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Complicaciones Anestésicas - Cesárea - Bloom 2005
Complicaciones Anestésicas - Cesárea - Bloom 2005
Complicaciones Anestésicas - Cesárea - Bloom 2005
Delivery
Steven L. Bloom, MD, Catherine Y. Spong, MD, Steven J. Weiner, MS, Mark B. Landon, MD,
Dwight J. Rouse, MD, Michael W. Varner, MD, Atef H. Moawad, MD, Steve N. Caritis, MD,
Margaret Harper, MD, Ronald J. Wapner, MD, Yoram Sorokin, MD, Menachem Miodovnik, MD,
Mary J. OSullivan, MD, Baha Sibai, MD, Oded Langer, MD, and Steven G. Gabbe, MD,
for the National Institute of Child Health and Human Development MaternalFetal
Medicine Units Network*
Objective: To quantify anesthesia-related complications
associated with cesarean delivery in a well-described,
prospectively ascertained cohort from multiple universitybased hospitals in the United States and to evaluate
whether certain factors would identify women at increased
risk for a failed regional anesthetic.
Methods: A prospective observational study was conducted of women (n 37,142) with singleton gestations
undergoing cesarean delivery in the centers forming the
National Institute of Child Health and Human Development MaternalFetal Medicine Units Network. Detailed
information was collected regarding choice of anesthesia
and procedure-related complications, including failed regional anesthetic and maternal death. Potential risk factors
for a failed regional anesthetic were analyzed.
Results: Of the women studied, 34,615 (93%) received a
regional anesthetic. Few (3.0%) regional procedures failed,
and related maternal morbidity was rare. Increased maternal size, higher preoperative risk, rapid decision-to-incision
* For a list of other members of the National Institute of Child Health and Human
Development MaternalFetal Medicine Units Network, see the Appendix.
From the Department of Obstetrics and Gynecology, University of Texas
Southwestern Medical Center, Dallas, Texas.
Supported by grants (HD34116, HD27915, HD27869, HD34208,
HD34136, HD27917, HD21410, HD27860, HD34122, HD27905,
HD21414, HD27861, HD34210, HD36801) from the National Institute of
Child Health and Human Development.
Presented at the 24th Annual Meeting of the Society for MaternalFetal
Medicine, February 6, 2004, New Orleans, Louisiana.
Corresponding author: Steven L. Bloom, MD, Department of Obstetrics and
Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines
Boulevard, Dallas, TX 75390-9032; e-mail: steven.bloom@utsouthwestern.edu.
2005 by The American College of Obstetricians and Gynecologists. Published by
Lippincott Williams & Wilkins.
ISSN: 0029-7844/05
281
Bloom et al
Definition
Respiratory suppression requiring intubation
Inability to place an endotracheal tube
Epidural or spinal attempted but general anesthesia required
Severe positional headache following delivery and/or instillation of blood into the
epidural space for relief of headache
Meningitis, not viral or bacterial, following regional anesthesia
Collection of blood beneath epidural site causing back pain and neurological dysfunction
An abscess outside the dura mater
RESULTS
Of the 70,442 women entered into the cesarean
registry, 47,112 delivered within the first 2 years. Of
these, a total of 9,970 were excluded from this analysis, including 7,829 with prior cesareans who delivered vaginally, 2,073 with multiple fetuses, and 68
with incomplete anesthesia records. The remaining
37,142 women included 21,809 (59%) who underwent
a primary cesarean delivery, 12,576 (34%) who underwent a repeat cesarean delivery, and 2,757 (7%)
who had an unsuccessful attempt at a vaginal birth
after a prior cesarean.
Over 93% of the women studied received a
regional anesthetic. Specifically, 14,797 (40%) women
received a spinal as the first anesthetic attempted;
15,443 (42%) women received an epidural as the first
anesthetic attempted; and 4,375 (12%) women received a combined spinal-epidural as the first anesthetic attempted. The remaining 2,527 (7%) women
received a primary general anesthetic. Shown in
Table 2 are the demographic characteristics for the
37,142 women analyzed in this study.
The distribution of cesarean deliveries according
to indication and type of anesthesia initially attempted
is shown in Table 3. Subarachnoid block (spinal) was
the most commonly used method in women undergoing a repeat cesarean, whereas epidural was the
most commonly used method in women undergoing
a primary cesarean delivery. General anesthesia was
VOL. 106, NO. 2, AUGUST 2005
Overall Cohort
(n 37,142)
27.8 (6.4)
1151
14,670 (39.5)
11,316 (30.5)
9,222 (24.8)
1,934 (5.2)
15,120 (40.9)
12.1 (2.8)
016
36,169 (97.4)
Bloom et al
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Characteristic
Primary cesarean
Total
Dystocia
Fetal distress
Malpresentation
Other
Repeat cesarean
Total
No labor
Labor
Failed VBAC
Emergency cesarean*
Decision-to-incision
time 15 min
ASA Score
1 or 2
3
4
5
Pregnancy hypertension
None
Preeclampsia
Eclampsia
Spinal
(n 14,797)
Epidural
(n 15,443)
Combined
Spinal-Epidural
(n 4,375)
6,537
848 (13)
1,148 (18)
2,708 (41)
1,833 (28)
11,401
6,591 (58)
2,764 (24)
968 (8.5)
1,078 (9.5)
1,964
777 (40)
384 (20)
374 (19)
429 (22)
1,907
51 (2.7)
908 (48)
276 (14)
672 (35)
8,260
6,157 (75)
1,497 (18)
606 (7.3)
4,042
1,787 (44)
478 (12)
1,777 (44)
2,411
1,733 (72)
461 (19)
217 (9.0)
620
295 (48)
168 (27)
157 (25)
241 (1.9)
922 (6.2)
100 (2.4)
900 (38)
12,754 (88)
1,646 (11)
33 (0.2)
0
12,802 (86)
2,093 (14)
64 (0.4)
0
3,696 (86)
599 (14)
7 (0.2)
0
1,648 (67)
710 (29)
85 (3.5)
0
13,028 (88)
1,748 (12)
21 (0.1)
12,775 (83)
2,634 (17)
33 (0.2)
3,734 (85)
631 (14)
10 (0.2)
1,947 (77)
552 (22)
27 (1.1)
General
(n 2,527)
Includes women diagnosed either with preeclampsia, gestational hypertension, or hemolysis, elevated liver
enzymes, low platelets (HELLP) syndrome.
Table 4. Odds Ratio of Selected Newborn Infant Outcomes According to Type of Anesthesia Compared
With the Remainder of the Cohort
Type of Anesthesia
Characteristic
Apgar score
3 at 1 min
3 at 5 min
Umbilical artery
blood pH 7.0*
Neonatal death
Spinal
(n 14,471)
Epidural
(n 14,753)
Combined
Spinal-Epidural
(n 4,293)
General
(n 2,485)
General for
Failed Regional
(n 1,043)
0.52 (0.460.58)
0.52 (0.390.69)
0.89 (0.800.99)
0.57 (0.420.77)
0.70 (0.590.84)
1.01 (0.651.55)
2.86 (2.523.25)
2.68 (2.033.53)
2.46 (2.032.97)
2.69 (1.764.10)
0.49 (0.370.65)
1.13 (0.901.41)
0.84 (0.651.08)
0.71 (0.530.93)
1.08 (0.691.68)
0.96 (0.641.44)
2.71 (2.063.56)
1.17 (0.901.52)
1.15 (0.721.82)
1.19 (0.672.09)
Excluded are 3 cases without birth data and 94 stillbirths. Data are expressed as odds ratio (95% confidence interval). Odds ratios are
adjusted for cesarean delivery indication, birth gestational age, and emergency cesarean.
* Data are missing for 57% of patients.
Bloom et al
Complication
Failed regional
Spinal headache
Blood patch
High spinal
Extradural abscess
Chemical meningitis
Epidural hematoma
Spinal
(n 14,797)
313 (2.1, 1.92.4)
73 (0.5, 0.40.6)
27 (0.2, 0.10.3)
9 (0.06, 0.030.12)
0
0
0
Epidural
(n 15,443)
666 (4.3, 4.04.6)
41 (0.3, 0.20.4)
32 (0.2, 0.10.3)
11 (0.07, 0.040.13)
0
0
0
Combined
Spinal-Epidural
(n 4,375)
74 (1.7, 1.32.1)
21 (0.5, 0.30.7)
18 (0.4, 0.20.7)
3 (0.07, 0.010.20)
0
0
0
DISCUSSION
We performed a large study of anesthetic use and
complications in more than 37,000 women undergoing cesarean delivery from 13 university-based hospitals in the United States. Our results indicate that
regional techniques are clearly the most common
method of anesthesia, accounting for 93% of the
procedures performed. Few (3.0%) of the regional
procedures failed, and these were more likely to be
associated with increased maternal size, higher preoperative risk, rapid decision-to-incision interval, and
placement later in labor. Maternal mortality and
serious morbiditysuch as high spinal, meningitis,
and central nervous system hematomawere rare,
and this attests to the safety of modern obstetrical
anesthesia for cesarean delivery.
During the last 2 decades, there has been an
increasing impetus to avoid general anesthesia in
Characteristic
Body mass index at delivery (kg/m2)
Mean ( SD)
29
ASA Category
1 or 2
3
4
Decision-to-incision time 15 min
Cervical dilatation when regional placed (cm)*
03
49
10
Successful Regional
(n 33,562)
Failed Regional
Requiring General
Anesthesia
(n 1,053)
33.0 7.2
21,715 (68)
33.7 7.8
697 (71)
28,412 (87)
4,172 (13)
97 (0.3)
1,090 (3.5)
840 (83)
166 (16)
7 (0.7)
173 (17)
10,143 (51)
9,392 (47)
510 (2.5)
306 (40)
432 (57)
21 (2.8)
P
.004
.06
.001
.001
.001
Bloom et al
285
Bloom et al
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
APPENDIX
Other members of the MaternalFetal Medicine Units
Network include:
1. University of Texas Southwestern Medical Center:
2.
15.
Bloom et al
287