Pharmacology, Physiology, and Practice in Obstetric Anesthesia

Dr. Alan David Kaye, MD, PhD, attended the University of Arizona in Tucson for college and medical school. He also completed his PhD in Vascular Pharmacology at Tulane School of Medicine in New Orleans. Dr. Kaye is the Immediate Former Vice Chancellor of Academic Affairs, Chief Academic Officer, Provost, Pain Fellowship Program Director, and Tenured Professor in the Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences at Louisiana State University Health Sciences Center in Shreveport. He is also the Vice Chairman of Research and Tenured Professor in the Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences at the Louisiana State University School of Medicine. He served as Program Director and Chairman of anesthesia for 21 years, for 6 years at Texas Tech Health Sciences Center in Lubbock, Texas, and for 15 years at LSU Health Sciences Center in New Orleans, Louisiana, and was a member of the FDA Advisory Committee on Anesthetics, Analgesics, and Addiction Medicine from 2012 to 2020. Dr. Aaron Joshua Kaye, MD, graduated from Stanford University in Palo Alto, California, and the Medical University of South Carolina in Charleston, South Carolina. He completed his anesthesia residency at the Medical University of South Carolina in Charleston, South Carolina, and is in private practice with Wake Anesthesiology in Raleigh, North Carolina.

• Contributors About the editors Preface 1. Physiological maternal adaptive changes during pregnancy, e.g., alterations of endometrium and decidua, menstruation, placenta, fetal membranes, placental hormones, morphological and functional fetal developmentAmber N. Edinoff, Brooke Williams, Layne Landry, Elyse M. Cornett and Alan David Kaye1. Introduction 2. Estrogen and progesterone in pregnancy 2.1 Progesterone 2.2 Estrogen 2.3 Decidualization 3. Physical changes in pregnancy 3.1 Cardiovascular system 3.2 GI system 3.3 Respiratory system 3.4 Skin 3.5 Sensory 3.6 Hematology 4. Pharmacologic changes in pregnancy 4.1 Absorption 4.2 Distribution 4.3 Metabolism 4.4 Elimination 5. Issues arising from the physiologic changes of pregnancy 5.1 Hypertensive disorders of pregnancy 5.2 Peripartum cardiomyopathy 5.3 Pulmonary changes in pregnancy 5.4 Postpartum depression 6. ConclusionReferences2. Anatomy of the reproductive tract: The placenta, uteroplacental circulation, anatomy, transfer of drugs, and respiratory gas exchangeJessica Galey, Amy Zheng and Shobana Bharadwaj1. Anatomy of the female reproductive tract1.1 Organs1.2 Innervation 1.3 Blood flow1.4 Uterine blood flow changes during pregnancy 2. Anatomy of the placenta2.1 Embryology2.2 Macroscopic anatomy2.3 Maternal vasculature2.4 Fetoplacental vasculature3. Placental physiology3.1 Oxygen transfer3.2 Carbon dioxide transfer 3.3 Acid base3.4 Placental drug transfer3.5 Common drugs used during pregnancy3.6 Anesthetic drugs and placental transfer4. Conclusion3. Uterine blood flow and the effects of obstetric anesthesiaJohn Pallan, Amy Zheng, Jessica Galey and Shobana Bharadwaj1. Introduction2. Anatomy3. Uteroplacental blood flow4. Response to vasoactive agents5. Mechanisms of changes6. Determinants of uterine blood flow7. Measuring uterine blood flow8. Regional anesthesia and uterine blood flow9. Doppler ultrasonography and uterine blood flow10. General anesthesia and uterine blood flow11. Effects of obstetric drugs12. Conclusion4. Perinatal pharmacologyRucha Kelkar, Alina Smoleva, Therese Larson, Sahar Shekoohi and Alan David Kaye1. Definition, background2. Maternal factors3. Placental factors4. Basic fetal pathophysiology and risk factors5. Fetal drug uptake, distribution, metabolism, and excretion6. Related issues, historical trendsReferences5. Parturient anesthesia assessment and evaluationHrayr Ghazaryan, Artush Grigoryan and Lincoln Frederick Arbogast1. Introduction2. History of anesthesia in obstetrics3. Physiological changes in pregnancy3.1 Cardiovascular3.2 Respiratory3.3 Gastrointestinal3.4 Urinary3.5 Endocrine3.6 Hematologic 3.7 Coagulation4. Preanesthesia evaluation of parturients4.1 Past surgical history and anesthetic history4.2 Past obstetric history4.3 Past medical history4.4 Physical examination5. Evaluation of parturient with systemic disease5.1 Cardiovascular diseases 5.2 Respiratory diseases 5.3 Anemias 5.4 Coagulation disorders 6. Endocrine diseases 6.1 Diabetes mellitus 6.2 Hyperthyroidism 6.3 Musculoskeletal disorders 6.4 Renal diseases6.5 Liver diseases7. Conclusion References6. How to create and maintain a safe and an efficient obstetric anesthesia practiceAnjum Anwar, Huma Wali and Hina Shamim1. Introduction2. Maternal care framework in the United States3. Preanesthesia evaluation for obstetric patients 3.1 Background 4. Current state of affairs and challenges 4.1 Recommendations 5. Telemedicine 6. Patient education 7. Intrapartum care for parturient 7.1 Introduction 8. Challenges and recommendations 8.1 Medication shortages 8.2 Staffing and training/anesthesia workforce 8.3 Recommendations 8.4 Anesthesia management of high-risk pregnancies 8.5 Peripartum obstetric hemorrhage 8.6 Concept of the pregnancy heart team and cardiac obstetrics 8.7 Critical care in obstetrics 9. Enhanced recovery after CD 10. Process improvement to enhance patient safety in obstetric anesthesia 11. Handoffs and checklists 12. Simulation and team working in obstetric anesthesia 13. Racial disparities 14. Strategies to improve global inequities in obstetric anesthesia 15. Trauma informed care in obstetrics References 7. Obstetric anesthesia consultationCourtney Hood, Kristen L. Fardelmann and Benjamin Cobb1. Indications for consultation 2. Components of consultation 3. Common indications for anesthesiology consultation 3.1 Anticoagulation 4. Thrombocytopenia 5. Placenta accreta spectrum (PAS) 6. Maternal cardiovascular disease 6.1 Interventions/ECMO 7. Spinal column/cord pathology, neurologic disease 8. Obesity 9. Opioid use disorder (OUD) 10. History of anesthetic complications 11. Consultation clinics 12. Conclusion References 8. Obstetric management of labor and delivery, including preoperative assessment and basic standards for preanesthesia careHuma Wali, Haneen Alnazzawi and Anjum Anwar1. Introduction 2. CVD in the pregnant patient 3. Pregnancy counseling risk stratification 4. Mode and timing of delivery 5. Type of hospital and location within the hospital 6. Peripartum plan 7. The difficult airway in obstetrical anesthesia assessment 8. Preparation for difficult airway management 9. Difficult airway trolley 10. Difficult airway management 11. Simulation and training 12. Mental health and pregnancy 13. Management of psychiatric patients during pregnancy 14. Racial disparities in maternity care 15. Strategies for reducing disparities 15.1 Implementing protocols and safety bundles 16. Health care professionals’ education and communication 17. Outcome measurement, reviews, and community partnerships 18. Neuroobstetrics 19. Antenatal period/preconception 20. Intrapartum 21. Postpartum 22. Multiple sclerosis 23. Cerebrovascular diseases in pregnancy 24. Role of anesthesiologist in the management of stroke 25. Headache during pregnancy and postpartum 26. Evaluation of pregnant patients with headaches 27. Pregnancy and hematology 28. Iron-deficient anemia 29. Coagulation disorders 30. Hereditary coagulation disorders 31. Acquired coagulation disorders 32. Venous thromboembolism 32.1 Antepartum recommendations 32.2 Intrapartum recommendations 33. Respiratory diseases in pregnancy 34. Asthma 35. Respiratory failure 36. Obstructive sleep apnea References 9. Fetal assessment and physiologyMariana Montes, Chad T. Dean and Thomas James1. Antenatal fetal assessment 2. Estimating gestational age 3. Routine ultrasonography 4. Evaluating the well-being of the fetus 4.1 Clinical assessment 5. Antepartum fetal testing 6. Fetal development and physiology 7. Fetal environment 8. Fetal cardiovascular system 9. Fetal respiratory system 10. Fetal hematologic system 11. Fetal neurologic system 12. Transition to the extrauterine environment 13. Physiologic changes in postnatal life 13.1 Cardiovascular and respiratory changes 14. Thermal regulation 15. Postnatal fetal assessment 16. APGAR score and umbilical cord gas and pH References 10. Opioid analgesics in laborPeter Louis Kovacs, Jayanth Dasika and Venkata Satya Lakshmi Damalanka1. Introduction2. Opioids2.1 Mechanism of action3. Pharmacokinetics3.1 Absorption3.2 Distribution3.3 Biotransformation3.4 Excretion4. Effect on organ systems4.1 Cardiovascular4.2 Respiratory4.3 Cerebral4.4 Gastrointestinal5. Plan for labor analgesia6. Pharmacologic options for labor analgesia7. Systemic analgesics7.1 Opioid analgesia8. Patient-controlled analgesia8.1 Remifentanil PCA8.2 Fentanyl PCA8.3 Intermittent bolus opioid8.4 Choice of opioid8.5 Butorphanol8.6 Fentanyl8.7 Morphine8.8 Meperidine9. Regional analgesia9.1 Neuraxial analgesia9.2 Mechanism and site of action9.3 Epidural opioids9.4 Intrathecal opioids10. Summary and conclusionReferences11. Mechanisms of labor pain and anesthesia in healthy parturientsJustin Swengel and Patrick McConville1. Mechanisms of labor pain and its management2. Nonpharmacologic treatment of pain3. Pharmacologic techniques for labor pain control3.1 Inhaled agents3.2 Opioids 3.3 Neuraxial techniquesReferences 12. Nonopioid analgesiaJayanth Dasika, Peter Louis Kovacs and Venkata Satya Lakshmi Damalanka1. Nitrous oxide2. Acetaminophen and nonsteroidal antiinflammatory drugs3. Sedatives and analgesic adjunctsReferences13. Nonpharmacologic and alternative management of labor and delivery analgesiaDavid Gutman and Michael Marotta1. Introduction2. Water immersion3. Biofeedback4. Hypnosis5. Acupuncture6. Subcutaneous of intracutaneous sterile water injection7. Manual/massage/reflexology8. Conclusion Reference 14. Local anesthetics and adjuvants in healthy obstetric patientsJeffery Cao, Munfarid Zaidi, Lee Chang, Melissa Nikolaidis and Yi Deng1. Introduction2. Lidocaine2.1 Mechanism of action2.2 Clinical application2.3 Side-effect profile3. Ropivacaine3.1 Mechanism of action3.2 Clinical application3.3 Side-effect profile4. Bupivacaine4.1 Mechanism of action4.2 Clinical application4.3 Side-effect profile5. Chloroprocaine5.1 Clinical application5.2 Side-effect profile6. Mepivacaine6.1 Clinical application6.2 Side-effect profile7. Local anesthetic systemic toxicity8. Adjuncts in neuraxial anesthesia9. Epinephrine10. Bicarbonate11. Clonidine12. Dexmedetomidine13. Neostigmine14. Magnesium15. Experimental adjuncts16. Opioids17. ConclusionReferences15. Epidural anatomy and epidural anesthesia for labor and cesarean deliveryFatoumata Kromah and Nicholas Malki1. Introduction 2. Background 2.1 Epidural analgesia for labor and vaginal delivery 2.2 Epidurals for CD 3. Definition of topic 4. Issues related to this topic 5. Historical evolution/trends 6. Pathophysiology 6.1 Anatomy of the epidural space 7. Risk factors 8. Patient evaluation 9. Diagnosis 9.1 Medical History 9.2 Coagulation Status 9.3 Infection Control 9.4 Anatomical Considerations 9.5 Patient Preference and Informed Consent 9.6 Multidisciplinary Collaboration 10. Treatment 11. Anesthetic management 12. Pharmacology 13. Clinical issues or considerations 14. Prevention and self-care 15. Global impact and challenges 16. Future directions, novel treatments, and research studies 17. Summary/conclusion 18. Relevant images and tables Abbreviations References Suggested readings 16. Neuraxial anesthesia for vaginal deliveryKristin N. Bembenick, Angela Nguyen, Corrie Jackson, Sahar Shekoohi, Aaron J. Kaye, Alan D. Kaye and Harish Siddaiah1. Introduction 2. Background 2.1 Epidural analgesia for labor and vaginal delivery 2.2 Epidurals for CD 3. Definition of topic 4. Issues related to this topic 5. Historical evolution/trends 6. Pathophysiology 6.1 Anatomy of the epidural space 7. Risk factors 8. Patient evaluation 9. Diagnosis 9.1 Medical History 9.2 Coagulation Status 9.3 Infection Control 9.4 Anatomical Considerations 9.5 Patient Preference and Informed Consent 9.6 Multidisciplinary Collaboration 10. Treatment 11. Anesthetic management 12. Pharmacology 13. Clinical issues or considerations 14. Prevention and self-care 15. Global impact and challenges 16. Future directions, novel treatments, and research studies 17. Summary/conclusion 18. Relevant images and tables Abbreviations References Suggested readings 17. Neuraxial analgesia for cesarean deliveryAndrew Jensen, Kevin Chen, Melissa Nikolaidis and Yi Deng1. Background 1.1 Cesarean delivery 1.2 Anesthesia with cesarean delivery 1.3 Trends in cesarean sections 2. The cesarean delivery 2.1 Indications 2.2 Contraindications 2.3 Degree of urgency 2.4 Risks 3. Anesthetic considerations for cesarean delivery: General anesthesia 3.1 Airway 3.2 Volatile anesthetics 3.3 Anterograde amnesia 4. Anesthetic considerations for the cesarean delivery: Neuraxial approach 4.1 Spinal 4.2 Epidural 4.3 Combined spinal and epidural 5. Acquiring the neuraxial blockade 5.1 Anatomic landmarks 5.2 Epidural placement 5.3 Procedural steps 5.4 Spinal placement 5.5 Procedural steps 5.6 Combine spinal-epidural placement 5.7 Procedural steps 5.8 Settings of placement 6. Diagnosing the coverage of neuraxial anesthesia 6.1 Appropriate coverage 6.2 Assessment using pinprick or temperature sensation 7. Troubleshooting inadequate coverage of neuraxial analgesia 7.1 Epidural management 7.2 Spinal management 8. Side effects of effective neuraxial block 8.1 Hypotension 8.2 Nausea 8.3 Shivering 9. The awake patient 9.1 Communication with parturient 9.2 Communication with other members of the medical team 9.3 Patient positioning 10. Global impact and challenges 11. Future directions, novel treatments, or research studies References Further reading 18. General anesthesia for normal, uncomplicated cesarean delivery: Indications and strategiesFatoumata Kromah1. Introduction 2. Background 3. Definition of the topic 3.1 General anesthesia 3.2 Cesarean delivery 4. Issues related to GA for the CD 4.1 Potential risks and side effects 4.2 Choice of anesthetic agents 4.3 RA versus GA 5. Historical evolution/trends 5.1 Early developments 5.2 Advent of RA 5.3 Shift from GA to RA 5.4 Current practices 6. Pathophysiology 6.1 Nervous system 6.2 Maternal physiology 6.3 Fetal physiology 6.4 Postoperative recovery 7. Risk factors 7.1 Maternal health conditions 7.2 Obstetric complications 7.3 Fetal health concerns 7.4 Specific perioperative risks 8. Patient evaluation 8.1 History taking 8.2 Physical examination 8.3 Relevant investigations 9. Diagnosis 10. Treatment 10.1 Preoperative preparation 10.2 Preoxygenation and preinduction 10.3 Induction and intubation 10.4 Maintenance and emergence 10.5 Postoperative care 11. Anesthetic management 11.1 Preoperative preparation 11.2 Intraoperative management 11.3 Postoperative management 12. Pharmacology 13. Clinical issues or considerations 13.1 Urgent versus elective CD 13.2 Patient preference 13.3 General health status 14. Prevention and self-care 15. Global impact and challenges 16. Future directions, novel treatments, and research studies 16.1 Improved monitoring techniques 16.2 Novel anesthetic agents 16.3 Enhanced recovery after surgery protocols 16.4 Telemedicine and digital health 16.5 Research on long-term impacts 17. Summary and conclusion Abbreviations References Additional suggested readings 19. Airway management of the pregnant patient for labor and cesarean deliveryMoataz Maher Emara, Mohamed Maher Elwaraky, Laila Alhafez and Sally Hamdy Abdelaziz Ahmed1. Incidence of GA and difficult airways in the obstetric population 2. Physiological changes during pregnancy: Implications on airway management 2.1 Respiratory parameters and gas exchange alterations 2.2 Airway obstruction and difficulty in intubation 2.3 Gastric emptying and aspiration risk 2.4 Pharmacological considerations 3. Evaluation and prediction of difficult airway 4. Maternal complications related to airway management 4.1 Aspiration pneumonitis 4.2 Bronchospasm 4.3 Post-extubation hypoventilation 4.4 Accidental awareness 5. Suggested protocol for airway management in pregnant women 5.1 Preparation of the parturient 5.2 Preparation of equipment and personnel 5.3 Positioning 5.4 Preoxygenation/apneic oxygenation 5.5 Rapid sequence induction 5.6 Induction and neuromuscular drugs 5.7 Cricoid pressure 5.8 Laryngoscopes 5.9 Tracheal extubation 6. Guidelines for difficult airway in pregnant women (UK-OAA/DAS) 6.1 Anticipated difficult intubation 6.2 Unanticipated difficult or failed intubation 6.3 Direct and indirect (video) laryngoscopy direct laryngoscopy 6.4 Obstetric Anesthetists’ Association and Difficult Airway Society guidelines 6.5 Other relative guidelines References 20. Postoperative pain management for cesarean deliveryAntonio Gonzalez Fiol, P.J. McGuire, Kristen L. Fardelmann and Aymen Awad Alian1. Acute pain after cesarean delivery 2. Neuraxial anesthesia and adjuvant drugs 2.1 Multimodal analgesia 2.2 Shared decision-making for pain management in the postpartum period 2.3 Opioid-sparing multimodal analgesia (OSMMA) 3. Opioid analgesics 4. Enhanced Recovery After Cesarean (ERAC) 4.1 Racial and ethnic disparities 5. General anesthesia 6. Local and regional analgesia techniques 7. Acute pain management for the patient with substance use disorder (SUD) References 21. Postoperative sterilization surgery and anesthesia considerationsMelissa Nikolaidis, Jacy Gressen, Tommy Li and Yi Deng1. Introduction: Postpartum birth control 1.1 The advantages of postpartum birth control preplanning 2. Methods for immediate postpartum contraception 2.1 Reversible contraception 2.2 Irreversible contraception 3. Current policies affecting postpartum sterilization 4. Postpartum sterilization procedure 4.1 Surgical considerations 4.2 Anesthetic considerations 5. Postsurgical sterilization pain management 6. Chapter summary References 22. Anesthesia for assisted reproductive techniquesFouzia Khalid and Amber Naz1. Introduction 1.1 What is assisted fertilization 1.2 Ovum retrieval done through 1.3 Sperm collection 1.4 Patient preparation 1.5 Does ART procedure need anesthesia? 1.6 Conscious sedation 2. General anesthesia 2.1 Propofol 2.2 Thiopental 2.3 Ketamine 2.4 Etomidate 2.5 Inhalational anesthesia 2.6 Benzodiazepine 2.7 Dexmedetomidine 2.8 Opioids 2.9 Non-opioid analgesic 2.10 Antiemetics 2.11 Neuraxial anesthesia 2.12 Paracervical block 2.13 Patient controlled analgesia 2.14 Newer techniques 2.15 Complications associated with assisted fertilization 2.16 Ovarian hyperstimulation syndrome 2.17 Ectopic pregnancy 2.18 Multiple gestation References 23. Anesthesia considerations for pregnant patients with cardiovascular diseaseIslam Mohammad Shehata Elsayed, Yasmeen Ahmed Mohamed Taha, Hala Mostafa Goma and Nesrine Abdel Rahman Elrefai1. Cardiac diseases in pregnancy 2. Common risk factors of cardiac disease in pregnancy 3. Types of cardiac diseases in pregnancy 4. Risk classification of the patient with cardiac diseases 5. General considerations of cardiac parturients 6. Preoperative evaluation of cardiac pregnant patient 7. History 8. Preoperative clinical assessment 8.1 Cardiac tests during pregnancy 9. Preoperative considerations for specific cardiac lesions 9.1 Congenital heart diseases 9.2 Arrhythmia 9.3 Prosthetic heart valves 10. Rheumatic valvular disease 10.1 Mitral stenosis (MS) 10.2 Mitral or aortic regurgitation 10.3 Myocardial infarction 11. Peripartum cardiomyopathy 11.1 Cardiac tests for diagnosis of peripartum cardiomyopathy 12. Preoperative preparation of cesarean section 12.1 Monitoring for cesarean delivery 13. Anesthesia techniques 13.1 Regional anesthesia 14. Anticoagulant therapy considerations 14.1 The cardiovascular effects of regional anesthesia 14.2 The type and severity of cardiac illness 14.3 How to conduct safe neuraxial anesthesia 15. Postpartum care 16. Conclusion References 24. Anesthesia considerations for pregnant patients with lung diseaseAdam Lin Wendling and Clinton Pillow1. Introduction 2. Background 3. Issues related to this topic 4. Historical evolution/trends 5. Pathophysiology 6. Risk factors 6.1 Preexistent pulmonary disease 6.2 Acquired pulmonary disease 7. Patient evaluation 7.1 History 7.2 Physical 7.3 Confirmatory tests 8. Diagnosis 8.1 Obstructive lung disease 8.2 Restrictive lung disease 8.3 Respiratory tract infections 8.4 ARDS 9. Treatment 9.1 Asthma 9.2 Cystic fibrosis 10. Anesthetic management 10.1 General principles 11. Global impact and challenges 12. Future directions, novel treatments, or research studies 13. Summary and conclusion References 25. Anesthesia considerations for patients with renal, hematologic, connective tissue, and immunologic diseasesRucha A. Kelkar, Alexandra D. Dautel, Lillian V. Lauck, Michael J. Quintana, Sahar Shekoohi and Alan David Kaye1. Introduction 2. Renal considerations 2.1 Definition, background, related issues, historical trends 2.2 Pathophysiology 2.3 Risk factors 2.4 Patient evaluation, diagnosis, treatment 2.5 Anesthetic management, pharmacology 3. Hematologic considerations 3.1 Definition, background, related issues, historical trends 3.2 Pathophysiology 3.3 Risk factors 3.4 Patient evaluation, diagnosis, treatment 3.5 Anesthetic management, pharmacology 3.6 Clinical issues/considerations, prevention, self-care 3.7 Global impact and challenges 4. Connective tissue considerations 4.1 Definition, background, related issues, historical trends 4.2 Pathophysiology 4.3 Anesthetic management and risk management 4.4 Patient evaluation, clinical issues/considerations, prevention 5. Immunologic considerations 5.1 Definition, background, related issues, historical trends 5.2 Pathophysiology 5.3 Risk factors 5.4 Patient evaluation, diagnosis, treatment 5.5 Anesthetic management, pharmacology 5.6 Clinical issues/considerations, prevention, self-care 5.7 Global impact and challenges 6. Future directions, novel treatments, or research studies 7. Summary and conclusion References 26. Anesthesia considerations for parturients with endocrine disordersEvan Nicholas Lian, Asher Le and Aladino De Ranieri1. Introduction 2. Diabetes mellitus 2.1 Anesthetic implications 3. Thyroid disease 3.1 Hyperthyroidism 3.2 Hypothyroidism 3.3 Temperature regulation 4. Pituitary disease 4.1 Acromegaly 5. Adrenal disease 5.1 Cushing syndrome 5.2 Adrenocortical insufficiency 5.3 Pheochromocytoma References 27. Anesthetic considerations for patients with neurologic disorders in pregnancyPhilip Rubin and Lisa Leffert1. Introduction 2. Background 3. Case #1 3.1 Historical evolution/trends 3.2 Pathophysiology 3.3 Risk factors 3.4 Patient evaluation/diagnosis 3.5 Treatment/surgical correction 3.6 Impact on pregnancy 4. Case #2 4.1 Historical evolution/trends 4.2 Pathophysiology 4.3 Risk factors 4.4 Treatment 4.5 Impact of pregnancy 5. Case #3 5.1 Pathophysiology 5.2 Risk factors 5.3 Patient evaluation/diagnosis 5.4 Treatment 5.5 Impact on pregnancy 6. Case #4 6.1 Historical evolution/trends 6.2 Pathophysiology 6.3 Impact on pregnancy 7. Conclusion References 28. Anesthesia considerations for fetal growth restriction and macrosomia in pregnancyKylie Dufrene, James Ilochi, Caleigh Foto, Julia Hebert, Carlos Narvaez, Sahar Shekoohi and Alan David Kaye1. Fetal macrosomia 2. Obstetric anesthesia considerations complicated by macrosomia and fetal growth restriction 2.1 Anesthesia considerations for a cesarean birth 2.2 Anesthesia considerations for conversion from vaginal to cesarean birth 2.3 Pregnancy complications related to fetal growth outcomes and anesthesia considerations 2.4 Intraoperative complications 2.5 Intraoperative complications associated with FGR 2.6 Intraoperative complications associated with macrosomia 3. Common intraoperative complications in both conditions 3.1 Blood loss and hemorrhage 3.2 Amniotic fluid embolism 3.3 Monitoring and management strategies 3.4 Fetal growth restriction: Definition, diagnosis, and anesthetic implications 3.5 Anesthetic considerations for FGR 3.6 Optimal timing for induction in FGR 3.7 Minimizing risks and enhancing safety 3.8 Anesthetic agent teratogenicity References 29. Anesthesia considerations for pregnant patients with morbid obesity and neoplasmErica Johnson, Teshi Kaushik and Christina Faya1. Introduction and background 1.1 Definition 2. Issues related to maternal obesity 3. Pathophysiology 3.1 Effect of obesity on the respiratory system 3.2 Effect of obesity on the cardiovascular system 3.3 Effect of obesity on the gastrointestinal system 4. Anesthetic management 4.1 Preoperative assessment 4.2 Preoperative counseling 4.3 Monitors and access 5. Labor analgesia 5.1 Equipment set up 5.2 Patient positioning 5.3 Epidural versus DPE versus CSE for labor analgesia 5.4 Epidural catheter dislodgement 5.5 Initiation of epidural analgesia-Local anesthetic pharmacology 6. Anesthesia for cesarean delivery 6.1 General considerations for anesthesia for cesarean delivery 7. Neuraxial anesthesia for cesarean delivery 7.1 Spinal anesthesia 7.2 Combined spinal epidural anesthesia 7.3 Continuous spinal anesthesia 7.4 Local anesthetic dosage 7.5 Phenylephrine dosage 7.6 Postdural puncture headache 8. General anesthesia for cesarean delivery 8.1 Unique challenges for general anesthesia for C-sections 9. Postoperative pain management 10. Summary and conclusion 10.1 Neoplasm in pregnancy References Further reading 30. Anesthesia considerations for parturients with substance abuse or psychiatric disordersJustin Swengel and Patrick McConville1. Psychiatric disease and substance abuse in the parturient 3132. Psychiatric diseases 3133. Depression 3134. Anxiety 3155. Bipolar disorder 3166. Schizophrenia 3177. Substance use and abuse 3188. Licit drugs 3188.1 Tobacco 3188.2 Alcohol 3198.3 Caffeine 3209. Illicit drugs 3209.1 Marijuana 3209.2 Cocaine 3219.3 Amphetamines 3219.4 Opioids 3229.5 Hallucinogens 324References 325Further reading 32631. Opioid use disorder in pregnancySonal Zambare, Lauren Brown-Berchtold and Amy I. Lee1. Introduction 2. Historical evolution and trends 3. Pregnancy and opioid use 4. Treatment of opioid use disorder 5. Pharmacology 5.1 Buprenorphine 5.2 Methadone 5.3 Naltrexone 6. Challenges in managing patients with an opioid use disorder 7. Barriers to effective analgesia 7.1 Antenatal considerations 7.2 Labor analgesia 7.3 Anesthesia and analgesia for cesarean delivery 8. Teams involved in managing patients with OUD 9. Neonatal effects 10. Breastfeeding 11. Conclusion References 32. Anesthesia considerations for patients with renal, hematologic, connective tissue, and immunologic diseasesAdam Lin Wendling and Seth Garrett1. Introduction 2. Issues related to this topic 2.1 Renal disease 2.2 Selected pathophysiologic conditions leading to AKI and CKD 2.3 Treatment for renal disorders 3. Immunologic disease 3.1 Background 3.2 Historical evolution/trends 3.3 Multiple sclerosis and the related condition neuromyelitis optica 3.4 Myasthenia gravis (MG) 3.5 Rheumatoid arthritis (RA) 3.6 Systemic lupus erythematosus 3.7 Sjogren’s syndrome 3.8 Systemic sclerosis/scleroderma 3.9 Inflammatory bowel disease (IBD) 3.10 Autoimmune hepatitis (AIH) 4. Connective tissue diseases 4.1 Background 4.2 Historical evolution/trends 4.3 Selected connective tissue disorders with significant impact on obstetric and perioperative management 5. Hematologic complications of pregnancy 5.1 Background 5.2 Historical evolution/trends 5.3 Selected hematologic disorders with significant impact on obstetric and perioperative management 5.4 Thrombocytopenia 5.5 Immune thrombocytopenia (ITP) 5.6 Hypertensive disease of pregnancy 6. Coagulation disorders 6.1 VWD 6.2 Acquired hemophilia 6.3 Procoagulant disorders 7. Future directions, novel treatments, or research studies 8. Summary and conclusion References 33. Anesthesia considerations for patients with COVID-19Nesrine Refai, Hala Mostafa Goma, Islam Mohammad Shehata Elsayed and Ahmed Hashim1. Introduction 2. Pathophysiology 3. Risk factors 4. Diagnosis 5. Treatment 5.1 Preoperative assessment of COVID pregnant patient 5.2 Exclusion of acute phase of COVID infection 6. A respiratory complication of COVID-19 which indicates pre- or postoperative ventilation 7. Early diagnosis of pulmonary embolism 7.1 Preoperative medications 8. Preoperative assessment of intrauterine fetus 9. How to improve oxygenation in COVID-19 pregnant patient 9.1 Methods of improving oxygenation 9.2 High-flow nasal cannula 10. Noninvasive positive pressure ventilation 11. Extracorporeal membrane oxygenation 11.1 Preparation of the operating room for COVID patients 11.2 Equipments 11.3 Personal protection References 34. Anesthesia considerations for patients with preeclampsiaAlexandra Waits, Kennedy Kirkpatrick, Melissa Nikolaidis and Yi Deng1. History of preeclampsia 2. Epidemiology 3. Pathophysiology 4. Histologic findings 5. Risk factors for preeclampsia development 6. Diagnostic criteria and clinical presentation 7. Morbidity and mortality 8. Risk stratification 9. Healthcare economic burden 10. Treatment of hypertensive disorders of pregnancy 11. Anesthetic considerations in preeclampsia 11.1 Cardiovascular 11.2 Fluid management 11.3 Neuraxial anesthesia 11.4 General anesthesia 11.5 Regional techniques 11.6 Uterotonic agents 11.7 Eclampsia management References 35. Anesthesia considerations for patients with infections, HIV, and sexually transmitted diseasesClaudia Wei and Amy I. Lee1. Introduction 2. Bacterial infections 2.1 General considerations 2.2 Anesthetic management of the septic parturient 3. Viral infections 3.1 Human immunodeficiency virus 3.2 Coronavirus disease 2019 3.3 Herpes simplex virus 3.4 Human papilloma virus 3.5 Hepatitis 3.6 Varicella 3.7 Others-cytomegalovirus, rubella, measles 4. Conclusion References 36. Anesthesia considerations with multiple births and fetal malpresentationJoseph Bavaro, Candice Cuppini and Andrew Hallmark1. Anesthesia considerations for multiple births 1.1 Introduction 1.2 Definitions/epidemiology 1.3 Maternal physiologic changes 1.4 Fetal morbidity in multiple gestation 1.5 Anesthetic management 2. Anesthesia for fetal malpresentation 2.1 Definitions and epidemiology 2.2 Obstetric considerations 2.3 Anesthetic considerations References 37. Anesthesia considerations for vaginal birth after C-section, and for abnormalities of the reproductive tractEmily Dinges1. Trial of labor after cesarean 1.1 Introduction 1.2 Background 1.3 Historical evolution and trends 1.4 Issues related to this topic 1.5 Anesthetic management 1.6 Other causes of uterine rupture 2. Abnormalities of the reproductive tract 2.1 Hymen malformations 2.2 Mullerian anomalies 2.3 Mullerian anomalies and effects on reproduction 2.4 Anesthetic considerations References 38. Anesthetic considerations for nonobstetric surgery during pregnancyKristin Horton and Mary Lynne Roberts1. Introduction 2. Brief review of physiologic changes in pregnancy 2.1 Cardiovascular 2.2 Hematology 2.3 Pulmonary 2.4 Airway 2.5 Gastrointestinal 2.6 Neurologic and neuromuscular 2.7 Endocrine 2.8 Pharmacologic 2.9 Uteroplacental blood flow 2.10 Summary of physiologic changes 3. Preoperative assessment and management 3.1 Risks of surgery and general anesthesia during pregnancy 3.2 Timing of surgery 3.3 Choosing anesthetic type 3.4 Monitoring 3.5 Patient assessment 3.6 Premedications 3.7 Pain control and multimodal analgesia 3.8 Aspiration prophylaxis 3.9 Other medications 4. Intraoperative management 4.1 Positioning 4.2 Induction/airway 4.3 Hemodynamic and respiratory goals 4.4 Anesthetic medications and the fetus 4.5 Maternal code blue 4.6 Considerations for surgical subspecialty procedures 5. Postoperative management 5.1 Postoperative monitoring 5.2 Imaging 5.3 Pain management 6. Summary References 39. Anesthesia considerations for rare obstetric procedures: Cerclage placement, external cephalic version, and fetal intrauterine proceduresHani El-Omrani, Thanh-Giang Vu and Emily Dinges1. Cerclage 1.1 Background 1.2 Types of cerclage 1.3 Methods of cerclage placement 1.4 Anesthesia for cerclage placement 1.5 Cerclage removal 2. External cephalic version 2.1 Introduction 2.2 The impact of regional anesthesia or analgesia on ECV outcomes 2.3 Recommendations for regional anesthetic or analgesic techniques for ECV 2.4 Summary 3. Fetal intrauterine procedures 3.1 Operative techniques 3.2 Common indications 3.3 Anesthesia considerations References 40. Anesthesia considerations for patients with spine surgeryAlan David Kaye, Rucha A. Kelkar, Alexandra D. Dautel, Lillian V. Lauck, Michael J. Quintana, Shahab Ahmadzadeh and Sahar Shekoohi1. Introduction 2. Pathophysiology, diagnosis, and treatment 2.1 Scoliosis 2.2 Discectomy and laminectomy 2.3 Chronic spinal cord injury 2.4 Spinal dysraphism 2.5 Implantable devices 3. Patient evaluation 4. Anesthetic management 4.1 The use of neuraxial ultrasound 4.2 Considerations for scoliosis 4.3 Considerations for chronic spinal cord injury 4.4 Considerations for spinal dysraphism 4.5 Considerations for the presence of implantable devices 4.6 Considerations for failed neuraxial and operative delivery 5. Future directions 6. Conclusion References 41. Anesthesia considerations for patients with special spine considerations including chronic spinal cord injury, spinal dysraphism, and implantable devicesMikayla Troughton, Helen Pappas and Carmen Lopez1. Introduction 2. Pathophysiology, diagnosis, and treatment 2.1 Scoliosis 2.2 Discectomy and laminectomy 2.3 Chronic spinal cord injury 2.4 Spinal dysraphism 2.5 Implantable devices 3. Patient evaluation 4. Anesthetic management 4.1 The use of neuraxial ultrasound 4.2 Considerations for scoliosis 4.3 Considerations for chronic spinal cord injury 4.4 Considerations for spinal dysraphism 4.5 Considerations for the presence of implantable devices 4.6 Considerations for failed neuraxial and operative delivery 5. Future directions 6. Conclusion References 42. Peripartum hemorrhage and managementDana Darwish, Christopher Choi and Faiza A. Khan1. Overview 2. Causes 3. Management of PPH 3.1 Stages of hemorrhagic shock 3.2 Transfusion protocols and use of TXA 3.3 Medical management 3.4 Surgical management 3.5 Anesthetic evaluation and management 4. Anesthetic management 4.1 Preoperative checklist 4.2 Anesthetic induction and maintenance 4.3 Anesthetic risks and complications 4.4 Complications of postpartum hemorrhage 5. Special considerations: Placenta accrete spectrum 5.1 Anesthetic management 6. Conclusion References 43. Point-of-care coagulation testing for obstetric hemorrhageElvera L. Baron and Daniel Katz1. Postpartum hemorrhage (PPH) and need for point-of-care (POC) coagulation testing 2. Hemostasis: Normal pregnancy as compared to patients with PPH 3. Viscoelastic testing: ROTEM, TEG, others 3.1 Identification of hemostatic changes in pregnancy 3.2 Identification of clinical coagulopathy 4. Advantages of VTs 5. Disadvantages and limitations of viscoelastic tests 6. Other viscoelastic tests and new machines 7. Conclusion References 44. Trauma during pregnancyJoseph Abro, Grayce Davis, Rishi Patel and Travis Pecha1. Epidemiology 2. Maternal complications and outcomes 3. Fetal complications and outcomes 4. Assessment and resuscitation in pregnancy 4.1 Primary survey 4.2 Secondary survey 4.3 Cardiopulmonary resuscitation 5. Critical care during pregnancy 5.1 Preeclampsia/eclampsia 5.2 Amniotic fluid embolism 5.3 Cardiomyopathy in pregnancy 5.4 Hemorrhagic shock in pregnancy 5.5 Sepsis 5.6 PRES References 45. Postdural puncture headachesPeter Arrabal, John Crowe, Andrea Girnius and Michael Hawryschuk1. Introduction 2. Pathophysiology 3. Incidence and risk factors 4. Prevention of PDPH after unintentional dural puncture 5. Clinical features and diagnosis of PDPH 6. Treatment options 6.1 Epidural blood patch 6.2 Other treatments for PDPH 7. Long-term outcomes 8. Summary References 46. Fetal and neonatal assessment of complications and injuries (including abnormal labor, dystocia abnormalities of expulsive forces, abnormal presentation, position and development, and pelvic contraction)Anusha Kallurkar, Jackie Hanners, Kristina Gambino and Dani Zoorob1. Abnormal fetal presentation 1.1 Occiput-posterior (OP) presentation 2. Abnormal fetal testing 2.1 Tachysystole 2.2 Maternal hypotension 3. Labor complications 3.1 Cord prolapse 3.2 Chorioamnionitis 3.3 Uterine rupture 3.4 Uterine inversion 4. Delivery complications 4.1 Operative vaginal deliveries 4.2 Shoulder dystocia 5. Conclusion References 47. Hypotension and hypertension in pregnancyDaniel Hernandez-Barajas, Brooke Ingram Tsao and Jose Humanez1. Hypotensive disease of pregnancy 1.1 Introduction 2. Background 2.1 Definition of hypotension in obstetric patients 2.2 Issues related to this topic 2.3 Pathophysiology of hypotension in obstetrics 3. Risk factors 4. Patient evaluation 5. Diagnosis 6. Treatment 6.1 Left uterine displacement 7. Anesthetic management 8. Prevention 9. Global impact and challenges 10. Gestation hypertension and preeclampsia 11. Preeclampsia 12. Diagnostic criteria of preeclampsia 12.1 Hypertension 12.2 Proteinuria 12.3 Thrombocytopenia 12.4 Renal insufficiency 12.5 Impaired liver function 12.6 Abdominal pain 12.7 Pulmonary edema 12.8 Headache 13. Hemolysis, elevated liver enzymes, and low platelet count syndrome 14. Eclampsia 15. Gestational hypertension 16. Pathophysiology 17. Clinical recommendations and treatment 18. Anesthetic management References 48. Pulmonary aspiration and interventions to reduce the risk of aspirationJason Gabriel Hirsch1. Background 2. History 3. Incidence 4. Physiology of pregnancy 5. Risk factors 6. Pathophysiology 7. Management 8. Prevention References 49. Amniotic fluid embolismBrooke Ingram Tsao and Grace Cruz1. Introduction 2. Incidence 3. Diagnosis 3.1 Disseminated intravascular coagulation 3.2 Differential diagnosis 4. Risk factors 5. Pathophysiology 6. Pharmacology and treatment 7. Anesthesia considerations References 50. Intraamniotic infectionLauren Brown-Berchtold and Sterling Adams1. Introduction 2. Historical evolution 3. Pathophysiology 3.1 Microbiology 3.2 Risk factors 4. Patient evaluation 4.1 Initial evaluation 4.2 Clinical history 4.3 Physical examination 4.4 Laboratory testing 4.5 Imaging 5. Diagnosis 5.1 Steroids and leukocytosis 6. Treatment 6.1 Intrapartum 6.2 Length of antibiotic therapy 6.3 Isolated maternal fever considerations 7. Prevention 8. Clinical considerations 8.1 Dysfunctional labor 8.2 Maternal outcomes 8.3 Neonatal outcomes 9. Anesthetic management 10. Conclusion References 51. Preterm birthEdward Springel, Arunthevaraja Karuppiah, Miheret Yitayew, Nayef Chahin, Jenny R. Fox and Joseph A. Khoury1. Epidemiology of preterm birth 2. Risk factors for preterm birth 3. Pathophysiology of preterm birth 4. Prediction of preterm birth 5. Obstetric strategies to reduce risk of preterm birth and improve outcomes of premature neonates 5.1 Primary prevention of preterm birth 5.2 Secondary prevention of preterm birth 5.3 Tertiary prevention of preterm birth 6. Measures to improve neonatal outcome 6.1 Betamethasone 6.2 Magnesium sulfate for neuroprotection 6.3 Antibiotics 7. Anesthesia impact on fetal heart rate monitoring 7.1 Fetal heart rate monitoring in preterm fetus 7.2 Impact of perinatal anesthesia on the newborn 7.3 Analgesia for preterm labor and vaginal delivery 7.4 Anesthesia for cesarean delivery 7.5 Interactions between tocolytic therapy and anesthesia References 52. Neurologic complications from regional anesthesia and general anesthesia in obstetric practiceCarmen Lopez, Mikayla Troughton and Emery McCrory1. Introduction 2. Peripheral nerve injury 2.1 Mechanism 2.2 Risk factors 2.3 Lateral femoral cutaneous nerve 2.4 Femoral nerve 2.5 Obturator nerve 2.6 Lumbosacral plexus 2.7 Common peroneal nerve 2.8 Treatment and prevention 3. Central nervous injury 3.1 Unintentional dural puncture and postdural puncture headache 3.2 Cerebral vein thrombosis 3.3 Spinal cord trauma 3.4 Anterior spinal artery syndrome 3.5 Spinal epidural hematoma 3.6 Epidural abscess 3.7 Chemical injury and arachnoiditis 3.8 Transient neurological symptoms 4. Neurological complications from general anesthesia 4.1 Ulnar nerve 4.2 Brachial plexus 4.3 Common peroneal nerve References 53. Intraoperative and postoperative anesthesia-related morbidity and mortality, extremes of reproductive life, and abortionAlexander M. Aldanese, Fadi M. Huzien, Denver Stutler, Nikole K. Nikolov, Kylie Dufrene, Aaron J. Kaye, Harish Siddaiah, Sahar Shekoohi and Alan David Kaye1. Introduction 2. Anesthetic causes of maternal mortality 2.1 Management of the difficult airway in obstetrics 2.2 Aspiration of gastric acid 2.3 Maternal mortality and the complex landscape of local anesthetic toxicity 2.4 Obstetric anesthesiologic mortality due to high spinal or epidural block: a comprehensive analysis 3. Anesthetic causes of maternal morbidity 3.1 Postdural puncture headache 3.2 Postpartum neurologic deficits and related pathophysiology 3.3 Postpartum back pain 3.4 Common complications of extreme maternal ages and anesthesia management 3.5 Anesthetic complications during a cesarean section 3.6 Intrapartum and postpartum hemorrhage 3.7 Effect of anesthesia on preeclampsia and eclampsia 3.8 Anesthesia in preterm labor 3.9 Common complications of anesthesia use during abortive procedures 4. Conclusion References 54. Anesthesia for fetal surgeryKylie Dufrene, Alexandra Dicke, Van Smith III, James Ilochi, John David Sawyer, Sahar Shekoohi and Alan David Kaye1. Indications for fetal surgery 2. Anesthesia considerations in fetal surgery 2.1 Minimally invasive surgery 2.2 Open fetal surgery 2.3 Exit procedure 3. Anesthetic considerations for fetal surgery 3.1 Epidural 3.2 Regional anesthesia 3.3 General anesthesia 3.4 Gestational age considerations 3.5 Intraoperative fetal monitoring during fetal surgery 3.6 Rationale for fetal monitoring 3.7 Monitoring parameters and interpretation 3.8 Challenges and considerations References 55. Obstetric anesthesia and medicolegal/ethical issuesAlan David Kaye, Angela Nguyen, Emily Dantes, Cameron Robicheaux, Julia Trettin, Kylie Dufrene, Aaron J. Kaye, Sahar Shekoohi and Harish Siddaiah1. Introduction 2. Physiological changes in pregnancy relevant to anesthesia 3. Standard obstetric anesthesia techniques 4. Anesthetic management of obstetric complications 5. Medicolegal and ethical considerations in obstetric anesthesia 6. Informed consent in obstetric anesthesia 7. Liability issues in obstetric anesthesia 8. Ethical dilemmas in obstetric anesthesia 9. Cultural and religious considerations 10. Patient advocacy and rights 11. Future direction and innovations in obstetric anesthesia 12. Summary and conclusion References 56. Fetal evaluation, including the premature fetus and the compromised fetusHamdy Bakry Alqenawy, Mohamed Elmezaien, Rania Gamal El-Skaan and Mohamad Ismail1. Antenatal surveillance 1.1 Fetal movement count 1.2 Fetal heart rate-based tests 1.3 Imaging-based tests 2. Intrapartum fetal heart rate monitoring 2.1 NICHD classification, interpretation, and management of FHR patterns 3. Anesthesia in special situations 3.1 Twin to twin transfusion syndrome 3.2 External cephalic version 3.3 Shoulder dystocia 3.4 Intrauterine transfusion References 57. Fetal and neonatal complications and treatment, including resuscitationJenny R. Fox, Kelly Stanley, Edward Springel, Fatoumata Kromah and Joseph A. Khoury1. Introduction 2. Antepartum management 2.1 Fetal heart rate monitoring 2.2 Rapid clinical assessment of suspected fetal hypoxemia and acidosis 2.3 Maternal positioning 2.4 Cessation of uterine stimulation 2.5 Intravenous fluid resuscitation 2.6 Tocolytics 2.7 Correction of maternal hypotension 2.8 Maternal oxygen supplementation 2.9 Amnioinfusion 2.10 Altering pushing efforts in labor 2.11 Cord prolapse 3. Newborn management 3.1 Role of obstetrical anesthesiologist in neonatal resuscitation 3.2 Transition from fetal circulation to newborn circulation 3.3 Team communication: Maternal team to neonatal team 3.4 Thermoregulation 3.5 Delayed cord clamping 3.6 Initial assessment of the newborn 3.7 Neonatal resuscitation 3.8 Assessing heart rate 3.9 Positive pressure ventilation 3.10 Newborn endotracheal intubation equipment 3.11 Target oxygenation saturation 3.12 Chest compressions 3.13 Epinephrine and volume resuscitation 3.14 Post resuscitation care 4. Neonatal complications 4.1 Pneumothorax and airway obstruction 5. Special considerations 6. Summary References 58. Diagnosis and treatment of fetal/newborn asphyxia and respiratory failureMiheret Yitayew, Grace Mueller, Whitney Bender, Joseph A. Khoury, Fatoumata Kromah and Nayef Chahin1. Anesthetic management in the context of asphyxia and respiratory failure 2. Defining birth asphyxia 3. Historical evolution of birth asphyxia 4. Global impact and challenges 5. The fetus’ cardiovascular response to asphyxia 6. Antenatal fetal surveillance for signs of chronic asphyxia 7. Intrapartum fetal heart rate assessment 8. Ancillary intrapartum fetal well-being assessments 9. Physiology of a neonatal hypoxic-ischemic brain injury 10. Evaluating for hypoxic ischemic encephalopathy 11. Therapeutic hypothermia and prognostication 12. Neonatal respiratory failure 12.1 Respiratory distress syndrome 13. Meconium-stained amniotic fluid and meconium aspiration syndrome 14. Congenital diaphragmatic hernia 15. Transient tachypnea of the newborn 16. Congenital pulmonary airway malformation References Further reading 59. Retrolental fibroplasia and anesthesiaAlan David Kaye, Evan Sinnathamby, Claire Fisher, Hannah Matejowsky, Kristin N. Bembenick, Thomas J. Tran, Shahab Ahmadzadeh and Sahar Shekoohi1. Introduction 2. Epidemiology 3. Risk factors 4. Clinical considerations and anesthetic management 5. Patient evaluation 6. Prevention 7. Global impact and challenges 8. Diagnostic steps 9. Diagnostic modalities 10. Treatment 11. Advances in treatment 12. Clinical studies 13. Conclusion References 60. Long-term effects of anesthetics on the fetal and neonateFarzad Ebrahimi1. Introduction 2. Is there any empirical evidence demonstrating the teratogenic effects of anesthetic agents administered during the first trimester of pregnancy? 2.1 Nitrous oxide 2.2 Benzodiazepines 2.3 Opioids 2.4 Nonsteroidal anti-inflammatory drugs 3. Fetal nervous systems development 4. Long-term effects of anesthetics administered during the second trimester on the fetus 5. Is it safe to administer anesthetics during the third trimester? 5.1 Is dexmedetomidine capable of providing brain protection against neuroapoptosis caused by inhalation of gases? 6. What are the drawbacks of the prior research? 7. Conclusion References 61. Illustrated ultrasound evaluation of the stomach fasting/nonfasting statusSydney T. Gennaro-Dennis, Emily Johnson, Karlee Mott, Alex Wandler, Shahab Ahmadzadeh, Sahar Shekoohi and Alan David Kaye1. Introduction 2. Background 3. Gastric ultrasound as an effective clinical tool 4. Evolving concepts in clinical use of point-of care ultrasounds 5. Historical evolution and trends in gastric ultrasound 6. Pathophysiology 7. Risk factors 8. Patient evaluation 9. Diagnosis 10. Treatment 11. Anesthetic management 12. Pharmacology 13. Clinical issues or considerations 14. Prevention and self-care 15. Global impact and challenges 16. Future directions, novel treatments, or research studies 17. Summary and conclusion References 62. Ultrasound evaluation of the spinal vertebraeEmile Legendre, Grace Wester, Kristen Adams, Alison Hawkins, Varsha Allampalli, Sahar Shekoohi and Alan David Kaye1. Key summary points 2. Introduction 2.1 History 2.2 Benefits of neuraxial anesthesia 2.3 Traditional landmark approach 2.4 History of ultrasound-guided neuraxial anesthesia 3. Why use ultrasound? 4. Physics and anatomy 4.1 Physics of sonography 4.2 Gross anatomy of the lumbar spine 5. Technical procedure 5.1 Sonography of the lumbar spine 6. Conclusion Acknowledgment References 63. Neurological injury after neuraxial anesthesiaRuba Elmaoued and Amy I. Lee1. Introduction/background 2. Incidence of nerve injuries 3. Intrinsic obstetric palsies 3.1 Lateral femoral cutaneous nerve 3.2 Femoral nerve 3.3 Obturator nerve 3.4 Lumbosacral plexus 3.5 Peroneal nerve 3.6 Sciatic nerve 3.7 Pudendal nerve 4. Anesthesia-related neurologic deficits 4.1 Postdural puncture headache 4.2 Spinal/epidural hematoma 4.3 Infection: epidural abscess and meningitis 4.4 Direct trauma 4.5 Chemical injury 4.6 Arachnoiditis 4.7 Transient neurologic syndrome 5. Medicolegal implications 6. Conclusion References Index