The mission of SOAP is to improve pregnancy-related outcomes of women and neonates through the support of obstetric anesthesiology research, the provision of education to its members, other providers and pregnant women, and the promotion of excellence in clinical anesthetic care.

The Society of Obstetric Anesthesia and Perinatology (SOAP) has come a long way since the first organizational meeting in May 25, 1968. The six “Founders” of SOAP (Drs. Bauer, Elam, Smith, Hustead, Clark, and Evans) would be proud of the “present day” SOAP 50 years later.

The organization’s membership has grown from the 64 “Charter Members” of SOAP in 1969 to over 1030 in 2018, and meeting attendance has expanded from 64 registered enrollees at the annual meeting in 1970 to 784 in 2016. Under the leadership of SOAP, obstetric anesthesia has expanded far beyond the technical aspects of labor analgesia and cesarean anesthesia. SOAP has been integral in helping improve maternal and fetal outcomes, and advance the care of expectant mothers through research, education and inter-societal partnerships.

With my tenure as SOAP President nearing an end, allow me to reflect on the accomplishments of the past year. Specifically, I want to outline the progress we have made on the SOAP strategic plan key priorities (i.e. introducing SOAP Centers of Excellence; increasing the size and reach of membership; stimulating fellowship growth and interest; establishing a stronger brand and online digital presence; fostering closer inter-societal relationships; delivering more obstetric anesthesia content for practitioners and patients; evaluating and updating meeting formats; creating a multi-center research network; and reorganizing the SOAP governance structure) identified last year as key aims for fulfilling SOAP’s mission goals.

President’s Message continued on page 2

www.soap.org Spring 2018

President’s MessageBrendan Carvalho, MBBCh, FRCA, MDCH Stanford University School of Medicine Stanford, CA

CONTENTS:PRESIDENT’S MESSAGE

PAGES 1-2

EDITOR’S CORNER PAGE 3

SCIENTIFIC PROGRAM 50TH ANNUAL

MEETING UPDATE PAGES 4-5

50TH ANNUAL MEETING SCHEDULE

PAGES 5-7

TREASURER’S REPORT PAGES 8-9

EDUCATION COMMITTEE - LABOR ANALGESIA: PAST,

PRESENT AND FUTURE PAGES 10-11

EDUCATION COMMITTEE - CRITICAL CARE IN

OBSTETRIC ANESTHESIA: PAST, PRESENT,

AND FUTURE PAGE 12

THANK YOU 2018 SUPPORTERS

PAGE 13

ANNOUNCEMENTS PAGE 15

2

President’s Message continued from page 1

We have developed and will be launching the SOAP Centers of Excellence for Anesthesia Care of Obstetric Patients Award after the 2018 SOAP Annual Meeting. The Centers of Excellence award aims to recognize programs that demonstrate excellence in obstetric anesthesia care; set a benchmark level of care to improve the standard of obstetric anesthesia care provided nationally; promote the sub-specialty of obstetric anesthesia; and increase interest and participation in obstetric anesthesia fellowships.

SOAP has recently introduced free membership to trainees (medical students, residents and fellows) to encourage trainee participation in the society and improve education in obstetric anesthesia amongst trainees. This initiative has been well received and membership amongst trainees has doubled since its introduction a few months ago. We hope this program coupled with the introduction of significantly reduced annual meeting registration fees for resident and fellows will increase trainee participation in SOAP and thereby further fulfill our education mission.

The SOAP website redesign which will be launched in a couple of months, coupled with a rejuvenated Media Committee and Social Media program lead by Heather Nixon will help fulfil SOAP’s strategic plan of developing a stronger brand and online digital presence. Under the leadership of Lisa Leffert, SOAP has made vast gains over the past year on fostering closer inter-societal relationships and collaborations with several societies, including the Society for Maternal-Fetal Medicine (SMFM) and American College of Obstetricians and Gynecologists (ACOG). Our strategic plan to deliver more obstetric anesthesia content for practitioners and patients has advanced significantly this year. SOAP published a consensus statement “Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants”, and another consensus statement “Consensus Statement for the Prevention and Detection of Respiratory Depression Associated with Neuraxial Morphine Administration for Cesarean Delivery Analgesia” is awaiting membership input and final approval from the Board. SOAP has also published clinician and patient educational material, a response to ACOG/SMFM Practice Advisory on Codeine and Tramadol for Breastfeeding Women, and a clinical practice advisory and safety alert in response to the national shortage of local anesthetics.

Our strategic plan of evaluating and updating meeting formats has led to the introduction of a clinical track at our annual meeting. This initiative will appeal to more clinically-orientated physicians and will debut at the upcoming 50th

SOAP Annual Scientific Meeting in May. The Board is looking into developing an online obstetric anesthesia course and content to supplement in-person meetings and extend educational opportunities to clinically-focused obstetric anesthesiologists and community physician practices. SOAP will host two pre-meeting symposium prior to this year’s annual meeting, the 4th Latin American Symposium and 2nd Chinese Symposium on Obstetric Anesthesia. We hope these symposiums, combined with efforts of the international outreach committee, will further SOAP’s international education and outreach mission.

Our strategic aim of creating a multi-center research network is still in development under the leadership of Phil Hess. We hope to overcome financial and logistical constraints and launch this initiative in the coming year to replace the individual SOAP Gertie Marx Education and Research Grants and complement the SOAP Young Investigator Grants.

The last strategic plan is the reorganizing of SOAP’s governance structure and associated bylaws. For SOAP to grow and become a more relevant and influential medical society, we need a system in place to be able to able to solicit membership input about governance structure and bylaws more frequently than once a year at the business meeting. Therefore, we will be asking the membership to vote on creating an online membership voting system to supplement the annual business meeting vote. I implore all members to support this online voting initiative to create a modernized mechanism to make important changes in a timely and considered fashion.

Lastly, I want to thank the SOAP membership for entrusting me with the role of President of the society, and to the SOAP Board, our Management Company, strategic plan taskforce chairs and members, and SOAP’s committee chairs and members for driving the society forward over the past year. SOAP’s accomplishments could not have been realized without these hard working and dedicated members. It has been a great privilege to serve as President of this incredible organization, and I am honored to serve until I hand over SOAP presidency to Mark Zakowski at the upcoming annual meeting. I promise to continue working beyond my tenure, to help move the society forward and fulfill our mission of improving pregnancy-related outcomes of women and neonates through the support of obstetric anesthesiology research, the provision of education, and the promotion of excellence in clinical anesthetic care. I look forward to seeing everyone at the 50th SOAP Annual Scientific Meeting in May 9-13, 2018 at the Lowes Miami Beach Hotel, Miami Beach, Florida.

3

The Spring Newsletter focuses on the theme of the upcoming 50th Annual SOAP Meeting, “Obstetric Anesthesia: Past, Present and Future”, which will be

held in Miami, Florida from May 9th-13th. In this issue, our authors provide conference details and articles in line with the conference theme.

Dr. Carvalho discusses SOAP’s current initiative and the progress we have made in the past year. He clearly outlines areas for growth as well as innovation for the society. Dr. Zakowski reveals the educational offerings for this year’s annual meeting including keynote speakers, educational tracks and new some new educational designs. Our treasurer, Dr. Klaus Kjaer providers us a comprehensive look at how SOAP is ensuring its future financial health while it continues to grow. From the education committee, Drs. Kathleen Smith and Dr. Padilla discuss the history of labor analgesia and maternal mortality and provide insights to new evolving technology and areas of research and education in these important areas.

This issue also includes annual meeting event schedules and timelines to help you plan your educational experience at this year’s annual meeting. May is an exceptional time to visit Miami and we look forward to seeing your there.

Please Note: Traditionally, the chair of our Bylaws Committee presents us with an article for the spring newsletter regarding proposed changes to bylaws for the annual meeting vote. This year, in line with several SOAP initiatives to provide members with targeted information, an email blast was released to inform members of the proposed changes. Please make sure to review this before the annual meeting vote.

Editor’s CornerHeather C. Nixon, MDUniversity of Illinois Hospital and Health Sciences SystemChicago, IL

SOAP 50TH

ANNUAL MEETING

REGISTER NOW!

May 9-13, 2018Loews Miami

Beach Hotel Miami, Florida

C E L E B R A T I N G 1 9 6 8 - 2 0 1 8

4

Don’t miss out! Come join us for SOAP’s Golden Anniversary – a very, very, very unique meeting.

On behalf of the SOAP Board of Directors and the SOAP 2018 Annual Meeting Program Committee, I am excited to welcome you to SOAP’s 50th Annual

Meeting held at the Loews Miami Beach on May 9-13th, 2018.

We have special speakers, once in a lifetime events, and new programs created to not only meet your needs, but to give you a leg up on our future. Be a SOAP quinquagenarian. Bring your family and friends. Don’t be left behind!

The theme of the meeting will be Obstetric Anesthesia: Past, Present, and Future. Sessions honoring SOAP’s past will include this year’s Gertie Marx Education Lecture, which will be given by Bradley Smith, MD and Richard Clark, MD, two of the original six founders of SOAP. Given the ongoing national opioid crisis, special sessions will be dedicated to understanding and addressing the opioid epidemic. Dr. Jerome Adams, the first physician-anesthesiologist to serve as Surgeon General, will speak on the opioid epidemic on Friday afternoon.*

This year’s meeting will begin with a day of pre-meeting workshops. These workshops include both hands-on skill development, such as the workshops on improving point-of-care ultrasound skills (e.g. transversus abdominis plane blockade, gastric ultrasound, transthoracic echocardiograms), as well as faculty development workshops for practicing anesthesiologists (innovations in medical education and managing di cult conversations). The Research Committee will hold a half-day symposium on the opioid epidemic, taking a deep dive into what research has been done, and what research is needed. The Spanish-language SOAP 4th Latin American Symposium will include speakers from the US and Latin America, focusing on issues critical to care in Latin America. In addition, a Chinese Symposium will be focusing on obstetric anesthesia issues. Simultaneous translation will be available for symposiums and key lectures.

Several sessions will be devoted towards the future of obstetric anesthesia and obstetric anesthesia patient safety. So YOU will be prepared to not only handle emergencies but also to create policies that align with the future of obstetric anesthesia. All of the workshops and conference events will occur on site at the Loews.

Many of your favorite sessions will return, including the Gertie Marx Research Competition, Best Paper Sessions and the year’s complete obstetric anesthesia related literature review (the Gerard W. Ostheimer Lecture).

New this year is the first ever Saturday clinician track, filled with the most requested refresher course lectures for the practicing and occasional obstetric anesthesia clinicians. The Clinician Track includes eight 30-minute lectures including ERAS for cesarean delivery, practice management, anticoagulation and regional anesthesia guideline reviews as well as the main session keynote lectures that day. What a fantastic opportunity for private practitioners to join the SOAP community and sample the best of SOAP. Please attend and bring your friends and colleagues. Enjoy the benefits of knowledge, employing the latest techniques and protocols to improve patient outcomes and sharing your experiences, problems and solutions.

50th Annual Meeting Scientific Program UpdateMark I. Zakowski MD, FASACedars-Sinai Medical CenterLos Angeles, CA

Annual Meeting Update continued on next page

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Another new feature this year is optional small group lunch discussions. Learn in an interactive small group, get your personal questions answered, and get help with setting up policies for your own L&D.

Come interact with an exceptional slate of distinguished speakers. This year’s “What’s New in Obstetrics” will be delivered by Sean Blackwell, M.D., President of the Society for Maternal Fetal Medicine. The “What’s New in Neonatology Lecture” will be given by University of Miami’s Eduardo Bancalari, MD. Our own Ashraf Habib, M.D. will deliver the Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” lecture, and this year’s Fred Hehre Lecturer is Robert Dyer, MD from the University of Cape Town South Africa. On Saturday afternoon, U.S. House of Representatives Congressman, Andy Harris M.D., will give a healthcare policy update. ASA President James Grant, M.D. will give an update on national issues affecting the practice of anesthesiology.

You will have many opportunities to visit with friends and colleagues in Miami. The Welcome Reception will be held outdoors on Wednesday afternoon. The reception will capture the essence of Miami and kick o the beginning of the 50th anniversary celebrations. On Friday morning, wake up early for complimentary yoga on the beach, led by instructors from the Exhale Spa. Finally, on Saturday, make sure to get your tickets for the SOAP Banquet. The banquet will be held in the Americana Ballroom overlooking the ocean. Enjoy an exquisite sit-down meal and then dance the night away as we celebrate the beginning of SOAP’s next 50 years.

The elegant Loews hotel is a Miami Beach icon, and the perfect setting for the Annual Meeting. The hotel is situated on three and a half acres of ocean front property. The hotel was recently renovated, has 790 guest rooms, and a luxurious pool deck. For additional relaxation, visit the on-site, full-service, Exhale Spa. The hotel is also steps away from shopping, award winning restaurants, and Miami’s historic Art Deco District. If you are bringing your family, the hotel is conveniently located near many of Miami’s best children’s attractions.

Come for the meeting, but save time to enjoy Miami at its best! We look forward to welcoming you to the Annual Meeting that you won’t want to miss!

*Pending HHS Approval

Annual Meeting Update continued from previous page

Annual Meeting Schedule continued on next page

Wednesday, May 9, 2018 7:30 a.m. - 6:00 p.m.Registration Hours

8:00 a.m. - 12:00 p.m.SOAP Education Committee Workshop - Past, Present, and Future: Innovations in Education Faculty: Jacqueline M. Galvan, M.D.; Bryan Mahoney, M.D.; Rebecca D. Minehart, M.D., M.S.H.P.Ed.; Heather C. Nixon, M.D.

8:00 a.m. - 12:00 p.m.SOAP Research Workshop: Opioids in the Obstetric PopulationCourse Directors: Ruth Landau, M.D.; Brian Bateman, M.D., M.Sc.

8:00 a.m. - 12:00 p.m.The Use of Ultrasound in Obstetric Anesthesia: Vascular Access, Neuraxial Anesthesia, TAP Block, Gastric Assessment and Identification of the Cricothyroid Membrane (NEW)Course Director: Jose C.A. Carvalho, M.D., Ph.D., FANZCA, FRCPC

1:00 p.m. - 5:00 p.m.Applications of Focused Cardiac Ultrasound in the Management of the High Risk Parturient WorkshopCourse Director: Laurie A. Chalifoux, M.D.

1:00 p.m. - 5:00 p.m.SOAP Education and Patient Safety Workshop: Expert Communication Strategies: Speaking Up, Giving Feedback, and Negotiating to SucceedCourse Directors: Grant C. Lynde, M.D., M.B.A.; Rebecca D. Minehart, M.D., M.S.H.P.Ed.; Grace H. Shih, M.D.

1:00 p.m. - 5:30 p.m.Latin American Symposium on Obstetric AnesthesiaCourse Directors: Vilma E. Ortiz, M.D.; Mauricio Vasco, M.D.

1:00 p.m. - 5:00 p.m.Chinese Symposium on Obstetric AnesthesiaCourse Director: Jie Zhou, M.D., M.S., M.B.A.

6:00 p.m. - 8:00 p.m.Welcome Reception

Thursday, May 10, 2018 6:30 a.m. - 5:00 p.m.Registration Hours

Program Schedule

6

Annual Meeting Schedule continued from previous page

Annual Meeting Schedule continued on next page

Thursday, May 10, 2018 cont. 6:30 a.m. - 7:45 a.m.Continental Breakfast & View Posters - Exhibits Open

7:30 a.m. - 7:45 a.m.Welcome to the 50th Annual MeetingMark I. Zakowski, M.D., FASA; Paloma Toledo, M.D., M.P.H.; Brendan Carvalho, M.B.B.Ch., F.R.C.A., M.D.C.H.

7:45 a.m. - 9:15 a.m.Gertie Marx Research CompetitionModerator: Cynthia A. Wong, M.D.

9:15 a.m. - 9:30 a.m.Distinguished Service AwardRecipient: David H. Chestnut, M.D.Presenter: Curtis L. Baysinger, M.D.

9:30 a.m. - 10:15 a.m.Coffee Break, Exhibits & Poster Viewing

10:15 a.m. - 11:15 a.m. What’s New in Maternal Fetal MedicineIntroduction: Mark I. Zakowski, M.D., FASASpeaker: Sean C. Blackwell, M.D.

10:15 a.m. - 11:15 a.m. Poster Session 1

11:15 a.m. - 12:15 p.m.Maternal Cardiac Disease PanelModerator: Katherine W. Arendt, M.D.Speakers: Marie-Louise Meng, M.D.; Felicity Plaat, M.D.

11:15 a.m. - 12:15 p.m.Poster Session 2

12:15 p.m. - 1:30 p.m. Lunch Discussion Table: Overcoming Obstacles to Patient Safety on Labor and DeliverySpeakers: Jennifer Banayan, M.D.; Unyime Ituk, M.B.B.S.; Rachel M. Kacmar, M.D.

12:15 p.m. - 1:30 p.m. Lunch Discussion Table: Why is it Important to Implement an ERAS Program for your Cesarean Section Patients?Speakers: Mohamed Tiouririne, M.D.

12:15 p.m. - 1:30 p.m. Lunch Discussion Table: Critical Care Scenarios: Improving Obstetric OutcomesSpeakers: Cesar Padilla, M.D.

12:15 p.m. - 1:45 p.m.Lunch On Your Own

1:45 p.m. – 3:15 p.m. Oral Presentations IModerator: Regina Y. Fragneto, M.D.

2:00 p.m. - 3:00 p.m.Poster Session 3

3:00 p.m. - 4:00 p.m.Poster Session 4

3:15 p.m. - 4:00 p.m.Coffee Break, Exhibits & Poster Viewing

4:00 p.m. - 5:00 p.m.What’s New in NeonatologyIntroduction: Daria M. Moaveni, M.D., B.S.Speaker: Eduardo Bancalari, M.D.

4:00 p.m. - 5:00 p.m.Poster Session 5

6:00 p.m. - 8:00 p.m.Fellows’ and Residents' Reception(By Invitation)

Friday, May 11, 2018 6:30 a.m. - 5:00 p.m.Registration Hours

6:30 a.m. - 8:00 a.m.Continental Breakfast & View Posters - Exhibits Open

7:00 a.m. - 8:00 a.m. Yoga on the Beach

7:55 a.m. - 8:00 a.m.Opening RemarksMark I. Zakowski, M.D., FASA

8:00 a.m. - 9:30 a.m.Best Paper SessionModerator: Lawrence C. Tsen, M.D.

8:30 a.m. - 9:30 a.m. Poster Session 6

9:30 a.m. - 10:15 a.m.Coffee Break, Exhibits & Poster Viewing

10:15 a.m. - 11:15 a.m.Gertie Marx Education Lecture: SOAP’s 50th AnniversarySpeakers: Brendan Carvalho, M.B.B.Ch., F.R.C.A., M.D.C.H.; Richard B. Clark, M.D.; Bradley Smith, M.D.; Mark I. Zakowski, M.D., FASA

10:15 a.m. - 11:15 a.m. Poster Session 7

11:15 a.m. - 12:30 p.m.Innovations for Obstetric Hemorrhage Moderator: Alexander Butwick, M.B.B.S., M.S., F.R.C.A.Speakers: Daniela A. Carusi, M.D., M.S.C.; Michaela K. Farber, M.D., M.S.; Daniel Katz, M.D.; Jill M. Mhyre, M.D.

11:15 a.m. - 12:15 p.m. Poster Session 8

12:30 p.m. - 1:30 p.m.Lunch On Your Own

1:30 p.m. - 2:30 p.m.Opioid EpidemicIntroduction: May C.M. Pian-Smith, M.D., M.S.Speaker: Jerome M. Adams, M.D., M.P.H., U.S. Surgeon General*

2:15 p.m. - 3:15 p.m. Poster Session 9

2:30 p.m. - 3:30 p.m.Best Poster SessionModerator: Grace Lim, M.D., M.S.

3:30 p.m. - 4:00 p.m.Coffee Break, Exhibits & Poster Viewing

3:45 p.m. - 4:45 p.m. Poster Session 10

4:00 p.m. - 5:00 p.m.Research Hour - Opioids in Pregnancy and the Postpartum: New Insights from Research Moderator: Ruth Landau, M.D.Speakers: Brian T. Bateman, M.D., M.Sc.; Emily S. Miller, M.D., M.P.H.

Saturday, May 12, 2018 7:00 a.m. - 5:15 p.m.Registration Hours

7:00 a.m. - 8:30 a.m.Continental Breakfast & View Posters

7:55 a.m. - 8:00 a.m.Opening RemarksMark I. Zakowski, M.D., FASA

8:00 a.m. - 9:00 a.m.Oral Presentations IIModerator: Nuala Lucas, M.B., B.S., F.R.C.A.

8:00 a.m. - 8:30 a.m.Preeclampsia UpdateSpeaker: McCallum R. Hoyt, M.D., M.B.A.

Program Schedule

*Pending HHS Approval

7

Annual Meeting Schedule continued from previous page

Saturday, May 12, 2018 cont. 8:00 a.m. - 9:00 a.m. Poster Session 11

8:30 a.m. - 9:00 a.m.Enhanced Recovery After Surgery (ERAS) CesareanSpeaker: Laurent A. Bollag, M.D.

9:00 a.m. - 9:30 a.m.Coffee Break & Poster Viewing

9:30 a.m. - 10:30 a.m.Obstetric Critical Care: Finally Understanding the Clotting Cascade and DICSpeaker: Michael Foley, M.D.

9:30 a.m. - 10:00 a.m.Vasopressors: What’s NewSpeaker: Richard M. Smiley, M.D., Ph.D.

9:30 a.m. - 10:30 a.m. Poster Session 12

10:00 a.m. - 10:30 a.m.Obstetric HemorrhageSpeaker: Alexander Butwick, M.B.B.S., M.S., F.R.C.A.

10:30 a.m. - 11:30 a.m.Gerard W. Ostheimer LectureWhat’s New in Obstetric Anesthesia?Introduction: Brian T. Bateman, M.D., M.Sc.Speaker: Ashraf S. Habib, M.B., B.Ch., M.H.Sc., F.R.C.A.

11:30 a.m. - 1:00 p.m.SOAP Annual Business Meeting and Elections Boxed lunch will be provided.

1:00 p.m. - 2:00 p.m.Fred Hehre LectureIntroduction: Brendan Carvalho, M.B.B.Ch., F.R.C.A., M.D.C.H. Speaker: Robert A. Dyer, FCA (SA), Ph.D.

2:00 p.m. - 2:15 p.m.American Society of Anesthesiologists (ASA) UpdateJames D. Grant, M.D., M.B.A., FASA, ASA President

2:15 p.m. - 3:15 p.m.Future of Obstetric Anesthesia 2028 PanelModerator: Mark I. Zakowski, M.D., FASASpeakers: Robert R. Gaiser, M.D.; Heather C. Nixon, M.D.; Mark I. Zakowski, M.D., FASA

2:15 p.m. - 2:45 p.m.Practice Management: Obstetric AnesthesiaSpeaker: Edward A. Yaghmour, M.D.

2:15 p.m. - 3:15 p.m. Poster Session 13

2:45 p.m. - 3:15 p.m. Anticoagulation and Regional Anesthesia: Guideline ReviewSpeaker: Klaus Kjaer, M.D., M.B.A.

3:15 p.m. - 4:00 p.m. Pro-Con Debate - Obstetric Patients Do Not Need Respiratory Monitoring After Neuraxial MorphineModerator: Brendan Carvalho, M.B.B.Ch., F.R.C.A., M.D.C.H. Pro: Carolyn Weiniger, M.B., Ch. B.Con: Jeanette R. Bauchat, M.D.

3:15 p.m. - 3:45 p.m.Nitrous Oxide for Labor Analgesia Speaker: Mark D. Rollins, M.D., Ph.D.

3:15 p.m. - 4:15 p.m. Poster Session 14

3:45 p.m. - 4:15 p.m.The Baby Friendly Initiative - Coming Soon to Your Labor & Delivery UnitSpeaker: William R. Camann, M.D.

4:00 p.m. - 4:30 p.m.Obstetric Healthcare DisparitiesSpeaker: Paloma Toledo, M.D., M.P.H.

4:15 p.m. - 5:15 p.m. Poster Session 15

4:30 p.m. - 5:15 p.m.The Future of Health Care PolicySpeaker: Congressman Andy Harris, M.D.

6:00 p.m. - 10:00 p.m.50th Anniversary Celebration Banquet

Sunday, May 13, 2018 7:30 a.m. - 11:45 a.m.Registration Hours

7:00 a.m. - 8:30 a.m.Continental Breakfast

7:55 a.m. - 8:00 a.m.Opening RemarksMark I. Zakowski, M.D., FASA

8:00 a.m. - 9:00 a.m.Vasopressors: Ephedrine vs. Phenylephrine vs. NorepinephrineModerator: Richard M. Smiley, M.D., Ph.D.Speakers: Allison J. Lee, M.D., M.B., B.S.; Kenneth E. Nelson, M.D.; Manuel C. Vallejo, Jr., M.D., D.M.D.

9:00 a.m. - 9:30 a.m.Shared Decision MakingSpeaker: May C.M. Pian-Smith, M.D., M.S.

9:30 a.m. - 9:45 a.m.Coffee Break

9:45 a.m. - 10:15 a.m.Patient Safety in Obstetric Anesthesia: Where Are We Now and What’s in the Future?Speaker: David J. Birnbach, M.D., M.P.H.

10:15 a.m. - 10:45 a.m.Venous Thromboembolism and Obstetric Anesthesia GuidelinesSpeaker: Lisa R. Leffert, M.D.

10:45 a.m. - 11:30 a.m.Best Case ReportsModerator: Chawla LaToya Mason-Bolden, M.D.

11:30 a.m. - 11:45 a.m.Final Awards Presentations and Closing RemarksSpeaker: Mark I. Zakowski, M.D., FASA

11:45 a.m.Adjournment

Program Schedule

8

I am pleased to present this Treasurer’s report for our society, reflecting our financial

status as of the end of 2017. To present a complete picture of the society’s finances, this report will include both Non-Endowment and Endowment Income/Expenses (Figure 1), and will look at Operating and Investment Income separately (Figure 2). The source of financial data is the Combined Financial Statements (CFS) from our accounting firm’s annual audit. As of this writing, the 2017 audit has not yet been completed, so all 2017 data comes from QuickBooks, the day-to-day financial software used by our management team.

SOAP finished 2017 with the strongest performance since 2014. This result was driven by a reversal of the downward trend in Operating Income which occurred 2014-16, along with the highest Investment Income in the last five years. Combined Operating Income increased from $(-)171,715 in 2016 to $(-)98,378 in 2017. Combined Investment income increased from $129,502 in 2016 to $307,691 in 2017, driven by a strong stock market performance with the S&P up 19.5% in 2017 v 9.5% in 2016. Investment gains more than made up for operating losses, resulting in a Combined Net Income of $209,313 (Figure 2).

Member Dues were the greatest source of Operating Income in 2017, bringing in $172,943, slightly ahead of budget and on par with 2016. This was followed by the

Treasurer’s ReportKlaus Kjaer, MD, MBAWeill Cornell Medical CollegeNew York, NY

Meetings Member Dues Donations Investments Member Services Grants Operations Grand Total

Actual 100,651 172,943 30,342 307,691 -44,132 -134,880 -223,302 209,313Budgeted 90,864 170,000 5,150 132,958 -40,000 -152,940 -221,775 -15,743

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Combined Income/Expenses 2017(QuickBooks)ActualvBudgeted

Figure1

2013 2014 2015 2016 2017 (QuickBooks)Operating Income 282,176 172,802 32,747 -171,715 -98,378 Investment Income 252,635 63,750 -76,885 129,503 307,691Net Income 534,811 236,552 -44,138 -42,212 209,313

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Figure2

Treasurer’s Report continued on next page

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Annual Meeting and Sol Shnider Meeting, which together brought in net income of $100,651, also slightly ahead of budget (Figure 1). Both meetings, however, performed below their 2016 levels (Figure 3). Grant expenses decreased from $171,087 in 2016 to $134,880 in 2017, and are expected to decrease further in 2018. This is due to discontinuation of the $100,000/year Gertie Marx Grant until Endowment assets can recover enough to support an annual grant program of that size with sustainable investment income. Overall, in spite of negative Operating Income, SOAP’s Combined Net Assets grew 6.9% in 2017, reversing the slightly negative growth of 2015 and 2016 (Figure 4).

SOAP’s cash holdings in its Non-Endowment investment account have remained high over the last few years, totaling $441,806 as of the end of 2017. The Board of Directors identified this as an opportunity for additional investment income and has voted to shift all but $200,000 of this into a 70/30 allocation of 70% stocks and 30% bonds over the next 2 years. The remainder of the Non-Endowment and Endowment funds invested by SOAP’s financial advisors, Independence Advisors, is already held in a 70/30 allocation.

Going forward, SOAP’s Board of Directors have voted to target an annual growth of 5% for the society, which will allow continued support of SOAP’s strategic plan as its mission expands to include a broader platform for promoting the highest standards of clinical practice. This will be accomplished by budgeting both the Endowment and Non-Endowment to steadily increasing assets, in part by controlling expenses and in part by exploring options for alternative sources of revenue. SOAP is well-positioned for the financial growth required to take on new mission-aligned opportunities

2014 2015 2016 2017AnnualMeeting 157,179 74,941 170,167 127,153SolShniderMeeting 28,427 24,874 1,598 -26,502

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Figure3

2013 2014 2015 2016 2017 (QuickBooks)Non-Endowment 565,858 1,039,410 1,082,556 1,071,876 1,130,039Endowment 2,328,010 2,091,010 2,003,726 1,972,194 2,123,344Net Assets 2,893,868 3,130,420 3,086,282 3,044,070 3,253,383

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Figure4

Treasurer’s Report continued from previous page

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Education Committee continued from previous page

Education Committee - Labor Analgesia: Past, Present and FutureKathleen A. Smith, MDUniversity of North Carolina Chapel Hill, NC

Edited by: Grace Lim, MD, MS University of PittsburghPittsburgh, PA

In 1848, Sir James Young Simpson introduced labor analgesia by providing ether in laboring women. He wrote, “[Labor pain] seems to be more than human nature

would be able to bear… It is our duty to use all legitimate means to mitigate suffering”.1 Today, neuraxial analgesia is considered the gold standard for labor pain management, although patient preferences and medical co-morbidities will continue to dictate labor analgesia utilization.

Labor analgesia modalities have spanned a wide range, from volatile agents like ether and chloroform, to “twilight sleep,” a combination of scopolamine and morphine (Figure 1). At one point, up to 60-90% of patients received inhalational general anesthesia with high dose nitrous oxide (70-80%) or methoxyflurane for vaginal delivery (VD).2,3 These practices were abandoned due to concerns about maternal safety and neonatal sedation and toxicity. First described in the 1940s, labor epidural analgesia was not widely adopted until the 1970s.1,2 Epidural analgesia was linked to reduced anesthetic complications and improved satisfaction, although questions persist on its relationship with sterile fever and risk for instrumental delivery.2-4

Early practice involved intermittent manual bolus of local anesthetic, which was labor intensive and had periods of inadequate analgesia. In the mid-1980s continuous epidural infusion of local anesthesia was adopted.5 High concentrations of bupivacaine were used for bolus (0.5%) and infusion (0.25%), but cardiotoxicity and motor blockade led to the need for dilute local anesthesia with adjuncts (epinephrine and opioids),6,7 which were linked to reduced risk of operative VD. In the 1990s, the combined spinal epidural (CSE) was shown to be a reliable and safe technique, resulting in rapid analgesia without motor blockade;8 and now evidence suggests that CSE techniques may reduce epidural catheter failure rates.9 The dural puncture epidural (DPE) technique10 also shows promise for superior sacral analgesia and reduced analgesia failure compared to epidural alone. DPE may be better than CSE for reduced abnormal fetal heart rate, although the effect of CSE on fetal heart rate remains controversial.4

Continuous epidural infusion (CEI) is an improvement over manual bolus but may provide inadequate analgesia, and

it requires manual supplemental dosing. In 1988, patient controlled epidural analgesia (PCEA) was introduced and was linked to less local anesthetic consumption, motor blockade and pain scores.4,11 ASA practice guidelines support PCEA with or without CEI;12 most practices use low-concentration infusions with PCEA to reduce breakthrough pain.

Programmed intermittent epidural bolus (PIEB) without infusion is a relatively new innovation that may improve maternal satisfaction and reduce local anesthesia consumption, motor blockade and operative VD compared to CEI.13 Intermittent bolus administration is thought to improve the spread of local anesthesia. Optimal volume and frequency of injection are ongoing topics of investigation. Individualized epidural analgesia regimen by interactive drug delivery software also shows improved maternal satisfaction without increased local anesthetic consumption, but this software is not currently widely available.4

In some patients, neuraxial analgesia is undesirable or contraindicated. Nitrous oxide, first used for labor analgesia in Poland in 1881, is used widely in Europe and Canada;14 availability in the U.S. remains limited, although it is increasing in popularity. The Federal Drug Administration recent warning against general anesthesia and sedatives in pregnant women may hinder widespread availability due to unknown risk of fetal neurotoxicity, although many experts contend that this warning was premature and overly cautious. Intravenous opioid options, such as fentanyl or remifentanil PCA, continue to be common, but their use

Key Points• Neuraxial analgesia has

improved the safety of labor pain management

• Low dose infusion with patient administered boluses is common practice

• Interactive software and precision medicine may dictate future direction

11

Education Committee continued from previous page

may be limited by concerns for maternal and neonatal respiratory depression.

Labor analgesia has evolved over the last century, with significant improvements in safety and patient satisfaction. The future of labor analgesia will likely be shaped by technological advancements, as well as precision medicine based on genetic variations in analgesic requirements.15

Figure. Historical evolution of some labor analgesia and anesthesia modalities, and reasons for abandoning earlier approaches. Current areas of uncertainty or controversy surrounding epidural analgesia are listed. List of modalities is not comprehensive.

References:1. Moir DD, Willocks J. Epidural analgesia in Brittish Obstetrics. Brit.

J. Anaesth 1968(40):129-138. 2. Catton DV. Epidural analgesia for labor and delivery. Anesth Analg

1969;48(4):587-91.

3. Ong B et al. Obstetrical anaesthesia at Winnipeg Women’s Hospital 1975-83: anaesthetic techniques and complications. Can J Anaesth. 1987 May;34(3 ( Pt 1)):294-9.

4. Sng BL, Kwok SC, Sia ATH. Modern Neuraxial Labor Analgesia. Curr Opin Anaesthesiol. 2015 Jun;28(3):285-9.

5. Abboud TK, Afrasiabi A, Sarkis F et al. Continuous infusion epidural analgesia in parturients receiving bupivacaine, chloroprocaine, or lidocaine--maternal, fetal, and neonatal effects.

6. Eisenach JC, Grice SC, Dewan DM. Epinephrine Enhances Analgesia Produced by Epidural Bupivacaine during Labor. Anesth Analg 1987;66:447-51.

7. Phillips G. Continuous infusion epidural analgesia in labor: the effect of adding sufentanil to 0.125% bupivacaine. Anesth Analg. 1988 May;67(5):462-5.

8. Collis RE, Baxandall ML, Srikantharajah ID, Edge G, Kadim MY, Morgan BM. Combined spinal epidural (CSE) analgesia: technique, management, and outcome of 300 mothers. Int J Obstet Anesth. 1994 Apr;3(2):75-81.

9. Albright GA, Foster RM. The safety and efficacy of combined spinal and epidural analgesia/anesthesia (6,002 blocks) in a community hospital. Reg Anesth Pain Med. 1999 Mar-Apr;24(2):117-25.

10. Chau A, Bibbo C, Huang CC, Elterman KG, Cappiello EC, Robinson JN, Tsen LC. Dural Puncture Epidural Technique Improves Labor Analgesia Quality With Fewer Side Effects Compared With Epidural and Combined Spinal Epidural Techniques: A Randomized Clinical Trial. Anesth Analg. 2017 Feb;124(2):560-569

11. Gambling DR, McMorland GH, Yu P, Laszlo C. Comparison of Patient-Controlled Epidural Analgesia and Conventional Intermittent ”Top-Up” Injections During Labor. ANESTH ANALG 1990:70:256-61.

12. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016; 124:270-300.

13. Carvalho B, George RB, Cobb B, McKenzie C, Riley ET. Implementation of Programmed Intermittent Epidural Bolus for the Maintenance of Labor Analgesia. Anesth Analg. 2016 Oct;123(4):965-71

14. Markley JC, Rollins MD. Non-Neuraxial Labor Analgesia: Options. Clin Obstet Gynecol 2017;60(2):35-64.

15. Landau R, Kern C, Columb MO et al. Genetic variability of the mu-opioid receptor influences intrathecal fentanyl analgesia requirements in laboring women. Pain 2008;139:5-14.

Adapted from Lim, G. (2017). Obstetric Anesthesia in the 21st Century [Powerpoint slides]. Retrieved from University of Pittsburgh Pitt Box, https://pitt.account.box.com/login

FeverInstrumental delivery

12

Education Committee - Critical Care in Obstetric Anesthesia: Past, Present, and FutureCesar R. Padilla, MD Brigham and Women’s HospitalBoston, MA

Numerous media outlets have now reported on the medical dilemma that faces our nation: The U.S. represents the only industrialized country where

maternal mortality continues to rise.1 Women’s health and maternal mortality have finally seeped into our nation’s public consciousness. If we look at this challenge through a historical lens, we can appreciate that obstetric anesthesiology has faced similar challenges since its inception. Perhaps history can provide some sort of blueprint for our future?

Obstetric anesthesiology has faced challenges, and through ingenuity and multidisciplinary collaboration it has undergone remarkable transformations, becoming a field central to the birthing experience and well-being for women across the world. Queen Victoria’s use of inhaled chloroform for the birth of her eighth and ninth children helped adjust cultural attitudes towards labor anesthesia and led to acceptance of its use in obstetrics.2 A century later, in the 1940’s, the practice of obstetric anesthesiology was still far from providing routine, safe anesthesia to laboring women. During this era, the use of parenteral narcotics and scopolamine was commonly utilized for laboring patients, leading to both heavily sedated mothers and newborns. Mortality due to anesthetic related events was 3-10%.3

Soon thereafter, to improve maternal outcomes, in 1968, several influential and visionary physicians from different subspecialties convened to establish the Society for Obstetric Anesthesia and Perinatology. James Elam, one of SOAP’s founding fathers, was a renowned respiratory researcher and the first to experimentally show the benefits of mouth-to-mouth resuscitation. Elam was known to greatly influence Peter Safar, the father of CPR and modern critical care.

In 2018, obstetric anesthesiology once again faces an opportunity for reinvention and leadership. As the founders of SOAP once did, we must search for answers across medical specialties to address our current challenges.

The Society for Maternal Fetal Medicine, together with Banner-University Medical Center in Phoenix, Arizona hosts an annual conference in obstetrical critical care. The program invites healthcare providers from all levels (midwife, nurses, residents, and fellows) and offers an online and hands-on curriculum which includes critical care simulation, airway

workshops and other critical care skills such as thoracic ultrasonography. I was invited as an instructor to help debrief critical care simulation sessions and teach ultrasonography. Witnessing nurses, midwives, residents, and obstetricians work together in collaboration emphasizes what our need is at this moment; to approach maternal mortality in a multidisciplinary effort.

Critical care skills, such as focused cardiac and lung ultrasonography, are now being actively emphasized by our obstetric colleagues. Critical care simulation and ultrasonography represent vital educational tools that we, as a society, must utilize in the education and training of fellows and residents in obstetric anesthesiology. More importantly, providing an inclusive environment where we work together with obstetric residents, nurses and midwives will help establish strong, innovative and collaborative ways to address maternal morbidity and mortality.

Looking ahead, we must look at the education of anesthesiology residents and obstetric anesthesia fellows as opportunities to meet the demands our field currently faces. Last year, we conducted a survey amongst obstetric anesthesiology fellowship programs which showed only 12% of programs include a specific ICU rotation. Over half of responding program directors indicated that an ICU rotation would be of educational benefit. Our survey highlights OB critical care as a potential area of improvement in the OB anesthesiology fellowship curriculum. By creating a formal critical care curriculum, which includes simulation and ultrasonography, much like our obstetric colleagues have, we can enhance and standardize the delivery of maternal critical care.

References:1. Global, regional, and national levels of maternal mortality, 1990-

2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. (2016, October 06)

2. Frerichs, R. R. Anesthesia and Queen Victoria http://www.ph.ucla.edu/epi/snow/victoria.html. Accessed March 25, 2017

3. A Celebration of Forty Years - Milestones and Pioneers. (2008). Society for Obstetric Anesthesia and Perinatology Retrieved from https://soap.org/pdfs/pioneers-booklet.pdf

4. Padilla et al. Assessment of critical care education in the obstetric anesthesiology fellowship curriculum. Presented at SOAP 2017. Retrieved from https://soap.org/display_2017_abstract.php?id=SAT-22

13

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Board NominationsSOAP is calling for nominations for the elected positions of 2nd Vice President and Secretary. Interested members should send a short statement and picture to kelli@soap.org for post-ing to the SOAP website.If you have any questions, please do not hesitate to contact SOAP headquarters at (414) 389-8611.

Announcements

SOAP SOL SHNIDER, MD OBSTETRIC ANESTHESIA

MEETING

S A V E T H E D A T E

March 14-17, 2019Grand Hyatt Hotel

San Francisco, California

16

6737 W. Washington St.Ste. 4210Milwaukee, WI 53214

2017-2018 SOAP Board of DirectorsPresident

Brendan Carvalho, MBBCh, FRCA, MDCH

President-Elect Mark I. Zakowski, MD, FASA

1st Vice President Lisa R. Leffert, MD

2nd Vice President Ruth Landau, MD

Secretary Jeanette R. Bauchat, MD

Treasurer KIaus Kjaer, MD, MBA

Immediate Past President John T. Sullivan, MD, MBA

ASA Delegate and 2018 Host Paloma Toledo, MD, MPH

ASA Alternate Delegate

Katherine W. Arendt, MD

Director at Large Ashraf Habib, MB, BCh, MSc, MHSc

Chair, ASA Committee on OB Anesthesia

McCallum R. Hoyt, MD, MBA

2017 Host Alexander Butwick, MBBS, FRCA, MS

Journal Liaison Brian T. Bateman, MD, MSc

Newsletter Editor and 2019 Host

Heather C. Nixon, MD

Chair, Educational Track Subcommittee on OB Anesthesia of the ASA

Robert R. Gaiser, MD