal] OR "Science"[Journal] OR "Lancet Glob Health"[Journal] OR "Thromb Res"[Journal] OR "Transfusion"[Journal] OR "Sleep"[Journal] OR "MMWR Morb Mortal Wkly Rep"[Journal] OR "Natl Vital Stat Rep"[Journal])

AND ("Pregnancy"[Mesh] OR pregnancy OR pregnant OR maternal OR "Labor, Obstetric"[Mesh] OR labor OR "Pregnant Women"[Mesh] OR "Postpartum Period"[Mesh] OR postpartum OR antepartum OR "Mothers"[Mesh] OR maternal OR "Parturition"[Mesh] OR parturition OR "Postnatal Care"[Mesh] OR postnatal OR "Delivery, Obstetric"[Mesh] OR "Cesarean Section"[Mesh] OR cesarean OR delivery OR vaginal delivery OR "Infant, Newborn"[Mesh] OR "Fetus"[Mesh] OR fetus OR newborn OR neonatal OR obstetric OR "Obstetrics"[Mesh])

AND ("Analgesia, Epidural"[Mesh] OR "Injections, Epidural"[Mesh] OR "Anesthesia, Epidural"[Mesh] OR "Anesthesia, Spinal"[Mesh] OR "Anesthesia"[Mesh] OR "Analgesia, Obstetrical"[Mesh] OR "Anesthesia, Obstetrical"[Mesh] OR "Injections, Spinal"[Mesh] OR Epidural OR spinal OR anesthesia)

C. OSTHEIMER LECTURE REFERENCES

Abstract # Citation Country of origin

AGlobal Perspective (5)

1 Ameh CA, Meka RJ, West F, Dickinson F,Allott H, Godia P A synthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014-2017. Int J Gynaecol Obstet. 2022 Jun;158 Suppl 1(Suppl 1):14-22

2 Meh C, SharmaA, Ram U, Fadel S, Correa N, Snelgrove JW, Shah P, Begum R, Shah M, HanaT, Fu SH, Raveendran L, Mishra B, Jha P Trends in maternal mortality in India over two decades in nationally representative surveys. BJOG. 2022 Mar;129(4):550-561.

6 Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’Care Core Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2022 URL: Saving Lives, Improving Mothers’Care

7 Ockenden Final Report Findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury andTelford Hospital NHSTrust. March 2022. URL: Findings, conclusions and essential actions from the indepedendent review of maternity services at the Shrewsbury andTelford Ho

8 Royal College ofAnaesthetists. Guidelines for the provision of anesthesia services URL: Chapter 9: Guidelines for the Provision of Anaesthesia Services for an Obstetric Population 2023 |The Royal College ofAnaesthetists

NorthAmerican Obstetric Practice (13)

9 Center for Disease Control and Prevention - Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019 URL: Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019 | CDC

Kenya

India

UK

UK

UK

US

10 Baghirzada L,Archer D, WalkerA, Balki M Anesthesia-related adverse events in obstetric patients: a population-based study in Canada. Can JAnaesth. 2022 Jan;69(1):72-85.

11

12

Lee W, George RB The continued evolution of peripartum anesthesiologists. Can JAnaesth. 2022 Mar;69(3):283-288. USA

ASAstatement on quality metrics Oct 2022: URL: ASAquality metrics USA

16 Im M, Riley ET, Hoang D, Lim G, Zakowski M, Carvalho B. Obstetric Anesthesia Procedure-Based Workload and Facility Utilization of Society of ObstetricAnesthesia and Perinatology Centers of Excellence Designated Institutions.AnesthAnalg. 2022 Dec 1;135(6):1142-1150

17 GinosarY, WimpfheimerA, Weissman C. Using MeanAnesthesia Workload to PlanAnesthesia WorkforceAllocations:The "Flaw of Averages".AnesthAnalg. 2022 Dec 1;135(6):1138-1141.

19 NewYorkTimes In 6-to-3 Ruling, Supreme Court Ends Nearly 50 Years ofAbortion Rights. URL: In 6-to-3 Ruling, Supreme Court Ends Nearly 50Years ofAbortion Rights -The NewYorkTimes

21

Editors Lawmakers v The Scientific Realities of Human Reproduction New England Journal of Medicine 2022 Jul 28;387(4):367-8.

USA

23 Tanne JH US Supreme Court ends constitutional right to abortion BMJ. 2022 Jun 27;377:o1575. USA

24 The Lancet Why Roe v Wade must be defended Lancet 2022 May 14;399(10338):1845. USA

26 Landau R, BurgartAM, Sutton CD Loss of access to legal abortion in America: History, implications, and action items for anesthesiologists. Anaesth Crit Care Pain Med 2022 Oct;41(5):101125

27 SOAPstatement on Dobbs ruling URL: https://www.soap.org/index.php?option=com content&view=article&id =91:news---alerts&catid=20:site-content&Itemid=153

US

US

25 Wong CA, Galley HF, Leslie K. Maternal mortality, safe abortion, and the anaesthetist Br JAnaesth 2022 Dec;129(6):833-835 USA

Antenatal Studies (2)

30 Suarez EA, Huybrechts KF, Straub L, Hernández-Díaz S, Jones HE, Connery HS, Davis JM, Gray KJ, Lester B,Terplan M, Mogun H, Bateman BT Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy. N Engl J Med. 2022 Dec 1;387(22):2033-2044

33 Gill MM, Gasner S, BankenA, Park M, WeaverA, Sharpe E,Theiler R Improving routine prenatal penicillin allergy testing for reported penicillin allergy BMJ Open Qual 2022 Jul;11(3):e001859

LaborAnalgesia and SurgicalAnesthesia Studies (10)

36 LeeA, Shatil B, Landau R, Menon P, Smiley R Intrathecal 2-Chloroprocaine 3% Versus Hyperbaric Bupivacaine 0.75% for Cervical Cerclage:ADouble-Blind Randomized ControlledTrial AnesthAnalg. 2022 Mar 1;134(3):624-632.

37 Sharawi N,Tan HS,Taylor C, Fuller ME, Landreth RA, Diomede OI, Williams M, Martinello C, Mhyre JM, HabibAS ED 90 of Intrathecal Chloroprocaine With Fentanyl for Prophylactic Cervical Cerclage:A SequentialAllocation Biased-Coin Design AnesthAnalg 2022Apr 1;134(4):834-842.

43 Tan HS, Reed SE, Mehdiratta JE, Diomede OI, Landreth R, Gatta LA, Weikel D, HabibAS Quality of LaborAnalgesia with Dural Puncture Epidural versus Standard EpiduralTechnique in Obese Parturients:A Double-blind Randomized Controlled Study Anesthesiology 2022 May 1;136(5):678-687.

49 Halliday L, Kinsella M, Shaw M, Cheyne J, Nelson SM, Kearns RJ Comparison of ultra-low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta-analysis Anaesthesia 2022Aug;77(8):910-918

53 Patel R, Kua J, Sharawi N, Bauer ME, Blake L, Moonesinghe SR, Sultan P Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review.Anaesthesia. 2022 May;77(5):598-604

USA

USA

USA

USA

USA

55 Plaat F, Stanford SER, Lucas DN,Andrade J, Careless J, Russell R, Bishop D, Lo Q, Bogod D Prevention and management of intra-operative pain during caesarean section under neuraxial anaesthesia: a technical and interpersonal approach Anaesthesia 2022 May;77(5):588-597

58 MetodievY, Lucas DN The role of total intravenous anaesthesia for caesarean delivery Int J ObstetAnesth 2022Aug;51:103548 UK

60 Singh NP, Makkar JK,Yadav N, Goudra BG, Singh PM The analgesic efficacy of intravenous dexamethasone for post-caesarean pain:Asystematic review with meta-analysis and trial sequential analysis Eur JAnaesthesiol 2022 Jun 1;39(6):498-510

69 Sarker M, DeBolt C, Getrajdman C, Rattner P, Katz D, Ferrara L, Stone J, BiancoA Perioperative dexamethasone with neuraxial anesthesia for scheduled cesarean delivery and neonatal hypoglycemia. Eur J Obstet Gynecol Reprod Biol. 2022 Nov;278:109-114

63 McDonagh F, Carvalho JCA,Abdulla S, Cordovani D, Downey K,Ye XY, Farine D, Morais M, Balki M Carbetocin vs oxytocin at elective caesarean delivery: a double-blind, randomised, controlled, non-inferiority trial of low- and high-dose regimens.Anaesthesia. 2022Aug;77(8):892-900

Postpartum Studies (2)

72 Sultan P, George R, Weiniger CF, El-Boghdadly K, Pandal P, Carvalho B; CRADLE Study Investigators. Expert Consensus Regarding Core Outcomes for Enhanced Recovery after Cesarean Delivery Studies:ADelphi Study Anesthesiology 2022Aug 1;137(2):201-211.

79 GuptaA, Van de Velde M, MagnusonA, von Heymann C, Guasch E, Alahuhta S, Mercier FJ, Schyns-van den BergAMJV; European Practices in the Management ofAccidental Dural Puncture in Obstetrics Investigators Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study Br JAnaesth 2022 Nov;129(5):758-766

USA

USA

Canada

USA

Sweden (Multicenter)

References and abstracts for included articles

D.AGLOBALPERSPECTIVE

Data from Low and middle income countries (LMICs)

1 Ameh CA, Meka RJ, West F, Dickinson F,Allott H, Godia P Asynthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014-2017. Int J Gynaecol Obstet. 2022 Jun;158 Suppl 1(Suppl 1):14-22

ABSTRACT

Objective: To describe maternal deaths from postpartum hemorrhage (PPH) in Kenya by secondary analysis of the Kenya Confidential Enquiry into Maternal Deaths (CEMD) database and clinical audit of a sample of those deaths, and to identify the perceived challenges to implementing country-specific PPH guidelines Methods: Aretrospective descriptive study using the Kenyan CEMD database and anonymized maternal death records from 2014-2017. Eight standards from the Kenya National Guidelines for Quality Obstetric and Perinatal Care were selected to perform clinical audit The process of supporting eight Sub-SaharanAfrican countries to develop country-specific PPH guidelines was described and perceived challenges implementing these were identified Results: In total, 725 women died from PPH Most women attended at least one antenatal care visit (67.2%) and most did not receive iron and folate supplementation (35.7%). Only 39.0% of women received prophylactic uterotonics in the third stage of labor Factors significantly associated with receiving prophylactic uterotonics were place of delivery (χ2 = 43 666, df = 4; P< 0.001), being reviewed by a medical doctor (χ2 = 16.905, df = 1; P< 0.001), and being reviewed by a specialist (χ2= 49 244, df = 1; P< 0 001) Only three of eight standards had a greater percentage of met cases in comparison to unmet cases. Key concerns about implementation of the new WHO PPH guidance included use of misoprostol by unskilled health personnel, availability of misoprostol and tranexamic acid (TXA) at primary healthcare level, lack of availability of heat-stable carbetocin (HSC) due to cost, lack of awareness and education about HSC andTXA, and lack of systems to ensure quality oxytocin is available at point of care Conclusion: There is a need for improved quality of care for women to minimize the risk of mortality from PPH, by implementing updated clinical guidelines combined with focused health system interventions

ABSTRACT

Objective: To assess national and regional trends and causes-specific distribution of maternal mortality in India. Design: Nationally representative cross-sectional surveys. Setting: All of India from 1997 to 2020 Sample: About 10 000 maternal deaths among 4 3 million live births over two decades Methods: We analysed trends in the maternal mortality ratio (MMR) from 1997 through 2020, estimated absolute maternal deaths and examined the causes of maternal death using nationally representative data sources We partitioned female deaths (aged 15-49 years) and live birth totals, based on the 2001-2014 Million Death Study to United Nations (UN) demographic totals for the country. Main outcome measures: Maternal mortality burden and distribution of causes Results: The MMR declined in India by about 70% from 398/100 000 live births (95% CI 378-417) in 1997-98 to 99/100 000 (90-108) in 2020.About 1.30 million (95% CI 1 26-1 35 million) maternal deaths occurred between 1997 and 2020, with about 23 800 (95% CI 21 700-26 000) in 2020, with most occurring in poorer states (63%) and among women aged 20-29 years (58%).The MMRs forAssam (215), Uttar Pradesh/Uttarakhand (192) and Madhya Pradesh/Chhattisgarh (170) were highest, surpassing India's 2016-2018 estimate of 113 (95% CI 103-123) After adjustment for education and other variables, the risks of maternal death were highest in rural and tribal areas of north-eastern and northern states.The leading causes of maternal death were obstetric haemorrhage (47%; higher in poorer states), pregnancy-related infection (12%) and hypertensive disorders of pregnancy (7%)

Conclusions: India could achieve the UN 2030 MMR goals if the average rate of reduction is maintained However, without further intervention, the poorer states will not

2 Meh C, SharmaA, Ram U, Fadel S, Correa N, Snelgrove JW, Shah P, Begum R, Shah M, HanaT, Fu SH, Raveendran L, Mishra B, Jha P.Trends in maternal mortality in India over two decades in nationally representative surveys BJOG 2022 Mar;129(4):550-561

Data and reports from higher income countries

3. KallianidisAF, Schutte JM, Schuringa LEM, Beenakkers ICM, Bloemenkamp KWM, Braams-Lisman BAM, Cornette J, Kuppens SM, RietveldAL, SchaapT, Stekelenburg J, Zwart JJ, van denAkkerT. Confidential enquiry into maternal deaths in the Netherlands, 2006-2018 Acta Obstet Gynecol Scand 2022Apr;101(4):441-449

ABSTRACT

Introduction: To calculate the maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare this with 1993-2005, and to describe women's characteristics, causes of death and improvable factors Material and methods: We performed a nationwide, cohort study of all maternal deaths between January 1, 2006 and December 31, 2018 reported to theAudit Committee Maternal Mortality and Morbidity. Main outcome measures were the national MMR and causes of death Results: Overall MMR was 6 2 per 100 000 live births, a decrease from 12.1 in 1993-2005 (risk ratio [RR] 0.5). Women with a non-western ethnic background had an increased MMR compared with Dutch women (MMR 6 5 vs 5 0, RR 1 3) The MMR was increased among women with a background from Surinam/DutchAntilles (MMR 14 7, RR 2 9) Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 171 pregnancy-related deaths within 1 year postpartum, 102 (60%) had a direct and 69 (40%) an indirect cause of death Leading causes within 42 days postpartum were cardiac disease (n = 21, 14.9%), hypertensive disorders (n = 20, 14.2%) and thrombosis (n = 19, 13.5%). Up to 1 year postpartum, the most common cause of death was cardiac disease (n = 32, 18 7%)

Improvable care factors were identified in 76 (47 5%) of all deaths Conclusions: Maternal mortality halved in 2006-2018 compared with 1993-2005. Cardiac disease became the main cause In almost half of all deaths, improvable factors were identified and women with a background from Surinam/DutchAntilles had a threefold increased risk of death compared with Dutch women without a background of migration

16;379:e070621

ABSTRACT

Objective: To compare maternal mortality in eight countries with enhanced surveillance systems Design: Descriptive multicountry population based study Setting: Eight countries with permanent surveillance systems using enhanced methods to identify, document, and review maternal deaths The most recent available aggregated maternal mortality data were collected for three year periods for France, Italy, and the UK and for five year periods for Denmark, Finland, the Netherlands, Norway, and Slovakia. Population: 297 835 live births in Denmark (2013-17), 301 169 in Finland (2008-12), 2 435 583 in France (2013-15), 1 281 986 in Italy (2013-15), 856 572 in the Netherlands (2014-18), 292 315 in Norway (2014-18), 283 930 in Slovakia (2014-18), and 2 261 090 in the UK (2016-18) Outcome measures: Maternal mortality ratios from enhanced systems were calculated and compared with those obtained from each country's office of vital statistics.Age specific maternal mortality ratios; maternal mortality ratios according to women's origin, citizenship, or ethnicity; and cause specific maternal mortality ratios were also calculated Results: Methods for identifying and classifying maternal deaths up to 42 days were very similar across countries (except for the Netherlands). Maternal mortality ratios up to 42 days after end of pregnancy varied by a multiplicative factor of four from 2 7 and 3 4 per 100 000 live births in Norway and Denmark to 9 6 in the UK and 10 9 in Slovakia. Vital statistics offices underestimated maternal mortality by 36% or more everywhere but Denmark Age specific maternal mortality ratios were higher for the youngest and oldest mothers (pooled relative risk 2.17 (95% confidence interval 1.38 to 3.34) for women aged <20 years, 2 10 (1 54 to 2 86) for those aged 35-39, and 3 95 (3 01 to 5 19) for those aged ≥40, compared with women aged 20-29 years) Except in Norway, maternal mortality ratios were ≥50% higher in women born abroad or of minoritised ethnicity, defined variously in different countries Cardiovascular diseases and suicides were leading causes of maternal deaths in each country Some other conditions were also major contributors to maternal mortality in only one or two countries: venous thromboembolism in the UK and the Netherlands, hypertensive disorders in the Netherlands, amniotic fluid embolism in France, haemorrhage in Italy, and stroke in Slovakia. Only two countries, France and the UK, had enhanced methods for studying late maternal deaths, those occurring between 43 and 365 days after the end of pregnancy.

Conclusions: Variations in maternal mortality ratios exist between high income European countries with enhanced surveillance systems. In-depth analyses of differences in the quality of care and health system performance at national levels are needed to reduce maternal mortality further by learning from best practices and each other Cardiovascular diseases and mental health in women during and after pregnancy must be prioritized in all countries.

4 Diguisto C, Saucedo M, KallianidisA, Bloemenkamp K, Bødker B, Buoncristiano M, Donati S, Gissler M, Johansen M, Knight M, Korbel M, KristufkovaA, Nyflot LT, Deneux-Tharaux C Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study. BMJ. 2022 Nov

5 Masterson JA,Adamestam I, Beatty M, Boardman JP, Johnston P, Joss J, Lawrence H, Litchfield K, WalshTS, WiseA, Wood R, Weir CJ, Denison FC, Lone NI. Severe maternal morbidity in Scotland Anaesthesia 2022 Sep;77(9):971-980

ABSTRACT

Using a cohort study design, we analysed 17 diagnoses and 9 interventions (including critical care admission) as a composite measure of severe maternal morbidity for pregnancies recorded over 14 years in Scotland There were 762,918 pregnancies, of which 7947 (10 in 1000 pregnancies) recorded 9345 severe maternal morbidity events, 2802 episodes of puerperal sepsis being the most common (30%). Severe maternal morbidity incidence increased from 9 in 1000 pregnancies in 2012 to 17 in 1000 pregnancies in 2018, due in part to puerperal sepsis recording The odds ratio (95%CI) for severe maternal morbidity was higher for: older women, for instance 1.22 (1.13-1.33) for women aged 35-39 years and 1.44 (1.27-1.63) for women aged > 40 years compared with those aged 25-29 years; obese women, for instance 1 13 (1 06-1 21) for BMI 30-40 kg m-2 and 1 32 (1 15-1 51) for BMI > 40 kg m-2 compared with BMI 18 5-24 9 kg.m-2 ; multiple pregnancy, 2.39 (2.09-2.74); and previous caesarean delivery, 1.52 (1.40-1.65). The median (IQR [range]) hospital stay was 3 (2-5 [1-8]) days with severe maternal morbidity and 2 (1-3 [1-5]) days without. Forty-one women died during pregnancy or up to 42 days after delivery, representing mortality rates per 100,000 pregnancies of about 365 with severe maternal morbidity and 1 6 without There were 1449 women admitted to critical care, 807 (58%) for mechanical ventilation or support of at least two organs. We recorded an incidence of severe maternal morbidity higher than previously published, possibly because sepsis was coded inaccurately in our databases Further research may determine the value of this composite measure of severe maternal morbidity.

6 Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds ) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’Care Core Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2022 URL: Saving Lives, Improving Mothers’Care

RECOMMENDATIONS

For professional organizations:

● Develop guidance for the use of Brain Natriuretic Peptide measurement in pregnancy

● Develop guidance on ketone testing in pregnancy and the subsequent response to an abnormal test.

● Ensure that guidance on the management of diabetic ketoacidosis in pregnancy is included in all guidelines used outside of the maternity setting

For policy makers, service planners/commissioners and service managers:

● Commissioning bodies should ensure that providers of specialist Perinatal Mental Health Teams have sufficient resources to advise, and in complex or high-risk cases, be involved, in mental health assessments when in normal working hours.

● Consider skills and drills training on the management of diabetic ketoacidosis in pregnancy to ensure that obstetricians and midwives are aware of the symptoms and signs of diabetic ketoacidosis.

● Ensure the appropriate national Maternity Early Warning Score is used to monitor a pregnant woman wher- ever in the hospital she receives care

● Ensure that the national Patient Group Direction allowing prescription of aspirin for pregnant women at risk of pre-eclampsia by midwives and pharmacists is widely implemented

● Ensure that women’s electronic records can be easily accessed and shared when they receive care in differ- ent settings

● Be aware of how to contact the regional maternal medicine lead for urgent advice to ensure multidisciplinary senior review of women who are unwell

● Ensure maternal medicine networks and their equivalents in the devolved nations and Republic of Ireland can provide appropriate expertise and supervision for all women including those in rural/remote areas

● Vulnerable and young women remain disproportionately represented amongst those who have died from ectopic pregnancy Ensure care is personalized to provide appropriate additional safety measures

● Recognise the importance of a trauma history in the assessment of risk. Involve specialist Perinatal Mental HealthTeams where there is a history of significant involvement with secondary mental health services or significant risk, particularly if it is a first pregnancy

● Allow sufficient opportunity in electronic records systems for free text comment rather than relying solely on ‘tick boxes’ Where a woman has a history of mental health difficulties, make a brief (as a minimum) comment on mental health

For health professionals and those designing professional education programmes:

● Assess women with persistent and severe insomnia carefully for signs of underlying mental illness

● Access services such as Psychiatric Liaison, Crisis and StreetTriageTeams should alert specialist Perinatal Mental HealthTeams to any referrals of self-harm in pregnant or postpartum women that they have received to allow triage regarding the need for specialist follow-up

● Be alert to factors, such as cultural stigma or fear of child removal, which may influence the willingness of a woman or her family to disclose symptoms of mental illness, thoughts of self-harm or substance misuse

● Wheeze can be due to pulmonary oedema Consider wheeze which does not respond to standard asthma management and exertional syncope as red flag symptoms of cardiovascular disease in addition to orthopnoea and chest pain

● Be aware of the common risk factors for heart disease and venous thromboembolism, such as extreme obesity, and consider on an individual basis whether women should be made aware of the symptoms and signs of heart disease as well as those of venous thromboembolism

● Be aware that women using oral anticoagulation with warfarin may be more safely managed without transition to low molecular weight heparin treatment when having an early termination of pregnancy Be aware of the added risk of fetal compromise when a woman's pregnancy is complicated by both hypertension and diabetes. It is not only babies predicted to be small for gestational age who may be at risk

● Involve the critical care team antenatal multidisciplinary team planning for women with serious morbidity who are anticipated to require admission to ITU after childbirth.

7 Ockenden Report UK

URL: Findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury andTelford Hospital NHS Trust

SUMMARY

Failings in maternity care at Shrewsbury andTelford Hospital NHSTrust 2000-2019

Widely reported in the media: 12 women and 498 babies died

· Failure to investigate change and listen after adverse events

Safe staffing levels, well trained workforce, learn from incidents, willingness to listen to families are crucial for safe maternal care

· These incidents arise from complex factors combined with inadequate leadership and wrong workplace culture – fear of reporting

· Obsession with natural childbirth at the expense of safety and choice

· Lack of safe and personalized care

Over-protocolization diminishes choice for pregnant patients

· Negatives are defensive practice, stretched resources and blame culture

Needs workforce capacity

Identify poor performing units in no blame manner

· Few incentives for pharmaceutical companies to develop new therapies - small financial returns and adverse risk for baby potential

More funding for fetal monitoring in labor studies (14 studies 4030 patients)

· Accountability important

8. Royal College ofAnaesthetists (UK). Guidelines for the provision of anaesthesia services for an obstetric population (URL: https://rcoa ac uk/gpas/chapter-9)

E. NORTHAMERICAN OBSTETRIC PRACTICE

Pregnancy-related deaths

9 Center for Disease Control and Prevention – Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019 URL: https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html

SUMMARY

Background – rising US maternal mortality rate

CDC mortality report data – most deaths occur in the outpatient setting

· Among pregnancy-related deaths with information on timing, 22% of deaths occurred during pregnancy, 25% occurred on the day of delivery or within 7 days after, and 53% occurred between 7 days to 1 year after pregnancy

84% of pregnancy related deaths were preventable

The leading underlying causes of pregnancy-related death include:

o Mental health conditions (including deaths to suicide and overdose/poisoning related to substance use disorder) (23%)

o Excessive bleeding (hemorrhage) (14%)

o Cardiac and coronary conditions (relating to the heart) (13%)

o Infection (9%)

o Thrombotic embolism (a type of blood clot) (9%)

o Cardiomyopathy (a disease of the heart muscle) (9%)

o Hypertensive disorders of pregnancy (relating to high blood pressure) (7%)

· The leading underlying cause of death varied by race and ethnicity.

· Cardiac and coronary conditions were the leading underlying cause of pregnancy-related deaths among non-Hispanic Black people,

· mental health conditions were the leading underlying cause for Hispanic and non-Hispanic White people, and hemorrhage was the leading underlying cause for non-HispanicAsian people.

Anesthesia-related adverse events (Canada)

10.Baghirzada L,Archer D,

M.Anesthesia-related adverse events in obstetric patients: a population-based study in Canada Can JAnaesth 2022 Jan;69(1):72-85.

ABSTRACT

WalkerA, Balki

Background: Anesthesia-related complications in obstetric patients could be catastrophic and impact the lives of both the parturient and the neonate The objective of this study was to determine the frequency, temporal trend, and risk factors of anesthesia-related adverse events during hospitalization for delivery in Canada. Methods: This retrospective population-based study utilized the hospitalization database of the Canadian Institute for Health Information for all parturients (gestation ≥ 20 weeks) in Canada (except Quebec) hospitalized for childbirth from April 2004 to March 2017. Complications were identified by the enhanced Canadian version of the tenth revision of the International Statistical Classification of Diseases and Related Health Problems codes. Data were summarized with descriptive statistics.Associations between hospitalizations with an anesthesia-related adverse event and patient characteristics, delivery method, and modality of anesthesia were assessed using multivariate logistic regression Results: Among 2,601,034 hospitalizations (3,194,875 interventions), 8,361 anesthesia-related adverse events occurred over a 13-year period (262 per 100,000 interventions; 95% confidence interval [CI], 256 to 267), with a significant decline over time (P< 0 001) These were two-fold and seven-fold higher per 100,000 interventions with general (488; 95% CI, 438 to 542) and general plus neuraxial (1,476; 95% CI, 1,284 to 1,689) anesthesia compared with neuraxial anesthesia alone (225; 95% CI, 219 to 230). Serious adverse events constituted 9% of all adverse events.The most common adverse event was spinal and epidural anesthesia-induced headache (6,908/8,361; 83%); the overall rate of failed or difficult intubations was low (201/8,361; 2%).Anesthesia-related events were more likely in those who had a Cesarean delivery compared with vaginal delivery (odds ratio [OR], 1 12; 95% CI, 1 06 to 1 18) and general anesthesia compared with neuraxial anesthesia (OR, 1 71; 95% CI, 1 53 to 1 93) Noteworthy associations were found between any anesthesia-related adverse events and cardiomyopathy (OR, 8 34; 95% CI, 2 59 to 26 83), eclampsia (OR, 3 11; 95% CI, 1 95 to 4 97), and obstructive sleep apnea (OR, 1 91; 95% CI, 1 66 to 2 19) Conclusion: The incidence of anesthesia-related adverse events in obstetric patients in Canada is low and declining. High vigilance is required in parturients undergoing Cesarean delivery, receiving general anesthesia, and those with pre-existing medical conditions.

11 Lee W, George RB The continued evolution of peripartum anesthesiologists Can J Anaesth. 2022 Mar;69(3):283-288.

SUMMARY

Editorial reviewing the change from looking at maternal mortality (only one maternal death associated with anesthesia in the latest Confidential enquiry into Maternal Deaths and Morbidity in the UK) to morbidity (note the change in the name to include morbidity) and then discuss the study by Balki et al They also discuss the role of the OB anesthesiologist in designing and implementing protocols to detect and manage maternal sepsis, such as MEWS) They further look at how our role has expanded as perioperative / peripartum physicians and should continue to expand beyond labor and delivery analgesia

Quality metrics in obstetric anesthesia

12.ASAstatement on quality metrics Oct 2022: URL: ASA quality metrics

Recommendations:

The following recommendations were developed following input from a broad group of obstetric anesthesiologists and approved by theASACommittee on Obstetric Anesthesia.These suggested quality metrics were selected to highlight various areas for potential improvement, and to assist in improving the quality of care provided, but this is not a complete list.

This statement outlines six areas for quality improvement based on relevant and quantifiable metrics to measure obstetric anesthesia care.

1 Mode ofAnesthesia for Cesarean Delivery

2. Neuraxial-Induced Hypotension during Cesarean Delivery

3 Post Cesarean Opioid Consumption

4 Responsiveness to the Request for LaborAnalgesia

5. Post Dural Puncture HeadacheAccountability

6 Labor Epidural Replacements

These measures reflect the perioperative and peripartum continuum of care being provided by anesthesiologists on labor and delivery (L&D). These suggested metrics are intended to help guide anesthesiologists in various types of practices, varying locations, and varyingACOG Levels of Maternal Care in the development of meaningful clinical improvements for their local environments. The measure should not be viewed as a comprehensive list, rather a starting point for quality metrics to assess obstetric anesthesia care.The following six tables were created to help frame, outline, and explain each of these measures.

13 Howell EA, Sofaer S, BalbierzA, KheyfetsA, Glazer KB, Zeitlin J

Distinguishing High-Performing From Low-Performing Hospitals for Severe Maternal Morbidity:AFocus on Quality and Equity Obstet Gynecol 2022 Jun 1;139(6):1061-1069

ABSTRACT

Objective: To investigate which organizational factors, policies, and practices distinguish hospitals with high compared with low risk-adjusted rates of severe maternal morbidity (SMM). Methods: Using a positive deviance approach, this qualitative study included 50 semistructured interviews with healthcare professionals (obstetrics and gynecology chairs, labor and delivery medical directors, nurse managers, frontline nurses, physicians or nurses responsible for quality and safety, and chief medical officers) in four low-performing and four high-performing hospitals in NewYork City Hospital performance was based on risk-adjusted morbidity metrics from previous research. Major topics explored were structural characteristics (eg, staffing, credentialing), organizational characteristics (eg, culture, leadership, communication, use of data), labor and delivery practices (eg, use of standardized, evidence-based practices, teamwork), and racial and ethnic disparities in SMM All interviews were audiotaped, professionally transcribed, and coded using NVivo software Researchers blinded to group assignment conducted qualitative content analysis. Researchers wrote analytic memos to identify key themes and patterns emerging from the interviews, highlight illustrative quotes, and draw qualitative comparisons between the two hospital clusters with different (but unrevealed) performance levels. Results: Six themes distinguished high-performing from low-performing hospitals High-performing hospitals were more likely to have: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment Conclusion: Organizational factors, policies, and practices at multiple levels distinguish high-performing from low-performing hospitals for SMM. Findings illustrate the potential for targeted quality initiatives to improve maternal health and reduce obstetric disparities arising from delivery in low-performing hospitals

Perinatal substance use disorder

14.Smid MC,Terplan M. What Obstetrician-Gynecologists Should KnowAbout Substance Use Disorders in the Perinatal Period Obstet Gynecol 2022 Feb 1;139(2):317-337

ABSTRACT

Substance use in pregnancy is common; nearly one of five of pregnant individuals have past-month nicotine, alcohol, or illicit substance use, and more than one in 10 meet criteria for a substance use disorder (SUD) Substance use disorders are among the most stigmatized and poorly understood medical conditions, particularly in the perinatal period The obstetrician-gynecologist (ob-gyn) is a critical member of the health care and social support team for pregnant and postpartum individuals with SUD Yet, many do not feel knowledgeable in screening and treating SUD, hampering efforts to identify and treat this population In this review, we focus on practices that ob-gyns can incorporate into daily care. We start with the unique vulnerabilities of the perinatal period and discuss overdose as a leading cause of maternal death in the United States. We then review the basic tenets of addiction medicine including person-centered language and current medical terminology as well as best practices for substance use screening We provide a review of maternal, fetal, and child effects of the most common substances including tobacco, alcohol, cannabis, opioids, stimulants, and benzodiazepines and their respective treatment recommendations, so that ob-gyns can incorporate basic addiction management into their daily practice

Deaths due to drugs, suicide and homicide

15.Margerison CE, Roberts MH, GemmillA, Goldman-Mellor S. Pregnancy-Associated Deaths Due to Drugs, Suicide, and Homicide in the United States, 2010-2019 Obstet Gynecol. 2022 Feb 1;139(2):172-180.

ABSTRACT

Objective: To estimate the prevalence of pregnancy-associated deaths due to drugs, suicide, and homicide nationwide from 2010 to 2019 Methods: Using U S death certificate records from 2010 to 2019 for 33 states plus the District of Columbia, we identified pregnancy-associated deaths using the pregnancy checkbox and International Classification of Diseases,Tenth Revision codes, calculated pregnancy-associated death ratios, and categorized deaths by cause, timing relative to pregnancy, race or ethnicity, and age Results: Of 11,782 pregnancy-associated deaths identified between 2010 and 2019, 11.4% were due to drugs, 5 4% were due to suicide, and 5 4% were due to homicide, whereas 59 3% were due to obstetric causes and the remaining 18.5% were due to other causes. Drug-related deaths, suicide, and homicide accounted for 22 2% of pregnancy-associated deaths All three causes of death increased over the study period, with drug-related pregnancy-associated deaths increasing 190%. Homicide during pregnancy and drug-related deaths, suicides, and homicide in the late postpartum period (43-365 days) accounted for a larger proportion of all deaths in these time periods than the contribution of these causes to all deaths among females of reproductive age. Pregnant and postpartum people identified as non-HispanicAmerican Indian orAlaska Native were at highest risk of drug-related and suicide death, and people identified as non-Hispanic Black were at highest risk of homicide. Conclusion: Deaths due to drug use, suicide, and homicide constitute more than one fifth of all deaths during pregnancy and the first year postpartum Drug-related deaths and homicides have increased over the past decade Substantial racial and ethnic inequities in these deaths exist.

Staffing and workload

16.Im M, Riley ET, Hoang D, Lim G, Zakowski M, Carvalho B. ObstetricAnesthesia

Procedure-Based Workload and Facility Utilization of Society of ObstetricAnesthesia and Perinatology Centers of Excellence Designated Institutions.AnesthAnalg. 2022 Dec 1;135(6):1142-1150

ABSTRACT

Background: Optimal workload and staffing for obstetric anesthesia services have yet to be determined. We surveyed Society of ObstetricAnesthesia and Perinatology (SOAP) Centers of Excellence (COE) for ObstetricAnesthesia Care institutions to evaluate procedure-based obstetric anesthesia workload and facility use.Methods: After institutional review board (IRB) exemption, an online survey instrument (REDCap) was sent by email (1 initial and 2 reminders) to all SOAP COEs. Survey data included the number of deliveries, cesarean delivery rate, neuraxial labor analgesia rate, the number of labor and operating rooms, and the number of in-house and backup obstetric anesthesia providers. Obstetric anesthesia activity was estimated using a time-based workload ratio per provider (Stanford Work Index, 1.0 = clinically working every minute of every hour on duty) during weekday, weeknight, and weekend shifts. We compared workload between academic and nonacademic centers and correlated operating and labor rooms with cesarean and vaginal delivery volume. Results: Fifty-one of 53 surveys were returned (96% response rate). Data from 33 academic and 14 nonacademic US institutions were analyzed. For academic centers, median Stanford Work Index for all staff (included trainees and Certified Registered NurseAnesthetists) was 0.20 (weekday) and 0.19 (weeknight and weekends); nonacademic centers were 0.33 (weekday, P< .001 versus academic), 0.23 (weeknight, P = .009 versus academic), and 0.23 (weekends, P = .03 versus academic practices).Attending-only Stanford Work Indices were similar between academic and nonacademic centers. Total number of rooms on the obstetric suite (operating, labor, or triage room) was strongly correlated with delivery volume ( R2 = 0.55).Conclusions: The results outline staffing procedure-based workload ratios and facility utilization at SOAP COEs in the United States.These data can be used by other institutions that provide obstetric anesthesia services to guide their obstetric anesthesia staffing.The importance of considering the workload associated with different shifts and between academic and nonacademic centers is also highlighted. The results show that approximately one-third of an obstetric anesthesiologist's workload is spent on performing procedures. We did not, however, measure the other tasks anesthesiologists practice as peripartum physicians (eg, managing critically ill parturients, doing pre- and postprocedural evaluations, or performing emergent and unexpected procedures), and future studies are required to determine the time required to perform these tasks. Studies to determine the optimal staffing models to handle workload fluctuations and improve outcomes are also required.

17.GinosarY, WimpfheimerA, Weissman C. Using MeanAnesthesia Workload to Plan Anesthesia WorkforceAllocations:The "Flaw ofAverages" AnesthAnalg 2022 Dec 1;135(6):1138-1141.

SUMMARY

Accompanying editorial to Im et al..Authors point out that it is the workload variability, not the average workload, that is crucial in terms of safety They note that it is important to collect institution-specific data Recommendations arising from that data need to be assessed using benchmarks, such as epidural analgesia waiting time and the use of general anesthesia for cesarean delivery which reflect the adequacy of obstetric anesthesia workforce allocation

Dobbs vs Roe:AbortionAccessArticles and Editorials

18 Special Edition: Roe v Wade Is Overturned -The NewYorkTimes

19 In 6-to-3 Ruling, Supreme Court Ends Nearly 50Years ofAbortion Rights -The New YorkTimes

20 WilliamsAM, Chaturvedi R, Pollalis I, Ibarra-Cobarru J,Aaronson JA, White RS Associations between state policies, race, ethnicity and rurality, and maternal mortality and morbidity following the United States Supreme Court Dobbs v. Jackson Women's Health Organization ruling Br JAnaesth 2022 Dec;129(6):e145-e147

21.Editors. Lawmakers v.The Scientific Realities of Human Reproduction. New England Journal of Medicine 2022 Jul 28;387(4):367-8

22 Giglio ME, Magalski GR, DoanYP, Bowman S AbortionTraining in Medical EducationImplications of the Supreme Court's Upcoming Decision N Engl J Med 2022 Feb 24;386(8):707-709.

23 Tanne JH US Supreme Court ends constitutional right to abortion BMJ 2022 Jun27;377:o1575.

24.Editorial.The Lancet. Why Roe v. Wade must be defended. Lancet. 2022 May 14;399(10338):1845. doi: 10.1016/S0140-6736(22)00870-4.

25.Wong CA, Galley HF, Leslie K. Maternal mortality, safe abortion, and the anaesthetist. Br JAnaesth 2022 Dec;129(6):833-835

SUMMARY

● Countries with greater restrictions on abortion have higher maternal mortality

● In the USA, states with greater restrictions on abortion have higher maternal mortality than those with more protective abortion laws.

● In a correspondence published in this issue of the British Journal ofAnaesthesia (BJA), Williams and colleagues compared maternal mortality and severe maternal morbidity between 2018 and 2020 in the USAbetween states with restrictive abortion laws and those with less restrictive (‘protective’) abortion laws They estimated that the current maternal mortality ratio is 25.4 in restrictive states and 17.0 in protective states, although the pattern for severe maternal morbidity was reversed Both mortality and severe morbidity were greater in Black and Hispanic women compared with White women

● Banning abortion does not significantly decrease the number of abortions; it merely makes them significantly less safe For example, in Mexico, decriminalising abortion resulted in a sharp decline in maternal morbidity Therefore, the US Supreme Court decision in the matter of Dobbs v. Jackson Women’s Health Organization, which

overturned almost 50 yr of constitutional protection of abortion rights afforded by the 1973 Roe v. Wade decision, is expected to worsen maternal morbidity and mortality.

● One analysis suggests that if there were a total ban on abortion in the USA, maternal mortality would increase by 24%. This is of great concern, as maternal mortality in the USAis already higher than in comparable nations

● The increase in maternal mortality will be greatest amongst Hispanic and Black women, thus widening an already grossly unjust difference in healthcare outcomes between racial and ethnic groups

● Reproductive health is a critical aspect of health worldwide Along with the enormous role that anaesthetists play in peripartum care, we collaborate with our obstetric and surgical colleagues to provide safe anaesthesia care for reproductive health procedures, including abortions, intensive care for critically ill women and neonates who suffer from complications of pregnancy and delivery, and pain medicine services to patients suffering acute and chronic pain related to reproduction

● In jurisdictions where abortion is restricted, more unsafe abortions and more full-term pregnancies will likely result in more complications requiring our care

● Laws restricting abortion may also have other downstream consequences, such as physician hesitancy in providing definitive treatment for ectopic pregnancies or previable rupture of membranes The lack of constitutional protection for reproductive health procedures in the USAis predicted to affect physician training in reproductive health Obstetric and anaesthesia trainees will no longer be able to receive the training necessary to become competent in these procedures, so when they are necessary to save the life of the mother, the skills may be lacking.

● Some States are considering legislation that criminalises care provided by physicians who provide abortion services Those who provide anaesthesia services for abortion procedures would also be at risk of criminal prosecution. Importantly, healthcare workers would be at risk for moral injury if they are prevented by law from providing care that they deem necessary to women’s reproductive health

BJAStatement:

BJAis a charity whose primary goals are to ‘advance and improve theoretical and practical knowledge and skills in all branches of anaesthesia, critical care and pain medicine, and related topics’and to ‘promote the health, safety and welfare of all persons by improving and disseminating knowledge and skills of anaesthesia, critical care and pain medicine and thereby reducing the suffering and dangers of anaesthesia and surgery’. Reports are selected for publication in BJAon the basis of their fulfilment of these goals Thus, BJAis invested in promoting reproductive health, particularly as it pertains to anaesthesia, intensive care, and pain medicine BJAcannot do this without also supporting safe abortion care, as this is an integral part of safe reproductive health We will continue to publish relevant research to assist anaesthetists, intensivists, and pain medicine specialists in providing evidence-based reproductive healthcare and continue to address disparities in reproductive health, whether geographic, racial, or socioeconomicWe call on governing bodies across the world to consider the substantial existing body of knowledge about the role of safe access to abortion in maternal health

26 Landau R, BurgartAM, Sutton CD Loss of access to legal abortion inAmerica: History, implications, and action items for anesthesiologists.Anaesth Crit Care Pain Med. 2022

Oct;41(5):101125

SUMMARY

During this past half century, safe and effective medication and surgical abortion have helped millions of patients, thousands of obstetrician-gynecologists have been trained in more than 100 programs, and thousands of clinical, epidemiologic, and sociologic studies have demonstrated the importance of abortion to personal and public health Obstetrician-gynecologists must support one another in amending or defying laws that subvert the principles of medical practice, training, and evidence

For those who live where abortion remains legal, now is the time to start providing abortions and enhancing your abortion-referral process For all, regardless of state legislation, ob-gyns must be leaders in advocacy by facilitating abortion care-across state lines, using telehealth, or with self-managed abortion-and avoiding any contribution to the criminalization of those who seek or obtain essential abortion care Our patients deserve a specialty-wide concerted effort to deliver comprehensive reproductive health care to the fullest extent.

27 SOAPstatement on Dobbs ruling URL: https://www.soap.org/index.php?option=com content&view=article&id=91:news---alerts& catid=20:site-content&Itemid=153

July 2022 - In light of the Supreme Court decision of the Dobbs v Jackson Women’s Health Organization case that overturns Roe v Wade and Casey v Planned Parenthood, thereby making the legality of abortion a state issue, SOAPreiterates and affirms our position statement issued June 1, 2022

28 McDonnell J, Jarlenski M, Borrero S, Vinekar K Association ofAvailability of State Medicaid Coverage forAbortion WithAbortionAccess in the United States. Obstet Gynecol 2022

Oct 1;140(4):623-630

ABSTRACT

Objective: To evaluate the association between state Medicaid coverage for abortion and abortion access measures among U.S. patients. Methods: We analyzed data from the Guttmacher Institute's 2014Abortion Patient Survey Respondents were included if they reported being enrolled in Medicaid, regardless of whether Medicaid covered the abortion The exposure was self-report of residence in a state where Medicaid can be used to pay for abortion Access outcomes included more than 14 days' wait time between decision for abortion and abortion appointment, presentation at more than 10 weeks of gestation when in the first trimester, and travel time more than 60 minutes to the clinic. Multivariable regression was performed to test the association between state Medicaid abortion coverage and dichotomous access outcomes, controlling for patient demographics. Results: Of 2,579 respondents enrolled in Medicaid who reported state of residence, 1,694 resided in states with Medicaid coverage for abortion and 884 resided in states without Medicaid coverage for abortion Patients residing in states with Medicaid coverage for abortion had lower odds and rates of waiting more than 14 days between deciding to have an abortion and the appointment (adjusted odds ratio [aOR] 0 70; 95% CI 0 57-0 85, 66 8% vs 74 1%, P< 001), having abortions at more than 10 weeks of gestation when in the first trimester (aOR 0.62; 95% CI 0.49-0.80, 13.6% vs 20.1%, P<.001), and traveling more than 60 minutes to the abortion clinic (aOR 0 63; 95% CI 0 51-0 78, 18 7% vs 27.6%, P<.001) when compared with patients residing in states without Medicaid coverage for abortion. Conclusion: Availability of state Medicaid coverage for abortion is associated with increased abortion access Our findings support repealing the HydeAmendment to promote equitable access to reproductive health care, particularly in the post-Roe era.

Impact of Medicaid expansion on epidural utilization

29.Xiao MZX, Whitney D, Guo N, Sun EC, Wong CA, Bentley J, ButwickAJ.Association of Medicaid Expansion With Neuraxial LaborAnalgesia Use in the United States:A Retrospective Cross-SectionalAnalysis.AnesthAnalg. 2022 Mar 1;134(3):505-514.

ABSTRACT

Background: TheAffordable CareAct has been associated with increased Medicaid coverage for childbirth among low-income US women We hypothesized that Medicaid expansion was associated with increased use of labor neuraxial analgesia Methods: We performed a cross-sectional analysis of US women with singleton live births who underwent vaginal delivery or intrapartum cesarean delivery between 2009 and 2017 Data were sourced from births in 26 US states that used the 2003 Revised US Birth Certificate Difference-in-difference linear probability models were used to compare changes in the prevalence of neuraxial labor analgesia in 15 expansion and 11 nonexpansion states before and after Medicaid expansion Models were adjusted for potential maternal and obstetric confounders with standard errors clustered at the state level Results: The study sample included 5,703,371 births from 15 expansion states and 5,582,689 births from 11 nonexpansion states In the preexpansion period, the overall rate of neuraxial analgesia in expansion and nonexpansion states was 73.2% vs 76 3% Compared with the preexpansion period, the rate of neuraxial analgesia increased in the postexpansion period by 1 7% in expansion states (95% CI, 1 6-1 8) and 0 9% (95% CI, 0.9-1.0) in nonexpansion states.The adjusted difference-in-difference estimate comparing expansion and nonexpansion states was 0 47% points (95% CI, -0 63 to 1 57; P= 39)

Conclusions: Medicaid expansion was not associated with an increase in the rate of neuraxial labor analgesia in expansion states compared to the change in nonexpansion states over the same time period Increasing Medicaid eligibility alone may be insufficient to increase the rate of neuraxial labor analgesia.

F.ANTENATALSTUDIES

Opioid use disorder

30.Suarez EA, Huybrechts KF, Straub L, Hernández-Díaz S, Jones HE, Connery HS, Davis JM, Gray KJ, Lester B,Terplan M, Mogun H, Bateman BT Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy N Engl J Med 2022 Dec 1;387(22):2033-2044.

ABSTRACT

Background: Opioid agonist therapy is strongly recommended for pregnant persons with opioid use disorder Buprenorphine may be associated with more favorable neonatal and maternal outcomes than methadone, but existing data are limited Methods: We conducted a cohort study involving pregnant persons who were enrolled in public insurance programs in the United States during the period from 2000 through 2018 in which we examined outcomes among those who received buprenorphine as compared with those who received methadone. Exposure to the two medications was assessed in early pregnancy (through gestational week 19), late pregnancy (gestational week 20 through the day before delivery), and the 30 days before delivery. Risk ratios for neonatal and maternal outcomes were adjusted for confounders with the use of propensity-score overlap weights Results: The data source for the study consisted of 2,548,372 pregnancies that ended in live births In early pregnancy, 10,704 pregnant persons were exposed to buprenorphine and 4387 to methadone. In late pregnancy, 11,272 were exposed to buprenorphine and 5056 to methadone (9976 and 4597, respectively, in the 30 days before delivery) Neonatal abstinence syndrome occurred in 52 0% of the infants who were exposed to buprenorphine in the 30 days before delivery as compared with 69.2% of those exposed to methadone (adjusted relative risk, 0 73; 95% confidence interval [CI], 0 71 to 0 75) Preterm birth occurred in 14.4% of infants exposed to buprenorphine in early pregnancy and in 24 9% of those exposed to methadone (adjusted relative risk, 0 58; 95% CI, 0 53 to 0 62); small size for gestational age in 12 1% and 15 3%, respectively (adjusted relative risk, 0 72; 95% CI, 0.66 to 0.80); and low birth weight in 8.3% and 14.9% (adjusted relative risk, 0.56; 95% CI, 0.50 to 0 63) Delivery by cesarean section occurred in 33 6% of pregnant persons exposed to buprenorphine in early pregnancy and 33 1% of those exposed to methadone (adjusted relative risk, 1.02; 95% CI, 0.97 to 1.08), and severe maternal complications developed in 3.3% and 3 5%, respectively (adjusted relative risk, 0 91; 95% CI, 0 74 to 1 13) Results of exposure in late pregnancy were consistent with results of exposure in early pregnancy. Conclusions: The use of buprenorphine in pregnancy was associated with a lower risk of adverse neonatal outcomes than methadone use; however, the risk of adverse maternal outcomes was similar among persons who received buprenorphine and those who received methadone. (Funded by the National Institute on DrugAbuse )

31 Lim G, Soens M, WanaseljaA, ChyanA, Carvalho B, Landau R, George RB, Klem ML, Osmundson SS, Krans EE,Terplan M, Bateman BT.ASystematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for ObstetricAnesthesia and Perinatology and Society for Maternal Fetal Medicine.AnesthAnalg. 2022 Nov 1;135(5):912-925.

ABSTRACT

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD.This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence Atotal of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38 1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports.There were 5 randomized controlled trials Most studies (64%) were published in perinatology (32; 38 1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting We observed an increasing number of publications on peripartum pain management in pregnant people with OUD However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%) Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management

Penicillin allergy testing

32.Kwah JH, Burn MS, Liao J, Cate J, Son M. Outpatient penicillin allergy evaluation during pregnancy and associated clinical outcomes Am J Obstet Gynecol MFM 2022 Sep;4(5):100674.

ABSTRACT

Background: Beta-lactam antibiotics are often clinically indicated in the peripartum period, posing a challenge for pregnant women who report a penicillin allergy Allergy verification testing is rarely performed during pregnancy, even though most women do not have a true allergy

Objective: This study aimed to evaluate a hospital-wide multidisciplinary program introduced in August 2020 to identify, refer, evaluate, and test pregnant women with unverified penicillin allergies and assess its association with maternal and neonatal outcomes Study design: We conducted a retrospective cohort study at a large academic hospital of all pregnant women with a penicillin allergy documented in the electronic medical record who delivered from September 2020 to October 2021. Data were abstracted by medical record review. Women referred for penicillin allergy evaluation were compared with those who were not Maternal outcomes were alternative antibiotic (clindamycin or vancomycin) use, postpartum infection, and maternal length of postpartum hospital stay. Neonatal outcomes were intensive care unit admission, postnatal blood draw, antibiotic treatment, and birth hospitalization length of hospital stay

Bivariate and multivariable analyses were performed Results: Of 689 women with a documented penicillin allergy, 232 (33.7%) were referred for allergy evaluation during the study period Of those referred, 175 (75 4%) underwent allergy consultation, and of these patients, 167 (95.4%) were considered appropriate for allergy verification testing. Of note, 117 women (70.1%) underwent skin testing with or without graded oral amoxicillin drug challenge, and all but 1 woman (99 1%) were found to be penicillin tolerant Moreover, 5 additional women were delabeled of their penicillin allergy based on history and pharmacy confirmation of penicillin tolerance subsequent to index reaction Referred women had a 62% lower likelihood of receiving an alternative antibiotic than those who were not referred, and this significance persisted even after adjusting for potential confounders (adjusted odds ratio, 0.49; 95% confidence interval, 0 27-0 89) Other maternal and neonatal adverse outcomes were less frequent in those referred, but these associations did not reach statistical significance

Conclusion: This study documented the feasibility, safety, and clinical benefit of an outpatient penicillin allergy referral program for pregnant women Referred patients were significantly less likely to receive alternative antibiotics; however, more patients are needed to assess whether there are additional clinical benefits.

33 Gill MM, Gasner S, BankenA, Park M, WeaverA, Sharpe E,Theiler R Improving routine prenatal penicillin allergy testing for reported penicillin allergy. BMJ Open Qual. 2022 Jul;11(3):e001859

ABSTRACT

Background: Patients with self-reported antibiotic allergies have a higher cost of care, more frequent infections with resistant bacteria and worse health outcomes than patients without antibiotic allergies Ultimately, less than 5% of patients who report a penicillin allergy have a clinically significant immune-mediated hypersensitivity reaction when tested As 10%-30% of the population of pregnant patients are colonised for group B Streptococcus (GBS) and guidelines recommend penicillin as the treatment of choice for GBS, current recommendations support penicillin allergy testing in pregnant patients who report an allergy Methods and intervention: In this quality improvement project, nursing staff used an algorithm outlining inclusion and exclusion criteria to determine which patients were eligible to have penicillin allergy testing completed. Penicillin allergy testing consisted of a skin test using benzylpenicilloyl polylysine (Pre-Pen), penicillin G potassium, amoxicillin and alkaline hydrolysis mix (penicilloate) as a prick skin test, followed by intradermal skin test and finally an oral challenge with either amoxicillin or penicillin. Patient outcomes were analysed to evaluate the impact of the intervention. Results:

Of the 1266 patients receiving prenatal care during the intervention, 236 (19%) reported a history of penicillin allergy, and 212 if these were eligible for testing 150 of the eligible patients were offered penicillin allergy testing. 101 patients (67%) completed testing and 49 (33%) declined testing Seven patients (7%) had positive penicillin allergy testing, while 94 patients (93%) had negative penicillin allergy testing and were immediately de-labelled as penicillin allergic. Seventeen of the de-labelled patients subsequently tested positive for GBS colonisation, and all received intrapartum penicillin without adverse events Conclusions: Pursuing penicillin allergy testing for pregnant patients with reported penicillin allergy is a safe and feasible approach, allowing for allergy de-labelling and safe, guideline-driven antimicrobial therapy during subsequent labour and delivery hospitalisations Cost-effectiveness of the allergy testing and impact on later episodes of care should be further investigated.

Intermediate vs low dose LMWH

34.Bistervels IM, BuchmüllerA, Wiegers HMG, Ní Áinle F,Tardy B, Donnelly J, Verhamme P, JacobsenAF, HansenAT, Rodger MA, DeSancho MT, Shmakov RG, van Es N, Prins MH, Chauleur C, Middeldorp S; Highlow Block writing committee; Highlow Investigators. Intermediate-dose versus low-dose low-molecular-weight heparin in pregnant and post-partum women with a history of venous thromboembolism (Highlow study): an open-label, multicentre, randomised, controlled trial. Lancet. 2022 Nov 19;400(10365):1777-1787

ABSTRACT

Background: Pregnancy-related venous thromboembolism is a leading cause of maternal morbidity and mortality, and thromboprophylaxis is indicated in pregnant and post-partum women with a history of venous thromboembolism.The optimal dose of low-molecular-weight heparin to prevent recurrent venous thromboembolism in pregnancy and the post-partum period is uncertain. Methods: In this open-label, randomised, controlled trial (Highlow), pregnant women with a history of venous thromboembolism were recruited from 70 hospitals in nine countries (the Netherlands, France, Ireland, Belgium, Norway, Denmark, Canada, the USA, and Russia). Women were eligible if they were aged 18 years or older with a history of objectively confirmed venous thromboembolism, and with a gestational age of 14 weeks or less Eligible women were randomly assigned (1:1), before 14 weeks of gestational age, using a web-based system and permuted block randomisation (block size of six), stratified by centre, to either weight-adjusted intermediate-dose or fixed low-dose low-molecular-weight heparin subcutaneously once daily until 6 weeks post partum.The primary efficacy outcome was objectively confirmed venous thromboembolism (ie, deep-vein thrombosis, pulmonary embolism, or unusual site venous thrombosis), as determined by an independent central adjudication committee, in the intention-to-treat (ITT) population (ie, all women randomly assigned to treatment) The primary safety outcome was major bleeding which included antepartum, early post-partum (within 24 h after delivery), and late post-partum major bleeding (24 h or longer after delivery until 6 weeks post partum), assessed in all women who received at least one dose of assigned treatment and had a known end of treatment date This study is registered with ClinicalTrials gov, NCT01828697, and is now complete Findings: BetweenApril 24, 2013, and Oct 31, 2020, 1339 pregnant women were screened for eligibility, of whom 1110 were randomly assigned to weight-adjusted intermediate-dose (n=555) or fixed low-dose (n=555) low-molecular-weight heparin (ITTpopulation). Venous thromboembolism occurred in 11 (2%) of 555 women in the weight-adjusted intermediate-dose group and in 16 (3%) of 555 in the fixed low-dose group (relative risk [RR] 0·69 [95% CI 0·32-1·47]; p=0·33) Venous thromboembolism occurred antepartum in five (1%) women in the intermediate-dose group and in five (1%) women in the low-dose group, and post partum in six (1%) women and 11 (2%) women On-treatment major bleeding in the safety population (N=1045) occurred in 23 (4%) of 520 women in the intermediate-dose group and in 20 (4%) of 525 in the low-dose group (RR 1·16 [95% CI 0·65-2·09]) Interpretation: In women with a history of venous thromboembolism, weight-adjusted intermediate-dose low-molecular-weight heparin during the combined antepartum and post-partum periods was not associated with a lower risk of recurrence than fixed low-dose low-molecular-weight heparin These results indicate that low-dose

low-molecular-weight heparin for thromboprophylaxis during pregnancy is the appropriate dose for the prevention of pregnancy-related recurrent venous thromboembolism.

Childbirth classes and postpartum depression

35.Hassanzadeh R,Abbas-Alizadeh F, Meedya S, Mohammad-Alizadeh-Charandabi S, Mirghafourvand M Comparison of childbirth experiences and postpartum depression among primiparous women based on their attendance in childbirth preparation classes. J Matern Fetal Neonatal Med. 2022 Sep;35(18):3612-3619.

ABSTRACT

Background: Assessment of women's childbirth experience is an important indicator in maternity services Positive childbirth experiences improve mothers' health, whereas negative childbirth experiences can cause psychological stresses and, in extreme cases, may lead to postpartum depression Methods: In this cohort study, 204 women at 35-37 weeks of gestation were selected using cluster sampling from the health centers ofTabriz, Iran Women were divided into three groups (68 women in each group) based on their attendance in childbirth preparation classes: (a) non-attenders (did not attend any sessions), (b) irregular attenders (attended 1-3 sessions), and (c) regular attendants (attended 4-8 sessions). Interviews were conducted at one month postpartum to complete the Childbirth Experience Questionnaire (CEQ) and Edinburgh Postnatal Depression Scale (EPDS) The general linear model (GLM) was used to identify associations between women's attendance to the classes and either their childbirth experience or postpartum depression scores Results: Based on the GLM, the mean score of childbirth experience among the regular attenders was significantly higher than women who were irregular attenders (p = .032) or non-attenders (p < .001). In addition, the mean score of postpartum depression scale was significantly lower among regular attenders compared with non-attenders (p < .001). However, there was no significant difference in postpartum depression score among regular and irregular attenders (p = .257). Conclusions: Attending prenatal classes was associated with positive childbirth experience and low postpartum depression score.

G. LABORANALGESIA& SURGICALANESTHESIA

Cervical Cerclage

36.LeeA, Shatil B, Landau R, Menon P, Smiley R. Intrathecal 2-Chloroprocaine 3% Versus Hyperbaric Bupivacaine 0 75% for Cervical Cerclage:ADouble-Blind Randomized ControlledTrial AnesthAnalg 2022 Mar 1;134(3):624-632

Abstract

Background: Cervical cerclage is a short ambulatory procedure For spinal anesthesia, local anesthetic agents with rapid postoperative resolution are desired We hypothesized that in combination with fentanyl, intrathecal 2-chloroprocaine would produce earlier resolution of motor block, resulting in shorter time to meet recovery room discharge criteria than hyperbaric bupivacaine. Methods: Women undergoing cervical cerclage with spinal anesthesia were randomized to receive intrathecal 2-chloroprocaine 3% 50 mg or hyperbaric bupivacaine 0.75% 9 mg, both with fentanyl 15 µg Doses were empirically selected The onset and resolution of sensory and motor blockade and time to achieve recovery room discharge criteria were monitored On postoperative day 1, patients rated their satisfaction with the anesthetic and reported on transient neurologic symptoms (TNS), back pain, or headache The primary outcome was time from spinal injection to motor block resolution.The main secondary outcomes included times from spinal injection to (i)T12 dermatomal level, (ii) sensory block resolution, and (iii) ability to ambulate and void Results: Forty-three women were enrolled and randomized to either the chloroprocaine (N = 23) or bupivacaine group (N = 20).The mean (standard deviation [SD]) duration of surgery was 35 3 (11 4) minutes There was no difference between groups for time to motor block resolution-the median [interquartile range] time for the bupivacaine group (N = 17) was 112 [97-143] minutes versus 109 [88-148] minutes in the chloroprocaine group (N = 22), P= 66, but there was a significant difference in median time to sensory block resolution: 143 [116-162] minutes in the chloroprocaine group versus 198 [152-263] minutes in the bupivacaine group, P= 002 The recovery room discharge criteria, which at our institution include the ability to ambulate unassisted and void urine, were met 76 (95% CI, 33-145) minutes earlier in the chloroprocaine group, P< .0005. One complete block failure occurred with hyperbaric bupivacaine and 2 subjects in each group received treatment for intraoperative discomfort No patients reportedTNS Conclusions: Intrathecal 2-chloropocaine 3% provided similarly effective surgical anesthesia for cerclage placement.Although no difference in time to motor block resolution between groups was observed, the time to sensory block resolution and time to meet recovery room discharge criteria were both significantly shorter among patients who received chloroprocaine than patients who received bupivacaine Future studies are needed to identify and compare equipotent doses of chloroprocaine and bupivacaine to confirm the superiority of chloroprocaine for this ambulatory obstetric procedure.

Abstract

Background: Chloroprocaine is a short-acting local anesthetic that has been used for spinal anesthesia in outpatient surgery There is limited experience with spinal chloroprocaine for prophylactic cervical cerclage placement We sought to determine the effective dose of intrathecal chloroprocaine for 90% of patients (ED90) undergoing prophylactic cervical cerclage placement We hypothesized that the ED90 of intrathecal chloroprocaine when combined with 10-ug fentanyl would be between 33 and 54 mg Methods: In this prospective 2-center double-blinded study, we enrolled women undergoing prophylactic cervical cerclage placement under combined spinal-epidural anesthesia Apredetermined dose of intrathecal 3% chloroprocaine with fentanyl 10 ug was administered.The initial dose was 45-mg intrathecal chloroprocaine Subsequent dose adjustments were determined based on the response of the previous subject using an up-down sequential allocation with a biased-coin design Adose was considered effective if at least aT12 block was achieved, and there was no requirement for epidural activation or intraoperative analgesic supplementation during the procedure The primary outcome was the ED90 of intrathecal chloroprocaine with fentanyl 10 ug Secondary outcomes included duration of surgery, anesthetic side effects, time to resolution of motor and sensory block, time to achieve recovery room discharge criteria, and patient satisfaction with anesthetic care. Isotonic regression was used to estimate the ED90. Results: Forty-seven patients were enrolled into the study.Two patients were excluded (1 protocol violation and 1 failed block) In total, 45 patients completed the study The estimated ED90 (95% confidence interval) for intrathecal chloroprocaine combined with fentanyl 10 ug was 49.5 mg (45.0-50.1 mg) The median (interquartile range [IQR]) duration of surgery was 15 (10-24) minutes

Resolution of the motor (Bromage 0) and sensory block took a median time of 60 (45-90) minutes and 90 (75-105) minutes, respectively.The median time to achieve recovery room discharge criteria was 150 (139-186) minutes Satisfaction with anesthetic management was high in all patients There were no reports of postdural puncture headache or transient neurological symptoms postoperatively. Conclusions: The ED90 of intrathecal chloroprocaine combined with fentanyl 10 ug was 49 5 mg Intrathecal chloroprocaine was associated with rapid block recovery and high patient satisfaction, which makes it well suited for outpatient obstetric procedures.

37 Sharawi N,Tan HS,Taylor C, Fuller ME, Landreth RA, Diomede OI, Williams M, Martinello C, Mhyre JM, HabibAS. ED 90 of Intrathecal Chloroprocaine With Fentanyl for Prophylactic Cervical Cerclage:ASequentialAllocation Biased-Coin Design Anesth Analg. 2022Apr 1;134(4):834-842.

38 Liu K, Zhao P, Ding M, Ji H,Tao

B Median effective dose of ropivacaine for prophylactic cervical cerclage in Chinese women: a dose-finding study. RegAnesth Pain Med. 2022 Dec 30:rapm-2022-104242

Abstract

Background: Although intrathecal ropivacaine has been widely used for caesarean delivery, there are limited data for the use of ropivacaine for prophylactic cervical cerclage. We sought to determine the median effective dose of intrathecal ropivacaine for prophylactic cervical cerclage in 50% of patients (ED50) and the calculated dose required for successful block in 95% of patients (ED95). Methods: We included Chinese women scheduled for prophylactic cervical cerclage under combined spinal-epidural (CSE) anaesthesia in the first or second trimester A predetermined dose of intrathecal isobaric ropivacaine was administered If this determined dose achieved an effective block at a level not lower thanT12, the next dose was decreased by 0 5 mg Otherwise, the next dose was increased by 0 5 mg The primary outcome was the ED50 of intrathecal ropivacaine. Secondary outcomes included the calculated ED95, time from CSE to the start of surgery and so on Results: Forty patients were included in the study, 23 (57 5%) of 40 received an effective block only with intrathecal ropivacaine, while 17 (42 5%) patients needed extra epidural lidocaine to achieve a successful block.The ED50 of intrathecal ropivacaine confirmed by isotonic regression was 6 9 mg (95% CI, 6 68 to 7 12 mg), and the calculated ED95 was 7 8 mg (95% CI, 7 69 to 10 05 mg) When an effective block was achieved with intrathecal ropivacaine alone, the time to resolution of the sensory and motor blocks was 90 (75-100) min and 90 (60-100) min, respectively

Conclusions: The ED50 of intrathecal ropivacaine for prophylactic cervical cerclage was 6.9 mg. Intrathecal ropivacaine (7.8 mg) is likely to produce successful anaesthesia in 95% of patients undergoing prophylactic cervical cerclage

Labor-related studies

Epidural-Related Maternal Fever

39.Ackland GL, Van Duijvenboden S,AbbottTEF, Gutierrez DelArroyoA, Wilson MJ, David AL; EPIFEVER-2 investigators Interleukin-1 receptor antagonist, mode of analgesia and risk of Caesarean delivery after onset of labour: a Mendelian randomisation analysis Br JAnaesth. 2022 Jan;128(1):89-97.

ABSTRACT

Background: Lower circulating levels of the anti-inflammatory cytokine interleukin-1 receptor antagonist (IL-1ra) are associated with intrapartum inflammation and epidural analgesia-related maternal fever, both of which increase the rate of obstetric interventions We hypothesised that genetic variants determining IL-1ra levels would be associated with Caesarean delivery rates after the onset of labour Methods: We performed Mendelian randomisation analyses in parous women ≥16 yr old who received either non-neuraxial or neuraxial analgesia for their first two labours (UK Biobank) We used an established genetic score (calculated as 0-4, determined by the presence/absence of rs6743376 and rs1542176 alleles), in which the complete absence of both alleles causes the lowest IL-1ra levels.The primary outcome was Caesarean delivery after the onset of labour (odds ratio [OR]: 95% confidence intervals) Results: There were 7731 women (mean [standard deviation] age at first birth: 25 [5] yr) who had complete genetic scores and delivery data. For women who received non-neuraxial analgesia, Caesarean delivery rates were different across allele scores (χ2=12 4; P=0 015): 104/596 (17 4%) women with zero allele score underwent Caesarean delivery, compared with 654/5015 (13.0%) with allele score ≥1 (OR 1.41; 1.12-1.77). For women who had neuraxial analgesia, Caesarean delivery was not different across allele scores, ranging from 18 1% to 20 8% (χ2=0 29; P=0 99) Caesarean delivery was independent of type of analgesia for 818/7731 (10.6%) women with zero allele scores (OR 0.93; 0 63-1 39), but was higher in women receiving neuraxial analgesia with allele scores ≥1 (OR 1 55; 1 35-1 79; P<0 001) Conclusions: Mendelian randomisation analysis suggests that higher IL-1ra levels are associated with reduced Caesarean delivery rate. Neuraxial analgesia appears to disrupt this link

40 Seiler FA,

Scavone BM,

Shahul

S,Arnolds DE Maternal FeverAssociated With Continuous Spinal Versus Epidural LaborAnalgesia:ASingle-Center Retrospective Study

AnesthAnalg 2022 Dec 1;135(6):1153-1158

ABSTRACT

Background: Neuraxial labor analgesia is associated with elevations in maternal temperature; the mechanism responsible is unknown. Proposed mechanisms have included infection, altered thermoregulation, and inflammation, potentially triggered by local anesthetics Studies of the association between neuraxial labor analgesia and maternal fever have focused on epidural analgesia, and there have been no comparisons of the rate of maternal fever between continuous spinal and epidural labor analgesia Methods: We performed a retrospective study to compare the rate of maternal fever between patients who received continuous spinal versus epidural labor analgesia between June 2012 and March 2020 Each patient who received continuous spinal analgesia was matched to 2 patients who received epidural analgesia and had the same nulliparous status.The primary outcome of our study was the incidence of intrapartum maternal fever, which we defined as any temperature ≥38 °C before delivery and compared between the continuous spinal and epidural groups using Fisher exact test. Results: We identified 81 patients who received continuous spinal analgesia and 162 matched controls who received epidural analgesia Demographic and obstetric characteristics of the patients were similar between groups. While the duration of analgesia did not significantly differ, there was markedly increased bupivacaine consumption in women with epidural analgesia Eight of 81 (9 9%; 95% confidence interval [CI], 5 1-18 3) women with continuous spinal analgesia developed an intrapartum fever compared to 18 of 162 (11.1%; 95% CI, 7.1-16.9) of women with epidural analgesia ( P= 83; Fisher exact test) Conclusions: There was no significant difference in the rate of maternal fever between women with continuous spinal compared to epidural labor analgesia. While the route of administration and dose of bupivacaine differs between epidural and spinal labor analgesia, they are titrated to produce similar levels of neuraxial blockade. Our results are consistent with a model in which epidural related maternal fever is due to altered thermoregulation from a central neuraxial block and argue against a direct effect of bupivacaine or fentanyl, although we cannot rule out a concentration-independent effect of bupivacaine or fentanyl or an inflammatory effect of the catheter itself These retrospective results highlight the importance of prospective and mechanistic study of neuraxial analgesia-related maternal fever

41 Baron EL, Katz D Hot Off the Press! Commentary on "Maternal FeverAssociated With Continuous Spinal Versus Epidural LaborAnalgesia:ASingle-Center Retrospective Study" AnesthAnalg 2022 Dec 1;135(6):1151-1152

SUMMARY

Baron ELand Katz D have written an accompanying editorial that points out the problems with this study.These include the small sample size from a single institution, the outcome rate (maternal fever) was low, the retrospective nature of the study and their ability to limit the number of confounders was low Although ideally the results of the study would be followed up by a RCTethically one would not consider it due to the problems inherent with a dural puncture in the one group Baron and Katz suggest replicating the trial by Seiler et al but making it a multicenter effort with a larger sample size

42 CartledgeA, Hind D, Bradburn M, Martyn-St James M, Davenport S,Tung WS,Yung H, Wong J, Wilson M. Interventions for the prevention or treatment of epidural-related maternal fever: a systematic review and meta-analysis Br JAnaesth 2022 Oct;129(4):567-580.

Abstract

Background: Epidural-related maternal fever in women in labour has consequences for the mother and neonate There has been no systematic review of preventive strategies Methods: RCTs evaluating methods of preventing or treating epidural-related maternal fever in women in active labour were eligible. We searched MEDLINE, EMBASE, CINAHL, Web of Science, CENTRAL, and grey literature sources were searched from inception toApril 2021 Two review authors independently undertook study selection Data extraction and quality assessment was performed by a single author and checked by a second.The Cochrane Risk of Bias 2 tool was used Meta-analyses for the primary outcome, incidence of intrapartum fever, were performed using the DerSimonian and Laird random effects model to produce summary risk ratios (RRs) with 95% confidence intervals (95% CIs) Results: Forty-two records, representing 34 studies, were included Methods of reduced dose epidural reduced the incidence of intrapartum fever, but this was not statistically significant when six trials at high risk of bias were removed (seven trials; 857 participants; RR=0 83; 95% CI, 0 41-1 67) Alternative methods of analgesia and high-dose prophylactic systemic steroids reduced the risk of intrapartum fever compared with epidural analgesia. Prophylactic paracetamol was not effective. Conclusions: There is no clear evidence to support the use of any individual preventative or therapeutic intervention for epidural-related maternal fever. Further research should focus on understanding the mechanism of fever development to enable RCTs of potential interventions to reduce the incidence of intrapartum fever development and the subsequent disease burden felt by the neonate

Dural Puncture Epidural

43.Tan HS, Reed SE, Mehdiratta JE, Diomede OI, Landreth R, Gatta LA, Weikel D, Habib AS Quality of LaborAnalgesia with Dural Puncture Epidural versus Standard Epidural Technique in Obese Parturients:ADouble-blind Randomized Controlled Study. Anesthesiology. 2022 May 1;136(5):678-687.

ABSTRACT

Background: The dural puncture epidural technique may improve analgesia quality by confirming midline placement and increasing intrathecal translocation of epidural medications This would be advantageous in obese parturients with increased risk of block failure.This study hypothesizes that quality of labor analgesia will be improved with dural puncture epidural compared to standard epidural technique in obese parturients

Methods: Term parturients with body mass index greater than or equal to 35 kg · m-2, cervical dilation of 2 to 7 cm, and pain score of greater than 4 (where 0 indicates no pain and 10 indicates the worst pain imaginable) were randomized to dural puncture epidural (using 25-gauge Whitacre needle) or standard epidural techniques Analgesia was initiated with 15 ml of 0 1% ropivacaine with 2 µg ml-1 fentanyl, followed by programed intermittent boluses (6 ml every 45 min), with patient-controlled epidural analgesia. Parturients were blinded to group allocation The data were collected by blinded investigators every 3 min for 30 min and then every 2 h until delivery The primary outcome was a composite of (1) asymmetrical block, (2) epidural top-ups, (3) catheter adjustments, (4) catheter replacement, and (5) failed conversion to regional anesthesia for cesarean delivery Secondary outcomes included time to a pain score of 1 or less, sensory levels at 30 min, motor block, maximum pain score, patient-controlled epidural analgesia use, epidural medication consumption, duration of second stage of labor, delivery mode, fetal heart tones changes,Apgar scores, maternal adverse events, and satisfaction with analgesia.

Results: Of 141 parturients randomized, 66 per group were included in the analysis There were no statistically or clinically significant differences between the dural puncture epidural and standard epidural groups in the primary composite outcome (34 of 66, 52% vs. 32 of 66, 49%; odds ratio, 1 1 [0 5 to 2 4]; P= 0 766), its individual components, or any of the secondary outcomes

Conclusions: Alack of differences in quality of labor analgesia between the two techniques in this study does not support routine use of the dural puncture epidural technique in obese parturients.

Programmed Intermittent Epidural Bolus

44 SongY, Du W,TaoY, Li Q, Shen F, Xu Z, Liu Z Optimum programmed intermittent epidural bolus interval time between 8 mLboluses of Ropivacaine 0.1% with sufentanil

0.3 μg/mLwith dural puncture epidural technique for labor analgesia:Abiased-coin up-and-down sequential allocation trial J ClinAnesth 2022Aug;79:110698.

ABSTRACT

Objective: The combination of dural puncture epidural (DPE) technique and programmed intermittent epidural bolus (PIEB) is a novel alternative labor analgesia regimen providing rapid analgesia onset and improved analgesia quality However, the optimum PIEB settings for using the DPE technique remain unclear Design: Biased-coin up-and-down sequential allocation design. Setting: Labor analgesia. Patients: Forty nulliparous women requesting labor analgesia. Interventions: Dural was punctured using a 25-gauge Whitacre needle 12 mLof 0 1% ropivacaine with 0.3 μg/mLof sufentanil was used for initiation. Labor analgesia was maintained using the same solution with a fixed 8 mLvolume beginning 1 h after initiation The interval for the first patient was 60 min and varied for subsequent patients according to the biased-coin design (groups 60, 50, 40, and 30; interval 60, 50, 40, and 30 min, respectively).

Measurements: The primary outcome was adequate analgesia, defined as no request of patient-controlled epidural analgesia or provider boluses for 6 h after the epidural analgesia initiation or until the maternal cervix was fully dilated, whichever came first.The secondary outcomes included sensory blockade level, motor strength, maternal hypotension, and pruritus

Results:The estimated effective interval in 90% of participants was 41.5 min (95% CI 39.5-43.5 min) and 40.5 min (95% CI 33.7-47.5 min) by the truncated Dixon and Mood method and the isotonic regression method, respectively, for the 40 women included The proportions of patients with the highest sensory block level achieving or aboveT6 were 60%, 26%, 27%, and 0% in groups 30, 40, 50, and 60, respectively One patient presented a Bromage score of 1 There was a low incidence of hypotension in all the groups with no need for vasopressor treatment

Conclusions: The optimum PIEB interval time between 8 mLboluses of ropivacaine 0.1% and sufentanil 0 3 μg/mLwhen using the DPE technique was approximately 41 min

45 MazdaY,Arzola C, Downey K,Ye XY, Carvalho JCA Programmed intermittent epidural bolus for labour analgesia: a randomized controlled trial comparing bolus delivery speeds of 125 mL hr-1 versus 250 mL hr-1 . Can JAnaesth. 2022 Jan;69(1):86-96.

ABSTRACT

Purpose: Programmed intermittent epidural bolus (PIEB) provides better analgesia for labour pain than continuous epidural infusion does. Nevertheless, commonly used PIEB regimens are associated with high sensory block We hypothesized that a PIEB technique with slower bolus delivery speed would produce lower sensory levels Methods: We recruited term nulliparous women with singleton pregnancies during the first stage of labour.All participants had an American Society ofAnesthesiologists Physical Status score of II-III, had epidural catheters placed at L3/4, and had epidural analgesia maintained with PIEB 10 mLevery 40 min using 0 0625% bupivacaine with fentanyl 2 µg·mL-1 Women were randomized to receive PIEB delivered at 250 mL hr-1 (G250) or 125 mL hr-1 (G125) The study was completed six hours after the loading dose or at full cervical dilatation, whichever occurred first.The primary outcome was the presence of sensory block to ice ≥T6 in at least one assessment during the study period (maximum six hours) Results: We analyzed data from 90 women The proportion of women presenting sensory block ≥T6 at any time was not different between G125 and G250 groups (60 0% vs 64 4%; difference, -4 4%; 95% confidence interval [CI], -24 5 to 15 6; P= 0 66) The median [interquartile range] highest sensory block level was also not different between G125 and G250 groups (T6 [T7-T5] vsT5 [T7-T5], P= 0.39). Women in the G125 group had a lower incidence of hypotension than women in the G250 group did (11 1% vs 33 3%; difference, -22.2%; 95% CI, -38.8 to -5.67; P= 0.01). Quality of analgesia and patient satisfaction were not different between groups Conclusion: The maintenance of epidural analgesia with a PIEB delivery speed of 125 mL hr-1 did not produce lower sensory block levels when compared with 250 mL hr-1.The slower injection speed regimen was associated with lower incidence of hypotension, but this secondary finding warrants confirmation in a future trial

46 Zuo RH, Dang JJ, Zhuang JW, Chen QM, Zhang JY, Zheng HW, Wang ZP

The incidence of breakthrough pain associated with programmed intermittent bolus volumes for labor epidural analgesia: a randomized controlled trial Int J ObstetAnesth 2022 Aug;51:103571.

ABSTRACT

Background: In this randomized, blinded study, we evaluated the effects of different programmed intermittent epidural bolus (PIEB) volumes for labor analgesia on the incidence of breakthrough pain and other analgesic outcomes Methods: Nulliparous women with term cephalic singleton pregnancies who requested labor analgesia had epidural analgesia initiated with 10 mL0 1% ropivacaine with sufentanil 0 3 μg/mL The pump was programmed to deliver a 4, 6 or 8 mLbolus every 45 min (groups 4, 6 or 8, respectively) The primary outcome was the incidence of breakthrough pain, defined as inadequate analgesia after two patient-controlled epidural analgesia administrations in a 20-min period Secondary outcomes included ropivacaine consumption, time of the first patient-controlled epidural analgesia request, duration of the second stage of labor, and incidence of motor block Results: Among 210 women randomly allocated the incidence of breakthrough pain was 34 9%, 19 7%, and 13 1%, for groups 4, 6 and 8, respectively (P=0.011).The incidence of breakthrough pain in group 8 was lower than in group 4 (P=0 006) The median (interquartile range) hourly ropivacaine consumption was 8 2 mg/h (7 1-11 3), 10 4 mg/h (9 2-13 0), and 12 0 mg/h (11 2-13 8) in groups 4, 6 and 8, respectively (P<0.001). Group 8 had a longer duration of effective analgesia and longer second stage of labor than group 4 There was no significant difference between groups in the incidence of motor block. Conclusion: The larger PIEB volumes were preferred for epidural labor analgesia compared with a smaller volume because of improved analgesia without clinically significant increases in adverse effects

Gastric Ultrasound

47 Bouvet L, SchulzT, Piana F, Desgranges FP, Chassard D Pregnancy and Labor Epidural Effects on Gastric Emptying:AProspective Comparative Study Anesthesiology

2022Apr 1;136(4):542-550.

ABSTRACT

Background: The lack of reliable data on gastric emptying of solid food during labor has led to some discrepancies between current guidelines regarding fasting for solid food in the parturient This prospective comparative study aimed to test the hypothesis that the gastric emptying fraction of a light meal would be reduced in parturients receiving epidural analgesia and with no labor analgesia compared with nonpregnant and pregnant women Methods: Ten subjects were enrolled and tested in each group: nonpregnant women, term pregnant women, parturients with no labor analgesia, and parturients with epidural labor analgesia.After a first ultrasound examination was performed to ensure an empty stomach, each subject ingested a light meal (125 g yogurt; 120 kcal) within 5 min.Then ultrasound measurements of the antral area were performed at 15, 60, 90, and 120 min.The fraction of gastric emptying at 90 min was calculated as [(antral area90 min / antral area15 min) - 1] × 100, and half-time to gastric emptying was also determined. For the Parturient-Epidural group, the test meal was ingested within the first hour after the induction of epidural analgesia Results: The median (interquartile range) fraction of gastric emptying at 90 min was 52% (46 to 61), 45% (31 to 56), 7% (5 to 10), and 31% (17 to 39) for nonpregnant women, pregnant women, parturients without labor analgesia, and parturients with labor epidural analgesia, respectively (P< 0 0001) The fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient-Epidural group than in the Nonpregnant and Pregnant Control groups. In addition, the fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient-No-Epidural group than in the Parturient-Epidural group. Conclusions: Gastric emptying in parturients after a light meal was delayed, and labor epidural analgesia seems not to worsen but facilitates gastric emptying.This should be taken into consideration when allowing women in labor to consume a light meal

Accompanying editorial:

48 Palmer CM, JiangY Limiting Oral Intake during Labor: Do We Have It Right? Anesthesiology. 2022Apr 1;136(4):528-530.

LAconcentration for labor analgesia

49 Halliday L, Kinsella M, Shaw M, Cheyne J, Nelson SM, Kearns RJ Comparison of ultra-low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta-analysis.Anaesthesia. 2022Aug;77(8):910-918.

ABSTRACT

Lumbar epidural is the gold standard for labour analgesia Low concentrations of local anaesthetic are recommended This network meta-analysis investigated whether further reducing the concentration of local anaesthetic can improve maternal and neonatal outcomes without compromising analgesia We conducted a systematic search of relevant databases for randomised controlled trials comparing high (>0.1%), low (>0.08% to ≤0.1%) or ultra-low (≤0.08%) concentration local anaesthetic (bupivacaine or equivalent) for labour epidural. Outcomes included mode of delivery, duration of labour and maternal/neonatal outcomes Bayesian network meta-analysis with random-effects modelling was used to calculate odds ratios or weighted mean differences and 95% credible intervals Atotal of 32 studies met inclusion criteria (3665 women) The total dose of local anaesthetic received increased as the concentration increased; ultra-low compared with low (weighted mean difference -14.96 mg, 95% credible interval [-28 38 to -1 00]) and low compared with high groups (weighted mean difference -14 99 [-28 79 to -2 04]), though there was no difference in the number of rescue top-ups administered between the groups. Compared with high concentration, ultra-low concentration local anaesthetic was associated with increased likelihood of spontaneous vaginal delivery (OR 1.46 [1.18 to 1.86]), reduced motor block (Bromage score >0; OR 0.32 [0.18 to 0 54]) and reduced duration of second stage of labour (weighted mean difference -13 02 min [-21 54 to -4 77]) Compared with low, ultra-low concentration local anaesthetic had similar estimates for duration of second stage of labour (weighted mean difference -1.92 min [-14.35 to 10 20]); spontaneous vaginal delivery (OR 1 07 [0 75 to 1 56]; assisted vaginal delivery (OR 1 35 [0 75 to 2 26]); caesarean section (OR 0 76 [0 49 to 1 22]); pain (scale 1-100, weighted mean difference -5.44 [-16.75 to 5.93]); and maternal satisfaction.Although a lower risk of an Apgar score < 7 at 1 min (OR 0 43 [0 15 to 0 79]) was reported for ultra-low compared with low concentration, this was not sustained at 5 min (OR 0 12 [0 00 to 2 10]) Ultra-low concentration local anaesthetic for labour epidural achieves similar or better maternal and neonatal outcomes as low and high concentration, but with reduced local anaesthetic consumption

Epidural and reduced SMM

50 Guglielminotti J, Landau R, Daw J, FriedmanAM, Chihuri S, Li G Use of Labor NeuraxialAnalgesia for Vaginal Delivery and Severe Maternal Morbidity JAMANetw Open. 2022 Feb 1;5(2):e220137.

ABSTRACT

Importance: Addressing severe maternal morbidity (SMM) is a public health priority in the US. Use of labor neuraxial analgesia for vaginal delivery is suggested to reduce the risk of postpartum hemorrhage (PPH), the leading cause of preventable severe maternal morbidity

Objective: To assess the association between the use of labor neuraxial analgesia for vaginal delivery and SMM Design, setting, and participants: In this population-based cross-sectional study, women aged 15 to 49 years undergoing their first vaginal delivery were included Data were taken from hospital discharge records from NewYork between January 2010 and December 2017 Data were analyzed from November 2020 to November 2021 Exposures: Neuraxial analgesia (ie, epidural or combined spinal-epidural) vs no neuraxial analgesia. Main outcomes and measures: The primary outcome was SMM, as defined by the US Centers for Disease Control and Prevention, and the secondary outcome was PPH Adjusted odds ratios (aORs) and 95% CIs of SMM associated with neuraxial analgesia were estimated using the inverse propensity score-weighting method and stratified according to race and ethnicity (non-Hispanic White vs racial and ethnic minority women, including non-HispanicAsian or Pacific Islander, non-Hispanic Black, Hispanic, and other race and ethnicity) and to the comorbidity index for obstetric patients (low-risk vs high-risk women) The proportion of the association of neuraxial analgesia with the risk of SMM mediated through PPH was estimated using mediation analysis. Results: Of 575 524 included women, the mean (SD) age was 28 (6) years, and 46 065 (8 0%) were non-HispanicAsian or Pacific Islander, 88 577 (15 4%) were non-Hispanic Black, 104 866 (18.2%) were Hispanic, 258 276 (44.9%) were non-Hispanic White, and 74 534 (13.0%) were other race and ethnicity.Atotal of 400 346 women (69.6%) were in the low-risk group and 175 178 (30 4%) in the high-risk group, and 272 921 women (47.4%) received neuraxial analgesia. SMM occurred in 7712 women (1.3%), of which 2748 (35 6%) had PPH Before weighting, the incidence of SMM was 1 3% (3486 of 272 291) with neuraxial analgesia compared with 1 4% (4226 of 302 603) without neuraxial analgesia (risk difference, -0.12 per 100; 95% CI, -0.17 to -0.07).After weighting, the aOR of SMM associated with neuraxial analgesia was 0 86 (95% CI, 0 82-0 90) Decreased risk of SMM associated with neuraxial analgesia was similar between non-Hispanic White women and racial and ethnic minority women and between low-risk and high-risk women. More than one-fifth (21%; 95% CI, 14-28) of the observed association of neuraxial analgesia with the risk of SMM was mediated through the decreased risk of PPH. Conclusions and relevance: Findings from this study suggest that use of neuraxial analgesia for vaginal delivery is associated with a 14% decrease in the risk of SMM Increasing access to and utilization of labor neuraxial analgesia may contribute to improving maternal health outcomes.

Assessment of sensory block during labor epidural analgesia

51.de Souza Soares EC, Balki M, Downey K,Ye XY, Carvalho JCA.Assessment of sensory block during labour epidural analgesia: a prospective cohort study to determine the influence of the direction of testing. Can JAnaesth. 2022 Jun;69(6):750-755.

ABSTRACT

Purpose: Assessment of sensory block level during labour epidural analgesia is an essential component of clinical practice and patient safety Nevertheless, the methods and direction of testing are not standardized In our hospital, sensory block testing to ice is routinely used, but while some anesthesiologists test the block from a nonanesthetized to an anesthetized area, some do it in the opposite direction It is unknown how these two different practices affect identification of the sensory block level The objective of this study was to determine the agreement between these two practices. Methods: We enrolled 31 patients admitted to the labour and delivery unit in a prospective cohort study At their request, labour epidural analgesia was performed as per institutional routine. Sensory block level to ice was assessed using opposite directions by two randomly assigned independent investigators, one and two hours after the loading dose was administered Results: Sensory block levels to ice assessed from an anesthetized area to a nonanesthetized area were lower than those when assessed with the stimulus applied in the opposite direction, typically one segment lower Discussion: Given the small difference detected with both methods, it may be acceptable to use either in clinical practice. Nevertheless, the lack of standardization may have a significant impact when comparing studies involving assessment of sensory block to ice

Change in Sensory level during PIEB for labor

52.Casellato JF,Ye XY, Downey K, Carvalho JCA. Changes in sensory block level during a programmed intermittent epidural bolus regimen for labour analgesia: a prospective observational cohort study. Can JAnaesth. 2022 Dec;69(12):1471-1476.

ABSTRACT

Purpose: In the context of a programmed intermittent epidural bolus (PIEB) regimen for labour analgesia, one can identify an upper sensory block level (USBL), defined as the highest dermatome with any altered sensation to cold, and a lower sensory block level (LSBL), defined as the highest dermatome with complete sensory block to cold.This study investigated whether and how these sensory block levels vary within PIEB cycles Methods: We enrolled patients requesting epidural analgesia An epidural catheter was placed at L2/L3 or L3/L4 Atest dose of 3 mLof bupivacaine 0.125% with fentanyl 3.3 µg·mL-1 was administered, followed by 12 mLof the same solution as the loading dose APIEB plus patient-controlled epidural analgesia (PCEA) regimen was initiated 40 min after the loading dose, with bupivacaine 0.0625% with fentanyl 2 µg·mL-1: PIEB 10 mL, PIEB interval 40 min, PCEA5 mL, lockout interval 10 min, maximum hourly 30 mL As per institutional protocol, sensory block levels to ice were assessed 20 min after the loading dose and then hourly. Patients included in the study underwent eight extra assessments: immediately before the second and fourth PIEB and 10, 20, and 30 min after the second and third PIEB Results: We studied 30 patients The USBLand LSBL achieved their peak value 100 min after the loading dose.The median [interquartile range]

USBLwasT8 [T9-T7] andT6 [T7-T4] 20 and 100 min after the loading dose, respectively; LSBL wasT10 [T11-T6] andT8 [T9-T6], respectively.There was no significant variation in USBLor LSBL within the PIEB cycle between the second and the third or the third and the fourth PIEB.

Conclusion: Once peak sensory block levels are established, there is no significant variation in the USBLand LSBLwithin the PIEB cycles.

Cesarean Delivery

Intraoperative breakthrough Pain

53.Patel R, Kua J, Sharawi N, Bauer ME, Blake L, Moonesinghe SR, Sultan P. Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review Anaesthesia 2022 May;77(5):598-604

ABSTRACT

Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine the prevalence of inadequate neuraxial anaesthesia for elective caesarean section; prevalence of conversion from neuraxial anaesthesia to general anaesthesia following inadequate neuraxial anaesthesia; and the effect of mode of anaesthesia. We searched studies reporting inadequate neuraxial anaesthesia that used ≥ ED95 doses (effective dose in 95% of the population) of neuraxial local anaesthetic agents. Our primary outcome was the prevalence of inadequate neuraxial anaesthesia, defined as the need to convert to general anaesthesia; the need to repeat or abandon a planned primary neuraxial technique following incision; unplanned administration of intra-operative analgesia (excluding sedatives); or unplanned epidural drug supplementation. Fifty-four randomised controlled trials were included (3497 patients) The overall prevalence of requirement for supplemental analgesia or anaesthesia was 14 6% (95%CI 13 3-15 9%); 510 out of 3497 patients.The prevalence of general anaesthesia conversion was 2 out of 3497 patients (0 06% (95%CI 0 0-0 2%)) Spinal/combined spinal-epidural anaesthesia was associated with a lower overall prevalence of inadequate neuraxial anaesthesia than epidural anaesthesia (10.2% (95%CI 9.0-11.4%), 278 out of 2732 patients vs. 30.3% (95%CI 26 5-34 5%), 232 out of 765 patients) Further studies are needed to identify risk factors, optimise detection and management strategies and to determine long-term effects of inadequate neuraxial anaesthesia

Accompanying Editorial

54 Stanford SER What is 'genuine' failure of neuraxial anaesthesia?Anaesthesia 2022 May;77(5):523-526

SUMMARY

Frequency of inadequate anesthesia unknown – more patent centric data needed. Frequency of supplementary analgesia may underestimate true incidence Similarly Conversion to GAmay just be the tip of the iceberg What is the frequency of experiencing pain but not reporting it? What is the best way to study this? ‘pressure / tugging’can be painful for some women

55 Plaat F, Stanford SER, Lucas DN,Andrade J, Careless J, Russell R, Bishop D, Lo Q, Bogod D. Prevention and management of intra-operative pain during caesarean section under neuraxial anaesthesia: a technical and interpersonal approach Anaesthesia 2022 May;77(5):588-597.

ABSTRACT

Awoman who experiences pain during caesarean section under neuraxial anaesthesia is at risk of adverse psychological sequelae Litigation arising from pain during caesarean section under neuraxial anaesthesia has replaced accidental awareness under general anaesthesia as the most common successful medicolegal claim against obstetric anaesthetists. Generic guidelines on caesarean section exist, but they do not provide specific recommendations for this area of anaesthetic practice This guidance aims to offer pragmatic advice to support anaesthetists in caring for women during caesarean section. It emphasises the importance of non-technical skills, offers advice on best practice and aims to encourage standardisation The guidance results from a collaborative effort by anaesthetists, psychologists and patients and has been developed to support clinicians and promote standardisation of practice in this area

Peripheral nerve blocks for Cesarean delivery analgesia

56.Singh NP, Monks D, Makkar JK, PalanisamyA, Sultan P, Singh PM. Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials.Anaesthesia. 2022Apr;77(4):463-474.

ABSTRACT

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this We aimed to compare and rank these sites We searched PubMed, Google Scholar, EMBASE and CENTRALto June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants).The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1 2 (0 2-2 1); erector spinae 1 3 (-0 5 to 3 1); quadratus lumborum 1 0 (0 1-1 8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0 8 (-1 8 to 0 2) We categorised our confidence in effect sizes as low or very low.

Uterine exteriorization

57.Tan HS,Taylor CR, Sharawi N, Sultana R, Barton KD, HabibAS. Uterine exteriorization versus in situ repair in Cesarean delivery: a systematic review and meta-analysis Can J Anaesth. 2022 Feb;69(2):216-233.

ABSTRACT

Purpose: We conducted an updated systematic review and meta-analysis on maternal outcomes associated with uterine exteriorization compared with in situ repair in women undergoing Cesarean delivery Methods: We searched for randomized controlled trials comparing uterine exteriorization with in situ repair during Cesarean delivery. Primary outcomes were intraoperative nausea and vomiting (IONV) and perioperative decrease in hemoglobin concentration Secondary outcomes were postoperative nausea and vomiting (PONV), estimated blood loss, fever, endometritis, wound infection, intraoperative and postoperative pain, postoperative analgesic use, duration of surgery and hospital stay, and time to return of bowel function. Results: Twenty studies with 20,909 parturients were included. Exteriorization was associated with higher risk of IONV (odds ratio [OR], 2 09; 95% confidence interval [CI], 1 66 to 2 63; I2 = 0%), with no difference in perioperative hemoglobin concentration decrease (mean difference, - 0.06 g dL-1; 95% CI, - 0.20 to 0.08; I2 = 97%) compared with in situ repair. There were no significant differences in estimated blood loss, transfusion requirement, PONV, duration of surgery, duration of hospital stay, time to return of bowel function, fever, endometritis, or wound infection. Postoperative pain (incidence of pain graded > 5/10) at six hours (OR, 1.64; 95% CI, 1 31 to 2 03; I2 = 0%) was higher with exteriorization, but there was no difference in need for rescue analgesia (OR, 2.48; 95% CI, 0.89 to 6.90; I2 = 94%) or pain scores at 24 hr compared with in situ repair. Conclusions: In this updated systematic review and meta-analysis, uterine exteriorization was associated with an increased risk of IONV but no significant change in perioperative hemoglobin decrease compared with in situ repair.

Comment:They looked at risk of bias, certainty of evidence and also performed trial sequential analysis (TSA) for the estimated required information size.in the majority of included studies the investigators did not specify whether antiemetic prophylaxis was administered, important element in these studies, and possibly of equal import is the timing of administration of antiemetic prophylaxis. If administered simultaneously with uterine exteriorization it is unlikely to have an impact, as opposed to earlier administration Tan et al also point out the potential importance of hypotension as only one study used a prophylactic phenylephrine infusion.

TIVAfor cesarean

58.MetodievY, Lucas DN.The role of total intravenous anaesthesia for caesarean delivery. Int J ObstetAnesth 2022Aug;51:103548

ABSTRACT

Obstetric general anaesthesia technique usually involves intravenous induction and maintenance with volatile agents.Total intravenous anaesthesia has gained in popularity in non-obstetric practice because of environmental concerns associated with volatile inhalational anaesthetics and evidence of a superior recovery profile Publications on the use of total intravenous anaesthesia for caesarean delivery are sparse.The limited evidence suggests that total intravenous anaesthesia may confer benefits for caesarean delivery, including reducing the risk of haemorrhage However, there are practical barriers to utilising total intravenous anaesthesia in obstetric anaesthesia. We discuss the evidence and potential role of total intravenous anaesthesia for caesarean delivery

Difficult intubation in obstetrics

59.Reale SC, Bauer ME, KlumpnerTT,Aziz MF, Fields KG, Hurwitz R, Saad M, Kheterpal S, Bateman BT; Multicenter Perioperative Outcomes Group Collaborators Frequency and Risk Factors for Difficult Intubation in Women Undergoing GeneralAnesthesia for Cesarean Delivery:AMulticenter Retrospective CohortAnalysis.Anesthesiology. 2022 May 1;136(5):697-708

ABSTRACT

Background: Estimates for the incidence of difficult intubation in the obstetric population vary widely, although previous studies reporting rates of difficult intubation in obstetrics are older and limited by smaller samples.The goals of this study were to provide a contemporary estimate of the frequency of difficult and failed intubation in women undergoing general anesthesia for cesarean delivery and to elucidate risk factors for difficult intubation in women undergoing general anesthesia for cesarean delivery Methods: This is a multicenter, retrospective cohort study utilizing the Multicenter Perioperative Outcomes Group database The study population included women aged 15 to 44 yr undergoing general anesthesia for cesarean delivery between 2004 and 2019 at 1 of 45 medical centers Coprimary outcomes included the frequencies of difficult and failed intubation Difficult intubation was defined as Cormack-Lehane view of 3 or greater, three or more intubation attempts, rescue fiberoptic intubation, rescue supraglottic airway, or surgical airway Failed intubation was defined as any attempt at intubation without successful endotracheal tube placement The rates of difficult and failed intubation were assessed Several patient demographic, anatomical, and obstetric factors were evaluated for potential associations with difficult intubation Results: This study identified 14,748 cases of cesarean delivery performed under general anesthesia There were 295 cases of difficult intubation, with a frequency of 1:49 (95% CI, 1:55 to 1:44; n = 14,531) There were 18 cases of failed intubation, with a frequency of 1:808 (95% CI, 1:1,276 to 1:511; n = 14,537) Factors with the highest point estimates for the odds of difficult intubation included increased body mass index, Mallampati score III or IV, small hyoid-to-mentum distance, limited jaw protrusion, limited mouth opening, and cervical spine limitations Conclusions: In this large, multicenter, contemporary study of more than 14,000 general anesthetics for cesarean delivery, an overall risk of difficult intubation of 1:49 and a risk of failed intubation of 1:808 were observed Most risk factors for difficult intubation were nonobstetric in nature These data demonstrate that difficult intubation in obstetrics remains an ongoing concern.

Dexamethasone for cesarean delivery

60.Singh NP, Makkar JK,Yadav N, Goudra BG, Singh PM.The analgesic efficacy of intravenous dexamethasone for post-caesarean pain:Asystematic review with meta-analysis and trial sequential analysis. Eur JAnaesthesiol. 2022 Jun 1;39(6):498-510.

ABSTRACT

Background: Analgesic efficacy of intravenous dexamethasone has not been well defined after caesarean delivery We performed a systematic review and meta-analysis to evaluate the impact of peri-operative dexamethasone administration on postoperative pain after caesarean delivery Objectives: We investigated the impact of perioperative intravenous dexamethasone on postoperative pain after caesarean delivery The two primary outcomes of interest were early (4 to 6 h) resting pain scores and time to first rescue analgesia. Design: Asystematic review and meta-analysis of randomised controlled trials (RCTs) Data sources: PubMed, EMBASE, Scopus and the Cochrane central registers of controlled trials were searched to identify RCTs from inception toApril 2021 Eligibility criteria: Prospective RCTs comparing the role of intravenous dexamethasone with non-active control were eligible for inclusion Exclusion criteria included trials comparing various doses of dexamethasone without any control treatment arm, dexamethasone with other active drugs and trials comparing different routes of dexamethasone, for example, wound infiltration Results: Thirteen RCTs constituting of 988 parturients undergoing caesarean delivery were included. Patients receiving dexamethasone had lower pain scores at rest at 4 to 6 h after surgery, mean difference -1 29 [95% confidence interval (CI), -1 85 to -0 73], P< 0 0001, with low quality of evidence (I2 = 94%) Moderate quality of evidence (I2 = 17%) suggested that the time to first rescue analgesia in the dexamethasone group was significantly longer, mean difference 2 64 h (95% CI, 1 85 to 3 42), P< 0 0001 Trial sequential analysis for pain scores suggested the benefit of dexamethasone; however, the requisite information size (RIS) could not be reached, whereas RIS was adequate for time to rescue analgesia Significant reduction in pain scores at all times and opioid consumption at 24 h with dexamethasone were observed with sparse reporting on adverse effects. Conclusion: Peri-operative intravenous dexamethasone was associated with a significant decrease in postoperative pain scores at rest and a longer time to first rescue analgesia, along with a small but statistically significantly reduced opioid consumption after caesarean delivery compared with nonactive control

Peri-induction oxygenation

61. Wong CA, Mushambi M. Peri-intubation oxygenation for Caesarean delivery: is there an optimal technique? Br JAnaesth. 2022 Oct;129(4):468-471. doi:

10 1016/j bja 2022 07 014

ABSTRACT

Peri-intubation oxygen administration to the pregnant patient during induction of general anaesthesia is critical to avoiding hypoxaemia and harm to the mother and fetus. Recent modelling comparing low-flow with high-flow nasal oxygen in simulated term pregnant women of varying body habitus, taken together with previous work, suggests that face mask preoxygenation with the use of low-flow or high-flow nasal oxygen during the period of apnoea prolongs the safe apnoea period, with the benefit varying by body habitus Low-flow compared with high-flow nasal oxygen may be easier to combine with face mask preoxygenation and is readily available in all operating theatres, although future improvements in high-flow nasal oxygen delivery systems may improve ease of use for this indication

Uterotonics

62.TyagiA, MohanA, SinghY, LuthraA, Garg D, Malhotra RK. Effective Dose of Prophylactic Oxytocin Infusion During Cesarean Delivery in 90% Population of Nonlaboring Patients With Preeclampsia Receiving Magnesium SulfateTherapy and Normotensives:An Up-Down SequentialAllocation Dose-Response Study.Anesth

Analg 2022 Feb 1;134(2):303-311

ABSTRACT

Background: Oxytocin administration during cesarean delivery is the first-line therapy for the prevention of uterine atony. Patients with preeclampsia may receive magnesium sulfate, a drug with known tocolytic effects, for seizure prophylaxis However, no study has evaluated the minimum effective dose of oxytocin during cesarean delivery in women with preeclampsia

Methods: This study compared the effective dose in 90% population (ED90) of oxytocin infusion for achieving satisfactory uterine tone during cesarean delivery in nonlaboring patients with preeclampsia who were receiving magnesium sulfate treatment with a control group of normotensives who were not receiving magnesium sulfate This prospective dual-arm dose-finding study was based on a 9:1 biased sequential allocation design Oxytocin infusion was initiated at 13 IU/h, on clamping of the umbilical cord, in the first patient of each group. Uterine tone was graded as satisfactory or unsatisfactory by the obstetrician at 4 minutes after initiation of oxytocin infusion The dose of oxytocin infusion for subsequent patients was decided according to the response exhibited by the previous patient in the group; it was increased by 2 IU/h after unsatisfactory response or decreased by 2 IU/h or maintained at the same level after satisfactory response, in a ratio of 1:9 Oxytocin-associated side effects were also evaluated Dose-response data for the groups were evaluated using a log-logistic function and ED90 estimates were derived from fitted equations using the delta method Results: The ED90 of oxytocin was significantly greater for the preeclampsia group (n = 27) than for the normotensive group (n = 40) (24 9 IU/h [95% confidence interval {CI}, 22 4-27 5] and 13 9 IU/h [95% CI, 12 4-15 5], respectively); the difference in dose requirement was 10 9 IU/h (95% CI, 7 9-14 0; P < .001).The number of patients with oxytocin-related hypotension, defined as a decrease in systolic blood pressure >20% from baseline or to <90 mm Hg, was significantly greater in the preeclampsia group (92 6% vs 62 5%; P= 030), while other side effects such as ST-T depression, nausea/vomiting, headache, and flushing, were not significantly different.There was no significant difference in the need for additional uterotonic or uterine massage, estimated blood loss, and need for re-exploration for uncontrolled bleeding. Conclusions: Patients with preeclampsia receiving preoperative magnesium therapy need a greater intraoperative dose of oxytocin to achieve satisfactory contraction of the uterus after fetal delivery, as compared to normotensives.

63 McDonagh F, Carvalho JCA,Abdulla S, Cordovani D, Downey K,Ye XY, Farine D, Morais M, Balki M. Carbetocin vs. oxytocin at elective caesarean delivery: a double-blind, randomised, controlled, non-inferiority trial of low- and high-dose regimens Anaesthesia. 2022Aug;77(8):892-900.

ABSTRACT

Carbetocin or oxytocin are given routinely as first-line uterotonic drugs following delivery of the neonate during caesarean delivery to prevent postpartum haemorrhage Low doses may be as effective as high doses with a potential reduction in adverse effects In this double-blind, randomised, controlled, non-inferiority trial, we assigned low-risk patients undergoing elective caesarean delivery under spinal anaesthesia to one of four groups: carbetocin 20 μg; carbetocin 100 μg; oxytocin 0 5 IU bolus + infusion; and oxytocin 5 IU bolus + infusion The study drug was given intravenously after delivery of the neonate. Uterine tone was assessed by the obstetrician 2, 5 and 10 minutes after study drug administration according to an 11-point verbal numerical rating scale (0 = atonic, 10 = excellent tone).The primary outcome measure was uterine tone 2 min after study drug administration The pre-specified non-inferiority margin was 1 2 points on the 11-point scale Secondary outcomes included uterine tone after 5 and 10 minutes, use of additional uterotonics, blood loss and adverse effects. Data were available for 277 patients. Carbetocin 20 μg resulting in uterine tone of (median (IQR [range])) 8 (7-8 [1-10]) was non-inferior to carbetocin 100 μg with tone 8 (7-9 [3-10]), median (95%CI) difference 0 (-0.44-0.44). Similarly, oxytocin 0.5 IU with tone 7 (6-8 [3-10]) was non-inferior to oxytocin 5 IU with tone 8 (6-8 [2-10]), median (95%CI) difference 1 (0 11-1 89) Carbetocin 20 μg was also non-inferior to oxytocin 5 IU, and oxytocin 0 5 IU was non-inferior to carbetocin 100 μg Uterine tone after 5 and 10 minutes, use of additional uterotonics, blood loss and adverse effects were similar in all groups

64

Jaffer

D,

Singh PM,AslamA, CahillAG, PalanisamyA, Monks DT

Preventing postpartum hemorrhage after cesarean delivery: a network meta-analysis of available pharmacologic agents

Am J Obstet Gynecol 2022 Mar;226(3):347-365

ABSTRACT

Background: Postpartum hemorrhage causes a quarter of global maternal deaths The World Health Organization recommends oxytocin as the first line agent to prevent hemorrhage during cesarean delivery However, some randomized controlled trials suggest that other uterotonics are superior Objective: We conducted a network meta-analysis comparing the ability of pharmacologic agents to reduce blood loss and minimize the need for additional uterotonics during cesarean delivery Data sources: We searched the Cochrane Central Register of ControlledTrials, Embase, and MEDLINE databases from inception to May 2020. Study eligibility criteria: We included randomized controlled trials that compared oxytocin, carbetocin, misoprostol, ergometrine, carboprost, or combinations of these in the prevention of postpartum hemorrhage during cesarean delivery. Methods: We performed a systematic review followed by an NMAin accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines Quality of the evidence was assessed with the Confidence in Network Meta-Analysis approach and Grading of Recommendations,Assessment, Development and Evaluations tool within the summary of findings table Our primary outcomes were the estimated blood loss and need for additional uterotonics. Secondary outcomes included nausea and postpartum hemorrhage of >1000 mL. We performed sensitivity analyses to explore the influence of surgical context and oxytocin administration strategy Results: Atotal of 46 studies with 7368 participants were included. Of those, 21 trials (6 agents and 3665 participants) formed the "estimated blood loss" network and, considering the treatment effects, certainty in the evidence, and surface under the cumulative ranking curve scores, carbetocin was assessed to probably be superior to oxytocin, but only in reducing the estimated blood loss by a clinically insignificant volume (54 83 mL; 95% confidence interval, 26 48-143 78)

Misoprostol, ergometrine, and the combination of oxytocin and ergometrine were assessed to probably be inferior, whereas the combination of oxytocin and misoprostol was assessed to definitely be inferior to oxytocin Atotal of 37 trials (8 agents and 6193 participants) formed the "additional uterotonic" network and, again, carbetocin was assessed to probably be superior to oxytocin, requiring additional uterotonics 185 (95% confidence interval, 130-218) fewer times per 1000 cases Oxytocin plus misoprostol, oxytocin plus ergometrine, and misoprostol were assessed to probably be inferior, whereas carboprost, ergometrine, and the placebo were definitely inferior to oxytocin For both primary outcomes, oxytocin administration strategies had a higher probability of being the best uterotonic, if initiated as a bolus Conclusion: Carbetocin is probably the most effective agent in reducing blood loss and the need for additional uterotonics Oxytocin appears to be more effective when initiated as a bolus

TranexamicAcid

65.Ogunkua OT, Duryea EL, Nelson DB, Eddins MM, Klucsarits SE, McIntire DD, Leveno KJ Tranexamic acid for prevention of hemorrhage in elective repeat cesarean delivery-a randomized study.Am J Obstet Gynecol MFM. 2022 Mar;4(2):100573.

Background: TheAmerican College of Obstetricians and Gynecologists states that the current data are insufficient to recommend tranexamic acid prophylaxis for postpartum hemorrhage Objective: This study's objective was to evaluate if prophylactic tranexamic acid treatment reduces the calculated blood loss when compared with a placebo in women undergoing an elective repeat cesarean delivery. Study design: This was a double-blind, randomized, placebo-controlled trial in which the calculated blood loss was determined after administration of prophylactic doses of 1 g of tranexamic acid before skin incision and after placental delivery and standard uterotonics in women with singleton pregnancies at ≥37 weeks' gestation presenting for their second or third cesarean delivery under neuraxial anesthesia The primary outcome was calculated blood loss at 24 hours The calculation was based on each participant's height, weight, and the difference in hematocrit before the start of surgery and 24 hours after delivery Prespecified secondary outcomes were quantification of maternal coagulation activity during the perioperative course Asample size of 50 women per group was planned (N=100) based on a meta-analysis of mean reduction in blood loss after tranexamic acid Results: Atotal of 723 women were screened, and 110 women were randomized as follows: 55 to the tranexamic acid group and 55 to the placebo group.The primary outcome of mean calculated blood loss was 2274±469 mLfor the tranexamic acid group and 2407±388 mL for the placebo group (P> 05) For the secondary outcomes, D-dimer levels were lower in the tranexamic acid group than in the placebo group 24 hours after delivery (2.1±1.2 µg/mLvs 4 3±2 4 µg/mL; P< 001) Conclusion: Prophylactic tranexamic acid treatment did not decrease the mean calculated blood loss Significantly less participants had a calculated blood loss >2000 mLin the tranexamic acid group than in the placebo group and had lower levels of D-dimer at 24 hours

66 Ducloy-BouthorsAS, Gilliot S, Kyheng M, Faraoni D,TurbelinA, Keita-Meyer H, RigouzzoA, Moyanotidou G, Constant B, Broisin F, GouezAL, Favier R, Peynaud E, Ghesquiere L, Lebuffe G, DuhamelA,Allorge D, Susen S, Hennart B, Jeanpierre E, Odou P;TRACES working group.Tranexamic acid dose-response relationship for antifibrinolysis in postpartum haemorrhage during Caesarean delivery:TRACES, a double-blind, placebo-controlled, multicentre, dose-ranging biomarker study Br J Anaesth. 2022 Dec;129(6):937-945.

Background: The optimal dose of tranexamic acid to inhibit hyperfibrinolysis in postpartum haemorrhage is unclear.TranexamicAcid to Reduce Blood Loss in Hemorrhagic Cesarean Delivery (TRACES) was a double-blind, placebo-controlled, randomised, multicentre dose-ranging study to determine the dose-effect relationship for two regimens of intravenous tranexamic acid vs placebo. Methods: Women experiencing postpartum haemorrhage during Caesarean delivery were randomised to receive placebo (n=60), tranexamic acid 0 5 g (n=57), or tranexamic acid 1 g i v (n=58) Biomarkers of fibrinolytic activation were assayed at five time points, with inhibition of hyperfibrinolysis defined as reductions in the increase over baseline in D-dimer and plasmin-antiplasmin levels and in the plasmin peak time Results: In the placebo group, hyperfibrinolysis was evidenced by a mean increase over baseline [95% confidence interval] of 93% [68-118] for D-dimer level at 120 min and 56% [25-87] for the plasmin-antiplasmin level at 30 min Adose of tranexamic acid 1 g was associated with smaller increases over baseline (D-dimers: 38% [13-63] [P=0.003 vs placebo]; plasmin-antiplasmin: -2% [-32 to 28] [P=0 009 vs placebo]) Adose of tranexamic acid 0 5 g was less potent, with non-significant reductions (D-dimers: 58% [32-84] [P=0 06 vs placebo]; plasmin-antiplasmin: 13% [18-43] [P=0.051]).Although both tranexamic acid doses reduced the plasmin peak, reduction in plasmin peak time was significant only for the 1 g dose of tranexamic acid Conclusions: Fibrinolytic activation was significantly inhibited by a dose of intravenous tranexamic acid 1 g but not 0.5 g. Pharmacokinetic-pharmacodynamic modelling of these data might identify the best pharmacodynamic monitoring criteria and the optimal tranexamic acid dosing regimen for treatment of postpartum haemorrhage

67 Sentilhes L, Madar H, Le Lous M, Sénat MV, Winer N, Rozenberg P, Kayem G, Verspyck

E, Fuchs F,Azria E, Gallot D, Korb D, Desbrière R, Le Ray C, Chauleur C, de Marcillac F, Perrotin F, Parant O, Salomon LJ, Gauchotte E, Bretelle F, Sananès N, Bohec C, Mottet N, Legendre G, Letouzey V, Haddad B, Vardon D, MattuizziA, FroeligerA, Bouchghoul H, Daniel V, Regueme S, Roussillon C, GeorgetA, DarsonvalA, BenardA, Deneux-Tharaux C; Groupe de Recherche en Obstétrique et Gynécologie Tranexamic acid for the prevention of blood loss after cesarean among women with twins: a secondary analysis of theTRAnexamicAcid for Preventing Postpartum Hemorrhage

Following a Cesarean Delivery randomized clinical trial Am J Obstet Gynecol 2022 Dec;227(6):889.e1-889.e17.

Background: Although prophylactic tranexamic acid administration after cesarean delivery resulted in a lower incidence of calculated estimated blood loss of >1000 mLor red cell transfusion by day 2, its failure to reduce the incidence of hemorrhage-related secondary clinical outcomes (TRAnexamicAcid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial) makes its use questionable.The magnitude of its effect may differ in women at higher risk of blood loss, including those with multiple pregnancies Objective: This study aimed to compare the effect of tranexamic acid vs placebo to prevent blood loss after cesarean delivery among women with multiple pregnancies. Study design: This was a secondary analysis of theTRAnexamicAcid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial data, a double-blind, randomized controlled trial from March 2018 to January 2020 in 27 French maternity hospitals, that included 319 women with multiple pregnancies Women with a cesarean delivery before or during labor at ≥34 weeks of gestation were randomized to receive intravenously 1 g of tranexamic acid (n=160) or placebo (n=159), both with prophylactic uterotonics The primary outcome was a calculated estimated blood loss of >1000 mLor a red blood cell transfusion by 2 days after delivery The secondary outcomes included clinical and laboratory blood loss measurements. Results: Of the 4551 women randomized in this trial, 319 had a multiple pregnancy and cesarean delivery, and 298 (93 4%) had primary outcome data available This outcome occurred in 62 of 147 women (42 2%) in the tranexamic acid group and 67 of 152 (44.1%) receiving placebo (adjusted risk ratio, 0.97; 95% confidence interval, 0 68-1 38; P= 86) No significant between-group differences occurred for any hemorrhage-related clinical outcomes: gravimetrically estimated blood loss, provider-assessed clinically significant hemorrhage, additional uterotonics, postpartum blood transfusion, arterial embolization, and emergency surgery (P> 05 for all comparisons) Conclusion: Among women with a multiple pregnancy and cesarean delivery, prophylactic tranexamic acid did not reduce the incidence of any blood loss-related outcomes

Accreta Management

68.Sentilhes L, SecoA,Azria E, Beucher G, Bonnet MP, Branger B, Carbillon L, Chiesa C, Crenn-Hebert C, Dreyfus M, Dupont C, Fresson J, Huissoud C, Langer B, Morel O, Patrier S, Perrotin F, Raynal P, Rozenberg P, Rudigoz RC, Vendittelli F, Winer N, Deneux-Tharaux C, Kayem G; PACCRETAStudy Group. Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETAprospective study.Am J Obstet Gynecol. 2022 Jun;226(6):839.e1-839.e24.

Background: Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management. Objective: This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ). Study design: From a source population of 520,114 deliveries in 176 hospitals (PACCRETAstudy), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery Secondary outcomes were other maternal complications within 6 months We used propensity score weighting to account for potential indication bias. Results: Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0 29; 95% confidence interval, 0 19-0 45) The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy Conclusion: Among women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy

Neonatal Outcomes

Dexamethasone for CD and neonatal hypoglycemia

69.Sarker M, DeBolt C, Getrajdman C, Rattner P, Katz D, Ferrara L, Stone J, BiancoA. Perioperative dexamethasone with neuraxial anesthesia for scheduled cesarean delivery and neonatal hypoglycemia Eur J Obstet Gynecol Reprod Biol 2022 Nov;278:109-114

ABSTRACT

Objective: While the use of dexamethasone for cesarean delivery to prevent post-operative nausea and vomiting has become routine, the impact on fetal glucose metabolism is unknown. We aim to examine whether perioperative dexamethasone administration prior to scheduled non-labor cesarean delivery is associated with neonatal hypoglycemia Study design: Multi-institution retrospective cohort study of singleton, full-term, non-anomalous pregnancies delivered by scheduled non-labor cesarean delivery with neuraxial anesthesia from 2013 to 2019.The exposure was intravenous dexamethasone after neuraxial anesthesia placement. Primary outcome was neonatal hypoglycemia and secondary outcomes included lowApgar, umbilical artery pH < 7 1, NICU admission, and meconium-stained amniotic fluid Asubgroup analysis was performed on pregnancies complicated by diabetes (both gestational and pre-gestational) Multivariate regression adjusting for baseline differences and potential confounders was used to the determine the strength of association between dexamethasone and adverse outcomes. Results: Of the 4991 women in the study, 2719 (54.5%) received dexamethasone Compared to non-receipt, women receiving dexamethasone were older, more likely to be White, non-Hispanic, have private insurance, and less likely to have diabetes. Perioperative dexamethasone receipt was not associated with neonatal hypoglycemia (adjusted OR 0 90, 95% CI 0 71-1 14) In a subgroup analysis of the 466 (9 3%) pregnancies complicated by pre-gestational and gestational diabetes, 219 (47.0%) received dexamethasone and receipt was associated with a significantly increased rate of neonatal hypoglycemia (adjusted OR 1 96, 95% CI 1 28-3 00) No significant associations were found between perioperative dexamethasone and other outcomes. Conclusions: Dexamethasone administration after neuraxial anesthesia placement for scheduled non-labor cesarean delivery is associated with altered neonatal glucose metabolism only in pregnancies complicated by diabetes

Phenylephrine vs Noradrenaline

70.SinghA, Jain K, Goel N,AroraA, Kumar P. Neonatal outcomes following prophylactic administration of phenylephrine or noradrenaline in women undergoing scheduled caesarean delivery:Arandomised clinical trial. Eur JAnaesthesiol. 2022 Mar 1;39(3):269-276.

ABSTRACT

Background: There is limited evidence to support the use of noradrenaline over phenylephrine during elective caesarean section with regards to its impact on foetal acidosis Concerns regarding a deleterious effect of noradrenaline on foetal blood gas analysis because of its β-mimetic activity cannot currently be ruled out by data from randomised controlled trials Objective: We hypothesised that noradrenaline would be associated with higher umbilical artery base excess values and less foetal acidosis compared with phenylephrine.This study aimed to observe the effect of prophylactic infusions of phenylephrine or noradrenaline in low-risk elective caesarean delivery on umbilical artery blood gas analysis. Design: Aprospective, randomised, double-blind trial Setting: Labour room operating theatre of tertiary care hospital in Northern India fromApril 2020 to November 2020 Patients: Full-term, nonlabouring pregnant women, scheduled for elective caesarean delivery under spinal anaesthesia.Intervention: Equipotent prophylactic infusions of either phenylephrine 100 μg min-1 or noradrenaline 5 μg min-1 were administered to maintain maternal SBPbetween 90 and 110% of baseline using a predefined algorithm. Main outcome measure: The primary outcome was umbilical artery base excess in noradrenaline versus the phenylephrine group The incidence of foetal acidosis defined as umbilical artery base excess less than -6 mmol l-1 was also assessed for noradrenaline versus phenylephrine Results: Median [IQR] umbilical artery base excess was significantly higher in the noradrenaline group: -5 4 [-6 6 to -4 03] versus -6 95 [-9 02 to -4 53] in the phenylephrine group (P= 0.014). No significant difference in the incidence of foetal acidosis was observed between noradrenaline and phenylephrine groups: 36 versus 54% (P0 07); difference 18% (95% CI, -1 4 to 35 6%) Conclusion: Prophylactic noradrenaline 5 μg min-1 infusion resulted in higher base excess values compared with phenylephrine 100 μg min-1 infusion.Acomparable incidence of foetal acidosis was observed in women receiving either noradrenaline or phenylephrine Maternal bradycardia was more pronounced with phenylephrine while targeting blood pressure goals.

Litigation related to HIE

71.McCombe K, Bogod DG. Learning from the law: a review of 21years of litigation for anaesthetic negligence resulting in peripartum hypoxic ischaemic encephalopathy Anaesthesia. 2022Aug;77(8):919-928.

ABSTRACT

One of the most devastating complications that can result from medical mismanagement during labour and delivery is hypoxic ischaemic encephalopathy Hypoxic ischaemic encephalopathy has profound implications for the newborn and its family, as well as for the healthcare team involved. Hypoxic ischaemic encephalopathy can take only minutes to develop, but the repercussions of this complication can last a lifetime Aproportion of these injuries arise from failure to deliver the baby within a sufficiently short time frame once fetal compromise has been recognised. Obstetric anaesthetists are often involved in such claims, usually in relation to a perception that provision of anaesthesia for caesarean section was unduly delayed In the following article, using a database of over 360 cases spanning 21 years, we break down and examine the recurrent components of medicolegal claims concerning the anaesthetic involvement in hypoxic ischaemic encephalopathy, and consider how increased awareness of the anaesthetic contribution to this complication might reduce future harm, improve clinical standards and consequently decrease the need for litigation

H. POSTPARTUM

Core outcome set for enhanced recovery after cesarean studies

72.Sultan

P, George R, Weiniger CF, El-Boghdadly K, Pandal P, Carvalho B; CRADLE Study Investigators Expert Consensus Regarding Core Outcomes for Enhanced Recovery after Cesarean Delivery Studies:ADelphi Study.Anesthesiology. 2022Aug

1;137(2):201-211

ABSTRACT

Background: Heterogeneity among reported outcomes from enhanced recovery after cesarean delivery impact studies is high This study aimed to develop a standardized enhanced recovery core outcome set for use in future enhanced recovery after cesarean delivery studies. Methods: An international consensus study involving physicians, patients, and a director of midwifery and nursing services was conducted using a three-round modified Delphi approach (two rounds of electronic questionnaires and a third-round e-discussion) to produce the core outcome set.An initial list of outcomes was based on a previously published systematic review Consensus was obtained for the final core outcome set, including definitions for key terms and preferred units of measurement. Strong consensus was defined as 70% or greater agreement and weak consensus as 50 to 69% agreement Of the 64 stakeholders who were approached, 32 agreed to participate.All 32, 31, and 26 stakeholders completed Rounds 1, 2 and 3, respectively. Results: The number of outcomes in the final core outcome set was reduced from 98 to 15 Strong consensus (70% or greater stakeholder agreement) was achieved for 15 outcomes The core outcome set included length of hospital stay; compliance with enhanced recovery protocol; maternal morbidity (hospital re-admissions or unplanned consultations); provision of optimal analgesia (maternal satisfaction, compliance with analgesia, opioid consumption or requirement and incidence of nausea or vomiting); fasting times; breastfeeding success; and times to mobilization and urinary catheter removal The Obstetric Quality of Recovery-10 item composite measure was also included in the final core outcome set.Areas identified as requiring further research included readiness for discharge and analysis of cost savings Conclusions: Results from an international consensus to develop a core outcome set for enhanced recovery after cesarean delivery are presented.These are outcomes that could be considered when designing future enhanced recovery studies

73 Ciechanowicz S, Ke JXC, Sharawi N, Sultan P Measuring enhanced recovery in obstetrics: a narrative review.AJOG Glob Rep. 2022 Dec 24;3(1):100152.

ABSTRACT

Enhanced recovery after cesarean delivery is a protocolized approach to perioperative care, with the aim to optimize maternal recovery after surgery. It is associated with improved maternal and neonatal outcomes, including decreased length of hospital stay, opioid consumption, pain scores, complications, increased maternal satisfaction, and increased breastfeeding success. However, the pace and enthusiasm of adoption of enhanced recovery after cesarean delivery internationally has not yet been matched with high-quality evidence demonstrating its benefit, and current studies provide low- to very low-quality evidence in support of enhanced recovery after cesarean delivery This article provides a summary of current measures of enhanced recovery after cesarean delivery success, and optimal measures of inpatient and outpatient postpartum recovery. We summarize outcomes from 22 published enhanced recovery after cesarean delivery implementation studies and 2 meta-analyses.Avariety of disparate metrics have been used to measure enhanced recovery after cesarean delivery success, including process measures (length of hospital stay, bundle compliance, preoperative fasting time, time to first mobilization, time to urinary catheter removal), maternal outcomes (patient-reported outcome measures, complications, opioid consumption, satisfaction), neonatal outcomes (breastfeeding success,Apgar scores, maternal-neonatal bonding), cost savings, and complication rates (maternal readmission rate, urinary recatheterization rate, neonatal readmission rate).Acore outcome set for use in enhanced recovery after cesarean delivery studies has been developed through Delphi consensus, involving stakeholders including obstetricians, anesthesiologists, patients, and a midwife. Fifteen measures covering key aspects of enhanced recovery after cesarean delivery adoption are recommended for use in future enhanced recovery after cesarean delivery implementation studies. The use of these outcome measures could improve the quality of evidence surrounding enhanced recovery after cesarean delivery. Using evidence-based evaluation guidelines developed by the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) group, the Obstetric Quality of Recovery score (ObsQoR) was identified as the best patient-reported outcome measure for inpatient postpartum recovery Advances in our understanding of postpartum recovery as a multidimensional and dynamic construct have opened new avenues for the identification of optimum patient-reported outcome measures in this context. The use of standardized measures such as these will facilitate pooling of data in future studies and improve overall levels of evidence surrounding enhanced recovery after cesarean delivery. Larger studies with optimal study designs, using recommended outcomes including patient-reported outcome measures, will reduce variation and improve data quality to help guide future recommendations.

Epidural and Maternal Infant Bonding

74.BinyaminY, WainstockT, Sheiner E, BattatTL, Reuveni I, LeibsonT, Pariente G.The association between epidural analgesia during labor and mother-infant bonding J Clin Anesth. 2022 Sep;80:110795.

ABSTRACT

Study objective: This study was aimed to assess the association between the use of epidural analgesia during labor and mother-infant bonding Design: Across-sectional study Setting: Maternity ward at Soroka University Medical Center during 2020 Patients: Women who delivered a singleton live-born infant vaginally in their immediate post-partum period. Interventions: Women completed questionnaires 25 items post-partum bonding questionnaire (PBQ) to assess mother-infant bonding (Ahigh score on the PBQ indicates impaired mother-infant bonding) and the Edinburgh postnatal depression scale (EPDS) questionnaire to assess risk for post-partum depression Measurements: The study used PBQ questionnaire and four sub-scales to assess mother-infant bonding and the EPDS questionnaire to assess risk for post- partum depression Generalized linear regression models (gamma) were constructed to examine the association between epidural analgesia and mother-infant bonding total score and impaired bonding sub- scale, while adjusting for confoundersAdditional information such as pregnancy complications and sociodemographic data was drawn from women's medical records Main results: Atotal of 234 women were included in the final analysis, of them 126 (53.8%) delivered with epidural analgesia.The total PBQ score was significantly lower among women who received epidural analgesia compared to women without epidural analgesia (7 6 vs 10 2, p = 0 024), demonstrating a better mother -infant bonding Using two multivariable linear regression models, controlling for confounders such as maternal age and educational status, epidural analgesia during labor was independently associated with a better mother -infant bonding total score and better impaired bonding sub-scale score (Beta coefficient-0.252, 95% CI -0 5; -0 006, p = 0 045 and Beta coefficient - 0 34, 95% CI -0 52; -0 08, p = 0 01 for mother-infant bonding total score and sub-scale score, respectively) No differences in post-partum depression risks were found between the groups (EDPS≥13, 5.7% vs. 13%, p = 0 058) Conclusion: Our study demonstrated better mother -infant bonding among women delivering with epidural analgesia

Postpartum PTSD

75 FroeligerA, Deneux-Tharaux C, SecoA, Sentilhes L;TRAnexamicAcid for Preventing postpartum hemorrhage after vaginal delivery (TRAAP) Study Group* Posttraumatic Stress Disorder Symptoms 2 MonthsAfter Vaginal Delivery. Obstet Gynecol. 2022 Jan 1;139(1):63-72

ABSTRACT

Objective: To assess the prevalence of posttraumatic stress disorder (PTSD) symptoms and identify characteristics associated with it 2 months after singleton vaginal delivery at or near term. Methods: We conducted an ancillary cohort study of theTRAAP(TRAnexamicAcid for Preventing postpartum hemorrhage after vaginal delivery) randomized controlled trial in 15 French hospitals in 2015-2016 Women who had singleton vaginal delivery after 35 weeks of gestation were enrolled.After randomization, characteristics of labor and delivery were prospectively collected and paid special attention to postpartum blood loss Posttraumatic stress disorder profile and provisional diagnosis were assessed 2 months after childbirth by two self-administered questionnaires: the IES-R (Impact of Event Scale-Revised) and theTES (Traumatic Event Scale) Associations between potential risk factors and PTSD symptoms were analyzed by multivariable logistic or linear regression modeling, depending on the type of dependent variable Results: Questionnaires were returned by 2,740 of 3,891 women for the IES-R and 2,785 of 3,891 women for theTES (70 4% and 71 6% response rate) The prevalence of PTSD symptoms was 4.9% (95% CI 4.1-5.8%; 137/2,785) with theTES, and the prevalence of PTSD provisional diagnosis was 1 6% (95% CI 1 2-2 1%; 44/2,740), with the IES-R and 0 4% (95% CI 0 2-0 8%; 9/2,080) with theTES Characteristics associated with a higher risk of PTSD in multivariable analysis were vulnerability factors - notably migrant status and history of psychiatric disorder (adjusted odds ratio [aOR] 2 7 95% CI 1 4-5 2) - and obstetric factors - notably induced labor (aOR 1.5 95% CI 1.0-2.2), being labor longer than 6 hours (aOR 1.7 95% CI 1.1-2.5), postpartum hemorrhage of 1,000 mLor more (aOR 2.0 95% CI 1.0-4.2), and bad memories of delivery at day 2 postpartum (aOR 4 5 95% CI 2 4-8 3) as assessed with the IES-R. Results were similar with theTES. Conclusion: Approximately 1 of 20 women with vaginal delivery have PTSD symptoms at 2 months postpartum History of psychiatric disorder, postpartum hemorrhage, and bad memories of deliveries at day 2 were the main factors associated with a PTSD profile.

76 Carter J, Bick D, Gallacher D, ChangYS Mode of birth and development of maternal postnatal post-traumatic stress disorder:Amixed-methods systematic review and meta-analysis Birth 2022 Dec;49(4):616-627

ABSTRACT

Background: Post-traumatic stress disorder (PTSD) affects approximately 3% of women in the postnatal period, but less is known about risk factors for PTSD than other postnatal mental illnesses.This review aimed to analyze the literature on the impact of mode of birth on postnatal PTSD Methods: Searches were undertaken of CINAHL, the Cochrane Library, MEDLINE, PsycINFO, and Scopus for studies investigating the link between mode of birth and postnatal PTSD in high-resource countries from January 1990 to February 2021 Quantitative and qualitative data were collected and synthesized Meta-analysis was performed with four of the studies, and the rest were analyzed narratively. Results: Twelve quantitative studies, presenting data on 5567 women, and two qualitative studies, with 92 women, were included in the review Most studies found a significant relationship between mode of birth and maternal PTSD symptoms. Meta-analysis found cesarean birth was more closely associated with PTSD than vaginal delivery (VD) (P= 0 005), emergency cesarean birth (EmCB) more than elective cesarean birth (ElCB) (P&lt; 0.001), instrumental vaginal delivery (IVD) more than spontaneous vaginal delivery (SVD) (P&lt; 0.001), and EmCB more than SVD (P&lt; 0.001). Women who developed PTSD after EmCB felt less in control and less supported than those who did not develop it after the same procedure. Request for repeat ElCB appeared more common among women with pre-existing postnatal PTSD, but this may subsequently leave them feeling dissatisfied and their fears of childbirth unresolved Conclusions: Modes of birth involving emergency intervention may be risk factors for the development of postnatal PTSD. Ensuring that women feel supported and in control during emergency obstetric interventions may mediate against this risk

Ketamine and postpartum depression

77 HanY, Li P, Miao M,TaoY, Kang X, Zhang J S-ketamine as an adjuvant in patient-controlled intravenous analgesia for preventing postpartum depression: a randomized controlled trial. BMCAnesthesiol. 2022 Feb 16;22(1):49.

ABSTRACT

Background: Postpartum depression (PPD) is a common complication of cesarean section. S-ketamine given intravenously during surgery can help prevent PPD However, whether S-ketamine in patient-controlled intravenous analgesia (PCIA) can reduce the incidence of PPD is unknown.This study assessed the effect of S-ketamine as an adjuvant in PCIAfor preventing PPD in women undergoing cesarean delivery Methods: Atotal of 375 parturients scheduled to undergo cesarean section and then receive PCIAwere recruited from a single center and were randomly assigned to control (C) group (sufentanil 2 μg/kg + tropisetron 10 mg) or S-ketamine (S) group (S-ketamine 0 5 mg/kg + sufentanil 2 μg/kg + tropisetron 10 mg) The primary outcome was the incidence of PPD measured by the Edinburgh postnatal depression scale (EPDS) after surgery.The secondary outcomes were EPDS scores, visual analog scale (VAS) scores, Ramsay sedation scale (RSS) scores, and the rate of adverse events, including headache, nausea, dizziness, drowsiness, and vomit. Results: Atotal of 275 puerperal women were included in the study The rate of depression in parturient on postoperative days 3, 14, 28 in the C group and S group were 17 6 and 8 2% (p < 0 05), 24 2 and 9 8% (p < 0 05), and 19 0 and 17.2% (p = 0.76) respectively. EPDS scores in the C group and S group on postoperative days 3,14, and 28 were 7 65 ± 3 14 and 6 00 ± 2 47 (p < 0 05), 7 62 ± 3 14 and 6 38 ± 2 67 (p < 0 05), and 7 35 ± 3 17 and 6 90 ± 2 78 (p = 0 15), respectively The rate of adverse events in the C group and S group were headache 3.3 and 4.1% (p = 0.755), nausea 5.9 and 8.2% (p = 0 481), dizziness 9 2 and 12 3% (p = 0 434), drowsiness 6 5 and 10 7%(p = 0 274), and vomit 5.9 and 5.7% (p = 0.585). Conclusions: S-ketamine (0.01 mg/kg/h) as an adjuvant in PCIA significantly reduces the incidence of PPD within 14 days and relieves pain within 48 h after cesarean delivery, without increasing the rate of adverse reactions

Length of hospital stay impact of COVID

78.Handley SC, Gallagher K, Lindgren E, Lo JY, Burris HH, Dysart KC, Greenspan J, Culhane JF, Son M Postpartum Length of Stay and Hospital Readmission Before and During the Coronavirus Disease 2019 (COVID-19) Pandemic. Obstet Gynecol. 2022 Mar 1;139(3):381-390.

ABSTRACT

Objective: To compare postpartum hospitalization length of stay (LOS) and hospital readmission among obstetric patients before (March 2017-February 2020; prepandemic) and during the coronavirus disease 2019 (COVID-19) pandemic (March 2020-February 2021). Methods: We conducted a retrospective cohort study, using Epic Systems' Cosmos research platform, of obstetric patients who delivered between March 1, 2017, and February 28, 2021, at 20-44 weeks of gestation and were discharged within 7 days of delivery.The primary outcome was short postpartum hospitalization LOS (less than two midnights for vaginal births and less than three midnights for cesarean births) and secondary outcome was hospital readmission within 6 weeks of postpartum hospitalization discharge Analyses compared outcomes before and during the pandemic using standardized differences and Bayesian logistic mixed-effects models, among all births and stratified by mode of delivery. Results: Of the 994,268 obstetric patients in the study cohort, 742,113 (74 6%) delivered prepandemic and 252,155 (25 4%) delivered during the COVID-19 pandemic During the COVID-19 pandemic, the percentage of short postpartum hospitalizations increased among all births (28.7-44.5%), vaginal births (25 4-39 5%), and cesarean births (35 3-55 1%), which was consistent with the adjusted analysis (all births: adjusted odds ratio [aOR] 2 35, 99% credible interval 2 32-2 39; vaginal births: aOR 2.14, 99% credible interval 2.11-2.18; cesarean births aOR 2.90, 99% credible interval 2 83-2 98) Although short postpartum hospitalizations were more common during the COVID-19 pandemic, there was no change in readmission in the unadjusted (1.4% vs 1.6%, standardized difference=0 009) or adjusted (aOR 1 02, 99% credible interval 0 97-1 08) analyses for all births or when stratified by mode of delivery Conclusion: Short postpartum hospitalization LOS was significantly more common during the COVID-19 pandemic for obstetric patients with no change in hospital readmissions within 6 weeks of postpartum hospitalization discharge The COVID-19 pandemic created a natural experiment, suggesting shorter postpartum hospitalization may be reasonable for patients who are self-identified or health care professional-identified as appropriate for discharge

Post dural puncture headache (PDPH)

79.GuptaA, Van de Velde M, MagnusonA, von Heymann C, Guasch E,Alahuhta S, Mercier FJ, Schyns-van den BergAMJV; European Practices in the Management of Accidental Dural Puncture in Obstetrics Investigators. Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study Br JAnaesth 2022 Nov;129(5):758-766

ABSTRACT

Background: Epidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture.The primary aim was to determine factors associated with failed epidural blood patch Methods: In this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0-48 h after epidural blood patch All others were considered partial success Multinominal logistic regression was used for statistical analyses with P<0 01 considered statistically significant Results: In all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91 9%) women Failed epidural blood patch occurred in 167 (28 3%) patients; 195 (33 0%) were completely successful and 229 (38 7%) partially successful Atotal of 126 women (19 8%) received a second epidural blood patch.Astatistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed <48 h compared with ≥48 h after accidental dural puncture. In patients having radiological investigations, three intracranial bleeds were diagnosed Conclusions: Failed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch Ahistory of migraine was associated with a higher risk of second epidural blood patch.

80 Zhang Q, Pang SY, Liu CW Chronic headaches related to post-dural puncture headaches: a scoping review. Br JAnaesth. 2022 Nov;129(5):747-757.

ABSTRACT

Post-dural puncture headache (PDPH) is a well-recognised complication of neuraxial procedures Although it is generally considered to be self-limiting, there is mounting evidence suggesting an association between PDPH and chronic headaches. In this review, chronic headache after dural puncture was defined as the reporting of persistent headaches more than 1 month after the index dural puncture This scoping review aims to: (1) review the relationship between PDPH and chronic headaches, (2) explore the pathophysiology of chronic headache arising from a dural puncture, and (3) make recommendations about the follow-up and treatment of these patients The pooled relative risk of chronic headache from 15 863 patients reported in 12 cohort studies in patients with an accidental dural puncture compared with those without accidental dural puncture were 1 9 (95% confidence interval [CI], 1 2-2 9), 2 5 (95% CI, 2.0-3.2), and 3.6 (95% CI, 1.9-7.1) at 2, 6, and 12 months, respectively. We also identified 20 case reports of 49 patients who developed chronic headache after a dural puncture Epidural blood patch and fibrin glue injection and surgery have been used to treat chronic postural headaches. Overall, the level of evidence is low for all reported outcomes (aetiology, intervention and outcome) by virtue of the type of studies available (cohort and case reports) and significant risk of bias in the cohort studies Based on findings from this review, we recommend that the risk of chronic headache is included in the informed consent discussion for all neuraxial procedures Patients with PDPH should be closely followed up after hospital discharge

Opioid utilization

81.Osmundson SS, HalvorsonA, Graves KN, Wang C, Bruehl S, Grijalva CG, France D, Hartmann K, Mokshagundam S, Harrell FE Jr Development and Validation of a Model to Predict Postdischarge Opioid UseAfter Cesarean Birth. Obstet Gynecol. 2022 May

1;139(5):888-897

ABSTRACT

Objective: To develop and validate a prediction model for postdischarge opioid use in patients undergoing cesarean birth Methods: We conducted a prospective cohort study of patients undergoing cesarean birth. Patients were enrolled postoperatively, and they completed pain and opioid use questionnaires 14 days after cesarean birth Clinical data were abstracted from the electronic health record (EHR) Participants were prescribed 30 tablets of hydrocodone 5 mg-acetaminophen 325 mg at discharge and were queried about postdischarge opioid use.The primary outcome was total morphine milligram equivalents used We constructed three proportional odds predictive models of postdischarge opioid use: a full model with 34 predictors available before hospital discharge, an EHR model that excluded questionnaire data, and a reduced model The reduced model used forward selection to sequentially add predictors until 90% of the full model performance was achieved. Predictors were ranked a priori based on data from the literature and prior research Predictive accuracy was estimated using discrimination (concordance index) Results: Between 2019 and 2020, 459 participants were enrolled and 279 filled the standardized study prescription. Of the 398 with outcome measurements, participants used a median of eight tablets (interquartile range 1-18 tablets) after discharge, 23 5% used no opioids, and 23 0% used all opioids Each of the models demonstrated high accuracy predicting postdischarge opioid use (concordance index range 0.74-0.76 for all models). We selected the reduced model as our final model given its similar model performance with the fewest number of predictors, all obtained from the EHR (inpatient opioid use, tobacco use, and depression or anxiety) Conclusion: Amodel with three predictors readily found in the EHR-inpatient opioid use, tobacco use, and depression or anxiety-accurately estimated postdischarge opioid use This represents an opportunity for individualizing opioid prescriptions after cesarean birth.

82 Komatsu R, Nash M, Mandalia S, Dinges E, Kamal U, Singh

D, El-Omrani H,AnwarA, Delgado C, ZigaTM, Carvalho B. In-Hospital

Opioid ConsumptionAfter the Previous Cesarean Delivery Weakly Predicts Opioid ConsumptionAfter Index Delivery:A Retrospective Cohort Study.AnesthAnalg. 2022 Jun 1;134(6):1280-1287.

Background: To predict opioid consumption and pain intensity after the index cesarean delivery, we tested a hypothesis that opioid consumption after the previous cesarean delivery of the same patient can predict the opioid consumption after the index cesarean delivery. We further tested a secondary hypothesis that the pain scores after the previous cesarean delivery can predict the pain scores after the index cesarean delivery. Methods: This is a retrospective cohort study of 470 women who underwent both previous and index cesarean deliveries at a single institution from January 2011 to June 2019 To predict the opioid consumption (primary outcome) and average pain scores (on 11-point numeric rating scale) after their index cesarean delivery, we used a linear regression model incorporating only the opioid consumption and average pain scores after the previous cesarean delivery, respectively (unadjusted models) Demographic and obstetric variables were then added as predictors (adjusted models).The bootstrap was used to compare these models with respect to proportion of variance of the outcome accounted for (R2) Results: Unadjusted models were weakly predictive of opioid consumption (R2 = 0.268; 95% confidence interval [CI], 0.146-0.368) and average pain scores (R2 = 0 176; 95% CI, 0 057-0 250) An adjusted model for opioid consumption was weakly predictive (R2 = 0.363; 95% CI, 0.208-0.478), but an adjusted model for average pain scores was not predictive of the outcomes (R2 = 0 070; 95% CI, -0 143 to 0 219) Adjusted models failed to explain variances of opioid consumption and average pain scores significantly better than unadjusted models (P= .099 and P= .141, respectively). Conclusions: Opioid consumption and pain scores after women's previous cesarean delivery only explain 27% of variance of opioid consumption and 18% of variance of their pain after their index cesarean delivery.Therefore, previous cesarean delivery analgesic metrics are not robust enough to be used as clinically applicable predictors for index delivery

I. CRITICALCARE

ECMO

83 Taha B, Guglielminotti J, Li G, Landau R Utilization and Outcomes of Extracorporeal Membrane Oxygenation in Obstetric Patients in the United States, 1999-2014:A Retrospective Cross-Sectional Study.AnesthAnalg. 2022Aug 1;135(2):268-276.

ABSTRACT

Background: Utilization of extracorporeal membrane oxygenation (ECMO) for adult critically ill patients is increasing, but data in obstetric cohorts are scant This study analyzed ECMO utilization and maternal outcomes in obstetric patients in the United States. Methods: Data were abstracted from the 1999-2014 National Inpatient Sample (NIS), a 20% US national representative sample ECMO hospitalizations (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 39.65) in patients ≥15 years of age were categorized into obstetric ECMO and nonobstetric ECMO Obstetric patients included 4 categories: (1) loss or termination of pregnancy, (2) delivery (term or preterm), (3) postdelivery hospitalization, and (4) pregnancy without an obstetrical outcome. Possible underlying causes for obstetric ECMO were identified by analysis of ICD-9-CM codes in individual records

In-hospital death was abstracted from the NIS, and ECMO complications were identified using ICD-9-CM algorithms. Statistical significance in time-effect was assessed using weighted regression models Results: During the 16-year study period, 20,454 adult ECMO cases were identified, of which 331 occurred in obstetric patients (1.6%; 95% confidence interval [CI], 1.4-1.8). Obstetric ECMO utilization rate was 4.7 per million obstetric discharges (95% CI, 4 2-5 2) The top 3 possible indications were sepsis (22 1%), cardiomyopathy (16 6%), and aspiration pneumonia (9.7%). Obstetric ECMO utilization rate increased significantly during the study period from 1 1 per million obstetric discharges in 1999-2002 (95% CI, 0 6-1 7) to 11 2 in 2011-2014 (95% CI, 9 6-12 9), corresponding to a 144 7% increase per 4-year period (95% CI, 115.3-178.1). Compared with nonobstetric ECMO, obstetric ECMO was associated with decreased in-hospital all-cause mortality (adjusted odds ratio [aOR] 0 78; 95% CI, 0 66-0 93)

In-hospital all-cause mortality for obstetric ECMO decreased from 73 7% in 1999-2002 (95% CI, 48.8-90.8) to 31.9% in 2011-2014 (95% CI, 25.2-39.1), corresponding to a 26.1% decrease per 4-year period (95% CI, 10 1-39 3) Compared with nonobstetric ECMO, obstetric ECMO was associated with significantly increased risk of both venous thromboembolism without associated pulmonary embolism (aOR 1 83; 95% CI, 1 06-3 15) and of nontraumatic hemoperitoneum (aOR 4 32; 95% CI, 2 41-7 74) Conclusions: During the study period, obstetric ECMO utilization has increased significantly and maternal prognosis improved.

84 Wong MJ, Bharadwaj S, Galey JL, LankfordAS, Galvagno S, Kodali BS Extracorporeal Membrane Oxygenation for Pregnant and Postpartum Patients.AnesthAnalg. 2022Aug

1;135(2):277-289

SUMMARY

Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Growing experience continues to demonstrate the feasibility of ECMO in obstetric patients and attest to its favorable outcomes However, the interaction of pregnancy physiology with ECMO life support requires careful planning and adaptation for success.Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing pregnancy during ECMO support This review summarizes the considerations for use of ECMO in obstetric patients and how to address these concerns.

J. INNOVATION

Double IV vasopressor automated system 85. Nagarajan S, Chan JJI,Tan CW,Al-Hashim ZGA, Sultana R, SiaATH, Sng BL.An advanced double intravenous vasopressor automated system to treat hypotension during spinal anaesthesia for caesarean section:Apilot study Eur JAnaesthesiol 2022 Jan 1;39(1):42-49.

ABSTRACT

Background: During spinal anaesthesia for caesarean section, haemodynamic instability may lead to maternal and foetal complications We developed a novel advanced double intravenous vasopressor automated system (ADIVA) by using a continuous blood pressure and heart rate monitor.Treatment of hypotension was based on three criteria: the drug (phenylephrine or ephedrine) according to the heart rate; the dose of vasopressor determined by the degree of hypotension; a fast or slow bolus of vasopressor administered depending on whether there was a negative or positive gradient of SBPchanges, respectively Objective: The aim of this pilot study was to investigate the feasibility of theADIVAalgorithm Design: Aprospective pilot study. Setting: Single obstetrics and gynaecology centre in Singapore. Patients: Women undergoing elective caesarean delivery under spinal anaesthesia Intervention: Automated administration of ephedrine or phenylephrine based on changes in blood pressure and heart rate (via theADIVAalgorithm) detected on continuous noninvasive haemodynamic monitoring using noninvasive continuous haemodynamic monitor (Nexfin) Main outcome measures: The primary outcome was the incidence of hypotension, defined as SBPless than 80% of baseline. The secondary outcome measures were reactive hypertension, total vasopressor requirement, maternal and neonatal outcomes and system performance Results: Forty-five women were recruited.Thirty-one women (69.9%) had at least one reading of hypotension. SBPwas within ±20% of the baseline in a mean ± SD of 79 7 ± 17 6% of measurements Forty-four (97 8%) women required phenylephrine before delivery, while 15 (33 3%) required ephedrine No rescue medications were required.Three women (6.7%) had nausea and two (4.4%) vomiting.All neonates hadAPGAR scores of 9 at 5 min Conclusion: TheADIVAsystem, with noninvasive continuous haemodynamic monitoring, was able to maintain maternal SBPwithin ±20% of baseline for the vast majority of the measurements.This system had good maternal and foetal outcomes with minimal intervention from the attending anaesthetist

Doppler in spinal US for assessing labor epidural catheter position

86.van den Bosch OFC, GleicherY,Arzola C, Siddiqui N, Downey K, Carvalho JCA. Color flow Doppler in spinal ultrasound: a novel technique for assessment of catheter position in labor epidurals. RegAnesth Pain Med. 2022 Dec;47(12):775-779.

ABSTRACT

Background: Ultrasound is commonly used to facilitate epidural catheter placement. However, data are lacking regarding its potential to confirm its position in the epidural space Our aim was to visualize flow in the epidural space of patients receiving epidural analgesia for labor using color flow Doppler ultrasound. Methods: We conducted a prospective observational cohort study that included patients who had delivered vaginally under epidural analgesia We used a 5-2 mHz curvilinear probe in a left and right paramedian longitudinal oblique view to visualize the anterior and posterior complex at the interspace of epidural catheter insertion, one and two interspaces above and below At each window, the color flow Doppler function was used to visualize flow within the epidural space on injection of normal saline (1 mL). If no flow was visualized at any interspace, one assessment at the level of insertion was repeated with a 1 mL air/saline mixture We studied a convenience sample size of 40 patients Results: We visualized flow in the epidural space in all 40 patients. Flow was visualized on injection of 1 mL of saline in 37/40 patients (93%) In the remaining 3/40 patients (7%), flow was visualized with an air/saline mixture Flow on injection of saline was visualized only at the interspace of insertion in 26/37 patients (70%), at the interspace of insertion and one interspace above in 10/37 (27%), or only at one interspace above in 1/37 (3%) Flow was visualized only on the left or on the right paramedian view in 19/37 patients (51%), despite a symmetrical sensory block in all patients. Conclusion: Color flow Doppler ultrasound is a feasible and fast way to determine flow in the epidural space in the obstetric population Its potential clinical uses are confirmation of the epidural catheter position after placement, as well as troubleshooting of unsatisfactory epidural analgesia Interestingly, our results suggest that epidural catheters predominantly remain at the interspace of insertion

Infrared thermography for spinal anesthesia assessment

87 Murphy B, McCaul C CL, O'Flaherty D Infrared thermographic assessment of spinal anaesthesia-related cutaneous temperature changes during caesarean section Int J ObstetAnesth. 2022 Feb;49:103245.

ABSTRACT

Introduction: Assessment of adequacy of spinal anaesthesia, prior to obstetric surgery is extremely important but can be problematic because currently available clinical assessment methods are indirect and subjective As the sympathectomy associated with spinal anaesthesia is known to cause vasodilation and heat redistribution, we sought to assess whether spinal anaesthesia led to significant and consistent cutaneous temperature changes as measured by infrared thermography Methods: Following ethics committee approval, this observational study was conducted in a tertiary level obstetric centre. Participants included women undergoing elective caesarean section under spinal anaesthesia Following consent, a FlirT540 infrared camera captured thermographic images over the feet, patella, buttock, iliac crests, xiphisternum and axilla.Temperature was measured prior to spinal needle insertion (T0) and following clinical assessment when the block was deemed adequate Results: Thirty patients were included Baseline temperature varied considerable by site. Spinal anaesthesia altered skin temperature in all areas of interest: right and left hallux (mean of differences (MD) +4 0°C and 5 2°C respectively, P<0 0001), right and left plantar (MD +6 1°C and 6 8°C respectively, P<0 0001), patella (MD -0.33°C, P=0.0445), buttock (MD -0.5°C, P=0.009), iliac crest (MD -0.7°C, P=0 0004), xiphisternum (MD -0 95°C, P<0 0001) and axilla (MD -0 71°C, P=0 0002)

Conclusions: Following spinal anaesthesia thermographic imaging identified different patterns of skin temperature changes, with pronounced temperature increases measured in the feet and cooling of a lesser amplitude in the thoracic and lumbar dermatomes Infrared thermography has the potential to provide objective measurement of sympathectomy.

Novel US for lumbar level identification

88.Hetherington J, Brohan J, Rohling R, Gunka V,Abolmaesumi P,AlbertA, ChauA.A novel ultrasound software system for lumbar level identification in obstetric patients Can JAnaesth. 2022 Oct;69(10):1211-1219.

ABSTRACT

Purpose: Using machine learning, we developed a proprietary ultrasound software called the Spine Level Identification (SLIDE) system, which automatically identifies lumbar landmarks in real time as the operator slides the transducer over the lumber spine Here, we assessed the agreement between SLIDE and manual palpation and traditional lumbar ultrasound (LUS) for determining the primary target L3-4 interspace Methods: Upon institutional ethics approval and informed consent, 76 healthy term parturients scheduled for elective Caesarean delivery were recruited.The L3-4 interspace was identified by manual palpation and then by the SLIDE method The reference standard was located using traditional LUS by an experienced operator The primary outcome was the L3-4 interspace identification agreement of manual palpation and SLIDE with the reference standard, as percentage agreement and Gwet's agreement coefficient (AC1) Results: The raw agreement was 70% with Gwet's agreement coefficient (AC1) = 0 59 (95% confidence interval [CI], 0.41 to 0.77) for manual palpation and 84% with Gwet'sAC1 = 0 82 (95% CI, 0 70 to 0 93) for SLIDE When the levels differ from the reference, the manual palpation method identified L2-3 more often than L4-5 while the SLIDE method identified equally above or below L3-4.The SLIDE system had greater agreement than palpation in locating L3-4 and all other lumber interspaces after controlling for body mass index (adjusted odds ratio, 2 99; 95% CI, 1 21 to 8 7; P= 0 02) Conclusion: The SLIDE system had higher agreement with traditional ultrasound than manual palpation did in identifying L3-4 and all other lumber interspaces after adjusting for BMI in healthy term obstetric patients Future studies should examine factors that affect agreement and ways to improve SLIDE for clinical integration.

Opthalmic artery POCUS

89. Lau KGY, WrightA, Kountouris E, Nicolaides KH, Kametas NA. Ophthalmic artery peak systolic velocity ratio distinguishes pre-eclampsia from chronic and gestational hypertension:Aprospective cohort study. BJOG. 2022 Jul;129(8):1386-1393.

ABSTRACT

Objective: To examine whether the ophthalmic artery peak systolic velocity ratio (OAPSV-ratio) is higher in women with pre-eclampsia compared with gestational hypertension (GH) and chronic hypertension (CH), after controlling for confounding variables Design: Prospective cohort. Setting: Specialist hypertension clinic in a tertiary referral centre. Population: Singleton pregnancies presenting between 32+0 and 36+6 weeks of gestation with pre-eclampsia (n = 50), GH (n = 54) and CH (n = 56) Methods: Paired measurements of maternal mean arterial pressure (MAP) and OAPSV-ratio were performed by trained sonographers. Multiple linear regression was fitted to the OAPSV-ratio, including maternal characteristics and medical history, GH, pre-eclampsia and MAPand use of antihypertensive medication. Main outcome measure: Whether pre-eclampsia is independently associated with higher OAPSV-ratio

Results: MAPwas significantly higher in both GH (p = 0 0015) and pre-eclampsia (p = 0 008) than in CH pregnancies.There was no significant difference between pre-eclampsia and GH (0 670) The OAPSV-ratio was significantly higher in pre-eclampsia than CH (p = 0 0008) and GH (p = 0 015) There was no significant difference between the OAPSV-ratio in CH and GH (p = 0.352). Multiple linear regression modelling showed that the OAPSV-ratio was influenced by maternal weight (p = 0 005), maternal age (p = 0 014), antihypertensive medications (p = 0 007) and MAP(p < 0 0001) After controlling for these variables, the OAPSV-ratio was still significantly higher in those with pre-eclampsia (p = 0.0002). Conclusions: The OAPSV-ratio is influenced by maternal weight, age, antihypertensive medications and MAP Pre-eclampsia is an independent predictor of OAPSV-ratio, which therefore may be a useful point-of-care test when assessing women presenting with hypertension

90.Gonser M, Vonzun L, Ochsenbein-Kölble N. Ophthalmic artery Doppler in hypertensive pregnancies BJOG 2022 Jul;129(8):1394-1395

SUMMARY

This mini commentary suggests this test may be useful in tailoring therapy

Biomarkers for pre-eclampsia

91.Limonta G, Intra J, Brambilla P.The clinical utility of D-dimer/platelet count ratio in pregnant women J Matern Fetal Neonatal Med 2022 Sep;35(18):3602-3611

ABSTRACT

Objective: We performed a retrospective study to assess the clinical utility of a new index, D-dimer/platelet count (DD/PLT) ratio, in discriminating preeclampsia from normal pregnancy and gestational hypertension during third trimester, compared to the biomarkers currently used, such as D-dimer (DD), platelet (PLT), lymphocyte (LIN) and neutrophil (NEU) counts, fibrinogen (FIB), PLT/NEU, NEU/LIN and PLT/LIN ratios. Study design: We retrospectively included 213 subjects Of them, 163 and 50 were singleton pregnant and healthy non-pregnant women, respectively Among pregnant women, 105 had normal pregnancy, 33 had gestational hypertension, and 25 had preeclampsia. Results: Using Receiver Operating Curve (ROC) analysis, DD/PLTratio showed significant higher area under the curve (AUC) (0 90; 95% confidence interval (CI) 0.84-0.95) in discriminating preeclampsia from normal pregnancy compared to those of DD, NEU, FIB, LIN, PLT/NEU, NEU/LIN and PLT/LIN ratios (p < 03) In discriminating preeclampsia from gestational hypertension, the DD/PLTAUC (0 90; 95% CI 0.79-0.96) was significantly higher than those of DD, NEU, FIB, LIN, NEU/LIN and PLT/LIN ratios (p < 03), and not statistically different from those of PLT(p = 22) and PLT/NEU ratio (p = 46) Conclusions: This study shows that DD/PLTratio helps to discriminate preeclampsia from normal pregnancy and gestational hypertension. Large-scale studies are needed to verify its clinical usefulness, and to suggest more appropriate cutoff values for a widespread use

GDM Prediction

92.Hou G, GaoY, Poon LC, RenY, Zeng C, Wen B, SyngelakiA, Lin L, Zi J, Su F, Xie W, Chen F, Nicolaides KH Maternal plasma diacylglycerols and triacylglycerols in the prediction of gestational diabetes mellitus. BJOG. 2023 Feb;130(3):247-256.

ABSTRACT

Objective: To define the lipidomic profile in plasma across pregnancy, and identify lipid biomarkers for gestational diabetes mellitus (GDM) prediction in early pregnancy Design: Case-control study Setting: Tertiary referral maternity unit Population or sample: Plasma samples from 100 GDM and 100 normal glucose tolerance (NGT) women, divided into a training set (GDM first trimester = 50, GDM second trimester = 40, NGTfirst trimester = 50, NGTsecond trimester = 50) and a validation set (GDM first trimester = 45, GDM second trimester = 34, NGT first trimester = 44, NGTsecond trimester = 40). Methods: Plasma samples were collected in the first (11+0 to 13+6 weeks), second (19+0 to 24+6weeks), and third trimesters (30+0 to 34+6 weeks), and tested by ultra-high-performance liquid chromatography coupled with electrospray ionisation-quadrupole-time of flight-mass spectrometry;The GDM prediction model was established by the machine-learning method of random forest Main outcome measures: Gestational diabetes mellitus. Results: In both the GDM and NGTgroup, lyso-glycerophospholipids were down-regulated, whereas ceramides, sphingomyelins, cholesteryl ester, diacylglycerols (DGs) and triacylglycerols (TGs) and glucosylceramide were up-regulated across the three trimesters of pregnancy. In the training dataset, sevenTGs and five DGs demonstrated good performance in the prediction of GDM in the first and second trimesters (area under the curve [AUC] = 0 96 with 95% confidence interval [CI] of 0 93-1 and AUC = 0.97 with 95% CI of 0.95-1, respectively), independent of maternal body mass index (BMI) and ethnicity In the validation dataset, the predictive model achieved anAUC of 0 88 and 0.94 at the first and second trimesters, respectively. Conclusions: Our results have proposed new lipid biomarkers for the first trimester prediction of GDM, independent of ethnicity and BMI

K. GREEN INITIATIVES

93 PinderA, Fang L, FieldhouseA, GoddardA, Lovett R, Khan-Perez J, Maclennan K, Mason E, MacCarrickT, Shelton C. Implementing nitrous oxide cracking technology in the labour ward to reduce occupational exposure and environmental emissions: a quality improvement study Anaesthesia 2022 Nov;77(11):1228-1236

ABSTRACT

Nitrous oxide, a potent greenhouse gas, is a common labour analgesic. One method which may reduce its carbon footprint is to 'crack' the exhaled gas into nitrogen and oxygen using catalytic destruction In this quality improvement project, based on environmental monitoring and staff feedback, we assessed the impact of nitrous oxide cracking technology in the maternity setting. Mean ambient nitrous oxide levels were recorded during the final 30 minutes of uncomplicated labour in 36 cases and plotted on a run chart Interventions were implemented in four stages, comprising: stage 1, baseline (12 cases); stage 2, cracking with nitrous oxide delivered and scavenged via a mouthpiece (eight cases); stage 3, cracking with nitrous oxide via a facemask with an air-filled cushion (eight cases); stage 4, cracking with nitrous oxide via a low-profile facemask, and enhanced coaching on the use of the technology (eight cases).The median ambient nitrous oxide levels were 71% lower than baseline in stage 2 and 81% lower in stage 4 Staff feedback was generally positive, though some found the technology to be cumbersome; successful implementation relies on effective staff engagement Our results indicate that cracking technology can reduce ambient nitrous oxide levels in the obstetric setting, with potential for reductions in environmental impacts and occupational exposure.

L. DIVERSITYEQUITYAND INCLUSION & DISPARITIES

94.Sheikh J,Allotey J, KewT, Fernández-Félix BM, Zamora J, KhalilA,Thangaratinam S; IPPIC Collaborative Network. Effects of race and ethnicity on perinatal outcomes in high-income and upper-middle-income countries: an individual participant data meta-analysis of 2 198 655 pregnancies. Lancet. 2022 Dec 10;400(10368):2049-2062.

ABSTRACT

Background: Existing evidence on the effects of race and ethnicity on pregnancy outcomes is restricted to individual studies done within specific countries and health systems We aimed to assess the impact of race and ethnicity on perinatal outcomes in high-income and upper-middle-income countries, and to ascertain whether the magnitude of disparities, if any, varied across geographical regions Methods: For this individual participant data (IPD) meta-analysis we used data from the International Prediction of Pregnancy Complications (IPPIC) Network of studies on pregnancy complications; the full dataset comprised 94 studies, 53 countries, and 4 539 640 pregnancies We included studies that reported perinatal outcomes (neonatal death, stillbirth, preterm birth, and small-for-gestational-age babies) in at least two racial or ethnic groups (White, Black, southAsian, Hispanic, or other) For our two-step random-effects IPD meta-analysis, we did multiple imputations for confounder variables (maternal age, BMI, parity, and level of maternal education) selected with a directed acyclic graph The primary outcomes were neonatal mortality and stillbirth Secondary outcomes were preterm birth and a small-for-gestational-age baby We estimated the association of race and ethnicity with perinatal outcomes using a multivariate logistic regression model and reported this association with odds ratios (ORs) and 95% CIs We also did a subgroup analysis of studies by geographical region. Findings: 51 studies from 20 high-income and upper-middle-income countries, comprising 2 198 655 pregnancies, were eligible for inclusion in this IPD meta-analysis Neonatal death was twice as likely in babies born to Black women than in babies born to White women (OR 2 00, 95% CI 1 44-2 78), as was stillbirth (2 16, 1 46-3 19), and babies born to Black women were at increased risk of preterm birth (1·65, 1·46-1·88) and being small for gestational age (1 39, 1 13-1 72) Babies of women categorised as Hispanic had a three-times increased risk of neonatal death (OR 3 34, 95% CI 2 77-4 02) than did those born to White women, and those born to southAsian women were at increased risk of preterm birth (OR 1 26, 95% CI 1 07-1 48) and being small for gestational age (1 61, 1 32-1 95).The effects of race and ethnicity on preterm birth and small-for-gestational-age babies did not vary across regions Interpretation: Globally, among underserved groups, babies born to Black women had consistently poorer perinatal outcomes than White women after adjusting for maternal characteristics, although the risks varied for other groups The effects of race and ethnicity on adverse perinatal outcomes did not vary by region

95 LeeA, Guglielminotti J, JanvierAS, Li G, Landau R Racial and Ethnic Disparities

in the Management of Postdural Puncture Headache With Epidural Blood Patch for Obstetric Patients in NewYork State

JAMANetw Open 2022Apr 1;5(4):e228520

ABSTRACT

Importance: Characterizing and addressing racial and ethnic disparities in peripartum pain assessment and treatment is a national priority. Objective: To evaluate the association of race and ethnicity with the provision and timing of an epidural blood patch (EBP) for management of postdural puncture headache in obstetric patients Design, setting, and participants: This cross-sectional study used NewYork State hospital discharge records from January 1, 1998, to December 31, 2016, from mothers 15 to 49 years of age with a postdural puncture headache after neuraxial analgesia or anesthesia for childbirth

Statistical analysis was performed from February 2020 to February 2022. Exposures: Patients' race and ethnicity (reported as provided by each participating hospital; the method of determining race and ethnicity [ie, self-reported or not] cannot be determined from the data) were categorized into non-Hispanic White (reference group), non-Hispanic Black, Hispanic, and other race and ethnicity (includingAsian and Pacific Islander,American Indian,Alaskan Native, and other) Main outcomes and measures: The primary outcome was the rate of EBPuse.The secondary outcome was the interval (days) between hospital admission and provision of EBP Odds ratios (ORs) and 95% CIs of EBPuse associated with race and ethnicity were estimated using mixed-effect logistic regression models, adjusting for patient and hospital characteristics. Results: During the study period, 8921 patients (mean [SD] age, 30 [6] years; 1028 [11 5%] Black; 1301 [14 6%] Hispanic; 4960 [55 6%] White; and 1359 [15 2%] other race and ethnicity) with postdural puncture headache were identified among 1.9 million deliveries with a neuraxial procedure. Of these 8921 patients, 4196 (47 0%; 95% CI, 46 0%-48 1%) were managed with an EBP Atotal of 2650 White patients (53.4%; 95% CI, 52.0%-54.8%) used an EBP; this rate was significantly higher than that among Hispanic patients (41 7% [543]; 95% CI, 39 9%-44 5%), Black patients (35 7% [367]; 95% CI, 32 8%-38 7%), or patients of other race and ethnicity (35 2% [478]; 95% CI, 32 6%-37 8%)

Timing of EBPwas at a median of 2 days (IQR, 2-3 days) after hospital admission for White patients compared with a median of 3 days (IQR, 2-4 days) for Hispanic patients, Black patients, and patients of other race and ethnicity (P< 001 for the comparison with White patients) After adjustment for patient and hospital characteristics, the EBPrate was not different between White and Hispanic patients (adjusted OR, 1 11; 95% CI, 0 94-1 30) It was significantly lower for Black patients (adjusted OR, 0.80; 95% CI, 0.67-0.94) and patients of other races and ethnicities (adjusted OR, 0.85; 95% CI, 0.73-0.99). Conclusions and relevance: In this study, significant racial and ethnic disparities in the management of postdural puncture headache with EBPwere observed, with both lower rates and delayed timing, which may be associated with long-term adverse effects

96 SahmoudA, Hamilton D, Pope R ATrauma-Informed and Gender-Inclusive Medical Nomenclature. Obstet Gynecol. 2022 Jul 1;140(1):115-120.

Abstract

Transgender individuals face discrimination in several contexts and spaces, which exacerbates dysphoria and disparities in mental and physical well-being Gender-exclusionary environments in the health care system lead to limitations in access to care and unaddressed health care needs The full spectrum of gender is often not recognized in the field of medicine, which is predicated on the binary of male and female Obstetrics and gynecology is societally viewed as a field for cisgender women, but transgender individuals can, and do, benefit from services offered by obstetricians and gynecologists It is imperative that all specialties consider which aspects of care can be altered to promote the safety and health care of medically marginalized groups, including transgender patients.Alternative vocabulary to gendered language commonly used in medicine is discussed in three contexts: patient counseling, medical records, and institutional language. Understanding and using gender-inclusive language is an important step to create safer, respectful, affirming spaces for transgender people to receive medical care

Abstract

Background: Perinatal quality improvement lacks valid tools to measure adverse hospital experiences disproportionately impacting Black mothers and birthing people Measuring and mitigating harm requires using a framework that centers the lived experiences of Black birthing people in evaluating inequitable care, namely, obstetric racism. We sought to develop a valid patient-reported experience measure (PREM) of Obstetric Racism© in hospital-based intrapartum care designed for, by, and with Black women as patient, community, and content experts. Methods: PROMIS© instrument development standards adapted with cultural rigor methodology Phase 1 included item pool generation, modified Delphi method, and cognitive interviews. Phase 2 evaluated the item pool using factor analysis and item response theory. Results: Items were identified or written to cover 7 previously identified theoretical domains 806 Black mothers and birthing people completed the pilot test Factor analysis concluded a 3 factor structure with good fit indices (CFI = 0.931-0.977, RMSEA= 0.087-0.10, R2 > .3, residual correlation < 0 15) All items in each factor fit the IRTmodel and were able to be calibrated Factor 1, "Humanity," had 31 items measuring experiences of safety and accountability, autonomy, communication, and empathy.A12-item short form was created to ease respondent burden Factor 2, "Racism," had 12 items measuring experiences of neglect and mistreatment Factor 3, "Kinship," had 7 items measuring hospital denial and disruption of relationships between Black mothers and their child or support system. Conclusions: The PREM-OB Scale™ suite is a valid tool to characterize and quantify obstetric racism for use in perinatal improvement initiatives.

97 White VanGompel E, Lai JS, Davis DA, Carlock F, CamaraTL,Taylor B, Clary C, McCorkle-JamiesonAM, McKenzie-Sampson S, Gay C,ArmijoA, Lapeyrolerie L, Singh L, Scott KA Psychometric validation of a patient-reported experience measure of obstetric racism© (The PREM-OB Scale™ suite). Birth. 2022 Sep;49(3):514-525.

98 Fishel Bartal M, Chen HY, Mendez-Figueroa H, Wagner SM, Chauhan SSP

Racial and Ethnic Disparities in Primary Cesarean Birth andAdverse OutcomesAmong Low-Risk Nulliparous People Obstet Gynecol 2022 Nov 1;140(5):842-852

Abstract

Objective: To compare trend of primary cesarean delivery rate and composite neonatal and maternal adverse outcomes in low-risk pregnancies among racial and ethnic groups: non-Hispanic White, non-Hispanic Black, and Hispanic Methods: This population-based cohort study used U S vital statistics data (2015-2019) to evaluate low-risk, nulliparous patients with nonanomalous singletons who labored and delivered at 37-41 weeks of gestation.The primary outcome was the primary cesarean delivery rate Secondary outcomes included composite neonatal adverse outcome (Apgar score less than 5 at 5 minutes, assisted ventilation for more than 6 hours, seizure, or death), and composite maternal adverse outcome (intensive care unit admission, blood transfusion, uterine rupture, or unplanned hysterectomy), as well as infant death. Multivariable Poisson regression models were used to estimate adjusted relative risks (aRR) and 95% CIs Results: Among 4 3 million births, 60 6% identified as non-Hispanic White, 14 6% identified as non-Hispanic Black, and 24 8% identified as Hispanic The rate of primary cesarean delivery was 18.5% (n=804,155).An increased risk for cesarean delivery was found in non-Hispanic Black (21 7%, aRR 1 24, 95% CI 1 23-1 25) and Hispanic (17 3%, aRR 1 09, 95% CI 1 09-1 10) individuals, compared with non-Hispanic White individuals (18 1%) after multivariable adjustment.There was an upward trend in the rate of primary cesarean delivery in all racial and ethnic groups ( Pfor linear trend&lt;0 001 for all groups) However, the racial and ethnic disparity in the rate of primary cesarean delivery remained stable during the study period The composite neonatal adverse outcome was lower in Hispanic individuals in all newborns (10 7 vs 8 3 per 1,000 live births, aRR 0 74, 95% CI 0 72-0 75), and in newborns delivered by primary cesarean delivery (18.5 vs 15.0 per 1,000 live births, aRR 0.73, 95% CI 0.70-0.76), compared with non-Hispanic White individuals Conclusion: Using a nationally representative sample in the United States, we found racial and ethnic disparities in the primary cesarean delivery rate in low-risk nulliparous patients, which persisted throughout the study period.

M. MONKEYPOX

99.Dashraath P, Nielsen-Saines K, RimoinA, Mattar CNZ, PanchaudA, Baud D. Monkeypox in pregnancy: virology, clinical presentation, and obstetric management.Am J Obstet Gynecol 2022 Dec;227(6):849-861 e7

ABSTRACT

The 2022 monkeypox outbreak, caused by the zoonotic monkeypox virus, has spread across 6 World Health Organization regions (theAmericas,Africa, Europe, Eastern Mediterranean, Western Pacific, and South-EastAsia) and was declared a public health emergency of international concern on July 23, 2022 The global situation is especially concerning given the atypically high rate of person-to-person transmission, which suggests viral evolution to an established human pathogen Pregnant women are at heightened risk of vertical transmission of the monkeypox virus because of immune vulnerability and natural depletion of population immunity to smallpox among reproductive-age women, and because orthopoxviral cell entry mechanisms can overcome the typically viral-resistant syncytiotrophoblast barrier within the placenta. Data on pregnancy outcomes following monkeypox infection are scarce but include reports of miscarriage, intrauterine demise, preterm birth, and congenital infection This article forecasts the issues that maternity units might face and proposes guidelines to protect the health of pregnant women and fetuses exposed to the monkeypox virus. We review the pathophysiology and clinical features of monkeypox infection and discuss the obstetrical implications of the unusually high prevalence of anogenital lesions We describe the use of real-time polymerase chain reaction tests from mucocutaneous and oropharyngeal sites to confirm infection, and share an algorithm for the antenatal management of pregnant women with monkeypox virus exposure. On the basis of the best available knowledge from prenatal orthopoxvirus infections, we discuss the sonographic features of congenital monkeypox and the role of invasive testing in establishing fetal infection We suggest a protocol for cesarean delivery to avoid the horizontal transmission of the monkeypox virus at birth and address the controversy of mother-infant separation in the postpartum period Obstetrical concerns related to antiviral therapy with tecovirimat and vaccinia immune globulin are highlighted, including the risks of heart rate-corrected QT-interval prolongation, inaccuracies in blood glucose monitoring, and the predisposition to iatrogenic venous thromboembolism The possibility of monkeypox vaccine hesitancy during pregnancy is discussed, and strategies are offered to mitigate these risks. Finally, we conclude with a research proposal to address knowledge gaps related to the impact of monkeypox infection on maternal, fetal, and neonatal health

N. PROFESSIONALSOCIETYGUIDELINES

100 Pregnancy atAge 35Years or Older:ACOG Obstetric Care Consensus No 11 Obstet Gynecol. 2022Aug 1;140(2):348-366.

Abstract

Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those in a younger pregnant population, even in healthy individuals with no other comorbidities There are several studies that suggest advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality.This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age.The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetric care with anticipated delivery at age 35 years or older within the framework of routine pregnancy care This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.

101 Kietaibl S, Ferrandis R, GodierA, Llau J, Lobo C, MacfarlaneAJ, Schlimp CJ, Vandermeulen E, VolkT, von Heymann C, Wolmarans M,AfshariA. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRAguidelines Eur J Anaesthesiol. 2022 Feb 1;39(2):100-132.

ABSTRACT

Background: Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs This joint guideline from the European Society ofAnaesthesiology and Intensive Care and the European Society of RegionalAnaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia Design: Asystematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations ADelphi process was used to prepare a clinical practice guideline Results: Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57 5% of recommendations and consensus (75 to 90% agreement) in 42.5%. Discussion: Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible) These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. Conclusion: In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.

2022 Int J Gynaecol Obstet 2022 Mar;157 Suppl 1(Suppl 1):3-50

SUMMARY

FIGO (International Federation of Gynecology and Obstetrics) is actively contributing to the global effort to reduce maternal death and disability around the world Its mission statement reflects a commitment to promoting health, human rights, and well‐being of all women, especially those at the most significant risk of death and disability associated with childbearing FIGO provides evidence‐based interventions that can reduce the incidence of maternal morbidity and mortality when applied with informed consent.

Postpartum hemorrhage (PPH) continues to be the leading cause of maternal morbidity and mortality in most countries around the world. Despite multiple collaborative efforts at all levels, there is still a lack of implementation or adherence to the recommendations for management of PPH when faced with this obstetric emergency. In part, this delay in implementation lies in the lack of information from current evidence and a lack of unification of the multiple guidelines for diagnosis and strategies to control bleeding To provide clear and practical tools to approach this obstetric emergency, especially for low‐ and middle‐income countries (LMICs), the FIGO Safe Motherhood and Newborn Health Committee (SMNH), supported by a group of experts worldwide, developed this updated review It aims to provide multiple alternatives for the diagnosis and management of PPH tailored to the resources available at the institutional, local, or regional level This document reflects the best available evidence, drawn from scientific literature and expert opinion, on the prevention and treatment of PPH in low‐resource settings. FIGO believes that the greatest impediment in the adoption of a given strategy is the absence of an effective implementation tool

102 Escobar MF, NassarAH,Theron G, Barnea ER, Nicholson W, Ramasauskaite D, Lloyd I, Chandraharan E, Miller S, BurkeT, Ossanan G,Andres Carvajal J, Ramos I, Hincapie MA, Loaiza S, Nasner D; FIGO Safe Motherhood and Newborn Health Committee. FIGO recommendations on the management of postpartum hemorrhage

103 ACOG Committee on Clinical Practice Guidelines–Obstetrics Headaches in Pregnancy and Postpartum:ACOG Clinical Practice Guideline No. 3. Obstet Gynecol. 2022 May 1;139(5):944-972

ABSTRACT

Purpose: To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum. Target population: Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches Methods: This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by theACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of ControlledTrials, EMBASE, PubMed, and MEDLINE Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria Included studies underwent quality assessment, and a modified GRADE (Grading of RecommendationsAssessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements Recommendations: This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation

Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

104 ShennanAH, Story L; Royal College of Obstetricians, Gynaecologists Cervical Cerclage: Green-top Guideline No. 75. BJOG. 2022 Jun;129(7):1178-1210.

105 Girling J, Knight CL, Chappell L; Royal College of Obstetricians and Gynaecologists

Intrahepatic cholestasis of pregnancy: Green-top Guideline No. 43 June 2022. BJOG. 2022 Dec;129(13):e95-e114

106. Navaratnam K,Alfirevic Z; Royal College of Obstetricians and Gynaecologists. Amniocentesis and chorionic villus sampling: Green-top Guideline No 8 July 2021: Green-top Guideline No. 8. BJOG. 2022 Jan;129(1):e1-e15.

O. HIGH IMPACT REVIEWARTICLES

Pre-eclampsia

107. Magee LA, Nicolaides KH, von Dadelszen P. Preeclampsia. N Engl J Med. 2022 May 12;386(19):1817-1832.

Obesity in pregnancy

108 CreangaAA, Catalano PM, Bateman BT Obesity in Pregnancy N Engl J Med 2022 Jul 21;387(3):248-259

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19 URL: In 6-to-3 Ruling, Supreme Court Ends Nearly 50 Years ofAbortion Rights -The New YorkTimes

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81 Osmundson SS, HalvorsonA, Graves KN, Wang C, Bruehl S, Grijalva CG, France D, Hartmann K, Mokshagundam S, Harrell FE Jr Development and Validation of a Model to Predict Postdischarge Opioid UseAfter Cesarean Birth. Obstet Gynecol. 2022 May 1;139(5):888-897

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