Clinical Assistant Professor, Anesthesiology, Perioperative and Pain Medicine
Outpatient Treatment With Gabapentin in Women With Severe Acute Pain After Cesarean Delivery Is Ineffective: A Randomized, Double-Blind, Placebo-Controlled Trial.
Anesthesia and analgesia
Most of the 1.1 million women who deliver by cesarean in the United States each year have an uncomplicated recovery. However, severe pain resistant to standard multimodal therapy within the first days after surgery is associated with an increased risk for prolonged pain and opioid use. The best outpatient management for parturients with severe resistant early onset pain is not known.We performed a prospective, double-blind, placebo-controlled, randomized trial of up to 12 weeks of outpatient treatment with gabapentin to evaluate its effectiveness to facilitate opioid cessation in women with at least 2 reports of severe pain during the immediate postpartum period resistant to standard multimodal pain management. Time to opioid cessation was the primary outcome. Time to pain resolution; time to discontinuation of gabapentin, acetaminophen, and ibuprofen; time to self-reported recovery; and National Institute of Health Patient-Reported Outcomes System (PROMIS) surveys for anxiety, depression, fatigue, and physical function were assessed as secondary outcomes.There was no difference in time to opioid cessation between patients who were randomly assigned to be treated with gabapentin (Kaplan-Meier estimated median of 2 [25th-75th percentiles of 1-3] weeks, n = 35) versus those who were treated with placebo (2 [1-3] weeks, n = 35). The hazard ratio was 1.1 (95% confidence interval [CI], 0.67-1.8), P = .65. There were no differences in any secondary end points between the study groups.Outpatient supplementation with gabapentin did not reduce time to opioid cessation, pain, anxiety, depression, fatigue, or improve physical function in women with severe pain after cesarean delivery. Gabapentin should not be routinely added to the standard outpatient multimodal regimen of ibuprofen, acetaminophen, and opioids.
View details for DOI 10.1213/ANE.0000000000006429
View details for PubMedID 37043404
Anesthetic Considerations for Second-Trimester Surgical Abortions.
Anesthesia and analgesia
Although most abortion care takes place in the office setting, anesthesiologists are often asked to provide anesthesia for the 1% of abortions that take place later, in the second trimester. Changes in federal and state regulations surrounding abortion services may result in an increase in second-trimester abortions due to barriers to accessing care. The need for interstate travel will reduce access and delay care for everyone, given limited appointment capacity in states that continue to support bodily autonomy. Therefore, anesthesiologists may be increasingly involved in care for these patients. There are multiple, unique anesthetic considerations to provide safe and compassionate care to patients undergoing second-trimester abortion. First, a multiday cervical preparation involving cervical osmotic dilators and pharmacologic agents results in a time-sensitive, nonelective procedure, which should not be delayed or canceled due to risk of fetal expulsion in the preoperative area. In addition, a growing body of literature suggests that the older anesthesia dogma that all pregnant patients require rapid-sequence induction and an endotracheal tube can be abandoned, and that deep sedation without intubation is safe and often preferable for this patient population through 24 weeks of gestation. Finally, concomitant substance use disorders, preoperative pain from cervical preparation, and intraoperative management of uterine atony in a uterus that does not yet have mature oxytocin receptors require additional consideration.
View details for DOI 10.1213/ANE.0000000000006321
View details for PubMedID 36729414
Hospital-level variation in rates of postpartum hemorrhage in California.
BACKGROUND: To examine the extent of hospital-level variation in risk-adjusted rates of postpartum hemorrhage (PPH).STUDY DESIGN AND METHODS: We performed a cross-sectional study examining live births in 257 California hospitals between 2011 and 2015 using linked birth certificate and maternal discharge data. PPH was measured using International Classification of Diseases Codes version 9. Mixed-effects logistic regression models were used to examine the presence and extent of hospital-level variation in PPH before and after adjustment for patient-level risk factors and select hospital characteristics (teaching status and annual delivery volume). Risk-adjusted rates of PPH were estimated for each hospital. The extent of hospital variation was evaluated using the median odds ratio (MOR) and intraclass correlation coefficient (ICC).RESULTS: Our study cohort comprised 1,904,479 women who had a live birth delivery hospitalization at 247 hospitals. The median, lowest, and highest hospital-specific rates of PPH were 3.48%, 0.54%, and 12.0%, respectively. Similar rates were observed after adjustment for patient and hospital factors (3.44%, 0.60%, and 11.48%). After adjustment, the proportion of the total variation in PPH rates attributable to the hospital was low, with a MOR of 2.02 (95% confidence interval [CI]: 1.89-2.15) and ICC of 14.3% (95% CI: 11.9%-16.3%).DISCUSSION: Wide variability exists in the rate of PPH across hospitals in California, not attributable to patient factors, hospital teaching status, and hospital annual delivery volume. Determining whether differences in hospital quality of care explain the unaccounted-for variation in hospital-level PPH rates should be a public health priority.
View details for DOI 10.1111/trf.17036
View details for PubMedID 35920049
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 (2 rounds of electronic questionnaires and a 3rd 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% agreement and weak consensus as 50-69% 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% 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 / 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.
View details for DOI 10.1097/ALN.0000000000004263
View details for PubMedID 35511169
Calcium chloride for the prevention of uterine atony during cesarean delivery: A pilot randomized controlled trial and pharmacokinetic study.
Journal of clinical anesthesia
2022; 80: 110796
To assess the feasibility, patient tolerance, pharmacokinetics, and potential effectiveness of a randomized controlled trial protocol investigating intravenous calcium chloride for the prevention of uterine atony during cesarean delivery.Double-blind, randomized controlled pilot trial with nested population pharmacokinetic analysis.This study was performed at Lucile Packard Children's Hospital, from August 2018 to September 2019.Forty patients with at least two risk factors for uterine atony at the time of cesarean delivery.One gram of intravenous calcium chloride (n = 20 patients) or a saline placebo control (n = 20 patients), in addition to standard care with oxytocin, upon umbilical cord clamping.The primary efficacy-related outcome was the presence of uterine atony defined as the use of a second-line uterotonic medication, surgical interventions for atony, or hemorrhage with blood loss >1000 mL. Blood loss, uterine tone numerical rating scores, serial venous blood calcium levels, hemodynamics, and potential side effects were also assessed.The study protocol proved feasible. The incidence of atony was 20% in parturients who received calcium compared to 50% in the placebo group (relative risk 0.38, P = 0.07, 95% CI 0.15-1.07, NNT 3.3). Calcium recipients tolerated the drug infusion well, with no adverse events and an equal incidence of potential side effects in the calcium and placebo groups. Ionized calcium concentration rose significantly in all patients who received calcium infusion, from baseline 1.18 mmol/L to peak levels 1.50-1.60 mmol/L. One-compartment population pharmacokinetics established clearance of 0.93 (95% CI 0.63-1.52) L/min and volume of distribution 76 (95% CI 49-94) L.In this pilot study, investigators found that intravenous calcium chloride was well-tolerated by the 20 patients assigned to receive the study drug and may be effective in prevention of uterine atony. A 1-g dose was sufficient to substantially increase calcium levels without any critically elevated lab values or concern for adverse side effects. These encouraging findings warrant further investigation of calcium as a novel agent to prevent uterine atony with an adequately powered clinical trial. Clinical trial registry NCT03867383 https://clinicaltrials.gov/ct2/show/NCT03867383.
View details for DOI 10.1016/j.jclinane.2022.110796
View details for PubMedID 35447502
Current opinion in obstetrics & gynecology
PURPOSE OF THE REVIEW: Postpartum hemorrhage (PPH) is the leading preventable cause of maternal morbidity and mortality worldwide. Uterine atony is identified as the underlying etiology in up to 80% of PPH. This serves as a contemporary review of the epidemiology, risk factors, pathophysiology, and treatment of uterine atony.RECENT FINDINGS: Rates of postpartum hemorrhage continue to rise worldwide with the largest fraction attributed to uterine atony. A simple 0-10 numerical rating score for uterine tone was recently validated for use during cesarean delivery and may allow for more standardized assessment in clinical and research settings. The optimal prophylactic dose of oxytocin differs depending on the patient population, but less than 5 units and as low as a fraction of one unit is needed for PPH prevention, with an increased requirements within that range for cesarean birth, those on magnesium, and advanced maternal age. Carbetocin is an appropriate alternative to oxytocin. Misoprostol shows limited to no efficacy for uterine atony in recent studies. Several uncontrolled case studies demonstrate novel mechanical and surgical interventions for treating uterine atony.SUMMARY: There is a critical, unmet need for contemporary, controlled studies to address the increasing threat of atonic PPH.
View details for DOI 10.1097/GCO.0000000000000776
View details for PubMedID 35102109
Clinical factors associated with a positive postpartum depression screen in people with cardiac disease during pregnancy.
Current research in psychiatry
2022; 2 (2): 25-29
Background: While people with cardiac disease are known to be at increased lifetime risk of depression, little is known about postpartum depression rates in this population. Describing rates of positive postpartum depression screens and identifying risk factors that are unique to cardiac patients may help inform risk reduction strategies.Methods: This retrospective cohort study included pregnant patients with congenital and/or acquired cardiac disease who delivered at a single institution between 2014 and 2020. The primary outcome was a positive postpartum depression screen, defined as Edinburgh Postpartum Depression Score (EPDS) ≥10. Potential exposures were selected a priori and compared between patients with and without a positive postpartum depression screen using Wilcoxon rank-sum and Fisher's exact tests. Secondary outcomes were responses to a longitudinal follow-up survey sent to English-speaking patients evaluating cardiac status, mental health, and infant development.Results: Of 126 eligible cardiac patients, 23 (18.3%) had a positive postpartum depression screen. Patients with a positive postpartum depression screen were more likely to have had antepartum anticoagulation with heparin or enoxaparin (56.5% versus 26.2%, p=0.007), blood transfusion during delivery (8.7% versus 0%, p=0.032), and maternal-infant separation postpartum (52.2% versus 28.2%, p=0.047) compared to patients with a negative screen. Among 29 patients with a positive screen who responded to the follow up survey, 50% reported being formally diagnosed with anxiety or depression and 33.3% reported child development problems.Conclusions: Our results highlight the importance of screening for postpartum depression in patients with cardiac disease, especially those requiring antepartum anticoagulation or maternal-infant separation postpartum.
View details for DOI 10.46439/Psychiatry.2.027
View details for PubMedID 36570491
Chronic disabling postpartum headache after unintentional dural puncture during epidural anaesthesia: a prospective cohort study.
British journal of anaesthesia
2021; 127 (4): 600-607
BACKGROUND: Unintentional dural puncture with an epidural needle complicates approximately 1% of epidural anaesthetics and causes an acute headache in 60-80% of these patients. Several retrospective studies suggest an increased risk of chronic headache. We assessed the relationship between unintentional dural puncture and chronic disabling headache, defined as one or more functionally limiting headaches within a 2-week interval ending 2, 6, and 12 months postpartum.METHODS: In this prospective observational study, parturients who experienced unintentional dural puncture were matched 1:4 with control patients. Patients completed questionnaires regarding characteristics of headache and back pain pre-pregnancy, during pregnancy, immediately postpartum, and at 2, 6, and 12 months postpartum. The primary outcome was prevalence of disabling headache in the past 2 weeks, assessed at 2 months postpartum. Secondary outcomes included prevalence and characteristics of headache and back pain at these time points.RESULTS: We enrolled 99 patients. At 2 and 6 months postpartum, the prevalence of disabling headache was greater among patients with unintentional dural puncture than matched controls (2 months, 74% vs 38%, relative risk 1.9, 95% confidence interval 1.2-2.9, P=0.009; 6 months, 56% vs 25%, relative risk 2.1, 95% confidence interval 1.1-4.0, P=0.033). There was no difference in the prevalence of back pain at any time point.CONCLUSIONS: Our prospective trial confirms retrospective studies that chronic headache is more prevalent among women who experienced unintentional dural puncture compared with controls who received uncomplicated neuraxial anaesthesia. This finding has implications for the. patient consent process and recommendations for long-term follow-up of patients who experience unintentional dural puncture.
View details for DOI 10.1016/j.bja.2021.05.020
View details for PubMedID 34548152
Postpartum headaches after epidural or spinal anesthesia.
Current opinion in obstetrics & gynecology
2021; 33 (2): 94–99
PURPOSE OF REVIEW: Postpartum headache is a common occurrence with various obstetric, neurologic, and anesthetic etiologies. Post dural puncture headache (PDPH) after neuraxial anesthesia is a culprit that may be less familiar to obstetricians. In this review, authors will discuss the differential diagnosis and management of postpartum headache, review PDPH, and explore evidence suggesting that PDPH may have greater implications than previously considered.RECENT FINDINGS: Emerging evidence suggests that PDPH, previously believed to be benign and self-limited, is associated with significant acute and chronic sequelae. A recent large database study links PDPH to subdural hematoma and cerebral venous sinus thrombosis. The authors also identified associations between PDPH and bacterial meningitis, depression, and back pain. A growing body of literature also links PDPH or unintentional dural puncture with an epidural needle (UDP) with development of chronic headaches.SUMMARY: Patients who experience UDP or PDPH should be counseled to return for evaluation for new or worsening headache. In the immediate postpartum setting, clinicians assessing these patients should have a low threshold to obtain brain imaging. In addition, obstetricians should be alerted that patients who suffer UDP may be prone to develop chronic headache disorders and consider referral to pain specialists.
View details for DOI 10.1097/GCO.0000000000000685
View details for PubMedID 33620887
Superficial Cervical Plexus Block for Awake Large-Bore Central Line Placement in Parturients: A Case Series.
2021; 15 (3): e01429
Pregnant patients with high-risk conditions including abnormal placentation or severe cardiovascular disease may require large-bore central venous access at the time of delivery. Central lines are generally inserted while obstetric patients are awake, either because neuraxial anesthesia is planned or to minimize fetal exposure to anesthetic medications. Despite local infiltration, the procedure can cause significant patient discomfort. This case series describes use of a superficial cervical plexus block (SCPB) to facilitate line placement in 4 pregnant women with high-risk conditions. SCPB is technically straightforward with low reported complication rates and should be considered for pregnant patients requiring large-bore central lines.
View details for DOI 10.1213/XAA.0000000000001429
View details for PubMedID 33740791
Management of brain tumors presenting in pregnancy: a case series and systematic review
Management of brain tumors presenting in pregnancy: a case series and systematic review
2021; 3 (1)
View details for DOI 10.1016/j.ajogmf.2020.100256
Ampicillin Pharmacokinetics in Peripartum and Laboring Women.
American journal of perinatology
Ampicillin is used for multiple peripartum indications including prevention of neonatal group beta streptococcus (GBS) and treatment of chorioamnionitis. Despite its widespread use in obstetrics, existing pharmacokinetic data for ampicillin do not address contemporary indications or dosing paradigms for this population. We sought to characterize the pharmacokinetic profile of ampicillin administered to laboring women.Using whole blood dried blood spot sampling technique, maternal blood samples were collected at specified times from 31 women receiving IV ampicillin for peripartum indications. Women received either a 2-g loading dose with 1-g administered every 4 h (GBS), or 2-g every 6 h (chorioamnionitis). Pharmacokinetics were analyzed via a population approach with non-linear mixed-effect modeling.The data were best described by a two-compartment model with first-order elimination, with the following whole blood parameters: central volume of distribution (V1) 75.2 L (95% CI 56.3-93.6), clearance (CL) 82.4 L/h (95% CI 59.7-95.7), inter-compartmental clearance (Q) 20.9 L/h (95% CI 16.2-38.2), and peripheral volume of distribution (V2) 61.1 L (95% CI 26.1-310.5). Inter-patient variation in CL and V1 was large (42.0% and 56.7% respectively). Simulations of standard dosing strategies demonstrated over 98% of women are predicted to achieve an estimated free plasma concentration above MIC 0.5 mcg/mL for more than 50% of the dosing interval.Although large variation in the pharmacokinetics of ampicillin in pregnant women exists, as predicted by our model, current standard dosing strategies achieve adequate exposure for GBS in nearly all patients.
View details for DOI 10.1055/a-1674-6394
View details for PubMedID 34670320
Did she have an epidural? The long-term consequences of postdural puncture headache and the role of unintended dural puncture.
This narrative literature review examines the long-term impact of postdural puncture headache (PDPH) in postpartum women following an unintended dural puncture (UDP) with a large bore needle commonly used for epidural catheter placement. It seeks to bridge the knowledge gap for the neurologist as to the mounting body of obstetric anesthesia literature on the development of chronic headache after PDPH with this unique needle.Headache is the most common complication of dural puncture, and the risk is greatest in the parturient population. Preexisting risk factors for this population include youth and sex, and after UDP with a large bore needle, almost 70%-80% report a headache. Additionally, there appears to be a significant cohort who experience long-term, persistent headache after UDP.We performed a narrative review of literature using PubMed, searching terms that included long-term follow-up after UDP with a large bore needle in the postpartum population.In women who had UDP with a large bore needle used for epidural catheter placement at delivery, the rate of chronic debilitating headache is around 30% in the months following delivery and may persist for up to a year or longer.Based on the existing literature, we have mounting evidence that UDP with the large bore needle used to place an epidural catheter should be understood as a high-risk inciting event for the development of long-term headaches not simply a high risk of acute PDPH. Additionally, consideration should be given to stratifying the etiology of PDPH, based on needle type, and recognizing the entity of chronic PDPH, thus allowing for improvements in research and diagnosis.
View details for DOI 10.1111/head.14221
View details for PubMedID 34570902
Confounders Not General Anesthesia Likely Explain Greater Postpartum Depression.
Anesthesia and analgesia
2020; 131 (6): e248–e250
View details for DOI 10.1213/ANE.0000000000004850
View details for PubMedID 33196470
Bicuspid Aortic Valve and Ascending Aortic Aneurysm in a Twin Pregnancy.
JACC. Case reports
2020; 2 (1): 96-100
Bicuspid aortic valve with ascending aortic aneurysm is a common condition encountered in pregnancy. There are limited data on how to manage these patients. To our knowledge, we report the only case of a bicuspid aortic valve and aortic aneurysm with twin gestations. (Level of Difficulty: Intermediate.).
View details for DOI 10.1016/j.jaccas.2019.12.012
View details for PubMedID 34316973
A Bun in the Oven How to Use TIVA in Obstetrics
TAKING ON TIVA: DEBUNKING MYTHS AND DISPELLING MISUNDERSTANDINGS
View details for Web of Science ID 000648922100019
Transesophageal Echocardiographic Observation of Caval Thrombus Followed by Intraoperative Placement of Inferior Vena Cava Filter for Presumed Pulmonary Embolism During Cesarean Hysterectomy for Placenta Percreta: A Case Report
A & A PRACTICE
2019; 12 (2): 37–40
View details for DOI 10.1213/XAA.0000000000000836
View details for Web of Science ID 000460561800002
Transesophageal Echocardiographic Observation of Caval Thrombus Followed by Intraoperative Placement of Inferior Vena Cava Filter for Presumed Pulmonary Embolism During Cesarean Hysterectomy for Placenta Percreta: A Case Report.
During a cesarean hysterectomy for placenta percreta, transesophageal echocardiography was used to monitor volume status and guide resuscitation. After delivery of the neonate but before massive surgical hemorrhage, a thrombus appeared in the inferior vena cava. Roughly 3 hours later, the patient had hemodynamic changes consistent with an intraoperative pulmonary embolism. Boluses of epinephrine stabilized the patient. An inferior vena cava filter was placed via an in situ internal jugular central venous cannula to prevent further embolic events. We believe transesophageal echocardiography is a useful monitor during surgery for placenta percreta.
View details for PubMedID 30020106
Pharmacokinetics and Pharmacodynamics of Drugs Commonly Used in Pregnancy and Parturition.
Anesthesia and analgesia
2016; 122 (3): 786-804
The majority of pregnant women will be treated with a medication other than a vitamin supplement during their pregnancy. Almost half of these medications will be category C or D according to the former US Food and Drug Administration classification system, indicating a lack of human studies with animal studies suggesting adverse fetal effects (category C) or evidence of risk in humans (category D). Changes in maternal physiology alter drug bioavailability, distribution, clearance, and thus the drug half-life in often unpredictable ways. For many drugs, good pharmacokinetic and pharmacodynamic data in pregnancy and parturition are lacking. For other drugs, recent studies demonstrate major pharmacokinetic or pharmacodynamic changes that require dose adjustment in pregnancy, but current dosing guidelines do not reflect these data. In this review, we address the principles that underlie changes in pharmacology and physiology in pregnancy and provide information on drugs that anesthesiologists commonly encounter in treating pregnant patients.
View details for DOI 10.1213/ANE.0000000000001143
View details for PubMedID 26891392