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.
Division of Obstetrical Anesthesiology, Department of Anesthesiology, Kapiolani Medical Center for Women & Children, Hawaii Pacific Health, Honolulu, Hawaii.
Am J Perinatol. 2024 May;41(S 01):e3091-e3098. doi: 10.1055/a-2196-6660. Epub 2023 Oct 23.
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.
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).
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.
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.
· 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..
本研究旨在探讨椎管内麻醉后持续低血压对行择期剖宫产术（CD）产妇新生儿酸中毒和不良结局的影响，并探讨新生儿酸中毒状态下椎管内麻醉至分娩时间的差异。
本回顾性队列研究于 2019 年 1 月至 2021 年 12 月在一家四级保健中心进行，纳入了单胎、足月、非畸形妊娠，在脊髓麻醉下进行择期 CD。低血压定义为收缩压（SYS-BP）<100mmHg（SYS-BP100）或与基础血压（SYS-BP20）相比下降>20%。研究了低血压的发生、程度和持续时间；后者通过开发一个低血压指数来进行。SYS-BP20 和 SYS-BP100 的低血压指数的第 90 个和第 95 个百分位数分别用于定义持续低血压。主要结局是新生儿酸中毒（脐动脉 pH 值≤7.1 或碱剩余≤-12mmol）。次要结局是新生儿（CNAO）和产妇（CMAO）不良结局的综合指标。使用稳健误差方差分析的多变量泊松回归模型来估计调整后的相对风险（aRR）和 95%置信区间（CI）。
本研究共纳入 332 名接受择期 CD 的患者；其中 330 名（99.4%）接受了预防性血管加压素治疗。新生儿酸中毒的发生率为 4.2%。椎管内麻醉后持续低血压，在队列中的发生率为 12.3%，与新生儿酸中毒的风险增加相关（aRR 3.96，95%CI 1.21-12.98），但与 CNAO 或 CMAO 无关。有和没有新生儿酸中毒的患者，从脊髓到分娩的时间没有差异。
尽管普遍使用预防性血管加压素，但椎管内麻醉后持续低血压仍与新生儿酸中毒相关，但与其他围产期不良结局无关。我们的研究结果可能为采用预防性血管加压素减少术中血流动力学不稳定对新生儿的脊髓低血压和下游影响提供额外支持。
尽管在择期 CD 中使用了预防性血管加压素，但仍有 4%的患者出现新生儿酸中毒。
椎管内麻醉后持续低血压与新生儿酸中毒相关，但与新生儿不良结局无关。
择期 CD 中，从脊髓到分娩的时间与新生儿酸中毒无关。
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