The Effect of Neuraxial Anesthesia on Maternal Cerebral Hemodynamics

Ineke R. Postma; Teelkien R. van Veen; Scott L. Mears; Gerda G. Zeeman; Sina Haeri; Michael A. Belfort

doi:10.1055/s-0033-1359715

American Journal of Perinatology, Table of Contents

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

¹Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

,

Teelkien R. van Veen

¹Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

,

Scott L. Mears

²Department of Anesthesiology, St Mark's Hospital, Salt Lake City, Utah

,

Gerda G. Zeeman

³Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands

,

Sina Haeri

⁴Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas

,

Michael A. Belfort

⁴Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas

› Author Affiliations

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

Full Text

References

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
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
3 Langesæter E, Dyer RA. Maternal haemodynamic changes during spinal anaesthesia for caesarean section. Curr Opin Anaesthesiol 2011; 24 (3) 242-248
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
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
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
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
8 Cipolla MJ. Cerebrovascular function in pregnancy and eclampsia. Hypertension 2007; 50 (1) 14-24
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
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
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
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
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
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
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
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
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
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
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
20 Bellapart J, Fraser JF. Transcranial Doppler assessment of cerebral autoregulation. Ultrasound Med Biol 2009; 35 (6) 883-893
21 Panerai RB. The critical closing pressure of the cerebral circulation. Med Eng Phys 2003; 25 (8) 621-632
22 Dupont WD, Plummer Jr WD. Power and sample size calculations. A review and computer program. Control Clin Trials 1990; 11 (2) 116-128
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
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
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
26 McParland P, Pearce JM. Doppler blood flow in pregnancy. Placenta 1988; 9 (4) 427-450
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
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
29 Paul DL, Wildsmith JA. Extradural pressure following the injection of two volumes of bupivacaine. Br J Anaesth 1989; 62 (4) 368-372
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
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
32 Milde LN, Milde JH, Gallagher WJ. Cerebral effects of fentanyl in dogs. Br J Anaesth 1989; 63 (6) 710-715
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