Anesthesiology Manual:
Best Practices and Case Management

Maternal cardiac arrest (MCA) during the peripartum period remains one of the most critical emergencies in obstetric medicine. A newly published multicenter cohort study in Anesthesiology (2026) provides one of the most comprehensive analyses to date, offering detailed insights into incidence, etiology, risk factors, and management during anesthetic care. Overview of the study This large retrospective cohort study analyzed 778,102 deliveries across 60 U.S. institutions between 2015 and 2022. The investigation focused specifically on cardiac arrest occurring during or within 7 days of anesthetic care. Key findings Incidence: 11.2 per 100,000 deliveries (~1 in 9,000) Total cases identified: 87 confirmed maternal cardiac arrests Survival outcomes: Return of spontaneous circulation (ROSC): 77% 30-day survival: 67.8% Primary causes: Hemorrhage: 40.2% Amniotic fluid embolism (AFE): 31.0% Anesthesia-related arrests: 11.5% of cases  What is maternal cardiac arrest? Maternal cardiac arrest refers to the cessation of effective cardiac output during pregnancy or postpartum, resulting in loss of perfusion to vital organs. Clinical definition Absence of pulse or cardiac activity Requires Advanced Cardiac Life Support (ACLS) interventions Occurs during pregnancy or within 42 days postpartum (in broader definitions) Incidence and timing When do cardiac arrests occur? The study revealed important timing patterns: 62.1% occurred after delivery 20.7% occurred before delivery 85% occurred within 12 hours postpartum Median onset: 26 minutes after delivery Location of arrest Operating room: 81.6% Labor ward: 10.3% Post-anesthesia care unit: 4.6% Major causes of maternal cardiac arrest Obstetric hemorrhage The leading cause of MCA: Accounts for 40.2% of cases Often associated with: Placenta accreta spectrum (PAS) Placental abruption Surgical complications Clinical significance: Despite lower ROSC rates compared to AFE, patients who achieved ROSC after hemorrhagic arrest had excellent survival outcomes. Amniotic fluid embolism (AFE) Second most common cause: Represents 31% of cases Rapid onset, often within minutes of delivery Characterized by: Cardiovascular […]

Placenta accreta spectrum (PAS) remains one of the most challenging and high-risk conditions in modern obstetrics. A newly published multicenter study by Padilla et al. (Anesthesiology, 2026) provides critical insights into anesthetic management patterns during cesarean hysterectomy, offering valuable guidance for clinicians navigating this complex scenario. What is placenta accreta spectrum? Placenta accreta spectrum refers to abnormal placental adherence or invasion into the uterine wall. It is categorized into three subtypes based on depth of invasion: Placenta accreta – superficial adherence to the myometrium Placenta increta – invasion into the myometrium Placenta percreta – penetration through the uterus, possibly involving adjacent organs Why it matters PAS is associated with massive obstetric hemorrhage Frequently requires cesarean hysterectomy Carries significant maternal morbidity and mortality The incidence has risen dramatically, from approximately 1 in 10,000 deliveries in the 1960s to 3.11 per 1,000 deliveries today, largely due to rising cesarean delivery rates. Study overview: large multicenter analysis This landmark study analyzed: 1,257 patients 43 U.S. hospitals Timeframe: 2015–2021 The goal was to evaluate real-world anesthesia practices in PAS patients undergoing cesarean hysterectomy. Key anesthetic modalities studied General anesthesia (GA) Neuraxial anesthesia (spinal, epidural, combined spinal-epidural) Neuraxial anesthesia with conversion to general anesthesia Major findings: how anesthesia is actually practiced Distribution of anesthesia techniques 40.3% – neuraxial anesthesia with conversion to general anesthesia 33.3% – general anesthesia alone 26.5% – neuraxial anesthesia alone The most common approach was combined neuraxial + general anesthesia, typically involving planned or unplanned conversion. Why does anesthetic choice vary? Severity of placental invasion Patients with more severe disease were more likely to receive general anesthesia: Placenta increta → OR 2.04 Placenta percreta → OR 2.14 Clinical reasoning: Increased risk of hemorrhage Longer surgical duration Need for rapid airway control and hemodynamic stability Scheduled vs. emergency surgery Unscheduled cases had […]