Obstetric Anesthesiology Research

Abstract

Postpartum hemorrhage (PPH) is the leading preventable cause of maternal mortality. Most PPH cases are caused by uterine atony, which is inconsistently defined in clinical care. We used the electronic health record (EHR) to prompt communication between the anesthesia and obstetric care teams about uterine tone using a validated 11-point numeric rating scale (NRS) at 0, 5, and 10-minutes after placental delivery for all cesarean deliveries (CDs) at our institution. Our primary hypothesis was that lower uterine tone NRS would be strongly associated with progression to major PPH.This was a single-center, prospective observational study conducted over a one-year period. The primary predictor was the 0-10 uterine tone NRS recorded 10-minutes after placental delivery, and the primary outcome was major PPH, defined as quantitative blood loss (QBL) ≥ 1,500 mL. Area under the receiver operating characteristic (AUROC) curves were created, and relative risk of major PPH for each one-point change in the tone score estimated. Key secondary outcomes analyzed included associations between tone scores, PPH, and blood transfusion.1,599 consecutive CDs were performed by obstetricians from academic (39.3%), county public health (21.1%), and private practice (38.8%) services. Major PPH complicated 9.9% and transfusion 6.7% of CDs. Uterine tone NRS was documented at 0-minutes after placental delivery in 91.6%, 5-minutes in 97.4%, and 10-minutes in 97.0% of CDs. The 10-minute NRS was a strong predictor of major PPH, with an AUROC of 0.78 (95% CI 0.73-0.82). Each one-point decrease in NRS increased the risk of major PPH by 71% (95% CI 0.58-0.86). A 10-minute uterine tone NRS ≤ 6 had high positive predictive value for major PPH (32.9%) as well as PPH (64.2%) and transfusion (20.6%).Standardized uterine tone assessments on a 0-10 scale are feasible to implement and strongly associated with progression to major PPH and blood transfusion. Future studies should investigate whether implementation of PPH interventions based on uterine tone NRS can reduce major PPH and hemorrhage-associated morbidity.

View details for DOI 10.1097/ALN.0000000000005476

View details for PubMedID 40214225

View details for DOI 10.1056/NEJMp2511434

View details for PubMedID 41283218

View details for DOI 10.1001/jama.2025.13225

View details for PubMedID 40864437

Abstract

Buprenorphine combined with naloxone is commonly used to treat opioid use disorders outside of pregnancy. In pregnancy, buprenorphine alone is generally recommended because of limited perinatal safety data on the combination product.To compare perinatal outcomes following prenatal exposure to buprenorphine with naloxone vs buprenorphine alone.Population-based cohort study using health care utilization data from Medicaid-insured beneficiaries in the US from 2000 to 2018. The cohort was restricted to pregnant individuals linked to their liveborn infants, with maternal Medicaid enrollment from 3 months before pregnancy to 1 month after delivery and infant enrollment for the first 3 months after birth, unless they died sooner.Use of buprenorphine with naloxone vs buprenorphine alone during the first trimester based on outpatient dispensings.Outcomes included major congenital malformations, low birth weight, neonatal abstinence syndrome, neonatal intensive care unit admission, preterm birth, respiratory symptoms, small for gestational age, cesarean delivery, and maternal morbidity. Confounder-adjusted risk ratios were calculated using propensity score overlap weights.This study identified 3369 pregnant individuals exposed to buprenorphine with naloxone during the first trimester (mean [SD] age, 28.8 [4.6] years) and 5326 exposed to buprenorphine alone or who switched from the combination to buprenorphine alone by the end of the first trimester (mean [SD] age, 28.3 [4.5] years). When comparing buprenorphine combined with naloxone with buprenorphine alone, a lower risk for neonatal abstinence syndrome (absolute risk, 37.4% vs 55.8%; weighted relative risk, 0.77 [95% CI, 0.70-0.84]) and a modestly lower risk for neonatal intensive care unit admission (absolute risk, 30.6% vs 34.9%; weighted relative risk, 0.91 [95% CI, 0.85-0.98]) and small for gestational age (absolute risk, 10.0% vs 12.4%; weighted relative risk, 0.86 [95% CI, 0.75-0.98]) was observed. For maternal morbidity, the comparative rates were 2.6% vs 2.9%, respectively, and the weighted relative risk was 0.90 (95% CI, 0.68-1.19). No differences were observed with respect to major congenital malformations overall, low birth weight, preterm birth, respiratory symptoms, or cesarean delivery. Results were consistent across sensitivity analyses.There were similar and, in some instances, more favorable neonatal and maternal outcomes for pregnancies exposed to buprenorphine combined with naloxone compared with buprenorphine alone. For the outcomes assessed, compared with buprenorphine alone, buprenorphine with naloxone during pregnancy appears to be a safe treatment option. This supports the view that both formulations are reasonable options for the treatment of opioid use disorder in pregnancy, affirming flexibility in collaborative treatment decision-making.

View details for DOI 10.1001/jama.2024.11501

View details for PubMedID 39133511

View details for DOI 10.1001/jama.2024.5003

View details for PubMedID 38648036

View details for PubMedCentralID PMC11036309

Abstract

Maternal use of valproate during pregnancy has been associated with an increased risk of neurodevelopmental disorders in children. Although most studies of other antiseizure medications have not shown increased risks of these disorders, there are limited and conflicting data regarding the risk of autism spectrum disorder associated with maternal topiramate use.We identified a population-based cohort of pregnant women and their children within two health care utilization databases in the United States, with data from 2000 through 2020. Exposure to specific antiseizure medications was defined on the basis of prescription fills from gestational week 19 until delivery. Children who had been exposed to topiramate during the second half of pregnancy were compared with those unexposed to any antiseizure medication during pregnancy with respect to the risk of autism spectrum disorder. Valproate was used as a positive control, and lamotrigine was used as a negative control.The estimated cumulative incidence of autism spectrum disorder at 8 years of age was 1.9% for the full population of children who had not been exposed to antiseizure medication (4,199,796 children). With restriction to children born to mothers with epilepsy, the incidence was 4.2% with no exposure to antiseizure medication (8815 children), 6.2% with exposure to topiramate (1030 children), 10.5% with exposure to valproate (800 children), and 4.1% with exposure to lamotrigine (4205 children). Propensity score-adjusted hazard ratios in a comparison with no exposure to antiseizure medication were 0.96 (95% confidence interval [CI], 0.56 to 1.65) for exposure to topiramate, 2.67 (95% CI, 1.69 to 4.20) for exposure to valproate, and 1.00 (95% CI, 0.69 to 1.46) for exposure to lamotrigine.The incidence of autism spectrum disorder was higher among children prenatally exposed to the studied antiseizure medications than in the general population. However, after adjustment for indication and other confounders, the association was substantially attenuated for topiramate and lamotrigine, whereas an increased risk remained for valproate. (Funded by the National Institute of Mental Health.).

View details for DOI 10.1056/NEJMoa2309359

View details for PubMedID 38507750

Abstract

Enhanced Recovery After Cesarean Delivery (ERAC) protocols include evidence-based interventions designed to improve maternal and neonatal outcomes and patient experiences while reducing healthcare-related costs. This is the first update to the Enhanced Recovery After Surgery Society guidelines for postoperative care in cesarean delivery published in 2019. Interventions were selected based on expert consensus. An updated literature search was performed in September 2024 using Embase, PubMed, MEDLINE, EBSCO CINAHL, Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2019 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each postoperative Enhanced Recovery After Cesarean Delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. After a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation system. The 13 recommended Enhanced Recovery After Cesarean Delivery interventions were (1) early drinking and feeding (low evidence, strong recommendation), (2) early discontinuation of intravenous fluid (very low evidence, strong recommendation), (3) early mobilization and ambulation (low evidence, strong recommendation), (4) early removal of urinary catheter (low evidence, strong recommendation), (5) scheduled acetaminophen (moderate evidence, strong recommendation), (6) scheduled nonsteroidal anti-inflammatory drugs (high evidence, strong recommendation), (7) oral rescue opioids (low evidence, strong recommendation), (8) standardized rescue medication protocol for side effects (low to moderate evidence, strong recommendation), (9) venous thromboembolism prophylaxis (low evidence, strong recommendation), (10) anemia remediation (moderate evidence, strong recommendation), (11) breastfeeding support and education (low evidence, strong recommendation), (12) promotion of rest periods (low evidence, strong recommendation), and (13) facilitate patient-centered transition to discharge (low evidence, strong recommendation). The 13 recommended postoperative interventions should be considered in the absence of contraindications in patients undergoing cesarean delivery to optimize maternal recovery and outcomes.

View details for DOI 10.1016/j.ajog.2025.01.038

View details for PubMedID 40335351

Abstract

Existing patient-reported outcome measures (PROMs) evaluating outpatient postpartum recovery lack content validity and were mostly not designed for this population. A Delphi process was performed, aiming to develop a patient-reported outcome measure for outpatient postpartum recovery and then evaluate it in a multicenter cohort study.Development of the Stanford Obstetric Recovery Checklist (STORK) involved 3 phases: (1) postpartum recovery questions were identified in published reviews; (2) after institutional review board approval, 16 multidisciplinary experts and patient stakeholders participated in 3 Delphi rounds (January 11 to April 12, 2021) to select items, resulting in the development of STORK (47 items; total score range, 0-188, with 0 indicating the worst recovery and 188 indicating the best recovery); and (3) cognitive debriefing interviews were conducted with 10 postpartum individuals to finalize STORK items. Individuals then completed STORK during their inpatient stay and at 2, 6, and 12 weeks post partum in a prospective, 3-center, US longitudinal cohort study conducted from June 13, 2022, to February 28, 2023. Recruitment occurred until 300 six-week STORK surveys were completed. STORK was evaluated at 6 weeks for validity (ability to measure recovery), reliability, and responsiveness. Validity included (1) structural validity (exploratory factor analysis using root mean square residual [RMSR]; <0.08 indicates a good fit); (2) convergent validity (correlation with global health visual analog scale score [GHVAS; scale, 0-100] and EuroQoL Five-Dimensions Three-Levels [EQ-5D-3L]); (3) discriminant validity (mean difference in STORK scores with GHVAS <70 vs ≥70); and (4) confirmatory telephone interviews with postpartum individuals scoring the highest and lowest 10th percentiles of STORK scores. Reliability (consistency of STORK scores) was evaluated using Cronbach α, interitem correlation, split-half reliability, and floor and ceiling effects. Responsiveness (ability of STORK to detect changes in recovery over time) was evaluated using percentage change in score from baseline to 12 weeks.A total of 525 individuals were recruited after all delivery modes (response rate, 62% [324 of 525] at 6 weeks); 498 (mean [SD] age, 33.3 [4.9] years) completed baseline inpatient postpartum surveys. STORK demonstrated validity: (1) a 4-factor model was the best fit (RMSR = 0.05); (2) correlation with GHVAS scores was ρ = 0.52 (95% CI, 0.43-0.61), and correlation with EQ-5D-3L scores was ρ = -0.67 (95% CI, -0.76 to -0.63); (3) STORK was able to discriminate between patients reporting good and poor recovery (good recovery: median STORK score, 151 [IQR, 136-163] vs poor recovery: median STORK score, 129 [IQR, 107-148]; P < .001); and (4) the highest and lowest scores corresponded to subjective assessments. STORK demonstrated reliability (Cronbach α = 0.92; interitem correlation r = 0.20; and split-half reliability ρ = 0.98). It also demonstrated responsiveness: percentage increases in overall STORK scores from baseline to week 12 were 19% after spontaneous vaginal delivery, 31% after operative vaginal delivery, 27% after scheduled cesarean delivery, and 20% after nonscheduled cesarean delivery (P < .001).In this cohort study of US individuals, STORK was found to be a valid, reliable, and responsive measure of outpatient postpartum recovery. Future clinical trials are needed to determine its clinical utility.

View details for DOI 10.1001/jamanetworkopen.2025.5713

View details for PubMedID 40244582

Abstract

To better understand outcomes in postpartum patients who receive peripartum anaesthetic interventions, we aimed to assess quality of recovery metrics following childbirth in a UK-based multicentre cohort study. This study was performed during a 2-week period in October 2021 to assess in- and outpatient post-delivery recovery at 1 and 30 days postpartum. The following outcomes were reported: obstetric quality of recovery 10-item measure (ObsQoR-10); EuroQoL (EQ-5D-5L) survey; global health visual analogue scale; postpartum pain scores at rest and movement; length of hospital stay; readmission rates; and self-reported complications. In total, 1638 patients were recruited and responses analysed from 1631 (99.6%) and 1282 patients (80%) at one and 30 days postpartum, respectively. Median (IQR [range]) length of stay postpartum was 39.3 (28.5-61.0 [17.7-513.4]), 40.3 (28.5-59.1 [17.8-220.9]), and 35.9 (27.1-54.1 [17.9-188.4]) h following caesarean, instrumental and vaginal deliveries, respectively. Median (IQR [range]) ObsQoR-10 score was 75 ([62-86] 4-100) on day 1, with the lowest ObsQoR-10 scores (worst recovery) reported by patients undergoing caesarean delivery. Of the 1282 patients, complications within the first 30 days postpartum were reported by 252 (19.7%) of all patients. Readmission to hospital within 30 days of discharge occurred in 69 patients (5.4%), with 49 (3%) for maternal reasons. These data can be used to inform patients regarding expected recovery trajectories; facilitate optimal discharge planning; and identify populations that may benefit most from targeted interventions to improve postpartum recovery experience.

View details for DOI 10.1111/anae.16039

View details for PubMedID 37226593

Abstract

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

View details for DOI 10.1097/ALN.0000000000004263

View details for PubMedID 35511169

Abstract

Outpatient postpartum recovery is an underexplored area of obstetrics. There is currently no consensus regarding which patient-reported outcome measure (PROM) clinicians and researchers should use to evaluate postpartum recovery.To evaluate PROMs of outpatient postpartum recovery using Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines.An initial literature search performed in July 2019 identified postpartum recovery PROMs and validation studies. A secondary search in July 2020 identified additional validation studies. Both searches were performed using 4 databases (Web of Science, Embase, PubMed, and CINAHL), with no date limiters. Studies with PROMs evaluating more than 3 proposed outpatient postpartum recovery domains were considered. Studies were included if they assessed any psychometric measurement property of the included PROMs in the outpatient postpartum setting. The PROMs were assessed for the following 8 psychometric measurement properties, as defined by COSMIN: content validity, structural validity, internal consistency, cross-cultural validity and measurement invariance, reliability, measurement error, hypothesis testing, and responsiveness. Psychometric measurement properties were evaluated in each included study using the COSMIN criteria by assessing (1) the quality of the methods (very good, adequate, doubtful, inadequate, or not assessed); (2) overall rating of results (sufficient, insufficient, inconsistent, or indeterminate); (3) level of evidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations assessment tool; and (4) level of recommendation, which included class A (recommended for use; showed adequate content validity with at least low-quality evidence for sufficient internal consistency), class B (not class A or class C), or class C (not recommended).In total, 15 PROMs (7 obstetric specific and 8 non-obstetric specific) were identified, evaluating outpatient postpartum recovery in 46 studies involving 19 165 women. The majority of psychometric measurement properties of the included PROMs were graded as having very-low-level or low-level evidence. The best-performing PROMs that received class A recommendations were the Maternal Concerns Questionnaire, the Postpartum Quality of Life tool, and the World Health Organization Quality of Life-BREF. The remainder of the evaluated PROMs had insufficient evidence to make recommendations regarding their use (and received class B recommendations).This review found that the best-performing PROMs currently available to evaluate outpatient postpartum recovery were the Maternal Concerns Questionnaire, the Postpartum Quality of Life tool, and the World Health Organization Quality of Life-BREF; however, these tools all had significant limitations. This study highlights the need to focus future efforts on robustly developing and validating a new PROM that may comprehensively evaluate outpatient postpartum recovery.

View details for DOI 10.1001/jamanetworkopen.2021.11600

View details for PubMedID 34042993