(Reg Anesth Pain Med. 2018;43:263–309) The American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Fourth Consensus Conference on Regional Anesthesia and Anticoagulation in conjunction with the European Society of Anesthesiology (ESA) in response to emerging patient safety issues. Among these are the heightened risk of neuraxial bleeding due to increasingly potent antithrombotic medications, changing standards for venous thromboembolism (VTE) prevention, and conflicting recommendations by various bodies and societies. Spinal hematoma is an uncommon and catastrophic complication of epidural or spinal anesthesia. Previous versions of this report have been published in 1998, 2003 and 2010 as ASRA Consensus Documents. For this update, authors performed a systematic and general review of relevant literature published between 2010 and 2017. The members represented ASRA, ESA, and the Society for Obstetric Anesthesia and Perinatology (SOAP).

PPH is a relatively common complication of delivery and is associated with substantial maternal morbidity and mortality. It is increasing in frequency in the United States. PPH caused by uterine atony resulting in transfusion often occurs in the absence of recognized risk factors.

Objective To define the amount of opioid analgesics prescribed and consumed after discharge after cesarean delivery. Methods We conducted a survey at six academic medical centers in the United States from 9/2014 to 3/2016. Women who had undergone a cesarean delivery were contacted by phone two weeks after discharge and participated in a structured interview about the opioid prescription they received upon discharge and their oral opioid intake while at home. Results A total of 720 women were enrolled; of these, 615 (85.4%) filled an opioid prescription. The median number of dispensed opioid tablets was 40 (interquartile range (IQR) 30 to 40), the median number consumed was 20 (IQR 8 to 30), and leftover was 15 (IQR 3 to 26). Of those with leftover opioids, 95.3% had not disposed of the excess medication at the time of the interview. There was an association between a larger number of tablets dispensed and the number consumed independent of patient characteristics. The amount of opioids dispensed did not correlate with patient satisfaction, pain control, or the need to refill the opioid prescription. Conclusion The amount of opioid prescribed after cesarean delivery generally exceeds the amount consumed by a significant margin, leading to substantial amounts of leftover opioid medication. Lower opioid prescription correlates with lower consumption without a concomitant increase in pain scores or satisfaction.

Background Stroke risk is increased during pregnancy, but estimates of pregnancy-related stroke incidence vary widely. Aims A systematic review and meta-analysis was conducted to assess the incidence of stroke during pregnancy and the puerperium. Ovid Medline, EMBASE, and ISI Web of Science were searched for studies published between 1990 and January 2017 reporting stroke incidence during pregnancy and postpartum, from defined pregnancy populations. Pooled analyses were conducted using a random effects approach and expressed as an incidence rate per 100,000 pregnancies, with 95% confidence intervals. Subgroup analyses of stroke type and timing were conducted. Summary of review Eleven studies met inclusion criteria. Variation in estimated rates was noted based on geography and study methodology. The pooled crude rate of pregnancy-related stroke was 30.0 per 100,000 pregnancies (95% confidence interval 18.8-47.9). The pooled crude rates from nonhemorrhagic stroke (arterial and cerebral venous sinus thrombosis) were 19.9 (95% confidence interval 10.7-36.9) and from hemorrhage 12.2 (95% confidence interval 6.4-23.2) per 100,000 pregnancies. For studies separately reporting cerebral venous sinus thrombosis, the rates were roughly equal between ischemic stroke (12.2, 95% confidence interval 6.7-22.2), cerebral venous sinus thrombosis (9.1, 95% confidence interval 4.3-18.9), and hemorrhage (12.2, 95% confidence interval 6.4-23.2). The crude stroke rate for antenatal/perinatal stroke was 18.3 (95% confidence interval 11.9-28.2), and for postpartum stroke was 14.7 (95% confidence interval 8.3-26.1). Conclusions Stroke affects 30.0 per 100,000 pregnancies, with ischemia, cerebral venous sinus thrombosis, and hemorrhage causing roughly equal numbers and with highest risk peripartum and postpartum. Organized approaches to the management of this high-risk population, informed by existing evidence from stroke and obstetrical care are needed.