DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20220981

Department of Anaesthesiology and Critical Care, Lady Hardinge Medical College and Associated Shrimati Sucheta Kriplani Hospital, Connaught Place, New Delhi, India

Ranju Singh, Surbhi Saini, Ratna Biswas

Abstract


Background: Currently phenylephrine (PE) is recommended to treat hypotension after spinal anesthesia for cesarean delivery (CD). Recently low dose norepinephrine has been proposed as effective alternative with advantage of less depression of maternal heart rate and cardiac output.

Methods: This was prospective observational study in women scheduled for CD under spinal anesthesia, patients received either PE 100 µg (group PE) or norepinephrine 8 µg (group NE). Primary objective was to study the difference in umbilical artery pH with use of both drugs. The secondary objectives were to compare maternal hemodynamics, number of boluses required and neonatal outcome.

Results: Total 593 patients were enrolled and 226 patients who developed post-spinal hypotension were analysed, 106 patients received PE and 120 patients received norepinephrine. Umbilical artery pH was similar in both groups (p=0.199) but in fetal distress, pH was acidotic in both groups with a greater dip with PE than norepinephrine (p<0.001). Incidence of bradycardia was significantly higher with PE (p<0.001) and number of boluses was greater with norepinephrine. No difference observed in episodes of hypotension and neonatal outcome.

Conclusions: Fetal pH was maintained within normal range with both drugs but in fetal distress, fetal pH was acidotic in both groups, however better maintained with norepinephrine than PE. Norepinephrine was as effective as PE for post-spinal hypotension, with lower incidence of bradycardia and similar neonatal outcome. Norepinephrine is recommended to prevent hypotension in CD, particularly in fetal distress. However, further research is needed to confirm this.


Keywords


Spinal anaesthesia, C-section, Norepinephrine, PE, Umbilical artery pH, Hypotension

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References


Klohr S, Roth R, Hofmann T, Rossaint R, Heesen M. Definitions of hypotension after spinal anesthesia for cesarean section: literature search and application to parturients. Acta Anaesthesiol Scand. 2010;54:909-21.

Rasanen, J, Alahuhtat S, Kangas-Saarelat T, Jouppilat R, Jouppila P. The effects of ephedrine and etilefrine on uterine and fetal blood flow and on fetal myocardial function during spinal anesthesia for cesarean section. Int J Obstet Anesth. 1991;1:3-8.

Loughrey JPR, Yao, N, Datta S, Segal S, Pian-Smith M, Tsen LC. Hemodynamic effects of spinal anesthesia and simultaneous intravenous bolus of combined phenylephrine and ephedrine versus ephedrine for cesarean delivery. Int J Obstet Anesth. 2005;14:43-7.

Cyna AM, Andrew M, Emmett Rs, Middleton P, Simmons SW. Techniques for preventing hypotension during spinal anesthesia for cesarean section. Cochrane Database Syst Rev. 2006:CD002251.

Ngan Kee WD, Khaw KS, Ng FF, Lee BB. Prophylactic phenylephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2004;98:815-21.

Nag DS, Samaddar DP, Chatterjee A, Kumar H, Dembla A. Vasopressors in obstetric anesthesia: A current perspective World J Clin Cases. 2015;3:58-64.

Lee A, Ngan Kee WD, Gin T. A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2002;94:920-6.

Cooper DW, Carpenter M, Mowbray P, Desira WR, Ryall DM, Kokri MS. Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology. 2002;97:1582-90.

Ngan Kee WD, Lee A. Multivariate analysis of factors associated with umbilical arterial pH and standard base excess after cesarean section under spinal anesthesia. Anesthesia. 2003;58:125-30.

American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology. 2007;106:843-63.

Ngan Kee WD, Khaw KS, Ng FF, Lee BB. Prophylactic phenylephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2004;98:815-21.

Stewart A, Fernando R, McDonald S, Hignett R, Jones T, Columb M. The dose-dependent effects of phenylephrine for elective cesarean delivery under spinal anesthesia. Anesth Analg. 2010;111:1230-7.

Hasanin AM, Amin SM, Agiza NA, Elsayed MK, Refaat S, Hussein HA et al. Norepinephrine infusion for preventing postspinal anesthesia hypotension during cesarean delivery: A randomized dose-finding trial. Anesthesiology. 2019;130:55-62.

Carvalho B and Dyer RA. Norepinephrine for spinal hypotension during cesarean delivery: another paradigm shift? Anesthesiology 2015; 122:728-730.

Ngan Kee WD. A random-allocation graded dose-response study of norepinephrine and phenylephrine for treating hypotension during spinal anesthesia for cesarean delivery. Anesthesiology 2017;127:934–41.

Dong L, Dong Q, Song X, Liu Y, Wang Y. Comparison of prophylactic bolus norepinephrine and phenylephrine on hypotension during spinal anesthesia for cesarean section. Int J Clin Exp Med. 2017;10:12315-21.

Sharkey AM, Siddiqui N, Downey K, Ye XY, Guevara J, Carvalho JCA. Comparison of intermittent intravenous boluses of phenylephrine and norepinephrine to prevent and treat spinal-induced hypotension in cesarean deliveries: randomized controlled trial. Anesth Analg. 2018.

Vallejo MC, Attaallah AF, Elzamzamy OM, Citarelli DT, Phelps AL et al. An open-label randomized controlled clinical trial for comparison of continuous phenylephrine versus norepinephrine infusion in prevention of spinal hypotension during cesarean delivery. Int J Obstet Anesth. 2016;29:18-25.

Ngan Kee WD, Lee S, Ng FF, Tan PE, Khaw KS. Randomized double-blinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesthesiol. 2015;122:736-45.

Ngan Kee WD, Khaw KS, Tam YH, Ng FF, Lee SW. Performance of a closed-loop feedback computer-controlled infusion system for maintaining blood pressure during spinal anesthesia for cesarean section: a randomized controlled comparison of norepinephrine versus phenylephrine. J Clin Monit Comput. 2016;31:617-23.

Jain K, Makkar JK, Subramani VPS, Gander S, Kumar P. A randomized trial comparing prophylactic phenylephrine and ephedrine infusion during spinal anesthesia for emergency cesarean delivery in cases of acute fetal compromise. J Clin Anesth. 2016;34:208-15.

Xu S, Shen X, Liu S, Yang J, Wang X. Efficacy and safety of norepinephrine versus phenylephrine for the management of maternal hypotension during cesarean delivery with spinal anesthesia. Medicine. 2019;98:5(e14331).