Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

BACKGROUND: Early reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing. METHODS: Deliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2–infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery <37 weeks), an adverse neonatal outcome composite measure (primary), and anesthetic utilization (eg, neuraxial labor analgesia and anesthesia). Outcomes were analyzed using generalized estimating equations to account for clustering within centers. Sensitivity analyses compared symptomatic and asymptomatic patients to controls. RESULTS: One thousand four hundred fifty four peripartum women were included: 490 with SARS-CoV-2 infection (176 [35.9%] symptomatic) and 964 were controls. SARS-CoV-2 patients were slightly younger, more likely nonnulliparous, nonwhite, and Hispanic than controls. They were more likely to have diabetes, obesity, or cardiac disease and less likely to have autoimmune disease. After adjustment for confounders, individuals experiencing SARS-CoV-2 infection exhibited an increased risk for delivery <37 weeks of gestation compared to controls, 73 (14.8%) vs 98 (10.2%) (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.03–2.09). Effect estimates for other obstetric outcomes and the neonatal composite outcome measure were not meaningfully different between SARS-CoV-2 patients versus controls. In sensitivity analyses, compared to controls, symptomatic SARS-CoV-2 patients exhibited increases in cesarean delivery (aOR, 1.57; 95% CI, 1.09–2.27), postpartum length of stay (aOR, 1.89; 95% CI, 1.18–2.60), and delivery <37 weeks of gestation (aOR, 2.08; 95% CI, 1.29–3.36). These adverse outcomes were not found in asymptomatic women versus controls. SARS-CoV-2 patients (asymptomatic and symptomatic) were less likely to receive neuraxial labor analgesia (aOR, 0.52; 95% CI, 0.35–0.75) and more likely to receive general anesthesia for cesarean delivery (aOR, 3.69; 95% CI, 1.40–9.74) due to maternal respiratory failure. CONCLUSIONS: In this large, multicenter US cohort study of women with and without peripartum SARS-CoV-2 infection, differences in obstetric and neonatal outcomes seem to be mostly driven by symptomatic patients. Lower utilization of neuraxial analgesia in laboring patients with asymptomatic or symptomatic infection compared to patients without infection requires further investigation.

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Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.

Health algorithms can also inappropriately predict health outcomes. In one algorithm used to predict the likelihood of vaginal delivery after cesarean delivery, adjusting only for race to African American or Hispanic can reduce the chance of vaginal delivery by 10%. This may encourage obstetricians to forgo trial of labor in favor of repeat cesarean delivery in these groups.Addressing implicit bias requires longitudinal and intentional training, such as Harvard University's Implicit Association Test. It also requires critical self-examination of how bias affects clinical practice as well as strategies to change biases. Health care organizations, too, can take steps to address structural racism. The Institute of Medicine advocates 5 elements to reduce health disparities in health care organizations: prioritization of health equity, use of process and structure to achieve equitable outcomes, plans and actions to address institutional racism, activity to address social factors impacting health and partnerships with community groups. Increased representation of Black and Hispanic physicians is also needed, with support for education pathways to careers in health care.

Human follicle stimulating hormone (hFSH) is a gonadotropin responsible for the maturation of ovarian follicles in women and production of sperm in men. The receptor (hFSHR) is a G protein‐coupled receptor (GPCR); a class of receptors found embedded in the cell membrane to receive the hormone resulting in initiation of a complex downstream signaling cascade. Through previous research in the Cohen lab, hFSHR has been shown to be located within compartments of the cell membrane known as lipid rafts. Lipid rafts are microdomains of the membrane containing a higher concentration of cholesterol, glycosphingolipids, and a protein known as caveolin. Current research is focused on evaluating the mechanisms and effects of hFSHR lipid raft residency. Using discontinuous sucrose gradients we have shown that hFSH stimulation of an HEK293 cell line stably transfected with hFSHR cDNA results in alteration of hFSHR lipid raft residency in a time dependent manner.To better understand the mechanism and effect of hFSHR lipid raft residency the same cells were treated with a peptide mimetic of transmembrane domain 4 of hFSHR. This peptide includes a sequence consistent with a motif shown in other proteins to interact with caveolin (ϕXϕXXXXϕXXϕ where ϕ is an aromatic amino acid). The putative caveolin interaction motif of hFSHR was synthesized along with the HIV‐TAT leader sequence to allow passage through the membrane. A second peptide where the aromatic amino acids were replaced with leucine was also used. Cells treated with the wild type peptide showed elevated basal signaling in the absence of hFSH, an effect not observed with the mutant peptide.Together, these results suggest that hFSHR residency in lipid rafts is dependent on hormone treatment and interaction with caveolin. Through studying hFSHR lipid raft residency and signaling we hope to identify ways to control the receptor for improved methods for contraception and treatment of infertility.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.