Arendt, Katherine W.

BACKGROUND: Childbirth can have a substantial impact on maternal health-related quality of life. Cesarean delivery is the most performed inpatient operation, yet little is known about normal postpartum recovery profiles. The primary aim of our study was to longitudinally evaluate global health visual analog scale (GHVAS; 0–100) scores up to 12 weeks after scheduled cesarean delivery and identify the time to plateau of scores. The secondary aims were to evaluate different domains of postpartum recovery using validated patient-reported outcome measures (Obstetric Quality of Recovery score [ObsQoR-10] and 5-level 5-dimensional EuroQol questionnaire [EQ-5D]). METHODS: After institutional review board approval, this single-center, prospective longitudinal study enrolled healthy women scheduled for cesarean delivery. Women were excluded for gestational age <32 weeks, neonatal demise, neonatal intensive care unit admission, inability to read or understand English, and if general anesthesia was used. Women completed baseline surveys before delivery and then at 24 and 48 hours after delivery. After hospital discharge, women completed surveys (including GHVAS, OBsQoR-10, EQ-5D, Edinburgh Postnatal Depression Scale, and activities of daily living) at 1 week, 3 weeks, 6 weeks, and 12 weeks postpartum. One-way repeated measures analysis of variance (ANOVA) was used to detect the difference in GHVAS and postpartum recovery outcomes with different follow-up time points. RESULTS: We enrolled 66 parturients and 3 were withdrawn. Response rates were 95%, 84%, 83%, and 76% at 1, 3, 6, and 12 weeks, respectively. Mean ± standard deviation [SD] GHVAS scores were 78 ± 16 at baseline, 64 ± 17 at 24 hours, 69 ± 15 at 48 hours, 75 ± 19 at 1 week, 88 ± 11 at 3 weeks, 88 ± 15 at 6 weeks, and 90 ± 12 at 12 weeks postpartum ( P < .001). The global health VAS improved up until week 3 and then plateaued close to the maximum score between 3 weeks and 12 weeks postpartum. Mean ± SD ObsQoR-10 scores were 75 ± 15 at 24 hours, 85 ± 10 at 48 hours, and 81 ± 28 at 1 week postpartum ( P = .003). The mean ± SD EQ-5D composite scores improved at 6 weeks (4.9 ± 2.9) and 3 months (4.2 ± 2.6) compared to baseline (6.5 ± 1.8) with usual activities ( P = .001) and pain/discomfort ( P < .001) showing significant improvement over time. ObsQoR-10 score at 24 hours correlated with ObsQoR-10 scores at 48 hours (r = 0.629, P < .001) and 1 week (r = 0.429, P < .001) but did not correlate with EQ-5D scores at 6 weeks and 12 weeks. CONCLUSIONS: Our study demonstrates that GHVAS after scheduled CD plateaus at week 3. This data can be used to inform patients about the anticipated trajectory of key postpartum recovery domains up to 12 weeks postpartum.

Background. Dexmedetomidine is a selective α-2 agonist commonly used for sedation that has been used in obstetric anesthesia for multimodal labor analgesia, postcesarean delivery analgesia, and perioperative shivering. This study evaluated the role of intravenous dexmedetomidine to provide rescue analgesia and/or sedation during cesarean delivery under neuraxial anesthesia. Methods. We conducted a single-center, retrospective cohort study of all parturients undergoing cesarean delivery under neuraxial anesthesia between December 1, 2018, and November 30, 2019, who required supplemental analgesia during the procedure. Patients were divided into two groups: patients who received intravenous dexmedetomidine (Dexmed group) and patients who received adjunct medications such as fentanyl, midazolam, ketamine, and nitrous oxide (Standard group). Primary outcome was incidence of conversion to general anesthesia. Results. During the study period, 107 patients received adjunct medications. There was no difference in conversion to general anesthesia between the Dexmed group and the Standard group (6% (4/62) vs. 9% (4/45); p = 0.718 ). In the Dexmed group, the mean dexmedetomidine dose received was 37 μg (range 10 to 140 μg). While the use of inotropic/vasopressor medications was common and similar in both groups, there was an increase in the incidence of bradycardia (Dexmed 15% vs. Standard 2%; p = 0.042 ) but not hypotension (Dexmed 24% vs. Standard 24%; p = 1.00 ) in the Dexmed group. Conclusion. In patients who required supplemental analgesia for cesarean delivery, those who received dexmedetomidine versus other medications had a similar rate of conversion to general anesthesia, a statistically significant increase in bradycardia, but no difference in the incidence of hypotension.

Antisynthetase syndrome is a rare multisystem autoimmune disorder which clinically manifests with myositis, arthritis, interstitial lung disease, Raynaud phenomenon, and skin hyperkeratosis. Lung involvement represents the most severe form of disease and has rarely been reported in pregnancy. We present the case of a 22-year-old woman with antisynthetase syndrome and severe restrictive pulmonary disease who experienced a successful pregnancy and delivery. We discuss anesthetic considerations and highlight the importance of a multidisciplinary team approach in caring for parturients with multifactorial medical conditions.

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 10 6 /L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

Abstract Hereditary angioedema (HAE) is a disease manifested by repeated episodes of localized submucosal or subcutaneous edematous episodes, potentially triggered by emotional stress, mechanical trauma, or intake of estrogens. We present our experience managing two parturients with HAE. Multidisciplinary care is essential for planning and executing the specialized care of these patients, and management included extensive planning among obstetric, anesthesiology, and allergy and immunology teams. Pregnancy has been shown to have a variable effect on triggering HAE episodes. First-line treatment includes C1 esterase inhibitor concentrate, which can also be used for prophylaxis in high-risk patients. Neuraxial analgesia is recommended to avoid general anesthesia and was established early in both individuals. Vaginal delivery was well tolerated without need for emergent treatment for angioedema symptoms.

Maternal–fetal surgery is a rapidly evolving specialty, and significant progress has been made over the last 3 decades. A wide range of maternal–fetal interventions are being performed at different stages of pregnancy across multiple fetal therapy centers worldwide, and the anesthetic technique has evolved over the years. The American Society of Anesthesiologists (ASA) recognizes the important role of the anesthesiologist in the multidisciplinary approach to these maternal–fetal interventions and convened a collaborative workgroup with representatives from the ASA Committees of Obstetric and Pediatric Anesthesia and the Board of Directors of the North American Fetal Therapy Network. This consensus statement describes the comprehensive preoperative evaluation, intraoperative anesthetic management, and postoperative care for the different types of maternal–fetal interventions.

Abstract Background Intrathecal opioids are routinely administered during spinal anesthesia for postcesarean analgesia. The effectiveness of intrathecal morphine for postcesarean analgesia is well established, and the use of intrathecal hydromorphone is growing. No prospective studies have compared the effectiveness of equipotent doses of intrathecal morphine versus intrathecal hydromorphone as part of a multimodal analgesic regimen for postcesarean analgesia. The authors hypothesized that intrathecal morphine would result in superior analgesia compared with intrathecal hydromorphone 24 h after delivery. Methods In this single-center, double-blinded, randomized trial, 138 parturients undergoing scheduled cesarean delivery were randomized to receive 150 µg of intrathecal morphine or 75 µg of intrathecal hydromorphone as part of a primary spinal anesthetic and multimodal analgesic regimen; 134 parturients were included in the analysis. The primary outcome was the numerical rating scale score for pain with movement 24 h after delivery. Static and dynamic pain scores, nausea, pruritus, degree of sedation, and patient satisfaction were assessed every 6 h for 36 h postpartum. Total opioid consumption was recorded. Results There was no significant difference in pain scores with movement at 24 h (intrathecal hydromorphone median [25th, 75th] 4 [3, 5] and intrathecal morphine 3 [2, 4.5]) or at any time point (estimated difference, 0.5; 95% CI, 0 to 1; P = 0.139). Opioid received in the first 24 h did not differ between groups (median [25th, 75th] oral morphine milligram equivalents for intrathecal hydromorphone 30 [7.5, 45.06] vs. intrathecal morphine 22.5 [14.0, 37.5], P = 0.769). From Kaplan–Meier analysis, the median time to first opioid request was 5.4 h for hydromorphone and 12.1 h for morphine (log-rank test P = 0.200). Conclusions Although the hypothesis was that intrathecal morphine would provide superior analgesia to intrathecal hydromorphone, the results did not confirm this. At the doses studied, both intrathecal morphine and intrathecal hydromorphone provide effective postcesarean analgesia when combined with a multimodal analgesia regimen. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Abstract Supraventricular tachycardia is a common arrhythmia in pregnancy. During labor and delivery, neuraxial analgesia is important to prevent arrhythmia recurrence. We present the case of a 27-year-old gravida 2 para 1 woman at 35 weeks’ gestation presenting with supraventricular tachycardia that converted to normal sinus rhythm with adenosine. To prevent recurrence of the arrhythmia, an early epidural was provided during labor to minimize catecholamine release.