The Society for Obstetric Anesthesia and Perinatology (SOAP) was formed in 1968 by a small group of anesthesiologists to foster research and education, improving the obstetric anesthesia care provided to pregnant women and their fetuses. In 1969, 64 anesthesiologists gathered in Kansas City, Kansas.a Guided by Adolph Giesecke and Robert Hustead, they selected the acronym “SOAP” for their new organization, with the assurance that this would be the cleanest society in the world. Since then, SOAP has grown to over 1000 members worldwide. The SOAP Annual Meeting attracts around 600 individuals interested in improving clinical care during pregnancy, childbirth, and postpartum recovery. Members of SOAP have made fundamental contributions to the safe practice of obstetric anesthesia.
Perhaps no obstetric anesthesiologist has made a greater contribution to medical practice than Virginia Apgar. For >60 years, her eponymous scoring system for newborn infants1 has been the worldwide standard for rapid assessment of neonatal well-being. As of 2015, PubMed lists nearly 10,000 references to the “Apgar Score.” Dr. Apgar is only 1 of the 2 anesthesiologists to appear on a United States postage stamp; the other is Crawford Long.2 This issue of Anesthesia & Analgesia celebrates the contributions of both Virginia Apgar and the SOAP to the safe care of the parturient and neonate.
Dr. Selma Calmes3–6 has written extensively about Virginia Apgar. In this issue of Anesthesia & Analgesia, Dr. Calmes describes the events in Apgar’s life that led to the introduction of the Apgar score.7 A recurring theme in Apgar’s career was that her intelligence and ambition frequently pressed against the low glass ceiling that constrained women physicians at that time. She was interested in surgery but was directed to anesthesia because surgeons thought “feminine characteristics were helpful in managing anesthesia.”7 After training in anesthesia, Apgar became the Director of the Division of Anesthesia at Columbia University in 1938 but was passed over in 1949 for the position of chair of the Division of Anesthesiology. Her 1953 paper in Current Researches in Anesthesia & Analgesia describing the Apgar score1 was published without any editorial acknowledgment by editor-in-chief Howard Dittrick, who had lost interest in the journal.8
This issue of Anesthesia & Analgesia addresses 2 of these missed opportunities in Apgar’s career. Dr. Margaret Wood, Chair of the Department of Anesthesiology at Columbia University, reflects on the role of women in academic medicine, academic anesthesiology, and the challenges still faced by women interested in pursuing academic careers.9 Dr. Wood also reflects on her own legacy as the first woman physician to chair a clinical department at Columbia University, an honor that should have gone to Virginia Apgar. Also in this issue is a faux editorial by Wong and Shafer10 “submitted on behalf of Howard Dittrick.” This is the editorial that should have accompanied Apgar’s landmark 1953 article in Anesthesia & Analgesia.
Although passionate about patients, Apgar’s career was dedicated to research. She believed anesthesiology research was critical to the development of the specialty. The Gerard Ostheimer Lecture “What’s New in Obstetric Anesthesia” is presented annually at the SOAP meeting by a respected obstetric anesthesiologist. The lecture honors the contributions to obstetric anesthesiology made by the late Gerard Ostheimer. The lecturer, chosen for his/her stature in the field, summarizes important research in obstetric anesthesiology published in the previous calendar year. In a written summary of her 2014 Ostheimer lecture, Dr. Lisa Leffert11 shows that research is still flourishing in obstetric anesthesiology. Leffert describes recent epidemiologic studies examining maternal and fetal outcomes, including the role of hemorrhage, sepsis, mode of delivery, timing of delivery, and method of anesthesia. Dr. Apgar would be pleased that we are still working to improve infant outcomes. Dr. Allison Lee provides a summary of the entire 2014 Annual Meeting of the SOAP.12
The SOAP Annual Meeting has become the preeminent international forum for the presentation and discussion of research in obstetric anesthesia. This past year, the Journal invited the authors of the abstracts presented in the “Best Paper” session, and the winners of special awards (Gertie Marx Award [best abstract presented by a trainee], Zuspan Award [best interdisciplinary collaborative abstract produced by an obstetrician and anesthesiologist], Research in Education, Patient Safety Award, and the Best Case Report) to submit their work to the Journal. Several of the authors responded. The articles that passed peer review (which is never waived) are included in this issue of the Journal.
Dr. Apgar introduced basic research to the Division of Anesthesia at Columbia University in 1950.7 Later, in 1959, she joined the March of Dimes and helped to redirect its focus from polio, which had been eradicated, to preterm birth, which remains a problem today. An article published in this issue carries this legacy forward by investigating a mechanism of preterm birth. Tumor necrosis factor α (TNFα) is part of the inflammatory cascade leading to preterm premature rupture of amniotic membranes. Progestins attenuate the activity of TNFα. Allen and colleagues13 found that medroxyprogesterone (a progestin) attenuated the changes in gene expression caused by TNFα, a possible mechanism by which progestins prevent premature rupture of membranes.
Postpartum hemorrhage is the leading cause of maternal mortality worldwide and a leading cause of maternal morbidity in the developed world. Hemorrhage attributed to uterine atony is increasing.14 One explanation is the rising incidence of induced labor; prolonged exposure to exogenous oxytocin appears to lead to oxytocin receptor desensitization and uterine atony.15,16 To unravel the mechanism of oxytocin desensitization, Balki and colleagues17 examined the pharmacologic interaction of oxytocin, ergonovine, and carboprost on the in vitro contractility of human myometrial strips.
The rising incidence of induced labor reflects the modern desire to control childbirth, including scheduling delivery neatly into the workday. But childbirth remains an unpredictable physiologic process. Painful contractions develop at all hours of day and night. The logistics of ensuring safe, timely, patient-centered labor analgesia remain a fundamental challenge for both academic and community anesthesia groups. Elterman and colleagues18 conducted a “natural experiment,” using a change in the resident obstetric anesthesia call system (introduction of a night float system) at the Brigham and Women’s Hospital to assess whether a change in the overnight anesthesia house staff coverage increased the incidence of unintentional dural puncture. It did. It is sobering to consider that details such as how we schedule overnight staff might affect not only the availability of epidural analgesia, but also its quality and safety.
Finally, Handlogten and colleagues19 describe anesthesia for awake craniotomy in a 27-year-old woman at 20 weeks’ gestation. The woman received dexmedetomidine for intraoperative sedation, without apparent adverse effect on maternal or fetal status, or uterine tone, despite its α-adrenergic agonist activity. Fortunately, there were no Apgar scores to report until she delivered a healthy neonate at term! The case report appears in Anesthesia & Analgesia, rather than Anesthesia & Analgesia Case Reports, because it is part of this inaugural SOAP collection.
Obstetric anesthesiology has come a long way in the 62 years since Apgar’s landmark article and the nearly half-century since the founding of SOAP. Apgar’s eponymous score remains the standard for neonatal assessment. However, we have much to learn about the safety of anesthetic drugs for the fetus and neonate, stopping preterm labor, starting term labor, ensuring postpartum uterine tetany, and preventing maternal hemorrhage. Every year SOAP members gather at the Annual Meeting to understand the progress anesthesiologists have made advancing maternal and neonatal health. The current issue of Anesthesia & Analgesia pays tribute to the legacy of Virginia Apgar and offers a sample of the work presented at the 2014 Annual Meeting of the Society for Obstetric Anesthesia and Perinatology.
Name: Jill M. Mhyre, MD.
Contribution: This author helped write the manuscript.
Attestation: Jill M. Mhyre approved the final manuscript.
Name: Cynthia A. Wong, MD.
Contribution: This author helped write the manuscript.
Attestation: Cynthia A. Wong approved the final manuscript.
Dr. Cynthia Wong is the Section Editor for Obstetric Anesthesiology for the Journal. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Wong was not involved in any way with the editorial process or decision.
a A celebration of 40 years. SOAP. http://soap.org/pdfs/pioneers-booklet.pdf. Accessed February 6, 2015.
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2. Sekhar KC. A philatelic history of anesthesiology. J Anaesthesiol Clin Pharmacol. 2013;29:19–25
3. Calmes SH. Virginia Apgar: a woman physician’s career in a developing specialty. J Am Med Womens Assoc. 1984;39:184–8
4. Calmes SH. Virginia Apgar: at the forefront of obstetric anesthesia. ASA Newsl. 1992;56:9–12
5. Calmes SH. And what about the baby? Virginia Apgar and the Apgar score. ASA Newsl. 1997;61:20–2
6. Calmes SHRupreht J, van Lieburg MH, Lee JA, Erdman W. Development of the Apgar score. In: Anaesthesia: Essays on Its History. 1985 Berlin Springer-Verlag:45–8
7. Calmes SH. Dr. Virginia Apgar and the Apgar score: how the Apgar score came to be. Anesth Analg. 2015;120:1060–4
8. Bause GS, Edmonson JM. Howard Dittrick: curator to the McMechans’ legacy journal. Anesth Analg. 2012;115:1410–5
9. Wood M. Women in medicine: then and now. Anesth Analg. 2015;120:963–5
10. Wong CA, Shafer SL. Dittrick’s missing editorial about Apgar’s score. Anesth Analg. 2015;120:962
11. Leffert L. What’s new in obstetric anesthesia: the 2014 Gerard W. Ostheimer lecture. Anesth Analg. 2015;120:1065–73
12. Lee A. Society for Obstetric Anesthesia and Perinatology 2014 Meeting Report. Anesth Analg. 2015;120:1171–3
13. Allen TK, Feng L, Nazzal M, Grotegut CA, Buhimschi IA, Murtha AP. The effect of progestins on tumor necrosis factor α-induced matrix metalloproteinase-9 activity and gene expression in human primary amnion and chorion cells in vitro. Anesth Analg. 2015;120:1085–94
14. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg. 2010;110:1368–73
15. Phaneuf S, Asbóth G, Carrasco MP, Liñares BR, Kimura T, Harris A, Bernal AL. Desensitization of oxytocin receptors in human myometrium. Hum Reprod Update. 1998;4:625–33
16. Grotegut CA, Paglia MJ, Johnson LN, Thames B, James AH. Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony. Am J Obstet Gynecol. 2011;204:56.e1–6
17. Balki M, Erik-Soussi M, Ramchandran N, Kingdom J, Carvalho JCA. The contractile effects of oxytocin, ergonovine and carboprost and their combinations: an in vitro study on human myometrial strips. Anesth Analg. 2015;120:1074–84
18. Elterman KG, Tsen LC, Huang CC, Farber MK. The influence of a night-float call system on the incidence of unintentional dural puncture: a retrospective impact study. Anesth Analg. 2015;120:1095–8
19. Handlogten KS, Sharpe EE, Brost BC, Parney IF, Pasternak JJ. Dexmedetomidine and Mannitol for awake craniotomy in a pregnant patient. Anesth Analg. 2015;120:1099–103