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.

From the Columbia University Vagelos College of Physicians & Surgeons, New York, New York. Accepted for publication November 15, 2024. Conflicts of Interest, Funding: Please see DISCLOSURES at the end of this article. Reprints will not be available from the author. Address correspondence to Richard Smiley, MD, PhD, Columbia University Vagelos College of Physicians & Surgeons, 630 W 168th St PH-5, New York, NY 10032. Address e-mail to [email protected].

The use of anticoagulation has increased significantly in the obstetric population in recent years, to mitigate the risk of venous thrombo-embolism (VTE).1 There are guidelines for discontinuation and re-starting of anticoagulation therapy near the time of neuraxial anesthesia.2 However, guidelines for starting and stopping anticoagulation near the time of vaginal or operative delivery are vague and disparate, and depend on its indication; confusion over when to restart previously held anticoagulation can result in adverse outcomes for obstetric patients.

CONTEXT:Individual responses to weight loss (WL) medications vary widely and prediction of response remains elusive.OBJECTIVE:We investigated biomarkers associated with use of lorcaserin (LOR), a 5HT2cR agonist that targets proopiomelanocortin (POMC) neurons that regulate energy and glucose homeostasis, to identify predictors of clinical efficacy.METHODS:Thirty individuals with obesity were treated with 7 days of placebo and LOR in a randomized crossover study. Nineteen participants continued on LOR for 6 months. Cerebrospinal fluid (CSF) POMC peptide measurements were used to identify potential biomarkers that predict WL. Insulin, leptin, and food intake during a meal were also studied.RESULTS:LOR induced a significant decrease in CSF levels of the POMC prohormone and an increase in its processed peptide β-endorphin after 7 days; β-endorphin/POMC increased by 30% (P < .001). This was accompanied by a substantial decrease in insulin, glucose, and homeostasis model assessment of insulin resistance before WL. Changes in CSF POMC peptides persisted after WL (6.9%) at 6 months that were distinct from prior reports after diet alone. Changes in POMC, food intake, or other hormones did not predict WL. However, baseline CSF POMC correlated negatively with WL (P = .07) and a cutoff level of CSF POMC was identified that predicted more than 10% WL.CONCLUSION:Our results provide evidence that LOR affects the brain melanocortin system in humans and that effectiveness is increased in individuals with lower melanocortin activity. Furthermore, early changes in CSF POMC parallel WL-independent improvements in glycemic indexes. Thus, assessment of melanocortin activity could provide a way to personalize pharmacotherapy of obesity with 5HT2cR agonists.

(Anesth Analg. 2022;134:634–632) Cervical cerclage, an operation designed to reduce preterm delivery and improve perinatal outcomes, is often performed under spinal anesthesia. While the benefits of spinal anesthesia are well documented, a short-acting local anesthetic agent, such as 2-chloroprocaine, could shorten postanesthesia care unit (PACU) stay compared with longer acting agents. Currently, bupivacaine is the most used local anesthesia for cerclage because of historical concern regarding 2-chloroprocaine’s safety. This study randomly compared the outcome of 2-chloroprocaine 3% 50 mg and hyperbaric bupivacaine 0.75% 9 mg on dermatomal level, sensory block resolution, ability to ambulate and void, and motor blockade.

Maternal mortality is at an all-time high in the United States, with maternal cardiac disease being the leading cause of death.1Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. Available at: https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm. Accessed Nov 1, 2021.Google Scholar National calls to improve maternal care before, during, and after pregnancy prompt all subspecialties to identify ways to mitigate maternal morbidity and mortality.2Mehta LS Sharma G Creanga AA et al.Call to action: Maternal health and saving mothers: A policy statement from the American Heart Association.Circulation. 2021; 144: e251-e269Crossref PubMed Scopus (11) Google Scholar Cardiothoracic anesthesiologists can contribute to maternal care in unique ways, presenting great opportunity for the field to answer this call and improve maternal outcomes.Recent national efforts to standardize maternal care include the formation of Pregnancy Heart Teams to improve the care of high-risk cardio-obstetric patients and the designation of Maternal Levels of Care to provide risk-appropriate care to all women.3American Association of Birth Centers; Association of Women's Health, Obstetric and Neonatal Nurses; American College of Obstetricians and Gynecoloists, et al. Obstetric care consensus # 9: Levels of maternal care: (Replaces obstetric care consensus number 2, February 2015).Obstet Gynecol. 2019; 221: B19-B30Google Scholar,4American College of Obstetricians and Gynecologists’ Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 212: Pregnancy and heart disease.Obstet Gynecol. 2019; 133: e320-e356Crossref PubMed Scopus (136) Google Scholar Pregnancy Heart Teams are multidisciplinary teams with specific expertise in obstetrics, maternal-fetal medicine, cardiology, nursing, pharmacy, obstetric anesthesiology, and, when necessary, cardiothoracic anesthesiology and cardiac surgery. Pregnancy Heart Teams create individualized peripartum care plans for cardio-obstetric patients. Women with modified World Health Organization (mWHO) group III and IV lesions should be cared for at Maternal Level of Care Level III or IV centers. Level III centers must have subspecialists in critical care and cardiology; to qualify as a Maternal Level of Care Center Level IV, a center must have a cardiac surgery program. The cardiothoracic anesthesiologist, by virtue of working at a center with cardiac surgery, will likely practice at a Level IV center where women with the highest pregnancy risk will seek obstetric care.In last month's edition of this Journal, Dr. Wolla et al provided an example of expert anesthetic management of a patient with severe pulmonary hypertension who required termination of pregnancy due to maternal decompensation.5Wolla CD Matos JR Wineland R. Anesthetic management of severe pulmonary hypertension in pregnancy.J Cardiothorac Vasc Anesth. 2022; 36: 542-545Abstract Full Text Full Text PDF Scopus (2) Google Scholar The authors here wish to praise specific aspects of the care and emphasize (1) the risk of undiagnosed cardiac disease in pregnancy, (2) the medical need for the termination of pregnancy in certain situations, and (3) the role of the cardiothoracic anesthesiologist in assisting the obstetric anesthesiologist.Dr. Wolla et al outlined the challenges that the physiology of pregnancy poses in patients with pulmonary hypertension. Pregnancy in patients with pulmonary hypertension carries a mortality rate of 16%, with group-1 pulmonary hypertension carrying the highest risk of mortality, with reported mortality rates of 23%-to-43% for idiopathic pulmonary hypertension.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar,7Sliwa K van Hagen IM Budts W et al.Pulmonary hypertension and pregnancy outcomes: Data from the Registry Of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology.Eur J Heart Fail. 2016; 18: 1119-1128Crossref PubMed Scopus (116) Google Scholar For this reason, pulmonary hypertension is considered an mWHO group-IV lesion, the highest-risk group of cardiac diseases in pregnancy. Women with mWHO group-IV lesions are counseled against pregnancy and advised to terminate a pregnancy should it occur.8Hemnes AR Kiely DG Cockrill BA et al.Statement on pregnancy in pulmonary hypertension from the Pulmonary Vascular Research Institute.Pulm Circ. 2015; 5: 435-465Crossref PubMed Scopus (120) Google ScholarExpert opinion and multiple cases series have demonstrated the safety of neuraxial anesthesia for vaginal and cesarean delivery in patients with pulmonary hypertension.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar,9Bédard E Dimopoulos K Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension?.Eur Heart J. 2009; 30: 256-265Crossref PubMed Scopus (403) Google Scholar,10Sliwa K van Hagen IM Budts W et al.Pulmonary hypertension and pregnancy outcomes: Data from the Registry Of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology.Eur J Heart Fail. 2016; 18: 1119-1128Crossref PubMed Scopus (94) Google Scholar As discussed by Dr. Wolla et al, neuraxial analgesia is absolutely essential to facilitate a safe vaginal delivery and is strongly recommended over general anesthesia when cesarean delivery is necessary.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar,9Bédard E Dimopoulos K Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension?.Eur Heart J. 2009; 30: 256-265Crossref PubMed Scopus (403) Google Scholar,10Sliwa K van Hagen IM Budts W et al.Pulmonary hypertension and pregnancy outcomes: Data from the Registry Of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology.Eur J Heart Fail. 2016; 18: 1119-1128Crossref PubMed Scopus (94) Google Scholar While the cardiothoracic anesthesiologist is adept at and familiar with providing general endotracheal anesthesia to the patient with pulmonary hypertension, the pregnant patient with pulmonary hypertension about to undergo delivery of the fetoplacental unit poses the additional challenge of large preload changes peri- and postdelivery. These fluid shifts precipitate additional increases and decreases in right ventricular filling and pulmonary flow, resistance, and pressure, and the authors here believe that the avoidance of mechanical ventilation in this setting may be useful. The obstetric anesthesiologist, of course, is more familiar and comfortable with cesarean delivery with neuraxial anesthesia. This scenario provides a perfect arena for collaboration between the 2 subspecialties.The appropriate use of pulmonary vasodilators and diuresis in this patient likely contributed to the good maternal outcome. The authors opined that the administration of a 1-L fluid bolus at the time of initiation of epidural analgesia likely was unnecessary and possibly an error, but did not result in harm due to prior diuretic therapy. While a liter of crystalloid may not have been absolutely necessary, and usually is not necessary in healthy parturients, there may have been some role for moderate fluid administration (and/or moderate vasopressor infusion therapy) to maintain preload, critical in many patients with pulmonary arterial hypertension, with diuresis remaining the “rescue” strategy. An arterial line would seem to be quite useful in this regard, and it is not clear if there was one present. While there is concern for pulmonary artery rupture or arrhythmia with the use of a pulmonary artery catheter, Dr. Wolla et al demonstrated the utility of this monitor peripartum, and the authors here encourage pulmonary artery catheter use by expert teams in the interpretation of the data provided by pulmonary artery catheters and in settings in which pulmonary vasodilator medications are being rapidly titrated. If a pulmonary artery catheter is used, simple precautions to lessen the risk of rupture include very limited use of balloon inflation and wedge pressure measurements, and, generally, the catheter should be left in a position that will not allow it to wedge.It is imperative to note that this patient, along with countless other women, had congenital or acquired heart disease that was undiagnosed through childhood, only manifesting with the physiologic stress of pregnancy. In the authors’ practice, they have seen many of these patients coming from the developing world with undiagnosed severe cardiac disease, but this scenario also occurs in the developed world, and pulmonary arterial hypertension may develop (or present) during pregnancy. As Wolla et al described, the physiologic stress specific to women with pulmonary hypertension who become pregnant is the increased circulating blood volume that leads to higher flow through the pulmonary circulation and increased pulmonary pressures. This increase in pulmonary pressure can lead to right-heart decompensation in the second or third trimester. There is a somewhat lesser but still real risk from moderate-to-severe postpartum hemorrhage, which can lead to an underfilled right ventricle, unable to generate enough pressure or flow through a high-pressure pulmonary circulation. Therefore, this patient and many others are faced with the incredibly challenging decision to terminate a possibly very desired pregnancy. Although termination is often recommended and probably a very appropriate option, it should be acknowledged that it is not completely clear that termination in the late second trimester is much less risky than delivery in the mid-third trimester.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google ScholarThe CARPREG II risk stratification index by Silversides et al is a useful guide for the prediction of adverse cardiac events in women with cardiac disease. The index includes a variable related to process of care, delayed access to care, or late pregnancy assessment as a risk factor for adverse events. Delayed identification of pulmonary hypertension in this patient corresponded to a 15% predicted incidence of an adverse cardiac event. When the physiologic challenges of pregnancy unmask underlying severe cardiac disease, patients are at high risk of severe morbidity and mortality and may require termination of pregnancy. These are the cases in which the cardiothoracic anesthesiologist may have the potential to improve care and outcomes.Case series demonstrated that mortality within 1 year of delivery is higher in women with severe pulmonary hypertension versus those with mild pulmonary hypertension, 21%-to-22% v 9%.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar,11Zhou Q Peng P Liu X et al.Evaluation of maternal and fetal outcomes in pregnancy complicated with pulmonary arterial hypertension.Ann Palliat Med. 2021; 10: 1404-1410Crossref PubMed Scopus (5) Google Scholar This case describes a patient with severe pulmonary hypertension who should be counseled against pregnancy, and for early (preferably first trimester) termination should pregnancy occur. Current attempts to curtail the medically necessary use of terminations of pregnancy do a disservice, potentially fatal, to women with an undiagnosed cardiac disease whose illness becomes manifest at or after the late first trimester as pregnancy blood volume and cardiac output increase.In this case, the patient was faced with the challenging decision of continuing pregnancy for an uncertain amount of time before her probable cardiopulmonary decompensation, potentially resulting in an emergency delivery, which almost all series have indicated is the most dangerous scenario, or terminating the pregnancy and avoiding the birth of a severely preterm neonate.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar Either way, this patient had a very high risk of maternal morbidity and mortality, so the decision centered around the possibility of a severe preterm neonate with a critically ill mother. The short- and long-term consequences of prematurity are not insignificant. Short-term consequences of prematurity include respiratory compromise, bronchopulmonary dysplasia, apnea, patent ductus arteriosus, hypotension, intraventricular hemorrhage, temperature control problems, hypoglycemia, necrotizing enterocolitis, anemia, newborn jaundice, and infection from immature immune systems. Long-term consequences of prematurity include cerebral palsy, impaired learning, vision and hearing problems, dental problems, behavioral and psychological problems, and other chronic health issues. The ethics of a mother with severe pulmonary hypertension with a preterm neonate are, to say the least, complex, and should be approached with compassion and individualized, as in this case.When pregnancy is noted in a patient with a high-risk cardiac lesion and termination is advised, the earlier the termination occurs, the less hemodynamic consequence and risk the pregnancy, termination, and recovery will pose to the mother. As stated above, termination is not proven safer than the continuation of pregnancy for maternal health at this point of 23 weeks' gestation, but termination does avoid a severely preterm birth. Hence, the early identification of maternal cardiac disease is imperative.A recent review for the cardiac anesthesiologist outlined how the cardiac anesthesiologist can help the obstetric or general anesthesiologist in the care of the cardio-obstetric patient.12Girnius A Meng ML. Cardio-obstetrics: A review for the cardiac anesthesiologist.J Cardiothorac Vasc Anesth. 2021; 35: 3483-3488Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Both the CARPREG II risk score and mWHO grouping can aid in identifying patients who are at high risk of cardiovascular morbidity and mortality and for whom a cardiothoracic anesthesiologist may be an essential member of the “Pregnancy Heart Team.”4American College of Obstetricians and Gynecologists’ Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 212: Pregnancy and heart disease.Obstet Gynecol. 2019; 133: e320-e356Crossref PubMed Scopus (136) Google Scholar,13Regitz-Zagrosek V Roos-Hesselink JW Bauersachs J et al.Scientific document group: 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy.Eur Heart J. 2018; 39: 3165-3241Crossref PubMed Scopus (807) Google Scholar,14Silversides CK Grewal J Mason J et al.Pregnancy outcomes in women with heart disease: The CARPREG II study.J Am Coll Cardiol. 2018; 71: 2419-2430Crossref PubMed Scopus (212) Google Scholar Cardiac anesthesiologists may aid in echocardiography image acquisition and interpretation, inotrope titration, and facilitation of mechanical support (eg, extracorporeal membrane oxygenation) when necessary. This case demonstrated that the skills of a cardiothoracic anesthesiologist may be necessary not just for patients who are having vaginal or cesarean delivery, but also for patients who require terminations of pregnancy. If a cardio-obstetric patient is sick enough to need a termination of pregnancy, she may well be sick enough to need the care of a cardiothoracic anesthesiologist.Editorials or commentaries regarding case reports are uncommon; however, this case highlighted a unique and critical area for the subspecialty to consider. As this subspecialty increases its role in the care of the cardio-obstetric patient and contributes to the data and scientific literature surrounding how these patients are cared for, acute maternal morbidity in this population may diminish. The authors encourage the cardiothoracic anesthesiologist to partner with the obstetric anesthesiologist, as the bidirectional flow of knowledge and experience will certainly improve the care of childbearing patients. Maternal mortality is at an all-time high in the United States, with maternal cardiac disease being the leading cause of death.1Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. Available at: https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm. Accessed Nov 1, 2021.Google Scholar National calls to improve maternal care before, during, and after pregnancy prompt all subspecialties to identify ways to mitigate maternal morbidity and mortality.2Mehta LS Sharma G Creanga AA et al.Call to action: Maternal health and saving mothers: A policy statement from the American Heart Association.Circulation. 2021; 144: e251-e269Crossref PubMed Scopus (11) Google Scholar Cardiothoracic anesthesiologists can contribute to maternal care in unique ways, presenting great opportunity for the field to answer this call and improve maternal outcomes. Recent national efforts to standardize maternal care include the formation of Pregnancy Heart Teams to improve the care of high-risk cardio-obstetric patients and the designation of Maternal Levels of Care to provide risk-appropriate care to all women.3American Association of Birth Centers; Association of Women's Health, Obstetric and Neonatal Nurses; American College of Obstetricians and Gynecoloists, et al. Obstetric care consensus # 9: Levels of maternal care: (Replaces obstetric care consensus number 2, February 2015).Obstet Gynecol. 2019; 221: B19-B30Google Scholar,4American College of Obstetricians and Gynecologists’ Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 212: Pregnancy and heart disease.Obstet Gynecol. 2019; 133: e320-e356Crossref PubMed Scopus (136) Google Scholar Pregnancy Heart Teams are multidisciplinary teams with specific expertise in obstetrics, maternal-fetal medicine, cardiology, nursing, pharmacy, obstetric anesthesiology, and, when necessary, cardiothoracic anesthesiology and cardiac surgery. Pregnancy Heart Teams create individualized peripartum care plans for cardio-obstetric patients. Women with modified World Health Organization (mWHO) group III and IV lesions should be cared for at Maternal Level of Care Level III or IV centers. Level III centers must have subspecialists in critical care and cardiology; to qualify as a Maternal Level of Care Center Level IV, a center must have a cardiac surgery program. The cardiothoracic anesthesiologist, by virtue of working at a center with cardiac surgery, will likely practice at a Level IV center where women with the highest pregnancy risk will seek obstetric care. In last month's edition of this Journal, Dr. Wolla et al provided an example of expert anesthetic management of a patient with severe pulmonary hypertension who required termination of pregnancy due to maternal decompensation.5Wolla CD Matos JR Wineland R. Anesthetic management of severe pulmonary hypertension in pregnancy.J Cardiothorac Vasc Anesth. 2022; 36: 542-545Abstract Full Text Full Text PDF Scopus (2) Google Scholar The authors here wish to praise specific aspects of the care and emphasize (1) the risk of undiagnosed cardiac disease in pregnancy, (2) the medical need for the termination of pregnancy in certain situations, and (3) the role of the cardiothoracic anesthesiologist in assisting the obstetric anesthesiologist. Dr. Wolla et al outlined the challenges that the physiology of pregnancy poses in patients with pulmonary hypertension. Pregnancy in patients with pulmonary hypertension carries a mortality rate of 16%, with group-1 pulmonary hypertension carrying the highest risk of mortality, with reported mortality rates of 23%-to-43% for idiopathic pulmonary hypertension.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar,7Sliwa K van Hagen IM Budts W et al.Pulmonary hypertension and pregnancy outcomes: Data from the Registry Of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology.Eur J Heart Fail. 2016; 18: 1119-1128Crossref PubMed Scopus (116) Google Scholar For this reason, pulmonary hypertension is considered an mWHO group-IV lesion, the highest-risk group of cardiac diseases in pregnancy. Women with mWHO group-IV lesions are counseled against pregnancy and advised to terminate a pregnancy should it occur.8Hemnes AR Kiely DG Cockrill BA et al.Statement on pregnancy in pulmonary hypertension from the Pulmonary Vascular Research Institute.Pulm Circ. 2015; 5: 435-465Crossref PubMed Scopus (120) Google Scholar Expert opinion and multiple cases series have demonstrated the safety of neuraxial anesthesia for vaginal and cesarean delivery in patients with pulmonary hypertension.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar,9Bédard E Dimopoulos K Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension?.Eur Heart J. 2009; 30: 256-265Crossref PubMed Scopus (403) Google Scholar,10Sliwa K van Hagen IM Budts W et al.Pulmonary hypertension and pregnancy outcomes: Data from the Registry Of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology.Eur J Heart Fail. 2016; 18: 1119-1128Crossref PubMed Scopus (94) Google Scholar As discussed by Dr. Wolla et al, neuraxial analgesia is absolutely essential to facilitate a safe vaginal delivery and is strongly recommended over general anesthesia when cesarean delivery is necessary.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar,9Bédard E Dimopoulos K Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension?.Eur Heart J. 2009; 30: 256-265Crossref PubMed Scopus (403) Google Scholar,10Sliwa K van Hagen IM Budts W et al.Pulmonary hypertension and pregnancy outcomes: Data from the Registry Of Pregnancy and Cardiac Disease (ROPAC) of the European Society of Cardiology.Eur J Heart Fail. 2016; 18: 1119-1128Crossref PubMed Scopus (94) Google Scholar While the cardiothoracic anesthesiologist is adept at and familiar with providing general endotracheal anesthesia to the patient with pulmonary hypertension, the pregnant patient with pulmonary hypertension about to undergo delivery of the fetoplacental unit poses the additional challenge of large preload changes peri- and postdelivery. These fluid shifts precipitate additional increases and decreases in right ventricular filling and pulmonary flow, resistance, and pressure, and the authors here believe that the avoidance of mechanical ventilation in this setting may be useful. The obstetric anesthesiologist, of course, is more familiar and comfortable with cesarean delivery with neuraxial anesthesia. This scenario provides a perfect arena for collaboration between the 2 subspecialties. The appropriate use of pulmonary vasodilators and diuresis in this patient likely contributed to the good maternal outcome. The authors opined that the administration of a 1-L fluid bolus at the time of initiation of epidural analgesia likely was unnecessary and possibly an error, but did not result in harm due to prior diuretic therapy. While a liter of crystalloid may not have been absolutely necessary, and usually is not necessary in healthy parturients, there may have been some role for moderate fluid administration (and/or moderate vasopressor infusion therapy) to maintain preload, critical in many patients with pulmonary arterial hypertension, with diuresis remaining the “rescue” strategy. An arterial line would seem to be quite useful in this regard, and it is not clear if there was one present. While there is concern for pulmonary artery rupture or arrhythmia with the use of a pulmonary artery catheter, Dr. Wolla et al demonstrated the utility of this monitor peripartum, and the authors here encourage pulmonary artery catheter use by expert teams in the interpretation of the data provided by pulmonary artery catheters and in settings in which pulmonary vasodilator medications are being rapidly titrated. If a pulmonary artery catheter is used, simple precautions to lessen the risk of rupture include very limited use of balloon inflation and wedge pressure measurements, and, generally, the catheter should be left in a position that will not allow it to wedge. It is imperative to note that this patient, along with countless other women, had congenital or acquired heart disease that was undiagnosed through childhood, only manifesting with the physiologic stress of pregnancy. In the authors’ practice, they have seen many of these patients coming from the developing world with undiagnosed severe cardiac disease, but this scenario also occurs in the developed world, and pulmonary arterial hypertension may develop (or present) during pregnancy. As Wolla et al described, the physiologic stress specific to women with pulmonary hypertension who become pregnant is the increased circulating blood volume that leads to higher flow through the pulmonary circulation and increased pulmonary pressures. This increase in pulmonary pressure can lead to right-heart decompensation in the second or third trimester. There is a somewhat lesser but still real risk from moderate-to-severe postpartum hemorrhage, which can lead to an underfilled right ventricle, unable to generate enough pressure or flow through a high-pressure pulmonary circulation. Therefore, this patient and many others are faced with the incredibly challenging decision to terminate a possibly very desired pregnancy. Although termination is often recommended and probably a very appropriate option, it should be acknowledged that it is not completely clear that termination in the late second trimester is much less risky than delivery in the mid-third trimester.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar The CARPREG II risk stratification index by Silversides et al is a useful guide for the prediction of adverse cardiac events in women with cardiac disease. The index includes a variable related to process of care, delayed access to care, or late pregnancy assessment as a risk factor for adverse events. Delayed identification of pulmonary hypertension in this patient corresponded to a 15% predicted incidence of an adverse cardiac event. When the physiologic challenges of pregnancy unmask underlying severe cardiac disease, patients are at high risk of severe morbidity and mortality and may require termination of pregnancy. These are the cases in which the cardiothoracic anesthesiologist may have the potential to improve care and outcomes. Case series demonstrated that mortality within 1 year of delivery is higher in women with severe pulmonary hypertension versus those with mild pulmonary hypertension, 21%-to-22% v 9%.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar,11Zhou Q Peng P Liu X et al.Evaluation of maternal and fetal outcomes in pregnancy complicated with pulmonary arterial hypertension.Ann Palliat Med. 2021; 10: 1404-1410Crossref PubMed Scopus (5) Google Scholar This case describes a patient with severe pulmonary hypertension who should be counseled against pregnancy, and for early (preferably first trimester) termination should pregnancy occur. Current attempts to curtail the medically necessary use of terminations of pregnancy do a disservice, potentially fatal, to women with an undiagnosed cardiac disease whose illness becomes manifest at or after the late first trimester as pregnancy blood volume and cardiac output increase. In this case, the patient was faced with the challenging decision of continuing pregnancy for an uncertain amount of time before her probable cardiopulmonary decompensation, potentially resulting in an emergency delivery, which almost all series have indicated is the most dangerous scenario, or terminating the pregnancy and avoiding the birth of a severely preterm neonate.6Meng ML Landau R Viktorsdottir O et al.Pulmonary hypertension in pregnancy: A report of 49 cases at four tertiary North American sites.Obstet Gynecol. 2017; 129: 511-520Crossref PubMed Scopus (58) Google Scholar Either way, this patient had a very high risk of maternal morbidity and mortality, so the decision centered around the possibility of a severe preterm neonate with a critically ill mother. The short- and long-term consequences of prematurity are not insignificant. Short-term consequences of prematurity include respiratory compromise, bronchopulmonary dysplasia, apnea, patent ductus arteriosus, hypotension, intraventricular hemorrhage, temperature control problems, hypoglycemia, necrotizing enterocolitis, anemia, newborn jaundice, and infection from immature immune systems. Long-term consequences of prematurity include cerebral palsy, impaired learning, vision and hearing problems, dental problems, behavioral and psychological problems, and other chronic health issues. The ethics of a mother with severe pulmonary hypertension with a preterm neonate are, to say the least, complex, and should be approached with compassion and individualized, as in this case. When pregnancy is noted in a patient with a high-risk cardiac lesion and termination is advised, the earlier the termination occurs, the less hemodynamic consequence and risk the pregnancy, termination, and recovery will pose to the mother. As stated above, termination is not proven safer than the continuation of pregnancy for maternal health at this point of 23 weeks' gestation, but termination does avoid a severely preterm birth. Hence, the early identification of maternal cardiac disease is imperative. A recent review for the cardiac anesthesiologist outlined how the cardiac anesthesiologist can help the obstetric or general anesthesiologist in the care of the cardio-obstetric patient.12Girnius A Meng ML. Cardio-obstetrics: A review for the cardiac anesthesiologist.J Cardiothorac Vasc Anesth. 2021; 35: 3483-3488Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Both the CARPREG II risk score and mWHO grouping can aid in identifying patients who are at high risk of cardiovascular morbidity and mortality and for whom a cardiothoracic anesthesiologist may be an essential member of the “Pregnancy Heart Team.”4American College of Obstetricians and Gynecologists’ Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 212: Pregnancy and heart disease.Obstet Gynecol. 2019; 133: e320-e356Crossref PubMed Scopus (136) Google Scholar,13Regitz-Zagrosek V Roos-Hesselink JW Bauersachs J et al.Scientific document group: 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy.Eur Heart J. 2018; 39: 3165-3241Crossref PubMed Scopus (807) Google Scholar,14Silversides CK Grewal J Mason J et al.Pregnancy outcomes in women with heart disease: The CARPREG II study.J Am Coll Cardiol. 2018; 71: 2419-2430Crossref PubMed Scopus (212) Google Scholar Cardiac anesthesiologists may aid in echocardiography image acquisition and interpretation, inotrope titration, and facilitation of mechanical support (eg, extracorporeal membrane oxygenation) when necessary. This case demonstrated that the skills of a cardiothoracic anesthesiologist may be necessary not just for patients who are having vaginal or cesarean delivery, but also for patients who require terminations of pregnancy. If a cardio-obstetric patient is sick enough to need a termination of pregnancy, she may well be sick enough to need the care of a cardiothoracic anesthesiologist. Editorials or commentaries regarding case reports are uncommon; however, this case highlighted a unique and critical area for the subspecialty to consider. As this subspecialty increases its role in the care of the cardio-obstetric patient and contributes to the data and scientific literature surrounding how these patients are cared for, acute maternal morbidity in this population may diminish. The authors encourage the cardiothoracic anesthesiologist to partner with the obstetric anesthesiologist, as the bidirectional flow of knowledge and experience will certainly improve the care of childbearing patients. Dr. Meng denies any potential conflicts of interest including commercial relationships, such as consultation and equity interests. Dr. Meng is currently supported by the NIH T32 GM 008600-25. Dr. Smiley's wife owns stock in the following healthcare/pharmaceutical firms: Abbvie, Amgen, Merck, Pfizer, and United Health Group. Dr. Smiley received research funding in 2020 from Pacira Pharmaceuticals. Anesthetic Management of Severe Pulmonary Hypertension in PregnancyJournal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 2PreviewDespite improvements in advanced therapies, pulmonary hypertension (PHTN) remains one of the highest risk and least-tolerated conditions in pregnant women. Therefore, women with PHTN should be strongly counseled against pregnancy. If women with PHTN become pregnant, termination of the pregnancy is the preferred management.1,2 Despite these recommendations, women with known PHTN and those with undiagnosed PHTN will choose to proceed with pregnancy. The anesthesiologist, as a part of a multidisciplinary pregnancy heart team, must be prepared to manage these challenging patients. Full-Text PDF

BACKGROUND: The utility of prophylactic endovascular internal iliac balloon placement in the surgical management of placenta accreta spectrum is debated. OBJECTIVE: In this study, we review outcomes of surgical management of placenta accreta spectrum with and without prophylactic endovascular internal iliac balloon catheter use at a single institution. STUDY DESIGN: This is a retrospective cohort study of consecutive viable singleton pregnancies with a confirmed pathologic diagnosis of placenta accreta spectrum undergoing scheduled delivery from October 2018 through November 2020. In the T1 period (October 2018-August 2019), prophylactic endovascular internal iliac balloon catheters were placed in the operating room before the start of surgery. Balloons were inflated after neonatal delivery and deflated after hysterectomy completion. In the T2 period (September 2019-November 2020), endovascular catheters were not used. In both time periods, all surgeries were performed by a dedicated multidisciplinary team using a standardized surgical approach. The outcomes compared included the estimated blood loss, anesthesia duration, operating room time, surgical duration, and a composite of surgical complications. Comparisons were made using the Wilcoxon rank-sum test and the Fisher exact test. RESULTS: A total of 30 patients were included in the study (T1=10; T2=20). The proportion of patients with placenta increta or percreta was 80% in both groups, as defined by surgical pathology. The median estimated blood loss was 875 mL in T1 and 1000 mL in T2 (P=.84). The proportion of patients requiring any packed red blood cell transfusion was 60% in T1 and 40% in T2 (P=.44). The proportion of patients requiring >4 units of packed red blood cells was 20% in T1 and 5% in T2 (P=.25). Surgical complications were observed in 1 patient in each group. Median operative anesthesia duration was 497 minutes in T1 and 296 minutes in T2 (P<.001). Median duration of operating room time was 498 minutes in T1 and 205 minutes in T2 (P<.001). Median surgical duration was 227 minutes in T1 and 182 minutes in T2 (P<.05). The median duration of time for prophylactic balloon catheter placement was 74 minutes (range, 46-109 minutes). The median postoperative length of stay was similar in both groups (6 days in T1 and 5.5 days in T2; P=.36). CONCLUSION: The use of prophylactic endovascular internal iliac balloon catheters was not associated with decreased blood loss, packed red blood cell transfusion, or surgical complications. Catheter use was associated with increased duration of anesthesia, operating room time, and surgical time.

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 reported TNS. 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 The need for personalized medicine in obesity is pressing, but we are currently unable to predict individual responses to weight loss (WL) medications. The melanocortin (MC) system consisting of proopiomelanocortin (POMC) and agouti related protein (AgRP) neurons and brain MC-Rs plays a critical role in regulating energy homeostasis and is targeted by lorcaserin (LOR), a 5HT2cR agonist previously FDA approved for WL. We therefore investigated the short and long-term effects of LOR on the MC system as assessed by cerebrospinal fluid (CSF) neuropeptide measurements and other parameters in order to identify potential biomarkers to predict WL response. Methods In phase-1 of our two-phase study, thirty subjects with obesity were randomized to receive placebo or LOR for 7-days and were then crossed over to 7-days of LOR or placebo after a 3-week washout period. Subjects then continued to phase-2 and were treated with LOR for 6-months. The study was terminated early as LOR was withdrawn from the market and only 19 subjects completed 6M. Anthropometrics, plasma and CSF were collected and test meals were administered after both placebo and LOR during phase-1 and at the end of phase-2. POMC prohormone and the POMC-derived peptide, β-endorphin (β-EP), were measured in CSF by in house ELISA and RIA. The MC-R antagonist, AgRP, was measured by ELISA in CSF and plasma as both may reflect brain AgRP. Results During phase-1 there was a decline in CSF POMC (p=0.001) and an increase in CSF β-EP (p=0.0017) resulting in an increase in the ratio of β-EP /POMC (processed peptide/prohormone) (p<0.0001) after 7-days of LOR vs placebo. Serum insulin and HOMA-IR also decreased despite no WL during phase-1 (p<0.005). After 6M of LOR, average WL was 6.9%, with 11/19 subjects achieving >5% and 7/19 >10% WL. Leptin, insulin and HOMA-IR declined. CSF POMC remained lower and β-EP and β-EP/POMC remained higher after 6M vs 7-day placebo (baseline), whereas AgRP increased only at 6M. Anthropometrics and caloric intake during test meals were not significantly different between LOR and placebo in phase-1 and did not predict WL at 6M. Phase-1 changes in POMC or β-EP did not predict WL. However, baseline CSF POMC and POMC/AgRP ratio correlated negatively with WL and were significantly lower in subjects with >10% WL. A CSF POMC cutoff of < 220 fmol/ml at baseline was found to predict 10% WL at 6M (p=0.045 Fisher). Conclusion In this study we show that the melanocortin system is impacted after 1 week of LOR. Furthermore lower melanocortin activity at baseline predicted a better weight loss response to drug treatment. Assessment of melanocortin activity could thus provide a way to personalize the pharmacotherapy of obesity with possible future alternative selective 5HT2cR agonists. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Sunday, June 12, 2022 1:00 p.m. - 1:05 p.m.

Story-Vaginal progesterone compared with intramuscular 17-alpha-hydroxyprogesterone

(Br J Anaesth. 2020;125:e247–e248) The report by Zhong and colleagues in Wuhan, China reported a similar experience of spinal anesthesia in patients with coronavirus disease 2019 (COVID-19) to the experience of clinicians in New York. The report, however, also raises some questions.

(J Clin Anesth. 2021;75:110527. doi: 10.1016/j.jclinane.2021.110527) Intrathecal morphine (ITM) is regularly used for analgesia following cesarean delivery (CD), although there is no standardized dose. Employed as part of a multimodal analgesia system, recommended ITM dosing ranges from 50 to 150 µg. Dose-dependent opioid-related adverse events including vomiting, nausea, pruritus, and respiratory depression call for investigation into alternate methods that provide effective analgesia with fewer opioid-related adverse events. Previous studies of transverse abdominis plane (TAP) block with long-acting liposomal bupivacaine (LB) combined with ITM suggest enhanced analgesia compared to LB TAP or ITM alone. The comparison of efficacy and safety of LB TAP block with or without ITM (LB and LB + ITM) versus ITM alone has not been previously undertaken. The adequacy of analgesia including pain scores and postsurgical opioid consumption was studied for the 3 intervention groups (LB and LB + ITM, vs. ITM) with noninferiority tested before superiority.

Do genes matter? Well, of course they do, but how much do they matter to obstetric anesthesiologists? In this issue of the International Journal of Obstetric Anesthesia (IJOA), Tan et al. report an investigation of the effect of genetic variants within three genes involved in the renin-angiotensin-aldosterone system on maternal hypotension during spinal anesthesia for cesarean delivery. 1 Tan HS, Gan YY, Tan EC, et al. Association of renin-angiotensin-aldosterone system genetic polymorphisms with maternal hypotension duirng spinal anaethesia for caesarean delivery - a retrospective cohort study. Int J Obstet Anesth 2020;44:3–12. Google Scholar They demonstrate an increase in the incidence of hypotension in patients carrying a specific allele of one of the three genes studied - the gene coding for the angiotensin receptor. So, does this mean that genes do matter with regard to spinal hypotension or potentially with regard to other issues in obstetric anesthesia?

The objective of this study is to compare maternal outcomes during 2 time periods (T1 10/2016 - 09/2018; T2 10/2018 – 09/2020) using 2 strategies in the multidisciplinary management of placenta accreta spectrum (PAS); interval hysterectomy versus immediate cesarean hysterectomy. This is a retrospective cohort study of viable singleton pregnancies with a high pre-operative suspicion of PAS who underwent scheduled surgical management. During T1, the multidisciplinary approach included the use of interval hysterectomy in the most severe cases of PAS at the discretion of the covering surgical team. In the T2 period, immediate hysterectomy at the time of cesarean delivery was performed by a consistent and dedicated multidisciplinary team. Outcome variables included total estimated blood loss (EBL), maternal transfusion, surgical complications, and patient complications during the waiting period in the interval hysterectomy group. Comparisons were made using the Chi square test, Fisher’s exact test and the Wilcoxon rank sum test. 51 women were included in the study (T1 25; T2 26). All the women included in the cohort had a confirmed pathologic diagnosis of PAS. Results are summarized in Table 1. The proportion of women with placenta increta/percreta was similar in both groups (T1=64% and T2=77%, p=.31). The median total EBL was 3L during T1 and 1L during T2 (p<.0001). The percentage of women requiring any RBC transfusion was 92% during T1 and 42% during T2 (p=.0002), and 60% required more than 4uRBC during T1, whereas 12% did during T2 (p=.0002). The rate of urinary tract complications was 20% in T1 and 7.7% in T2 (p=.25). During the waiting period in the interval hysterectomy group, 3/10 (30%) women developed a complication requiring an emergency hysterectomy. Immediate hysterectomy in the management of PAS was associated with less blood loss compared to interval hysterectomy. The institution of a consistent multidisciplinary team may be associated with improvement in maternal outcomes, however further studies are warranted to assess its effect in the management of PAS.

Sun, Lena S. MD; Brambrink, Ansgar MD, PhD; Emala, Charles W. MD; Hua, May MD, MS; Lee, H. Thomas MD; Levy, Richard J. MD; Smiley, Richard M. MD, PhD; Whittington, Robert A. MD; Narula, Jacquelin H. BS Author Information