Background: Guidance on waiting intervals for neuraxial anesthesia in pregnant patients receiving higher-dose subcutaneous unfractionated heparin (SQH) relies largely on limited peripartum data. Whether elapsed time since the last heparin dose reliably reflects coagulation status in this population remains uncertain. The objective of this study was to characterize the coagulation recovery profile of the parturients after an intermediate or high dose of SQH. Methods: This retrospective cohort study examined parturients admitted to labor and delivery at a tertiary academic center from January 2017 to May 2024 who were receiving greater than or equal to 15,000 IU/day SQH antepartum and underwent neuraxial anesthesia or analgesia for delivery. Characterizing coagulation recovery after intermediate-dose (15,000 to 20,000 IU/day) or high-dose (greater than 20,000 IU/day) SQH was carried out by measuring activated partial thromboplastin time (aPTT) in the central lab. The actual coagulation recovery was analyzed versus the guideline-recommended interval after the last heparin dose (12 h for intermediate-dose regimens; 24 h for high-dose). Results: Sixty-six patients were included: 57 received intermediate-dose SQH and 9 received high-dose SQH. Only 9 of 57 intermediate-dose patients (16%) had a measured normal aPTT within 12 h of the last heparin dose, and three of nine high-dose patients (33%) had a measured normal aPTT within 24 h. Overall, 58 of 66 patients (88%) had a normal first aPTT after admission, whereas eight (12%) had an initially prolonged aPTT. Among those with initially prolonged aPTT, normalization was not documented until after 12 h in two of three intermediate-dose patients and after 24 h in three of five high-dose patients. The median time to first documented aPTT normalization was 16.5 h (interquartile range: 13.0 to 20.3) in intermediate-dose patients and 28.4 h (17.5 to 33.5) in high-dose patients. No neuraxial hematomas or neurologic complications were observed. Conclusions: In this cohort, parturients receiving higher-dose SQH demonstrated marked variability in time to aPTT normalization. These findings suggest that elapsed time alone may not reliably reflect coagulation status and that individualized laboratory assessment may be useful for time-sensitive neuraxial decision-making.

BACKGROUND:Game-based learning shows promise in health professions training, but guidance for large-group education is limited. We describe the design, implementation, and evaluation of a multi-station game-based workshop delivered during anesthesiology grand rounds. METHODS:Four game-based stations were designed using constructive alignment. Seventy-two participants, including anesthesia residents and faculty, rotated through all four 15-min stations focusing on anesthesia in pregnancy, point-of-care ultrasound, thromboelastography, and crisis resource management. Each station included structured debriefing. A post-workshop survey assessed perceived engagement, knowledge reinforcement, and participant experience. RESULTS:Fifty-five participants completed the survey (76.4%). Median item scores ranged from 4 to 5, with agreement rates above 80% across items. Free-text comments emphasized enjoyment, and perceived knowledge reinforcement, while a minority noted concerns about learning depth. CONCLUSIONS:A game-based workshop was well-received for obstetric anesthesia education, with findings highlighting the importance of aligning game mechanics with learning objectives and protecting time for structured debriefing.

BACKGROUND:Raising the pH of local anesthetics shortens their time to onset, and this is commonly done in clinical practice via addition of sodium bicarbonate. A prior study found that the pH of local anesthetics decreases over time after a factory-sealed vial has been opened, presumably due to hydrolysis of atmospheric carbon dioxide. We hypothesized that the alkalinization effect achieved by adding bicarbonate to local anesthetics may similarly be unstable, potentially affecting the drug's time-to-onset if not used immediately. METHODS:We prepared solutions of chloroprocaine 3% and lidocaine 2% each buffered with sodium bicarbonate 1 M at a 10:1 vol ratio. Mixtures were stored at room temperature, and to assess the effects of atmospheric exposure, we compared syringes sealed with a rubber cap versus a blunt needle. We recorded electrochemical pH measurements at timepoints of 0, 1, 2, 4, 6, 12, and 24 h. RESULTS:Adding bicarbonate to lidocaine raised pH from 6.5 ± 0.02 to 7.4 ± 0.04. Adding bicarbonate to chloroprocaine raised pH from 3.5 ± 0.03 to 7.6 ± 0.03. We found that the pH of each bicarbonated local anesthetic solution was stable to within 0.2 pH units across 24 h, regardless of type of seal. CONCLUSIONS:These findings indicate that the faster onset time achieved by adding bicarbonate is likely to be preserved for at least 24 h when these solutions are stored in a syringe at room temperature. From the standpoint of pH stability, these findings support the practice of preparing buffered local anesthetic mixtures before they are needed, in order to minimize delay of administration (as for emergency indications); however, safety standards for drug compounding and storage must always guide practice.

BACKGROUND:Post-dural-puncture headache (PDPH) is a common complication of neuraxial procedures used during labor and delivery, affecting about 1% of patients. Epidural blood patch (EBP) is the most effective treatment for PDPH, but few studies assess the success of an EBP based on the volume of injected blood, especially >20 mL. Our practice is injection until the patient feels persistent back pressure. We aimed to determine whether the volume of injected blood was associated with an improved outcome after an EBP in the obstetric population. METHODS:We reviewed records for patients receiving EBP after an obstetric epidural procedure over a 10-year period (May 2014-February 2024) at a single tertiary academic medical center. The primary outcome was failure of the first EBP, defined by the patient receiving a second EBP for treatment. Secondary outcome included the complete resolution of symptoms after the primary EBP. We used a binomial generalized model to identify factors associated with the success of the primary EBP. A value of P ≤ .05 was considered statistically significant. RESULTS:Records from 317 patients were available, and we excluded 32 patients who received only single-shot spinal anesthesia from the primary analysis. Repeat EBP was performed in 65 (22.8%, 95% confidence interval [CI], 18.1%-28.1%) patients. In univariable analyses, the injected volume during EBP (median 28.0 mL, interquartile range [IQR] (22.0-32.0)), days from procedure to PDPH diagnosis, and from PDPH to EBP were associated with a successful EBP. In multivariable analyses, injected volume (odds ratio [OR] 0.96 per 1 mL, P = .028, 95% CI, 0.92-0.999) and days from PDPH diagnosis to EBP (OR 0.61 per day, P = .002, 95% CI, 0.43-0.81) were significantly associated with successful EBP. An analysis of the relationship between injected volume and repeated EBP suggested a dose-response relationship ( P = .030). Complete symptomatic follow-up data documented for at least 3 days were available for 226 patients, and headache was completely resolved in 118 (52.2%, 95% CI, 45.5%-58.9%). In a multivariable analysis, a dichotomous division of the population revealed a significant association with headache resolution in the group receiving an injected volume of ≥30 mL compared with patients receiving <30 mL (OR 1.85, P = .049, 95% CI, 1.01-3.47). CONCLUSION:We found that a larger injected volume of blood during an EBP was associated with a reduced likelihood of receiving a second EBP. Injection of 30 mL or more was significantly associated with complete resolution of headache symptoms after the first EBP. A prospective trial to determine the etiology of this relationship is warranted.

BACKGROUND:Placenta accreta spectrum is a highly morbid obstetric condition, often necessitating cesarean hysterectomy and requiring specialist anesthesia care. There are few hospital-level data describing anesthetic management of these cases. The authors performed this study to describe anesthetic modalities for these cases across a cohort of U.S. hospitals. METHODS:The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database and identified patients who underwent cesarean hysterectomy for placenta accreta spectrum between January 1, 2015, and December 31, 2021. The primary outcome was mode of anesthesia, classified as general anesthesia, neuraxial anesthesia, or neuraxial with conversion to general anesthesia. Descriptive statistics were used to describe the cohort. A mixed effects logistic regression model was fit for the intended anesthetic technique for the hysterectomy portion of the procedure (general or neuraxial) for suspected placenta accreta spectrum. Patients who received both were classified according to whether the conversion was planned (classified as general) or unplanned (classified as neuraxial). RESULTS:The authors identified 1,257 cases from 43 institutions. Of those, 418 (33.3%) received general anesthesia, 333 (26.5%) received neuraxial anesthesia, and 506 (40.3%) received neuraxial anesthesia with conversion to general anesthesia. In the multivariable model, placenta percreta versus accreta (odds ratio [OR], 2.14 [95% CI, 1.33 to 3.44]), increta vs . accreta (OR, 2.04 [95% CI, 1.25 to 3.34]), unscheduled vs . scheduled cases (OR, 3.28 [95% CI, 2.04 to 5.26]), American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status III vs . II (OR, 1.57 [95% CI, 1.02 to 2.40]), and American Society of Anesthesiologists Physical Status IV vs . II (OR, 2.95 [95% CI, 1.51 to 5.74]) were associated with higher odds of general anesthesia for the hysterectomy for suspected placenta accreta spectrum. CONCLUSIONS:Neuraxial anesthesia followed by conversion to general anesthesia was the most common choice for cesarean hysterectomy. Future studies should evaluate maternal morbidity and recovery after various modes of anesthesia to help refine decision-making for the choice of anesthetic technique.

OBJECTIVES:Determine whether peripartum antihypertensive use increases secondary uterotonic use, neonatal hypoglycemia, bradycardia, or NICU admission. Hypertensive disorders of pregnancy are common and increasing. Treatment includes beta- and calcium channel- blocking medications. Outpatient beta-blockers were associated with increases in neonatal bradycardia, hypoglycemia, and NICU admissions. Calcium channel blockers are weak tocolytics and may precipitate uterine atony and hemorrhage. STUDY DESIGN:Retrospective, single-center study at a tertiary academic hospital. Records of 26,058 parturients over 5 years were reviewed. We compared exposure to labetalol and nifedipine in separate analyses. We calculated univariate odds ratio and binomial generalized models to account for covariates. P < 0.05 was considered significant. MAIN OUTCOME MEASURES:Primary outcomes were incidence of 1-hour neonatal hypoglycemia and maternal secondary uterotonic or antifibrinolytic use. Additional maternal outcomes were change in hemoglobin concentration and estimated blood loss; neonatal outcomes included hypoglycemia at 24-hours, bradycardia, and NICU admissions. RESULTS:We analyzed 24,845 records. Labetalol exposure occurred in 605 (2.4 %) deliveries and nifedipine in 426 (1.7 %). In multivariate analyses in the full cohort and matched cohorts, labetalol administration was significantly associated with 1-hour hypoglycemia (p < 0.001, OR 1.72, 95 %CI 1.33-2.23), but not 24-hour hypoglycemia (p = 0.12), bradycardia (p = 0.65), or NICU admissions (p = 0.86). Labetalol and nifedipine were associated with uterine atony (p = 0.006 and p = 0.027). Confounders and sensitivity analyses accounted for magnesium exposure, general anesthesia, and hypertensive diagnoses. CONCLUSION:Labetalol exposure was significantly and independently associated with neonatal hypoglycemia. Any hypertensive use associated with uterine atony. Clinicians should consider 1-hour assessment of glucose in neonates born to labetalol-treated mothers.

Pulmonary embolism (PE) is a significant cause of morbidity and mortality worldwide. In the USA, it is estimated that 900,000 people are affected annually. Mortality in high-risk PE remains as high as 50

Int J Obstet Anesth . 2025 May;62:104363. doi:10.1016/j.ijoa.2025.104363 Cesarean delivery (CD) is among the most frequently performed surgical procedures, accounting for roughly 1 in 5 births worldwide and up to half in some nations. Managing postoperative pain following CD is critical for maternal comfort and also for ensuring mothers can care for themselves and their newborns. Long-term postoperative pain is another critical concern in this population. Although no analgesic approach is universally ideal, intrathecal morphine (ITM) has been refined through decades of research and is now widely adopted, with about 80% of US hospitals using it as a standard method. With ITM, effective analgesia can be achieved with relatively small doses, reducing systemic side effects. The Society for Obstetric Anesthesia and Perinatology (SOAP) recommends avoiding higher doses (over 250 μg), once associated with respiratory depression. Instead, modern practice favors lower doses, where the most common adverse effects are itching, nausea, and vomiting, typically requiring only limited postoperative monitoring.

The anesthetic management of the patient with placenta accreta spectrum begins before surgery by assessing the patient and their comorbidities and providing psychological preparation for the perioperative period. Choosing neuraxial or general anesthesia for surgery balances the procedure’s clinical needs with the patient’s desires. Intraoperatively, management of homeostasis during acute blood loss requires assessments of central volume to avoid over-transfusion. Viscoelastic testing may be useful to assess coagulation to target the replacement of coagulation factors. Postoperative care is an essential continuum of the procedure, and the availability of bedside ultrasound can aid rapid decision-making.

The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible hemorrhagic shock requiring blood product transfusion, hemodynamic instability and risk of end-organ damage, having an intensive care unit (ICU) with surgical expertise (surgical ICU or equivalent based on institutional resources) is highly recommended. Intensive care units physicians and nurses should be familiarized with intraoperative anesthetic and surgical techniques as well as obstetrics physiologic changes to provide postpartum management of PAS. Validated tools such of bedside point of care ultrasound and viscoelastic tests such as thromboelastogram/rotational thromboelastometry (TEG/ROTEM) are clinically useful in the assessment of hemodynamic status (shock diagnosis, assessment of both fluid responsiveness and tolerance) and transfusion guidance (in patients requiring massive transfusion as opposed to tranditional hemostatic resuscitation) respectively. The future of PAS management lies in the collaborative and multidisciplinary environment. We recommend that women with high suspicion or a confirmed PAS should have a preoperative plan in place and be managed in a tertiary center who is experienced in managing surgically complex cases. Key Points

BACKGROUND:Intrathecal morphine is frequently administered after cesarean delivery to provide pain relief lasting up to 24 h. An enhanced recovery after cesarean pathways reduces the amount of postoperative opioids needed. The ideal dose of intrathecal morphine when combined with a pathway has not been determined. METHODS:This was a non-inferiority trial in 72 healthy women undergoing a scheduled cesarean delivery. Women were randomized to receive either 50 mcg, 150 mcg, or 250 mcg of intrathecal morphine during spinal anesthesia, with a standardized postoperative enhanced recovery pathway. The time to request supplemental opioids was the primary outcome. Secondary outcomes included pain scores, side effects, and quality of recovery at 24 h. RESULTS:The duration of analgesia with 50 mcg of morphine (median 24.5 h [IQR: 3.5-34.4]) was inferior to 150 mcg (29.4 h [24.5-72]), and both doses were inferior to 250 mcg (32 h [30.5-72]). Women who received 50 mcg morphine had higher pain scores than the other doses, received more supplemental opioids, and had lower quality recovery scores. The secondary outcomes between 150 mcg and 250 mcg were similar. Side effects were similar among all groups. 63% of women who received 250 mcg remained opioid-free at 72 h, compared to 150 mcg (52%) and 50 mcg (30%). CONCLUSIONS:The duration of analgesia using intrathecal morphine with an enhanced recovery pathway was longer with 250 mcg than with lower doses, and side effects were similar. 50 mcg provided inferior pain relief over 24 h. More than half of our patients avoided additional opioids for up to 72 h with either 150 mcg or 250 mcg doses. REGISTRATION:Clinical trial number NCT05069012.

Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. KEY POINTS: · Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum.. · Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS.. · Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy..

Thrombocytopenia is common (up to 12%) in pregnancy; thrombotic thrombocytopenia is a rare cause of thrombocytopenia; however, it is immediately life-threatening to both mother and fetus and requires immediate intervention. This is compounded by the need to act on a presumptive diagnosis with high level of suspicion given the relatively long laboratory confirmation time. A 31-year-old gravida 3, para 1 parturient at 26 weeks of gestation presented to outside hospital with recent onset of easy bruising and blurry vision. A blood count was drawn and showed a platelet count of 19,000/μL. She was transferred to our institution for management where an initial diagnosis of preeclampsia with severe features was made based on thrombocytopenia and fetal growth restriction (<1%). Platelet count nadired at 14,000/μL and a blood smear showed schistocytes, suggesting microangiopathic hemolysis, prompting discussion of urgent cesarean delivery and anesthesia consult. An urgent hematology consult led to presumptively diagnosing thrombotic thrombocytopenic purpura and cesarean delivery was deferred after discussion with the patient and team. Plasma exchange and steroid therapy were started promptly, and her platelet count improved within 12 hours. Unfortunately, the patient experienced neonatal demise. Undetectable ADAMTS13 levels confirmed diagnosis of thrombotic thrombocytopenia. She was transitioned to rituximab, platelets recovered to baseline, and she continues to do well. Thrombotic thrombocytopenia is a rare, life-threatening cause of thrombocytopenia in pregnancy. Despite grim fetal prognosis, especially in early pregnancy, low threshold of suspicion, early anesthesia involvement, and multi-disciplinary approach can facilitate diagnosis and timely intervention. In our case, it was likely lifesaving.

Placenta accreta spectrum (PAS) disorder is a potentially life-threatening condition that can occur during pregnancy. PAS puts pregnant individuals at a very high risk of major blood loss, hysterectomy, and intensive care unit admission. These patients should receive care in a center with multidisciplinary experience and expertise in managing PAS disorder. Obstetric anesthesiologists play vital roles in the peripartum care of pregnant patients with suspected PAS. As well as providing high-quality anesthesia care, obstetric anesthesiologists coordinate peridelivery care, drive transfusion-related decision making, and oversee postpartum analgesia. However, there are a number of key knowledge gaps related to the anesthesia care of these patients. For example, limited data are available describing optimal anesthesia staffing models for scheduled and unscheduled delivery. Evidence and consensus are lacking on the ideal surgical location for delivery; primary mode of anesthesia for cesarean delivery; preoperative blood ordering; use of pharmacological adjuncts for hemorrhage management, such as tranexamic acid and fibrinogen concentrate; neuraxial blocks and abdominal wall blocks for postoperative analgesia; and the preferred location for postpartum care. It is also unclear how anesthesia-related decision making and interventions impact physical and mental health outcomes. High-quality international multicenter studies are needed to fill these knowledge gaps and advance the anesthesia care of patients with PAS.

When compared to unplanned peripartum hysterectomy in the setting of placenta accreta spectrum (PAS), planned PAS cases have fewer complications and lower rates of blood loss and transfusion. Unplanned peripartum hysterectomy is indicated in the setting of refractory uterine bleeding. We compare maternal morbidity in people undergoing planned versus unplanned peripartum hysterectomy for all indications. We performed a retrospective cohort study of all people who underwent a peripartum hysterectomy, defined as hysterectomy within 24 hours of delivery, since 2014. The primary outcome is a maternal morbidity composite (MMC) defined as transfusion of ≥4 units of red blood cells, use of additional hemorrhage management procedures, surgical complications, dialysis/acute renal failure, venous thromboembolism, intensive care unit admission, hospital readmission, and maternal death. Data was stratified according to planned versus unplanned status. Comparisons were made using a Chi-square or Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. Eighty-six patients were included, 53 (61.6%) in the planned group and 33 (38.4%) in the unplanned group. The planned group was older (median age 37.2 years [interquartile range (IQR) 33.6-39.1] versus 34.8 years [IQR 31.8-39.0]) and were more likely to be nulliparous (21.2% versus 1.9%). All planned cases were for suspected PAS, compared to 72% in the unplanned group. (Table 1). The unplanned group had a higher MMC score compared to the planned group (p=0.004) (Table 2). The unplanned group had larger estimated blood loss (3000 [IQR 2000-4500] mL vs 2000 [IQR 1500-3500] mL, p=0.06) and were more likely to require activation of the massive transfusion protocol (42.4% vs. 5.7%, p< 0.001). There were no maternal deaths in either group. Despite all planned cases having PAS, unplanned hysterectomy carries a higher incidence of maternal morbidity. This highlights the benefit of advanced planning for complex cases with high risk of maternal morbidity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

( Int J Obstet Anesth . 2022;52:103590) Lumbar epidural analgesia (LEA) is a common method of labor analgesia. Traditional LEA, dural-puncture epidural (DPE), and combined spinal-epidural analgesia (CSE) are approaches to epidural catheter placement. Epidural catheters are known to malfunction following placement (12% to 13%), requiring replacement or conversion to general anesthesia (GA) if failure occurs during emergency intrapartum cesarean delivery (CD). Factors contributing to placement failure include body mass index (BMI) or weight, procedure type (CSE vs. LEA), gestational age, anesthesiologist experience, type of epidural catheter, patient age, and mode of delivery. Few studies have compared catheter failure rates between LEA and CSE. This retrospective analysis compares epidural catheter failure rates of DPE or LEA.

(Anesth Analg. 2022;134:710–712) Globally, 9%, 5%, and 1.2% of pregnancies are complicated by preeclampsia, developing preeclampsia, and eclampsia, respectively. These complicated pregnancies represent 8% to 16% of maternal pregnancy deaths in high-income countries. In addition, these medical conditions often result in persistent vascular dysfunction after delivery, increased risk of lifelong hypertension and cardiovascular disease, diabetes, stroke, renal failure, and a 40% increase in premature mortality for the mother. In the child, hypertensive disorders often result in preterm delivery and subsequent severe complications of prematurity. This article analyzes two primary possible causes for preeclampsia and their corresponding studies.