Spinal anesthesia for postpartum tubal ligation after pregnancy complicated by preeclampsia or gestational hypertension.

BACKGROUND AND OBJECTIVES: The American College of Obstetricians & Gynecologists has opposed postpartum tubal ligation (PPTL) in patients whose pregnancies have been complicated by a medical condition, including hypertension. A prospective study was conducted to assess the appropriateness of spinal anesthesia for PPTL in patients with hypertensive disorders of pregnancy. METHODS: After institutional review board approval and written informed consent, women scheduled for PPTL were enrolled. The hypertensive group (n = 25) consisted of women whose pregnancies were complicated by gestational hypertension, preeclampsia, or chronic hypertension with superimposed preeclampsia. For each hypertensive patient, a matched control was designated by selecting the next consenting normotensive patient scheduled for PPTL. After an intravenous bolus of lactated ringers solution 500 mL, spinal anesthesia was induced with hyperbaric lidocaine. Hemodynamic measurements were recorded every 2 minutes for 20 minutes after spinal injection. Ephedrine IV was administered for systolic blood pressure < or =90 mm Hg. RESULTS: The mean preoperative mean blood pressure (MAP) was 107+/-17 mm Hg in the hypertensive group and 85+/-11 mm Hg in the controls, P<.0001. The hypertensive group sustained a more profound percentage decrease in MAP than did their control counterparts during spinal anesthesia (29%+/-12% v. 15%+/-8%, P<.0001). However, the lowest intraoperative MAP was similar in both groups. Thirty-five percent of hypertensive patients and 24% of the controls received ephedrine IV. CONCLUSIONS: PPTL during spinal anesthesia in patients whose pregnancies have been complicated by hypertension had results comparable with patients with uncomplicated pregnancies; however, further studies are needed to ascertain its safety.

Prophylactic angiotensin II infusion during spinal anesthesia for elective cesarean delivery.

BACKGROUND: Angiotensin II may prove useful in treating regional anesthesia-induced hypotension in obstetric patients, because it causes less uterine vasoconstriction than do other vasoconstrictor drugs (such as phenylephrine). This study compared (1) maternal blood pressure and heart rate and (2) fetal status at delivery in parturients given either prophylactic angiotensin II or ephedrine infusion during spinal anesthesia for elective cesarean delivery. METHODS: Fifty-four women were randomized to receive either angiotensin II or ephedrine infusion intravenously during spinal anesthesia for elective cesarean section delivery. Simultaneous with subarachnoid injection, infusion of angiotensin II (2.5 microg/ml) or ephedrine (5 mg/ml) was initiated at 10 ng x kg(-1) x min(-1) and 50 microg x kg(-1) x min(-1), respectively. The rate of each infusion was adjusted to maintain maternal systolic blood pressure at 90-100% of baseline. RESULTS: Cumulative vasopressor doses (mean+/-SD) through 10, 20, and 30 min were 150+/-100, 310+/-180, and 500+/-320 ng/kg in the angiotensin group and 480+/-210, 660+/-390, and 790+/-640 microg/kg in the ephedrine group. Maternal heart rate was significantly higher (P < 0.001) during vasopressor infusion in the ephedrine group than in the angiotensin group. Umbilical arterial and venous blood pH and base excess were all significantly higher (P < 0.05) in the angiotensin group than in the ephedrine group. CONCLUSIONS: Angiotensin II infusion maintained maternal systolic blood pressure during spinal anesthesia without increasing maternal heart rate or causing fetal acidosis.

Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia.

OBJECTIVE: Our purpose was to examine the effect of epidural analgesia on dystocia-related cesarean delivery in actively laboring nulliparous women. STUDY DESIGN: Active labor was confirmed in nulliparous women by uterine contractions, cervical dilatation of 4 cm, effacement of 80%, and fetopelvic engagement. Patients were randomized to one of two groups: epidural analgesia or narcotics. A strict protocol for labor management was in place. Patients recorded the level of pain at randomization and at hourly intervals on a visual analog scale. Elective outlet operative vaginal delivery was permitted. RESULTS: One hundred women were randomized. No difference in the rate of cesarean delivery for dystocia was noted between the groups (epidural 8%, narcotic 6%; p = 0.71). No significant differences were noted in the lengths of the first (p = 0.54) or second (p = 0.55) stages of labor or in any other time variable. Women with epidural analgesia underwent operative vaginal delivery more frequently (p = 0.004). Pain scores were equivalent at randomization, but large differences existed at each hour thereafter. The number of patients randomized did not achieve prestudy estimates. A planned interim analysis of the results demonstrated that we were unlikely to find a statistically significant difference in cesarean delivery rates in a trial of reasonable duration. CONCLUSIONS: With strict criteria for the diagnosis of labor and with use of a rigid protocol for labor management, there was no increase in dystocia-related cesarean delivery with epidural analgesia.