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 quality of anesthesia for cesarean delivery (CD), analgesia for labor (LA), hemodynamic changes, and neonatal effects of combined spinal and epidural anesthesia (CSE) with low intrathecal doses of bupivacaine and fentanyl in patients with severe preeclampsia.

METHODS: Of the 85 patients with severe preeclampsia (systolic pressures [SBP] > or = 160 mm Hg or diastolic pressures [DBP] > or = 110 mm Hg, and proteinuria > or = 100 mg/dL), 46 underwent CD and 39 delivered vaginally. The CD group received 7.5 mg of hyperbaric bupivacaine and 25 microg fentanyl intrathecally with a goal of obtaining a T4 sensory block. Those with levels less than T4 received 2% lidocaine epidurally to extend the block. In the LA group, the intrathecal dose was 1.25 mg of plain bupivacaine with 25 microg of fentanyl, followed by epidural infusion of 0.0625% to 0.125% bupivacaine with 2 to 4 microg fentanyl/mL at 12 to 15 mL/h.

RESULTS: In the CD group, all but 4 patients had > or = T4 block, and these 4 patients received 2% lidocaine epidurally. None required conversion to general anesthesia. In the LA group, sensory levels were T10 (range, T6-L2) with adequate analgesia. The baseline mean arterial pressure (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 +/- 12 mm Hg in the CD group and 96 +/- 13 mm 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 there were no significant correlations between UA pH and lowest MAP before delivery or the maximum percentage change in MAP in either group.

CONCLUSIONS: The results indicate that CSE with low intrathecal doses of bupivacaine and epidural supplementation, when needed, produces adequate anesthesia for CD and analgesia for labor in patients with severe preeclampsia. The maximum decreases in MAP after CSE were modest and quite similar in the 2 groups.