James C. Eisenach, M.D., Editor.
28th Annual Meeting of the Society for Obstetric Anesthesia and Perinatology. Tucson, Arizona, April 30-May 4, 1996.
The 28th annual meeting of the Society for Obstetric Anesthesia and Perinatology was held at the Sheraton El Conquistador Resort in Tucson, Arizona. The Society for Obstetric Anesthesia and Perinatology (SOAP) is the officially recognized component society of the American Society of Anesthesiologists relating to the subspecialty area of Obstetric Anesthesia. The Society currently lists more than 1,000 active members, and more than 500 members attended the meeting, making it the largest annual meeting in the Society's history.
The annual meeting was preceded by a premeeting symposium “The Original Investigations of Obstetric Anesthesia,” organized jointly by the Society's current President, Sheila Cohen, M.B., and the annual meeting host, Craig M. Palmer, M.D. Its purpose was to provide an overview of recent changes in the medical economic climate on the provision of obstetric anesthesia services, and, specifically, the effect of “managed care” on those services. Leslie Allison, C.E.O. of Integrated Specialist Management Services of San Diego, CA, opened the discussion with a presentation on “The Medical Marketplace: Dynamics of Consolidation.” Much of her talk focused on the strategy and evolution of ASMG Anesthesia Service Medical Group of San Diego as they adjusted to a marketplace increasingly dominated by large managed-care organizations. She highlighted some sobering statistics used by healthcare contractors to negotiate for anesthetic services, and emphasized the need for practitioners to develop and maintain sound actuarial data bases to be able to bargain effectively. James McMichael, M.D., of Capital Anesthesiology Associates of Austin, Texas, and a member of the A.S.A.'s Committee on Original Investigations, spoke on “Anesthesia Practice and Reimbursement Scenarios.” Concluding the opening session was Adrienne Lang, Executive Director of the California Society of Anesthesiologists; her presentation discussed the C.S.A.'s efforts in the legislative arena in California, including their success in causing the California Department of Health Services to review Medicaid reimbursement for obstetric anesthesia services, as well as their setbacks, such as Gov. Pete Wilson's veto of a bill that would have mandated publication of the profit margins of all managed-care organizations.
The second session of the symposium was opened by Valerie Arkoosh, M.D., of Thomas Jefferson University Hospital in Philadelphia. She reviewed some of the fundamentals of economic theory and illustrated how they can be applied to everyday anesthetic practice to decrease costs and improve efficiency. She was followed by David Birnbach, M.D., Director of Obstetric Anesthesia at St. Lukes-Roosevelt Hospital Center in New York City, who, while pointing out some of the abuses heaped on obstetric anesthesiologists by HMOs, painted a generally optimistic picture; he noted that labor analgesia is seen by very few women as “optional,” and consumer-driven initiatives have already been successful in several states. The final speaker at the symposium was Patricia Dailey, M.D., a member of the SOAP Board of Directors, who related the process by which her private practice group near San Francisco had evolved into an effective organization that could successfully negotiate contracts in response to the continuing consolidation of hospital and delivery services in Northern California. Her talk foreshadowed the transformation that many anesthetic practices in this country may undergo in the near future. The discussions that followed the scheduled presentations were lively and wide-ranging, and underscored the anxiety many practitioners feel when confronting these subjects.
After a festive opening reception on the evening of Wednesday, May 1, the annual meeting was called to order on the morning of Thursday, May 2. Mieczyslaw Finster, of Columbia Presbyterian Medical Center in New York, the outgoing president of the Society, moderated the Gertie Marx Symposium. The Gertie Marx Symposium, named in honor of one of the pioneers of obstetric anesthesia, is the Society's preeminent forum for the presentation of research by members in training, residents, and fellows; the competition includes cash prizes for presentations most highly judged by an international panel of scholars. More than 30 abstracts were submitted for consideration for the symposium, and five were chosen as finalists by the blinded reviewers. Third prize went to Lawrence Tsen of Brigham and Women's Hospital for “Combined Spinal/Epidural vs Epidural Analgesia: Effects on Progression and Outcome of Labor”; second place went to M.G. Parry and colleagues of The Royal Free Hospital in London for a study titled “Dorsal Column Function in Parturients Receiving Epidural and Combined Spinal Epidural (CSE) for Labor and Elective Cesarean Section.” The winner of the competition was R.J. Goldsmith, of the Obstetrical Anesthesia Research Laboratory of the University of Iowa, who presented “Acute Reversible Umbilical Cord Occlusion Increases Extracellular Glutamate Concentration in the Cerebral Cortex of the Immature Fetal Sheep.” L-glutamate plays an important neurotrophic role in the developing brain, and has been shown to result in neuronal damage in the hypoxic adult brain; the work indicates that alterations in L-glutamate concentrations in the developing brain can occur and may be a factor in the disruption of normal cortical development.
After the Gertie Marx Symposium, a new feature for the SOAP was unveiled, the position of the SOAP statistician. The position was created by the Board of Directors so members would have access to a professional with expertise in the statistical sciences, for consultation in the design and interpretation of studies and data. Stuart Baker, Sc.D., of the National Institutes of Health in Bethesda, MD, and an active member of the SOAP, is the inaugural occupant of the position. He gave a brief talk on how the membership could avail themselves of his expertise.
A perennial and popular feature of the annual meeting has been the “What's New” lecture series. Delivering the “What's New in Obstetrics” lecture was Maurice Druzin, M.D., Director of Maternal Fetal Medicine at Stanford University Hospital. His presentation focused on a couple of areas of mutual interest to obstetricians and anesthesiologists, specifically, current concepts in the use of tocolytic therapy and recent investigations in the pathogenesis of hypertensive disorders of pregnancy. He highlighted the fact that although tocolysis is widely used clinically, it is an area of considerable controversy among perinatologists; where anesthesia textbooks tend to focus on the use of beta-mimetic agents, other drugs, such as magnesium, calcium channel blockers, and prostaglandin synthetase inhibitors, are being widely used. Although the actual cause of disorders such as preeclampsia remains obscure, Dr. Druzin reviewed some very interesting recent work that looked at the role of nitric oxide, and even carbon monoxide, in the pathogenesis of the disorder.
Two other scientific sessions Thursday were devoted to oral presentations of abstracts. Though space does not permit them all to be discussed here, a few will be mentioned. Kang et al. and Ferouz et al., examining hyperbaric fentanyl and sufentanil for intrathecal labor analgesia, respectively, found analgesia to be markedly inferior to isobaric preparations. Two series looked at the incidence of fetal heart rate changes after intrathecal labor analgesia. Gossler et al. found the incidence of abnormal fetal heart rate patterns to be no different after 25 micro gram intrathecal fentanyl when compared with a standard epidural analgesic technique; in contrast, Gambling found an 18% incidence of fetal bradycardia after 10 micro gram intrathecal sufentanil. Finally, Segal et al. examined the interaction between obstetrician, epidural use, and Cesarean section in 18,333 deliveries. Practitioner identity, but not epidural use, correlated positively with the frequency of Cesarean delivery.
The Thursday session of the meeting closed with the annual business meeting of the society. In addition to a review of the finances of the Society, a decision was made to hold the annual meeting in the year 2000 in Montreal, in conjunction with the 12th World Congress of Anesthesiologists. Details of the arrangements will be forthcoming from the Society.
As has become a tradition, the Friday program is abbreviated to allow attendees some free time in the afternoon. The first of two major presentations in this shortened session was by Wallace Nogami, M.D., of the Departments of Anesthesiology and Pediatrics of the University of Arizona Health Sciences Center; his “What's New in Meeting Abstracts?” address pointed out the remarkable advances in recent years in the care of the very premature neonate, and the role that surfactant therapy and high frequency ventilators have played. He closed his talk by pointing out recent changes in training requirements for pediatric residents, which decrease the amount of time spent in neonatal intensive care training areas. With pediatricians performing the majority of neonatal resuscitations in this country, this decrease in training may have significant clinical implications. He encouraged all physicians involved in patient care in the peripartum period to complete and stay current in Neonatal Advanced Life Support training.
The Fred Hehre Lecture, named for one of the founding members of SOAP, is an honorary lectureship, delivered annually by a figure who has exerted a major influence in the subspecialty. Charles Gibbs, M.D., Professor and Chairman of the Department of Anesthesiology at the University of Colorado, spoke on “Obstetric Anesthesia: U.S.A.,” and chronicled the changes in the provision of obstetric anesthesia between 1981 and 1992, when major surveys of practice in the United States were completed. He noted several trends, generally regarded as favorable. These included a reduction in the number of hospitals that provide obstetric care, due to a decrease in small obstetric units; such a change indicates a trend toward regionalization and consolidation of services. A marked increase in the availability of labor analgesia was found, in all sizes of hospitals. The use of general anesthesia for Cesarean delivery also dropped dramatically in favor of regional techniques. Despite a perceived lack of opportunity for newly trained anesthesiologists, Dr. Gibbs pointed out that as much as 66% of obstetric anesthetics in smaller hospitals is provided by nurse anesthetists supervised by obstetricians or those practicing independently.
Among the oral abstract presentations on Friday, Richardson and Wissler used a very sensitive technique to measure the density of cerebrospinal fluid and a variety of dextrose-free drugs commonly used for intrathecal analgesia. They found that pregnancy lowers cerebrospinal fluid density, and many dextrose-free preparations are slightly hypobaric at room temperature. Patel and Ramanathan studied external cephalic version, and found that the use of epidural analgesia during this procedure was associated with a higher success rate and fewer Cesarean deliveries. Holdcroft et al. examined serial magnetic resonance imaging brain scans in the peripartum period in patients with preeclampsia; their findings suggest the primary central nervous system effect of the disease may be ischemia due to hypovolemia and cerebral vasospasm.
Saturday morning opened with a breakfast panel moderated by Sheila Cohen, M.B., on “The Use of New Drugs in Obstetric Anesthesia.” Among the panelists were Barbara Palmisano, M.D., of the Food and Drug Administration, Alan Santos, M.D., of Albert Einstein College of Medicine in New York, and D. Anthony Rocke, F.R.C.P., of the University of Natal in Durban, South Africa. Whereas Dr. Santos discussed the potential role of ropivacaine and Dr. Rocke focused on the use of the newer muscle relaxants in obstetrics, Dr. Palmisano defended the role of the Food and Drug Administration in the approval and labeling of medications for use in obstetrics. This latter area has been controversial in recent years, because labeling of a number of new drugs, notably ketorolac, has been very unfavorable for their use in obstetrics. She explained that the Food and Drug Administration's role in the labeling of new drugs was passive, that manufacturers actively develop the indications and contraindications for each medication.
The Poster Review Session that followed was conducted by two reviewers -- Mark Norris, M.D., of Jefferson University Hospital in Philadelphia, and William Camann, M.D., of Brigham and Women's Hospital in Boston. With more than 50 abstracts presented in the poster format, the moderators led an excellent review that compared, contrasted, and highlighted the results of the studies. Barbara Zucker-Pinchoff, M.D., presented preliminary results of OASIS (Obstetric Anesthesia Safety Improvement Study); the survey covered 126 hospitals, representing 368, 124 deliveries. The data presented indicate that incidence of complications due to anesthetic interventions in the peripartum period is extremely low.
The final and traditionally most popular of the “What's New” lectures, “What's New in Obstetric Anesthesiology?” was delivered by David Birnbach, M.D., of St. Lukes-Roosevelt Hospital Center in New York. Dr. Birnbach provided an in-depth, if necessarily fast-paced, review of the world's medical literature as it relates to obstetric anesthesia. With a bibliography of more than 270 citations to distill, Dr. Birnbach admirably highlighted the major developments impacting the field during 1995.
The final oral presentations of the meeting included an introduction to two drugs that may soon find their way into clinical practice. Krukowski et al. reported the use of intrathecal neostigmine for post-Cesarean analgesia, and found a decrease in PC morphine requirements with as little as 10 micro gram. Kan et al. described their initial experience with the opioid remifentanil during epidural anesthesia for Cesarean delivery.
The meeting was adjourned on Saturday afternoon, May 4. The 1997 Annual Meeting of the Society for Obstetric Anesthesiology and Perinatology will be held from Sunday, April 13, through Thursday, April 17, 1997, at the Southhampton Princess hotel in Bermuda.
The author thanks Mark Norris, M.D., for his efforts in preparation of this review.
Craig M. Palmer, M.D., Associate Professor of Clinical Anesthesiology, University of Arizona Health Sciences Center, Tucson, Arizona.