Obstetric Anesthesiology Research

Abstract

BACKGROUND: The phase III research evaluating migraine prophylaxis therapy (PREEMPT) protocol was developed in low-risk migraine patients. We studied longitudinal response to treatment in a sequential retrospective observational cohort to evaluate predictors of effectiveness in patients with multiple overlapping pain syndromes treated in a quaternary pain management clinic.METHODS: We evaluated indicators of individual response in 402 consecutive chronic migraine patients who provided demographic information and used the Collaborative Health Outcomes Information Registry.RESULTS: The patients were middle aged 47 (38-56) median (IQR) years old and 83% women. They reported multiple complex pain problems with 11 (6-18) regions represented on a pain body map. Evaluated with National Institutes of Health Patient-Reported Outcomes Measurement Information System measures, they reported higher scores for sleep impairment and disturbance, anxiety, depression, fatigue, pain behavior, pain interference and worse function and satisfaction with social roles compared with the general US population; p<0.001for all domains. Within 120days of treatment, 62% of patients reported reduced headache frequency. The best multivariable model developed for prediction of reduced headache frequency in response to treatment included lower treatment number, lower pain interference score, and less depression (p=0.001, 0.002, and 0.009). Depression may have been an obstacle to successful treatment; there was no association between depression score and number of treatments (p=0.54).CONCLUSIONS: Our findings point to the importance of identifying and addressing pain interference and depression early in chronic migraine management and, more broadly, highlights the importance of multidisciplinary evaluation and treatment in chronic migraine.

View details for DOI 10.1136/rapm-2018-100196

View details for PubMedID 31101743

View details for DOI 10.1016/j.ajog.2018.12.016

View details for Web of Science ID 000472481100020

Abstract

Patient-centred care and factors associated with patient satisfaction with anaesthesia have been widely studied. However, the most important considerations in the setting of obstetric anaesthesia are uncertain. Identification of, and addressing, factors that contribute to patient dissatisfaction may improve quality of care. We sought to identify factors associated with<100% satisfaction with obstetric anaesthesia care. At total of 4297 women treated by anaesthetists provided satisfaction data 24h after vaginal and 48h after caesarean delivery. As 78% of women were 100% satisfied, we studied factors associated with the dichotomous variable, 100% satisfied vs. < 100% satisfied. We evaluated patient characteristics and peripartum factors using multivariable sequential logistic regression. The following factors were strongly associated with maternal dissatisfaction after vaginal delivery: pain intensity during the first stage of labour; pain intensity during the second stage of labour; postpartum pain intensity; delay >15min in providing epidural analgesia and postpartum headache (all p<0.0001). Pruritus (p=0.005) also contributed to dissatisfaction after vaginal delivery, whereas non-Hispanic ethnicity was negatively associated with dissatisfaction (p=0.01). After caesarean delivery, the intensity of postpartum pain (p<0.0001), headache (p=0.001) and pruritus (p=0.001) were linked to dissatisfaction. Hispanic ethnicity also had a negative relationship with dissatisfaction after caesarean delivery (p=0.005). Thus, inadequate or delayed analgesia and treatment-related side-effects are associated with maternal dissatisfaction with obstetric anaesthesia care. Development of protocols to facilitate identification of ineffective analgesia and provide an appropriate balance between efficacy and side-effects, are important goals to optimise maternal satisfaction.

View details for DOI 10.1111/anae.14756

View details for PubMedID 31264207

Abstract

BACKGROUND: The burden of preeclampsia severity on the health of mothers and infants during the first year after delivery is unclear given the lack of population-based longitudinal studies in the United States.METHODS: We assessed maternal and infant adverse outcomes during the first year after delivery using population-based hospital discharge information merged with vital statistics and birth certificates of 2,021,013 linked maternal-infant births in California. We calculated sampling weights using the National Center for Health Statistics data to adjust for observed differences in maternal characteristics between California and the rest of the United States. Separately, we estimated the association between preeclampsia and gestational age and examined collider bias in models of preeclampsia and maternal and infant adverse outcomes.RESULTS: Compared with women without preeclampsia, women with mild and severe preeclampsia delivered 0.66 weeks (95% confidence interval [CI]: 0.64, 0.68) and 2.74 weeks (95% CI: 2.72, 2.77) earlier, respectively. Mild preeclampsia was associated with an increased risk of having any maternal adverse outcome (relative risk [RR]=1.95; 95% CI: 1.93, 1.97), as was severe preeclampsia (RR=2.80; 95% CI: 2.78, 2.82). The risk of an infant adverse outcome was increased for severe preeclampsia (RR=2.15; 95% CI: 2.14, 2.17) but only marginally for mild preeclampsia (RR=0.99; 95% CI: 0.98, 1). Collider bias produced an inverse association for mild preeclampsia and attenuated the association for severe preeclampsia in models for any infant adverse outcome.CONCLUSION: Using multiple datasets, we estimated that severe preeclampsia is associated with a higher risk of maternal and infant adverse outcomes compared with mild preeclampsia, including an earlier preterm delivery.

View details for PubMedID 30780187

Abstract

Colloid preloading diminishes post-spinal hypotension. However, whether colloid preloading is superior to crystalloid co-loading is uncertain. In this retrospective study, we compared the effects of a colloid preload versus a crystalloid co-load on vasopressor requirements and maternal haemodynamics among women undergoing elective caesarean delivery (CD) with spinal anaesthesia.We extracted data from the medical records of 160 healthy women who underwent elective CD with spinal anaesthesia at an academic obstetric centre before and after an institutional fluid-loading protocol change. Patients received a 500 mL 6% hydroxyethyl starch preload or a 1000 mL crystalloid co-load. The primary outcome was the total phenylephrine dose administered from spinal block placement to delivery.Our cohort comprised 79 women in the colloid group and 77 women in the crystalloid group. The mean phenylephrine use was significantly lower in the colloid group than in the crystalloid group (489±403 μg vs. 647±464 μg, respectively, p=0.02). The maximal drop in systolic blood pressure was greater in the colloid group than in the crystalloid group (36±20 mmHg vs. 29±16 mmHg, respectively, p=0.02). There were no clinically significant differences between the groups in heart rate, blood loss, temperature and Apgar scores.Vasopressor use was lower in colloid preloading than in crystalloid co-loading. However, differences in all outcome measures were minimal and likely clinically insignificant, suggesting that both fluid-loading techniques are appropriate to use for the prevention of spinal hypotension in women undergoing CD.

View details for DOI 10.5152/TJAR.2018.76402

View details for PubMedID 31276109

View details for PubMedCentralID PMC6598662

Abstract

OBJECTIVE: To assess the relationship between maternal body mass index (BMI) and pregnancy-related venous thromboembolism (VTE).DESIGN: Cross-sectional study.SETTING & POPULATION: 2,449,133 women with singleton pregnancies who underwent delivery hospitalization in California between 2008 and 2012.METHODS: Association of prepregnancy BMI and the risk of an antepartum and postpartum VTE was examined using logistic regression, with normal BMI as reference.MAIN OUTCOME MEASURES: Antepartum and postpartum VTE related hospitalization.RESULTS: The prevalences of antepartum and postpartum VTE increased with increasing BMI (antepartum: 2.3, 3.0, 3.8, 4.2, 4.7, and 10.6 per 10 000 women for underweight, normal BMI, overweight, obesity class I, II, and III, P<0.001. postpartum: 2.0, 3.1, 3.9, 5.6, 9.0, and 13.2 per 10 000 women, P<0.01). The adjusted odds of antepartum and postpartum VTE increased progressively with increasing BMI, and obese class III women being at highest risk of pregnancy-related VTE compared with normal BMI women: adjusted odds ratio (OR) for antepartum VTE: 2.9; 95% CI 2.2-3.8 and adjusted OR for postpartum VTE: 3.6; 95% CI 2.9-4.6.CONCLUSIONS: Our findings clearly demonstrate an increasing risk of pregnancy-related VTE with increasing BMI. This article is protected by copyright. All rights reserved.

View details for PubMedID 30500109

View details for DOI 10.1016/j.ajog.2018.12.016

View details for Web of Science ID 000472481100020

View details for DOI 10.1097/ALN.0000000000002708

View details for Web of Science ID 000467856100003

Abstract

The majority of women undergoing cesarean delivery in the United States receive neuraxial morphine, the most effective form of postoperative analgesia for this surgery. Current American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) recommend respiratory monitoring standards following neuraxial morphine administration in the general surgical population that may be too frequent and intensive when applied to the healthy obstetric population receiving a single dose of neuraxial morphine at the time of surgery. There is limited evidence to support or guide the optimal modality, frequency, and duration of respiratory monitoring in the postoperative cesarean delivery patient receiving a single dose of neuraxial morphine. Consistent with the mission of the Society for Obstetric Anesthesia and Perinatology (SOAP) to improve outcomes in pregnancy for women and neonates, the purpose of this consensus statement is to encourage the use of this highly effective analgesic technique while promoting safe practice and patient-centered care. The document aims to reduce unnecessary interruptions from respiratory monitoring in healthy mothers while focusing vigilance on monitoring in those women at highest risk for respiratory depression following neuraxial morphine administration. This consensus statement promotes the use of low-dose neuraxial morphine and multimodal analgesia after cesarean delivery, gives perspective on the safety of this analgesic technique in healthy women, and promotes patient risk stratification and perioperative risk assessment to determine and adjust the intensity, frequency, and duration of respiratory monitoring.

View details for PubMedID 31082964

View details for PubMedID 30985305

Abstract

OBJECTIVE: To perform a systematic review of randomized trials comparing oral versus intravenous iron therapy to treat postpartum anemia.DATA SOURCES: Data sources were: PubMed (1972-2017); Cochrane Central Register of Controlled Trials, CENTRAL (1972-2017); CINAHL (1972-2017); Web of Science; Excerpta Medica Database, and EMBASE (1972-2017).STUDY ELIGIBILITY CRITERIA: We included randomized trials comparing oral versus intravenous iron monotherapy to treat postpartum anemia (classified as a hemoglobin<12 g/dL).STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was assessed with the Cochrane risk of bias assessment tool. The primary outcome was the hemoglobin concentration at 6 weeks postpartum. Secondary outcomes included: hemoglobin concentration at 1 - 5 weeks postpartum, ferritin concentration at 1 - 6 weeks postpartum; and maternal adverse outcomes. For meta-analysis, mean differences and odds ratios using a random effects model were calculated. Risk of heterogeneity was reported as I2.RESULTS: Fifteen randomized trials met our inclusion criteria (n=1,001 and 1,181 women receiving oral iron and intravenous iron, respectively); 4 studies reported data for our primary outcome. We observed higher postpartum week 6 hemoglobin concentrations in the iv iron group compared to the oral iron group, (mean difference 0.9 g/dL, 95% CI=0.4, 1.3; p=0.0003). Compared to oral iron, women receiving iv iron had higher hemoglobin concentrations at postpartum weeks 1, 2, and 3; higher ferritin concentrations at postpartum weeks 1, 2, 4, and 6; an increased likelihood of skin flushing (odds ratio=6.95; 95% confidence interval, 1.56-31.03; P=0.01; I2=0%); and a decreased likelihood of constipation (odds ratio=0.08, 95% confidence interval, 0.03-0.21; P=<0.00001, I2=27%) and dyspepsia (odds ratio=0.07, 95% confidence interval, 0.01-0.42; P=0.004; I2=0%). The reported event rate for anaphylaxis among women receiving intravenous iron was 0.6%.CONCLUSIONS: In this systematic review, among women with postpartum anemia, hemoglobin concentrations at 6 weeks postpartum were almost 1 g/dL higher in women who received intravenous iron compared to oral iron. The safety profile of intravenous iron was also reassuring. Given the weaker hemoglobin response and higher risk of gastrointestinal side-effects with oral iron use, our findings suggest that intravenous iron be considered as a viable treatment option for postpartum iron deficiency anemia.

View details for PubMedID 30578747