Combined spinal and epidural anesthesia with low doses of intrathecal bupivacaine in women with severe preeclampsia: A preliminary report

Background and Objectives: The purpose of our study was to evaluate the qua lity of anesthesia for cesarean delivery (CD), analgesia for labor (LA), he modynamic changes, and neonatal effects of combined spinal and epidural ane sthesia (CSE) with tow intrathecal doses of bupivacaine and fentanyl in pat ients with severe preeclampsia. Methods: Of the 85 patients with severe preeclampsia (systolic pressures [S BP] greater than or equal to 160 mm Hg or diastolic pressures [DBP] greater than or equal to 110 mm Hg, and proteinuria greater than or equal to 100 m g/dL), 46 underwent CD and 39 delivered vaginally. The CD group received 7. 5 mg of hyperbaric bupivacaine and 25 mug fentanyl intrathecally with a goa l of obtaining a T4 sensory block. Those with levels less than T4 received 2% lidocaine epidurally to extend the block. Ln the LA group, the intrathec al dose was 1.25 mg of plain bupivacaine with 25 mug of fentanyl, followed by epidural infusion of 0.0625% to 0.125% bupivacaine with 2 to 4 mug fenta nyl/ml at 12 to 15 mL/h. Results: In the CD group, all but 4 patients had greater than or equal to T 4 block, and these 4 patients received 2% lidocaine epidurally. None requir ed conversion to general anesthesia. In the LA group, sensory levels were T IO (range, T6-L2) with adequate analgesia. The baseline mean arterial press ure (MAP) was 122 +/- 13 mm Hg in the CD group and 117 +/- 12 mm Hg in the LA group. After CSE, MAP decreased significantly and reached a nadir within 5 minutes in both groups (103 +/- IZ mm Kg in the CD group and 96 +/- 13 m m Hg in the LA group, P < .05). The maximum decrease in MAP was similar in the 2 groups (-15% +/- 8% in the CD group and -16% +/- 9% in the LA group). The neonatal Apgar scores and umbilical artery (UA) pH were similar, and t here were no significant correlations between UA pH and lowest MAP before d elivery or the maximum percentage change in MAP in either group. Conclusions: The results indicate that CSE with low intrathecal doses of bu pivacaine and epidural supplementation, when needed, produces adequate anes thesia for CD and analgesia for labor in patients with severe preeclampsia. The maximum decreases in MAP after CSE were modest and quite similar in th e 2 groups.