Babul Arya, Ashraf Sohi, Free Leanne, Desai Jyoti, Hussain Momina, Babul Najib
Biomedical Sciences, West Career & Technical Academy, Las Vegas, USA.
Biomedical Sciences, Society for Awareness of Neglected Diseases (SAND), Las Vegas, USA.
Cureus. 2025 Aug 12;17(8):e89934. doi: 10.7759/cureus.89934. eCollection 2025 Aug.
Spinal anesthesia-induced hypotension (SAIH) is a common complication of cesarean delivery (CD), potentially leading to maternal discomfort and fetal compromise. Vasopressors such as norepinephrine (NE), phenylephrine (PE), and ephedrine (EP) are frequently used for treatment, yet their comparative efficacy and safety remain uncertain. This study aimed to assess and compare the effectiveness and tolerability of NE, PE, and EP for managing postspinal hypotension (PSH) in low-risk elective CD. Systematic searches were conducted in PubMed, Embase, Cochrane CENTRAL, ScienceDirect, and ClinicalTrials.gov through June 2025. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251074831). We included randomized controlled trials (RCTs) involving parturients undergoing low-risk elective cesarean section who received NE, PE, or EP for the management of PSH. A systematic review, network meta-analysis (NMA), and trial sequential analysis (TSA) were performed. The primary outcome was the successful correction of PSH. Secondary outcomes included maternal bradycardia, nausea, vomiting, neonatal Apgar scores, and umbilical artery pH. Risk of bias was assessed using the Cochrane RoB 2 tool, and the certainty of evidence was graded with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. A total of 16 RCTs encompassing 2,102 parturients were included. NE demonstrated superior efficacy in reversing PSH (odds ratio (OR): 0.23; 95% confidence interval (CI): 0.09-0.58) and was associated with fewer adverse maternal events, including bradycardia (OR: 0.28) and nausea/vomiting (OR: 0.36), compared to PE and EP. Neonatal outcomes were generally comparable across groups, though NE showed a favorable trend in reducing the risk of neonatal acidosis (umbilical artery pH OR: 1.25; 95% CI: 1.06-1.54). Surface under the cumulative ranking curve (SUCRA) rankings and TSA supported the robustness of these findings. NE appears to be the most effective and best-tolerated vasopressor for treating SAIH during elective CD, without compromising neonatal safety. These results support the preferential use of NE over PE and EP in this clinical setting.
脊髓麻醉诱导的低血压（SAIH）是剖宫产（CD）的常见并发症，可能导致母体不适和胎儿窘迫。去甲肾上腺素（NE）、去氧肾上腺素（PE）和麻黄碱（EP）等血管升压药常用于治疗，但它们的相对疗效和安全性仍不确定。本研究旨在评估和比较NE、PE和EP治疗低风险择期剖宫产术后脊髓低血压（PSH）的有效性和耐受性。通过2025年6月在PubMed、Embase、Cochrane CENTRAL、ScienceDirect和ClinicalTrials.gov进行系统检索。该方案已在国际前瞻性系统评价注册库（PROSPERO）（CRD420251074831）中注册。我们纳入了涉及接受NE、PE或EP治疗PSH的低风险择期剖宫产产妇的随机对照试验（RCT）。进行了系统评价、网络荟萃分析（NMA）和试验序贯分析（TSA）。主要结局是PSH的成功纠正。次要结局包括母体心动过缓、恶心、呕吐、新生儿阿氏评分和脐动脉pH值。使用Cochrane RoB 2工具评估偏倚风险，并采用GRADE（推荐分级评估、制定和评价）方法对证据的确定性进行分级。共纳入16项RCT，涉及2102名产妇。与PE和EP相比，NE在逆转PSH方面显示出更高的疗效（优势比（OR）：0.23；95%置信区间（CI）：0.09 - 0.58），且与较少的母体不良事件相关，包括心动过缓（OR：0.28）和恶心/呕吐（OR：0.36）。各组间新生儿结局总体相当，尽管NE在降低新生儿酸中毒风险方面呈现出有利趋势（脐动脉pH值OR：1.25；95% CI：1.06 - 1.54）。累积排序曲线下面积（SUCRA）排名和TSA支持了这些发现的稳健性。在择期剖宫产期间治疗SAIH时，NE似乎是最有效且耐受性最佳的血管升压药，且不影响新生儿安全。这些结果支持在该临床环境中优先使用NE而非PE和EP。
