Placenta accreta spectrum (PAS) is a complex obstetric condition with a rising incidence in parallel with the rising rate of cesarean delivery. Given the significant and rapid hemorrhage associated with cesarean hysterectomy it is critically important to prepare for resuscitation and transfusion. Both neuraxial and general anesthesia can be used, each having their own advantages and disadvantages. The diagnosis of PAS can have significant mental health effects on the mother that need to be considered both during pregnancy and postpartum.
This review discusses the rising impact of opioid use disorder (OUD) on peripartum care, highlighting the maternal and neonatal risks, including neonatal abstinence syndrome. It traces the US opioid crisis from aggressive 1990s prescribing to 2016 Center for Disease Control guidelines and notes enduring regional disparities in opioid prescriptions. The text distinguishes OUD from opioid-induced hyperalgesia and explains the pharmacology of methadone (full agonist) and buprenorphine (partial agonist), along with their implications for treatment during pregnancy. In obstetric anesthesia, coordinated, multimodal pain management is essential, with medication for opioid use disorder continuation, early neuraxial analgesia, and avoidance of withdrawal-precipitating agents.
Viscoelastic hemostatic assays (VHAs), such as thromboelastography, rotational thromboelastometry, and Quantra, are increasingly used to guide postpartum hemorrhage (PPH) resuscitation. We review device principles, reference ranges, transfusion thresholds, and algorithmic integration. Pregnancy-specific VHA thresholds identify hypofibrinogenemia requiring replacement with cryoprecipitate or fibrinogen concentrate. Algorithms with VHA-guided bundles may reduce massive PPH morbidity and allogeneic transfusion requirements. VHA platelet indices correlate only at low counts; anticoagulants and temperature/pH can confound results. VHA-enabled, threshold-based algorithms expedite targeted therapy in PPH, reduce plasma exposure, and complement standard laboratories and clinical judgment.
Trauma-informed care continues to follow the 4R principles (realize the widespread nature of trauma, recognize what unresolved trauma looks like, respond by changing practices and protocols, and resist retraumatization) but has expanded to include 6 core guiding principles that include safety, trust, peer support, mutuality, empowerment, and the understanding of an individual's cultural context. Additionally, it is now recommended that trauma-informed practices be offered as universal precautions to all individuals, regardless of trauma history, focusing on trauma prevention. Obstetric anesthesia providers play an important role in minimizing and eliminating preventable trauma and mitigating psychological harm.
Pregnancy induces significant changes in the coagulation and fibrinolytic systems, creating a physiologic hypercoagulable state. While these adaptations protect against hemorrhage at delivery, they pose complex challenges in patients with underlying coagulation disorders. This review summarizes hemostasis in pregnancy, common inherited and acquired bleeding disorders, and the anesthetic considerations essential for safe peripartum management.
Cardiovascular disease (CVD) is a leading cause of maternal mortality. Patients with newly diagnosed or decompensating CVD are at high risk of morbidity and mortality. Pregnancy heart teams (PHTs) allow for multidisciplinary management of the cardio-obstetric patient. Anesthesiologists are key members of the PHT. A cardio-obstetric patient's delivery plan should consider the pathophysiology of their lesion in the context of the hemodynamic changes that occur during pregnancy, labor, delivery, or termination, and the postpartum period. More research is needed to provide evidence-based guidance for the management of cardio-obstetric patients.
