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Am J Perinatol 2014; 31(09): 787-794
DOI: 10.1055/s-0033-1359715
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Effect of Neuraxial Anesthesia on Maternal Cerebral Hemodynamics

Ineke R. Postma
1   Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
,
Teelkien R. van Veen
1   Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
,
Scott L. Mears
2   Department of Anesthesiology, St Mark's Hospital, Salt Lake City, Utah
,
Gerda G. Zeeman
3   Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
,
Sina Haeri
4   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
,
Michael A. Belfort
4   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
› Author Affiliations
Further Information

Publication History

15 April 2013

02 October 2013

Publication Date:
11 December 2013 (online)

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Abstract

Objective Neuraxial anesthesia is known to reduce sympathetic tone and mean arterial pressure. Effects on cerebral hemodynamics in pregnancy are not well known. We hypothesize that cerebral hemodynamic parameters will change with respect to baseline following regional analgesia/anesthesia.

Study Design We performed maternal transcranial Doppler of the middle cerebral artery in 20 women receiving epidural analgesia for labor, and 18 undergoing spinal anesthesia for cesarean section at baseline, 5 and 15 minutes. Systemic blood pressure (BP), systolic/diastolic/mean velocity, resistance and pulsatility index (PI) were recorded. Cerebral perfusion pressure, critical closing pressure (CrCP), resistance area product, and cerebral flow index were calculated.

Results Epidural placement was associated with significant decreases in systolic/diastolic BP/mean velocity/CrCP after 15 minutes, with a corresponding increase in PI. In the spinal group, systolic/diastolic BP/mean velocity uniformly decreased and remained low after 15 minutes, and PI significantly increased and remained constant after 15 minutes. No differences were seen in BP or cerebral hemodynamics between the groups.

Conclusion This study demonstrates that both epidural analgesia and spinal anesthesia result in measurable cerebral hemodynamic changes in normotensive term pregnancy that are likely to be clinically insignificant as they do not affect perfusion pressure or flow.

Keywords

neuraxial anesthesia - transcranial Doppler - cerebral hemodynamics - cerebral perfusion pressure
 

  • References

  • 1 Osterman MJK. BirthStats: Percentage of mothers receiving epidural/spinal anesthesia by age, race, and Hispanic origin of mother: total of 18 U.S. reporting areas, singletons only, 2006. Birth 2009; 36 (4) 340-341
    CrossrefPubMedGoogle Scholar
  • 2 Lorenz IH, Kolbitsch C, Hinteregger M , et al. Remifentanil and nitrous oxide reduce changes in cerebral blood flow velocity in the middle cerebral artery caused by pain. Br J Anaesth 2003; 90 (3) 296-299
    CrossrefPubMedGoogle Scholar
  • 3 Langesæter E, Dyer RA. Maternal haemodynamic changes during spinal anaesthesia for caesarean section. Curr Opin Anaesthesiol 2011; 24 (3) 242-248
    CrossrefPubMedGoogle Scholar
  • 4 Riskin-Mashiah S, Belfort MA, Saade GR, Herd JA. Cerebrovascular reactivity in normal pregnancy and preeclampsia. Obstet Gynecol 2001; 98 (5, Pt 1) 827-832
    CrossrefPubMedGoogle Scholar
  • 5 Nasr N, Czosnyka M, Arevalo F, Hanaire H, Guidolin B, Larrue V. Autonomic neuropathy is associated with impairment of dynamic cerebral autoregulation in type 1 diabetes. Auton Neurosci 2011; 160 (1–2) 59-63
    CrossrefPubMedGoogle Scholar
  • 6 Cipolla MJ, Bishop N, Chan SL. Effect of pregnancy on autoregulation of cerebral blood flow in anterior versus posterior cerebrum. Hypertension 2012; 60 (3) 705-711
    CrossrefPubMedGoogle Scholar
  • 7 Zunker P, Happe S, Georgiadis AL , et al. Maternal cerebral hemodynamics in pregnancy-related hypertension. A prospective transcranial Doppler study. Ultrasound Obstet Gynecol 2000; 16 (2) 179-187
    CrossrefPubMedGoogle Scholar
  • 8 Cipolla MJ. Cerebrovascular function in pregnancy and eclampsia. Hypertension 2007; 50 (1) 14-24
    CrossrefPubMedGoogle Scholar
  • 9 Belfort M, Van Veen T, White GL , et al. Low maternal middle cerebral artery Doppler resistance indices can predict future development of pre-eclampsia. Ultrasound Obstet Gynecol 2012; 40 (4) 406-411
    CrossrefPubMedGoogle Scholar
  • 10 Williams KP, Wilson S. Evaluation of cerebral perfusion pressure changes in laboring women: effects of epidural anesthesia. Ultrasound Obstet Gynecol 1999; 14 (6) 393-396
    CrossrefPubMedGoogle Scholar
  • 11 Fong J, Mack PF, Gurewitsch ED. The effect of lumbar epidural anesthesia on maternal middle cerebral artery blood flow in normal pregnancy: a prospective, randomized, double-blind comparison study. Am J Obstet Gynecol 1998; 179 (5) 1237-1240
    CrossrefPubMedGoogle Scholar
  • 12 Minville V, Asehnoune K, Salau S , et al. The effects of spinal anesthesia on cerebral blood flow in the very elderly. Anesth Analg 2009; 108 (4) 1291-1294
    CrossrefPubMedGoogle Scholar
  • 13 Bonnet MP, Larousse E, Asehnoune K, Benhamou D. Spinal anesthesia with bupivacaine decreases cerebral blood flow in former preterm infants. Anesth Analg 2004; 98 (5) 1280-1283
    PubMedGoogle Scholar
  • 14 Belfort MA, Saade GR, Grunewald C , et al. Association of cerebral perfusion pressure with headache in women with pre-eclampsia. Br J Obstet Gynaecol 1999; 106 (8) 814-821
    CrossrefPubMedGoogle Scholar
  • 15 Gosling RG, Dunbar G, King DH , et al. The quantitative analysis of occlusive peripheral arterial disease by a non-intrusive ultrasonic technique. Angiology 1971; 22 (1) 52-55
    CrossrefPubMedGoogle Scholar
  • 16 Stolz-Born G, Widder B, Born J. Vascular effects of oxytocin on human middle cerebral artery determined by transcranial Doppler sonography. Regul Pept 1996; 62 (1) 37-39
    CrossrefPubMedGoogle Scholar
  • 17 Aaslid R, Markwalder TM, Nornes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 1982; 57 (6) 769-774
    CrossrefPubMedGoogle Scholar
  • 18 Belfort MA, Tooke-Miller C, Varner M , et al. Evaluation of a noninvasive transcranial Doppler and blood pressure-based method for the assessment of cerebral perfusion pressure in pregnant women. Hypertens Pregnancy 2000; 19 (3) 331-340
    CrossrefPubMedGoogle Scholar
  • 19 Evans DH, Levene MI, Shortland DB, Archer LN. Resistance index, blood flow velocity, and resistance-area product in the cerebral arteries of very low birth weight infants during the first week of life. Ultrasound Med Biol 1988; 14 (2) 103-110
    CrossrefPubMedGoogle Scholar
  • 20 Bellapart J, Fraser JF. Transcranial Doppler assessment of cerebral autoregulation. Ultrasound Med Biol 2009; 35 (6) 883-893
    CrossrefPubMedGoogle Scholar
  • 21 Panerai RB. The critical closing pressure of the cerebral circulation. Med Eng Phys 2003; 25 (8) 621-632
    CrossrefPubMedGoogle Scholar
  • 22 Dupont WD, Plummer Jr WD. Power and sample size calculations. A review and computer program. Control Clin Trials 1990; 11 (2) 116-128
    CrossrefPubMedGoogle Scholar
  • 23 Belfort MA, Tooke-Miller C, Allen Jr JC , et al. Changes in flow velocity, resistance indices, and cerebral perfusion pressure in the maternal middle cerebral artery distribution during normal pregnancy. Acta Obstet Gynecol Scand 2001; 80 (2) 104-112
    CrossrefPubMedGoogle Scholar
  • 24 Czosnyka M, Richards HK, Whitehouse HE, Pickard JD. Relationship between transcranial Doppler-determined pulsatility index and cerebrovascular resistance: an experimental study. J Neurosurg 1996; 84 (1) 79-84
    CrossrefPubMedGoogle Scholar
  • 25 Schondorf R, Benoit J, Wein T. Cerebrovascular and cardiovascular measurements during neurally mediated syncope induced by head-up tilt. Stroke 1997; 28 (8) 1564-1568
    CrossrefPubMedGoogle Scholar
  • 26 McParland P, Pearce JM. Doppler blood flow in pregnancy. Placenta 1988; 9 (4) 427-450
    CrossrefPubMedGoogle Scholar
  • 27 Grocott HP, Mutch WA. Epidural anesthesia and acutely increased intracranial pressure. Lumbar epidural space hydrodynamics in a porcine model. Anesthesiology 1996; 85 (5) 1086-1091
    CrossrefPubMedGoogle Scholar
  • 28 Sivarajan M, Amory DW, Lindbloom LE, Schwettmann RS. Systemic and regional blood-flow changes during spinal anesthesia in the rhesus monkey. Anesthesiology 1975; 43 (1) 78-88
    CrossrefPubMedGoogle Scholar
  • 29 Paul DL, Wildsmith JA. Extradural pressure following the injection of two volumes of bupivacaine. Br J Anaesth 1989; 62 (4) 368-372
    CrossrefPubMedGoogle Scholar
  • 30 van Veen TR, Belfort MA, Zeeman GG. The effect of low-dose oxytocin infusion on cerebral hemodynamics in pregnant women. Am J Perinatol 2011; 28 (7) 579-584
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Chi OZ, Hunter C, Liu X, Chokshi SK, Weiss HR. Effects of fentanyl pretreatment on regional cerebral blood flow in focal cerebral ischemia in rats. Pharmacology 2010; 85 (3) 153-157
    CrossrefPubMedGoogle Scholar
  • 32 Milde LN, Milde JH, Gallagher WJ. Cerebral effects of fentanyl in dogs. Br J Anaesth 1989; 63 (6) 710-715
    CrossrefPubMedGoogle Scholar
  • 33 Trindle MR, Dodson BA, Rampil IJ. Effects of fentanyl versus sufentanil in equianesthetic doses on middle cerebral artery blood flow velocity. Anesthesiology 1993; 78 (3) 454-460
    CrossrefPubMedGoogle Scholar