| Background and objective:Hypertensive disorders of pregnancy are a multisystem disorder with heterogeneous presentation and ill-defined aetiology. Preeclampsia is one of the leading causes of maternal morbidity and mortality and occurs in 3–5% of all pregnancies worldwide.In the recent ten years, regional anesthesia has been accepted as the choice of anesthesia for cesarean delivery in severe preeclamptic patients among both anesthesiologists and obstetricians. Many anesthesiologists prefer epidural anesthesia (EA) for caesarean section in preeclampsia. Combined spinal-epidural anesthesia (CSE) can be performed faster, has fewer complications, and is more cost-effective for uncomplicated cesarean delivery, especially in urgent situation. The purpose of the current study is to evaluate and compare the effect of epidural anesthesia vs. combined spinal-epidural anesthesia on maternal hemodynamic changes in patients with severe preeclampsia during caesarean delivery. The outcome of neonates was also evaluated and the requirement of ephedrine in the two different anesthesia methods was compared.Method:Sixty females with severely preeclampsia scheduled for cesarean were randomized to epidural (EA n=30) or combine spinal-epidural (CSE n=30) group. In the operating room all patients received 5 L/min of 100% oxygen by facemask. The patients were monitored with standard monitoring devices including automated blood pressure cuff, electrocardiogram, and pulse oximetry. Before administering regional anesthesia, 300 mL of colloid solution was given over 20 min , followed by lactated Ringer's solution 100 mL/h. In the epidural group, Incremental doses of 5 mL of 2% lidocaine were given (total dose of 15–21 mL) until loss of sensation to pinprick to at least the T5 level was achieved. In the spinal group, administration similar to that in the epidural group, spinal needle was placed at the L3-4 interspace, 0.5% bupivacaine (1.5-1.7ml) was injected into the was injected into the subarachnoid space. Three milligrams of ephedrine was administered IV if the SAP decreased to 120 mm Hg but was more than 100 mm Hg, and 6 mg of ephedrine was given if the SAP decreased to or less than 100 mm Hg. Patient characteristic, obstetric, hemodynamic values (such as CO, SV, SVR, MAP, HR), and neonatal data and Apgar scores were gathered by noninvasive hemodynamic monitoring for defined time intervals i.e. before, during, and after anesthesia. The data was analyzed according to the anesthesia techniques used and the utilization and total volume of ephedrine used was compared.Result:There were no differences between two groups in terms of patient characteristics, obstetric profiles, surgical blood loss and surgical duration. The induction time of anesthesia was longer in the epidural group than in the combine epidural-spinal group (P<0.05). The time from skin incision to delivery, and the time from uterine incision to delivery were similar in both groups. Hemodynamic values were comparable between epidural group and combine spinal-epidural group. Hemodynamic values for defined time intervals were compared with the baseline. We found that MAP (EA 123±12.8mmHg to 117.4±8.6mmHg vs. CSE125.8±14.9mmHg to 114.8±17.6mmHg) and SVR(EA: 1723±263 dyn·s·cm-5 to 1460±202dyn·s·cm-5 vs. CSE :1633±306 dyn·s·cm-5 to 1378±262dyn·s·cm-5) following anesthesia were significantly lower than baseline. However, CO (EA 4.2±0.45 L/min to 5.5±0.2 L/min vs. CSE 4.05±0.82 L/min to 5.7±0.6L/min) and following anesthesia were higher than the baseline (P<0.05). From anesthesia induction to fetus delivery, the lowest mean SAP (EA 113±17mmHg vs. CSE:126±19mmHg ) and MAP (EA 90±12mmHg vs.CSE 80±15mmHg) were lower in the combine spinal-epidural group than epidural group. There was increased requirement of ephedrine in the combine spinal-epidural group than in the epidural group (5.3±1.6mg vs.12±5.7mg) but hypotension was easily corrected in all patients. Although the incidence of hypotension (SPA≤100mmHg) was more frequent in the combine spinal-epidural group (50%) than in the epidural group (20%), the duration of significant hypotension (SAP≤100mmHg) was short (<1 min) in both groups. Neonatal outcome assessed by Apgar scores and the umbilical arterial blood gas analysis were similar in both groups.ConclusionThe hemodynamic changes of patients with severely preeclampsia were comparable under combine spinal-epidural anesthesia and epidural anesthesia. These two different anesthesia techniques can reduce MAP and SVR and significantly improve cardiac output in patients with severe preeclampsia. Even though the incident of hypotensive event occurred more frequent in the combine spinal-epidural anesthesia group, the events were transient (< 1 minute) and easily corrected with ephedrine. There were no data indicated that these transient hypotension events disturbed neonatal well-being and the Apgar scores. Although epidural anaesthesia provides modestly superior haemodynamic stability, there are no differences between the two techniques in neonatal outcome. Combine spinal-epidural anesthesia appears to be as effective and safe as epidural anesthesia for preeclampsia and severe preeclampsia. It will reduce the risks of anesthesia complications in high-risk patients required urgent cesarean section under general anesthesia. |
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