Scherer R, Holzgreve W
Chefarzt der Klinik für Anästhesiologie und operative Intensivmedizin, Clemenshospital GmbH, Münster, Germany.
Eur J Obstet Gynecol Reprod Biol. 1995 May;59 Suppl:S17-29. doi: 10.1016/0028-2243(95)93909-8.
Epidural analgesia is a frequently used method to reduce the pain of child-bearing. Concerns regarding the safety and potential hazards still persist in the medical community. This review intends to examine how epidural analgesia determines the various factors of fetal and neonatal well-being. Placental drug transfer of opiates like morphine, pethidine and fentanyl is rapid and can lead to neonatal depression. Sufentanil seems to be the safest opiate to administer epidurally. Local anaesthetics are transferred to the fetus in substantial amounts, but the reported effects are subtle and are probably inconsequential. Utero- and fetoplacental blood flow seems to be improved by epidural analgesia with local anaesthetics. Even when using stronger solutions for more extensive blockade in patients for caesarean section, no adverse effects could be demonstrated using pulsed Doppler technique as long as prolonged hypotension (> 2 min) is avoided. Hypotension is best prevented with 20-25 ml/kg crystalloid preload and prompt treatment with ephedrine or etilephrine. Addition of adrenaline to local anaesthetics is considered to be safe for the healthy mother and fetus but it should best be avoided in mothers with pregnancy induced hypertension. Fetal and neonatal acid-base balance and gas-exchange are not adversely affected by epidural analgesia. Many studies show that epidural analgesia can indeed protect the fetus if hypotension is prevented. Neonatal well-being evaluated by APGAR, BRAZELTON, SCANLON and NACS scores is not significantly influenced by local anaesthetics. Neonatal depression can occur however with epidural use of morphine, fentanyl and alfentanil. Sufentanil, again in doses up to 30 micrograms in association with bupivacaine seems to be devoid of depressive effects on the neonate. In summary, the anaesthetist has good arguments to reassure his obstetrical colleagues that providing epidural analgesia for pregnant women in labour is a justifiable intervention to support the natural process of child-bearing.
硬膜外镇痛是减轻分娩疼痛常用的方法。医学界对其安全性和潜在危害仍存在担忧。本综述旨在探讨硬膜外镇痛如何影响胎儿和新生儿健康的各种因素。吗啡、哌替啶和芬太尼等阿片类药物通过胎盘的药物转运迅速，可导致新生儿抑制。舒芬太尼似乎是硬膜外给药最安全的阿片类药物。大量局部麻醉药会转运至胎儿，但报道的影响细微，可能无关紧要。局部麻醉药硬膜外镇痛似乎可改善子宫和胎盘-胎儿血流。即使在剖宫产患者中使用更强效溶液进行更广泛的阻滞，只要避免长时间低血压（>2分钟），使用脉冲多普勒技术未发现不良反应。通过20 - 25 ml/kg晶体液预负荷及麻黄碱或去氧肾上腺素快速治疗可最佳地预防低血压。局部麻醉药中添加肾上腺素对健康母亲和胎儿被认为是安全的，但妊娠高血压母亲最好避免使用。硬膜外镇痛不会对胎儿和新生儿酸碱平衡及气体交换产生不利影响。许多研究表明，如果预防了低血压，硬膜外镇痛确实可保护胎儿。通过阿氏评分、布雷泽尔顿评分、斯坎伦评分和新生儿急性疼痛评分评估的新生儿健康状况不受局部麻醉药的显著影响。然而，硬膜外使用吗啡、芬太尼和阿芬太尼可能会发生新生儿抑制。舒芬太尼与布比卡因联合使用剂量高达30微克时，似乎对新生儿没有抑制作用。总之，麻醉医生有充分理由向产科同事保证，为分娩中的孕妇提供硬膜外镇痛是支持自然分娩过程的合理干预措施。
