Open Journal of Obstetrics and Gynecology, 2011, 1, 159-162
doi:10.4236/ojog.2011.14030 Published Online December 2011 (http://www.SciRP.org/journal/ojog/
OJOG
).
Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJOG
The effect of postoperative epidural analgesia in women
possessing severe gestational hypertension
undergoing cesarean delivery
Misao Satomi, Yoshie Hiraizumi, Hidetaka Onodera, Shunji Suzuki
Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital, Tokyo, Japan.
Email: czg83542@mopera.ne.jp
Received 30 August 2011; revised 30 September 2011; accepted 15 October 2011.
ABSTRACT
Introduction: The purpose of this study was to exa-
mine the clinical usefulness of postoperative epidural
analgesia in patients possessing severe gestational
hypertension after Cesarean delivery. Methods: We
reviewed the obstetric records of 99 patients possess-
ing severe gestational hypertension undergoing sin-
gleton Cesarean delivery at 22 weeks’ gestation.
Thirty patients were received continuous epidural
analgesia with 0.2% ropivacaine for pain relief after
Cesarean delivery with spinal anesthesia, 69 patients
were not received epidural analgesia after Cesarean
delivery with spinal anesthesia. Results: During the
preoperative period, there were no measurable dif-
ferences in the diastolic blood pressure between the 2
groups (108 ± 7 vs. 106 mmHg ± 10 mmHg, p = 0.29).
The diastolic blood pressure at 2 and 4 hours after Ce-
sarean section in the epidural analgesia group were sig-
nificantly lower than those in the non-epidural group
(2 hours after Cesarean section: 88 ± 13 vs. 95 mmHg
± 8 mmHg, p < 0.01; 4 hours after Cesarean section: 92
± 15 vs. 102 mmHg ± 9 mmHg, p < 0.01). Conclusions:
The current results indicated that the postoperative
epidural analgesia can inhibit the rise in diastolic
blood pressure in patients possessing severe gesta-
tional hypertension after Cesarean delivery. This
electronic document is a “live” template. The various
components of your paper [title, text, heads, etc.] are
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Keywords: Postoperative Epidural Analgesia; Severe Ge-
stational Hypertension; Ropivacaine; Cesarean Delivery
1. INTRODUCTION
Recently, 0.5% bupivacaine has been widely used for
spinal anesthesia for Cesarean delivery, because it is lon-
ger-acting than the drugs used previously such as dibu-
caine and tetracaine [1,2]. For many years, spinal anes-
thesia had not been recommended as an anesthetic tech-
nique for Cesarean delivery with gestational hyperten-
sion to avoid critical hypotension, but recently spinal
anesthesia is getting popular for Cesarean delivery [2,3].
Continuous epidural analgesia now plays one of impor-
tant roles in postoperative pain control, and the clinical
usefulness of epidural analgesia after Cesarean delivery
has been reported for healthy pregnant women [1,3-5].
In Japan, 0.2% ropivacaine has been sometimes admini-
strated for continuous epidural analgesia to decrease po-
stoperative pain after Cesarean section [1]. To our know-
ledge, however, there have been no hemodynamic in-
vesttigations concerning the effect of postoperative epi-
dural analgesia on severely preeclamptic patients after
Cesarean delivery. The aim of this study was to examine
the clinical usefulness of postoperative epidural analge-
sia in patients possessing severe gestational hypertension
after Cesarean delivery.
2. PATIENTS AND METHODS
We reviewed the obstetric records of 99 Japanese pa-
tients possessing severe gestational hypertension under-
going singleton Cesarean delivery at 22 weeks’ gesta-
tion managed at the Japanese Red Cross Katsushika Ma-
ternity Hospital between 2008 and 2010. There were no
patients taking antihypertensive medications preopera-
tively. During this period, 30 patients were received con-
tinuous epidural analgesia with 0.2% ropivacaine for
pain relief after Cesarean delivery with spinal anesthesia,
69 patients were not received epidural analgesia after
Cesarean delivery with spinal anesthesia. This retrospec-
tive study was approved by the Ethics Committee of
Japanese Red Cross Katsushika Maternity Hospital. De-
mographic information and the characteristics of severe
gestational hypertension were extracted from the patient
charts. Patients with multiple pregnancy, chronic hyper-
M. Satomi et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 159-162
160
tension, renal disease and systemic illnesses were ex-
cluded. Severe gestational hypertension was defined as
blood pressure 160/110 mmHg measured on 2 or more
occasions at least six hours apart with the patient at rest.
HELLP syndrome was defined as a syndrome of in-
travascular hemolysis (H), elevated liver enzymes (EL)
and low platelets count (LP) previously reported.
In all cases, after fluid administration of 1000 ml of
lactated Ringer’s solution, a 25-gauge or 23-gauge spinal
needle was placed at the L2-3 or L3-4 interspace with
the patient in the lateral decubitus position. After ob-
serving the flow of cerebrospinal fluid, 1.7 ml - 2.5 ml of
0.5% hypervaric bupivacaine was injected into the su-
barachnoid space. The dose of 0.5% hypervaric bupiva-
caine was determined mainly based on the maternal
height. In the postoperative epidural analgesia group,
after spinal injection the epidural catheter was placed
with an 18-gauge Tuohy needle in the L1-2 or Th12-L1
interspace for postoperative analgesia. About 10 minutes
before the end of surgery, 100 ml of 0.2% ropivacaine
was administered through the epidural catheter at a rate
of 5 ml/minute for postoperative pain relief. In our de-
partment, bolus administration of an epidural initial dose
is thought to be unnecessary based on a previous study
by Hongo et al. [1] At anytime after surgery, the patient
could be given 50 mg flurbiprofen axetil iv or 15 mg pen-
tazocine iv if she experienced pain or discomfort. If the
systoric blood pressure increased over 160 or the diastolic
blood pressure increased over 110 mmHg on 2 or more
occasions at least 1 hour - 2 hours apart, a continuous in-
travenous infusion of nicardipine HCl was started.
Data are presented as mean ± SD or number (%). For
statistical analysis, the Χ2 test for categorical variables
and the Student’s t-test for continuous variables were used.
Differences with P < 0.05 were considered significant.
3. RESULTS
Table 1 shows the clinical characteristics of patients po-
ssessing severe gestational hypertension with and with-
out postoperative epidural analgesia. In this study, there
were no measurable differences in the bupivacaine dose
for spinal anesthesia between the 2 groups (epidural an-
algesia group: 2.1 ml ± 0.2 ml vs. non-epidural group:
2.2 ml ± 0.2 ml, p = 0.33). There were no significant
differences in maternal age, parity, height, body weight,
systolic and diastolic blood pressure, incidences of pro-
teinuria during preoperative period, HELLP syndrome
or eclampsia, surgical duration, maternal blood loss
during Cesarean section and duration of postoperative
hospitalization between the 2 groups. In this study, the
Table 1. The clinical characteristics of patients possessing severe gestational hypertension with and without postopera-
tive epidural analgesia.
Postoperative epidural analgesia (–) (+) P value
(n = 69) (n = 30)
Maternal age (years) 35 ± 4 34 ± 5 0.34
Nulliparity 46 (67%) 17 (57%) 0.34
Maternal height (cm) 159 ± 6 157 ± 5 0.09
Maternal weight at delivery (kg) 67 ± 13 68 ± 17 0.78
Gestational age at delivery (weeks) 35.5 ± 3 31.9 ± 2 <0.01
Blood pressure before surgery
Systolic blood pressure (mmHg) 179 ± 11 178 ± 9 0.64
Diastolic blood pressure (mmHg) 106 ± 10 108 ± 7 0.29
Proteinuria 100 mg/dl 25 (36%) 11 (37%) 0.97
HELLP syndromea 2 (2.9%) 1 (3.3%) 0.91
Eclampsia 0 (0%) 0 (0%) 1
Surgical duration (minutes) 32 ± 10 31 ± 7 0.57
Maternal blood loss during surgery (g) 650 ± 460 690 ± 460 0.69
Transfusion 0 (0%) 0 (0%) 1
Neonatal birth weight (g) 2276 ± 725 1770 ± 478 <0.01
Light for gestational age infants 14 (20%) 11 (37%) 0.08
Apgar score at 1 minute 8.3 ± 1.0 7.6 ± 1.1 <0.01
Apgar score at 5 minute 9.1 ± 0.6 9.1 ± 0.3 0.98
Umbilical artery pH 7.30 ± 0.04 7.30 ± 0.04 0.99
Duration of postoperative hospitalization (days) 7.6 ± 0.5 7.8 ± 0.6 0.09
aData are presented as mean ± SD or number (%). HELLP syndrome = hemolysis, elevated liver enzymes and low platelets syndrome.
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gestational age at Cesarean delivery in the epidural ana-
lgesia group was significantly earlier than that in the
non-epidural group. In addition, the neonatal birth wei-
ght and Apgar score at 1 minute in the epidural analgesia
group were significantly lower than those in the non-
epidural group.
Table 2 shows the infusion volume, urine volume, fre-
quency of intravenous injection of pain-killer and intra-
venous infusion of nicardipine HCl during postoperative
24 hours in patients with and without postoperative epi-
dural analgesia. There were no patients with postopera-
tive urination disorder in the 2 groups. The frequency of
receiving 50 mg flurbiprofen axetil iv in the epidural
analgesia group was significantly lower than that in the
non-epidural group. However, there was no significant
difference in the rate of patients requiring intravenous
infusion of nicardipine HCl during postoperative 24 hou-
rs between the 2 groups.
Table 3 shows the changes in systolic and diastolic
blood pressure in the patients with and without postop-
erative epidural analgesia. During the preoperative pe-
riod, there were no measurable differences in the systolic
and diastolic blood pressure between the 2 groups, and
there were no measurable differences in the systolic
blood pressure between the 2 groups at 2 and 4 hours
after Cesarean section. However, the diastolic blood
pressure at 2 and 4 hours after Cesarean section in the
epidural analgesia group were significantly lower than
those in the non-epidural group. One day after surgery,
there were no measurable differences in the blood pres-
sure between the 2 groups with the presence of patients
receiving intravenous infusion of nicardipine HCl.
Table 2. The infusion volume, urine volume, frequency of intravenous injection of pain-killer and intravenous
infusion of nicardipine HCl during postoperative 24 hours in patients with and without postoperative epidural
analgesia.
Postoperative epidural analgesia (–) (+) P value
(n = 69) (n = 30)
Total infusion volume (ml) 2650 ± 240 2720 ± 310 0.28
Urine volume
Total volume (ml) 3020 ± 840 3200 ± 660 0.26
Urine volume < 1000 ml 0 (0%) 0 (0%) 1
Furosemide use 0 (0%) 1 (3.3%) 0.13
Intravenous injection of pain-killer (times)
Flurbiprofen axetil 50 mg 1.9 ± 1.1 1.4 ± 0.9 0.02
Pentazocine 15 mg 2.0 ± 1.6 1.5 ± 1.2 0.09
Data are presented as mean ± SD or number (%).
Table 3. The changes in systolic and diastolic blood pressure in the patients with and without postoperative
epidural analgesia.
Postoperative epidural analgesia (–) (+) P value
(n = 69) (n = 30)
Duration preoperative period
Systolic blood pressure (mmHg) 179 ± 11 178 ± 9 0.64
Diastolic blood pressure (mmHg) 106 ± 10 108 ± 7 0.29
At delivery
Systolic blood pressure (mmHg) 125 ± 13 129 ± 10 0.1
Diastolic blood pressure (mmHg) 73 ± 5 76 ± 10 0.13
Two hours after surgery
Systolic blood pressure (mmHg) 151 ± 14 144 ± 17 0.05
Diastolic blood pressure (mmHg) 95 ± 8 88 ± 13 <0.01
Four hours after surgery
Systolic blood pressure (mmHg) 164 ± 14 163 ± 22 0.82
Diastolic blood pressure (mmHg) 102 ± 9 92 ± 15 <0.01
One day after surgery
Systolic blood pressure (mmHg) 136 ± 9 133 ± 11 0.19
Diastolic blood pressure (mmHg) 84 ± 8 82 ± 9 0.31
Data are presented as mean ± SD or number (%).
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4. DISCUSSION
In this study, the epidural continuous infusion provided
pain relief in severe hypertensive patients after Cesaren
section as previously reported [6,7]. In this study, there
was no significant difference in the rate of patients re-
quiring antihypertensive agents between the patients
with and without postoperative epidural analgesia be-
cause there were no significant differences in the systolic
blood pressure levels between the 2 groups; however the
current results indicated that the postoperative epidural
analgesia can inhibit the rise in diastolic blood pressure
in patients possessing severe gestational hypertension af-
ter Cesarean delivery.
In patients possessing gestational hypertension, the
blood pressure has been observed to be sometimes re-
increased to the severely levels after Cesarean delivery
associated with the postoperative pain and the return of
vascular tone following delivery [8,9]. This return of
vascular tone has been suggested to be also related to
profound fluid shifts that occur in the puerperium with a
rise in intravascular volume due to mobilization of ex-
travascular fluid [8,9]. Regional anesthesia-induced sy-
mpathetic blockade may be contributed to the decrease
in diastolic blood pressure associate with the systemic
peripheral vascular dilation in patients with severe gesta-
tional hypertension. However, the current results also
indicated the sympathetic blockade with vascular dila-
tion may not be able to prevent the fluid shifts associated
with the re-increased systolic blood pressure in patients
possessing gestational hypertension although there were
no significant differences in the urine volume during po-
stoperative 24 hours.
We know that there are some limitations in this retro-
spective study. Firstly, this may be a small study. Se-
condly, in this study the parturient required Cesarean
delivery at earlier gestation received epidural analgesia
more frequently. We cannot explain the reason for this
tendency well; however it may also support the efficacy
of postoperative epidural analgesia inhibiting the rise in
blood pressure because hypertensive disorders develop-
ing at earlier gestation have been reported to tend to be
severe [10]. Otherwise, a circulating blood volume may-
be smaller in the epidural group than that in the non-
epidural group and the smaller volume may explain the
decreased diastolic pressure in the epidural group after
Cesarean delivery. Therefore, a prospective study to clear
this difference may be needed.
The postoperative epidural analgesia may be useful in
the management of patient with severe gestational hy-
pertension after Cesarean delivery, because adequate
control of diastolic blood pressure is important to pre-
vent systemic organ dysfunction in severe gestational
hypertension [11]. However, further studies may be nee-
ded concerning the changes in systolic blood pressure.
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