Spinal Anesthesia for Cesarean Delivery in Severely Preeclamptic Women: Don???t Throw Out the Baby with the Bathwater!

Abstract

T he optimal anesthetic technique for cesarean delivery in severely preeclamptic women remains controversial. Recent clinical practice, however, indicates that spinal anesthesia can be, and is, safely used. In the past, there has been concern that intravascular volume contraction related to preeclampsia could result in catastrophic hypotension that would be difficult to treat (1). As a result, epidural anesthesia became the preferred neuraxial technique for cesarean delivery in women with severe preeclampsia because of a more gradual onset of sympathectomy. In fact, we now know that hypotension may occur less frequently when spinal anesthesia is administered to preeclamptic as compared with normotensive women having a cesarean delivery in modern day practice (2). Smalldose spinal as part of a combined spinal-epidural technique with subsequent top-off of the epidural component has also been advocated, but there are many anesthesiologists and obstetricians who are still concerned about the use of spinal anesthesia in preeclampsia (3). There are now several studies that support the use of spinal anesthesia in the severely preeclamptic (2–6). In the first, a prospective and randomized trial, there was no significant difference in the incidence of hypotension in severely preeclamptic women having spinal as compared with epidural anesthesia for cesarean delivery (4). The findings of this paper resonated among anesthesiologists and obstetricians because it was performed at Parkland Hospital in Dallas, Texas, an institution that for many years taught that spinal anesthesia was absolutely contraindicated in severely preeclamptic women. The second study, a retrospective review, reported that there was no significant difference in the lowest mean arterial blood pressure (MABP) between severely preeclamptic women having spinal as compared with epidural anesthesia for cesarean delivery (5). Most recently, Aya et al. (2) in a prospective cohort study reported that the incidence and severity of hypotension were in fact less in severely preeclamptic women as compared with normotensive women having a cesarean delivery with spinal anesthesia. In this issue of Anesthesia & Analgesia, two more studies weigh in on the subject, one by Visalyaputra et al. (6) and the other, a follow-up study, by Aya et al. (11). There is good news and bad news. First, the potentially bad news for advocates of spinal anesthesia is that Visalyaputra et al. (6) report that the use of spinal anesthesia for cesarean delivery in severely preeclamptic women was more likely to result in mild hypotension and to require more ephedrine to correct than epidural anesthesia. However—before we throw the baby out with the bathwater—there is also good news if we look at this finding in perspective. The hypotension was mild and the difference in the median lowest MABP measured in the spinal as compared with epidural anesthesia group was small and transient (generally 1 min). The current study by Visalyputra et al. (6) selected a group of preeclamptic women who were categorized as “severe” and thus would be at greatest risk to develop hypotension related to sympathectomy. They also excluded women who were in labor because labor can decrease the incidence of hypotension under regional anesthesia (7). Women were prepared for surgery with hydration and hydralazine administration (to decrease the diastolic blood pressure to at least 90 mm Hg), and most received magnesium sulfate. The authors attempted to standardize obstetric and Accepted for publication May 12, 2005. Address correspondence and reprint requests to David J. Birnbach, MD, Professor and Executive Vice Chair, Department of Anesthesiology University of Miami School of Med, 1611 NW 12th Avenue Miami, FL 33136. Address electronic mail to dbirnbach@miami.edu.