Concurrent medical conditions among pregnant women - ignore at their peril: report from an antenatal anesthesia clinic

Complex Pathology and Management in the Obstetric Patient: A Narrative Review for the Anesthesiologist

Pregnant patients may present with multiple complex comorbidities that can affect peripartum management and anesthetic care. The preanesthesia clinic is the ideal setting for early evaluation of high-risk pregnant patients. Comorbidities may include cardiovascular pathology such as valvular abnormalities, septal defects, aortopathies, arrythmias and cardiomyopathies. Additional comorbidities include pulmonary conditions such as obstructive sleep apnea as well as preexisting neuromuscular and skeletal disorders that may impact anesthetic management. Hematologic conditions involving both bleeding diathesis and thrombophilias may present unique challenges for the anesthesiologist. Patients may also present with endocrinopathies including diabetes and obesity. While not as common, high-risk patients may also have preexisting gastrointestinal conditions such as liver dysfunction, renal failure, and even post-transplant status. Ongoing and prior substance abuse, obstetric conditions such as placenta accreta spectrum disorders, and fetal conditions needing ex utero Intrapartum treatment also require advanced planning. Preanesthesia evaluations also help address important ethical and cultural considerations. Counseling patients regarding anesthetic considerations as well as addressing concerns will play a role in reducing racial and ethnic disparities. Anticipatory guidance by means of pre-anesthetic planning can facilitate multidisciplinary communication and planning. This can allow for an impactful and meaningful role in the care provided, allowing for safe maternal care and optimal outcomes.

Peripartum optimization and coordination of collaborative care practice: a critical role for the obstetric anesthesiologist in combating maternal morbidity and mortality

PURPOSE OF REVIEW

Antenatal anesthesia clinics remain uncommon despite the rising incidence of maternal morbidity and mortality in the United States. The purpose of the present review is to outline the major considerations and challenges surrounding antenatal anesthetic evaluation.

RECENT FINDINGS

Data from the general surgical population would suggest a mortality benefit associated with preoperative anesthesia evaluation, although no such data exists in the obstetric population.Robust systems for case ascertainment and referral are needed. Recent publications on obstetric comorbidity indices may provide useful tools to ascertain high-risk parturients for a referral to antenatal obstetric anesthesiology clinics and higher levels of maternal care. Major obstetric organizations have identified and laid out criteria for maternal level of care. Anesthesiology resources also play a role in these designations and can help triage patients to facilities with appropriate resources.

SUMMARY

Obstetric anesthesiologists have a critical role not only in preoperative patient optimization but also in coordinating multidisciplinary care for optimal patient outcomes.

Antenatal anaesthesia clinics - the way forward?

Specialist antenatal clinics are increasingly being used to enable anaesthetists to evaluate pregnant women with co-morbidities and those at high risk of obstetric complications. In this journal a team from Israel describe the process of setting up and running such a clinic over a 14 year period. One of the challenges they identify was the limited referral of high risk women. Based on UK and US literature, the use of structured referral tools, clear criteria for referral and regular antenatal multidisciplinary meetings may help to address this.