Download PDF
Am J Perinatol 2024; 41(S 01): e3091-e3098
DOI: 10.1055/a-2196-6660
Original Article

Spinal Hypotension and Time from Spinal-to-Delivery in Scheduled Cesarean Deliveries: Association with Neonatal Acidosis

Nayla G. Kazzi 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
,
Han-Yang Chen
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
,
Linden Lee
2   Division of Obstetrical Anesthesiology, Department of Anesthesiology, Kapiolani Medical Center for Women & Children, Hawaii Pacific Health, Honolulu, Hawaii
,
Sarah A. Nazeer
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
,
Kendra Brown
3   Division of Obstetrical Anesthesiology, Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
,
Baha M. Sibai
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
,
Suneet P. Chauhan
1   Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Objective This work aimed to study the effect of sustained hypotension after spinal on neonatal acidosis and adverse outcomes in those undergoing scheduled cesarean delivery (CD) with universal prophylactic vasopressor exposure and to examine differences in spinal-to-delivery time by neonatal acidosis status.

Study Design This retrospective cohort study conducted at a quaternary care center from January 2019 to December 2021 included singleton, term, nonanomalous pregnancies, with scheduled CD under spinal anesthesia. Hypotension was defined as a systolic blood pressure (SYS-BP) < 100 mm Hg (SYS-BP100) or a >20% drop from baseline blood pressure (SYS-BP20). Both the occurrence of hypotension and its magnitude and duration were studied; the latter through the development of a hypotension index. The 90th and 95th percentiles of the hypotension index for SYS-BP20 and SYS-BP100, respectively, were used to define sustained hypotension. The primary outcome was neonatal acidosis (umbilical artery pH ≤ 7.1 or base excess ≤ −12 mmol). Secondary outcomes were composites of neonatal (CNAO) and maternal (CMAO) adverse outcomes. Multivariable Poisson regression models with robust error variance analysis was used to estimate adjusted relative risks (aRRs) and 95% confidence intervals (CIs).

Results Our study included 332 individuals who underwent scheduled CD; among them 330 (99.4%) received prophylactic vasopressors. The rate of neonatal acidosis was 4.2%. Sustained hypotension after spinal anesthesia, which occurred in 12.3% of the cohort, was associated with increased risk for neonatal acidosis (aRR 3.96, 95% CI 1.21–12.98), but was not associated with CNAO or CMAO. Time from spinal-to-delivery was not different in those with and without neonatal acidosis.

Conclusion Despite universal exposure to prophylactic vasopressors, sustained hypotension after spinal anesthesia was still associated with neonatal acidosis, but no other adverse perinatal outcomes. Our findings may provide additional support for the adoption of prophylactic vasopressors to reduce spinal hypotension and downstream effects on the neonate from intraoperative hemodynamic instability.

Key Points

  • Despite prophylactic vasopressors during scheduled CD, neonatal acidosis occurred in 4% of subjects.

  • Sustained hypotension after spinal anesthesia was associated with neonatal acidosis, but not adverse neonatal outcomes.

  • Spinal-to-delivery time was not associated with neonatal acidosis in scheduled CD.

Keywords

cesarean delivery - neonatal acidosis - vasopressors - spinal hypotension

Supplementary Material



Publication History

Received: 26 May 2023

Accepted: 19 October 2023

Accepted Manuscript online:
23 October 2023

Article published online:
22 November 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Osterman MJK, Hamilton BE, Martin JA, Driscoll AK, Valenzuela CP. Births: final data for 2021. Natl Vital Stat Rep 2023; 72 (01) 1-53
    PubMedGoogle Scholar
  • 2 Bligard KH, Cameo T, McCallum KN. et al. The association of fetal acidemia with adverse neonatal outcomes at time of scheduled cesarean delivery. Am J Obstet Gynecol 2022; 227 (02) 265.e1-265.e8
    CrossrefPubMedGoogle Scholar
  • 3 Mueller MD, Brühwiler H, Schüpfer GK, Lüscher KP. Higher rate of fetal acidemia after regional anesthesia for elective cesarean delivery. Obstet Gynecol 1997; 90 (01) 131-134
    CrossrefPubMedGoogle Scholar
  • 4 Knigin D, Avidan A, Weiniger CF. The effect of spinal hypotension and anesthesia-to-delivery time interval on neonatal outcomes in planned cesarean delivery. Am J Obstet Gynecol 2020; 223 (05) 747.e1-74 -7.e13
    CrossrefPubMedGoogle Scholar
  • 5 Rimsza RR, Perez WM, Babbar S, O'Brien M, Vricella LK. Time from neuraxial anesthesia placement to delivery is inversely proportional to umbilical arterial cord pH at scheduled cesarean delivery. Am J Obstet Gynecol 2019; 220 (04) 389.e1-3 -89.e9
    CrossrefPubMedGoogle Scholar
  • 6 Roberts SW, Leveno KJ, Sidawi JE, Lucas MJ, Kelly MA. Fetal acidemia associated with regional anesthesia for elective cesarean delivery. Obstet Gynecol 1995; 85 (01) 79-83
    CrossrefPubMedGoogle Scholar
  • 7 Chauhan SP, Hendrix NW, Magann EF. et al. Neonatal organ dysfunction among newborns at gestational age 34 weeks and umbilical arterial pH<7.00. J Matern Fetal Neonatal Med 2005; 17 (04) 261-268
    CrossrefPubMedGoogle Scholar
  • 8 Malin GL, Morris RK, Khan KS. Strength of association between umbilical cord pH and perinatal and long term outcomes: systematic review and meta-analysis. BMJ 2010; 340: c1471
    CrossrefPubMedGoogle Scholar
  • 9 Low JA, Lindsay BG, Derrick EJ. Threshold of metabolic acidosis associated with newborn complications. Am J Obstet Gynecol 1997; 177 (06) 1391-1394
    CrossrefPubMedGoogle Scholar
  • 10 Andres RL, Saade G, Gilstrap LC. et al. Association between umbilical blood gas parameters and neonatal morbidity and death in neonates with pathologic fetal acidemia. Am J Obstet Gynecol 1999; 181 (04) 867-871
    CrossrefPubMedGoogle Scholar
  • 11 Yeh P, Emary K, Impey L. The relationship between umbilical cord arterial pH and serious adverse neonatal outcome: analysis of 51,519 consecutive validated samples. BJOG 2012; 119 (07) 824-831
    CrossrefPubMedGoogle Scholar
  • 12 Bailey EJ, Frolova AI, López JD, Raghuraman N, Macones GA, Cahill AG. Mild neonatal acidemia is associated with neonatal morbidity at term. Am J Perinatol 2021; 38 (S 01): e155-e161
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Hassanin AS, El-Shahawy HF, Hussain SH. et al. Impact of interval between induction of spinal anesthesia to delivery on umbilical arterial cord ph of neonates delivered by elective cesarean section. BMC Pregnancy Childbirth 2022; 22 (01) 216
    CrossrefPubMedGoogle Scholar
  • 14 NICE Guideline, No. 192. Caesarean birth. London: National Institute for Health and Care Excellence (NICE); 2021 . Accessed May 07, 2023 at: https://www.ncbi.nlm.nih.gov/books/NBK569570/
    PubMedGoogle Scholar
  • 15 Kinsella SM, Carvalho B, Dyer RA. et al; Consensus Statement Collaborators. International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. Anaesthesia 2018; 73 (01) 71-92
    CrossrefPubMedGoogle Scholar
  • 16 Klöhr S, Roth R, Hofmann T, Rossaint R, Heesen M. Definitions of hypotension after spinal anaesthesia for caesarean section: literature search and application to parturients. Acta Anaesthesiol Scand 2010; 54 (08) 909-921
    CrossrefPubMedGoogle Scholar
  • 17 DeBolt CA, Sarker M, Trejo FE. et al. Association between obesity and fetal acidosis at scheduled cesarean delivery. Obstet Gynecol 2022; 140 (06) 950-957
    CrossrefPubMedGoogle Scholar
  • 18 Ngan Kee WD, Khaw KS, Ng FF. Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section. Br J Anaesth 2004; 92 (04) 469-474
    CrossrefPubMedGoogle Scholar
  • 19 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 2019; 129 (05) 1312-1318
    CrossrefPubMedGoogle Scholar
  • 20 Veeser M, Hofmann T, Roth R, Klöhr S, Rossaint R, Heesen M. Vasopressors for the management of hypotension after spinal anesthesia for elective caesarean section. Systematic review and cumulative meta-analysis. Acta Anaesthesiol Scand 2012; 56 (07) 810-816 Erratum in: Acta Anaesthesiol Scand. 2012 Oct;56(9):1204. PMID: 22313496
    CrossrefPubMedGoogle Scholar