Treatment Of Maternal Hypotension Research Articles

Left-lateral position versus phenylephrine prophylactic treatment for hypotension following combined spinal epidural anesthesia during elective cesarean section

BackgroudHypotension is one of the most common and dangerous complications following combined spinal epidural anesthesia during elective cesarean delivery. Many methods are used to prevent or treat the hypotension with pharmacological or non-pharmacological measures. Our aim was to assess left-lateral position and phenylephrine prophylactic treatment for the prevention or treatment of maternal hypotension. MethodsA total of 127 pregnant women were enrolled to be analyzed. The primary outcome measure was the incidence of maternal hypotension and secondary outcome measures included maternal demographic characteristics, anesthesia-to-incision time interval, birthweight and Apgar scores. ResultsThe incidence of hypotension was 65.4 % in sequential reactive treatment and only 11.3 % achieved complete anesis after left-lateral position, significantly higher than 17.4 % in left-lateral position combined phenylephrine prophylactic treatment (P < 0.001). The increasing in gestational age may decrease the hypotension risk (P < 0.001). There were no significantly differences with maternal age, gravidity, parity, BMI before pregnancy, BMI before cesarean section, anesthesia-to-incision time interval, birthweight and Apgar scores (P > 0.05). The univariate logistic regression analysis revealed a significant association between treatment and hypotension (OR 0.11, 95 % CI 0.05–0.27). After adjusting for confounding variables, the risk of hypotension was decreased in subjects with treatment (OR 0.1, 95 % CI 0.04–0.25; OR 0.15, 95 % CI 0.05–0.43; OR 0.16, 95 % CI 0.05–0.46). The results of stratified and interaction analyses of the association between treatment revealed no interactive role from maternal age, gravidity and BMI before cesarean section (P > 0.05). ConclusionsSingle use of left-lateral position had limited effective and left-lateral position combined prophylactic phenylephrine used may be much better to prevent or treat hypetension, but larger studies with more robust data are needed to confirm these findings.

Neurodevelopmetal effects of maternal blood pressure management with noradrenaline during general anaesthesia for nonobstetric surgery in the pregnant rabbit model.

In pregnant women, anaesthesia-induced hypotension is commonly treated using phenylephrine or noradrenaline, the rationale being to maintain uterine perfusion pressure and thereby uterine blood flow. Evidence for this strategy during general anaesthesia for nonobstetric surgery is absent. To analyse the effects of treating anaesthesia-induced hypotension with noradrenaline on brain development of rabbit foetuses of mothers subjected to general anaesthesia for nonobstetric surgery. We hypothesised that treatment of maternal hypotension would improve foetal outcomes. Randomised controlled laboratory study using 21 pregnant rabbits (does) at 28 days of gestation. Two hours of sevoflurane anaesthesia for a laparotomy without treatment of anaesthesia-induced hypotension (hypotension group) or with maintaining maternal mean arterial pressure above 80% of the awake value using noradrenaline (noradrenaline group). In the control group, does remained untouched. At term, all pups were delivered by caesarean section. One day later, the neurobehaviour of the pups was assessed and brains were harvested. Neuron density in the frontal cortex for the comparison of noradrenaline groups versus hypotension groups was the primary outcome; the neurobehavioural scores and other histological outcomes were secondary outcomes. In the noradrenaline groups and hypotension groups, neuron density in the frontal cortex was similar (1181 ± 162 versus 1189 ± 200 neurons mm-2, P = 0.870). However, significantly less foetal survival, lower sensory scores in neurobehavioural assessment and less proliferation were observed in the noradrenaline group when compared with the hypotension group. Neuron densities in other regions, total cell densities, biometrics and synaptogenesis were not affected. There were no differences between the control group and hypotension group. During general anaesthesia for nonobstetric surgery in rabbits, treatment of anaesthesia-induced hypotension using noradrenaline did not affect neuron densities but was associated with impaired foetal outcomes according to several secondary outcome parameters. Further studies are needed to investigate any clinical relevance and to determine the target blood pressure in pregnant women during general anaesthesia.KEY POINTSIn pregnant women, anaesthesia-induced hypotension is commonly treated using phenylephrine or noradrenaline, with the rationale to maintain uterine perfusion pressure and thereby uterine blood flow.Evidence for this strategy during general anaesthesia for nonobstetric surgery is absent.We investigated the effects of treating anaesthesia-induced hypotension with noradrenaline on the brain development of rabbit foetuses, of mothers subjected to general anaesthesia for nonobstetric surgery.We hypothesised that treatment of maternal hypotension would improve foetal outcomes.Neuron densities were similar but significantly less foetal survival, impaired neurobehaviour and less proliferation were observed after treatment of anaesthesia-induced hypotension with noradrenaline, compared with untreated hypotension.

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.

Check the Blood Pressure!: An Educational Tool for Anesthesiology Trainees Converting Epidural Labor Analgesia to Cesarean Delivery Anesthesia.

Recognition and treatment of maternal hypotension during epidural anesthesia administration for intrapartum cesarean delivery preserves maternal-fetal perfusion. A case that required quality assurance review uncovered lapses in maternal hemodynamic monitoring during the transition to intrapartum cesarean delivery anesthesia. To address this, a practice outline was designed for trainee's education describing intrapartum epidural dosing for cesarean delivery and adequate blood pressure monitoring. The time-lapse between epidural dosing and subsequent blood pressure was evaluated before and after the introduction of our educational tool. The time-lapse between blood pressure measures decreased to <10 minutes (10.78-13.92 vs 8.8-9.76 minutes).

Ephedrine versus phenylephrine: effects on fetal acid-base status during spinal anesthesia for elective cesarean delivery

Background: During elective caesarean sections, post-spinal hypotension is a common problem. Prevention of this complication by sympathomimetic agents is of potential clinical significance. The objective of this study was to compare and evaluate the effects of ephedrine and phenylephrine on the fetal outcome when used in the treatment of maternal hypotension during spinal block in elective caesarean section.Methods: After fulfilling the inclusion criteria, hundred patients were enrolled in this study and were randomly allocated into two groups of fifty each. According to their group, patients received either ephedrine 6 mg (group E) or phenylephrine 75µg (group P) as vasopressor. For spinal anaesthesia lumber puncture was done in sitting position and 12.5mg, 0.5% hyperbaric bupivacaine was given intra-thecally to every patient. Throughout surgery, maternal and neonatal complications were controlled and recorded. During the study, Apgar scores on the 1st and 5th minutes, and blood gases of the umbilical cord blood were evaluated.Results: Ephedrine and phenylephrine were used in the mean doses of 6.72±1.97mg and 91.5±31.38µg respectively. There was no significant difference observed in total number of boluses used in treating post-spinal hypotension. The difference in the first- and fifth-minute Apgar scores was statistically insignificant between the group E and group P. There was a statistically significant difference observed in SaO2 and base excess in arterial gas sample between two studied groups. Similarly, a significant difference was observed in PCO2 of umbilical venous sample between two studied groups. However, none of the neonates had the true fetal acidosis.Conclusions: Intravenous phenylephrine 75µg and ephedrine 6 mg offer a comparable hypotensive control without any significant complication for mother or her fetus in elective caesarean section.

Old Ways Do Not Open New Doors: Norepinephrine for First-line Treatment of Spinal Hypotension

(Anesth Analg. 2018;126:1809–1811) Although phenylephrine is the first-choice vasopressor for the prevention and treatment of maternal hypotension during spinal anesthesia for cesarean delivery, its sole action as an alpha-adrenergic agonist can cause significant dose-dependent bradycardia, which in turn, may compromise fetal health. Consequently, norepinephrine, which has both alpha-1-adrenergic and beta-1-adrenergic activity has been proposed as an alternative.

Norepinephrine Intermittent Intravenous Boluses to Prevent Hypotension During Spinal Anesthesia for Cesarean Delivery: A Sequential Allocation Dose-Finding Study

(Anesth Analg. 2017;125(1):212–218) Phenylephrine, which is easy to titrate, is the current first-choice vasopressor for prevention and treatment of maternal hypotension during spinal anesthesia for cesarean delivery (CD). However, it has a propensity to increase afterload and reduce maternal heart rate and cardiac output. Norepinephrine has been suggested as an alternative, with a proposed potency ratio for norepinephrine to phenylephrine of 16:1, although its administration as a bolus during CD has not been established. The authors of the present study thus determined the effective norepinephrine dose (ED90), when given as intermittent intravenous boluses, to prevent post-spinal hypotension in women undergoing elective CD.

Norepinephrine Intermittent Intravenous Boluses to Prevent Hypotension During Spinal Anesthesia for Cesarean Delivery: A Sequential Allocation Dose-Finding Study.

The use of phenylephrine as the first-line agent for prevention and treatment of maternal hypotension during cesarean delivery (CD) may reduce cardiac output, posing a theoretical risk to mother and fetus. Norepinephrine has been suggested as a potential alternative, because its β-adrenergic effects might result in greater heart rate and cardiac output than phenylephrine. The use of norepinephrine to prevent and treat hypotension during CD is new, and its use as a bolus has not been fully determined in this context. The purpose of this study was to determine the effective norepinephrine dose, when given as intermittent intravenous (IV) boluses, to prevent postspinal hypotension in 90% of women undergoing elective CD (ED90). This was a prospective, double-blind sequential allocation dose-finding study, using the biased coin up-and-down design. Forty-term pregnant women undergoing elective CD under spinal anesthesia received a set intermittent norepinephrine bolus of either 3, 4, 5, 6, 7, or 8 µg every time their systolic blood pressure (SBP) fell to below 100% of baseline. The primary outcome was the success of the norepinephrine regimen to maintain SBP at or above 80% of baseline, from induction of spinal anesthesia to delivery of the fetus. Secondary outcomes included nausea, vomiting, hypertension (SBP > 120% of baseline), bradycardia (<50 bpm), upper sensory level of anesthesia to ice cold and umbilical artery and vein blood gases. The ED90 and 95% confidence intervals (CIs) were estimated using both truncated Dixon and Mood and isotonic regression methods. The estimated ED90 of norepinephrine was 5.49 µg (95% CI, 5.15-5.83) using the truncated Dixon and Mood method and 5.80 µg (95% CI, 5.01-6.59) using the isotonic regression method. The use of intermittent IV norepinephrine boluses to prevent spinal-induced hypotension in elective CD seems feasible and was not observed to be associated with adverse outcomes. Practically, we suggest an ED90 dose of 6 µg. Further work is warranted to elucidate the comparative effects of intermittent IV bolus doses of phenylephrine and norepinephrine, in terms of efficacy and safety.

Prevention and treatment of maternal hypotension under combined spinal and epidural anesthesia for caesarean section

Background Maternal hypotension is a common complication of combined spinal and epidural anesthesia(CSEA) during caesarean delivery, which is associated with adverse effects on both the mother and the fetus when appropriate treatments were not used. Objective To review the effects of different methods for preventing and treating maternal hypotension, improving the circulation and internal environment of maternal and fetus according to the mechanism of hypotension, and to provide a reference for clinical anesthesia. Content Hypotension could be relieved by the following treatments: fluid preloading, maternal position, anesthesia plane, local anesthetic, the 5-hydroxytryptamine 3(5-HT3) receptor antagonist, anticholinergic drugs or vasopressors although their effects are different. Therefore, combination of these treatments can get better effects. Trend Predicting the incidence and severity of hypotension according to maternal different conditions may help choose the targeted strategies, while more relevant researches should be carried out. Key words: Combined spinal and epidural anesthesia; Hypotension; Cesarean section

Phenylephrine versus ephedrine usage in the management of hypotension-induced spinal anaesthesia in pre-eclamptic patients undergoing caesarean section

Objective The aim of the current study is to assess and compare the effect of using phenylephrine and ephedrine for the prevention and treatment of maternal hypotension associated with induction of spinal anaesthesia in pre-eclamptic women undergoing a caesarean section. Study design This was a prospective randomized-controlled study. Patients and methods Sixty full-term pre-eclamptic patients, undergoing caesarean section under spinal anaesthesia, were divided into four groups: group 1 was administered 5 mg ephedrine intravenously and 5 mg boluses whenever there was maternal hypotension. Group 2 was administered 25 µg intravenous bolus phenylephrine and 25 µg boluses whenever there was maternal hypotension. Group 3 was administered a phenylephrine infusion at 25 µg/min; subsequently, the rate of infusion was adjusted according to systolic blood pressure (SBP). Group 4 was administered 15 ml/kg lactated ringer solution before spinal anaesthesia; subsequently, the rate of infusion was adjusted according to SBP. Results There was no statistically significant difference in the maternal heart rate changes, SBP changes, Doppler study of the uterine arteries, newborn blood pH and Apgar scores at 1 and 5 min between the four groups. Conclusion The use of an ephedrine or a phenylephrine infusion for the treatment of hypotension induced by spinal anaesthesia in pre-eclamptic patients yields comparable maternal and neonatal outcomes; further studies on a larger sample study are recommended to confirm our results.

HYPOTENSION AFTER SPINAL ANAESTHESIA;

Objective: Aim of the study is to compare the efficacy of Ephedrine and Phenylephrine for treatment of hypotension afterspinal anaesthesia for elective caesarean section. Study design: Randomized Clinical Trial. Setting: Operation theatre Department ofAnaesthesiology, Combined Military Hospital Quetta. Duration of study: Six month from 16th Sep 2011 to 15th March 2012. Materialand Method: Seventy women undergoing LSCS for singleton pregnancy under spinal anesthesia were randomly assigned in group A andB (35 in each group). All patients preloaded with Lactated Ringer’s solution 15ml/kg body weight 10 minutes before administration ofspinal anaesthesia. Mean Arterial Pressure (MAP) was recorded before administration of spinal anaesthesia considered as Base-lineMAP and then at 1 Minute, 3 minutes &amp; at 5 minutes after administration of spinal anaesthesia. When hypotension developed (MAP falls&gt;20% from base line), intravenous single dose of ephedrine administered in group A patients, while in group B, Phenylephrine was given.Blood pressure was recorded after 1 minute following drug administration and up to 3 minutes at 1 minute interval. Patient handed over forprocedure after 10 minutes of spinal block. The SPSS version 13 was applied to the data. Mean and standard deviation were computed fornumerical variables like age, weight, height, systolic blood pressure, Diastolic blood pressure, and Mean Arterial pressure; whereasfrequency and percentages were employed to assess the categorical variable like efficacy. Chi-square test was used to compare theefficacy of intravenous bolus of ephedrine and phenylephrine. Statistical significance was taken at p&lt;0.05. Results: There wassignificant difference in the efficacy of both the drugs, in the treatment of maternal hypotension. 74.29% were successfully treated ingroup “A” with a single dose of Ephedrine, as compared to group B where 51.43% were successfully treated with a single dose ofPhenylephrine. (p-value = 0.048). Conclusions: Intravenous ephedrine has more efficacy than phenylephrine in the treatment ofmaternal hypotension after spinal anesthesia for elective cesarean section.

Fluid and Vasopressor Management for Cesarean Delivery Under Spinal Anesthesia

The purpose of this Continuing Professional Development module is to review the physiology of maternal hypotension induced by spinal anesthesia in pregnant women, and the effects of fluids and vasopressors. Maternal hypotension induced by spinal anesthesia is caused mainly by peripheral vasodilatation and is not usually associated with a decrease in cardiac output. Although the intravenous administration of fluids helps to increase cardiac output, it does not always prevent maternal hypotension. Three strategies of fluid administrations are equivalent for the prevention of maternal hypotension and a reduced need for vasopressors: (1) colloid preload; (2) colloid coload; and (3) crystalloid coload. Crystalloid preload is not as effective as any of those three strategies. Unlike phenylephrine, ephedrine can cause fetal acidosis. Therefore, phenylephrine is recommended as first line treatment of maternal hypotension. A phenylephrine infusion (25-50 μg·min−1) appears to be more effective than phenylephrine boluses to prevent hypotension, and nausea and vomiting. In pre-eclamptic patients, spinal anesthesia produces less hypotension than in normal pregnant women and fluid volumes up to 1,000 mL are usually well tolerated. Therefore mild to moderate intravascular volume loading is recommended, keeping in mind the increased risk for pulmonary edema in this population. In pre-eclamptic patients, hypotension can be treated either with ephedrine or phenylephrine, and phenylephrine infusions are not recommended. A volume loading regimen other than crystalloid preload should be adopted. A phenylephrine infusion during elective Cesarean delivery is beneficial for the mother and safe for the newborn.

Which vasopressor for caesarean section?

One of the longest running debates in obstetric anaesthesia surrounds the prevention and treatment of maternal hypotension during caesarean section. Anaesthetic techniques have evolved and maternal mortality and morbidity is markedly reduced, but hypotension remains a problem, particularly following neuraxial blockade. Despite over 30 years of research no definitive consensus has been reached on the best treatment strategy and particular controversy surrounds the use of vasopressive agents. This article explores the evidence relating to the three most commonly used agents in the UK: ephedrine, phenylepherine and metaraminol.

Anesthetic management for resection of cor triatriatum during the second trimester of pregnancy

Hemodynamic changes during pregnancy can result in cardiovascular decompensation in women with pre-existing cardiac diseases. Despite optimized medical treatment, some patients with severe structural cardiac abnormalities may need surgical intervention during pregnancy. We describe a woman who presented at 20 weeks of gestation with acute heart failure due to cor triatriatum, a rare form of congenital heart disease. This condition is characterized by a perforated fibromuscular membrane dividing the left atrium into two chambers. The clinical presentation varies from asymptomatic to acute heart failure depending on the size of the fenestrations in the membrane and the presence of associated cardiac malformations. In our patient, two severely restrictive orifices in a membrane within the left atrium, moderate to severe pulmonary hypertension and good biventricular function were demonstrated by transthoracic echocardiography. Without surgical resection, the increased blood volume and cardiac output associated with pregnancy could have resulted in cardiovascular decompensation. She underwent urgent corrective open heart surgery with cardiopulmonary bypass. Perioperative anesthetic management included prevention of tachycardia, atrial dysrhythmias and pulmonary hypertension, close monitoring for and prompt treatment of maternal hypotension, maintaining euvolemia and good cardiac contractility and avoiding hemodilution and hypothermia. These approaches, together with minimizing bypass time, resulted in successful maternal and fetal outcome.

Maternal and neonatal effects of bolus administration of ephedrine and phenylephrine during spinal anaesthesia for caesarean delivery: a randomised study

Background Maternal haemodynamic changes and neonatal well-being following bolus administration of ephedrine and phenylephrine were compared in 60 term parturients undergoing elective caesarean delivery under spinal anaesthesia. Methods In a randomised double-blind study, women received boluses of either ephedrine 6 mg (group E; n=30) or phenylephrine 100 μg (group P; n=30) whenever maternal systolic pressure was ⩽80% of baseline. Results Changes in systolic pressure were comparable in the two groups. There were no differences in the incidence of bradycardia (group E: 0% vs. group P: 16.7%; P>0.05), nausea (group E: 13% vs. group: P 0; P>0.05) and vomiting (group E: 3.3% vs. group P: 0; P>0.05). Umbilical artery (UA) pH (group E: 7.29 ± 0.04 vs. group P: 7.32 ± 0.04; P=0.01) and venous pH (group E: 7.34 ± 0.04 vs. group P: 7.38 ± 0.05; P=0.002) were significantly greater in group P than in group E. UA base excess was significantly less in group E (-2.83 ± 0.94 mEq/L) than in group P (-1.61 ± 1.04 mEq/L; P<0.001). Apgar scores at 1, 5 and 10min and neurobehavioural scores at 2-4 h, 24 h and 48 h were similar in the two groups ( P>0.05). Conclusions Phenylephrine 100 μg and ephedrine 6 mg had similar efficacy in the treatment of maternal hypotension during spinal anaesthesia for elective caesarean delivery. Neonates in group P had significantly higher umbilical arterial pH and base excess values than those in group E, which is consistent with other studies.

Ephedrine and phenylephrine for the treatment of maternal hypotension in a chronic sheep model of increased placental vascular resistance

Ephedrine and phenylephrine for the treatment of maternal hypotension in a chronic sheep model of increased placental vascular resistance

Ephedrine and Phenylephrine for the Treatment of Maternal Hypotension in a Chronic Sheep Model of Increased Placental Vascular Resistance

Ephedrine and Phenylephrine for the Treatment of Maternal Hypotension in a Chronic Sheep Model of Increased Placental Vascular Resistance

Ex utero intrapartum procedure for delivery of a fetus with a large cervical mass

Ex utero intrapartum procedure for delivery of a fetus with a large cervical mass

Phenylephrine in the prevention of hypotension following spinal anesthesia for cesarean delivery

Study Objective: Phenylephrine and ephedrine were compared in the prevention of maternal hypotension following spinal anesthesia for elective cesarean delivery. Design: Randomized, double-blind trial. Setting: Obstetric suite at a university-affiliated hospital. Patients: Sixty healthy patients electively scheduled for cesarean delivery under spinal anesthesia. Interventions: Patients were randomly assigned to receive either ephedrine (n = 29) in 10 mg intravenous (IV) bolus injections or phenylephrine (n = 31) in 80 μg IV bolus injections to maintain systolic blood pressure (SBP) above 100 mmHg. Measurements and Main Results: Maternal venous, umbilical artery, and umbilical vein blood gases were measured, and neonatal Apgar scores and Early Neonatal Neurobehavior Scale scores were assessed. In the ephedrine group, umbilical artery pH was 7.28 ± 0.01 (mean ± SEM), umbilical artery partial pressure of carbon dioxide (PCO 2) was 56.6 ± 1.4 mmHg, and umbilical artery base deficit was 2.2 ± 0.04 meq. In the phenylephrine group, umbilical artery pH was 7.32 ± 0.01, umbilical artery PCO 2 was 52.1 ± 1.3 torr, and umbilical artery base deficit was 0.38 ± 0.35 meq. There were significant differences between the groups in mean umbilical artery pH, PCO 2 and base deficit, although all values obtained were within normal limits. There were no significant differences between the groups in the remaining acid-base values, neonatal Apgar scores, Early Neonatal Neurobehavior Scale scores, or frequency of maternal nausea and vomiting. Conclusions: Phenylephrine is as effective as ephedrine in the treatment of maternal hypotension, and when used in small incremental bolus injections, it appears to have no adverse neonatal effects in healthy, nonlaboring parturients.