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Chapter by: Toledano, Roulhac D; Leffert, Lisa
in: Quick hits in obstetric anesthesia by Fernando, Roshan; Sultan, Pervez; Philips, Sioned
[S.l.] : Springer, 2022
pp. 317-321
ISBN: 978-3-030-72487-0
CID: 5213202


Chapter by: Toledano, Roulhac D; Leffert, Lisa
in: Quick hits in obstetric anesthesia by Fernando, Roshan; Sultan, Pervez; Philips, Sioned
[S.l.] : Springer, 2022
pp. 313-316
ISBN: 978-3-030-72487-0
CID: 5213152

What's New in Neuraxial Labor Analgesia

Toledano, Roulhac D; Leffert, Lisa
Purpose of Review/UNASSIGNED:This article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed. Recent Findings/UNASSIGNED:There has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia. Summary/UNASSIGNED:/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.
PMID: 34466127
ISSN: 1523-3855
CID: 4989252

The Society for Obstetric Anesthesia and Perinatology (SOAP) COVID-19 Registry: An analysis of outcomes among pregnant women delivering during the initial SARS-CoV-2 outbreak in the United States

Katz, Daniel; Bateman, Brian T; Kjaer, Klaus; Turner, Dana P; Spence, Nicole Z; Habib, Ashraf S; George, Ronald B; Toledano, Roulhac D; Grant, Gilbert; Madden, Hannah E; Butwick, Alex J; Lynde, Grant; Minehart, Rebecca D; Beilin, Yaakov; Houle, Timothy T; Sharpe, Emily E; Kodali, Bhavani; Bharadwaj, Shobana; Farber, Michaela K; Palanisamy, Arvind; Prabhu, Malavika; Gonzales, Nikolai Y; Landau, Ruth; Leffert, Lisa
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.
PMID: 33830956
ISSN: 1526-7598
CID: 4851472

The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia

Bauer, Melissa E; Arendt, Katherine; Beilin, Yaakov; Gernsheimer, Terry; Perez Botero, Juliana; James, Andra H; Yaghmour, Edward; Toledano, Roulhac D; Turrentine, Mark; Houle, Timothy; MacEachern, Mark; Madden, Hannah; Rajasekhar, Anita; Segal, Scott; Wu, Christopher; Cooper, Jason P; Landau, Ruth; Leffert, Lisa
Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 10/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.
PMID: 33861047
ISSN: 1526-7598
CID: 4871512

Lumbar neuraxial procedures in thrombocytopenic patients across populations: A systematic review and meta-analysis

Bauer, Melissa E; Toledano, Roulhac D; Houle, Timothy; Beilin, Yaakov; MacEachern, Mark; McCabe, Madeline; Rector, Dana; Cooper, Jason P; Gernsheimer, Terry; Landau, Ruth; Leffert, Lisa
INTRODUCTION/BACKGROUND:There is currently no consensus regarding the minimum threshold platelet count to ensure safe neuraxial procedures. Numerous reports describe the safe performance of lumbar punctures in severely thrombocytopenic patients but reports of neuraxial anesthetic procedures in thrombocytopenic patients are limited. To date, the focus on specific populations in contemporary reviews has failed to include any actual hematoma cases. This systematic review aggregates reported lumbar neuraxial procedures from diverse thrombocytopenic populations to best elucidate the risk of spinal epidural hematoma. METHODS:/L) who received a lumbar neuraxial procedure (lumbar puncture; spinal, epidural, or combined spinal-epidural analgesia/anesthesia; epidural catheter removal), whether spinal epidural hematoma occurred. RESULTS:/L or above, reflecting a low probability of spinal epidural hematoma in this sample. Of the 19 spinal epidural hematoma cases for which the onset of symptoms was reported, 18 (95%) were symptomatic within 48 h of the procedure. CONCLUSIONS:/L or above, reflecting an estimated low spinal epidural hematoma event rate with more certainty given a larger sample size and inclusion of spinal epidural hematoma cases. Thrombocytopenic patients should be monitored, particularly in the first 48 h, and educated about symptoms concerning for spinal epidural hematoma.
PMID: 31810860
ISSN: 1873-4529
CID: 4224952

Neuraxial Blockade in Obstetric Patients with Thrombocytopenia: A Rational Approach to Risk Assessment

Toledano, Roulhac D; Byerly, Stephanie
ISSN: 0891-9917
CID: 5213252

Anesthetic Management of Placenta Accreta

Toledano, Roulhac; Munnur, Uma; Leffert, Lisa
ISSN: 0891-9917
CID: 5213262

UpToDate, 2019-

Serious neurologic complications of neuraxial anesthesia procedures in obstetric patients

Toledano, Roulhac d'Arby; Wlody, David
CID: 3896422

Anesthetic Management of Nonobstetric Surgery during Pregnancy

Toledano, R. d\Arby; Madden, Hannah E.; Leffert, Lisa
ISSN: 1523-3855
CID: 5213182