Original Article

Spinal Anesthesia for Cesarean section in

Preeclampsia
A. B. Shrestha*, K. R. Sharma**
*Senior Consultant Anesthesiologist and Associate Professor, Paropakar Maternity and Women’s Hospital,
Thapathali, Kathmandu, Nepal, **Consultant Anesthesiologist, Paropakar Maternity and Women’s Hospital,
Thapathali, Kathmandu, Nepal

ABSTRACT
INTRODUCTION: Preeclampsia a complex hypertensive disorder of pregnancy affecting multiple
systems. The choice of anesthesia in preeclamptic mothers undergoing Cesarean delivery has
been debated for years. General as well as regional anesthetic techniques are equally acceptable
for cesarean delivery in pregnancies complicated by preeclampsia. Currently, the safety of
regional anesthesia technique is well established and they can provide better obstetrical outcome.
Several studies have been carried out which have concluded spinal anesthesia more preferable
than epidural anesthesia in preeclampsia. Our aim is to study the outcome and elaborate the
hemodynamic changes associated with spinal anesthesia in preeclampsia.
METHODS: We carried out a retrospective study of all the preeclamptic women who underwent
Lower Segment Caesarean Section (LSCS) under spinal anesthesia in Paropakar Maternity
and Women’s Hospital (PMWH), Kathmandu, Nepal during 16 July 2007- 15 July 2008. Both
emergency as well as elective cases were included in the study. Patients’ records were studied and
analyzed and relevant information were taken into account. The drug used for spinal anesthesia
was hyperbaric Bupivacaine 0.5%. Subarachnoid block was performed in either L3-L4 or L4-L5
intervertebral segment with patient sitting up. Spinal needle 26G with Quincke’s bevel was used
for the purpose. The hemodynamic response (systolic blood pressure, diastolic blood pressure,
heart rate) and SpO2 were observed.
RESULTS: Total of 202 cases was included in our study. Age ranged from 17 to 37 years. The duration
of surgery ranged from 25min to 100min. According to observation, both systolic and diastolic
blood pressure dropped to minimum within the initial 10 minutes of spinal anesthesia. Heart
rate fluctuation was minimal with an initial small drop within 10 minutes of spinal anesthesia.
Similarly, SpO2 also showed a subtle decline within 20 minutes of spinal anesthesia.
CONCLUSION: Our study finds spinal anesthesia as a preferred method taking into account the
relatively stable and better hemodynamic stability, convenience in procedure and rapid and
predictable anesthesia and no risks of sudden critical hypotension.
KEY WORDS: Cesarean Section, Preeclampsia, Regional Anesthesia, Spinal Anesthesia

INTRODUCTION: new onset proteinuria >0.3gm/day and new-onset

nondependent edema during pregnancy, usually after
Preeclampsia has been described as the triad of new- 20 weeks.1
onset hypertension (BP ≥140/90mm Hg, or when there
is rise of ≥30mm Hg systolic or ≥15mm Hg diastolic), The choice of anesthesia in preeclamptic mothers
undergoing Caesarean delivery has been debated for
Correspondence :
years. General as well as regional anesthetic methods
Shrestha Amir Babu
are equally acceptable for caesarean delivery in
Paropakar Maternity and Women’s Hospital,
pregnancies complicated by preeclampsia.2 Currently,
Thapathali, Kathmandu, Nepal, Tel: 97714260066
the safety of regional anesthesia techniques is well
Email: ameer122@hotmail.com;

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established and they can provide better obstetrical
outcome when chosen properly. Thus, regional
anesthesia is extensively used for the management of
pain and labor in women with pre-eclampsia.1
Selection of regional anesthesia is another aspect
where the results for epidural and spinal have been
equivocal. Both of these techniques have their unique
benefits and risks. The benefit of epidural over spinal
anesthesia is that incrementally dosing the epidural
catheter increases the epidural sensory blockade
in stages and minimizes the risks of hypotension.3
However, the expertise and skill involved and higher
failure rate of epidural limit its frequent use. On the
other hand, significant maternal hypotension is believed
to be more likely with spinal compared with epidural
anesthesia.3 Despite the convenience in administration,
rapid onset of regional blockade and fairly predictable
course of anesthesia, spinal anesthesia is controversial
only in terms of hemodynamic compromise that it
is believed to cause in preeclampsia. Several studies
have been carried out which have concluded spinal
anesthesia more preferable than epidural anesthesia
in preeclampsia. Our aim is to study the outcome and
elaborate the hemodynamic changes associated with
spinal anesthesia in preeclampsia as our anesthetic
choice in preeclampsia has largely been predominated
by spinal anesthesia.
METHODS:
We carried out a retrospective study of all the
preeclamptic women who underwent Lower Segment
Caesarean Section (LSCS) under subarachnoid block in
Paropakar Maternity and Women’s Hospital (PMWH),
Kathmandu, Nepal during Nepalese fiscal year 2064/65
B.S. (16 July 2007- 15 July 2008). Both emergency
as well as elective cases were included in the study.
Patients' records were studied and analyzed and
relevant information were taken into account. To avoid
confounding factors as much as possible, following
cases were excluded:
• Patients not meeting the criteria for diagnosis of
pre-eclampsia
• Patients who received additional anesthetic
supplements (General anesthesia, sedatives,
Intravenous anesthetics)
• Surgical time more than one hour
Spinal Anesthesia for Cesarean section in Preeclampsia
• Patients having other significant co-morbidities
related to cardiovascular system
• Patients with ASA III and above
The drug used for spinal anesthesia was 2.2 ml
hyperbaric Bupivacaine 0.5%. Subarachnoid block
was performed in either L3-L4 or L4-L5 intervertebral
segment with patient sitting up. Spinal needle 26G
with Quincke's bevel was used for the purpose.
Crystalloids Lactated Ringer’s solution and Normal
saline were used as intraoperative fluid. One liter of
crystalloid as preload one hour before attempts to
spinal anesthesia and 15 ml/kg/hr as maintenance.
The hemodynamic response (systolic blood pressure,
diastolic blood pressure, heart rate) and SpO2 were
observed every 5 minutes after the administration
of spinal anesthesia for one hour. Intraoperative
vasopressor agent used was mephentermine 6mg at
the interval of 5-10 minutes as deemed necessary.
For descriptive purposes, other parameters taken into
account were age, gravida, antihypertensive taken and
duration of surgery.
RESULTS:
Total of 202 cases were included in our study. Age
ranged from 17 to 37 years (mean 25.13, SD±4.5).
The duration of surgery ranged from 25min to 100min
(mean 53.21, SD±13.3). However, we limited our
observation 5 min before performing spinal till one
hour of spinal anesthesia.
Most of the subjects were primigravida accounting
53.5% of the cases followed by G2 with 27.2%. Least
cases were G5 accounting for 1.0% of the total cases.
The gravida and parity frequency is shown in Table 1.
Table 1
Gravida Frequency Percent
Primi 108 53.5%
G2 55 27.2%
G3 29 14.4%
G4 8 4.0%
G5 2 1.0%
Total 202 100%
Systolic and diastolic blood pressures and heart rates
were monitored preoperatively, and every 5 minutes
after subarachnoid block was performed. Similarly,
SpO2 was monitored continuously and every 5 min
readings were recorded.
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 Spinal Anesthesia for Cesarean section in Preeclampsia

Table 2: Mean systolic blood pressure change

Time Mean Systolic Blood Standard
Pressure (mmHg) Deviation
Pre operative 146.0 13.9
5 min 120.4 18.2
10 min 118.2 17.7
15 min 116.3 15.7
20 min 117.9 14.0
Figure 2: Diastolic blood pressure change over one
25 min 116.1 11.1
hour of spinal anaesthesia
30 min 116.9 12.1
35 min 117.5 11.6 According to our observation, both systolic and
40 min 112.9 23.5 diastolic blood pressure dropped to minimum within
the initial 10 minutes of spinal anesthesia. After the
45 min 116.5 9.7
initial 10 minutes of spinal anesthesia, both systolic
50 min 114.6 21.2 and diastolic pressure followed an overall constant
55 min 120.5 12.9 reading. This might be because of the intravenous
60 min 120.2 12.2 fluids alone or due to the effect of pressor agents
(mephentermine was used in all cases for signicant
hypotension, the aim being to avoid incidences of fall
in blood pressure)

Table 4: Heart rate change

Time Heart Rate (bpm) Standard Deviation
Pre- 100.6 10.9
operative
5 min 95.2 9.4
10 min 96.4 9.7
15 min 96.8 14.7
Figure 1: Mean systolic blood pressure change 20 min 97.0 16.3
over one hour of spinal anesthesia 25 min 95.8 14.4
30 min 94.9 15.9
Table 3: Mean of diastolic blood pressure change 35 min 94.8 15.1
Time Mean Diastolic S t a n d a r d 40 min 93.4 14.8
Pressure (mmHg) Deviation 45 min 94.8 15.9
Pre operative 90.4 9.3 50 min 94.7 13.2
5 min 71.6 13.4 55 min 90.4 17.7
10 min 71.5 16.1 60 min 93.7 14.0
15 min 69.0 17.3 Heart rate fluctuation was minimal with an initial drop
20 min 70.3 15.0 within 10 minutes of spinal anesthesia and remained
25 min 71.0 12.1 almost constant over the one hour duration.
30 min 67.7 13.7
35 min 71.0 14.3
40 min 70.1 14.9
45 min 71.5 13.8
50 min 71.3 13.1
55 min 73.5 13.4
60 min 74.9 14.1

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 Spinal Anesthesia for Cesarean section in Preeclampsia

outcome depend on gestational age at onset, severity

of the disease and presence of preexisting medical
conditions.4 Anesthesia for Cesarean delivery in
patients with preeclampsia has been a debated issue
over years. However, numerous recent studies have
suggested regional anesthesia as a better choice
than general anesthesia. In one randomized study,
comparison of general and regional anesthesia for
cesarean delivery in pregnancies complicated by severe
Figure 3: Heart rate change over one hour of spinal preeclampsia, it was found that maternal hypotension
anesthesia resulting from regional anesthesia could be managed
without excessive IV fluid administration.2
Similarly, SpO2 also showed a subtle decline within
20 minutes of spinal anesthesia and then remained Spinal and epidural or combination of both has been
fairly constant. Oxygen was given to all mothers via practiced quite often as the regional anaesthetic
nasal prongs at the rate of 2litres/min right from the techniques. Previously, epidural anesthesia has been
moment a patient was brought to the Operating room. mentioned as the anesthetic method of choice for
cesarean delivery in preeclamptic patients.5
Table 5: SpO2 Change
Time Mean SpO2 % Standard Deviation In our study there were both systolic and diastolic
5 min 97.3 2.1 blood pressure dropped in the initial 10 minutes
10 min 96.6 2.0 of spinal anesthesia. After the initial 10 minutes of
15 min 94.0 14.9 spinal anesthesia, both systolic and diastolic pressure
20 min 96.1 2.3 followed an overall constant reading. Heart rate
25 min 96.2 2.2 fluctuation was minimal with an initial drop within
30 min 95.9 2.1 10 minutes of spinal anesthesia and remained almost
35 min 95.5 2.2 constant over the one hour duration. Similarly, SpO2
40 min 95.4 2.4 also showed a subtle decline within 20 minutes of
45 min 96.0 2.2 spinal anesthesia and then remained fairly constant.
50 min 95.7 2.2
55 min 95.6 2.0 Better hemodynamic stability with the use of low-
60 min 95.3 2.2 dose local anesthetic along with additives and better
neonatal outcomes has been found with the use
of subarachnoid block when compared to general
anesthesia.16 Study by Kanayama N et al has even
suggested epidural anesthesia as a treatment option
for severe preeclampsia not responding to diet
control and antihypertensive drugs thus avoiding
the risks of premature delivery.6 However, recent
studies comparing epidural versus spinal anesthesia
in preeclampsia have yielded almost similar results
in terms of maternal and fetal outcomes and some
have even advocated combined spinal and epidural
Figure 3: Heart rate change over one hour of spinal technique as the best anaesthetic choice.3,7 As far
anesthesia as the expertise and convenience is concerned,
spinal anesthesia finds a better place than epidural.
DISCUSSION:
As of now, it has been well established that spinal
Preeclampsia is one of the leading causes of maternal anesthesia is a better option than epidural or general
morbidity and mortality and occurs in 3-5% of all anesthesia. In a retrospective study carried out by
pregnancies worldwide. Maternal and neonatal Hood and Boese comparing extradural and spinal

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 Spinal Anesthesia for Cesarean section in Preeclampsia
anesthesia for elective caesarean section in patients
with severe pre-eclampsia, there was a slightly greater
reduction in arterial pressure in women who received
spinal anaesthesia. However, the authors remarked
that the difference between the two groups was
nearly statistically significant (p<0.052) and that spinal
anaesthesia is not as unsafe as generally thought.
However, this retrospective study involved only 34
patients in extradural group and 14 in the spinal
group. A larger prospective study would be required
before spinal anaesthesia can be recommended as
being safe for patients with pre-eclampsia.8,9 Another
retrospective study carried out by Chan and colleagues
concluded spinal anesthesia as the method of choice for
preeclamptic women. They did a 5 year retrospective
survey of anesthesia for caesarean section for mild/
moderate and severe preeclampsia including one
hundred and twenty-one cases of non-labouring
preeclamptic patients receiving spinal or epidural
anesthesia for caesarean section. Comparisons were
made of the lowest blood pressures recorded before
induction of anaesthesia, during the period from
induction to delivery and the period from delivery to
the end of operation. The decrease in blood pressure
was similar after spinal and epidural anaesthesia. There
was no difference in maternal or neonatal outcome.10 It
is recommended that a regional anaesthetic technique
should be used whenever possible in preference to
general anesthesia. General anesthesia is preferable
when regional techniques are contraindicated or
where they have been unsuccessful.1
Studies have suggested that spinal anesthesia
does not cause a very rapid fall in blood pressure
in preeclamptic patients as is seen in normal
pregnancy.11 This might be due to the fact that failure
to vasodilate is a common factor in preeclampsia.4 A
study by Dyer et al have found Spinal anesthesia in
severe preeclampsia to cause insignificant changes
in cardiac output12 further emphasizing the use of
spinal anesthesia in preeclamptic patients. Another
Prospective cohort study carried out by Aya AGM et al
has also concluded that the incidence of hypotension
is less in patients with severe preeclampsia undergoing
spinal anesthesia for cesarean delivery, as compared
with healthy parturient. In addition, the magnitude
of the decrease in mean BP is smaller in severely
preeclamptic patients.11 In another study by Aya
AGM et al compared the risk between patients with
severe preeclampsia and healthy women undergoing
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preterm cesarean delivery. It was found that the risk
of hypotension in the preeclamptic group was almost
2 times less than that in the preterm group concluding
that preeclampsia-associated factors, rather than
a smaller uterine mass, account for the infrequent
incidence of spinal hypotension in preeclamptic
patients.14 In addition to fairly stable hemodynamics,
spinal anesthesia has another important implication
regarding cost especially in third world countries. One
retrospective study carried out by Okafor and Okezie
in Nigeria has emphasized the use of spinal anesthesia
in view of recent favorable reviews and cheaper cost.15
CONCLUSION:
With the recent studies establishing the fact that
spinal anesthesia is a safer option for preeclamptic
patients, our study also finds spinal anesthesia as a
preferred method taking into account the relatively
stable hemodynamics, convenience in procedure and
rapid and predictable anesthesia. Moreover, it is a
method of choice for a developing country like Nepal
where resources and expertise are limited. However,
future prospective studies involving a large number of
patients and comparison with various other methods
of anesthesia are needed to further establish the safety
and utility of spinal anesthesia over other anesthetic
methods in preeclamptic patients.
REFERENCES:
1. Mandal NG, Surapaneni S. Regional anaesthesia in pre-
eclampsia: advantages and disadvantages. Drugs 2004;
64: 223-236.
2. Wallace DH, Leveno KJ, Cunningham FG, et al. Randomized
comparison of general and regional anesthesia for
cesarean delivery in pregnancies complicated by severe
preeclampsia. Obstet & Gynecol 1995; 86: 193-199
3. Hood DD, Regina C. Spinal versus Epidural anesthesia
for cesarean section in severely preeclamptic patients: a
retrospective survey. Anesthesiology. 1999; 90:1276-82.
4. Gogarten W. Preeclampsia and anaesthesia. Curr Opin
Anaesthesiol 2009, 22: 347-351
5. Morrison DH. Anaesthesia and pre-eclampsia. Can J
Anaesth 1987, 34: 415-22
6. Kanayama N, Belayet HM, Khatun S, et al. A new
treatment of severe pre-eclampsia by long-term epidural
anaesthesia. J Hum Hypertens 1999; 13: 167-171
7. Roofthooft E, Van de Velde M. Low-dose spinal
anaestheisa for caesarean section to prevent spinal-
induced hypotension. Curr Opin Anaesthesiol 2008 Jun;
21: 259-62

8. Mushambi MC, Halligan AW, Williamson K. Recent
developments in the pathophysiology and management
of pre-eclampsia. Br J Anaesth 1996; 76: 133-148
9. Hood DD, Boese PA. Epidural and spinal anesthesia for
caesarean section in severely pre-eclamptic patients.
Reg Anesth 1992, 17: 35
10. Chiu L, Mansor M, Ng KP, Chan YK. Retrospective review
of spinal versus epidural anaesthesia for caesarean
section in preeclamptic patients. Int J Obstet anesth.
2003 Jan; 12: 23-7
11. Sharwood-Smith G, Drummond GB. Hypotension in
obstetric spinal anaesthesia: a lesson from preeclampsia.
Br J Anaesth 2009, 102: 291-4
12. Dyer Ra, Piercy JL, Reed AR, et al. Hemodynamic changes
associated with spinal anesthesia for cesarean delivery in
severe preeclampsia. Anesthesiology 2008; 108: 802-811
13. Aya AGM, Mangin R, Vialles N, et al. Patients with severe
Spinal Anesthesia for Cesarean section in Preeclampsia
preeclampsia experience less hypotension during spinal
anesthesia for elective cesarean delivery than healthy
parturient: a prospective cohort comparison. Anesth
and Analg 2003; 97: 867-72
14. Aya AGM, Vialles N, Tanoubi I, et al. Spinal anesthesia-
induced hypotension: a risk comparison between
patients with severe preeclampsia and healthy women
undergoing preterm cesarean delivery. Anesth and Analg
2005; 101:869-75
15. Okafor UV, Okezie O. Maternal and fetal outcome of
anaesthesia for caesarean delivery in preeclampsia/
eclampsia in Enugu, Nigeria: a retrospective observational
study. Int J Obstet Anesth 2005, 14: 108-113
16. Sujata Chaudhary, Rashmi Salhotra. Subarachnoid
block for caesarean section in severe preeclampsia. J
Anaesthesiol Clin Pharmacol. 2011 Apr-Jun; 27(2): 169–
173
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