Obstetric units' preparedness to manage critically ill women. The second report from the MaCriCare study.

PURPOSE: We aimed to describe the availability of 31 distinct services and facilities to diagnose, resuscitate, and treat critically unwell obstetric patients. METHODS: Using a network of anesthesiologists, intensive care clinicians, obstetricians, critical care nurses, and midwives (MaCriCare) from September 2021 to January 2022, we conducted a descriptive international multicenter cross-sectional survey in centers with obstetric units (OUs) in the WHO Europe Region. RESULTS: The MaCriCare network covers 26 countries and received 1133 responses, corresponding to 2.5 million annual deliveries. The survey identified significant disparities in the availability of the measured 31 services among the OUs, with some services not immediately available and some not available at all. Point-of-care hemoglobin measurements were lacking in 13.8% of OUs. 15.2% of OUs lacked pointof-care lactate measurement, and 11% lacked transfusion services. 23.8% of OUs lacked the ability to administer hypotensive agent infusions in the labor ward. Samebuilding access to cell saver and thromboelastometry was unavailable to 45.5% and 64.4% of OUs, respectively. Access to invasive ventilation was unavailable to 3.4% of OUs, 11.7% were unable to offer same-building access to non-invasive ventilation, and extracorporeal membranous oxygenation was unavailable to 38.3% of the OUs. CONCLUSION: Critically ill obstetric patients have access to markedly different resources in the WHO Europe Region depending on the OU where they are managed. Consensus on which facilities and services should be universally available is urgently needed.

Preparedness for severe maternal morbidity in European hospitals: The MaCriCare study.

PURPOSE: To evaluate obstetric units (OUs) and intensive care units (ICUs) preparedness for severe maternal morbidity (SMM). METHODS: From September 2021 to January 2022, an international multicentre cross-sectional study surveyed OUs in 26 WHO Europe Region countries. We assessed modified early obstetric warning score usage (MEOWS), approaches to four SMM clinical scenarios, invasive monitoring availability in OUs, and access to high-dependency units (HDUs) and onsite ICUs. Within ICUs, we examined the availability of trained staff, response to obstetric emergencies, leadership, and data collection. RESULTS: 1133 responses were evaluated. MEOWS use was 34.5%. Non-obstetric early warning scores were being used. 21.4% (242) of OUs provided invasive monitoring in the OU. A quarter lacked access to onsite HDU beds. In cases of SMM, up to 13.8% of all OUs indicated the need for transfer to another hospital. The transfer rate was highest (74.0%) in small units. 81.9% of centers provided onsite ICU facilities to obstetric patients. Over 90% of the onsite ICUs provided daily specialist obstetric reviews but lacked immediate access to key resources: 3.4% - uterotonic drugs, 7.5% - neonatal resuscitation equipment, 9.2% - neonatal resuscitation team, 11.4% - perimortem cesarean section equipment. 41.2% reported obstetric data to a national database. CONCLUSION: Gaps in provision exist for obstetric patients with SMM in Europe, potentially compromising patient safety and experience. MEOWS use in OUs was low, while access to invasive monitoring and onsite HDU and ICU facilities was variable. ICUs frequently lacked resources and did not universally collect obstetric data for quality control.

Association of inpatient postpartum quality of recovery with postpartum depression: A prospective observational study.

STUDY OBJECTIVE: To explore the relationship between Obstetric Quality of Recovery survey (ObsQoR-10-Heb) and Edinburgh postnatal depression scale (EPDS) measured 6 weeks after delivery, adjusted for potential confounding factors. DESIGN: Prospective, longitudinal cohort study. SETTING: Large postpartum department, 13,000 annual deliveries, quaternary medical center in Israel. PATIENTS: Women ≥18 years old, gestational age ≥ 37 weeks after term delivery (spontaneous vaginal, operative vaginal, planned, and unplanned cesarean delivery), with non-anomalous neonates not requiring special support after delivery or at the time of recruitment. Written informed consent was provided. Women unable to read or understand Hebrew were excluded. INTERVENTIONS: No interventions were done. MEASUREMENTS: We investigated the relationship between inpatient postpartum recovery and positive postpartum depression (PPD) screening at 6 weeks postpartum. Enrolled women completed the validated Hebrew version of ObsQoR-10 survey (ObsQoR-10-Heb; scored between 0 and 100 with 0 and 100 representing worst and best possible recovery) from 24 to 48 h after delivery, and the Edinburgh Postnatal Depression Scale (EPDS) at 6- and 12 weeks postpartum. We assessed the univariate association between ObsQoR-10-Heb; patient factors; obstetric factors; and positive PPD screening at 6 weeks postpartum. Potential confounders were adjusted in a multiple logistic regression model. MAIN RESULTS: Inpatient ObsQoR-10-Heb has been completed by 325 postpartum women; 270 (83.1%) and 253 (77.9%) completed the 6- and 12 weeks EPDS respectively. Lower ObsQoR-10-Heb (aOR 0.95 (95% CI 0.92, 0.98); p = 0.001); depression or anxiety before delivery (aOR 4.53 (95% CI 1.88, 10.90); p = 0.001); and hospital readmission (aOR 9.08 (95% CI 1.23, 67.14); p = 0.031) were associated with positive screening for postpartum depression at 6 weeks. CONCLUSIONS: Our study demonstrates that worse inpatient postpartum recovery is an independent risk factor for positive PPD screening at 6 weeks postpartum. Other risk factors found in our study were maternal hospital readmission and a previous history of anxiety or depression.

Penny-wise and pound-foolish: the challenges of preoperative anaemia management.

The timely correction of anaemia before major surgery is important for optimising perioperative patient outcomes. However, multiple barriers have precluded the global expansion of preoperative anaemia treatment programmes, including misconceptions about the true cost/benefit ratio for patient care and health system economics. Institutional investment and buy-in from stakeholders could lead to significant cost savings through avoided complications of anaemia and red blood cell transfusions, and through containment of direct and variable costs of blood bank laboratories. In some health systems, billing for iron infusions could generate revenue and promote growth of treatment programmes. The aim of this work is to galvanise integrated health systems worldwide to diagnose and treat anaemia before major surgery.

A Prospective Observational Crossover Study Comparing Intubation by Pediatric Residents Using Video Laryngoscopy and Direct Laryngoscopy on a Pierre Robin Simulation Manikin.

INTRODUCTION: Video laryngoscopy (VL) has been proposed to increase the likelihood of successful intubation in patients with predicted difficult airways such as those with Pierre Robin sequence (PRS). Prior studies have focused on the performance of anesthesiologists, who are generally considered airway experts. Our primary aim was to investigate the success rate of intubation using VL compared with direct laryngoscopy (DL) when attempted by pediatric residents on a PRS model. METHODS: Participants were administered a 5-minute refresher video on 2 VL techniques (CMAC, conventional geometry VL, and McGrath, unconventional geometry VL) and DL. The participants were asked to intubate the AirSim PRS infant manikin. The order of VL and DL use was randomly selected. All intubations were video recorded, and the recordings were analyzed by 3 anesthesiologists blinded to the participant's identity and previous experience. RESULTS: Seventeen of 23 residents succeeded in intubating the PRS model using DL. Only 9 residents succeeded in intubating the PRS model using VL (conventional or unconventional geometry). Intubation success rate was higher when comparing DL with VL ( P = 0.04) and similar when comparing VL devices ( P = 0.69). DISCUSSION: Contrary to expectation, the intubation success rate was lower using VL than with DL among pediatric residents. This should be considered when designing residency training and in real-life resuscitation.

External Validation of a Multivariable Prediction Model for Placenta Accreta Spectrum.

BACKGROUND: Placenta accreta spectrum (PAS) is a disorder of abnormal placentation associated with severe postpartum hemorrhage, maternal morbidity, and mortality. Predelivery prediction of this condition is important to determine appropriate delivery location and multidisciplinary planning for operative management. This study aimed to validate a prediction model for PAS developed by Weiniger et al in 2 cohorts who delivered at 2 different United States tertiary centers. METHODS: Cohort A (Brigham and Women's Hospital; N = 253) included patients with risk factors (prior cesarean delivery and placenta previa) and/or ultrasound features of PAS presenting to a tertiary-care hospital. Cohort B (Columbia University Irving Medical Center; N = 99) consisted of patients referred to a tertiary-care hospital specifically because of ultrasound features of PAS. Using the outcome variable of surgical and/or pathological diagnosis of PAS, discrimination (via c-statistic), calibration (via intercept, slope, and flexible calibration curve), and clinical usefulness (via decision curve analysis) were determined. RESULTS: The model c-statistics in cohorts A and B were 0.728 (95% confidence interval [CI], 0.662-0.794) and 0.866 (95% CI, 0.754-0.977) signifying acceptable and excellent discrimination, respectively. The calibration intercept (0.537 [95% CI, 0.154-0.980] for cohort A and 3.001 [95% CI, 1.899- 4.335] for B), slopes (0.342 [95% CI, 0.170-0.532] for cohort A and 0.604 [95% CI, -0.166 to 1.221] for B), and flexible calibration curves in each cohort indicated that the model underestimated true PAS risks on average and that there was evidence of overfitting in both validation cohorts. The use of the model compared to a treat-all strategy by decision curve analysis showed a greater net benefit of the model at a threshold probability of >0.25 in cohort A. However, no net benefit of the model over the treat-all strategy was seen in cohort B at any threshold probability. CONCLUSIONS: The performance of the Weiniger model is variable based on the case-mix of the population with regard to PAS clinical risk factors and ultrasound features, highlighting the importance of spectrum bias when applying this PAS prediction model to distinct populations. The model showed benefit for predicting PAS in populations with substantial case-mix heterogeneity at threshold probability of >25%.

Long-term gynecological complications after conservative treatment of placenta accreta spectrum.

Objective: To examine the association between conservative treatment for PAS (placenta accreta spectrum) and subsequent gynecological and fertility complications. Methods: All women who underwent conservative treatment for PAS between January 1990 and December 2000 were included in this retrospective cohort study conducted in a tertiary teaching hospital. Gynecological and fertility complications experienced after the index delivery were collected from the medical records and telephone questionnaires. This data was compared to an age and parity-matched control group of women without PAS. Results: The study group included 134 women with PAS managed conservatively and 134 controls with normal deliveries matched by parity and age. Women in the PAS group required significantly more postpartum operative procedures such as hysteroscopy or D&C (OR = 6.6; 95%CI: 3.36-13.28; P = <0.001). Following the index delivery, there were 345 pregnancies among 107 women who attempted conception following conservative treatment for PAS vs. 339 pregnancies among 105 women who attempted conception in the control group. Among women who attempted conception following conservative treatment for PAS 99 (92.5%) delivered live newborns (a total of 280 deliveries) vs. 94 (89.5%) in the control group, (a total of 270 live newborns, p = 0.21). The need for fertility treatments was not different between the two groups (OR = 1.22; 95%CI: 0.51-2.93; P = 0.66). Conclusion: After conservative treatment for PAS, significantly more women required complementary procedures due to retained placenta and/or heavy vaginal bleeding. There was no evidence of fertility impairment in women post-conservative treatment for PAS.

Placenta accreta. A review of current anesthetic considerations.

Placenta accreta spectrum (PAS) is a potentially life-threatening disorder with unique anesthetic challenges, and its incidence has increased over the past decades. We review current guidelines and best practice evidence for antenatal diagnosis and preoperative evaluation, management pathways, multidisciplinary staff coordination, and surgery location. We address specific considerations for choice of anesthesia modality, the role of interventional radiology, and various techniques for minimizing hemorrhage for both planned and unplanned cases, as well as postoperative care for the PAS patient.

Expert Consensus Regarding Core Outcomes for Enhanced Recovery after Cesarean Delivery Studies: A Delphi Study.

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 (two rounds of electronic questionnaires and a third-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% or greater agreement and weak consensus as 50 to 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% or greater 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 or 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.

Placenta Accreta Spectrum Disorders: Knowledge Gaps in Anesthesia Care.

Placenta accreta spectrum (PAS) disorder is a potentially life-threatening condition that can occur during pregnancy. PAS puts pregnant individuals at a very high risk of major blood loss, hysterectomy, and intensive care unit admission. These patients should receive care in a center with multidisciplinary experience and expertise in managing PAS disorder. Obstetric anesthesiologists play vital roles in the peripartum care of pregnant patients with suspected PAS. As well as providing high-quality anesthesia care, obstetric anesthesiologists coordinate peridelivery care, drive transfusion-related decision making, and oversee postpartum analgesia. However, there are a number of key knowledge gaps related to the anesthesia care of these patients. For example, limited data are available describing optimal anesthesia staffing models for scheduled and unscheduled delivery. Evidence and consensus are lacking on the ideal surgical location for delivery; primary mode of anesthesia for cesarean delivery; preoperative blood ordering; use of pharmacological adjuncts for hemorrhage management, such as tranexamic acid and fibrinogen concentrate; neuraxial blocks and abdominal wall blocks for postoperative analgesia; and the preferred location for postpartum care. It is also unclear how anesthesia-related decision making and interventions impact physical and mental health outcomes. High-quality international multicenter studies are needed to fill these knowledge gaps and advance the anesthesia care of patients with PAS.

The effect of high-dose versus low-dose epidural fentanyl on gastric emptying in nonfasted parturients: A double-blinded randomised controlled trial.

BACKGROUND: Epidural fentanyl doses above 100 µg have been shown, using the paracetamol absorption test, to reduce gastric emptying in fasted labouring women. OBJECTIVE: To investigate the effect of fentanyl dose on gastric emptying in nonfasted labouring women using gastric ultrasonography. DESIGN: A double-blinded randomised controlled study. SETTING: A tertiary medical centre in Tel Aviv, Israel between 30 July 2020 and 11 October 2020. PATIENTS: Eighty labouring women with cervical dilation 5 cm or less, at least 18 years age, at least 37 weeks gestation with a singleton pregnancy and cephalad foetus. INTERVENTIONS: Women randomised to high (>100 µg) or low (<100 µg) cumulative epidural fentanyl had ultrasound gastric content assessment, measuring antral cross-sectional area (CSA) at epidural placement and 2 h thereafter (T2  h). MAIN OUTCOME MEASURES: The primary outcome was CSA at T2  h comparing high-dose versus low-dose fentanyl. Secondary outcomes included change in CSA between baseline and T2  h. Sub-group analysis compared stomach content at T2  h according to baseline stomach content, empty (CSA <381 mm2) or full (CSA ≥381 mm2), and high-dose versus low-dose fentanyl. RESULTS: Data from 80 women were analysed; 63 had empty and 17 had full stomach at baseline. There was no significant difference in CSA at T2  h between high-dose, mean 335 ±â€ŠSD 133 mm2, versus low-dose fentanyl, mean 335 ±â€ŠSD 172 mm2, P = 0.991. Change in CSA baseline to T2  h was 46 ±â€ŠSD 149 mm2 for high and 49 ±â€ŠSD 163 mm2 for low-dose group, P = 0.931. The subgroup analysis according to baseline stomach content showed no statistically significant differences in CSA at T2  h. CONCLUSION: The CSA at T2  h was similar for women who received high-dose versus low-dose epidural fentanyl, measured by ultrasound, in our nonfasted labouring cohort. TRIAL REGISTRATION: Clinicaltrials.gov number: NCT04202887.

Peripartum anesthetic management of women with SARS-CoV-2 infection in eight medical centers across three European countries: prospective cohort observation study.

OBJECTIVE: Several reports of obstetric anesthesia management have been published since the onset of the COVID-19 pandemic. We aimed to collect high-quality broad and detailed data from different university medical centers in several European Society of Anesthesiologist countries. METHODS: This prospective observational survey was performed in eight medical centers in Spain, Israel and Portugal from 1st April to 31st July 2020. Institutional review board approval was received at each participating center. Inclusion criteria: all women with a positive test for COVID-19. Retrieved data included maternal, delivery, anesthetic, postpartum details, and neonatal outcomes. Descriptive data are presented, and outcomes were compared for women with versus without respiratory signs and symptoms. RESULTS: Women with respiratory symptoms (20/12.1%) had significantly higher mean (standard deviation) temperature (37.2 °C (0.8) versus 36.8 °C (0.6)), were older (34.1 (6.7) years versus 30.5 (6.6)) and had higher body mass index kg m-2 - (29.5 (7.5) versus 28.2 (5.1)). Women with respiratory symptoms delivered at a significantly earlier gestational age (50% < 37 weeks) with a 65% cesarean delivery rate (versus 22.1% in the group without respiratory symptoms) and 5-fold increased rate of emergency cesarean delivery, 30% performed under general anesthesia. A higher rate of intrauterine fetal death (3%) was observed than expected from the literature (0.2-0.3%) in developed countries. There was no evidence of viral vertical transmission. CONCLUSION: Well-functioning neuraxial analgesia should be available to manage laboring women with respiratory symptoms, as there is a higher frequency of emergency cesarean delivery. We report a higher rate of undiagnosed parturient and intrauterine fetal death.

Indications and diagnosis-specific features of maternal and neonatal peripartum intensive care unit admissions: A retrospective study.

BACKGROUND: Although peripartum intensive care unit admission indications are well-reported, clinical and laboratory details rarely are. We described admission indications and categorised laboratory values and vital signs according to admission diagnosis. METHODS: Retrospective Institutional Review Board approved study. We identified intensive care unit admission diagnosis, laboratory values and vital signs from patient charts. Groups were compared according to admission diagnoses. Data were analysed using descriptive statistics. RESULTS: We included 91 general intensive care unit admissions among 56,865 deliveries (2011-2015) with complete data. The most common admission diagnosis was postpartum haemorrhage followed by hypertensive diseases of pregnancy and respiratory complications. Women with postpartum haemorrhage had lower mean (standard deviation) platelet counts (120.2 (45.8) vs. 181.2 (109.9), p = .003) and temperatures (35.7 (1.1) vs. 36.5 (1.2), p = .002). Women with hypertensive diseases of pregnancy had higher mean (standard deviation) blood pressures (systolic 150.4 (29.1) vs. 127.4 (21.0), p = .013, diastolic 100.3 (18.7) vs. 76.1 (16.1), p = .001), creatinine (1.1 (0.6) vs. 0.8 (0.3), p = .003), urea (14.6 (7.7) vs. 10.5 (4.7), p = .005) and liver enzymes, including aspartate transaminase (258.4 (297.0) vs. 41.4 (42.9), p = .000), alanine transaminase (184.4 (199.2) vs. 35.1 (75.9), p = .000), and alkaline phosphatase (166.6 (112.6) vs. 96.0 (60.0), p = .006). Women with respiratory complications had lower mean (standard deviation) oxygen saturations (93.7 (6.1) vs. 98.0 (2.6), p = .000), and higher mean (standard deviation) temperatures (37.1 (0.8) vs. 36.0 (1.2), p = .001). CONCLUSIONS: We report differences in laboratory values and vital signs, according to intensive care unit admission diagnosis. Recognising these differences might help individualise patient assessment and care.

Update on Non-neuraxial Labor Analgesia.

PURPOSE OF REVIEW: This review will present recent updates for the use of non-neuraxial analgesia for laboring women. RECENT FINDINGS: Non-neuraxial labor analgesia by nitrous oxide and intravenous opioids are described, and safety concerns with regard to remifentanil administration have been a major focus of recent studies. Fentanyl and nitrous oxide offer some efficacy, albeit less than remifentanil, however with a greater safety margin. SUMMARY: Women may request or require alternatives to neuraxial labor analgesia, in some cases due to concurrent comorbidities. Remifentanil offers the most efficacious alternative analgesia option; however, safety concerns may preclude widespread use.

A Retrospective Investigation of Neuraxial Anesthesia Rates for Elective Cesarean Delivery Before and During the SARS-CoV-2 Pandemic.

BACKGROUND: Our hospital used to perform cesarean delivery under general anesthesia rather than neuraxial anesthesia, mostly because of patient refusal of members of the conservative Bedouin society. According to recommendations implemented by the Israeli Obstetric Anesthesia Society, which were implemented due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, we increased the rate of neuraxial anesthesia among deliveries. OBJECTIVES: To compare the rates of neuraxial anesthesia in our cesarean population before and during SARS-CoV-2 pandemic. METHODS: We included consecutive women undergoing an elective cesarean delivery from two time periods: pre-SARS-CoV-2 pandemic (15 February 2019 to 14 April 2019) and during the SARS-CoV-2 pandemic (15 February 2020 to 15 April 2020). We collected demographic data, details about cesarean delivery, and anesthesia complications. RESULTS: We included 413 parturients undergoing consecutive elective cesarean delivery identified during the study periods: 205 before the SARS-CoV-2 pandemic and 208 during SARS-CoV-2 pandemic. We found a statistically significant difference in neuraxial anesthesia rates between the groups: before the pandemic (92/205, 44.8%) and during (165/208, 79.3%; P < 0.0001). CONCLUSIONS: We demonstrated that patient and provider education about neuraxial anesthesia can increase its utilization. The addition of a trained obstetric anesthesiologist to the team may have facilitated this transition.