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CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 00, Number 00, 000–000


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The Role of the


Anesthesiologist in
Preventing Severe
Maternal Morbidity
and Mortality
EMILY MCQUAID, MD,* LISA R. LEFFERT, MD,*
and BRIAN T. BATEMAN, MD, MSc†‡
*Department of Anesthesiology, Critical Care, and Pain Medicine,
Massachusetts General Hospital; †Department of Anesthesiology,
Perioperative and Pain Medicine; and ‡Department of Medicine,
Division of Pharmacoepidemiology and Pharmacoeconomics,
Brigham and Women’s Hospital, Harvard Medical School, Boston,
Massachusetts

Abstract: Anesthesiologists are responsible for the Key words: anesthesiology, obstetrics, maternal mor-
safe and effective provision of analgesia for labor and bidity, cesarean, neuraxial anesthesia
anesthesia for cesarean delivery and other obstetric
procedures. In addition, obstetric anesthesiologists Neuraxial anesthesia and analgesia is con-
often have a unique role as the intensivists of
the obstetric suite. The anesthesiologist is frequently sidered to be the technique of choice for
the clinician with the greatest experience in the acute labor analgesia and cesarean delivery anes-
bedside management of a hemodynamically unstable thesia. Advantages of neuraxial blocks for
patient and expertise in life-saving interventions. This labor include superior pain management,1,2
review will discuss (1) risks associated with neuraxial availability of an in situ epidural catheter
and general anesthesia for labor and delivery, and (2)
clinical scenarios in which the obstetric anesthesiologist should an urgent (or nonurgent) cesarean
is commonly called upon to function as a “peridelivery delivery be necessary, and decreasing circu-
intensivist.” lating catecholamines,3 of importance for
parturients with hypertensive disorders of
pregnancy or other cardiac comorbidities.
Correspondence: Brian T. Bateman, MD, MSc, Neuraxial anesthesia for cesarean de-
Department of Anesthesiology, Perioperative and livery is similarly associated with several
Pain Medicine, Brigham and Women’s Hospital,
Harvard Medical School, Boston, MA. E-mail: advantages for cesarean delivery. These
bbateman@partners.org include less exposure of the newborn to
The authors declare that they have nothing to disclose. (maternal) medications,4 better early

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 00 / NUMBER 00 / ’’ 2018

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2 McQuaid et al

maternal and fetal bonding,5–7 and avoid- There are many factors that contribute
ance of general anesthesia. Although in to the obstetric airway being potentially
the setting of enhanced supervision, end- difficult to manage. The Mallampati
tidal CO2 monitoring, and difficult airway score has been shown to increase over
algorithms, the general anesthesia-related the course of pregnancy and during
maternal mortality has improved to be labor,14–16 oral and nasal mucosa be-
comparable to neuraxial anesthesia,8 there comes edematous, hypervascular, and
are still several challenges that remain. prone to bleeding, and a combination of
decreased functional residual capacity
and increased oxygen consumption leads
to rapid desaturation when apneic. The
General Anesthesia-related emergent nature of cases in which general
Complications, Morbidity, and anesthesia is used for cesarean delivery
likely contributes as well, with one survey
Mortality finding that the relative risk of failed
In contemporary surveys, general anesthesia intubation in emergency cesarean delivery
is the mode of anesthesia for 3% to 4% of was approximately double that in elective
elective cesarean deliveries, however, it ac- cases (relative risk, 1.79; 95% confidence
counts for 14% to 19% of emergency cases.9 interval, 0.51-5.26).10 For a parturient
Common indications for general anesthesia with an anticipated difficult airway, the
for cesarean delivery include nonreassuring placement of an epidural catheter early in
fetal heart rate tracing in a patient without an the delivery course can help to avoid the
in situ epidural, cord prolapse, acute placen- morbidity associated with an urgent gen-
tal abruption, inability to achieve adequate eral anesthetic. A neuraxial technique is
anesthesia from a neuraxial technique, still typically preferred in these women,
or maternal contraindication to neuraxial even for urgent or emergent delivery, as
blockade (eg, coagulopathy, severe thrombo- neuraxial block (especially spinal) may
cytopenia, or tethered spinal cord). General take less time than an awake fiber optic
anesthesia can usually be administered intubation and will preserve maternal
quickly and safely and allows for a delivery oxygenation and ventilation. However,
that is free of maternal pain and anxiety. in cases where neuraxial techniques are
However, in rare cases general anesthesia can not possible, awake fiber optic intubation
be associated with severe maternal morbidity or other airway tools should be used to
and mortality, most notably in the form of secure the airway, if indicated. Maintain-
difficult or “failed” intubation, pulmonary ing maternal oxygenation and ventilation
aspiration, or postoperative pulmonary remains the most important considera-
events. tion, even in cases of fetal distress.
In the case of the unanticipated diffi-
DIFFICULT OR FAILED INTUBATION cult airway, the obstetric anesthesiologist
Difficult airway or failed intubation is per- should adhere to the principles of the
haps the most feared complication related to difficult airway algorithm. The algorithm
general anesthesia, in both general and ob- is based on the same key principles in
stetric populations. The risk of “failed” obstetric patients as in general surgical
intubation (typically defined as being unable patients: calling for help, optimizing pa-
to complete the intubation as planned) is tient positioning, letting up on cricoid
significantly higher in the obstetric popula- pressure if it is making laryngoscopy more
tion, with a reported incidence in recent difficult, having the most experienced
studies ranging from 1 in 250 to 1300 provider take over laryngoscopy, using a
intubations.10–13 video laryngoscope, and considering

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The Role of the Anesthesiologist 3

placement of a supraglottic airway such may place the patient at increased risk of
as a laryngeal mask airway (LMA). LMA pulmonary aspiration. Such conditions
is the rescue airway of choice, especially in include pregnancy, labor (especially in
the setting of difficult mask ventilation, the presence of epidural or intrathecal
and will often allow for oxygenation and opioids),24–29 obesity,30,31 diabetes
32
ventilation in a patient who could not be mellitus, and gastroesophageal reflux
intubated. Once an LMA has been placed disease. Once aspiration occurs, evidence
successfully, the decision about whether from animal models suggests that the risk
to proceed with surgery should be based and severity of aspiration pneumonitis is
on assessment of maternal and fetal con- inversely related to the pH of the aspirate,
dition; many cases have been described of and directly related to the volume.31,33–36
cesarean delivery being performed with The consistency of the aspirate is also
LMA as the final airway device with good important—solid matter poses the risk of
maternal and fetal outcomes.17–20 asphyxiation, and particulate matter is
associated with worse outcomes in animal
PULMONARY ASPIRATION models.35
Pulmonary aspiration in the setting of Although rare, pulmonary aspiration
general anesthesia is a controversial is associated with significant morbidity
topic in obstetric anesthesia. Histori- and mortality when it does occur.37–39
cally, aspiration was a major cause of The sequelae of aspiration and severity
morbidity and mortality for parturients of symptoms depend on multiple factors,
—it was the most common cause of including the nature of the aspirate, the
mortality related to obstetric anesthesia patient’s baseline health and comorbid-
in the United States before 1990, and ities, and how the event is managed in
during that same time it has been esti- the acute and chronic phases. Most
mated that the risk of death in patients aspiration events that occur in the set-
who received general anesthesia for ting of general anesthesia are witnessed
cesarean delivery was 17 times greater by an anesthesia provider. Initial symp-
than that of patients who received re- toms include tachypnea (in the sponta-
gional anesthesia.21 However, in recent neously breathing patient), tachycardia,
decades, pulmonary aspiration has be- bronchospasm, and hypoxemia. Cardiac
come rare, with contemporary surveys arrest has also been described both in
finding an incidence of 0% to case reports and in animal models.33,40
0.46%.12,22,23 The sharp decline can be Radiographic signs lag behind clinical
attributed to a combination of factors, symptoms by as much as 24 hours,
including increased awareness of the meaning that chest x-ray is unlikely to
risk of aspiration among anesthesiolo- be useful in the operating room, how-
gists, use of rapid sequence intubation ever, 85% to 90% of patients will even-
techniques when general anesthesia is tually develop alveolar infiltrates in
indicated, increased use of neuraxial dependent parts of the lung (in mild
techniques for cesarean delivery, use of cases) or diffusely (in severe cases).41,42
antacids before cesarean delivery, and Possible sequelae of pulmonary aspi-
the widespread practices of having pa- ration include acute respiratory distress
tients fast before planned cesarean de- syndrome, aspiration pneumonia, and
livery, and restricting oral intake to death.37–39 Management of pulmonary
clear liquids during active labor. aspiration depends on the patient’s pre-
Conditions that delay gastric empty- sentation. The oropharynx should be
ing, increase intra-abdominal pressure, or suctioned and airway rapidly secured.
decrease lower esophageal sphincter tone Rigid bronchoscopy may be considered

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4 McQuaid et al

if the aspirate contains large pieces of Neuraxial Anesthesia-related


solid food, and the tracheobronchial tree Complications, Morbidity, and
should be suctioned to remove any re-
maining liquid. Prophylactic antibiotics Mortality
are likely not necessary, although it is
worth noting that the use of antacids HEADACHE
may interfere with the bactericidal prop- Postpartum headache is extremely common,
erties of stomach acid, and place the occurring in as many as 40% of postpartum
patient at higher risk of developing women.51,52 Because of the well-known asso-
aspiration pneumonia.43,44 Corticoste- ciation of neuraxial anesthesia and postdural
roids are frequently administered to puncture headache, the anesthesiologist is
patients with aspiration pneumonitis, often asked to evaluate these patients. Single
however, their benefits have never been institution retrospective studies have found
clearly demonstrated, and some studies that ∼16% of postpartum headaches are
suggest that they increase the risk of likely to be of postdural puncture origin,51
pneumonia and the length of stay in related to either intentional dural puncture
the intensive care unit.43,45 Lung protec- during a spinal anesthetic procedure, or
tive ventilation strategies, including inadvertent dural puncture during an epidur-
low-tidal volumes of 4 to 6 mL/kg and al anesthetic procedure. The overall risk of
plateau pressures of 30 cm of water obstetric postdural puncture headache is 1%
or less, have been shown to decrease to 2%. Postdural puncture headache often
mortality patients with acute respiratory presents first with neck stiffness in the absence
distress syndrome.46 of fever, and then progresses to a headache
Fasting for 8 hours before planned that is exacerbated in the upright position.53
cesarean delivery is widely accepted, These headaches, a symptom of low cerebro-
however, the practice of restricting oral spinal fluid pressure, do eventually remit
intake during active labor, or during spontaneously, but can often cause consid-
labor epidural analgesia, varies consid- erable maternal discomfort and disruption in
erably from institution to institution, caring for her newborn. Pharmacologic (con-
and has been challenged in recent servative) therapy has been shown to have
years.47,48 Arguments for liberalizing little or no consistent benefits (eg, caffeine,
oral intake during labor include the low fioricet, non-steroidal anti-inflammatory
incidence of aspiration in modern ob- drugs, adrenocorticotropic hormone, cosyn-
stetric anesthesia and the high energy tropin)54 and overuse of agents such as non-
demands of labor. However, several steroidal anti-inflammatory drugs and fioricet
well-designed, randomized studies and can be associated with chronic headache.55,56
meta-analyses of restrictive versus liber- Autologous lumbar epidural blood patch can
al oral intake during labor have found improve the headache in many women with
no difference between groups with re- many women with post-dural puncture head-
gards to important outcomes such as the ache, although 3% to 28% of women will
duration of labor, neonatal outcomes, or require a second blood patch, depending on
the need for cesarean or operative vag- the study.57,58
inal delivery.47,49,50 In light of the seem- Whereas most other postpartum head-
ingly limited consequence of keeping aches are migraine or tension-type, some are
women fasted during labor, and the associated with more morbid diagnoses,
potential morbidity and mortality asso- especially if they are accompanied by coex-
ciated with pulmonary aspiration, poli- isting neurological deficits. Headaches that
cies of restricted oral intake during labor are worse in the supine position (the reverse
should probably be maintained. of many women with post-dural puncture

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The Role of the Anesthesiologist 5

headache) are particularly ominous, as they 1 in 1400.22,63–65 It can occur in a variety


may be associated with increased intracra- of clinical situations. The level of spread
nial pressure. Albeit a low-incidence event of local anesthetic is primarily governed
(occurring in about 34/100,000 deliveries),59 by the dose66,67 and baricity68,69 of the
stroke is a leading cause of maternal injectate. Spinal anesthetics (eg, for cesar-
mortality.60 Postpartum women, particu- ean delivery) performed with low dose,
larly those that are preeclamptic, are increas- hyperbaric solutions of local anesthetic
ingly at risk for stroke. Other neurological are less likely to result in a clinically
urgencies include cerebral venous sinus significant degree of high spinal blockade.
thrombosis (with or without stroke), rever- High spinal is more likely to result from
sible cerebral vasoconstriction syndrome, an epidural catheter that has been inad-
often with accompanying posterior reversi- vertently placed, or has migrated into, the
ble encephalopathy syndrome. Although intrathecal or subdural compartment.
rare in a young otherwise healthy obstetric High spinal may occur include during
patient, meningitis can occur, as can head- the administration of a “test dose” at
aches from tumor, medications, illicit sub- initiation of a newly placed epidural
stances, and other etiologies.61 Being well catheter, while bolusing an epidural cath-
versed in the differential diagnosis of post- eter for breakthrough pain or to convert
partum headache and able to discern, which to a surgical anesthetic, or when a spinal
patients need urgent neurological expert anesthetic is attempted in a patient after
attention, the anesthesiologist can play a epidural block. The purpose of the epi-
key role in mitigating related maternal dural test dose is to identify either intra-
morbidity and mortality. thecal or intravenous placement of an
epidural catheter, and therefore avoid
HIGH OR TOTAL SPINAL subsequent inadvertent injection of local
High spinal refers to progression of block anesthetic into the cerebrospinal fluid or a
height from an intrathecal injection to a more blood vessel. The typical test dose con-
cephalad level than was intended, with tains 45 mg of isobaric lidocaine and 15
variable consequences depending on the de- μg of epinephrine. It is important to note
gree of spread. “Total spinal” is a term that is that onset of spinal anesthesia following
colloquially used to refer to a high spinal 45 mg of lidocaine is variable, and it may
block that results in loss of consciousness. It is take in excess of 5 minutes to see clinically
important to note that the loss of conscious- significant sensory and motor blockade.70
ness is usually a result of hypotension causing If additional local anesthetic is injected
hypoperfusion of the brainstem, as opposed into the epidural catheter in the first
to the direct effects of local anesthetic on the couple of minutes following an appa-
brain.62 Furthermore, the effects of an in- rently negative test dose, high spinal block
appropriately high block are not necessarily could ensue. Aspiration of the epidural
immediate, and can continue to evolve over catheter is not 100% sensitive for detect-
several minutes from the time of injection. ing intrathecal catheter placement.71,72
Therefore, the distinction between the 2 (high Conversion of labor epidural catheter
vs. total spinal) is primarily one of semantics, to a surgical anesthetic for cesarean deliv-
and the providers should anticipate progres- ery is always a high-risk period. Such
sion to these symptoms when a high spinal is transitions are frequently marked by ur-
suspected. For the purposes of this chapter, gency due to deterioration of either the
the term high spinal will be used to describe fetal or maternal condition, which com-
both entities. pels the anesthesiologist to inject large
The reported incidence of high spinal volumes of high-concentration local anes-
varies widely, ranging from 1 in 16,200 to thetic into the epidural catheter over a

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6 McQuaid et al

short period of time. These injections may bearing in mind that fetal condition may
occur as the patient is being transferred stabilize once maternal hypotension and
from the labor room to the operating hypoxia are addressed. If fetal bradycar-
suite, often without monitoring. As many dia persists once the maternal condition
institutions now use very low concentra- has been stabilized, delivery may be
tions of local anesthetic for labor epidural indicated.
analgesia, it is possible that an intrathecal Subdural injection of local anesthetic is a
or intravascular catheter could be unrec- distinct clinical entity, and can also result in
ognized during labor, thereby exposing inappropriately high levels of anesthesia.
the patient to severe morbidity when The reported incidence ranges from 0.82%
dosing the epidural for surgical anesthesia to as high as 11%.75,76 Subdural injection
for cesarean delivery. In cases where the occurs when local anesthetic is injected
labor epidural fails to convert to an between the dura mater and the arachnoid
adequate surgical anesthetic, proceeding mater, and is characterized by a high,
with a spinal anesthetic must be done with patchy block sensory block, frequently with
extreme caution, as this sequence is high sacral sparing and relatively preserved mo-
risk for the development of a high tor function. It may also present as inad-
spinal.22,73,74 equate epidural analgesia or anesthesia.76
Regardless of the etiology, signs, symp- Cranial nerves may be involved, and Horn-
toms, the management of high spinal are er syndrome has been reported.77 Hypoten-
the same. Symptoms depend on the de- sion is typically less profound than with a
gree of cephalad spread of the block. high spinal, however, apnea and loss of
Sympathectomy and involvement of car- consciousness can occur secondary to direct
diac accelerator fibers from T1-T4 cause intracranial involvement. Onset of the block
severe hypotension and bradycardia. Pro- tends to be slower and more insidious than
found hypotension can result in nausea, that seen with intrathecal injection, resulting
confusion, agitation, or loss of conscious- in a delayed diagnosis. Treatment is symp-
ness. Hypopnea and hypoxia can be tomatic and depends on the degree and
caused by either weakness of the acces- quality of resulting block.
sory muscles of breathing, or by diaphrag-
matic paralysis once the block reaches the INTRAVASCULAR INJECTION OF
C3-5 nerve roots. Respiratory depression LOCAL ANESTHETIC
may be presaged by voice weakness or Intravascular injection of local anesthetic
inability to speak. Fetal condition may and subsequent local anesthetic systemic
also be compromised secondary to hypo- toxicity (LAST) is a rare but potentially
tension or hypoxia. Treatment includes devastating complication of epidural an-
placing the patient in a modest Trende- algesia during labor or for cesarean deliv-
lenburg position with left uterine displace- ery. Ideally, intravascular placement or
ment to decrease venous pooling, and migration of an epidural catheter will be
further supporting hemodynamics with identified before administration of large
volume expansion, vasopressors, or ino- doses of local anesthetic. An epinephrine-
tropes. There is a high risk of aspiration containing test dose has repeatedly been
secondary to decreased level of conscious- demonstrated to have excellent sensitivity
ness, supplemental oxygen should be ad- for detection of an intravascular catheter
ministered and the airway should be in non–beta-blocked patients.78,79 Un-
secured early, although in some instances fortunately, due to maternal heart rate
it may be sufficient to support respiration variability during labor, the specificity
with bag mask ventilation. The fetal heart may be considerably lower.78,80 The po-
rate should be monitored during this time, tential for false positives combined with

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The Role of the Anesthesiologist 7

concerns about the effects of epinephrine (3) Administration of 100% oxygen and
on placental blood flow in the setting of a early tracheal intubation (cardiotox-
positive test dose have led some institu- icity is exacerbated by hypoxia, hy-
tions to abandon the test dose in obstet- percapnia, and acidemia).
rics entirely. Although this practice is (4) Support of hemodynamics including
controversial, there are certain situations placing the patient in left uterine
in which it is advisable to avoid an displacement, initiation of advanced
epinephrine-containing test dose, such as cardiac life support, and early admin-
in patients with severe hypertension, or in istration of 20% lipid emulsion (1.5
the setting of certain forms of heart mL/kg over 1 min followed by 0.25
disease in which a sudden increase in mL/kg/min, bolus may be repeated for
afterload may be detrimental (eg, cardio- persistent cardiovascular collapse,
myopathy with reduced ejection fraction maximum dose of 10 mL/kg).87 For
or severe regurgitant valvular lesions). refractory collapse, cardiovascular
Aspiration of the catheter before injec- surgery should be consulted for pos-
tion, while highly specific, has been dem- sible initiation of cardiopulmonary
onstrated to have poor sensitivity.81,82 bypass or extracorporeal membrane
The sensitivity of aspiration may be im- oxygenation.
proved using a multiorifice catheter, but (5) Avoidance of high-dose epinephrine
false negatives can still occur.83,84 Use of ( > 1 mg/kg), vasopressin, calcium
a flexible epidural catheter appears to channel blockers, beta blockers, and
decrease the risk of erosion into a blood local anesthetics.
vessel.85 (6) Cesarean delivery should be consid-
Classically, signs and symptoms of ered early as it may improve efforts at
LAST start with neurological symptoms maternal resuscitation.
such as tinnitus, perioral numbness, agita-
tion, and seizures. Cardiovascular symp- EPIDURAL HEMATOMA
toms including hypotension, dysrhythmias, Hemorrhage into the epidural space is an
and cardiac arrest typically follow. High exceedingly rare complication of epidural
plasma levels of bupivacaine may cause for labor or delivery, albeit 1 that is
cardiotoxicity simultaneously with the on- associated with severe maternal morbid-
set of neurological symptoms, and can be ity. It is difficult to accurately estimate
especially difficult to treat,86 as a result of the incidence of epidural hematoma, as it
which high-concentration bupivacaine for is so rare that few events are seen even in
is no longer used for obstetric anesthesia. very large surveys of labor epidurals,
Conversely, 2-chloroprocaine is rapidly however, the reported incidence in recent
metabolized by plasma cholinesterases, studies ranges from 1 in 160,000 to 1 in
meaning that even if intravascular injection 250,000.22,88,89 Epidural hematoma is
were to occur, the resulting symptoms rarer in the obstetric population than in
would be expected to be less severe. Treat- the general surgical population.88,90 The
ment of LAST includes depends upon most important risk factors in the obstet-
symptoms, but includes: ric population seem to be disorders of
(1) Stopping administration of local anes- coagulation (including the iatrogenic
thetic and calling for help. administration of anticoagulants) and
(2) Management of seizure activity if thrombocytopenia, especially when asso-
present (starting dose of 2 to 5 mg ciated with the syndrome of hemolysis,
midazolam). Phenytoin should be elevated liver enzymes, and low platelets
avoided as it can worsen cardiotox- (HELLP syndrome),88,91,92 although
icity. there are very few reported cases in the

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8 McQuaid et al

literature. Other risk factors include multi- Perinatology recently created a multidis-
ple or traumatic placement attempts.91,92 ciplinary consensus statement on the care
There is no data to definitively deter- of pregnant and postpartum patients on
mine the minimal platelet count required anticoagulants and placement of a neu-
to safely perform a neuraxial anesthetic. raxial block.99 Multidisciplinary planning
Epidural hematoma can occur in the and communication between anesthesiol-
setting of a normal platelet count,93 and ogists, obstetricians, nurses, and patients
neuraxial anesthetics have been per- will be key in the effort to provide safe
formed uneventfully in patients who have and effective care to this growing popu-
subsequently been discovered to have lation of patients.
profound thrombocytopenia.94–96 Most The symptoms of epidural hematoma,
anesthesiologists will place an epidural caused by compression of neural struc-
block in patients with a platelet count of tures and resultant ischemia, include pain
> 70 to 80,000 without other contraindi- in the back and legs, loss of sensation in
cations. Risk of epidural hematoma in the lower extremities, motor weakness,
patients with a platelet count of 70 to and loss of bowel or bladder control.
100,000 has an upper 95% confidence Treatment is usually surgical, often with
interval of 0.2%.96 Factors that may laminectomy to evacuate the hematoma.
influence the decision include the etiology Early recognition, appropriate imaging,
of the thrombocytopenia, the rapidity of and prompt neurosurgical intervention
the drop in platelet count, whether or not are vital to improve outcomes—1 review
the patient has a reassuring airway exami- of 30 cases of epidural hematoma showed
nation, and the risk of general anesthesia. that patients who received surgery within
Single shot spinal technique is generally 12 hours of diagnosis had improved out-
considered lower risk than placement of comes as compared with patients with
an epidural catheter due to the smaller similar preoperative neurological deficits
needle size, relative ease of technique, and in whom surgery was delayed.100 Periph-
lack of need to later remove a catheter eral nerve injury after delivery is quite
from the epidural space. The decision common but fortunately is usually benign
about when to proceed with a neuraxial and self-limited 101; the high incidence of
anesthetic in the setting of thrombocyto- these types of symptoms may obscure or
penia requires a frank and thorough dis- delay diagnosis. Patients with signs or
cussion between providers and their symptoms of peripartum neurological in-
patients about the risks and benefits jury require a detailed history and phys-
associated with the choices, so that a truly ical examination, and frequent follow-up
informed decision can be made. to determine the time course and evolu-
Increasingly, parturients may be re- tion of their symptoms.
ceiving on anticoagulants at the time of
labor or for cesarean delivery. Iatrogenic EPIDURAL ABSCESS AND MENINGITIS
anticoagulation is a potential risk factor Infection in neuraxial space is a rare
for epidural hematoma97,98 and the complication of neuraxial anesthesia
appropriate timing of discontinuation or on labor and delivery, although with a
transition to shorter acting agents re- reported incidence of epidural abscess
quires careful interdisciplinary planning. ranging from 1 in 506,000102 up to 1 in
Depending on the agent being used, deci- <5000,103,104 it appears to be more com-
sion to proceed with neuraxial anesthetic mon than epidural hematoma. The inci-
may be based on timing of drug admin- dence of postspinal meningitis is difficult
istration, laboratory values, or both. The to estimate because it is not consistently
Society of Obstetric Anesthesiology and reported in surveys of complications

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The Role of the Anesthesiologist 9

related to obstetric anesthesia. In the ASA suggest that anesthesiologists may neglect
Closed Claim Projects database from this and other aspects of sterile
1980 to 1999, neuraxial infections (includ- technique.116–119 Skin preparation and
ing epidural abscess and meningitis) were adequate drying time are also important.
the most common cause of neuraxial There is growing evidence that chlorhex-
injury in obstetric cases.105 It is important idine in 70% alcohol is superior to povi-
to note that epidural abscess has been done-iodine for eliminating bacteria on
reported to occur spontaneously in both the skin.103,120,121 The largest concentra-
obstetric and nonobstetric patients,106,107 tion of bacterial colonies on the skin exists
and that community-acquired meningitis in hair follicles,120 emphasizing the im-
can occur in pregnancy or the postpartum portance of adequate duration of prepa-
period. ration to penetrate these areas.121 A
In the setting of a neuraxial anesthetic, sterile, occlusive dressing should be ap-
epidural catheterization is a prerequisite plied over the insertion site, and main-
for epidural abscess formation; no cases tained until the catheter is removed. Full
have been reported in patients who re- guidelines regarding use of aseptic or
ceived spinal anesthesia alone.108 Possible sterile technique can be found in the
risk factors for epidural abscess include American Society of Anesthesiologists’
prolonged catheterization, difficult or Practice Advisory for the Prevention,
traumatic procedure at the time of initial Diagnosis, and Management of Infec-
insertion, administration of epidural tious Complications Associated with
opioids without local anesthetic, and pa- Neuraxial Techniques.122
tient-level factors such as diabetes or As with other space-occupying lesions
immunosuppression.104,109–113 Staphylo- of the vertebral canal, the symptoms of
coccus aureus is the most common patho- epidural abscess relate to compression
gen, and skin the most likely source.106 In and ultimate ischemia of the spinal cord.
the case of meningitis, dural puncture is Initial symptoms include back pain (with
likely a prerequisite for infection to or without radiation), localized tender-
occur.108,114,115 Streptococcus salivarius ness over the insertion site (with or with-
is the most common pathogen, and pos- out drainage), neck stiffness, and fever.
sible risk factors include poor sterile Only a small portion of patients will have
technique, infection at another site the classic triad of back pain, fever, and
(eg, chorioamnionitis), prolonged cathe- neurological symptoms123,124; a high in-
terization, labor, and diabetes or dex of clinical suspicion is required to
immunosuppression.104,108,109,113 Evi- avoid diagnostic delays, which can result
dence for some of these risk factors is in poor outcomes. Laboratory evaluation
based on the fact that postspinal menin- typically reveals leukocytosis and in-
gitis is exceedingly rare in the setting of creased c-reactive protein. If untreated,
planned cesarean deliveries, which typi- symptoms may progress to include saddle
cally take place before labor, and in the anesthesia, leg weakness, incontinence of
more sterile environment of the operating the bowel and bladder, and other symp-
room, where providers are more likely to toms of cauda equina syndrome. If epi-
wear a mask and adhere to rigorous sterile dural abscess is suspected, an magnetic
technique. resonance imaging should be obtained to
With regards to preventing neuraxial confirm the diagnosis, and prompt neuro-
infections, sterile technique is the most surgical decompression is indicated if
significant modifiable risk factor for the neurological symptoms are already
anesthesiologist. Wearing a mask is of present. If symptoms are mild and neuro-
particular importance as there is data to logical sequelae are absent, there may be a

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10 McQuaid et al

role for nonsurgical management with (12.7%), hemorrhage (11.4%), cardiomyop-


antibiotics and close follow-up.125,126 In athy (11.0%), thrombotic pulmonary em-
either case, early and appropriate anti- bolism (9.2%), hypertensive disorders of
biotic therapy is important. Although pregnancy (7.4%), cerebrovascular acci-
many patients make a full neurological dents (6.6%), and amniotic fluid embolism
recovery, some will have permanent neu- (5.5%). Regardless of the etiology of the
rological deficits, and epidural abscess crisis, the obstetric anesthesiologist is fre-
can also lead to sepsis and death.127 quently called upon when a patient be-
Delayed diagnosis and increased duration comes unstable, and offers a perspective
of neurological symptoms conveys a high- and skill set that is unique on the labor and
er likelihood of permanent disability.124 delivery unit. The risk factors, presentation,
The classic triad of symptoms of acute and management of each of the obstetric
bacterial meningitis is fever, nuchal ri- and peripartum emergencies are covered in
gidity, and altered mental status. A se- detail in other articles in this issue. How-
vere, bilateral headache is also common. ever, there are certain common themes to
Not all patients present with the classic the skills and services that the obstetric
triad, although most have at least 2 of the anesthesiologist can provide in managing
4 most common symptoms.128,129 There is these high-risk patients.
significant overlap between the symptoms
of bacterial meningitis and those of spinal AIRWAY MANAGEMENT
epidural abscess. Clinical risk factors such Obstetric patients sometimes require
as placement of an epidural catheter, and ventilatory support or tracheal intubation
known puncture of the dura should be outside of the operating room. Any
considered, and imaging should be ob- patient with an altered level of conscious-
tained early to rule out epidural abscess. ness, impaired ability to protect her air-
When bacterial meningitis is suspected, way, or respiratory distress may require
appropriate antibiotics should be admin- airway management. Emergency airway
istered early; a delay in initiating anti- equipment should be readily available in
biotics is associated with worse outcomes, the obstetrics unit.
including death.129 Obstetric patients who
receive early diagnosis and therapy are INVASIVE MONITORS AND
expected to make a full recovery.106 VASCULAR ACCESS
Invasive blood pressure monitoring may
be indicated in any patient with hemody-
namic instability. Examples of patients
The Role of the Anesthesiologist who may benefit from an arterial catheter
in Obstetric Crises are parturients with cardiovascular, valv-
The primary threats to maternal well-being ular heart disease, or cardiomyopathy,
in the peripartum period are not related to postpartum hemorrhage, and refractory
anesthesia, but rather stem from obstetric hypertension. An arterial line is often
crises and underlying maternal disease. useful in these same settings to facilitate
From 2011 to 2013, anesthetic complica- frequent blood draws when following
tions accounted for 0.2% of pregnancy- serial laboratory values. Although more
related deaths in the United States.130 The invasive and a slightly higher risk proce-
leading causes of pregnancy-related deaths dure, central venous access is sometimes
in that time period were cardiovascular indicated in patients with difficult intra-
disease (accounting for 15.5% of preg- venous access, an ongoing need for vaso-
nancy-related deaths), noncardiovascular active infusions, or to monitor central
medical disease (14.5%), infection or sepsis venous pressure.

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The Role of the Anesthesiologist 11

BLOOD PRODUCT ADMINISTRATION 2. Landau R, Bollag L, Ortner C. Chronic pain


Many labor and delivery units have pro- after childbirth. Int J Obstet Anesth. 2013;22:
tocols in place for the massive transfusion 133–145.
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