Peripartum interventions for people with class III obesity: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to identify evidence-based peripartum interventions for people with a body mass index ≥40 kg/m2. DATA SOURCES: PubMed, MEDLINE, EMBASE, Cochrane, CINAHL, and ClinicalTrials.gov were searched from inception to 2022 without date, publication type, or language restrictions. STUDY ELIGIBILITY CRITERIA: Cohort and randomized controlled trials that implemented an intervention and evaluated peripartum outcomes of people with a body mass index ≥40 kg/m2 were included. The primary outcome depended on the intervention but was commonly related to wound morbidity after cesarean delivery (ie, infection, separation, hematoma). METHODS: Meta-analysis was completed for interventions with at least 2 studies. Pooled risk ratios with 95% confidence intervals and heterogeneity (I2 statistics) were reported. RESULTS: Of 20,301 studies screened, 30 studies (17 cohort and 13 randomized controlled trials) encompassing 10 types of interventions were included. The interventions included delivery planning (induction of labor, planned cesarean delivery), antibiotics during labor induction or for surgical prophylaxis, 6 types of cesarean delivery techniques, and anticoagulation dosing after a cesarean delivery. Planned cesarean delivery compared with planned vaginal delivery did not improve outcomes according to 3 cohort studies. One cohort study compared 3 g with 2 g of cephazolin prophylaxis for cesarean delivery and found no differences in surgical site infections. According to 3 cohort studies and 2 randomized controlled trials, there was no improvement in outcomes with a non-low transverse skin incision. Ten studies (4 cohort and 6 randomized controlled trials) met the inclusion criteria for the meta-analysis. Two randomized controlled trials compared subcuticular closure with suture vs staples after cesarean delivery and found no differences in wound morbidity within 6 weeks of cesarean delivery (n=422; risk ratio, 1.09; 95% confidence interval, 0.75-1.59; I2=9%). Prophylactic negative-pressure wound therapy was compared with standard dressing in 4 cohort and 4 randomized controlled trials, which found no differences in wound morbidity (cohort n=2200; risk ratio, 1.19; 95% confidence interval, 0.88-1.63; I2=66.1%) or surgical site infections (randomized controlled trial n=1262; risk ratio, 0.90; 95% confidence interval, 0.63-1.29; I2=0). CONCLUSION: Few studies address interventions in people with a body mass index ≥40 kg/m2, and most studies did not demonstrate a benefit. Either staples or suture are recommended for subcuticular closure, but available data do not support prophylactic negative-pressure wound therapy after cesarean delivery for people with a body mass index ≥40 kg/m2.

Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery.

Importance: General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity. Objective: To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity. Design, Setting, and Participants: In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023. Exposure: Cesarean delivery. Main Outcomes and Measures: The rate of general anesthesia for cesarean delivery by race and ethnicity. Results: Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity. Conclusions and Relevance: Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.

Performance Characteristics of Sepsis Screening Tools During Antepartum and Postpartum Admissions.

OBJECTIVE: To evaluate the performance characteristics of existing screening tools for the prediction of sepsis during antepartum and postpartum readmissions. METHODS: This was a case-control study using electronic health record data obtained between 2016 and 2021 from 67 hospitals for antepartum sepsis admissions and 71 hospitals for postpartum readmissions up to 42 days. Patients in the sepsis case group were matched in a 1:4 ratio to a comparison cohort of patients without sepsis admitted antepartum or postpartum. The following screening criteria were evaluated: the CMQCC (California Maternal Quality Care Collaborative) initial sepsis screen, the non-pregnancy-adjusted SIRS (Systemic Inflammatory Response Syndrome), the MEWC (Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System) obstetric SIRS, and the MEWT (Maternal Early Warning Trigger Tool). Time periods were divided into early pregnancy (less than 20 weeks of gestation), more than 20 weeks of gestation, early postpartum (less than 3 days postpartum), and late postpartum through 42 days. False-positive screening rates, C-statistics, sensitivity, and specificity were reported for each overall screening tool and each individual criterion. RESULTS: We identified 525 patients with sepsis during an antepartum hospitalization and 728 patients with sepsis during a postpartum readmission. For early pregnancy and more than 3 days postpartum, non-pregnancy-adjusted SIRS had the highest C-statistics (0.78 and 0.83, respectively). For more than 20 weeks of gestation and less than 3 days postpartum, the pregnancy-adjusted sepsis screening tools (CMQCC and UKOSS) had the highest C-statistics (0.87-0.94). The MEWC maintained the highest sensitivity rates during all time periods (81.9-94.4%) but also had the highest false-positive rates (30.4-63.9%). The pregnancy-adjusted sepsis screening tools (CMQCC, UKOSS) had the lowest false-positive rates in all time periods (3.9-10.1%). All tools had the lowest C-statistics in the periods of less than 20 weeks of gestation and more than 3 days postpartum. CONCLUSION: For admissions early in pregnancy and more than 3 days postpartum, non-pregnancy-adjusted sepsis screening tools performed better than pregnancy-adjusted tools. From 20 weeks of gestation through up to 3 days postpartum, using a pregnancy-adjusted sepsis screening tool increased sensitivity and minimized false-positive rates. The overall false-positive rate remained high.

Performance Characteristics of Sepsis Screening Tools During Delivery Admissions.

OBJECTIVE: To evaluate the screening performance characteristics of existing tools for the diagnosis of sepsis during delivery admissions. METHODS: This was a case-control study using electronic health record data, including vital signs and laboratory results, for all delivery admissions of patients with sepsis from 59 nationally distributed hospitals. Patients with sepsis were matched by gestational age at delivery in a 1:4 ratio with patients without sepsis to create a comparison group. Patients with chorioamnionitis and sepsis were compared with a complete cohort of patients with chorioamnionitis without sepsis. Multiple screening criteria for sepsis were evaluated: the CMQCC (California Maternal Quality Care Collaborative), SIRS (Systemic Inflammatory Response Syndrome), the MEWC (the Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System), and the MEWT (Maternal Early Warning Trigger Tool). Sensitivity, false-positive rates, and C-statistics were reported for each screening tool. Analyses were stratified into cohort 1, which excluded patients with chorioamnionitis-endometritis, and cohort 2, which included those patients. RESULTS: Delivery admissions at 59 hospitals were extracted for patients with sepsis. Cohort 1 comprised 647 patients with sepsis, including 228 with end-organ injury, matched with a control group of 2,588 patients without sepsis. Cohort 2 comprised 14,591 patients with chorioamnionitis-endometritis, of whom 1,049 had sepsis and 238 had end-organ injury. In cohort 1, the CMQCC and the UKOSS pregnancy-adjusted criteria had the lowest false-positive rates (6.9% and 9.6%, respectively) and the highest C-statistics (0.92 and 0.91, respectively). Although other screening criteria, such as SIRS and the MEWC, had similar sensitivities, it was at the cost of much higher false-positive rates (21.3% and 38.3%, respectively). In cohort 2, including all patients with chorioamnionitis-endometritis, the highest C-statistics were again for the CMQCC (0.67) and UKOSS (0.64). All screening tools had high false-positive rates, but the false-positive rates for the CMQCC and UKOSS were substantially lower than those for SIRS and the MEWC. CONCLUSION: During delivery admissions, the CMQCC and UKOSS pregnancy-adjusted screening criteria have the lowest false-positive results while maintaining greater than 90% sensitivity rates. Performance of all screening tools was degraded in the setting of chorioamnionitis-endometritis.

Feasibility Study to Compare Oxytocin Function Between Body Mass Index Groups at Term Labor Induction.

OBJECTIVE: To determine the feasibility of a protocol to examine the association between oxytocin system function and birth outcomes in women with and without obesity before induction of labor. DESIGN: Prospective descriptive. SETTING: Academic medical center in the U.S. Midwest. PARTICIPANTS: Pregnant women scheduled for induction of labor at 40 weeks of gestation or greater (n = 15 normal weight; n = 15 obese). METHODS: We collected blood samples and abstracted data by chart review. We used percentages to examine adherence to protocol. We used t tests and chi-square tests to describe differences in sample characteristics, oxytocin system function variables, and birth outcomes between the body mass index groups. RESULTS: The recruitment rate was 85.7%, protocol adherence was 97.1%, and questionnaire completion was 80.0%. Mean plasma oxytocin concentration was higher in the obese group (M = 2774.4 pg/ml, SD = 797.4) than in the normal weight group (M = 2193.5 pg/ml, SD = 469.8). Oxytocin receptor DNA percentage methylation (CpG -934) was higher in the obese group than in the normal weight group. CONCLUSION: Our protocol was feasible and can serve as a foundation for estimating sample sizes in forthcoming studies investigating the diversity in oxytocin system measurements and childbirth outcomes among pregnant women in different body mass index categories.

Programmed Intermittent Intrathecal Bolus for Maintenance of Labor Analgesia in an Obstetric Patient: A Case Report.

Maintenance of labor analgesia with programmed intermittent epidural boluses (PIEBs) has demonstrated benefits over the use of continuous infusions. While programmed intermittent boluses have been used for the maintenance of epidural analgesia, it has not been reported for the maintenance of intrathecal analgesia. Approximately 25% of intrathecal catheters (ITC) ultimately fail, often due to inadequate analgesic coverage. We describe the use of programmed intermittent intrathecal boluses for a laboring parturient who received an ITC. She reported excellent pain relief without significant motor block, high anesthetic block, hypotension, or respiratory distress. This delivery modality may increase the rate of ITC after unintentional dural puncture (UDP).

Pro-Con Debate: Perioperative Research Should Be Color-Blind.

Profound racial and ethnic disparities have been documented in health and health care outcomes in recent decades. Some researchers have erroneously ascribed these inequities to biological variations, prompting debate as to how, or even if, race and ethnicity should be included as an outcome variable. Color blindness is a racial ideology with roots in constitutional law that posits that equality is best achieved by disregarding the racial and ethnic characteristics of the individual. Color consciousness, in contrast, approaches disparities with the knowledge that experiences related to one's race and ethnicity influence an individual's health and well-being. In this Pro-Con commentary article, we discuss the concept of color blindness and debate its use as an approach in medicine and research.

The Anesthesiology Physician-Scientist Pipeline: Current Status and Recommendations for Future Growth-An Initiative of the Anesthesia Research Council.

The limited number and diversity of resident physicians pursuing careers as physician-scientists in medicine has been a concern for many decades. The Anesthesia Research Council aimed to address the status of the anesthesiology physician-scientist pipeline, benchmarked against other medical specialties, and to develop strategic recommendations to sustain and expand the number and diversity of anesthesiology physician-scientists. The working group analyzed data from the Association of American Medical Colleges and the National Resident Matching Program to characterize the diversity and number of research-oriented residents from US and international allopathic medical schools entering 11 medical specialties from 2009 to 2019. Two surveys were developed to assess the research culture of anesthesiology departments. National Institutes of Health (NIH) funding information awarded to anesthesiology physician-scientists and departments was collected from NIH RePORTER and the Blue Ridge Medical Institute. Anesthesiology ranked eighth to tenth place of 11 medical specialties in the percent of "research-oriented" entering residents, defined as those with advanced degrees (Master's or PhDs) in addition to the MD degree or having published at least 3 research publications before residency. Anesthesiology ranked eighth of 11 specialties in the percent of entering residents who were women but ranked fourth of 11 specialties in the percent of entering residents who self-identified as belonging to an underrepresented group in medicine. There has been a 72% increase in both the total NIH funding awarded to anesthesiology departments and the number of NIH K-series mentored training grants (eg, K08 and K23) awarded to anesthesiology physician-scientists between 2015 and 2020. Recommendations for expanding the size and diversity of the anesthesiology physician-scientist pipeline included (1) developing strategies to increase the number of research intensive anesthesiology departments; (2) unifying the diverse programs among academic anesthesiology foundations and societies that seek to grow research in the specialty; (3) adjusting American Society of Anesthesiologists metrics of success to include the number of anesthesiology physician-scientists with extramural research support; (4) increasing the number of mentored awards from Foundation of Anesthesia Education and Research (FAER) and International Anesthesia Research Society (IARS); (5) supporting an organized and concerted effort to inform research-oriented medical students of the diverse research opportunities within anesthesiology should include the specialty being represented at the annual meetings of Medical Scientist Training Program (MSTP) students and the American Physician Scientist Association, as well as in institutional MSTP programs. The medical specialty of anesthesiology is defined by new discoveries and contributions to perioperative medicine which will only be sustained by a robust pipeline of anesthesiology physician-scientists.

Association between breakthrough labor pain, patient-controlled epidural analgesia use, and numeracy: A pilot observational study.

OBJECTIVE: Labor analgesia can be maintained with a continuous epidural infusion, supplemented by patient-controlled epidural boluses. patient-controlled epidural boluses use and timing require numeric understanding, as patients need to understand when they can administer supplemental boluses, lockout intervals, and total doses. We hypothesized that women with lower numeric literacy have a higher rate of provider-administered supplemental boluses for breakthrough pain because they do not understand the concept behind patient-controlled epidural boluses. DESIGN: Pilot observational study SETTING: Labor and Delivery Suite PARTICIPANTS: Nulliparous, English-speaking patients with singleton, vertex pregnancies admitted for postdates (gestational age ≥ 41 weeks) induction of labor requesting neuraxial labor analgesia. INTERVENTIONS: Combined spinal-epidural labor analgesia was initiated with intrathecal fentanyl and epidural analgesia was maintained using continuous epidural infusion with patient-controlled epidural boluses. MEASUREMENTS AND FINDINGS: Numeric literacy was assessed using the Lipkus 7-item expanded numeracy test. Patients were stratified by whether or not they required supplemental provider-administered analgesia and patient-controlled epidural boluses use patterns were evaluated. A total of 89 patients completed the study. There were no demographic differences between patients who required supplemental analgesia compared with those who did not. Patients that required supplemental analgesia were more likely to request and receive patient-controlled epidural boluses (P<0.001). Hourly bupivacaine requirement was higher in women with breakthrough pain. There were no differences in numeric literacy between the two groups. KEY CONCLUSIONS: Patients who required treatment of breakthrough pain had higher patient-controlled epidural boluses demands-to-delivery ratio. Numeric literacy was not correlated with the need for provider-administered supplemental boluses. IMPLICATIONS FOR PRACTICE: Easy to understand scripts on how to use patient-controlled epidural boluses allows for understanding of patient-controlled epidural boluses use.

Bupivacaine Dosing for Cesarean Delivery in Parturients of Short Stature: A Retrospective Case-Control Study.

The ED50 and ED95 of spinal bupivacaine for cesarean delivery has been well described in the literature; however, parturients with extremes of stature have been excluded. Parturients of short stature are a height of ≤ 148 cm. This retrospective, case-control study evaluated anesthetic outcomes for parturients of short stature and controls who underwent cesarean delivery over a 10-year period. Women were matched for anesthetic type and body mass index. Data extracted included patient demographics and obstetric and anesthetic information. The primary outcome was dose of intrathecal bupivacaine. Categorical data were compared using a chi-squared test, continuous data were compared using a t-test or Mann-Whitney U test. Data for 26 women of short stature and 52 controls were evaluated. The mean dose of bupivacaine used for spinal anesthesia in parturients of short stature was 9.8 ± 1.0 mg (P <.0001). The mean intrathecal bupivacaine dose used in combined spinal epidural anesthesia was 10.5 mg (interquartile range, 9-10.9) in parturients of short stature (P = .002). All but one patient of short stature achieved an adequate surgical level; there were no instances of high spinal blockade. Adequate surgical anesthesia was achieved with reduced dosing of spinal bupivacaine in parturients of short stature without an increase in adverse outcomes.

The Management of Pregnant Trauma Patients: A Narrative Review.

Trauma is the leading nonobstetric cause of maternal death and affects 1 in 12 pregnancies in the United States. Adhering to the fundamentals of the advanced trauma life support (ATLS) framework is the most important component of care in this patient population. Understanding the significant physiologic changes of pregnancy, especially with regard to the respiratory, cardiovascular, and hematologic systems, will aid in airway, breathing, and circulation components of resuscitation. In addition to trauma resuscitation, pregnant patients should undergo left uterine displacement, insertion of 2 large bore intravenous lines placed above the level of the diaphragm, careful airway management factoring in physiologic changes of pregnancy, and resuscitation with a balanced ratio of blood products. Early notification of obstetric providers, initiation of secondary assessment for obstetric complications, and fetal assessment should be undertaken as soon as possible but without interference to maternal trauma assessment and management. In general, viable fetuses are monitored by continuous fetal heart rate for at least 4 hours or more if abnormalities are detected. Moreover, fetal distress may be an early sign of maternal deterioration. When indicated, imaging studies should not be limited out of fear for fetal radiation exposure. Resuscitative hysterotomy should be considered in patients approaching 22 to 24 weeks of gestation, who arrive in cardiac arrest or present with profound hemodynamic instability due to hypovolemic shock.

Readability, Content, and Quality of Online Patient Education Materials on Anesthesia and Neurotoxicity in the Pediatric Population.

OBJECTIVE: Internet-based patient education materials (PEMs) are often above the recommended sixth grade reading level recommended by the U.S. Department of Health and Human Services. In 2016 the U.S. Food and Drug Administration (FDA) released a warning statement against use of general anesthetic drugs in children and pregnant women due to concerns about neurotoxicity. The aim of this study is to evaluate readability, content, and quality of Internet-based PEMs on anesthesia in the pediatric population and neurotoxicity. STUDY DESIGN: The websites of U.S. medical centers with pediatric anesthesiology fellowship programs were searched for PEMs pertaining to pediatric anesthesia and neurotoxicity. Readability was assessed. PEM content was evaluated using matrices specific to pediatric anesthesia and neurotoxicity. PEM quality was assessed with the Patient Education Material Assessment Tool for Print. A one-sample t-test was used to compare the readability of the PEMs to the recommended sixth grade reading level. RESULTS: We identified 27 PEMs pertaining to pediatric anesthesia and eight to neurotoxicity. Mean readability of all PEMs was greater than a sixth grade reading (p <0.001). While only 13% of PEMs on anesthesia for pediatric patient mentioned the FDA warning, 100% of the neurotoxicity materials did. PEMs had good understandability (83%) and poor actionability (60%). CONCLUSION: The readability, content, and quality of PEMs are poor and should be improved to help parents and guardians make informed decisions about their children's health care. KEY POINTS: · The FDA issued a warning statement against the use of general anesthetic drugs in children and pregnant women.. · Readability, content, and quality of Internet-based patient education materials on the topic of neurotoxicity are poor.. · Improving the readability, content, and quality of PEMs could aid parents in making important health care decisions..

Peripartum care of persons with obesity: a scoping review of recommendations and practical tools for implementation.

OBJECTIVE: Despite the growing prevalence of obesity among reproductive aged persons in the USA, evidence-based guidelines for peripartum care are lacking. The objective of this scoping review is to identify obesity-related recommendations for peripartum care, evaluate grades of evidence for each recommendation, and identify practical tools (eg, checklists, toolkits, care pathways and bundles) to support their implementation in clinical practice. DATA SOURCES: We searched MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov from inception to December 2020 for eligible studies addressing peripartum care in persons with obesity. STUDY ELIGIBILITY CRITERIA: Inclusion criteria were published evidence-rated recommendations and practical tools for peripartum care of persons with obesity. STUDY APPRAISAL AND SYNTHESIS METHODS: Pairs of independent reviewers extracted data (source, publication year, content and number of recommendations, level and grade of evidence, description of tool) and identified similarities and differences among the articles. RESULTS: Of 18 315 screened articles, 18 were included including 7 articles with evidence-rated recommendations and 11 practical tools (3 checklists, 3 guidelines, 1 care bundle, 1 flowchart, 1 care pathway, 1 care map and 1 protocol). Thirteen of 39 evidence-rated recommendations were based on expert opinion. Recommendations related to surgical antibiotic prophylaxis and subcutaneous tissue closure at caesarean delivery received the highest grade of evidence. Some of the practical tools included a checklist from the USA regarding anticoagulation after caesarean delivery (evidence-supported recommendation), a bundle for surgical site infections after caesarean delivery in Australia (evidence did not support recommendation) and a checklist with content for several aspects of peripartum care from Canada (evidence supported seven of nine definitive recommendations). CONCLUSION: The recommendations for peripartum care for persons with obesity are based on limited evidence and few practical tools for implementation exist. Future work should focus on developing practical tools based on high-quality studies.

A Century of Progress and Collaboration Between Obstetric Anesthesiologists, Anesthesia & Analgesia, and the International Anesthesia Research Society.

The past century has seen significant advances in the practice of obstetric anesthesiology. This article will review the role of Anesthesia & Analgesia and the International Anesthesia Research Society in contributing to fundamental paradigm shifts in our understanding of obstetric anesthesiology.

Knowledge and perception of cardiovascular disease risk in women of reproductive age.

Objective: Women who experience adverse pregnancy outcomes (APO) are at increased risk for cardiovascular disease (CVD); however, their knowledge of CVD risk is not well characterized. We aimed to evaluate knowledge and perception of CVD risk in young women and to determine whether these factors differ based on experience of an APO. Methods: We conducted a cross-sectional study among women with a recent live birth at an urban medical center. Knowledge and perception of CVD risk were assessed through a self-administered online survey adapted from the American Heart Association Survey of Women's CVD Awareness. Results: Of 5612 individuals contacted between 3/1/21 and 4/18/21, 714 completed the survey; the mean (SD) age was 34 (4) years and 25% reported an APO. While 62% of respondents identified CVD as the leading cause of death in women, there was no significant difference in CVD knowledge scores between participants who reported experiencing an APO and those who did not (6.9 vs 6.8 out of 10; p = 0.51). Participants who reported experiencing an APO had higher perception of personal risk for CVD (adjusted odds ratio, 2.64 [95% CI 1.83-3.80]) compared with participants who did not. Half of participants who experienced an APO reported perceiving average, or below average, risk for CVD and only 41 (22.5%) reported speaking with a healthcare professional about CVD within the past year. Conclusions: Gaps remain in knowledge of CVD risk among young women, particularly after an APO. The peripartum period may represent a unique opportunity for targeted education when healthcare engagement is high.