Maternal Hypotension Research Articles

Chagasic heart failure in a pregnant woman in a non-endemic area: case report and long-term follow-up

Abstract Objectives Chagas disease (CD) is caused by infection with the protozoan Trypanosoma cruzi, a parasite that nests in various tissues, causing irreversible cardiac damage in 30% of patients with chronic disease and neurological or digestive lesions in 10%. CD is now found in areas receiving migrant populations where no vector-borne transmission occurs. Chagasic cardiomyopathy (CC) is the most serious complication of the chronic phase of CD and the major cause of morbidity and mortality among patients with CD. Case presentation Bolivian woman at 38 weeks of gestation was admitted at the emergency room with the diagnosis of congestive heart failure. Cesarean section was performed and maternal hypotension and uterine atony occurred. Dilated myocardiopathy with severe left ventricle dysfunction was diagnosed. The patient referred positive serology for T. cruzi and polymerase chain reaction (PCR) was positive so benznidazole therapy was started. She was discharged due to progressive improvement with cardiological treatment and implantable cardioverter defibrillator was placed 5 years later for the prevention of sudden cardiac death. Conclusions The diagnosis of CC in non-endemic areas requires a high index of suspicion and it is based on serology. Antiparasitic drugs are almost 100% effective in infected newborn babies and highly effective in the treatment of patients in the acute stage of the disease. However, the efficacy of both drugs decreases the longer a person has been infected. Treatment of CC that causes chronic heart failure is similar to that in non-Chagasic etiology.

A case of heterotopic pregnancy with intrauterine and cervical pregnancy coexisting: intrasacular KCl injection, intrauterine pregnancy being preserved, and then massive bleeding at 32 weeks

Background: Heterotopic pregnancy is the condition in which intrauterine and ectopic pregnancy coexist. The conservative management of the ectopic pregnancy, with the intrauterine pregnancy preserved, has been reported. Case(s): Here, we report a very rare case: intrauterine and cervical pregnancy coexist: intrasacular Potassium chloride (KCL) injection successfully terminated cervical pregnancy with intrauterine pregnancy preserved, but later massive bleeding occurred from the cervix. A 39-year-old woman at 7+1 weeks was diagnosed with a heterotopic cervical gestation, with intrauterine and cervical sac, both with live embryos. The ectopic pregnancy was successfully terminated with intrasacular injection of KCl, preserving the intrauterine pregnancy. At 32+4 weeks of gestation the patient started with a profuse bleeding from the cervical sac, causing maternal hypotension (80/45 mmHg) and tachycardia (160 bpm) and a decelerative pattern in the cardiotocographic fetal monitoring, prompting us to perform caesarean section. The cessation of bleeding was achieved using a double balloon intracervical catheter, which was withdrawn 24 hours after its insertion without observing a new bleeding episode. The patient was discharged after 8 days and the newborn after 35 days of life, both in good health. Conclusions: Conservative treatment of a heterotopic gestation is possible, managing to preserve the viability of the intrauterine pregnancy.

A Comparative Study to Evaluate the Effect of Norepinephrine and Phenylephrine in the Treatment of Post Spinal Hypotension for Caesarean Section

Background: Maternal hypotension due to spinal anaesthesia in caesarean section is commonly seen. Alongwith fluid loading, phenylephrine is used to manage the hypotension. However, this drug is associated with cardiovascular side effects. Methods: This is a prospective double blinded study which was conducted on 100 term parturients scheduled from elective caesarean section under spinal anaesthesia, randomly assigned into two groups. After spinal anaesthesia patients of group N and P were treated with norepinephrine (5mcg) and phenylephrine (50mcg) respectively as an IV bolus for hypotension. Blood pressure, heart rate, number of bolus doses given, and neonatal APGAR score was noted. Results: Patients of both groups were comparable with respect to haemodynamic parameters (HR, SBP, DBP, AND MAP). Incidence of bradycardia was higher in group P (22%, n=11) compared to group N (14%, n=7). Neonatal APGAR scores at different time intervals were similar in both groups. Conclusion: Intermittent boluses of norepinephrine were effective in the treatment of spinal anaesthesia induced hypotension during caesarean section and can be considered as an alternative to phenylephrine.

Comparison of phenylephrine and norepinephrine for prevention of hypotension in patients undergoing cesarean section under spinal anesthesia – A randomized prospective study

Background: Hypotension is a common side effect of spinal anesthesia for cesarean section with incidence of upto 71%. Various vasopressors are available for counteracting spinal hypotension each with different pharmacological profile. Norepinephrine is currently one of the feasible options for prophylaxis of spinal induced hypotension in patients undergoing cesarean section. Aims: To compare efficacy of phenylephrine and norepinephrine for reducing incidence of hypotension in patients undergoing cesarean section under spinal anesthesia and their effect on neonatal outcome. The primary outcome compared was incidence of hypotension (defined as fall in systolic blood pressure of >20% from the baseline value or a value <90 mmHg). The secondary outcomes noted were incidence of bradycardia, nausea, vomiting in the mother, and neonatal outcome. Methodology: A total of 80 singleton full term pregnant patients of American Society of Anesthesiology (ASA) grade II scheduled for elective cesarean section were randomly assigned to 2 groups of 40 patients each. Group P received phenylephrine 50 mcg and Group N received norepinephrine 10 mcg as intravenous bolus over 1 min immediately after the patient had been made supine after giving spinal anesthesia. The vital parameters, adverse effects, and neonatal outcome were assessed and analyzed statistically. Results: Intraoperatively, norepinephrine group had a significantly higher mean heart rate than phenylephrine group. Neonatal outcome was similar in both the groups with respect to appearance, pulse, grimace, activity, and respiration (Apgar) scores and umbilical arterial pH. Conclusions: In cesarean section under spinal anesthesia, norepinephrine efficacy in rescuing maternal hypotension is similar to that of phenylephrine without obvious maternal or neonatal adverse outcomes and with a lower incidence of bradycardia.

Comparison of Ramosetron, Ondansetron, and Granisetron in Attenuating Maternal Hypotension after Spinal Anesthesia in Patients Undergoing Lower Segment Caesarean Section

Abstract Background: Spinal anesthesia (SA) has many advantages in lower segment caesarean section (LSCS), but hypotension is the main issue that can be managed in different ways. This study was conducted to know the effectiveness of three intravenous serotonin receptor antagonists (ramosetron, ondansetron, and granisetron) in the prevention of bradycardia and hypotension during LSCS under SA. Patients and Methods: A total of 160 parturients posted for LSCS under SA were enrolled in this study and divided equally into four groups. Five minutes before SA, Group R received intravenous (IV) 0.3 mg ramosetron, Group O received 4 mg ondansetron IV, Group G received 1 mg granisetron IV, and Group S received IV normal saline. All solutions were diluted with normal saline to 5 mL to blind the drugs. Heart rate (HR), systolic and diastolic blood pressure, and mean arterial pressure were recorded. The total consumption of vasopressor and side effects were recorded. Results: The decrease in mean arterial pressure and mean HR was significantly lower in group R than other groups at all intervals (P &lt; 0.05). The incidence of hypotension was 25% in group R compared with 42.5%, 55%, and 72.5% in groups O, G, and S, respectively. Conclusion: Premedication with intravenous ramosetron significantly reduced hypotension, HR, and total vasopressor usage in LSCS parturients. Intravenous ondansetron and granisetron had lesser effects than ramosetron.

Randomized trial of bolus ephedrine or mephentermine for maintenance of arterial pressure and fetal outcome during spinal anesthesia for the cesarean section

Background and Aims: Spinal anesthesia remains the preferred choice for cesarean deliveries, but hypotension is one of the common complications which may have detrimental effects on both the mother and fetus. In this study, we compared the efficacy and adverse effects of bolus doses of ephedrine hydrochloride and mephentermine sulfate administered intravenously to treat spinal-induced hypotension and the fetal outcomes through Apgar scores and umbilical cord blood gas analysis in the lower segment cesarean section. Material and Methods: In this prospective, randomized, double-blind study, 60 patients undergoing the lower segment cesarean section (LSCS) under spinal anesthesia were randomized into two groups of 30 each using computer-generated random numbers which were kept in an opaque envelope. Patients were pre-loaded with Ringer's lactate solution 10 ml/kg before the spinal anesthesia. Hypotension was defined as the fall in systolic blood pressure of less than or equal to 20% of the baseline or systolic blood pressure of less than 90 mmHg. Whenever hypotension occurred, patients in group E (ephedrine) received a bolus dose of ephedrine 6 mg intravenous and patients in group M (mephentermine) received a bolus dose of mephentermine 6 mg intravenous. Intra-operative recording included maternal hemodynamic parameters and the number of bolus doses of study drugs required to treat maternal hypotension and the adverse effects of study drugs. The Apgar score and umbilical cord blood gas values were recorded. Data were analyzed by analysis of variance test, Student's t-test, and Chi-square test. A P value of < 0.05 was considered as significant. Results: There was a statistically significant (p < 0.05) increase in systolic and mean arterial blood pressure at the second min and fourth min after administration of ephedrine in group E compared to mephentermine in group M. The systolic blood pressure at the second min in the ephedrine group was 114.3 ± 12.06, whereas in the mephentermine group, it was 106.10 ± 8.41 and was statistically significant (p < 0.05). At the fourth min, the systolic blood pressure in the ephedrine group was 115.03 ± 8.87, whereas in the mephentermine group, it was 108.46 ± 8.10 and was statistically significant (p < 0.05). There was a transient increase in heart rate immediately after administration of spinal anesthesia. The mean number of bolus doses of vasopressor consumption was 2.4 (14.4 mg) in the ephedrine group and 2 (12 mg) in the mephentermine group. The umbilical cord blood gas analysis and Apgar scores were similar in both the groups. Three patients (10%) developed bradycardia in the mephentermine group compared to the ephedrine group (0%). The incidence of nausea (13.3% vs 3.3%) and vomiting (10% vs 1%) was higher in the ephedrine group compared to the mephentermne group, and it was not statistically significant (p > 0.05). No significant differences were observed in the umbilical arterial blood pH and Apgar scores. Conclusion: In conclusion, after hypotension, ephedrine and mephentermine administration as bolus doses are equally efficacious in preventing spinal-induced hypotension in patients undergoing the cesarean section and are associated with similar neonatal outcomes.

Mephentermine vs. Phenylephrine for Prevention and Management of Maternal Hypotension during Caesarean Section under Spinal Anaesthesia and their Effects on Foetal Outcome- A Randomised Control Trial

Introduction: For the best maternal and foetal outcome during caesarean section under spinal anaesthesia, maintaining Systolic Blood Pressure (SBP) at 100% of the baseline is necessary. Mephentermine and Phenylephrine are both sympathomimetic drugs used for timely correction of maternal hypotension. Aim: To compare the effect of intravenous bolus administration of mephentermine and phenylephrine for prevention and management of maternal hypotension and to evaluate the foetal outcome. Materials and Methods: In this randomised double-blinded controlled trial, a total of 150 American Society of Anaesthesiologist (ASA) II scheduled for elective Lower Segment Caeserean Section (LSCS) were randomly allocated into three groups to receive the study drugs: group A received mephentermine 6 mg in 2 mL Normal Saline (NS), group B received phenylephrine 100 mcg in 2 mL NS, and group C received 2 mL NS immediately following subarachnoid block. Whenever hypotension occurred (Systolic Blood Pressure (SBP) &lt;90 mm Hg) rescue boluses were given. Maternal haemodynamic parameters, umbilical cord blood gases, and complications were recorded from the time of sub-arachnoid block till the end of surgery. Results: There was no significant difference in the maternal haemodynamics and neonatal outcome among the three groups. It was observed that phenylephrine had quick peak effect, higher foetal umbilical pH and better neonatal outcome though statistically insignificant. Incidence of significant bradycardia (16%) and absence of intraoperative nausea and vomiting were also reported among group B. None of the neonate had APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) score &lt;7 and the umbilical pH was comparable in all the three groups (p &gt;0.05). The time of first rescue vasopressor and the total volume of requirement was earlier and higher in group C with the mean timing of 5.87±4.37 min and mean volume of 2.68±1.58 mL respectively. Conclusion: There is a significant improvement of arterial blood pressures and better neonatal outcome observed when phenylephrine (100 mcg) and mephentermine (6 mg) are given as a prophylactic intravenous (i.v.) bolus dose immediately after subarachnoid block; especially in the initial time period between skin incision and delivery of the baby. When given as a prophylactic i.v. bolus, it had the advantage of lesser total dose requirement of the vasopressor used and better haemodynamic maintenance till the delivery of the baby

Effect of Intravenous Ondansetron for Prevention of Spinal Anaesthesia Induced Hypotension during Caesarean Section

Introduction: Hypotension is one of the most common complications associated with spinal anaesthesia. Maternal hypotension during caesarean section is more dangerous as it can compromise fetal outcome. Serotonin (5-HT3) has been found to induce Bezold Jarisch Reflex (BJR) causing bradycardia and hypotension in background of decreased blood volume. Ondansetron, a serotonin antagonist may play important role in prevention of spinal induced hypotension. The aim of this study is to determine the effect of intravenous ondansetron to prevent spinal induced hypotension during caesarean section. Methods: A prospective randomised double blind study was done among singleton parturients scheduled for elective caesarean delivery under spinal anaesthesia from July 2nd 2020 to October 31st 2021 in College of Medical Sciences Teaching Hospital. One hundred and thirty patients were randomised by lottery method into two groups (group S and group O) each with 65 patients to receive either 4 mg of intravenous (IV) ondansetron diluted in 10 ml of normal saline or 10 ml of normal saline alone. Various haemodynamic parameters like systolic and diastolic blood pressure (SBP/DBP), mean arterial pressure (MAP), heart rate (HR), oxygen saturation (Spo2) and vasopressor requirement were compared between the two groups using SPSS 20. Student’s t test and chi-square test were used for comparison of parametric and non-parametric data. Results: Incidence of hypotension was 28 (43.07%) in saline group and 11 (16.92%) in ondansetron group. There were statistically significant differences in SBP, DBP and MAP at three, six, nine twelve, fifteen and eighteen minutes. Incidence of shivering was 15 (23.07%) in ondansetron while 28 (43.07%) in saline group which was statistically significant. No other benefit of ondansetron was observed in present study. Conclusions: Prophylactic administration of IV ondansetron could significantly reduce the incidence of spinal induced hypotension during caesarean section.

Ephedrine use in laboring patients with epidural anesthesia and risk of cesarean delivery

Epidural anesthesia may causes maternal hypotension, which may manifest with maternal symptoms or changes in fetal heart rate (FHR) thought to be due to transient placental hypoperfusion. Different treatments have been proposed for epidural-related hypotension, including ephedrine or phenylephrine. Ephedrine has been chosen as first line treatment at our center; however, the medication per se may cause fetal acidemia, possibly compounding the effects of maternal hypotension. The possible effect of ephedrine on risk of cesarean delivery (CD) in laboring women has not been studied; we have assessed whether ephedrine administration increases the risk of cesarean delivery (CD).

Risk factors for fetal acidemia at time of scheduled cesarean delivery

While fetal acidemia is most commonly detected after labor or in the setting of non-reassuring fetal status, it can also be seen in the setting of scheduled prelabor cesareans. We identified risk factors for unexpected acidemia at time of scheduled cesarean. This was a nested case-control study of all women delivering live, non-anomalous neonates via scheduled cesarean ≥ 37 weeks gestation from 2004-2014 at a single tertiary care center with a universal cord gas policy. Women with onset of labor prior to cesarean or cesarean performed for non-reassuring fetal status were excluded from this study. The primary outcome was the incidence of fetal acidemia (umbilical artery [UA] pH < 7.20). Bivariate analysis was conducted to identify maternal and fetal factors associated with acidemia. Multivariable logistic regression was used to adjust for confounders. Of 2081 pregnancies meeting inclusion criteria, 252 (12.1%) were complicated by fetal acidemia. In the bivariate analysis, breech presentation, macrosomia, gestational diabetes, and obesity were associated with acidemia (Table). In the multivariable regression model, obesity and breech presentation were the only remaining risk factors associated with acidemia after adjusting for confounding (Figure). There was a dose-dependent increase in odds of acidemia as BMI increased, with class 3 obesity (BMI > 40 kg/m2) conferring 3-fold increased odds of acidemia compared to non-obese women (aOR 3.00, 95% CI 2.01-4.47). In a secondary analysis using pH < 7.10 as the outcome, Class 3 obesity was the only significant risk factor (aOR 3.14, 95% CI 1.66-5.95). Maternal obesity and breech presentation confer an increased risk of fetal acidemia at the time of scheduled cesarean section, even in the setting of reassuring monitoring prior to delivery. Further research is needed to identify if any additional operative factors such as maternal hypotension or increased operative time may explain the increased odds of acidemia in these at-risk patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Rate of decline of fetal base excess (BE) after neuraxial anesthesia for scheduled cesarean delivery

In scheduled cesarean deliveries (CD), rate of decrease in umbilical artery (UA ) pH is related to the severity of maternal hypotension and interval from spinal placement to delivery (Rimsza RR et al. AJOG 2019;389.e9). Base excess (BE) values have a significantly greater usefulness than UA pH values because they do not change with respiratory acidosis and demonstrate a linear, rather than logarithmic, correlation to the degree of metabolic acidosis. Fetuses at term have BE of -2± 0.6 mmol/L (Lazarevic et al.

Colloid coload versus crystalloid coload to prevent maternal hypotension in women receiving prophylactic phenylephrine infusion during caesarean delivery: a randomised controlled trial

BackgroundThe optimal fluid strategy to prevent maternal hypotension during caesarean delivery remains unclear. This study aim was to compare the incidence of post-spinal anaesthesia hypotension in women receiving either colloid or crystalloid coload in the setting of prophylactic phenylephrine infusion during caesarean delivery. MethodsHealthy mothers undergoing elective caesarean delivery under spinal anaesthesia were randomised to receive a rapid intravenous coload with 6% hydroxyethyl starch 130/0.4 10 mL/kg (colloid group) or balanced crystalloid solution (Plasma Solution A) 10 mL/kg (crystalloid group) during spinal anaesthesia. All women had a prophylactic phenylephrine infusion initiated at 25 μg/min immediately after the subarachnoid block and titrated to systolic blood pressure using a standardised protocol. The primary outcome was the incidence of hypotension (systolic blood pressure <80% of baseline) until delivery. ResultsThe incidence of hypotension was 50% in the colloid group and 62% in the crystalloid group (absolute difference, −12% [95% CI −33% to 9%]; relative risk, 0.8 [95% CI 0.56 to 1.14]; P=0.314). No significant difference between groups was found in the number of hypotensive episodes (median 0.5 [IQR 0 to 1] vs 1 [0 to 2], P=0.132) or phenylephrine dose (675 [IQR 425 to 975] μg vs 750 [625 to 950] μg, P=0.109). The incidence of severe hypotension, symptomatic hypotension, bradycardia, nausea, and the neonatal outcomes were not significantly different. ConclusionsThis study found no benefit of colloid coload compared with crystalloid coload for preventing maternal hypotension in the presence of prophylactic phenylephrine infusion during caesarean delivery.

English

BACKGROUND Subarachnoid block has been widely used for caesarean sections and is found to be safe. Hypotension being the most common complication may adversely affect both the mother and foetus. Different measures used to treat this hypotension include preloading with crystalloids/colloids and treatment with vasopressors. The standard choice of vasopressor agents such as ephedrine and phenylephrine is still a controversial issue. It is therefore important to compare the efficacy of the two drugs in the prevention and treatment of maternal hypotension after subarachnoid block and particularly assess their effect on the foetus. The purpose of this study was to assess and compare the foetal acid-base status and APGAR score following administration of bolus dose of ephedrine or phenylephrine that was given intravenously for maintenance of arterial blood pressure during lower segment caesarean section (LSCS) under a subarachnoid block. METHODS 100 parturients (18 to 35 years) scheduled for elective caesarean section under subarachnoid block were selected and divided into two groups of 50 each. Group P received 50 mcg i.v bolus of phenylephrine and Group E received 6 mg of ephedrine IV bolus whenever the blood pressure dropped 20 % from baseline or systolic blood pressure ˂ 90 mmHg. Haemodynamic parameters were measured in all patients. APGAR scores at 1 and 5 minutes following delivery of baby were assessed and cord blood was obtained for acid-base status analysis immediately following delivery. RESULTS Hemodynamic parameters including heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure did not show any significant difference between the two groups, however, Group E showed higher heart rates. The difference in umbilical artery pH (P-value &lt; 0.001) and base excess (P-value = 0.004) was statistically significant with Group E showing lower pH and higher base excess values than Group P. There was no statistically significant difference in neonatal APGAR scores between the two groups. CONCLUSIONS Phenylephrine and ephedrine are equally efficient in managing hypotension during subarachnoid block for caesarean delivery. Thus, either vasopressor can be used although phenylephrine may be a better choice. KEY WORDS Caesarean Section, Phenylephrine, Ephedrine.

Comparison of Norepinephrine and Ephedrine Boluses in the Control of Spinal Anesthesia-Induced Hypotension during Cesarean Section: A Randomized Controlled Trial

Introduction: Phenylephrine and ephedrine are the first-line vasopressors used in obstetric anesthesia to manage maternal hypotension, but phenylephrine is sometimes associated with maternal cardiac depression, limiting its use among mothers with cardiac comorbidities. The use of ephedrine is generally associated with maternal tachycardia along with a decrease in fetal pH. Norepinephrine is another vasopressor that has recently been introduced in obstetrical anesthesia and has attracted increasing attention as a feasible substitute for these two molecules in this context. The objective of our study is to compare two vasopressor agents (norepinephrine vs ephedrine) dedicated to the treatement of post-spinal anesthesia hypotension, and then to define the place of norepinephrine in the pharmacopoeia of the latter. Materials and Method: A Randomized controlled study of 80 ASAI parturient randomized to receive either 8µg boluses of norepinephrine (NG)or 6mg boluses of ephedrine(EG).The criteria for judgment included the occurrence of tachycardia, the maintenance of blood pressure, and the number of boluses required, as well as the clinical condition of the neonate. Results: The incidence of tachycardia (HR&gt;80bpm) was lower in NG (18%) compared to that in EG(67.6%) p=0.0001, crude Odds Ratio 14.968 95% CI] 4.924, 45.505[ . Six in NG (12%) and eight in EG (26.7%) patients experienced nausea, OR 2.667 95% CI] 0.823-8.641[while only three in NG (6%), and four EG (13%) patients experienced vomiting p=0.41 OR:2.41 CI 95% ]0.501-11.605[. Blood pressure was stablefor both groups but with a superiority of norepinephrine which allowed more marked maintenance: 75% to 112% of the initial systolic value in NG versus 72% to 100% in EG), the difference was highly significant p&lt;0.0001. No significant differences in neonatal outcomes were observed. Conclusion: Norepinephrine can maintain blood pressure more effectively than ephedrine with less incidence of tachycardia .............

Norepinephrine versus Ephedrine Boluses To Treat Spinal-Induced Hypotension in Cesarean Deliveries

Abstract Corresponding Background Cesarean sections normally require an anesthetic block at T4 level, so hypotension is reported to occur in up to 80% of spinal anesthesia cases. When maternal hypotension associated with spinal anesthesia for cesarean section is severe and sustained, it can lead to serious maternal complications as well as impairment of the uterine and placental blood flow with consecutive fetal hypoxia, acidosis, and neurological injury. Aim of the Work to compare the administration of intermittent i.v. boluses of norepinephrine and ephedrine to counterbalance the hypotensive effect of spinal anesthesia during cesarean delivery. The results of the study showed that compared with ephedrine, norepinephrine maintained maternal blood pressure and uterine artery blood flow. Further, it was associated with lower numbers of hypotension and hypertension episodes and less frequency of bradycardia and tachycardia during cesarean delivery. Furthermore, the numbers of boluses of vasopressors used during spinal anesthesia were lower in norepinephrine compared with the use of ephedrine. Conclusion Norepinephrine can be used as an alternative vasopressor to maintain maternal blood pressure during spinal anesthesia for cesarean delivery, with no adverse effect on neonatal outcome.

Maternal Hypotension and Tachysystole Following Neuraxial Anesthesia: Effect on Fetus in Labor.

Maternal Hypotension and Tachysystole Following Neuraxial Anesthesia: Effect on Fetus in Labor.

Spinal Anesthesia-induced Hypotension: Is it More Than Just a Pesky Nuisance?

(Am J Obstet Gynecol. 2002;223:621–623) As early as the 1930s, maternal hypotension had been recognized as a significant problem when administering spinal anesthesia. Over the decades, the use of spinal anesthesia has peaked and waned as the practice of anesthesia has evolved. But since the 1990s, it has seen a resurgence as pencil-point needles reduced headache risk and the hemodynamic changes were better understood and management strategies were developed.

The Effect of Spinal Hypotension and Anesthesia-to-delivery Time Interval on Neonatal Outcomes in Planned Cesarean Delivery

(Am J Obstet Gynecol. 2020;223:747.e1–747.e13) While spinal anesthesia is the preferred anesthetic in planned cesarean deliveries (CDs), one of its major drawbacks is the potential for maternal hypotension. The literature has demonstrated the relationship between the degree of hypotension and neonatal acidosis, but the effect of hypotension duration is unclear. In addition, the window between the administration of anesthesia to delivery may provide an opportunity to decrease the risk of adverse neonatal events. The aim of this study was to examine the effect of maternal hypotension and the anesthesia-to-delivery time interval on neonatal events in planned CDs.

Comparison of norepinephrine and phenylephrine infusions for maintenance of haemodynamics following subarachnoid block in lower segment caeserean section.

Background and Aims:Phenylephrine is the vasopressor of choice in spinal anaesthesia–induced maternal hypotension. However, it results in reflex bradycardia and decrease in cardiac output (CO), an effect that is perhaps less evident with the use of norepinephrine. We sought to evaluate the effect of phenylephrine and norepinephrine infusion on maternal systolic blood pressure (SBP), heart rate (HR), intraoperative nausea vomiting (IONV) and fatal Apgar scores.Methods:A randomised double-blind study was conducted on 200 American Society of Anesthesiologists (ASA) II–III parturients undergoing caesarean section under subarachnoid block (SAB) who were randomised to two groups A and B to receive variable rate, manually controlled infusions of phenylephrine and norepinephrine targeting maintenance of SBP to 100% of the baseline value. Maternal haemodynamics especially episodes of hypotension, IONV and vasopressor consumption were observed and recorded.Results:A statistically significant trend of lower SBP was observed during the first 6 min following intrathecal injection in group A (P value – 0.000). Though a greater number of parturients experienced ≥1 episode of hypotension in Group A vs Group B (13% vs 9%), the difference was, however, statistically insignificant. The incidence of bradycardia was higher in group A than in group B (16% vs 1%) and was found to be statistically significant (P < 0.05). The episodes of hypertension, IONV, maternal vasopressor consumption and neonatal Apgar score were comparable among both the groups.Conclusion:A dilute solution of norepinephrine infusion is comparably efficacious to the current gold standard vasopressor phenylephrine in maintaining blood pressure following spinal anaesthesia for caesarean delivery, with a significantly lower incidence of bradycardia.

The association between persistent maternal hypotension and small for gestational age neonates

The association between maternal hypotension and poor fetal growth has not been well studied. We hypothesized that the presence of persistent maternal hypotension will reflect a chronic reduction of uteroplacental blood flow, leading to placental hypoperfusion and subsequent poor fetal growth. We aimed to evaluate whether persistent hypotension is associated with the risk of having a small for gestational age neonate. A secondary aim was to evaluate whether transient hypotension is associated with the same risk of having a small for gestational age neonate. We performed a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be data, a large prospective cohort study of nulliparous women. The inclusion criteria included delivery of subjects with singleton pregnancies at ≥24 weeks' gestation who had systolic and diastolic blood pressure data at 3 antenatal visits between 6 0/7 and 29 6/7 weeks' gestation. Univariable analyses were performed to evaluate the association among persistent hypotension (systolic blood pressure of <100 mm Hg and or diastolic blood pressure of <60 mm Hg at 3 antenatal visits), transient hypotension (systolic blood pressure <100 mm Hg and diastolic blood pressure <60 mm Hg at any 1 of 3 aforementioned visits but not all 3), maternal characteristics and small for gestational age neonates. Variables found to be significant (P<.05) were included in multivariable logistic regression. Here, 164 of 7233 participants (2.3%) had persistent hypotension. In univariable analyses, subjects with persistent hypotension compared with those without were significantly more likely to have small for gestational age neonates (21.3% vs 11.6%; P<.001). When adjusting for confounders, persistent hypotension remained significantly associated with an increased risk of having a small for gestational age neonate (adjusted odds ratio, 1.65; 95% confidence interval, 1.11-2.44). In multivariable analysis, transient hypotension was not associated with an increased risk of having a small for gestational age neonate. Persistent hypotension was significantly associated with small for gestational age among neonates born to low-risk nulliparous women.