The Golden Hour: Early Interventions for Medical Emergencies during Pregnancy.

Maternal mortality has increased in the last decades in the United States as a result of increased prevalence of coexisting medical diseases such as hypertension, diabetes, and both acquired and congenital heart diseases. Obstetricians and maternal-fetal medicine physicians should have the basic medical knowledge to initiate appropriate diagnostic and early therapeutic interventions since they may be the only provider available at the time of presentation. The goal of this article is not to extensively discuss the management of complex medical diseases during pregnancy, rather we provide a concise review of key early medical interventions that will likely result in improved clinical outcomes. KEY POINTS: · Obstetricians and maternal-fetal medicine physicians must be familiar with initial basic management of common medical emergencies.. · Management of these complex cases is ideally multidisciplinary.. · Residency/fellowship programs should include common disease management to improve maternal outcomes..

Quantifying the incidence of clinically significant respiratory depression in women with and without obesity class III receiving neuraxial morphine for post-cesarean analgesia: a retrospective cohort study.

BACKGROUND: Obesity is a suspected risk factor for respiratory depression following neuraxial morphine for post-cesarean analgesia, however monitoring guidelines for obese obstetric patients are based on small, limited studies. We tested the hypothesis that clinically significant respiratory depression following neuraxial morphine occurs more commonly in women with body mass index (BMI) ≥40 kg/m2 compared with BMI <40 kg/m2. METHODS: We conducted a single-center, retrospective chart review (2006-2017) of obstetric patients with clinically significant respiratory depression following neuraxial morphine, defined as: (1) opioid antagonist administration; (2) rapid response team activation (initiated in April 2010); or (3) tracheal intubation due to a respiratory event. The incidence of respiratory depression was compared between women with BMI ≥40 kg/m2 and BMI <40 kg/m2. RESULTS: In total, 11 327 women received neuraxial morphine (n=1945 BMI ≥40 kg/m2; n=9382 BMI <40 kg/m2). Women with BMI ≥40 kg/m2 had higher rates of sleep apnea, hypertensive disorders, and magnesium administration. Sixteen cases of clinically significant respiratory depression occurred within seven days postpartum. The incidence did not significantly differ between groups (odds ratio 2.2, 95% CI 0.6 to 6.9, P=0.174). Neuraxial morphine was not deemed causative in any case, however women with BMI ≥40 kg/m2 had higher rates of tracheal intubation unrelated to neuraxial morphine (2/1945 vs. 0/9382, P=0.029). CONCLUSIONS: Respiratory depression in this population is rare. A larger sample (∼75 000) is required to determine whether the incidence is higher with BMI ≥40 kg/m2. Tracheal intubation was higher among the BMI ≥40 kg/m2 cohort, likely due to more comorbidities.