Highlights From the Society for Obstetric Anesthesia and Perinatology 2004 Annual Meeting

William Camann, MD

Disclosures

June 18, 2004

The annual meeting of the Society for Obstetric Anesthesia and Perinatology (SOAP) was held May 12-16 in Ft. Myers, Florida. This society meets yearly to provide a forum for discussion of medical problems unique to the peripartum period and to promote excellence in research and education in anesthesia and obstetrics. A wide range of interesting topics was discussed at this year's meeting.

Guest lecturer Dr. Gary Hankins (The University of Texas, Galveston), who is Chair of the ACOG committee that recently published the consensus statement of neonatal encephalopathy, discussed the genesis of neonatal encephalopathy and cerebral palsy and outlined the criteria used to define intrapartum neonatal asphyxia. Dr. Hankins described the evidence supporting the observation that the majority of cases of cerebral palsy are likely caused by insults suffered before the onset of labor. He described the extensive process of peer review and revision that went into this document, including the wide range of expert opinion contributing to the final version. The executive summary of the final document was recently published in the Green Journal.[1] (Dr. Van Erden and Dr. Bernstein also discuss the ACOG report in another issue of "Field Notes in Maternal-Fetal Medicine."[2])

Guest lecturer Dr. Ruben Quintero (St. Joseph's Hospital, Tampa, Florida) discussed his extensive experience with laser umbilical cord surgery for twin-twin transfusion syndrome (TTS). Dr. Quintero is a leader in the development of laser blood vessel ablation for TTS. Success rates are very encouraging. The procedure was initially performed under general anesthesia, but with advances in surgical proficiency it is now virtually always performed with a local anesthetic and minimal maternal sedation. Dr. Quintero and colleagues have published an article on the topic in the May 2004 issue of Ultrasound in Obstetrics and Gynecology.[3]

A panel discussion was held to discuss alternatives to conventional epidural analgesia for labor pain. Although epidurals are used by nearly 60% of women in the United States, some women do not want to or cannot receive this technique.

Dr. Valerie Arkoosh (Drexel University, Philadelphia, Pennsylvania) discussed recent developments in the area of microspinal catheters for labor analgesia. Microspinal catheters (28-gauge or smaller), were withdrawn by the FDA from the market in 1993 because of fears of neurotoxicity from high doses of lidocaine administered via this route. The results of a multicenter, randomized trial using these catheters was conducted using only sufentanil (a narcotic) as a spinal analgesic during labor and were presented at this meeting. The results indicated no evidence of neurotoxicity, and acceptable analgesic effects. When and if these catheters will be available to the US marketplace remains to be seen.

Dr. Tracy Saunders (State University of New York at Stony Brook) discussed developments in parenteral opioid analgesia. In particular, a new opioid, remifentanil, may have some utility for labor analgesia. Remifentanil has an ultra-short half-life, and thus confers minimal fetal depression. The drug may be useful for patient-controlled analgesia during labor in patients with medical contraindications to regional anesthesia.

Dr. Kathryn Zuspan (Lake View Hospital, Stillwater, Minnesota) discussed her experience with single-injection spinal anesthetics for patients in advanced labor. These spinal injections, without the placement of an epidural catheter, are particularly useful for patients in advanced labor, where delivery is imminent, or in cases where there are limited anesthesiologist resources. Dr. Zuspan suggested that all anesthesiologists should consider offering this technique to patients when clinical circumstances warrant.

Dr. William Camann (Brigham and Women's Hospital, Boston, Massachusetts) discussed nonpharmacologic methods for labor analgesia. This presentation included recent evidence of the usefulness and effectiveness of water immersion during labor, the increasing popularity of hypnosis techniques, and the use of doulas, sterile water back injections, positioning changes and ambulation, acupressure, acupuncture, and massage therapy. Dr. Camann noted that all of these may have some degree of efficacy in motivated patients and that all are essentially risk free. He noted that all obstetric anesthesiologists should be familiar with the various modalities of nonpharmacologic techniques, as they are all safely compatible with the concomitant use of epidural analgesia.

A total of 140 research abstracts were presented. A few of the notable and interesting presentations included one by Dr. Nollag O'Rourke and colleagues (Brigham and Women's Hospital), who found that the addition of a scopolamine patch was safe and efficacious for prevention of nausea and vomiting following cesarean delivery in patients who have received intrathecal morphine.

Dr. P Pan and colleagues (Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina) presented a fascinating abstract concluding that the time of day may have impact on analgesic requirements. Specifically, the analgesic durations in patients receiving combined spinal-epidural analgesia were 20% longer during the day than at night. This new observation, noted by others also, falls under the category of "chronobiology." At present, the mechanism is unknown. However, the researchers stated that these observations may need to be taken into account when evaluating and planning for anesthetics at different times of the day.

A group of investigators from the Massachusetts General Hospital reported on their experience with simulator training for management of obstetric crisis situations. They report that simulation-based training is critical for building effective teamwork and fostering multidisciplinary communication skills.

The effect of regional analgesia on labor outcome continues to be controversial. Dr. Cynthia Wong and colleagues (Northwestern University, Chicago, Illinois) performed a randomized trial to compare early (< 2 cm) initiation of epidural analgesia to later (> 4 cm) administration. There were no differences in the cesarean delivery rate between groups, suggesting that regional anesthesia need not be withheld until some arbitrary degree of cervical dilation has been reached.

One of the more provocative abstracts was presented by Dr. Y Ginosar and colleagues (Hadassah School of Medicine, Jerusalem, Israel). These investigators performed a preliminary study to examine the effect of antepartum chronic epidural therapy (ACET) in patients with preeclampsia and/or intrauterine growth-restricted fetuses. Patients at gestational age between 22 and 32 weeks were given ACET for at least 5 days' duration. Although preliminary, their findings indicate that ACET may improve uterine blood flow in these patients, and may eventually prove to be an effective therapeutic adjunct in management.

The next SOAP meeting will be held May 4-7, 2005 in Palm Desert, California. Additional details can be found at: www.soap.org.

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