Anesthesia Considerations for Pregnant People With COVID-19 Infection.

The purpose of this review is to describe updates following initial recommendations on best anesthesia practices for obstetric patients with coronavirus disease 2019. The first surge in the United States prompted anesthesiologists to adapt workflows and reconsider obstetric anesthesia care, with emphasis on avoidance of general anesthesia, the benefit of early neuraxial labor analgesia, and prevention of emergent cesarean delivery whenever possible. While workflows have changed to allow sustained safety for obstetric patients and health care workers, it is notable that obstetric anesthesia protocols for labor and delivery have not significantly evolved since the first coronavirus disease 2019 wave.

What obstetricians should know about obstetric anesthesia during the COVID-19 pandemic.

The COVID-19 pandemic has prompted obstetric anesthesiologists to reconsider the ways in which basic anesthesia care is provided on the Labor and Delivery Unit. Suggested modifications include an added emphasis on avoiding general anesthesia, a strong encouragement to infected individuals to opt for early neuraxial analgesia, and the prevention of emergent cesarean delivery, whenever possible. Through team efforts, adopting these measures can have real effects on reducing the transmission of the viral illness and maintaining patient and caregiver safety in the labor room.

Building an obstetric intensive care unit during the COVID-19 pandemic at a tertiary hospital and selected maternal-fetal and delivery considerations.

During the novel Coronavirus Disease 2019 pandemic, New York City became an international epicenter for this highly infectious respiratory virus. In anticipation of the unfortunate reality of community spread and high disease burden, the Anesthesia and Obstetrics and Gynecology departments at NewYork-Presbyterian / Columbia University Irving Medical Center, an academic hospital system in Manhattan, created an Obstetric Intensive Care Unit on Labor and Delivery to defray volume from the hospital's preexisting intensive care units. Its purpose was threefold: (1) to accommodate the anticipated influx of critically ill pregnant and postpartum patients due to novel coronavirus, (2) to care for critically ill obstetric patients who would previously have been transferred to a non-obstetric intensive care unit, and (3) to continue caring for our usual census of pregnant and postpartum patients, who are novel Coronavirus negative and require a higher level of care. In this chapter, we share key operational details for the conversion of a non-intensive care space into an obstetric intensive care unit, with an emphasis on the infrastructure, personnel and workflow, as well as the goals for maternal and fetal monitoring.

Telehealth for High-Risk Pregnancies in the Setting of the COVID-19 Pandemic.

As New York City became an international epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic, telehealth was rapidly integrated into prenatal care at Columbia University Irving Medical Center, an academic hospital system in Manhattan. Goals of implementation were to consolidate in-person prenatal screening, surveillance, and examinations into fewer in-person visits while maintaining patient access to ongoing antenatal care and subspecialty consultations via telehealth virtual visits. The rationale for this change was to minimize patient travel and thus risk for COVID-19 exposure. Because a large portion of obstetric patients had underlying medical or fetal conditions placing them at increased risk for adverse outcomes, prenatal care telehealth regimens were tailored for increased surveillance and/or counseling. Based on the incorporation of telehealth into prenatal care for high-risk patients, specific recommendations are made for the following conditions, clinical scenarios, and services: (1) hypertensive disorders of pregnancy including preeclampsia, gestational hypertension, and chronic hypertension; (2) pregestational and gestational diabetes mellitus; (3) maternal cardiovascular disease; (4) maternal neurologic conditions; (5) history of preterm birth and poor obstetrical history including prior stillbirth; (6) fetal conditions such as intrauterine growth restriction, congenital anomalies, and multiple gestations including monochorionic placentation; (7) genetic counseling; (8) mental health services; (9) obstetric anesthesia consultations; and (10) postpartum care. While telehealth virtual visits do not fully replace in-person encounters during prenatal care, they do offer a means of reducing potential patient and provider exposure to COVID-19 while providing consolidated in-person testing and services. KEY POINTS: · Telehealth for prenatal care is feasible.. · Telehealth may reduce coronavirus exposure during prenatal care.. · Telehealth should be tailored for high risk prenatal patients..

Anesthesia for Fetal Surgery and Fetal Procedures.

Advances in imaging and technique have pushed the boundaries of the types of surgical interventions available to fetuses with congenital and developmental abnormalities. This review focuses on fundamental aspects of fetal anesthesia, including the physiologic changes of pregnancy, uteroplacental perfusion, and fetal physiology. We discuss the types of fetal surgeries and procedures currently being performed and discuss the specific anesthetic approaches to different categories of fetal surgeries. We also discuss ethical aspects of fetal surgery and anesthesia.

Reducing Adiposity in a Critical Developmental Window Has Lasting Benefits in Mice.

Although most adults can lose weight by dieting, a well-characterized compensatory decrease in energy expenditure promotes weight regain more than 90% of the time. Using mice with impaired hypothalamic leptin signaling as a model of early-onset hyperphagia and obesity, we explored whether this unfavorable response to weight loss could be circumvented by early intervention. Early-onset obesity was associated with impairments in the structure and function of brown adipose tissue mitochondria, which were ameliorated by weight loss at any age. Although decreased sympathetic tone in weight-reduced adults resulted in net reductions in brown adipose tissue thermogenesis and energy expenditure that promoted rapid weight regain, this was not the case when dietary interventions were initiated at weaning. Enhanced energy expenditure persisted even after mice were allowed to resume overeating, leading to lasting reductions in adiposity. These findings reveal a time window when dietary interventions can produce metabolic improvements that are stably maintained.

The anesthetic approach to operative delivery of the extremely obese parturient.

Extreme obesity (BMI ≥ 40) is thought to complicate approximately 5% of deliveries in the United States. Extreme obesity puts a pregnant woman at an increased risk for cardiovascular disease, including hypertension, coronary artery disease, and congestive heart failure; respiratory disease, including obstructive sleep apnea and asthma; as well as pregnancy-specific diseases including pregnancy-induced hypertension and gestational diabetes. Extreme obesity also puts a parturient at a significantly increased risk of requiring cesarean delivery. For the anesthesiologist, the physiologic changes of obesity combined with the normal physiologic changes of pregnancy can make for a complex and challenging case. This review will focus on the anesthetic approach to the extremely obese parturient undergoing scheduled operative delivery. With proper planning and a detailed understanding of the patient's comorbidities, a safe and effective anesthetic can be achieved.

Disruption of hypothalamic leptin signaling in mice leads to early-onset obesity, but physiological adaptations in mature animals stabilize adiposity levels.

Distinct populations of leptin-sensing neurons in the hypothalamus, midbrain, and brainstem contribute to the regulation of energy homeostasis. To assess the requirement for leptin signaling in the hypothalamus, we crossed mice with a floxed leptin receptor allele (Leprfl) to mice transgenic for Nkx2.1-Cre, which drives Cre expression in the hypothalamus and not in more caudal brain regions, generating LeprNkx2.1KO mice. From weaning, LeprNkx2.1KO mice exhibited phenotypes similar to those observed in mice with global loss of leptin signaling (Leprdb/db mice), including increased weight gain and adiposity, hyperphagia, cold intolerance, and insulin resistance. However, after 8 weeks of age, LeprNkx2.1KO mice maintained stable adiposity levels, whereas the body fat percentage of Leprdb/db animals continued to escalate. The divergence in the adiposity phenotypes of Leprdb/db and LeprNkx2.1KO mice with age was concomitant with increased rates of linear growth and energy expenditure in LeprNkx2.1KO mice. These data suggest that remaining leptin signals in LeprNkx2.1KO mice mediate physiological adaptations that prevent the escalation of the adiposity phenotype in adult mice. The persistence of severe adiposity in LeprNkx2.1KO mice, however, suggests that compensatory actions of circuits regulating growth and energy expenditure are not sufficient to reverse obesity established at an early age.