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Spinal Anesthesia in Severe Preeclampsia

September 2013 Volume 117 Number 3 www.anesthesia-analgesia.org 687

anesthesia (Table 1). A potential limitation of an initial study by Aya et al. 14 was that mean gestational age and fetalweight were signicantly lower in the severely preeclamp-tic group compared with the normotensive group. Resultingintergroup differences in degree of aortocaval compres-sion could have contributed to the nding that hypoten-sion was less severe in the preeclamptic group. Similarly,a study by Clark et al. 15 did not control for fetal weight or

gestational age. To correct for this limitation, a follow-upstudy by Aya et al. 13 studied preterm parturients present-ing for nonemergency cesarean delivery and matched thenormotensive and preeclamptic patients for gestational age(neonatal and placental weights were also comparable). Theseverely preeclamptic group experienced a lower incidenceof hypotension requiring treatment (25% vs 41%, P = 0.044)and received a lower mean cumulative ephedrine dose (10vs 16 mg, P = 0.031) compared with the normotensive con-trol group. These ndings indicate that spinal anesthesiacan be safely administered to severely preeclamptic par-turients undergoing nonemergency cesarean delivery andthat spinal anesthesiainduced hypotension can generally

be treated safely.SPINAL VERSUS EPIDURAL ANESTHESIA INSEVERE PREECLAMPSIA

It was traditionally believed that epidural is safer than spi-nal anesthesia in the setting of severe preeclampsia becauseepidural anesthesia was expected to confer a lower risk ofclinically signicant hypotension. 6 Studies are inconsistentas to whether hypotension is more severe after spinal anes-thesia as compared with epidural anesthesia. However,the most rigorous study addressing this question, byVisalyaputra et al., 16 concluded that although severely pre-eclamptic patients did experience more severe hypotensionafter spinal anesthesia than after epidural anesthesia, thatdifference was unlikely to be clinically signicant.

Earlier studies had reported that vasopressor require-ments for severely preeclamptic parturients were simi-lar when comparing spinal with epidural anesthesia 11,17,18 (Table 2) and when comparing CSE with epidural anesthesia(Table 3). 9 Limitations of these early studies included smallsample size, 17 retrospective design 11,18 and heterogeneouspopulations, and approaches to uid 11,17,18 and vasopressor 11,18 administration. In contrast, Visalyaputra et al. 16 conducteda larger, multicenter randomized controlled trial involving100 severely preeclamptic parturients (Table 2). Spinal anes-thesia was associated with a higher incidence (51% vs 23%,P < 0.001) of hypotension (dened as systolic blood pres-sure


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College of Obstetricians and Gynecologists (ACOG), 4 neur-axial anesthetic techniques, when feasible, are strongly pre-ferred to general anesthesia for preeclamptic parturients.Early epidural catheter placement in laboring preeclampticparturients is encouraged, since it secures a means of deliv-ering neuraxial anesthesia (avoiding the risks of generalanesthesia) in the event that an emergency cesarean deliveryis required. Additional benets of epidural labor analgesiaare reduced oxygen consumption and minute ventilationduring the rst and second stages of labor 21 and, in pre-eclamptic parturients, improved intervillous blood ow 22 (provided that hypotension is avoided) and decreasedmaternal plasma catecholamines. 23 Consequently, for com-plicated cases such as parturients with preeclampsia, theASA practice guideline recommends early epidural or spi-nal catheter placement, which may even precede onset oflabor or the patients request for analgesia. 20

In preeclampsia, spinal anesthesia is generally consid-ered for cesarean delivery when there is no indwellingepidural catheter or there is a contraindication to neuraxialanesthesia (e.g., coagulopathy, eclampsia with persistentneurologic decits). Spinal anesthesia affords quicker onsetof anesthesia than epidural or CSE anesthesia, which is acritical advantage in emergency situations. In the settingof severe hemodynamic instability or if a particularly longoperative time is anticipated, an alternative titratable neur-axial technique such as epidural, CSE, or continuous spinalanesthesia should be considered.

SPINAL VERSUS GENERAL ANESTHESIA

For most of the severely preeclamptic population, the risk benet proles of spinal anesthesia and general anesthesiastrongly favor the use of spinal anesthesia when feasible.Important factors to consider are the risks of clinically sig-nicant maternal hemodynamic derangements, difcult air-way management, stroke, spinal/epidural hematoma, andadverse neonatal outcomes. As described earlier, in severelypreeclamptic patients, spinal anesthesiainduced hypoten-sion is typically easily treated, the risk of spinal/epiduralhematoma is low, and there is no evidence that neonataloutcomes are compromised. In contrast, potential compli-cations of general anesthesia, such as hypertensive crisis,stroke, and difcult airway management, are leading causesof morbidity and mortality in the preeclamptic population.Therefore, in the majority of severely preeclamptic patients,who are not coagulopathic or thrombocytopenic, the risk ofdifcult or failed airway management and delayed recogni-

tion of maternal stroke during a general anesthetic are felt toexceed the risk of adverse outcomes from spinal anesthesiainduced hypotension or spinal/epidural hematoma. 19

Peripartum pharyngeal and glottic edema are accen-tuated in preeclamptic parturients, 24 and the risks of dif-cult/failed laryngoscopy and intubation are greateramong preeclamptic parturients than healthy parturients. 25 Traumatic laryngoscopy may trigger pharyngeal or hypo-pharyngeal bleeding, further obscuring visualization of theairway. Although the absolute risks of general anesthesia(failed/difcult airway management, hypertension withdirect laryngoscopy, delayed recognition of stroke undergeneral anesthesia, and aspiration) are low even among

preeclamptic parturients, the risk of difcult airway man-agement is a compelling reason to favor neuraxial anesthe-sia. Closed claims analysis from the United Kingdom from2006 to 2008 identied poor management of preeclampsiaas one of the main categories in which poor perioperativemanagement may have contributed to maternal death. 26

Severe preeclampsia is also a leading cause of peripar-tum hemorrhagic stroke. 27 During direct laryngoscopy andintubation, severely preeclamptic parturients experiencesignicantly larger increases in arterial blood pressure andmiddle cerebral artery velocity compared with healthy par-turients. 28 Cerebral hypertension may, in turn, precipitatehemorrhagic stroke. Hemorrhagic stroke was the leadingdirect cause of mortality in patients with severe preeclamp-sia according to the most recent analysis by the UnitedKingdom Center for Maternal and Child Enquiries. 29 If gen-eral anesthesia is necessary, equipment should be immedi-ately available to manage a difcult airway, and every effortshould be made to blunt the hemodynamic response tolaryngoscopy (e.g., via a bolus of an antihypertensive drugor remifentanil). 30,31

One study has been designed to detect differences inmaternal or neonatal outcomes associated with the useof spinal anesthesia compared with general anesthesiain severe preeclampsia. Dyer et al. 32 prospectively com-pared umbilical arterial fetal base decit and other mark-ers of maternal and neonatal well-being in 70 preeclampticpatients undergoing cesarean delivery due to nonreassuringfetal heart rate tracings, randomized to receive either spinalor general anesthesia (Table 4). The study was powered todetect an intergroup difference in the primary outcome,the incidence of umbilical arterial base decit >8 mEq/L.In both groups, mean umbilical arterial base decit valueswere within the range considered normal for vaginal deliv-

ery (


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of these monitors in the peripartum management of severepreeclampsia is ongoing. 45,46

COAGULOPATHY

In preeclampsia, endothelial dysfunction can stimulate exces-sive platelet activation and consumption, which may con-tribute to the increased incidence of thrombocytopenia. Theincidence of spinalepidural hematoma among preeclamp-

tic patients undergoing neuraxial procedures is unknown.Large survey studies have found that the incidence of spi-nalepidural hematoma after neuraxial anesthesia is loweramong parturients than the general population. 4749 Thesestudies have also shown that whether 47 or not 47,49 analysis islimited to parturients, spinalepidural hematoma is less com-mon after spinal anesthesia than CSE or epidural anesthe-sia. However, retrospective studies may underestimate theincidence of spinalepidural hematoma and/or the numberof neuraxial techniques performed. Evidence suggests thatthe incidence of spinalepidural hematoma has increasedsince the 1990s. 50 In large retrospective reviews 47,48 and casereports, 50 laboratory evidence of deranged hemostasis was

found in a large proportion of pregnant and nonpregnantpatients who developed spinalepidural hematomas afterneuraxial procedures. In 1 large retrospective study, 47 theonly 2 cases of obstetric spinalepidural hematoma occurredin patients with the syndrome of hemolysis, elevated liverenzymes, and low platelets. Spinal anesthesia may confer alower risk of spinal/epidural hematoma than CSE or epi-dural anesthesia, since smaller caliber needles are associatedwith a lower incidence of spinal hematoma 51 and single-shotspinal anesthesia avoids the risks of an indwelling catheter.

While there is no denitive data for a safe plateletcount, based on a consensus statement from the AmericanSociety of Regional Anesthesia 50 and case series data, 52 expertopinions from the hematology literature 53 and from theAmerican Society of Hematologists pertaining to immunethrombocytopenia, 54 many anesthesiologists require a plate-let count of at least 75,000 or 80,000/ L (and, if the plateletcount is


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692 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA

E FOCUSED REVIEW

preeclampsia and healthy women undergoing preterm cesar-ean delivery. Anesth Analg 2005;101:86975

14. Aya AG, Mangin R, Vialles N, Ferrer JM, Robert C, Ripart J, deLa Coussaye JE. Patients with severe preeclampsia experienceless hypotension during spinal anesthesia for elective cesareandelivery than healthy parturients: a prospective cohort com-parison. Anesth Analg 2003;97:86772

15. Clark VA, Sharwood-Smith GH, Stewart AV. Ephedrine require-ments are reduced during spinal anaesthesia for caesarean sec-tion in preeclampsia. Int J Obstet Anesth 2005;14:913

16. Visalyaputra S, Rodanant O, Somboonviboon W, TantivitayatanK, Thienthong S, Saengchote W. Spinal versus epidural anesthe-sia for cesarean delivery in severe preeclampsia: a prospectiverandomized, multicenter study. Anesth Analg 2005;101:8628

17. Sharwood-Smith G, Clark V, Watson E. Regional anesthesia forcesarean section in severe preeclampsia: spinal anesthesia is thepreferred choice. Int J Obstet Anesth 1999;8:859

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19. Santos AC, Birnbach DJ. Spinal anesthesia for cesarean deliveryin severely preeclamptic women: dont throw out the baby withthe bathwater! Anesth Analg 2005;101:85961

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22. Jouppila P, Jouppila R, Hollmn A, Koivula A. Lumbar epiduralanalgesia to improve intervillous blood ow during labor insevere preeclampsia. Obstet Gynecol 1982;59:15861

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30. Park BY, Jeong CW, Jang EA, Kim SJ, Jeong ST, Shin MH, Lee J,Yoo KY. Dose-related attenuation of cardiovascular responsesto tracheal intubation by intravenous remifentanil bolus insevere pre-eclamptic patients undergoing Caesarean delivery.Br J Anaesth 2011;106:827

31. Yoo KY, Jeong CW, Park BY, Kim SJ, Jeong ST, Shin MH, Lee J.Effects of remifentanil on cardiovascular and bispectral indexresponses to endotracheal intubation in severe pre-eclampticpatients undergoing caesarean delivery under general anesthe-sia. Br J Anesth 2009;102:8129

32. Dyer RA, Els I, Farbas J, Torr GJ, Schoeman LK, James MF.Prospective, randomized trial comparing general with spinalanesthesia for cesarean delivery in preeclamptic patients with anonreassuring fetal heart trace. Anesthesiology 2003;99:5619

33. Smiley RM. Burden of proof. Anesthesiology 2009;111:4702 34. Habib AS. A review of the impact of phenylephrine adminis-

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35. Ramanathan J, Vaddadi AK, Arheart KL. Combined spinal andepidural anesthesia with low doses of intrathecal bupivacainein women with severe preeclampsia: a preliminary report. RegAnesth Pain Med 2001;26:4651

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