Faculty Bibliography

BACKGROUND:Early reports associating SARS-CoV-2 infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) COVID Registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing. METHODS:Deliveries from 14 U.S. medical centers, March 19-May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2 infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (e.g., delivery mode, hypertensive disorders of pregnancy, delivery < 37 weeks), an adverse neonatal outcome composite measure (primary), and anesthetic utilization (e.g., neuraxial labor analgesia and anesthesia). Outcomes were analyzed using generalized estimating equations to account for clustering within centers. Sensitivity analyses compared symptomatic and asymptomatic patients to controls. RESULTS:1454 peripartum women were included: 490 with SARS-CoV-2 infection [176 (35.9%) symptomatic]; 964 controls. SARS-CoV-2 patients were slightly younger, more likely non-nulliparous, non-white, and Hispanic than controls. They were more likely to have diabetes, obesity, or cardiac disease and less likely to have autoimmune disease. After adjustment for confounders, individuals experiencing SARS-CoV-2 infection exhibited an increased risk for delivery < 37 weeks gestation compared to controls, 73 (14.8%) vs. 98 (10.2%) [adjusted odds ratio (aOR): 1.47 95% CI (1.03-2.09)]. Effect estimates for other obstetric outcomes and the neonatal composite outcome measure were not meaningfully different between SARS-CoV-2-patients versus controls. In sensitivity analyses, compared to controls, symptomatic SARS-CoV-2 patients exhibited: increases in cesarean delivery [aOR: 1.57 95% CI (1.09-2.27)]; postpartum length of stay [aOR 1.89 95% CI (1.18-2.60)]; delivery < 37 weeks gestation [aOR 2.08 95% CI (1.29-3.36)]. These adverse outcomes were not found in asymptomatic women versus controls. SARS-CoV-2 patients (asymptomatic and symptomatic) were less likely to receive neuraxial labor analgesia [aOR: 0.52 95% CI (0.35-0.75)] and more likely to receive general anesthesia for cesarean delivery [aOR: 3.69 95% CI (1.40-9.74)] due to maternal respiratory failure. CONCLUSIONS:In this large, multicenter U.S. cohort study of women with and without peripartum SARS-CoV-2 infection, differences in obstetric and neonatal outcomes seem to be mostly driven by symptomatic patients. Lower utilization of neuraxial analgesia in laboring patients with asymptomatic or symptomatic infection compared to patients without infection requires further investigation.

Shoulder tip pain may occur after thoracic surgical procedures. The pain is caused by diaphragmatic irritation and is referred to the shoulder. Shoulder tip pain is often resistant to treatment with conventional analgesics. The sphenopalatine ganglion block has been described to manage many painful conditions. We report here the first use of this block to treat shoulder tip pain in 2 thoracic surgical patients. In both patients, the block produced rapid and sustained relief of the shoulder tip pain. We suggest that sphenopalatine ganglion block be considered to treat postoperative shoulder tip pain after thoracic surgical procedures.

STUDY OBJECTIVE: At our hospital, although >90% of nulliparous parturients eventually choose epidural analgesia for labor, many delay its initiation, experiencing considerable pain in the interim. This survey probed parturients' views about the timing of initiation of epidural labor analgesia. DESIGN: Single-center, nonrandomized quantitative survey. SETTING: Labor and delivery suite in a large tertiary academic medical center. PATIENTS: Two hundred laboring nulliparous women admitted to the labor and delivery suite. INTERVENTIONS: After their pain was relieved, parturients completed a questionnaire regarding their decision to request labor epidural analgesia. MEASUREMENTS: A variety of factors regarding epidural use were assessed including the influence of painful contractions and of childbirth education class attendance on the decision to request epidural analgesia, and parturients' perception of the timing of epidural initiation on the progress and outcome of labor. MAIN RESULTS: Analysis revealed that the desire of parturients to use epidural analgesia was increased from 27.9% before the onset of painful contractions to 48.2% after (p<0.01). Two-thirds of participants attended a non-physician taught childbirth education class. An antepartum plan to definitely forgo an epidural was 1.8 times more likely among women who attended a childbirth class when compared to those who did not attend. (OR=1.8; 95%CI:1.1-3.1; p=0.04). The most common views affecting decision-making were that epidural analgesia should not be administered "too early" (67.5%), and that it would slow labor (68.5%). Both of these views were more likely to be held if the parturient had attended a childbirth class, OR=2.0 (95%CI:1.1-3.8; p=0.03) and OR=2.0 (95% CI: 1.1 to 3.7; p=0.03), respectively. CONCLUSIONS: We found that nulliparous parturients have misconceptions about epidurals, which are not supported by evidence-based medicine. Moreover, we found that attendance at childbirth education classes was associated with believing these misconceptions.

There is a chronic shortage of anesthesiologists in Israel. The study by Cohen et al. suggests that a marketing campaign may be one method of addressing this shortage. This commentary argues for a more comprehensive strategy based on the US experience. This would not only involve marketing as suggested by Cohen et al. but would also involve a fundamental change in the Israel anesthesia care model, as well as providing substantial financial incentives to young physicians. We believe that a combination of these approaches will help to alleviate the shortage of anesthesia providers in Israel. Creating a new class of physician extenders, namely, anesthesiologist assistants, would also provide an employment pathway for the skilled medical technicians trained by the Israel Defense Forces, and other non-physicians with an interest in anesthesiology.