ANALYSIS OF OUTCOME OF GENARAL ANALYSIS OF OUTCOME OF GENARAL VERSUS SPINAL ANAESTHESIA FOR VERSUS SPINAL ANAESTHESIA FOR

CAESAREAN DELIVERY IN SEVERECAESAREAN DELIVERY IN SEVERE PRE-ECLAMPSIA WITH FOETAL PRE-ECLAMPSIA WITH FOETAL

COMPROMISE COMPROMISE   

SpeakerSpeaker

Dr. Md. Harun-or- RashidDr. Md. Harun-or- RashidM.B.B.S, M.C.P.S, D.A, F.C.P.S (AnesthesiologyM.B.B.S, M.C.P.S, D.A, F.C.P.S (Anesthesiology))

ConsultantConsultant

Intensive Care UnitIntensive Care UnitMymensingh Medical College HospitalMymensingh Medical College Hospital

ChairpersonChairperson

Prof. Dr. Munirul IslamProf. Dr. Munirul IslamProf & Head of the Deptt.Prof & Head of the Deptt.

Anesthesiology & Intensive Care Anesthesiology & Intensive Care Mymensingh Medical College & HospitalMymensingh Medical College & Hospital

Source:Source: Biomedica/ New Journal, vol.20 (July – Dec, Biomedica/ New Journal, vol.20 (July – Dec,

2004)2004)

Place of study:Place of study: Pakistan Naval Hospital Shifa Pakistan Naval Hospital Shifa

Karachi, Karachi,

Pakistan. Pakistan.

STUDIED BYSTUDIED BY

MUHAMMAD HASAN-UL-HAQMUHAMMAD HASAN-UL-HAQDEPARTMENT OF ANAESTHESIA, MILITARY DEPARTMENT OF ANAESTHESIA, MILITARY

HOSPITAL,HOSPITAL,

RAWALPINDI, PAKISTAN RAWALPINDI, PAKISTAN

INTRODUCTION:INTRODUCTION: Pre-eclamptic toxaemia (PET) is a multi-Pre-eclamptic toxaemia (PET) is a multi-

systemic disorder that is characterized by systemic disorder that is characterized by endothelial cell dysfunction as a endothelial cell dysfunction as a consequence of abnormal genetic and consequence of abnormal genetic and immunological mechanisms. Despite immunological mechanisms. Despite active research for years, the exact active research for years, the exact aetiology of this potentially fatal disorder aetiology of this potentially fatal disorder remains unknown. Although remains unknown. Although understanding of the pathophysiology of understanding of the pathophysiology of pre-eclampsia has improved, pre-eclampsia has improved, management has not changed management has not changed significantly over the yearssignificantly over the years11. .

Cont:Cont:

Anaesthetic management of these Anaesthetic management of these patients remains a challenge. Although patients remains a challenge. Although general anesthesia can be used safely in general anesthesia can be used safely in pre-eclamptic women, it is fraught with pre-eclamptic women, it is fraught with greater maternal morbidity and mortality. greater maternal morbidity and mortality. Currently, the safety of regional Currently, the safety of regional anesthesia techniques is well established anesthesia techniques is well established and they can provide better obstetrical and they can provide better obstetrical outcome when chosen properly. Thus, outcome when chosen properly. Thus, regional anesthesia is extensively used regional anesthesia is extensively used for the obstetric management in women for the obstetric management in women with pre-eclampsiawith pre-eclampsia11..

Cont:Cont:

Where caesarean section is required Where caesarean section is required the relative risks of general anesthesia the relative risks of general anesthesia must be assessed. Regional anesthesia must be assessed. Regional anesthesia is usually considered safer, although is usually considered safer, although cases must be assessed on an cases must be assessed on an individual basis. The added risks individual basis. The added risks associated with general anesthesia associated with general anesthesia include airway difficulties due to include airway difficulties due to oedema (often aggravated by tracheal oedema (often aggravated by tracheal intubations), and the presser response intubations), and the presser response to laryngoscopy and extubation. to laryngoscopy and extubation.

Cont:Cont:

During the last decade, after the During the last decade, after the advent of pencil point spinal needles advent of pencil point spinal needles and newer local anesthetic agents, it and newer local anesthetic agents, it has been tried with favorable results. has been tried with favorable results. In most of the obstetrical centers it is In most of the obstetrical centers it is now being used as anesthesia of first now being used as anesthesia of first choice for pre-eclamptic patientschoice for pre-eclamptic patients6-96-9..

Cont:Cont: The data from previous studies The data from previous studies

demonstrates that pre-eclampsia / demonstrates that pre-eclampsia / eclampsia related complications and eclampsia related complications and haemorrhage are the leading causes for haemorrhage are the leading causes for admission of obstetric patients to the admission of obstetric patients to the ICUICU10,1110,11. Both are associated with increased . Both are associated with increased risks of maternal morbidity and mortalityrisks of maternal morbidity and mortality1212, , which is more prevalent perioperatively in which is more prevalent perioperatively in patients given general anesthesia as patients given general anesthesia as compared to regional anesthesiacompared to regional anesthesia11..

Cont:Cont:

Most of these studies recommend Most of these studies recommend further clinical trial to choose the further clinical trial to choose the best techniquebest technique6-96-9. In their centre they . In their centre they have been using both the techniques have been using both the techniques of anesthesia, general as well as of anesthesia, general as well as spinal since years and recently they spinal since years and recently they have adopted this technique in 98% have adopted this technique in 98% such patients.such patients.

STUDY DESIGNSTUDY DESIGN

Retrospective comparative analysis Retrospective comparative analysis of peri-operative morbidity and of peri-operative morbidity and mortality in severe pre-eclampsia, mortality in severe pre-eclampsia, was conducted after approval of was conducted after approval of Hospital Research Council, at Hospital Research Council, at Pakistan Naval Hospital Shifa Karachi Pakistan Naval Hospital Shifa Karachi Pakistan, from Jan 2002 to Dec 2003.Pakistan, from Jan 2002 to Dec 2003.

PATIENTS AND METHODSPATIENTS AND METHODS Sixty patients who had DBP> 110 mmHg Sixty patients who had DBP> 110 mmHg

and proteinuria > 3and proteinuria > 3++, were selected for , were selected for study. 30 patients were given general study. 30 patients were given general anaesthesia (GA group) & 30 were anaesthesia (GA group) & 30 were delivered under spinal anaesthesia (SA delivered under spinal anaesthesia (SA group). Incidence of morbidity, mortality & group). Incidence of morbidity, mortality & admission in ICU were noted. admission in ICU were noted.

Cont:Cont:

Foetal compromise criteria Foetal compromise criteria includes heart rate (HR) <60 includes heart rate (HR) <60 (bradycardia) and >150 (bradycardia) and >150 (tachycardia).(tachycardia).

Cont:Cont:

Exclusion criteriaExclusion criteria

Patients with deranged coagulation Patients with deranged coagulation profile, antipartum haemorrhage, profile, antipartum haemorrhage, intrauterine death or impending intrauterine death or impending eclampsia, were excluded from eclampsia, were excluded from study.study.

Table 2: Demographic Data.Table 2: Demographic Data.

SL. NoSL. No Demographic DataDemographic Data GA groupGA group SA groupSA group

11 Age , yr (mean Age , yr (mean ± SD)± SD) 25 25 ± 5± 5 27 27 ± 5± 5

22 Weight, Kg (mean Weight, Kg (mean ± SD± SD)) 67 67 ± 4± 4 68 68 ± 4± 4

33 Height, Cm (mean Height, Cm (mean ± SD± SD) ) 160 160 ± 3± 3 161 161 ± 4± 4

44 Systolic BP, mmHg (mean Systolic BP, mmHg (mean ± SD± SD) ) 182 182 ± 15± 15 180 180 ± 15± 15

55 Systolic BP, mmHg (mean Systolic BP, mmHg (mean ± SD± SD) ) 119 119 ± 7± 7 118 118 ± 8± 8

66 MAP, mmHg (mean MAP, mmHg (mean ± SD± SD) ) 140 140 ± 11± 11 139 139 ± 11± 11

77 Heart Rate, per min (mean Heart Rate, per min (mean ± SD± SD) ) 97 97 ± 5± 5 96 96 ± 5± 5

88 Proteinuria 3+, No.Proteinuria 3+, No. 1313 1616

99 Proteinuria 3+, No.Proteinuria 3+, No. 1717 1414

1010 Gravity, medoan (range)Gravity, medoan (range) 15(1-4)15(1-4) 1 (1-6)1 (1-6)

1111 Parity, (range)Parity, (range) 0.5 (0-3)0.5 (0-3) 0.5 (0-3)0.5 (0-3)

1212 Active labor, NoActive labor, No 1111 44

1313 Not induced, no labor, No.Not induced, no labor, No. 88 1616

1414 Induced, No labor, No.Induced, No labor, No. 1111 1010

1515 Gestational age, weeksGestational age, weeks 35.1 (3.2)35.1 (3.2) 39.9 (2.6)39.9 (2.6)

Technique of spinal anaesthesia

Role of Anaesthesiologist in pre-eclamptic Role of Anaesthesiologist in pre-eclamptic patient.patient.

To assist with pain management in labour To assist with pain management in labour To provide anaesthesia for Caesarean SectionTo provide anaesthesia for Caesarean Section To assist in the Intensive Care Management of life To assist in the Intensive Care Management of life

threatening complications which may arise from this threatening complications which may arise from this condition.condition.

Special attentionSpecial attention

01. Control of blood pressure.01. Control of blood pressure.

02. Optimization of intra vascular volume.02. Optimization of intra vascular volume.

03. Optimization of renal function.03. Optimization of renal function.

04. Prevention of convulsion.04. Prevention of convulsion.

05. Maintenance of oxygenation.05. Maintenance of oxygenation.

Comparison Of the advantages & disadvantages ofComparison Of the advantages & disadvantages of general vs. Spinal anaesthesia in pre-eclampsia general vs. Spinal anaesthesia in pre-eclampsia

Spinal anaesthesia Spinal anaesthesia general anaesthesia general anaesthesia

advantagesadvantages disadvantagesdisadvantages advantagesadvantages disadvantagedisadvantagess

AirwayAirway No intubation No intubation response.response.

No risk of No risk of failed failed intubation intubation

No controlNo control controlcontrol ExaggeratedExaggerated

Intubation Intubation response.response.

Increased risk of Increased risk of failed intubation.failed intubation.

ConvulsionsConvulsions NilNil No active control No active control Risk of convulsion.Risk of convulsion.

controlcontrol

Drugs & Drugs & TechniqueTechnique

No sedative No sedative drugdrug

Risk of convulsion.Risk of convulsion.

Risk of high block.Risk of high block.Maternal Maternal awareness.awareness.

Fetal depression.Fetal depression.

SpeedSpeed Spinals: quickSpinals: quick

5-10 mins.5-10 mins.Epidural: slow 20-Epidural: slow 20-30 mins.30 mins.

Fast:<5 mins.Fast:<5 mins.

Blood Pressure Blood Pressure ControlControl

Lower Lower catecholaminecatecholamines. s.

Less instability.Less instability.

Risk of Risk of hypotension.hypotension.

Less Less hypotension.hypotension.

Increased Increased catecholamines. catecholamines. Increases in BP, Increases in BP, PAWP, CVP with PAWP, CVP with intubation.intubation.

CoagulationCoagulation No airway No airway instrumentatioinstrumentation.n.

Risk of Risk of haematoma.haematoma.

Avoid spinal Avoid spinal haematoma.haematoma.

Risk of airway Risk of airway haemorrhage.haemorrhage.

Cont:Cont:Spinal anaesthesia Spinal anaesthesia general anaesthesia general anaesthesia

advantagesadvantages disadvantagesdisadvantages advantagesadvantages disadvantagedisadvantagess

AspirationAspiration No risk of No risk of aspiration of aspiration of gastric gastric contents.contents.

No chance of No chance of chemical chemical pneumonitis.pneumonitis.

Risk of aspiration Risk of aspiration of gastric of gastric contents causing contents causing chemical chemical pneumonitis.pneumonitis.

BabyBaby More alert and More alert and less sedated.less sedated.

Apgar Score is Apgar Score is higher (in 1min higher (in 1min after birth) after birth)

Less alert and Less alert and more sedatedmore sedated

Apgar Score is Apgar Score is lower (in 1min lower (in 1min after birth) after birth)

Post Operative Post Operative ComplicationComplication

LowLow HighHigh

Morbidity Morbidity LowLow HighHigh

Mortality Mortality LowLow HighHigh

Statistical analysisStatistical analysisData was analyzed by using SPSS Data was analyzed by using SPSS

version 10. Studentversion 10. Student,,s t- test was used s t- test was used for mean comparison of significant for mean comparison of significant factors and Variance test (ANOVA) factors and Variance test (ANOVA) for inter and intra group analysis of for inter and intra group analysis of the parameters. the parameters.

ResultsResults Statistically incidence of hypotension and Statistically incidence of hypotension and

bradycardia was significantly (p<0.05) bradycardia was significantly (p<0.05) high in SA group but hypertension and high in SA group but hypertension and tachycardia was more (p<0.05) in GA tachycardia was more (p<0.05) in GA group. But clinically haemodynamic group. But clinically haemodynamic changes in both the groups, were in changes in both the groups, were in acceptable and manageable limits during acceptable and manageable limits during the procedure. the procedure.

Table 3: Incidence of morbidity & mortality in GA and SP groups.Table 3: Incidence of morbidity & mortality in GA and SP groups.

Sl. Sl. NoNo

ParameterParameter GA group (n- GA group (n- 30)30)

SA group (n- SA group (n- 30)30)

11 Intraoperative Intraoperative HypotensionHypotension

5 (16.6 %)5 (16.6 %) 10 (33.3%)10 (33.3%)

22 Postoperative HypotensionPostoperative Hypotension 2 (6.6 %)2 (6.6 %) 4 (13.3%)4 (13.3%)

33 Intraoperative Intraoperative HypertensionHypertension

22 (73.3 %)22 (73.3 %) 2 (6.6%)2 (6.6%)

44 Postoperative Postoperative HypertensionHypertension

5 ( 16.6 %)5 ( 16.6 %) nilnil

55 TachycardiaTachycardia 22 (73.3 %)22 (73.3 %) 10 (33.3%)10 (33.3%)

66 BradycardiaBradycardia 5 (16.6 %)5 (16.6 %) 10 (33.3%)10 (33.3%)

77 Apgar scores ( 1 min)Apgar scores ( 1 min) 6(4-8)6(4-8) 8 (6-10)8 (6-10)

88 Apgar scores ( 5 min)Apgar scores ( 5 min) 99 99

99 Postoperative complicationPostoperative complication 20 (66.7%)20 (66.7%) 5 (16.6%)5 (16.6%)

1010 Admission in ICUAdmission in ICU 20 (66.7%)20 (66.7%) 5 (16.6%)5 (16.6%)

1111 Days in hospitalDays in hospital 12 (7-15)12 (7-15) 6 (4-10)6 (4-10)

1212 Mortality (mother)Mortality (mother) 2 (6.6%)2 (6.6%) nilnil

Table 4 : Indications for admission in ICUTable 4 : Indications for admission in ICU

Sl. NoSl. No IndicationsIndications GA groupGA group SA groupSA group

11 Post-operative Post-operative HypertensionHypertension

5 (16.6%)5 (16.6%) nilnil

22 Post-operative Post-operative HypotensionHypotension

2 (6.6%)2 (6.6%) 3 (10%)3 (10%)

33 FitsFits 2 (6.6%)2 (6.6%) 1 (3.3%)1 (3.3%)

44 Pulmonary oedemaPulmonary oedema 5 (16.6%)5 (16.6%) nilnil

55 Aspiration pneumonitisAspiration pneumonitis 1 (3.3%)1 (3.3%) nilnil

66 Acute renal failureAcute renal failure 2 (6.6%)2 (6.6%) 1 (3.3%)1 (3.3%)

77 Delayed recoveryDelayed recovery 3 (10%)3 (10%) nilnil

Total Total 26 (66.7%)26 (66.7%) 5 (16.6%) 5 (16.6%)

DISCUSSIONDISCUSSION

There are several reasons for There are several reasons for preferring spinal anaesthesia to preferring spinal anaesthesia to general anaesthesia for caesarean general anaesthesia for caesarean sections. Babies born to mothers sections. Babies born to mothers having spinal anaesthesia may be having spinal anaesthesia may be more alert and less sedated as they more alert and less sedated as they have not received any general have not received any general anaesthetic agents through the anaesthetic agents through the placental circulation. placental circulation.

Contd-Contd-

One previous study (Ahmed SM, et al) One previous study (Ahmed SM, et al) showed that the incidence of showed that the incidence of complications following GA (68.8%) complications following GA (68.8%) were significantly (P<0.05) more were significantly (P<0.05) more than that of SA (47.1%)than that of SA (47.1%)1616..

Contd-Contd-

Dyer and Farbas in their prospective, Dyer and Farbas in their prospective, randomized trial comparing general randomized trial comparing general with spinal anaesthesia for caesarean with spinal anaesthesia for caesarean delivery in preeclamptic patients delivery in preeclamptic patients concluded that one-minute APGAR concluded that one-minute APGAR scores were significantly lower scores were significantly lower (p<0.05) after general anaesthesia (p<0.05) after general anaesthesia than spinal anaesthesia but 5 than spinal anaesthesia but 5 minutes scores were almost similarminutes scores were almost similar88..

Contd-Contd-

The data from a previous study The data from a previous study conducted at United Arab Emirates conducted at United Arab Emirates University, demonstrate that University, demonstrate that hypertensive related complications hypertensive related complications (25%) and haemorrhage (28.5%) are (25%) and haemorrhage (28.5%) are the leading causes for admission of the leading causes for admission of obstetric patients to the ICUobstetric patients to the ICU1818..

Contd-Contd-

A previous study conducted in India A previous study conducted in India stated that the nature of stated that the nature of complications following GA were complications following GA were more serious which may even lead to more serious which may even lead to mortality (4.3%), whereas following mortality (4.3%), whereas following spinal anaesthesia it was less serious spinal anaesthesia it was less serious and easily manageable. Hence GA is and easily manageable. Hence GA is not as safe as it is thoughtnot as safe as it is thought16.16.

CONCLUSIONCONCLUSION

Spinal anaesthesia should be used as Spinal anaesthesia should be used as first choice for severe pre-eclamptic first choice for severe pre-eclamptic patients, which is as safe as general patients, which is as safe as general anaesthesia, with less post-operative anaesthesia, with less post-operative morbidity and mortality.morbidity and mortality.