Session 04S1: Parturients with a problem

Session 04S1: Parturients with a problem

Saturday 2 June, 14h00-15h30, auditorium 15

Three different problem scenarios for parturients will be covered in this Saturday session at Euroanaesthesia. In the first, the addicted parturient will be discussed by Professor Ruth Landau, Director of Obstetric Anesthesia at Columbia University Medical Center and Director of the Center for Precision Medicine, Department of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, NY, USA.

The opioid crisis has reached an unprecedented magnitude, and the data on opioid use and misuse in the obstetric population is alarming;1,2 in the United States, every 25 minutes, a baby is born with neonatal opioid withdrawal (NOWS),” explains Professor Landau.

The implications of an opioid use disorder affecting a pregnant woman and unresolved questions are multiple:

  1. Management of opioid-dependence during pregnancy will be challenging and the value of undergoing detoxification during pregnancy remains contested
  2. Which opioid for medical assistance therapy should be prescribed (methadone versus buprenorphine, other)?3
  3. The effects of in utero opioid exposure in the short term (NOWS)4 or long term (risk for later life opioid dependence) are not only potentially devastating but also tremendously costly
  4. Management of labour pain will likely be challenged by opioid-tolerance and the anxiety that systemic maintenance opioids may not be given during labour
  5. Management of post-caesarean pain will be complex and require a judicious combination of systemic and neuraxial multimodal analgesics and adjuvants (neuraxial opioids, clonidine, gabapentin, regional blocks) to provide safe and adequate pain relief while avoiding withdrawal.5

Professor Landau concludes: “In addition, important questions such as how postpartum pain management contributes to the opioid epidemic need to be resolved, in particular that opioid exposure may be precipitating persistent use,6 and that excessive prescribing may result in leftover medication (at least in North America).”7 (for references, see below)

The ‘elderly’ parturient will be presented by Professor Carolyn Weiniger, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. She says: “If you follow your favourite celebrities and read the tabloids, you might think there is no age limit for beautiful women to achieve a successful pregnancy. The oldest modern recorded pregnancy was by a 70-year-old Indian woman, although the first recorded geriatric pregnancy was that of Sara, wife of Abraham, described in the biblical book of Genesis.”

As women around the world wait longer to start a family, there are perinatal outcome consequences for mother and her neonate. Of course, the pregnancies at advanced maternal age (officially >35 years of age but usually considered > 40) are made possible by artificial reproductive therapies, involving many ethical considerations. “Advance maternal age is associated with increased maternal mortality, and many different morbidities such as haemorrhage, venous thromboembolism, gestational diabetes, abnormal placentation, cardiac disease, sepsis and depression,” explains Prof Weiniger.

Caesarean delivery is more likely for advanced maternal age pregnancies, as is the risk of peripartum hysterectomy. The fetus of an older mother is at increased risk of stillbirth. Professor Weiniger concludes: “There is some evidence that starting young and having many children may be protective for mothers, although having the first child at an older age increases the risk of the mother not surviving until the child’s 18th birthday. Those managing a population of elderly parturients will also become familiar with the ethics and special considerations of surrogacy.”

Marc Van de Velde (Professor of Anesthesiology and Chair, Department of Anaesthesiology, Catholic University Leuven and University Hospitals Leuven, Belgium) will close the session with his talk on parturients with previous bariatric surgery.

Obesity is a worldwide pandemic also affecting women in childbearing age. Obesity affects fertility and pregnancy outcome as well as fetal outcome (increased incidence of C-sections, infertility, premature delivery, diabetes). Professor Van de Velde says: “The types and overall outcome of bariatric surgery will be discussed in the presentation with focus on mortality, morbidity and evaluation of success of surgery. A critical appraisal of the available science will be discussed.”

He concludes: “Many young women will undergo bariatric surgery. Many will, later in their lives, become pregnant. A post-bariatric pregnant patient poses many obstetrical, fetal and anaesthetic challenges which will be discussed in the lecture. Malabsorption, mechanical bowel obstruction and intracerebral haemorrhage in the fetus are just some of the problems that are encountered in this group of patients.”

References

 

  1. Maeda A, Bateman BT, Clancy CR, Creanga AA, Leffert LR. Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes. Anesthesiology. 2014;121(6):1158-1165.
  2. Wanderer JP, Bateman BT, Rathmell JP. Opioid use is rising. Anesthesiology. 2014;121(6):A23.
  3. Kraft WK, Adeniyi-Jones SC, Chervoneva I, et al. Buprenorphine for the Treatment of the Neonatal Abstinence Syndrome. N Engl J Med. 2017;376(24):2341-2348.
  4. Desai RJ, Huybrechts KF, Hernandez-Diaz S, et al. Exposure to prescription opioid analgesics in utero and risk of neonatal abstinence syndrome: population based cohort study. BMJ. 2015;350:h2102.
  5. Tith S, Bining G, Bollag L. Management of eight labor and delivery patients dependent on buprenorphine (Subutex): A retrospective chart review. F1000Res. 2018;7:7.
  6. Bateman BT, Franklin JM, Bykov K, et al. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naive women. Am J Obstet Gynecol. 2016;215(3):353 e351-353 e318.
  7. Bateman BT, Cole NM, Maeda A, et al