The effect of postoperative epidural analgesia in women possessing severe gestational hypertension undergoing cesarean delivery

doi:10.4236/ojog.2011.14030

Paper Menu >>

Journal Menu >>

Open Journal of Obstetrics and Gynecology, 2011, 1, 159-162

doi:10.4236/ojog.2011.14030 Published Online December 2011 (http://www.SciRP.org/journal/ojog/

OJOG

Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJOG

The effect of postoperative epidural analgesia in women

possessing severe gestational hypertension

undergoing cesarean delivery

Misao Satomi, Yoshie Hiraizumi, Hidetaka Onodera, Shunji Suzuki

Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital, Tokyo, Japan.

Email: [email protected]

Received 30 August 2011; revised 30 September 2011; accepted 15 October 2011.

ABSTRACT

Introduction: The purpose of this study was to exa-

mine the clinical usefulness of postoperative epidural

analgesia in patients possessing severe gestational

hypertension after Cesarean delivery. Methods: We

reviewed the obstetric records of 99 patients possess-

ing severe gestational hypertension undergoing sin-

gleton Cesarean delivery at ≥22 weeks’ gestation.

Thirty patients were received continuous epidural

analgesia with 0.2% ropivacaine for pain relief after

Cesarean delivery with spinal anesthesia, 69 patients

were not received epidural analgesia after Cesarean

delivery with spinal anesthesia. Results: During the

preoperative period, there were no measurable dif-

ferences in the diastolic blood pressure between the 2

groups (108 ± 7 vs. 106 mmHg ± 10 mmHg, p = 0.29).

The diastolic blood pressure at 2 and 4 hours after Ce-

sarean section in the epidural analgesia group were sig-

nificantly lower than those in the non-epidural group

(2 hours after Cesarean section: 88 ± 13 vs. 95 mmHg

± 8 mmHg, p < 0.01; 4 hours after Cesarean section: 92

± 15 vs. 102 mmHg ± 9 mmHg, p < 0.01). Conclusions:

The current results indicated that the postoperative

epidural analgesia can inhibit the rise in diastolic

blood pressure in patients possessing severe gesta-

tional hypertension after Cesarean delivery. This

electronic document is a “live” template. The various

components of your paper [title, text, heads, etc.] are

already defined on the style sheet, as illustrated by

the portions given in this document.

Keywords: Postoperative Epidural Analgesia; Severe Ge-

stational Hypertension; Ropivacaine; Cesarean Delivery

1. INTRODUCTION

Recently, 0.5% bupivacaine has been widely used for

spinal anesthesia for Cesarean delivery, because it is lon-

ger-acting than the drugs used previously such as dibu-

caine and tetracaine [1,2]. For many years, spinal anes-

thesia had not been recommended as an anesthetic tech-

nique for Cesarean delivery with gestational hyperten-

sion to avoid critical hypotension, but recently spinal

anesthesia is getting popular for Cesarean delivery [2,3].

Continuous epidural analgesia now plays one of impor-

tant roles in postoperative pain control, and the clinical

usefulness of epidural analgesia after Cesarean delivery

has been reported for healthy pregnant women [1,3-5].

In Japan, 0.2% ropivacaine has been sometimes admini-

strated for continuous epidural analgesia to decrease po-

stoperative pain after Cesarean section [1]. To our know-

ledge, however, there have been no hemodynamic in-

vesttigations concerning the effect of postoperative epi-

dural analgesia on severely preeclamptic patients after

Cesarean delivery. The aim of this study was to examine

the clinical usefulness of postoperative epidural analge-

sia in patients possessing severe gestational hypertension

after Cesarean delivery.

2. PATIENTS AND METHODS

We reviewed the obstetric records of 99 Japanese pa-

tients possessing severe gestational hypertension under-

going singleton Cesarean delivery at ≥22 weeks’ gesta-

tion managed at the Japanese Red Cross Katsushika Ma-

ternity Hospital between 2008 and 2010. There were no

patients taking antihypertensive medications preopera-

tively. During this period, 30 patients were received con-

tinuous epidural analgesia with 0.2% ropivacaine for

pain relief after Cesarean delivery with spinal anesthesia,

69 patients were not received epidural analgesia after

Cesarean delivery with spinal anesthesia. This retrospec-

tive study was approved by the Ethics Committee of

Japanese Red Cross Katsushika Maternity Hospital. De-

mographic information and the characteristics of severe

gestational hypertension were extracted from the patient

charts. Patients with multiple pregnancy, chronic hyper-

M. Satomi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 159-162

160

tension, renal disease and systemic illnesses were ex-

cluded. Severe gestational hypertension was defined as

blood pressure ≥160/110 mmHg measured on 2 or more

occasions at least six hours apart with the patient at rest.

HELLP syndrome was defined as a syndrome of in-

travascular hemolysis (H), elevated liver enzymes (EL)

and low platelets count (LP) previously reported.

In all cases, after fluid administration of 1000 ml of

lactated Ringer’s solution, a 25-gauge or 23-gauge spinal

needle was placed at the L2-3 or L3-4 interspace with

the patient in the lateral decubitus position. After ob-

serving the flow of cerebrospinal fluid, 1.7 ml - 2.5 ml of

0.5% hypervaric bupivacaine was injected into the su-

barachnoid space. The dose of 0.5% hypervaric bupiva-

caine was determined mainly based on the maternal

height. In the postoperative epidural analgesia group,

after spinal injection the epidural catheter was placed

with an 18-gauge Tuohy needle in the L1-2 or Th12-L1

interspace for postoperative analgesia. About 10 minutes

before the end of surgery, 100 ml of 0.2% ropivacaine

was administered through the epidural catheter at a rate

of 5 ml/minute for postoperative pain relief. In our de-

partment, bolus administration of an epidural initial dose

is thought to be unnecessary based on a previous study

by Hongo et al. [1] At anytime after surgery, the patient

could be given 50 mg flurbiprofen axetil iv or 15 mg pen-

tazocine iv if she experienced pain or discomfort. If the

systoric blood pressure increased over 160 or the diastolic

blood pressure increased over 110 mmHg on 2 or more

occasions at least 1 hour - 2 hours apart, a continuous in-

travenous infusion of nicardipine HCl was started.

Data are presented as mean ± SD or number (%). For

statistical analysis, the Χ2 test for categorical variables

and the Student’s t-test for continuous variables were used.

Differences with P < 0.05 were considered significant.

3. RESULTS

Table 1 shows the clinical characteristics of patients po-

ssessing severe gestational hypertension with and with-

out postoperative epidural analgesia. In this study, there

were no measurable differences in the bupivacaine dose

for spinal anesthesia between the 2 groups (epidural an-

algesia group: 2.1 ml ± 0.2 ml vs. non-epidural group:

2.2 ml ± 0.2 ml, p = 0.33). There were no significant

differences in maternal age, parity, height, body weight,

systolic and diastolic blood pressure, incidences of pro-

teinuria during preoperative period, HELLP syndrome

or eclampsia, surgical duration, maternal blood loss

during Cesarean section and duration of postoperative

hospitalization between the 2 groups. In this study, the

Table 1. The clinical characteristics of patients possessing severe gestational hypertension with and without postopera-

tive epidural analgesia.

Postoperative epidural analgesia (–) (+) P value

(n = 69) (n = 30)

Maternal age (years) 35 ± 4 34 ± 5 0.34

Nulliparity 46 (67%) 17 (57%) 0.34

Maternal height (cm) 159 ± 6 157 ± 5 0.09

Maternal weight at delivery (kg) 67 ± 13 68 ± 17 0.78

Gestational age at delivery (weeks) 35.5 ± 3 31.9 ± 2 <0.01

Blood pressure before surgery

Systolic blood pressure (mmHg) 179 ± 11 178 ± 9 0.64

Diastolic blood pressure (mmHg) 106 ± 10 108 ± 7 0.29

Proteinuria ≥ 100 mg/dl 25 (36%) 11 (37%) 0.97

HELLP syndromea 2 (2.9%) 1 (3.3%) 0.91

Eclampsia 0 (0%) 0 (0%) 1

Surgical duration (minutes) 32 ± 10 31 ± 7 0.57

Maternal blood loss during surgery (g) 650 ± 460 690 ± 460 0.69

Transfusion 0 (0%) 0 (0%) 1

Neonatal birth weight (g) 2276 ± 725 1770 ± 478 <0.01

Light for gestational age infants 14 (20%) 11 (37%) 0.08

Apgar score at 1 minute 8.3 ± 1.0 7.6 ± 1.1 <0.01

Apgar score at 5 minute 9.1 ± 0.6 9.1 ± 0.3 0.98

Umbilical artery pH 7.30 ± 0.04 7.30 ± 0.04 0.99

Duration of postoperative hospitalization (days) 7.6 ± 0.5 7.8 ± 0.6 0.09

aData are presented as mean ± SD or number (%). HELLP syndrome = hemolysis, elevated liver enzymes and low platelets syndrome.

M. Satomi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 159-162 161

gestational age at Cesarean delivery in the epidural ana-

lgesia group was significantly earlier than that in the

non-epidural group. In addition, the neonatal birth wei-

ght and Apgar score at 1 minute in the epidural analgesia

group were significantly lower than those in the non-

epidural group.

Table 2 shows the infusion volume, urine volume, fre-

quency of intravenous injection of pain-killer and intra-

venous infusion of nicardipine HCl during postoperative

24 hours in patients with and without postoperative epi-

dural analgesia. There were no patients with postopera-

tive urination disorder in the 2 groups. The frequency of

receiving 50 mg flurbiprofen axetil iv in the epidural

analgesia group was significantly lower than that in the

non-epidural group. However, there was no significant

difference in the rate of patients requiring intravenous

infusion of nicardipine HCl during postoperative 24 hou-

rs between the 2 groups.

Table 3 shows the changes in systolic and diastolic

blood pressure in the patients with and without postop-

erative epidural analgesia. During the preoperative pe-

riod, there were no measurable differences in the systolic

and diastolic blood pressure between the 2 groups, and

there were no measurable differences in the systolic

blood pressure between the 2 groups at 2 and 4 hours

after Cesarean section. However, the diastolic blood

pressure at 2 and 4 hours after Cesarean section in the

epidural analgesia group were significantly lower than

those in the non-epidural group. One day after surgery,

there were no measurable differences in the blood pres-

sure between the 2 groups with the presence of patients

receiving intravenous infusion of nicardipine HCl.

Table 2. The infusion volume, urine volume, frequency of intravenous injection of pain-killer and intravenous

infusion of nicardipine HCl during postoperative 24 hours in patients with and without postoperative epidural

analgesia.

Postoperative epidural analgesia (–) (+) P value

(n = 69) (n = 30)

Total infusion volume (ml) 2650 ± 240 2720 ± 310 0.28

Urine volume

Total volume (ml) 3020 ± 840 3200 ± 660 0.26

Urine volume < 1000 ml 0 (0%) 0 (0%) 1

Furosemide use 0 (0%) 1 (3.3%) 0.13

Intravenous injection of pain-killer (times)

Flurbiprofen axetil 50 mg 1.9 ± 1.1 1.4 ± 0.9 0.02

Pentazocine 15 mg 2.0 ± 1.6 1.5 ± 1.2 0.09

Data are presented as mean ± SD or number (%).

Table 3. The changes in systolic and diastolic blood pressure in the patients with and without postoperative

epidural analgesia.

Postoperative epidural analgesia (–) (+) P value

(n = 69) (n = 30)

Duration preoperative period

Systolic blood pressure (mmHg) 179 ± 11 178 ± 9 0.64

Diastolic blood pressure (mmHg) 106 ± 10 108 ± 7 0.29

At delivery

Systolic blood pressure (mmHg) 125 ± 13 129 ± 10 0.1

Diastolic blood pressure (mmHg) 73 ± 5 76 ± 10 0.13

Two hours after surgery

Systolic blood pressure (mmHg) 151 ± 14 144 ± 17 0.05

Diastolic blood pressure (mmHg) 95 ± 8 88 ± 13 <0.01

Four hours after surgery

Systolic blood pressure (mmHg) 164 ± 14 163 ± 22 0.82

Diastolic blood pressure (mmHg) 102 ± 9 92 ± 15 <0.01

One day after surgery

Systolic blood pressure (mmHg) 136 ± 9 133 ± 11 0.19

Diastolic blood pressure (mmHg) 84 ± 8 82 ± 9 0.31

Data are presented as mean ± SD or number (%).

M. Satomi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 159-162

162

4. DISCUSSION

In this study, the epidural continuous infusion provided

pain relief in severe hypertensive patients after Cesaren

section as previously reported [6,7]. In this study, there

was no significant difference in the rate of patients re-

quiring antihypertensive agents between the patients

with and without postoperative epidural analgesia be-

cause there were no significant differences in the systolic

blood pressure levels between the 2 groups; however the

current results indicated that the postoperative epidural

analgesia can inhibit the rise in diastolic blood pressure

in patients possessing severe gestational hypertension af-

ter Cesarean delivery.

In patients possessing gestational hypertension, the

blood pressure has been observed to be sometimes re-

increased to the severely levels after Cesarean delivery

associated with the postoperative pain and the return of

vascular tone following delivery [8,9]. This return of

vascular tone has been suggested to be also related to

profound fluid shifts that occur in the puerperium with a

rise in intravascular volume due to mobilization of ex-

travascular fluid [8,9]. Regional anesthesia-induced sy-

mpathetic blockade may be contributed to the decrease

in diastolic blood pressure associate with the systemic

peripheral vascular dilation in patients with severe gesta-

tional hypertension. However, the current results also

indicated the sympathetic blockade with vascular dila-

tion may not be able to prevent the fluid shifts associated

with the re-increased systolic blood pressure in patients

possessing gestational hypertension although there were

no significant differences in the urine volume during po-

stoperative 24 hours.

We know that there are some limitations in this retro-

spective study. Firstly, this may be a small study. Se-

condly, in this study the parturient required Cesarean

delivery at earlier gestation received epidural analgesia

more frequently. We cannot explain the reason for this

tendency well; however it may also support the efficacy

of postoperative epidural analgesia inhibiting the rise in

blood pressure because hypertensive disorders develop-

ing at earlier gestation have been reported to tend to be

severe [10]. Otherwise, a circulating blood volume may-

be smaller in the epidural group than that in the non-

epidural group and the smaller volume may explain the

decreased diastolic pressure in the epidural group after

Cesarean delivery. Therefore, a prospective study to clear

this difference may be needed.

The postoperative epidural analgesia may be useful in

the management of patient with severe gestational hy-

pertension after Cesarean delivery, because adequate

control of diastolic blood pressure is important to pre-

vent systemic organ dysfunction in severe gestational

hypertension [11]. However, further studies may be nee-

ded concerning the changes in systolic blood pressure.

REFERENCES

[1] Hongo, T., Kitamura, A., Yokozuka, M., Kim, C. and Sa-

kamoto, A. (2006) An epidural initial dose in unneces-

sary in combined spinal epidural anesthesia for Caesar-

ean section. Journal of Nippon Medical Scool, 73, 70-74.

doi:10.1272/jnms.73.70

[2] Suzuki, H., Ogawa, S., Hanaoka, K., Kugimiya, T., Yo-

koyama, K., Isshiki, A., Hosoyamada, A., Kikuchi, H.

and Numata, K. (1998) Clinical study of AJ-007 (bupiva-

caine) in spinal anesthesia—investigation of clinical dos-

age of isobaric and hyperbaric formulations (in Japanese).

Masui, 47, 447-465.

[3] Block, B.M., Lieu, S.S., Rowlingson, A.J., Cowan, A.R.,

Cowan, J.A. Jr. and Wu, C.L. (2003) Efficacy of postope-

rative epidural analgesia. Journal of the American Medi-

cal Association, 290, 2455-2463.

doi:10.1001/jama.290.18.2455

[4] Mendez, R., Eisenach, J.C. and Kashtan, K. (1990) Epi-

dural clonidine analgesia after Cesarean section. Anes-

thesiology, 73, 848-852.

doi:10.1097/00000542-199011000-00009

[5] Jens-Christian, S., Adam, K., Joerg, Z., Joachim, N., An-

dreas, H. and Rudolf, H. (2009) Effects of spinal anaes-

thesia versus epidural anaesthesia for caesarean section

on postoperative analgesic consumption and postopera-

tive pain. European Journal of Anaesthesiology, 26, 52-

59. doi:10.1097/EJA.0b013e328318c639

[6] Hood, D.D. and Curry, R. (1990) Spinal versus epidural

anesthesia for Cesarean section in severely preeclamptic

patients. Anesthesiology, 90, 1276-1282.

doi:10.1097/00000542-199905000-00009

[7] Visalyaputa, S., Rodanant, O., Somboonviboon, W., Tan-

tivitayatan, K., Thienthong, S. and Saengchote, W. (2005)

Spinal versus epidural anesthesia for Cesarean delivery

in severe preeclampsia: A prospective randomized multi-

center study. Anesthesia and Analgesia, 101, 862-868.

doi:10.1213/01.ANE.0000160535.95678.34

[8] Ferrazani, S., DeCarolis, S., Pomini, F., Testa, A.C., Mas-

tomarino, C. and Caruso, A. (1994) The duration of hy-

pertension in the puerperium of preeclamptic women:

Relationship with renal impairment and week of delivery.

American Journal of Obstetrics and Gynecology, 171,

506-512.

[9] Walters, B.N., Thompson, M.E., Lee, A. and de Swiet, M.

(1986) Blood pressure in the puerperium. Clinical Sci-

ence(Lond), 71, 589-594.

[10] Paruk, F. and Moodley, J. (2000) Maternal and neonatal

outcome in early- and late-onset pre-eclampsia. Seminars

in Neonatology, 5, 197-207. doi:10.1053/siny.2000.0023

[11] Von Dadelszen, P., Menzies, J., Gilgoff, S., Xie, F.,

Douglas, M.J., Sawchuck, D. and Magee, L.A. (2007)

Evidence-based management for preeclampsia. Frontiers

in Bioscience, 12, 2876-2889. doi:10.2741/2279