The Most Influential Publications in Obstetric Anesthesiology, 1998-2017: Utilizing the Delphi Method for Expert Consensus.

BACKGROUND: There have been many advances in obstetric anesthesiology in the past 2 decades. We sought to create a list of highly influential publications in the field using the Delphi method among a group of obstetric anesthesiology experts to create an important educational, clinical, and research resource. METHODS: Experts in the field, defined as obstetric anesthesiologists selected to present the Gerard W. Ostheimer Lecture at the Society for Obstetric Anesthesia and Perinatology (SOAP) annual meeting within the past 20 years, were recruited to participate. The Delphi technique was used by administering 3 rounds of surveys. Participants were initially asked to identify the highly influential publications from the year they presented the Ostheimer lecture, in addition to the most influential publications from the time period overall. Highly influential publications were defined as those that changed traditional views, invoked meaningful practices, catalyzed additional research, and fostered ideas or practices that had durability over time. After each round of surveys, responses were collected and used as choices for subsequent surveys with the goal of obtaining group consensus. RESULTS: We determined expert consensus on 22 highly influential publications from 1998 to 2017. The focus of these publications ranged from disease entities, interventions, treatment methodologies, and complications. CONCLUSIONS: Key themes in the publications chosen included the reduction of maternal morbidity and mortality and refinements in the analgesic and anesthetic management of labor and delivery.

Nocebo-induced hyperalgesia during local anesthetic injection.

Common practice during local anesthetic injection is to warn the patient using words such as: "You will feel a big bee sting; this is the worst part." Our hypothesis was that using gentler words for administration of the local anesthetic improves pain perception and patient comfort. One hundred forty healthy women at term gestation requesting neuraxial analgesia were randomized to either a "placebo" ("We are going to give you a local anesthetic that will numb the area and you will be comfortable during the procedure") or "nocebo" ("You are going to feel a big bee sting; this is the worst part of the procedure") group. Pain was assessed immediately after the local anesthetic skin injection using verbal analog scale scores of 0 to 10. Median verbal analog scale pain scores were lower when reassuring words were used compared with the harsher nocebo words (3 [2-4] vs 5 [3-6]; P < 0.001). Our data suggest that using gentler, more reassuring words improves the subjective experience during invasive procedures.

Anesthetic management of seven deliveries in three sisters with the May-Hegglin anomaly.

May-Hegglin anomaly is a rare genetic hematological disorder characterized by thrombocytopenia, but platelet function is usually normal. Three sisters with May-Hegglin anomaly and thrombocytopenia (platelet counts 14,000-100,000/mm(3)) were given neuraxial anesthesia for a total of 7 deliveries, 5 vaginal and 2 cesarean. None of the women had complications and no blood products were transfused.

Factor XI deficiency and obstetrical anesthesia.

Factor XI (FXI) deficiency is a rare inherited coagulation disorder associated with prolonged activated partial thromboplastin time. The severity of bleeding often does not correlate with plasma factor levels. We reviewed the medical and anesthetic records of 13 parturients with FXI deficiency that presented for delivery. Nine cases were managed with neuraxial anesthesia. (epidural, seven; spinal, one; combined spinal-epidural, one). Three received general anesthesia for cesarean delivery, and one had an unmedicated vaginal delivery. Baseline factor levels ranged from severe (<15%) to mild (near 50%) deficiency. Fresh frozen plasma was administered to correct activated partial thromboplastin time in most, but not all, cases. Hematology consultation was obtained for all. No hematological or anesthetic complications were noted. FXI deficiency is not an absolute contraindication to neuraxial anesthesia, provided appropriate hematology consultation has been obtained, and factor replacement is provided as guided by clinical and laboratory hemostatic evaluation.

Anesthesia in the pregnant patient with hematologic disorders.

The management of patients with hematologic disorders in pregnancy involves a multidisciplinary approach involving specialists from hematology, obstetrics, and anesthesiology. Whereas regional anesthesia has led to a decline in maternal morbidity and mortality, the presence of uncorrected coagulopathy or the use of anticoagulant or antithrombotic medications pose a special risk for the rare complication of an epidural hematoma after neuraxial anesthesia. This article briefly reviews the common principles of anesthesia for obstetric patients, provides an obstetric anesthesiologist's perspective on the implications of regional anesthesia in obstetrics, and enhances communication between the specialties.

Anesthesia drugs in the obstetric and gynecologic practice.

The obstetrician-gynecologist is often solely responsible for analgesia/sedation and regional blocks during office-based and outpatient procedures. The American Society of Anesthesiologists guidelines for the provision of analgesia/sedation for nonanesthesiologists provide helpful recommendations to maximize patient safety during office-based and outpatient procedures. This article provides a review of the fundamentals of sedation/analgesia, monitored anesthesia care, and local anesthetics.