Placental Transfer and Fetal Metabolic Effects of Phenylephrine and Ephedrine during Spinal Anesthesia for Cesarean Delivery

Kee, Warwick D. Ngan; Khaw, Kim S.; Tan, Perpetua E.; Ng, Floria F.; Karmakar, Manoj K.

doi:10.1097/aln.0b013e3181b160a3

Cited by 233 publications

(75 citation statements)

References 20 publications

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“…Based on the limited available evidence, phenylephrine and ephedrine appear to be similarly effective in preventing and treating spinal-induced hypotension in parturients with potential uteroplacental insufficiency (29–32) or hypertensive disorders of pregnancy (30, 37, 38). These findings diverge from studies in healthy parturients, in which phenylephrine has been observed to be more effective at maintaining maternal blood pressure (7, 8) and preventing IONV (5, 7, 8) compared to ephedrine. Compared to healthy pregnancies, there appears to be reduced incidence of hypotension and lower vasopressor requirements in patients with uteroplacental insufficiency or hypertensive disorders of pregnancy (29–32, 37), which may be due to a combination of increased incidence of prematurity, shorter incision-to-delivery intervals in urgent circumstances, or preeclampsia-associated factors.…”

Section: Resultscontrasting

confidence: 89%

“…Subsequent studies conducted in healthy parturient undergoing elective cesarean deliveries have consistently demonstrated that phenylephrine use reduces incidence of fetal acidosis compared to ephedrine (5–9) and is more effective at maintaining maternal blood pressure (7, 8) and preventing intraoperative nausea and vomiting (IONV) (5, 7, 8) compared to ephedrine. It has been demonstrated that ephedrine crosses the placenta to a greater extent than phenylephrine and stimulation of β-adrenergic receptors in the fetus results in an increased fetal metabolic rate (5, 7, 8). Ephedrine-induced fetal tachycardia and acidosis appears to depend on dosage and timing of drug administration prior to delivery (8–10).…”

Section: Introductionmentioning

confidence: 99%

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Comparison of Phenylephrine and Ephedrine in Treatment of Spinal-Induced Hypotension in High-Risk Pregnancies: A Narrative Review

et al. 2017

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PurposeTo compare maternal and fetal effects of intravenous phenylephrine and ephedrine administration during spinal anesthesia for cesarean delivery in high-risk pregnancies.SourceAn extensive literature search was conducted using the US National Library of Medicine, MEDLINE search engine, Cochrane review, and Google Scholar using search terms “ephedrine and phenylephrine,” “preterm and term and spinal hypotension,” “preeclampsia and healthy parturients,” or “multiple and singleton gestation and vasopressor.” Society of Obstetric Anesthesia and Perinatology meeting abstracts for the past 4 years were also searched for relevant studies.Principle findingsBoth phenylephrine and ephedrine can be safely used to counteract hypotension after spinal anesthesia in patients with uteroplacental insufficiency, pregnancy-induced hypertension, and in non-elective cesarean deliveries. Vasopressor requirements before delivery in high-risk cesarean sections are reduced compared to healthy parturients. Among the articles reviewed, there were no statistically significant differences in umbilical arterial pH, umbilical venous pH, incidence of fetal acidosis, Apgar scores, or maternal hypotension when comparing maternal phenylephrine and ephedrine use.ConclusionFrom the limited existing data, phenylephrine and ephedrine are both appropriate selections for treating or preventing hypotension induced by neuraxial blockade in high-risk pregnancies. There is no clear evidence that either medication is more effective at maintaining maternal blood pressure or has a superior safety profile in this setting. Further investigations are required to determine the efficacy, ideal dosing regimens, and overall safety of phenylephrine and ephedrine administration in high-risk obstetric patients, especially in the presence uteroplacental insufficiency.

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Section: Resultscontrasting

confidence: 89%

Section: Introductionmentioning

confidence: 99%

Comparison of Phenylephrine and Ephedrine in Treatment of Spinal-Induced Hypotension in High-Risk Pregnancies: A Narrative Review

et al. 2017

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“…Though 60 years have passed since the Apgar scoring system was developed by Virginia Apgar, the Apgar score remains an important method for the early detection of infants at risk for serious and fatal conditions [14,15]. There were no differences in Apgar scores and the risk of low Apgar scores between the phenylephrine and ephedrine groups and among the phenylephrine, ephedrine and combination of phenylephrine and ephedrine groups [3,4,6,7,16,17,18,19,20]. However, the sample sizes of these studies may be too small to detect differences in Apgar scores.…”

Section: Discussionmentioning

confidence: 99%

“…Conventionally, ephedrine was the drug of choice for hypotension during spinal anesthesia for cesarean section. However, a number of studies have suggested ephedrine has a dose-related propensity to depress fetal pH and base excess (BE) in comparison to phenylephrine [3,4,5]. In addition, umbilical artery pH in a combination group of phenylephrine and ephedrine was lower than that of phenylephrine alone group [6,7].…”

Section: Introductionmentioning

confidence: 99%

The effects on Apgar scores and neonatal outcomes of switching from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic vasopressor during spinal anesthesia for cesarean section

Jeon

Jee

Lee

et al. 2014

Korean J Anesthesiol

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BackgroundEphedrine, unlike phenylephrine, has a dose-related propensity to depress fetal pH during spinal anesthesia during cesarean section. A low arterial umbilical cord pH has a strong association with neonatal mortality and morbidity. The purpose of this retrospective study was to investigate influences of vasopressor change on Apgar scores and adverse neonatal outcomes in cesarean section.MethodsIn obstetric anesthesia, we changed the prophylactic vasopressor from a combination of phenylephrine and ephedrine to phenylephrine alone in 2000. We evaluated the impact of vasopressor change on Apgar scores (1 and 5 min), incidence of Apgar score < 7 (1 and 5 min), neonatal seizure, continuous positive airway pressure (CPAP), intermittent positive pressure ventilation (IPPV), intraventricular hemorrhage (IVH), periventricular leucomalacia (PVL), and hypoxic ischemic encephalopathy (HIE) in low-risk elective cesarean sections during a period when the combination of phenylephrine and ephedrine was used (2008-2009, two years) and the period of phenylephrine use alone (2011-2012, two years).ResultsThere were no differences in Apgar scores (1 and 5 min), the incidence of 5 min Apgar score < 7, neonatal seizure, CPAP, IPPV, IVH, PVL, and HIE between the two time periods. However, the incidence of 1 min Apgar < 7 was decreased during the period of phenylephrine use compared with the period of phenylephrine and ephedrine use (P = 0.002).ConclusionsConversion from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic anti-hypotensive drug during spinal anesthesia for cesarean section in low-risk pregnancy may be associated with a significant decrease in the incidence of 1 min Apgar < 7.

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“…[78] However, several studies had observed that it causes fetal acidosis by increasing fetal heart rate (HR) and metabolic activity. [910] We hypothesized that the fetal acidosis could be minimized by reducing the maternal blood ephedrine concentration. We expected an optimal effect on maternal blood pressure and HR and less fetal acidosis with a slow bolus of ephedrine.…”

Section: Introductionmentioning

confidence: 99%

Comparing slow and rapid bolus of ephedrine in pregnant patients undergoing planned cesarean section under spinal anesthesia

Gunasekaran

Balachander

et al. 2017

J Anaesthesiol Clin Pharmacol

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Background and Aims:While ephedrine was the preferred drug for treating spinal-induced hypotension in pregnancy, its use has declined because of resultant fetal acidosis. The objective of this randomized control trial was to compare the effects of a slow and rapid bolus of ephedrine on fetal acidosis, maternal blood pressure, and heart rate (HR) during cesarean section performed under spinal anesthesia.Material and Methods:Eighty full-term parturients scheduled for cesarean section under spinal anesthesia were randomly allocated into two groups. While both groups received 6 mg of ephedrine to treat hypotension, Group R (n = 40) received it as a rapid intravenous bolus and Group S (n = 40) received it slowly over 20 s with an infusion pump. The maternal vital parameters were recorded until delivery of the baby using a video camera. Umbilical cord blood was obtained using the three clamp method. Hemodynamic parameters, fetal acidosis, total number of ephedrine bolus used, peak HR after the ephedrine bolus, and occurrence of postoperative nausea and vomiting (PONV) were compared between the groups.Results:Mean increase in HR and blood pressure were significantly higher in Group R than the Group S after the first ephedrine bolus. Umbilical artery pH was significantly lower in Group R than in Group S (7.2 [6.8-7.3] vs. 7.3 [7.3-7.4], P < 0.01). A total number of ephedrine boluses were comparable in the two groups. 35% of the patients had PONV in Group R, whereas none had it in Group S (P < 0.01).Conclusion:Slow bolus of ephedrine is better than rapid bolus to treat spinal-induced hypotension during cesarean section in view of less fetal acidosis.

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Placental Transfer and Fetal Metabolic Effects of Phenylephrine and Ephedrine during Spinal Anesthesia for Cesarean Delivery

Cited by 233 publications

References 20 publications

Comparison of Phenylephrine and Ephedrine in Treatment of Spinal-Induced Hypotension in High-Risk Pregnancies: A Narrative Review

Comparison of Phenylephrine and Ephedrine in Treatment of Spinal-Induced Hypotension in High-Risk Pregnancies: A Narrative Review

The effects on Apgar scores and neonatal outcomes of switching from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic vasopressor during spinal anesthesia for cesarean section

Comparing slow and rapid bolus of ephedrine in pregnant patients undergoing planned cesarean section under spinal anesthesia

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