Spinal Versus Epidural Anesthesia for Cesarean Delivery in Severe Preeclampsia: A Prospective Randomized, Multicenter Study

Abstract

In this randomized, multicenter study we compared the hemodynamic effects of spinal and epidural anesthesia for cesarean delivery in severely preeclamptic patients. The epidural group (n = 47) received 2% lidocaine with epinephrine 1:400,000, 18-23 mL, followed by 3 mg of morphine after delivery. The spinal group (n = 53) received 2.2 mL of 0.5% hyperbaric bupivacaine plus 0.2 mg morphine. We hypothesized that the lowest MAP (mean arterial blood pressure, the primary outcome) during the delivery period would have to be at least 10 mm Hg less in the spinal group to be of clinical importance. We found that there was a statistically significant difference in MAP, with more patients in the spinal group exhibiting hypotension (P < 0.001). Although the incidence of hypotension (systolic arterial blood pressure, SAP < or =100 mm Hg) was more frequent in the spinal group than in the epidural group (51% versus 23%), the duration of significant hypotension (SAP < or =100 mm Hg) was short (< or =1 min) in both groups. There was more use of ephedrine in the spinal group than in the epidural group (median, 6 versus 0 mg) but hypotension was easily treated in all patients. Neonatal outcomes assessed by Apgar scores and the umbilical arterial blood gas analysis were similar in both groups. Adverse neonatal outcomes (5-min Apgar score < 7 and umbilical arterial blood pH < 7.20) were found in only 2 premature newborns (weight < 1500 g) who were born without maternal hypotension after regional anesthesia. We conclude that the results of this large prospective study support the use of spinal anesthesia for cesarean delivery in severely preeclamptic patients.

General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update

“…Fourthly, the increased willingness to do emergent spinal anesthesia including intentional continuous spinal techniques, especially in individuals with certain comorbid conditions (e.g. severe preeclampsia and morbid obesity), [16][17][18] may have been partly responsible for this reduction.…”

Two doses of spinal bupivacaine for caesarean delivery in severe preeclampsia: a pilot study

“…Invasive monitoring detects rapid haemodynamic changes and allows early treatment during the evolving block. 4,5 Aggressive intravenous fluid loading may increase the risk of pulmonary oedema in these patients secondary to low plasma oncotic pressure and increased permeability of pulmonary alveolar capillaries. 6 Roofthooft and Van de Velde reported that when bupivacaine 6.5 mg was given with sufentanil as part of a combined spinal-epidural (CSE) technique, the need to top-up the epidural catheter was rare if surgery finished within 60 min.…”

Updates in Preeclampsia

“…Traditional concerns over avoiding spinal anesthesia due to excessive hypotension do not appear to have been warranted. Although Visalyaputra et al [69] found that significant hypotension (systolic \100 mmHg) was more frequent among patients receiving spinal rather than epidural anesthesia (51 vs. 23 %; P = 0.004), these episodes of hypotension lasted less than one minute and were easily treated (with 6 vs. 12 mg ephedrine). In addition, newborn outcomes were similar in both groups.…”

“…Regional techniques for delivery via cesarean section are preferred over general anesthesia, as there appears to be fewer morbid complications [68]. In the patient with severe preeclampsia, spinal anesthesia results in similar hemodynamic stability as either epidural or general anesthesia [69][70][71]. Traditional concerns over avoiding spinal anesthesia due to excessive hypotension do not appear to have been warranted.…”