Fetal Acidemia Associated With Regional Anesthesia for Elective Cesarean Delivery

Roberts, Scott W.; Leveno, K. J.; Sidawi, J. E.; Lucas, Michael J.; Kelly, Mary Ann

doi:10.1016/0029-7844(94)p4401-9

Cited by 119 publications

(61 citation statements)

References 10 publications

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“…Despite precautions in terms of prehydration and vasopressor administration, spinal anaesthesia in particular is frequently associated with maternal hypotension and lower umbilical cord arterial pH. [14][15][16][17][18] Vasopressor substances can cross the placenta, 14,[19][20][21][22] and the maternal supine wedged position during caesarean section frequently results in fetal heart rate changes as a result of occult aortocaval compression. 23 Doppler ultrasound has shown uteroplacental circulation to be affected after spinal blockade.…”

Section: Discussionmentioning

confidence: 99%

Hidden acidosis: an explanation of acid–base and lactate changes occurring in umbilical cord blood after delayed sampling

Mokarami

Wiberg

Olofsson

2013

BJOG

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Objective To explore the 'hidden acidosis' phenomenon, in which there is a washout of acid metabolites from peripheral tissues in both vaginal and abdominal deliveries, by investigating temporal umbilical cord blood acid-base and lactate changes after delayed blood sampling.Design Prospective comparative study.Setting University hospital.Sample Umbilical cord blood from 124 newborns.Methods Arterial and venous cord blood was sampled immediately after birth (T 0 ), and at 45 seconds (T 45 ), from unclamped cords with intact pulsations taken from 66 neonates born vaginally and 58 neonates born via planned caesarean section at 36-42 weeks of gestation. Non-parametric tests were used for statistical comparisons, with P < 0.05 considered significant.Main outcome measures Temporal changes (T 0 -T 45 ) in umbilical cord blood pH, the partial pressure of CO 2 (P CO 2 ) and O 2 (P O 2 ), and in the concentrations of lactate, haematocrit (Hct), and haemoglobin (Hb).Results In both groups all arterial parameters, except for P CO 2 in the group delivered by caesarean section, changed significantly (pH decreased and the other variables increased). There were corresponding changes in venous acid-base parameters. When temporal arterial changes were compared between the two groups, the decrease in pH and increase in P CO 2 were more pronounced in the group delivered vaginally. Neonates born vaginally had significantly lower pH and higher lactate, Hct, and Hb concentrations at T 0 and T 45 in both the artery and the vein. At T 45 , arterial P CO 2 and P O 2 levels in the group delivered vaginally were also significantly higher.Conclusions Delayed umbilical cord sampling affected the acidbase balance and haematological parameters after both vaginal and caesarean deliveries, although the effect was more marked in the group delivered vaginally. The hidden acidosis phenomenon explains this change towards acidaemia and lactaemia. Arterial haemoconcentration was not the explanation of the acid-base drift.

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Section: Discussionmentioning

confidence: 99%

Hidden acidosis: an explanation of acid–base and lactate changes occurring in umbilical cord blood after delayed sampling

Mokarami

Wiberg

Olofsson

2013

BJOG

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“…Consequences associated with the use of ephedrine that we assessed were reactive hypertension, maternal heart rate, low Apgar scores (< 7 or < 8 as defined by trial authors) and fetal acidosis which we defined as umbilical arterial pH < 7.20). 10 In RCTs 4,11 with more than one ephedrine treatment arm, we combined the data from each treatment arm for dichotomous outcomes (hypotension, hypertension, nausea and/or vomiting and Apgar scores). For continuous data (umbilical arterial and venous pH and standard base excess), the greatest ephedrine dose treatment arm was used as it was not possible to combine data from all ephedrine arms when only summary group means were reported.…”

Section: Discussionmentioning

confidence: 99%

Prophylactic ephedrine prevents hypotension during spinal anesthesia for Cesarean delivery but does not improve neonatal outcome: a quantitative systematic review

Lee

Kee

Gin

2002

Can J Anesth/J Can Anesth

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P Pu ur rp po os se e: : The objective of this systematic review was to assess the effectiveness and safety of ephedrine compared with control when given prophylactically to prevent hypotension during spinal anesthesia for Cesarean delivery.S So ou ur rc ce e: : Randomized, controlled trials obtained through MEDLINE, EMBASE, the Cochrane Controlled Trials Registry, contact with leading experts, and a reference list of published articles were analyzed. The following keywords were utilized: spinal anesthesia, hypotension, Cesarean section, pregnancy complications, pregnancy outcome, fetal outcome, neonatal outcome, umbilical blood cord gases, vasopressor and ephedrine. Clinical trials were considered if they compared prophylactic ephedrine, given by any dose or route, vs control. P Pr ri in nc ci ip pa al l f fi in nd di in ng gs s: : The 14 clinical trials identified included data from a total of 641 patients. Ephedrine was more effective than control for preventing hypotension (relative risk [RR], 0.73; 95% confidence interval [CI], 0.63 to 0.86). Most importantly, there was no difference in the risk of fetal acidosis, defined as umbilical arterial pH < 7.2 (RR, 1.36; 95% CI, 0.55 to 3.35) or the incidence of low Apgar scores (< 7 or < 8) at one minute (RR, 0.77; 95% CI, 0.29 to 2.06) and five minutes (RR, 0.72; 95% CI, 0.24 to 2.19).C Co on nc cl lu us si io on ns s: : Prophylactic ephedrine is more effective than control for preventing hypotension during spinal anesthesia for elective Cesarean delivery but a clinically relevant positive effect on neonatal outcome was not observed. Therefore, the routine use of prophylactic ephedrine to prevent any adverse effects of maternal hypotension following spinal anesthesia for Cesarean delivery is not supported by the current systematic review.Objectif : Évaluer l'efficacité et l'innocuité de l'éphédrine, comparée à un témoin, administrée de manière prophylactique pour prévenir l'hypotension pendant la rachianesthésie lors de l'accouchement par Césarienne. (RR,1,36 ; IC de 95 %, 0,55 à 3,35) ou l'incidence d'indice d'Apgar < 7 ou < 8 à une minute (RR, 0,77 ; IC 95 %, 0,29 à 2,06) et à cinq minutes (RR, 0,72 ; IC 95 %, 0,24 à 2,19 Source : Nous avons analysé des essais randomisés et contrôlés obtenus de MEDLINE, EMBASE, l'Index Cochrane des essais randomisés et contrôlés, personnes-ressources autorisées et une liste de références d'articles publiés. Les mots clés ont été

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“…Several studies have reported a surprisingly high incidence of fetal acidosis that is not accompanied by neonatal depression after spinal anaesthesia for Caesarean section [2,3,10]. Mercier et al [33] reported a 63% incidence of foetal acidosis with a prophylactic intravenous infusion of ephedrine in parturients receiving spinal anaesthesia during Caesarean section.…”

Section: ó 2005 Blackwell Publishing Ltdmentioning

confidence: 99%

“…Regional anaesthesia for Caesarean delivery is associated with a high incidence of maternal hypotension [1] and may result in fetal acidaemia due to decreased uteroplacental blood flow [2][3][4]. Commonly used methods to prevent or treat such hypotension include preloading with fluids [5], avoidance of aortocaval compression [6] and the administration of vasopressor drugs [7][8][9][10].…”

mentioning

confidence: 99%

Randomised trial of intravenous infusion of ephedrine or mephentermine for management of hypotension during spinal anaesthesia for Caesarean section

Kansal¹,

Mohta

Sethi³

et al. 2004

Anaesthesia

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SummaryThis study compared the effects of intravenous infusions of ephedrine and mephentermine for maintenance of maternal arterial pressure and neonatal outcome in pregnant women receiving subarachnoid block for lower segment Caesarean section. Sixty patients who developed hypotension following subarachnoid block for Caesarean section were randomly divided into two groups of 30 each to receive an intravenous infusion of ephedrine or mephentermine. Hypotension was defined as a decrease in systolic blood pressure of ‡ 20% from the baseline value or an absolute value of <100 mmHg, whichever was higher. The vasopressor infusion was titrated to maintain systolic blood pressure between 'hypotension' and baseline values. Baseline haemodynamic parameters, haemodynamic changes subsequent to the start of vasopressor infusion, duration of hypotension and amount of vasopressor required were statistically similar for both groups. Neonatal APGAR scores and acid-base profiles were also comparable. To conclude, mephentermine can be used as safely and effectively as ephedrine for the management of hypotension during spinal anaesthesia in patients undergoing elective Caesarean section.

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Fetal Acidemia Associated With Regional Anesthesia for Elective Cesarean Delivery

Abstract: Regional anesthesia is associated with fetal acidemia, occasionally severe, and has features of an acute respiratory type of acidemia. Fetal acidemia is less frequent with epidural anesthesia compared to subarachnoid techniques.

Cited by 119 publications

References 10 publications

Hidden acidosis: an explanation of acid–base and lactate changes occurring in umbilical cord blood after delayed sampling

Hidden acidosis: an explanation of acid–base and lactate changes occurring in umbilical cord blood after delayed sampling

Prophylactic ephedrine prevents hypotension during spinal anesthesia for Cesarean delivery but does not improve neonatal outcome: a quantitative systematic review

Randomised trial of intravenous infusion of ephedrine or mephentermine for management of hypotension during spinal anaesthesia for Caesarean section

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