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Research Article | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 330 - 335
An Observational Study on Assessing the Maternal Hemodynamic Changes After Spinal Anaesthesia in Patients Undergoing Elective Lower Segment Cesaerean Section
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 ,
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1
Post graduate, Department of Anesthesia, Chettinad Hospital and Research Institute, Kelambakkam, Chengelpet-603103, Tamil Nadu, India
2
Assistant Professor, Department of Anesthesia, Chettinad Hospital and Research Institute, Kelambakkam, Chengelpet-603103, Tamil Nadu, India
3
Professor, Department of Anesthesia, Chettinad Hospital and Research Institute, Kelambakkam, Chengelpet-603103, Tamil Nadu, India
4
Allied Health Sciences, Department of Anesthesia, Chettinad Hospital and Research Institute, Kelambakkam, Chengelpet-603103, Tamilnadu, India.
Under a Creative Commons license
Open Access
Received
Nov. 29, 2024
Revised
Jan. 3, 2025
Accepted
Jan. 20, 2025
Published
Jan. 25, 2025
Abstract

Background And Justification: Spinal Anaesthesia is widely regarded as a reasonable anaesthetic option for caesarean delivery, provided there is no contraindication. Pregnancy causes major physiological changes to the mother’s body. An understanding of the physiological changes in pregnancy is the key to safe obstetric anaesthesia. Spinal Anaesthesia is associated with hypotension which can have maternal and foetal side effects. Methods: This study was performed on 100 patients, after getting informed consent. In this study the baseline hemodynamic parameters of the patient was noted during intra operative period. After spinal anaesthesia is performed by the Anaesthesiologist, hemodynamics such as Heart Rate, Blood Pressure, Mean Arterial Pressure and SPO2 was noted for every 3 minutes for first 20 minutes after which it was noted for every 5 minutes, till end of the surgery.  Results: From the descriptive statistics and chi square test, after spinal anaesthesia performed there is a hypotension, p=0 which is <0.05, hence statistically significant, and there is fall in heart in rate, p=0.0029 which is <0.05, hence statistically significant.  Conclusion: 100 pregnant patients who underwent spinal anaesthesia for elective caesarean section were included in this study. Based on the result we concluded that hypotension and bradycardia are the frequent response after spinal anaesthesia due to arterial and venous vasodilatation resulting from the sympathetic block along with a paradoxical activation of cardio inhibitory receptors. This study benefits to the anaesthesiologist in prediction of possible adverse effects and to overcome the same.

Keywords
INTRODUCTION

When medically necessary, a caesarean section can be a life-saving procedure [1]. Caesarean sections can be either emergency, urgent, or elective [3]. As a result, regional anesthesia has become the anaesthetic method of choice for many anaesthesiologists doing elective procedures [5]. Spinal anestheisa is performed by injecting small doses of local anaesthetic are injected into the Sub arachnoid space.Often performed at level of L3-L4. Surgery below the umbilicus may be performed under spinal anaesthesia, which is simple to administer and has the potential to offer good operating conditions. [7]

 

Hemodynamic Monitoring:

Hemodynamic monitoring is a crucial aspect of the cardiovascular patient's perioperative therapy. It aids in the detection of hemodynamic changes, the diagnosis of their underlying causes, and the optimization of oxygen delivery to tissues. Additionally, hemodynamic monitoring is required to assess the efficacy of therapeutic measures such as volume expansion or vasoactive medicines. [9]

 

The purpose of hemodynamic monitoring is to keep tissue perfusion adequate. [10] The fundamental hemodynamic condition is determined by monitoring heart rate (HR) and mean blood pressure (BP) as a surrogate for tissue perfusion. When these qualities vary rapidly, a single measurement provides insufficient information, hence continuous measurement is preferred. Noninvasive and continuous blood pressure monitoring, on the other hand, has several advantages, especially when intra-arterial blood pressure measurement is not suggested and intermittent readings lack the required time resolution. [11]

MATERIALS AND METHODS

Study design : Observational study

Sample Size : A total of 100 patients belonging to ASA-II and ASA-III (American Society of Anesthesiologists) were enrolled in the study.

Subject Selection : Maternal woman who underwent for elective cesaerean section under spinal anaesthesia

 

INCLUSION CRITERIA

  1. Age group:>18 years
  2. ASA physical status: ASA-II,ASA-III
  3. Elective cesarean section

 

EXCLUSION CRITERIA

  1. Patient who are not willing to take part in this study
  2. Patients with contraindication to spinal anaesthesia
  3. Age group <18 years
  4. Patients who are hemodynamically unstable
  5. Preterm delivery
  6. Emergency caesarean section

 

STUDY PROCEDURE:

After the ethical clearance obtained from human ethics committee, the study was conducted on the Department of Anaesthesiology CHRI.  This study was performed on 100 patients, after getting the informed consent.

 

Patient was explained about the procedure well in advance. In sitting position, Subarachanoid block will be performed under sterile aseptic precautions using 25G or 26G quincke needle in L3-L4 space. Once CSF can be aspirated, which confirms the needle is at subarachnoid space, Local anesthetic will be given. Then the patient is made to lie down supine. Motor and sensory blockade will be noted. Sensory Level was evaluated by loss of sensation to cold using a cold ice pack and pin prick sensation and Motor block assessed by modified bromage scale.

 

In this study, the baseline hemodynamic parameters of the patient was noted during intra operative period. After performing spinal anaesthesia, hemodynamics such as Heart Rate, Blood Pressure, Mean Arterial Pressure and SPO2 was noted for every 3 minutes for first 20 minutes after which it was noted for every 5 minutes, till end of the surgery.

 

 STATISTICAL METHOD:

This study was analysed by an descriptive statistics, frequency and chi square test.  The study was conducted after obtaining approval by the Institutional Human Ethical Committee.  Informed consent was obtained from the patients who participate in the study. The collected data have been kept confidential.

RESULTS

Among the study population, we calculated the percentage of age distribution and was found that age group between 26-30 years (45%) had the highest number of study sample and the minimum was in between 40-45 years (1%) and found to be insignificant p >0.005

 

AGE GROUP

FREQUENCY

PERCENTAGE

18-25

30

30%

26-30

45

45%

31-35

16

16%

35-40

8

8%

40-45

1

1%

Tabel 1: Age Distribution In Study Population

 

Among the study population, patients who belong to ASA-PS II were found to be 92%. Only 8% of the study population were categorised under ASA III and is not significant p>0.005

 

Table 2: Asa Distribution In Study Population

ASA

FREQUENCY

PERCENTAGE

II

92

92%

III

8

8%

 

Baseline Heart rate was recorded for all the study population. None of the patients had baseline value <60/min. Around 76% had Heart rate around 60-100/min and 24% had Heart rate of >100/min

 

Table 3 : Baseline Heart Rate In Study Population

BASELINE-HR

FREQUENCY

PERCENTAGE

<60

0

0%

                    60-100

76

76%

>100

24

24%

 

GRAPH 1 : Baseline Heart Rate in study population

Baseline Blood pressure was recorded for all the study population. None of the patients had MAP  <60. In 95% of the study population, MAP was around 60-100 and in 5% had MAP >100

 

Table 4 : Baseline Map In Study Population

BASELINE-MAP

FREQUENCY

PERCENTAGE

MAP <60

0

0%

MAP 60-100

95

95%

MAP >100

5

5%

 


GRAPH 2 : Baseline MAP in study population

                      

Table 5: Baseline-Spo2 In Study Population

BASELINE-SPO2

FREQUENCY

PERCENTAGE

<100

54

54%

~100

46

46%

 

Table 6 : Baseline Respiratory Rate In Study Population

BASELINE-RR

FREQUENCY

PERCENTAGE

<12

8

8%

12-18

39

39%

>18

53

53%

 

Table 7: After Spinal Heart Rate In Study Population

             AFTER SPINAL-HR

FREQUENCY

PERCENTAGE

<60

0

0%

60-100

75

75%

>100

25

25%

 

Graph 3 : After Spinal Heart Rate In Study Population

 

Table 8: After Spinal Bp In Study Population

AFTER SPINAL-BP

FREQUENCY

PERCENTAGE

MAP <60

2

2%

MAP 60-100

96

96%

MAP >100

2

2%

 

Graph 4 : After Spinal Bp In Study Population

 

 

Table 9:  Cross Tabulation Between Baseline-Hr And After Spinal-Hr Parturients Underwent Between 21min

 

HEART RATE

<60

60-100

>100

TOTAL

BASELINE

0

76

24

100

AFTER SPINAL-HR

BETWEEN 21MIN

9

77

14

100

TOTAL

9

153

38

200

 

 

VALUE

Df

P

X2

11.636

2

0.0029

N

100

 

 

P=0.0029 which is <0.05 statistically significant. Hence, null hypothesis is rejected. So there is an evidence of significant fall in heart rate

TABLE 10: Chi-Square Test Between Baseline-BP And After Spinal-BP

BP

MAP <60

MAP 60-100

MAP >100

TOTAL

BASELINE

0

95

5

100

AFTER SPINAL-BP BETWEEN

21MIN

25

75

0

100

TOTAL

25

170

5

200

 

 

VALUE

Df

P

X2

32.352

2

0

N

100

 

 

P=0 which is <0.05 statistically significant. Hence, null hypothesis is rejected. So there is an evidence of significant fall in Blood Pressure

DISCUSSION

This study is based on assessing the hemodynamic changes after spinal anaesthesia in 100 pregnant patients underwent elective lower caesarean section. The result is based on the Descriptive statistics and Frequency. There are 30% people from 18-25 age group, 45% people from 26-30 age group,16% people from 31-35 age group,8% from 35-40 age group and 1% from 40-45 were participated in this study. There are 92% patients under ASA-II and 8% were under ASA-III. After the patient shifted into the OT, patient’s Baseline HR, SPO2, RR, SBP, DBP and MAP were monitored. After spinal anaesthesia performed, hemodynamics will be noted for 3min for first 21min and then noted for after 5min till the end of surgery. From the descriptive statistics and chi square test, after spinal anaesthesia performed there is a hypotension, p=0 which is <0.05, hence statistically significant, and there is fall in heart in rate, p=0.0029 which is <0.05, hence statistically significant.

 

The most common complication related to maternal morbidity and mortality during Caesarean section was hypotension following spinal anaesthesia.[12] The reported incidence of hypotension after spinal anaesthesia in Caesarean section varies between 7 and 89.2% due to conflicting definitions.[13]

 

In a study by Tikuneh Yetneberk Alemayehu et al. [12] on 122 pregnant patients (81 non preeclamptic and 41 preeclamptic parturients) based on age, weight, height, the volume of 0.5% plain bupivacaine, and speed of spinal administration between groups and based on result he concluded that Preeclamptic parturients had spinal anaesthesia-induced hypotension less frequently and to a lesser than non-preeclamptic parturients during caesarean delivery.

 

In a study by Anestezjologia I Ratownictwo et al. [10] on 195 pregnant patients based on Haemodynamic data SBP, DBP, MAP, heart rate and oxygen saturation and based on result, he concluded that the incidence of arterial hypotension, the need for ephedrine and phenylephrine, or the haemodynamic profile as compared to lateral decubitus position are unaffected by spinal anaesthesia delivered in the sitting position with hyperbaric bupivacaine and fentanyl.

CONCLUSION

100 pregnant patients underwent spinal anesthesia for elective caesarean section were included in this study. Based on the result we concluded that the hypotension and bradycardia are the frequent response after spinal anesthesia due to arterial and venous vasodilatation resulting from the sympathetic block along with a paradoxical activation of cardio inhibitory receptors. This study benefits to the anesthesiologist in prediction of possible adverse effects and to overcome the same. 

REFERENCES
  1. Temmerman M, Mohiddin Cesarean section: More than a maternal health issue. PLoS Medicine. 2021 Oct 12; 18(10):e1003792.
  2. Malaza N, Masete M, Adam S, Dias S, Nyawo T, Pheiffer C. A Systematic Review to Compare Adverse Pregnancy Outcomes in Women with Pregestational Diabetes and Gestational International Journal of Environmental Research and Public Health. 2022 Aug 31; 19(17):10846.
  3. Stjernholm YV, Petersson K, Eneroth E. Changed indications for cesarean sections. Acta obstetricia et gynecologica Scandinavica. 2010 Jan 1; 89(1):49-53.
  4. Lurie S, Shalev A, Sadan O, Golan A. The changing indications and rates of caesarean section in one academic center over a 16-year period (1997–2012). Taiwanese Journal of Obstetrics and Gynecology. 2016 Aug 1; 55(4):499-502.
  5. Madkour N, Ibrahim S, Ezz G. General versus spinal anaesthesia during elective caesarean section in term low-risk pregnancy as regards maternal and neonatal outcomes: a prospective, controlled clinical trial. Research and Opinion in Anaesthesia & Intensive Care. 2019; 6(1):119-24.
  6. Talbot L, Maclennan K. Physiology of pregnancy. Anaesthesia & intensive care medicine. 2016 Jul 1; 17(7):341-5
  7. Casey Spinal anaesthesia-A practical guide. Update Anaesth. 2000;12:1-7.
  8. Morgan & Mikhail’s Clinical Anesthesiology a LANGE medical book FIFTH EDITION
  9. Scheeren TW, Ramsay MA. New developments in hemodynamic monitoring. Journal of cardiothoracic and vascular anesthesia. 2019 Aug 1;33:S67-72.
  10. Bigatello LM, George E. Hemodynamic monitoring. Minerva anestesiologica. 2002 Apr 1;68(4):219-25.
  11. Truijen J, van Lieshout JJ, Wesselink WA, Westerhof BE. Noninvasive continuous hemodynamic monitoring. Journal of clinical monitoring and computing. 2012 Aug;26:267- 78.
  12. Alemayehu TY, Berhe YW, Getnet H, Molallign M. Hemodynamic changes after spinal anesthesia in preeclamptic patients undergoing cesarean section at a tertiary referral center in Ethiopia: a prospective cohort study. Patient Safety in Surgery. 2020 Dec;14:1-9.
  13. Ortiz-Gómez JR, Palacio-Abizanda FJ, Morillas-Ramirez F, Fornet-Ruiz I, LorenzoJiménez AM, Bermejo-Albares ML. Effect of position on maternal haemodynamics during elective caesarean delivery under spinal anaesthesia. anaesthesia. 2015;5(7).
  14. Balavenkatasubramanian J, Senthilkumar B, Kumar SV. Current Indications For Spinal Anaesthesia-A Narrative Review. Best Practice & Research Clinical Anaesthesiology. 2023 Apr 7.
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