Maternal Hemodynamic Status Research Articles

A longitudinal study on the effect of obesity upon circulating renin-angiotensin system in normal pregnancy

Background and aimsObesity is the most common health issue in women of reproductive age, which profoundly affects maternal-fetal health. Despite progress in understanding key inflammatory and metabolic changes, the pathogenesis of the cardiovascular phenotype of obese pregnant women remains to be fully understood. This study aimed at: (i) evaluating the changes of the renin-angiotensin system (RAS) throughout pregnancy in obese vs normal weight (control) women, and (ii) evaluating the presence of any associations between maternal hemodynamic status and RAS changes. Methods and resultsThirty-eight normal weight and nineteen obese pregnant women were included. Clinical assessment, blood samples and maternal hemodynamic evaluation were performed at 12, 20, 30, and 36 weeks, while ultrasound assessment was scheduled at 20, 30, and 36 weeks of gestation. Measurements of sFlt-1, PlGF, Angiotensinogen, Renin, AngII, Ang1-7, ACE and ACE2 were performed by ELISA. Our data show that normotensive obese women had lower placental blood supply, as assessed by UV-Q and UV-Q/EFW, as compared to controls, and significantly higher levels of AngII and AngII/Ang1-7 ratio, which were inversely related to placental blood supply. ConclusionsOur study shows for the first time that normotensive obese women exhibited a significant progressive increase of AngII and AngII/Ang1-7 throughout pregnancy, which were inversely related to placental blood supply as assessed by UV-Q and UV-Q/EFW. Our data shed light on the early changes in pregnant obese women and suggest that RAS dysregulation is a prerequisite rather than a consequence of hypertensive disorders of pregnancy and other maternal neonatal complications.

Posterior Placenta Accreta Spectrum Disorders: Risk Factors, Diagnostic Accuracy, and Surgical Management

Abstract Posterior placenta accreta spectrum (PAS) disorders are infrequent but potentially associated with significant maternal mortality and morbidity, especially if not diagnosed prenatally. Analysis of published literature is problematic since most experiences included only a few cases. Knowledge of the risk factors associated with posterior PAS is crucial to identifying mothers at higher risk and ask for high sensitivity studies. Ultrasound has poor diagnostic accuracy in detecting posterior PAS, while magnetic resonance imaging better delineates the posterior uterine wall. In comparison, prenatal imaging's diagnostic performance in detecting posterior PAS is significantly lower than anterior placenta invasion. Management of posterior PAS depends on several factors, including maternal hemodynamic status, available resources, clinical presentation, and invasion severity. For accreta or increta cases, a compression suture is habitually enough to perform hemostasis. Nevertheless, organ involvement habitually requires a multidisciplinary team with the assistant of a general or coloproctology surgeon. The present article aims to update the risk factors, prenatal diagnosis, and surgical management of pregnancies complicated by posterior PAS.

Prevention of hypotension during elective cesarean section with a combination of colloid co-load and a continuous infusion of a vasoconstrictive agent: A comparative randomized study

Background: Spinal anesthesia is considered the anesthetic technique of choice in cesarean section but it can be frequently complicated by hypotension, with occasionally serious consequences for both the mother and fetus. One of the standard techniques used in the prevention of maternal hypotension is the administration of a continuous phenylephrine infusion. However, phenylephrine can lead to baroreceptor-mediated reflex bradycardia with untoward consequences for the maternal cardiac output. Nowadays, noradrenaline has been proposed as an alternative agent in this context, since due to its additional weak dose-dependent β-action, it can be associated with an inferior incidence of maternal bradycardia and thus of propensity to decrease the cardiac output. Colloid co-hydration has also been proven to be an effective technique in the prevention of maternal hypotension. This double-blinded, prospective randomized study aimed to investigate whether the addition of a fixed rate phenylephrine infusion or noradrenaline infusion to a colloid co-hydration regimen results in better maternal hemodynamic status or in a more favorable metabolic profile in the newborn as compared to the administration of colloids alone without any vasoconstrictor during elective cesarean section under combined spinal-epidural anesthesia. Materials and methods: One hundred-twenty parturients were randomized to either phenylephrine 50 μg/min (group P) or noradrenaline 4 μg/min (group N) or placebo (group C). All infusions had been prepared in identical syringes and the infusion rate was 30 mL/h in order to ensure the “blindness” of the study. As soon as the spinal injection started, all groups were administered 10 mL/kg of hydroxyethyl starch (HES) solution simultaneously with the onset of vasoconstrictor infusion. The primary end-point of the study was the incidence of maternal hypotension (SAP <80% of baseline). Additionally, maternal hemodynamics at specific time-points were recorded using non-invasive technology (Edwards Lifesciences ClearSight System) as well as the incidence of reactive hypertension, bradycardia, the requirement for bolus vasoconstrictor administration and the fetal acid-base status, the umbilical venous and arterial blood gases and the newborn Apgar score. Results: The incidence of maternal hypotension was higher in group C than in group P and also higher in group C than in group N (p = 0.024 and 0.073, respectively). The need of bolus administration of vasoconstrictor was higher in group C than in group P and also higher in group C than in group N (p = 0.001 and 0.003, respectively). The incidence of bradycardia was higher in group P than in group N (p = 0.018). The incidence of reactive hypertension was higher in group P than in group N and also higher in group P than in group C (p = 0.029 and 0.005, respectively). The need of modification of the infusion rate was higher in group P than in group N and also higher in group P than in group C (p < 0.001 και p = 0.002, respectively). The fetal pH of the umbilical vein was higher in groups N and P than in group C (p < 0.001), the fetal pO2 of the umbilical vein was higher in group N than in group C (p = 0.023) and fetal blood glucose concentration was higher in group N than in group C (p = 0.025) as well as in group N than group P with no statistical significance. Higher systematic vascular resistance index (SVRI) and higher SAP were observed at specific time-points in group P versus the other two groups. Finally, post-delivery Apgar scores were similar in all groups. Conclusions: The combination of a fixed-rate infusion of noradrenaline with the co-administration of colloid seems to be the most effective in the obstetric management of the parturient during cesarean section under regional anesthesia since it ensures maternal hemodynamic stability and a favorable metabolic profile in the newborn. This regimen seems to be superior to either a combination of colloid co-administration with a fixed rate of phenylephrine or to the administration of colloid alone without any vasoconstrictor agent. The higher concentration of fetal blood glucose in group N might be due to a catecholamine-induced glucose metabolism activation and due to a β-receptor-mediated decrease of insulin release.

The Effect of Phenylephrine Infusion on Maternal Hemodynamic Changes During Spinal Anesthesia for Cesarean Delivery.

BackgroundSpinal anesthesia is used as a common anesthetic technique in many routine and outpatient surgeries.ObjectivesThe aim of this study was to determine the effect of phenylephrine on maternal hemodynamic changes during spinal anesthesia for cesarean delivery.MethodsThis double-blind randomized controlled trial was conducted on 116 pregnant women candidate for the elective cesarean section through spinal anesthesia in the Shahid Akbarabadi Hospital, Tehran in 2019. The eligible women were randomly divided into the intervention (phenylephrine; n = 58) and control (normal saline; n = 58) groups. The data collection tool was a checklist, including the demographic and clinical variables, such as age, height, weight, body mass index, gravid, gestational age, Apgar score of 1 and 5, systolic blood pressure, diastolic blood pressure, heart rate, mean arterial pressure, SPO2, PH of the umbilical cord, PCO2, HCO3, base excess, nausea, and vomiting. Data were analyzed using SPSS 24 software and P value < 0.05 was considered as significant.ResultsThe intervention and control groups showed a significant difference in terms of the PH of the umbilical cord, PCO2, and nausea and vomiting (P value < 0.05). The results of the repeated measure ANOVA test showed a significant statistical difference between the intervention and control groups at different time points in terms of arterial pressure, systolic and diastolic blood pressures (P value < 0.05).ConclusionsPhenylephrine is effective in the prevention of some complications, like reducing mean arterial pressure, systolic and diastolic blood pressures, nausea, and vomiting during spinal anesthesia for cesarean delivery. Therefore, these drugs can be used based on maternal hemodynamic status during spinal anesthesia for cesarean delivery.

Comparison of Intravenous Nalbuphine and Paracetamol on Maternal Hemodynamic Status, Neonatal APGAR Score, and Postoperative Pain given before Induction of General Anesthesia for Elective Cesarean Section.

Background:Stress response to endotracheal intubation and surgery is associated with exaggerated hemodynamic response and an increase in catecholamine levels which is deleterious to both the mother and fetus. We aimed to compare the effects of intravenous nalbuphine and paracetamol on maternal hemodynamic status, neonatal APGAR score, and postoperative pain using the visual analog scale for elective cesarean section under general anesthesia.Study Design:This was a prospective, randomized, double-blinded clinical study.Materials and Methods:Sixty full-term pregnant patients, belonging to the American Society of Anaesthesiologist physical status Classes I and II, scheduled for elective cesarean section under general anesthesia were enrolled for the study. The patients were randomly allocated into two groups of 30 patients each to receive paracetamol (15 mg.kg− 1) in Group Pand nalbuphine (0.2 mg.kg−1) in Group N before induction of general anesthesia. Maternal heart rate, blood pressure, and oxygen saturation were recorded before infusion of study drugs, after induction, after intubation, and during surgery across all periods. APGAR score of neonates was recorded by a pediatrician. Time to reach visual analogue score-1 was recorded.Results:Significant attenuation of maternal hemodynamic response was observed with nalbuphine compared to the paracetamol group (P < 0.05). The time to achieve visual analogue score-1 in the postoperative period was higher in the nalbuphine group. APGAR score at 1 min was significant between the groups and at 5 min, nonsignificant difference was observed (P > 0.05).Conclusion:Nalbuphine and paracetamol are effective in perioperative hemodynamic stability of mother and APGAR score of neonates. However, nalbuphine had better hemodynamic stability as compared to paracetamol with a comparable APGAR score at 5 min.

OC10.05: The “Valensise Radar” to understand the maternal hemodynamic status

OC10.05: The “Valensise Radar” to understand the maternal hemodynamic status

Abstract 445: Monitoring the Hemodynamic Status During Three Trimesters of Pregnancy and Non-pregnancy Periods

Pregnancy is an important stage in women and is associated with delicate cardiovascular adaptation from non-pregnancy to pregnancy. Maternal hemodynamic changes are made to provide sufficient nutrients and oxygen to support the normal growth of the developing fetus. This study was designed to assess maternal hemodynamic status during three trimesters of pregnancy and non-pregnancy periods. Total 326 women (84 pregnant women and 242 age-matched non-pregnant women of childbearing age) between the ages of 20 and 44 participated in this non-invasive observational study. In this cross-sectional study, enrolled participants underwent blood pressure and radial pressure pulse measurements. In order to compare the hemodynamic status of different subjects, we recorded the systolic and diastolic blood pressure and calculated the first five harmonic amplitudes(C1~C5) and phases(P1~P5) of radial pulse wave using Fourier transform method. Compared with non-pregnant women, the maternal systolic and diastolic blood pressures were lower, and heart rate, C2, C4, and P1 were higher in pregnant women (Table 1). Those hemodynamic changes may be due to decreased arterial stiffness and peripheral arterial vasodilatation in pregnancy. In summary, a series of changes in maternal hemodynamic status can be observed during the trimesters of pregnancy, including lowering blood pressure and increasing harmonics of radial pulse. This study demonstrates the feasibility of non-invasive monitoring of the hemodynamic status of pregnant women, which could be used for early detection of pregnancy disorder.

Physiologic and Hemodynamic Changes During Pregnancy.

Substantial physiologic changes accompany pregnancy, the most profound of which involve the cardiovascular system. These changes affect maternal hemodynamic and oxygen transport status. This article describes cardiovascular changes that occur during pregnancy including blood volume, heart rate, stroke volume, cardiac output, vascular resistance, and colloid osmotic pressure. Alterations in factors related to maternal oxygen transport including oxygen affinity, delivery, and consumption also are described. Concepts related to fetal oxygen transport and adaptive responses to hypoxemia are presented. Technical considerations regarding assessment of maternal hemodynamic and oxygen transport status during pregnancy are described and assessment findings during labor, birth, and the immediate postpartum period are interpreted. A maternal hemodynamic and oxygen transport profile is presented to illustrate these principles in clinical practice.

Effect of Glucose Containing Crystalloid Infusion on Maternal Hemodynamic Status After Spinal Anesthesia for Cesarean Section.

BackgroundDespite preventive strategies, hypotension is the most common complication of spinal anesthesia in cesarean section.ObjectivesThe aim of this study was to assess the effect of glucose-containing crystalloid infusion on maternal hemodynamic status after spinal anesthesia for cesarean section.MethodsIn this prospective, randomized, double-blind clinical trial, 80 parturients undergoing elective cesarean section with spinal anesthesia were studied. In group A (n = 40) ringer with 1% glucose solution (10 gr glucose in 1000 mL ringer) and in group B (n = 40) only ringer solution infused before and after spinal anesthesia. Demographic data, hemodynamic change, complications and their treatments, maternal blood sugar level and neonatal APGAR (appearance, pulse, grimace, activity and respiration) score, intraoperative fluid, duration of surgery, and anesthesia were recorded in the two groups.ResultsThe incidence of hypotension in group A was significantly lower than group B (27.5% vs 75%) (P = 0.002). Other complications (sustained hypotension, nausea, pallor, and shivering were significantly lower in parturients of the group A (P < 0.05). Maternal blood sugar (BS), before and after surgery, was not significantly different in the two groups (P = 0.207 and P = 0.239, respectively). There was no statistically significant difference in the APGAR score of neonates at the 1st and 5th minutes of the birth between the two groups (P = 0.076).ConclusionsIt seems that adding 1% glucose to crystalloid solution improves the hemodynamic status and decreases post-spinal anesthesia complications without significant changes in the maternal blood sugar level and APGAR score of neonates.

H2. Maternal hemodynamic status in pregnancies complicated by intrauterine growth restriction (IUGR) and post-partum follow up

Aims: To investigate maternal hemodynamic status in pregnancies complicated by IUGR and in the post-partum.Methods: In this prospective study, we enrolled pregnant women between 24 and 38 weeks divided in severe and mild IUGR and a group of controls matched for gestational age. Severe IUGR was defined as abdominal circumference <5th centile and a Doppler velocimetry in umbilical artery42SD. Mild IUGR was defined as an abdominal circumference <10th centile and a Doppler velocimetry in umbilical artery <2SD. A cardiologist performed maternal echocardiographies at diagnosis and 6–12 weeks post-partum, to calculate cardiac output (CO), total vascular resistance (TVR) and indexes of diastolic dysfunction evaluated with tissue Doppler (E0/A0).Results: We recruited 14 severe IUGR, 43 mild IUGR and 19 controls. CO was significantly decreased and TVR significantly increased in IUGR compared to controls. The group of severe IUGR showed the highest values. Only severe IUGR showed a decrease of the heart rate during pregnancy and maintains a low CO in the post-partum.Discussion: The hemodynamic parameters correlate with the degree of placental insufficiency.

C1. Maternal hemodynamic profile in hypertensive disorders of pregnancy (HDP) and intrauterine growth restriction

Aims: To investigate maternal hemodynamic status in pregnancies complicated by HDP and/or IUGR and by severe IUGR without HDP.Methods: In this prospective study we enrolled pregnant women between 24 and 38 weeks divided in: HDP with appropriate for gestational age fetuses (HDP-AGA), HDP associated with IUGR (HDPIUGR), severe IUGR and a group of controls matched for gestational age. Severe IUGR was defined as abdominal circumference <5th centile and a Doppler velocimetry in umbilical artery42SD. Diagnosis of HDP was made according to the criteria of the ISSHP. A cardiologist performed maternal echocardiographies to calculate cardiac output (CO), total vascular resistance (TVR) and indexes of diastolic dysfunction evaluated with tissue Doppler (E’/A’).Results: We recruited 16 HDP-AGA, 20 HDP-IUGR, 14 severe IUGR and 19 controls. Heart rate (HR) and CO were significantly decreased and TVR significantly increased in HDP-IUGR and severe IUGR compared to controls. HDP-AGA shows a significantly decrease in E0/A0 compared to all other groups.Discussion: Hemodynamic parameters have different patterns in pregnancies complicated by HDP and/or IUGR. Severe IUGR and HDP-IUGR show a similar profile, despite the absence of abnormal blood pressure in the former group. HDP-AGA, that in our data showed a maternal predisposition to metabolic syndrome, has a different hemodynamic profile, with a predominant diastolic dysfunction respect to the group of HDP-IUGR.

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Objectives To compare the efficacy of intravenous labetalol or oral nifedipine in treatment of acute maternal hypertension and study the fetal and maternal hemodynamic changes using color Doppler ultrasound that follows treatment Methods Thirty women with severe preeclampsia having acute hypertension (more than or equal to 160/105 mmHg) were randomized in 2 groups to receive intravenous labetalol or oral nifedipine until blood pressure was lowered to less than or equal to 140/90 mmHg. Doppler vascular indices namely pulsatility index, resistance index, S/D ratio of umbilical (UA), middle cerebral artery (MCA), maternal uterine and renal artery were measured baseline at the time of acute severe hypertension and repeated after control of blood pressure, to assess the changes in maternal and fetal hemodynamic status with labetalol or nifedipine. Results Both nifedipine and labetalol were found to be effective when used for rapid control of blood pressure. The median time to achieve target blood pressure was 20 min in labetalol group and 30 min in nifedipine group (p = 0.348). Mean age of women in both groups and mean gestational age was statistically comparable. Although labetalol caused more reduction in maternal heart rate after treatment (p = 0.058) which was insignificant compared to nifedipine which had no effect on maternal heart rate. No change in fetal heart rate before and after treatment was observed in both groups, Doppler vascular indices of UA and MCA showed no significant changes as compared to baseline values in both groups. Maternal uterine and renal artery Doppler showed no significant change following labetalol or nifedipine treatment. Conclusions Labetalol and nifedipine use was not related to any significant changes in fetal Doppler, which is reassuring about the safety of these drugs when treating acute severe hypertension in pregnancy. Choice between these two drugs should be based on cost, availability respective contraindications, and clinician’s experience. Disclosures S. Gainder: None. M. Thakur: None. S.C. Saha: None. M. Prakash: None.

Influence of phenylephrine or ephedrine on maternal hemodynamics upon umbilical cord clamping during cesarean delivery

Vasopressors ephedrine and phenylephrine are commonly used with spinal anesthesia during cesarean delivery. Studies on them have focused on the period before the umbilical cord is clamped, although anesthesia is continuously administered throughout and after this event. This study aimed to compare the effects of these drugs on maternal hemodynamics at and after clamping of the umbilical cord. Prospective, randomized, double-blind study. Parturients (n = 60) scheduled for elective cesarean delivery were randomly divided into an ephedrine group and a phenylephrine group. Each woman received an intrathecal injection of bupivacaine (7.5 mg). Patients in the ephedrine and phenylephrine groups were infused continuously with ephedrine (0.02 mg×kg-1×min-1) or phenylephrine (0.25 μg×kg-1×min-1), respectively, from immediately after the injection of bupivacaine until termination 10 minutes after the umbilical cord was clamped (the endpoint). Hemodynamic changes were recorded. After clamping the umbilical cord, the patients who were administered ephedrine experienced significant increases in heart rate (89 ± 11 beats/min to 106 ± 15 beats/min), cardiac output (6.4 ± 0.9 l/min to 7.6 ± 1.2 l/min) and cardiac index (3.5 ± 0.39 l×min-1×m-2 to 4.3 ± 0.48 l×min-1×m-2), while the systemic vascular resistance decreased (908 ± 296 dyne·s/cm5 to 711 ± 285 dyne·s/cm5). Such differences were not observed in the patients who received phenylephrine. Moreover, the heart rate of patients administered ephedrine was higher than that of patients given phenylephrine after clamping the umbilical cord. Continuous infusion of phenylephrine during cesarean delivery maintains a stable maternal hemodynamic status better than ephedrine.

Approach to Trauma During Pregnancy

Approach to Trauma During Pregnancy

Chronic anti-phencyclidine monoclonal antibody therapy decreases phencyclidine-induced in utero fetal mortality in pregnant rats

Illicit drug use during pregnancy is a serious social and public health problem inflicting an array of deleterious effects on both mother and offspring. We investigated the hypothesis that a murine anti-phencyclidine (PCP) monoclonal antibody (mAb6B5; KD=1.3nM) can safely protect mother and fetus from PCP-induced adverse health effects in pregnant rats. Pregnant Sprague–Dawley rats (n=4–5) were intravenously administered bolus injections of PCP (1mg/kg) on multiple days during pregnancy. They were also chronically treated with anti-PCP mAb6B5 at 45mg/kg as a PCP antagonist. This dose provided one mAb–PCP binding site for every four PCP molecules. Therapeutic and safety study endpoints included pregnancy outcome (litter size, number of live vs. dead pups), maternal hemodynamic status and locomotor activity. Maternal hemodynamic changes (i.e., blood pressure and heart rate) and locomotor activity were measured in dams from gestation days 6–21 (one day antepartum) using a radiotelemetry-tracking device with a femoral arterial pressure catheter. This mAb6B5 treatment regimen significantly (p=0.008) reduced the number of PCP-induced in utero fetal deaths (odds ratio=3.2; 95%CI 1.3 to 7.9) and significantly (p<0.05) reduced acute PCP-induced maternal locomotor effects in the second trimester. Maternal hemodynamic responses to PCP were not significantly affected by mAb6B5 treatment. In conclusion, these data suggest that anti-PCP mAb treatments administered during pregnancy can safely protect a mother and her fetus(es) from PCP-related morbidity and mortality even when the mAb dose is too low to significantly prevent other PCP-induced maternal pharmacological effects.

Unexplained Prelabor Uterine Rupture in a Term Primigravida

Uterine rupture is a catastrophic obstetric complication. The main risk factor is a scarred uterus, usually secondary to a previous cesarean delivery. Uterine rupture in a primigravid woman is a very rare event. A 33-year-old primigravida presented at term with severe abdominal pain, signs of hemodynamic instability, and fetal bradycardia. She was not in labor, and the fetal heart tones disappeared before a cesarean could be performed. After a failed attempt at induction, exploratory laparotomy was performed for worsening maternal hemodynamic status. A complete rupture of the posterior uterine wall was found with a well-grown fetus free in the abdominal cavity. The uterus was repaired in two layers, and the patient did well postoperatively. We report the rare occurrence of a spontaneous uterine rupture in a nonlaboring primigravid with no known risk factors. The differential diagnosis of this presentation includes concealed placental abruption, subhepatic hematoma with or without liver rupture, splenic rupture, rupture of the broad ligament, and rupture of a uterine vein. Although uterine rupture occurs more commonly in the multiparous population, it cannot be assumed that the primigravid uterus is immune to rupture.

Clinical Use of Propofol-Rocuronium for Caesarean Section Anesthesia

Background: The effects of propofol-rocuronium on the conditions of tracheal intubation, maternal hemodynamic changes and status of neonates were evaluated in 28 parturients undergoing an elective caesarean section. Methods: Anesthesia was induced with propofol 2 mg/kg and rocuronium 0.6 mg/kg and maintained with --Propofol. Neuromuscular transmission was assessed using the electromyographic response to the train-of-four stimulation of the ulnar nerve at the wrist every 10 s. Intubation was begun at the disappearance of the T3 of the TOF or 80 s from the administration of rocuronium, whichever occurred first. The conditions for tracheal intubation were classified into four grades as excellent, good, poor and inadequate. The time to the T1 disappearance (onset time) and the time to the reappearance of T2 (duration of the effect) were recorded. The maternal arterial blood pressure and heart rates were measured before and after propofol-rocuronium administration. The neonates were evaluated by the 1-5 min Apgar scores and the acid-base status of the umbilical cord blood. Results: The mean intubation time was 74.4 10.1 s and the onset time of rocuronium was 100.8 31.8 s. The intubation conditions were excellent or good in 26 patients (93%) but poor in 2 patients. The maternal arterial blood pressure decreased and the heart rate increased after administering the propofol-rocuronium. The neonatal Apgar scores and blood gas parameters were within the normal range. Conclusions: Rapid sequence intubation using propofol-rocuronium is clinically acceptable as a caesarean section anesthetic.

Acute Aortic Dissection Complicating Pregnancy

Acute aortic dissection occurring during pregnancy represents a lethal risk to both the mother and fetus. Our purpose was to study the prevalence, treatments, and outcome of this rare problem and to suggest therapeutic guidelines. During the past 12 years, 6 pregnant women were admitted with an acute aortic dissection. Four had a type A and 2 had a type B dissection (Stanford classification). Two of the 4 patients with a type A dissection underwent a combined emergency operation consisting of first cesarean section and then ascending aortic repair. Cesarean section was carried out 5 days after the emergency procedure on the aorta in the third patient, and 16 weeks later in the fourth patient. All 4 fetuses were delivered alive. One fetus died 6 days later, but the other 3 are alive and well at long-term follow-up. Of the 2 patients with a type B dissection, 1 was operated on for celiac ischemia; the other was treated medically. In both cases the fetus died in utero. There were no maternal deaths in either group. Cesarean section with concomitant aortic repair is recommended for pregnant women with a type A dissection, depending on the gestational age. The maternal hemodynamic status will determine the sequence of the two procedures. Medical treatment is advised for patients with a type B dissection, but surgical repair is indicated if complications such as bleeding or malperfusion of major side branches occur.

Spinal and epidural anesthesia, fetal and uterine response to acute hypo- and hypertension

1.1. Spinal or epidural anesthesia does not abolish uterine contractility as long as the blood pressure is maintained within normal limits. Factors associated with sensation of pain, bearing down, muscle rigidity, etc., which may enhance or inhibit uterine contractility, however, are abolished by spinal or epidural anesthesia. Although labor after spinal or epidural anesthesia may be altered, the intrinsic uterine work is preserved. In the clinical estimation of the duration of labor in patients with spinal or epidural anesthesia these factors should be considered.2.2. Acute postepidural hypotension resulted in a decrease of uterine contractility, fetal tachycardia, and oscillation of the fetal heart rate. Fetal bradycardia was encountered either with a severe maternal hypotension or more frequently with enhancement of uterine contractility following a posthypotensive period.3.3. Correction of an acute hypotension with one intravenous injection of 3 mg. of methoxamine hydrochloride resulted in 8 cases in tetanic uterine contraction and severe fetal distress.4.4. It is suggested in the management of postspinal hypotension by pressor amines that the intravenous drip should be used and the dose and effect individually followed by clinical monitoring of the fetal heart rate, uterine contractility, and the maternal hemodynamic status.