Spinal Versus Epidural Anesthesia for Cesarean Delivery in
Severe Preeclampsia: A Prospective Randomized,
Multicenter Study
Shusee Visalyaputra, MD*, Oraluxna Rodanant, MD†, Wanna Somboonviboon,
Kamthorn Tantivitayatan, MD‡, Somboon Thienthong, MD§, and
Wanawimol Saengchote, MD㛳
*Department of Anesthesiology, Siriraj Hospital, Faculty of Medicine, Mahidol University; †Department of
Anesthesiology, Chulalongkorn University Hospital, Faculty of Medicine; ‡Department of Anesthesiology, Rajvithi
Hospital, Tertiary Care Center, Bangkok, Thailand; §Department of Anesthesiology, Faculty of Medicine, Khonkaen
University, Khonkaen, Thailand; 㛳Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok, Thailand
In this randomized, multicenter study we compared
the hemodynamic effects of spinal and epidural anes-
thesia for cesarean delivery in severely preeclamptic
patients. The epidural group (n ⫽ 47) received 2% lido-
caine with epinephrine 1:400,000, 18 –23 mL, followed
by 3 mg of morphine after delivery. The spinal group (n
⫽ 53) received 2.2 mL of 0.5% hyperbaric bupivacaine
plus 0.2 mg morphine. We hypothesized that the lowest
MAP (mean arterial blood pressure, the primary out-
come) during the delivery period would have to be at
least 10 mm Hg less in the spinal group to be of clinical
importance. We found that there was a statistically sig-
nificant difference in MAP, with more patients in the
spinal group exhibiting hypotension (P ⬍ 0.001). Al-
though the incidence of hypotension (systolic arterial
blood pressure, SAP ⱕ100 mm Hg) was more frequent
E
pidural anesthesia has been accepted as the pre-
ferred anesthetic technique for cesarean delivery
in severely preeclamptic patients among both an-
esthesiologists (1) and obstetricians (2). Spinal anes-
thesia can be performed faster, has fewer complica-
tions, and is more cost-effective for uncomplicated
cesarean delivery (3). However, concern has been
raised that spinal anesthesia might be unsuitable for
cesarean delivery in severely preeclamptic patients, as
the potential for rapid and profound hypotension
Supported, in part, by Mahidol University Research Fund, Ma-
hidol University, Bangkok.
Accepted for publication February 11, 2005.
Address correspondence and reprint requests to Shusee Visalyapu-
tra, MD, Department of Anesthesiology, Siriraj Hospital, Bangkoknoi,
Bangkok, 10700, Thailand. Address e-mail to sisps@mahidol.ac.th.
DOI: 10.1213/01.ANE.0000160535.95678.34
862 Anesth Analg 2005;101:862–8
MD†,
in the spinal group than in the epidural group (51% ver-
sus 23%), the duration of significant hypotension (SAP
ⱕ100 mm Hg) was short (ⱕ1 min) in both groups. There
was more use of ephedrine in the spinal group than in
the epidural group (median, 6 versus 0 mg) but hypo-
tension was easily treated in all patients. Neonatal out-
comes assessed by Apgar scores and the umbilical arte-
rial blood gas analysis were similar in both groups.
Adverse neonatal outcomes (5-min Apgar score ⬍7 and
umbilical arterial blood pH ⬍7.20) were found in only 2
premature newborns (weight ⬍1500 g) who were born
without maternal hypotension after regional anesthe-
sia. We conclude that the results of this large prospec-
tive study support the use of spinal anesthesia for cesar-
ean delivery in severely preeclamptic patients.
(Anesth Analg 2005;101:862–8)
might further compromise an already potentially com-
promised newborn (4).
Several studies have investigated the hemodynamic
effects of spinal anesthesia in severely preeclamptic
patients. These studies include a descriptive study (5),
comparative studies with spinal anesthesia in normal
pregnancy (6,7), and a comparative study with general
anesthesia (8). On the basis of these studies, it has been
suggested that spinal anesthesia may be used in these
patients to avoid the risks associated with general
anesthesia in emergency situations and those arising
from the use of larger epidural needles in patients
with thrombocytopenia (9,10). Furthermore, minimal
hemodynamic effects from spinal anesthesia in se-
verely preeclamptic patients have been demonstrated
when using a small spinal dose in a combined spinal
epidural (CSE) technique (11).
©2005 by the International Anesthesia Research Society
0003-2999/05
ANESTH ANALG
2005;101:862–8
Although a large retrospective study by Hood and
Curry (12) and two small prospective studies by Wal-
lace et al. (13) and Sharwood-Smith et al. (14) have
shown that the hemodynamic effects of spinal anes-
thesia were similar to those seen with epidural anes-
thesia in severely preeclamptic patients, a large pro-
spective analysis has not been reported. Therefore, a
large prospective randomized multicenter study in
severely preeclamptic patients was undertaken to
evaluate the difference in hemodynamic changes be-
tween spinal and epidural anesthesia in severely pre-
eclamptic patients.
Methods
After approval by the IRB of 5 participating tertiary
care centers, 120 severely preeclamptic patients sched-
uled to have elective or urgent cesarean delivery un-
der regional anesthesia were studied during the 2-yr
period from November, 2000 to December, 2002. Se-
vere preeclampsia was defined as a systolic arterial
blood pressure (SAP) of 160 mm Hg or more or a
diastolic arterial blood pressure (DAP) of 110 mm Hg
or more and proteinuria of 100 mg/dL or more. Pa-
tients with coagulopathy, placental abruption, severe
“fetal distress,” or a history of allergy to local anes-
thetics were excluded from the study. Intravenous
magnesium sulfate (MgSO4) 4 g was given initially,
followed by 1 g/h for seizure prophylaxis. Intrave-
nous hydralazine 5 mg was given at 20-min intervals
to decrease the DAP to approximately 90 mm Hg.
Patients giving written informed consent to partici-
pate in this study were randomly assigned according
to a random number table for block randomization
(15), using numbered sealed envelopes to receive ei-
ther epidural or spinal anesthesia. Preoperative fluid
administration, which was limited to lactated Ringer’s
solution 100 mL/h, was given on arrival in the labor
room. In the operating room all patients received so-
dium citrate 30 mL orally and 5 L/min of 100% oxy-
gen by facemask. The patients were monitored with
standard monitoring devices including automated
blood pressure cuff, electrocardiogram, and pulse
oximetry.
Before administering regional anesthesia, 500 mL of
colloid solution (6% hydroxyethyl starch in balanced
salt solution) was given over 20 min (16,17), followed
by lactated Ringer’s solution 100 mL/h. In the epi-
dural group, a 17-gauge epidural needle was inserted
at the L3-4 interspace with the patient in the lateral
decubitus position, and an 18 gauge epidural catheter
was inserted 3– 4 cm into the epidural space. The
patient was then placed supine with left uterine dis-
placement and 5 L/min of oxygen was given via a
OBSTETRIC ANESTHESIA VISALYAPUTRA ET AL. 863
SPINAL VERSUS EPIDURAL BLOCK IN PREECLAMPSIA
facemask. Three mL of 2% lidocaine with epinephrine
1: 200,000 was given as a test dose, followed by 5 mL
of 2% lidocaine with epinephrine 1:400,000 plus 50 ␮g
of fentanyl. Incremental doses of 5 mL of 2% lidocaine
with epinephrine 1:400,000 were given (total dose of
18 –23 mL) until loss of sensation to pinprick to at least
the T6 level was achieved. Mean arterial blood pres-
sure (MAP) was measured every minute for the first
20 min, then every 2 min for the next 10 min, and
every 5 min thereafter until the end of the surgery.
Close monitoring of the MAP every minute during the
first 20 min would allow us to detect the severity and
duration of hypotension during this period.
Three milligrams of ephedrine was administered IV
if the SAP decreased to 120 mm Hg but was more than
100 mm Hg, and 6 mg of ephedrine was given if the
SAP decreased to or less than 100 mm Hg. To control
the unblinded ephedrine administration, ephedrine
was strictly given according to the requirements re-
lated to a change in SAP and was recorded along with
the printed recorded SAP. The recorded numbers for
ephedrine and SAP could be used as a cross-check for
verification of the necessity of ephedrine administra-
tion. Immediately after delivery, blood from the um-
bilical artery was drawn from an isolated segment of
the umbilical cord and immediately transported to the
laboratory. After delivery, 3 mg of preservative-free
morphine was administered via the epidural catheter.
The patients were closely observed for all complica-
tions of severe preeclampsia and epidural morphine
within the 24-h postoperative period.
In the spinal group, after fluid administration
similar to that in the epidural group, a 27-gauge
spinal needle was placed at the L3-4 interspace with
the patient in the lateral decubitus position. After
observing the flow of cerebrospinal fluid, 2.2 mL of
0.5% hyperbaric bupivacaine with 0.2 mg of
preservative-free morphine was injected into the
subarachnoid space. The patient was then turned
supine with left uterine displacement. Measurement
of the MAP in the operating room and postoperative
observation was done in the same way as it was in
the epidural group.
Demographic data, the highest MAP recorded be-
fore any medication administered in the labor room,
the baseline MAP (the mean of two consecutive
measurements taken 2 min apart) measured on ar-
rival in the operating room, the volume of IV fluid
administered and estimated blood loss were re-
corded. The pediatricians who examined the new-
borns and gave Apgar scores were unaware of the
anesthetic technique used in the mothers. The labo-
ratory technicians who analyzed the umbilical cord
blood were also unaware of the anesthetic technique
used in the patients.
864 OBSTETRIC ANESTHESIA VISALYAPUTRA ET AL. ANESTH ANALG
SPINAL VERSUS EPIDURAL BLOCK IN PREECLAMPSIA 2005;101:862–8

Table 1. Demographic Variables, Fluid Intake, Drug Therapy, Sensory Level Blocked at Incision Time, Estimated Blood
Loss, Anesthesia and Surgical Duration Times
Epidural Spinal
(n ⫽ 47) (n ⫽ 53) P value
Age (yr) 32 ⫾ 7 30 ⫾ 7 0.179*
Weight (kg) 71 ⫾ 12 75 ⫾ 13 0.130*
Height (cm) 155 ⫾ 6 155 ⫾ 5 0.588*
Gravidity 2 (1–7) 2 (1–5) 0.546†
Gestation (wk) 37 (26–41) 36 (28–42) 0.876†
Fluid (mL)
6-h preinduction 600 (350–1250) 600 (240–1500) 0.211†
Intraoperative 1000 (500–1700) 1000 (600–1800) 0.850†
MgSO4 therapy 43 (91%) 48 (91%) 1.000‡
Hydralazine therapy 16 (34%) 20 (38%) 0.835‡
Sensory level blocked at incision time T5 (T2–T6) T4 (T3–T6) 0.169†
Estimated blood loss (mL) 500 (100–1600) 500 (100–2800) 0.342†
Anesthesia duration (min) 23 ⫾ 8 12 ⫾ 8 ⬍0.0001
Surgical duration (min) 46 ⫾ 13 47 ⫾ 14 0.675
Skin incision to delivery (min) 8.0 ⫾ 3.2 7.8 ⫾ 3.1 0.779
Uterine incision to delivery (min) 2.8 ⫾ 2.2 2.7 ⫾ 1.6 0.749
Data are mean ⫾ sd, median (range) or n (%).
* Unpaired Student’s t-test; † Mann-Whitney U-test; ‡ Chi-square test, Fisher’s exact test.
Anesthesia duration ⫽ time from anesthesia skin preparation to skin incision; surgical duration ⫽ time from skin incision to skin closure.

A pilot study was performed in 10 severely pre-
eclamptic patients undergoing cesarean delivery un-
der epidural or spinal anesthesia. The purpose was to
determine the necessary descriptive statistics for sam-
ple size estimation using the lowest MAP (primary
outcome variable), which was unavailable from pre-
vious studies. These 10 patients were not included in
the main study.
We hypothesized that the lowest MAP would have
to be at least 10 mm Hg less in the spinal group than
in the epidural group to be clinically significant and
result in adverse neonatal effect. The statistical null
hypothesis of no difference in the lowest MAP be-
tween the 2 groups was tested against the alternative
hypothesis of 10 mm Hg difference. Using a 2-sided
type I error of 0.05, 80% power, and the standard
deviation of the lowest MAP of 17.5 (from the pilot
study), the required sample size was 51 per group. We
decided to study 120 patients (24 patients in each of 5
centers). By using a block randomization (15), we ac-
quired 10 sets of 12 numbers for patients to be equally
enrolled in the two groups of each set
Data were presented as mean (sd), median or num-
ber (percentage) as appropriate. ␹2 test or Fisher’s
exact test was used to test the difference in qualitative
variables between the two groups. An unpaired Stu-
dent’s t-test was used for normally distributed data
whereas the Mann-Whitney U-test was used for non-
normally distributed data. To test the difference be-
tween the mean SAP and DAP over time (0 to 30 min)
between the two groups, an unpaired Student’s t-test
was used . Type I error was set at 0.05 without adjust-
ment for multiple hypothesis testing because these
comparisons over time were only for the purpose of
exploratory analysis. All statistical data analysis was
performed using SPSS version 11.5 (SPSS, Chicago,
IL).
Results
Five patients in the epidural group were excluded
from the study as a result of inadequate anesthesia
and the need to proceed to general anesthesia. Eight of
55 patients in the epidural group and seven of 60
patients in the spinal group were in labor; the remain-
ing 47 and 53 patients, respectively, were not in labor.
Because laboring patients may have less hypotension
during regional anesthesia as a result of periodic aug-
mentation of circulating blood volume during uterine
contractions (18), statistical analysis was performed
only in nonlaboring patients.
Demographic data, the volume of IV fluid adminis-
tered, the proportion of patients receiving MgSO4 or
hydralazine therapy, and the volume of estimated
blood loss were similar in both groups. Anesthesia
duration was longer in the epidural group than in the
spinal group (P ⬍ 0.001), although the surgical dura-
tion time, skin incision to delivery time, and the uter-
ine incision to delivery time were similar in both
groups. Median sensory blocked levels at the time of
incision were also similar, with one level difference
(T5 and T4 in epidural and spinal groups, respec-
tively) (Table 1).
As illustrated in Table 2, the mean highest SAP,
DAP, and MAP values measured during the preoper-
ative period were similar in both groups. The mean
lowest SAP, DAP, and MAP measured during the
ANESTH ANALG OBSTETRIC ANESTHESIA VISALYAPUTRA ET AL. 865
2005;101:862–8 SPINAL VERSUS EPIDURAL BLOCK IN PREECLAMPSIA

Table 2. Hemodynamic Data and Ephedrine Use

Epidural Spinal
(n ⫽ 47) (n ⫽ 53) P value
Blood pressure (mm Hg)
During preoperative period
Highest SAP 182 ⫾ 22 180 ⫾ 18 0.639*
Highest DAP 115 ⫾ 14 113 ⫾ 13 0.466*
Highest MAP 138 ⫾ 16 136 ⫾ 13 0.509*
During induction to delivery
Lowest SAP 126 ⫾ 19 113 ⫾ 17 ⬍0.001*
Lowest DAP 72 ⫾ 16 63 ⫾ 16 0.005*
Lowest MAP 90 ⫾ 16 80 ⫾ 15 ⬍0.001*
During delivery to end of surgery
Lowest SAP 116 ⫾ 18 111 ⫾ 19 0.199*
Lowest DAP 60 ⫾ 16 59 ⫾ 16 0.745*
Lowest MAP 79 ⫾ 15 76 ⫾ 16 0.466*
Incidence of hypotension during 20-min postinduction period
SAP ⱕ80 mm Hg 1 (2%) 1 (2%) 0.004‡§
SAP 81–100 mm Hg 11 (23%) 27 (51%) –
SAP 101–120 mm Hg 10 (21%) 13 (24%) –
SAP ⬎120 mm Hg 25 (53%) 12 (23%) –
Duration of hypotension (min) (frequency of hypotension, measured every
1 min) during 20-min postinduction period
SAP ⱕ80 mm Hg 0 (0–1) 0 (0–1) 0.932†
SAP 81–100 mm Hg 0 (0–3) 1 (0–7) 0.003†
SAP 101–120 mm Hg 0 (0–14) 4 (1–18) ⬍0.001†
IV ephedrine
Predelivery use 21 (45%) 38 (72%) 0.006‡
Predelivery use (mg) 0 (0–18) 6 (0–36) 0.004†
Total ephedrine (mg) 6 (0–42) 12 (0–60) 0.025†
Data are mean ⫾ SD, median (range) or n (%).
SAP ⫽ systolic arterial blood pressure; DAP ⫽ diastolic arterial blood pressure; MAP ⫽ mean arterial blood pressure.
* Unpaired Student’s t-test; † Mann-Whitney U-test; ‡ Chi-Square test, Fisher’s exact test; § based on a 3 ⫻ 2 table by combining first and second category of
SAP.

induction to delivery period were consistently lower
in the spinal group than in the epidural group (mean
difference, 14, 9, and 10; 95% confidence intervals,
6 –21, 2–15, and 4 –17 mm Hg for SAP, DAP, and MAP,
respectively). The mean lowest SAP, DAP, and MAP
measured after delivery to the end of the operation
were similar in both groups. Although the incidence
of significant hypotension (SAP ⱕ100 mm Hg) was
about 2 times (51% versus 23%) more frequent in the
spinal group than in the epidural group, the duration
of hypotension (based on blood pressure measure-
ment every 1 min) was short (median, 1 versus 0 min)
in both spinal and epidural groups, respectively. One
patient in each group had SAP ⱕ80 mm Hg for only
1 min. Three newborns from mothers with the maxi-
mum duration of hypotension at each level (ⱕ80, 80 –
100, and 101–120 mm Hg) (Table 2) in the spinal group
had 5-min Apgar scores of 8, 10, and 10 as opposed to
10, 10, and 10 in the epidural group and umbilical
arterial blood pH of 7.26, 7.20, and 7.27 versus 7.38,
7.38, and 7.13 in the epidural group, respectively.
As illustrated in Figure 1, there were significant
differences in SAP at 1 to 15 min (P ⬍ 0.0001) and at 16
to 20 min (P ⬍ 0.005) and DAP at 1 to 15 min (P ⬍
0.0001) and at 16 to 20 min (P ⬍ 0.01) between the 2
groups. There were no significant differences in SAP
and DAP at 22 to 30 min between groups
Ephedrine was used to treat hypotension before
delivery more frequently in the spinal group than in
the epidural group (72% versus 45%, P ⫽ 0.006). The
amount of predelivery ephedrine and total ephedrine
were also larger in the spinal group than in the epi-
dural group (Table 2).
During the preoperative period, patients who
needed hydralazine therapy had a higher MAP than
did the patients who did not need hydralazine therapy
(P ⫽ 0.0014 and 0.0002, respectively). After the re-
gional block, the lowest MAP during the induction to
delivery period was significantly less in the spinal
group than in the epidural group, regardless of hy-
dralazine therapy (Table 3).
There were 4 sets of twins and one fetal death with
no neonatal data (hydrop fetalis) in the epidural group
and 2 sets of twins and 1 set of triplets in the spinal
group. To evaluate the effects of regional anesthesia
on neonatal outcomes we analyzed only the outcomes
of the first baby of the twins or triplets. Therefore, only
46 and 53 neonates in the epidural and spinal groups,
respectively, were included in the analysis.
866 OBSTETRIC ANESTHESIA VISALYAPUTRA ET AL.
SPINAL VERSUS EPIDURAL BLOCK IN PREECLAMPSIA
Table 3. Hemodynamic Data in the Epidural Group, Without Hydralazine Therapy (n ⫽ 31), With Hydralazine Therapy
(n ⫽ 16) and the Spinal Group, Without Hydralazine Therapy (n ⫽ 33), With Hydralazine Therapy (n ⫽ 20).
During preoperative period
Highest MAP (mm Hg)
Without hydralazine
With hydralazine
P value
During induction to delivery period
Lowest MAP (mm Hg)
Without hydralazine
With hydralazine
P value
Values are median (range).
MAP ⫽ mean arterial blood pressure.
P values by Mann-Whitney U-test.
Newborn weight, Apgar scores, and neonatal inten-
sive care unit admission were similar in both groups
(Table 4). The proportion of newborns with 5-min
Apgar scores ⱕ7 was 7% in the epidural group as
compared with 2% in the spinal group (95% confi-
dence interval, ⫺3,13). The umbilical arterial blood
pH, Pco2, Po2, base excess, and HCO3 were similar in
both groups (Table 5). Approximately 18% of new-
borns in the spinal group had an umbilical arterial
blood pH ⬍7.20, as compared with 13% in the epi-
dural group (95% confidence interval, ⫺11, 21). Only 2
premature newborns with pH ⬍7.20 (7.08 and 6.92)
had 5-min Apgar scores ⬍7; they were in the epidural
group (patients number 3 and 4 in Table 6).
Discussion
This study shows that spinal anesthesia for cesarean
delivery in severely preeclamptic patients causes
ANESTH ANALG
2005;101:862–8
Figure 1. Changes in the mean systolic arterial
blood pressure (SAP) and diastolic arterial blood
pressure (DAP) in the epidural group (n ⫽ 47) and
the spinal group (n ⫽ 53) during the first 30 min of
regional anesthesia. There are significant differ-
ences in SAP at 1 to 15 min (P ⬍ 0.0001) and at 16
to 20 min (P ⬍ 0.005) and in DAP at 1 to 15 min (P
⬍ 0.0001) and at 16 to 20 min (P ⬍ 0.01) between
the 2 groups. There are no significant differences in
SAP and DAP at 22 to 30 min between groups. Pre
ind ⫽ the baseline SAP, DAP in preinduction pe-
riod; delivery time ⫽ time from local anesthetic
administration to delivery. Data are mean ⫾ sd.
Epidural Spinal
(n ⫽ 47) (n ⫽ 53) P value
132 (111–157) 130 (113–156) 0.5897
144 (123–197) 140 (130–195) 0.1561
0.0014 0.0002
88 (57–117) 75 (57–112) 0.0081
95 (60–113) 75 (59–121) 0.0316
0.3751 0.4089
slightly more hypotension than does epidural anesthe-
sia during the induction to delivery period. The dura-
tion of hypotension, however, was short and there
was no difference in neonatal status.
In the previously published prospective study by
Wallace et al. (13) comparing general (n ⫽ 26), epi-
dural (n ⫽ 27), and CSE (n ⫽ 27) anesthesia for cesar-
ean delivery in severely preeclamptic patients, the
mean lowest SAP and DAP values after CSE technique
were similar, approximately 110 and 60 mm Hg, re-
spectively, similar to the lowest SAP and DAP values
in the spinal group (113 and 63 mm Hg) in our study.
However, the mean lowest SAP and DAP in the epi-
dural group of our study were higher than in the
epidural group of their study (126 and 72 mm Hg
versus 110 and 59 mm Hg, respectively). This may be
explained by the finding that the sensory level
achieved in our study tended to be higher in the spinal
group (T4) than in the epidural group (T5). In our
ANESTH ANALG OBSTETRIC ANESTHESIA VISALYAPUTRA ET AL. 867
2005;101:862–8 SPINAL VERSUS EPIDURAL BLOCK IN PREECLAMPSIA

Table 4. Newborn Weight, Apgar Score and Neonatal Intensive Care Unit (NICU) Admission
Epidural Spinal
(n ⫽ 46) (n ⫽ 53) P value
Newborn weight 2401 ⫾ 762 2410 ⫾ 825 0.954*
⬍2000 g 14 (30%) 18 (34%) 0.708‡
⬍1500 g 6 (13%) 8 (15%) 0.770‡
Apgar score
1 min 9 (2–10) 9 (5–10) 0.444†
5 min 10 (5–10) 10 (7–10) 0.571†
ⱕ7 at 1 min 12 (26%) 8 (15%) 0.174‡
ⱕ7 at 5 min 3 (7%) 1 (2%) 0.334‡
NICU admission 9 (20%) 9 (17%) 0.740‡
Data are mean ⫾ sd, median (range) or n (%).
* Unpaired Student’s t-test; † Mann-Whitney U-test; ‡ Chi-square test, Fisher’s exact test.

Table 5. Umbilical Artery Blood Gas Analysis

Epidural Spinal
(n ⫽ 32) (n ⫽ 40) P value
pH 7.26 (6.92–7.38) 7.27 (7.13–7.37) 0.522*
pH ⬍ 7.20 4 (12.5%) 7 (17.5%) 0.744†
PCO2 (mm Hg) 50 (41–72) 48 (35–71) 0.398*
Po2 (mm Hg) 19 (8–40) 21 (5–27) 0.866*
Base excess (mEq/L) 4.2 (0–11.1) 4.3 (1.5–11.7) 0.599*
HCO3 (mEq/L) 23.2 (17.0–30.7) 23.4 (14.8–26.5) 0.494*
Data are median (range) or n (%).
* Mann-Whitney U-test; † Chi-square test, Fisher’s exact test.
Analysis was available in 32 of 46 (68%) of newborns in the epidural group and 40 of 53 (75%) in the spinal group.

Table 6. All Four Newborns with 5-Min Apgar Score ⱕ 7

Apgar Type of NB weight Gestation Lowest Ephedrine
No. (5 min) anesthesia (g) (wk) Maternal diagnosis BP* (mg)* pH
1 7 Spinal 1750 36 Unfavorable cervix 99/55 18 7.19
2 7 Epidural 1200 30 Unfavorable cervix 114/60 6 7.26
3 5 Epidural 1490 32 IUGR 132/76 0 7.08
4 5 Epidural 1000 27 Chronic hypertension 127/75 0 6.92
* Recorded during induction to delivery interval.
IUGR ⫽ intrauterine growth retardation; NB ⫽ newborn; BP ⫽ blood pressure.

study, we used 2.2 mL of 0.5% hyperbaric bupivacaine
(11 mg) for spinal anesthesia, which was within the
dose range of 8 –12 mg used in other studies (7,8).
Using a lower spinal dose or using a CSE technique
with small-dose bupivacaine and supplementing with
local anesthetics via the epidural catheter or using
more aggressive MAP management may have re-
duced the difference in hypotension.
A retrospective study by Hood and Curry (12)
compared 103 severely preeclamptic patients hav-
ing spinal anesthesia with 35 patients having epi-
dural anesthesia for cesarean delivery. There was
only a 13% decrease in the mean lowest MAP from
the baseline MAP in both epidural and spinal
groups compared with a 25% decrease in both
groups in the Wallace et al. study and with a 23%
(epidural) and 31% (spinal) decrease in each group
in our study. This difference is probably attributable
to differences in study design among the various
studies.
Ephedrine was administered more often in the spi-
nal group (72%) than in the epidural group (45%) in
our study. This is in contradistinction to previous
studies. Ephedrine use was similar in the Hood and
Curry study (23 and 26%) and Wallace et al. study (22
and 30%) in the spinal and epidural groups, respec-
tively. We treated hypotension as soon as the SAP
decreased to 120 by administering 3 mg of ephedrine
or giving 6 mg if it decreased to or less than 100 mm
Hg. In contrast, Wallace et al. (13) administered
ephedrine 5 mg IV when SAP reached 100 mm Hg. In
a severely preeclamptic patient with some degree of
compromised placental function, we felt that a SAP of
100 mm Hg might compromise the fetus. We did not
find any massive hypertension in any patients given
early treatment with ephedrine in this study.
868 OBSTETRIC ANESTHESIA VISALYAPUTRA ET AL.
SPINAL VERSUS EPIDURAL BLOCK IN PREECLAMPSIA
By subgroup analysis, we found that patients who
needed hydralazine had higher MAP than did patients
who did not. However, the presence or absence of
hydralazine therapy did not influence the subsequent
decrease in MAP.
The failure rate of epidural block in our study (8%)
was more frequent than the 4.7% rate in a previous
report (19). However, this study had enough power
(86% by post hoc analysis) to analyze 47 nonlaboring
patients undergoing epidural anesthesia, as compared
with 53 nonlaboring patients undergoing spinal
anesthesia.
Neonatal outcomes assessed by Apgar scores and
the umbilical artery blood gas analysis were similar
for both groups. Because the duration time of SAP
ⱕ100 mm Hg was short, the uteroplacental blood flow
might not have been impaired in either group (5).
However, with a wide range of 95% confidence inter-
val differences in the incidence of newborns with
5-min Apgar score ⱕ7 (⫺3,13%) and in umbilical ar-
terial pH ⬍7.20 (⫺11,21%), a larger study with ade-
quate power or a systematic review is needed to eval-
uate differences in neonatal outcomes.
In summary, although the incidence of hypotension
and ephedrine requirement was slightly more fre-
quent in the spinal group than in the epidural group,
we found evidence that supports the use of spinal
anesthesia in severely preeclamptic patients. First, the
difference in mean lowest MAP (mean difference,
10 mm Hg; 95% confidence interval, 4 –17 mm Hg) did
not appear to be clinically significant. Second, the
hypotension was easily treated and there was only a
brief period of significant hypotension in either group.
Third, the neonatal outcomes assessed by the Apgar
score and the umbilical arterial blood gas analysis
were similar in both groups. Fourth, all 6 newborns
who were born with the maximum duration times of
hypotension in both groups had 5-min Apgar scores
and umbilical arterial blood pH within normal ranges.
Acknowledgment
The authors would like to thank Dr. Chulaluk Komol-
tri, DrPH, Division of Clinical Epidemiology, Faculty
of Medicine, Siriraj Hospital, for being the consultant
for statistics in this study and the Mahidol University
Research Fund for providing support for this study.
ANESTH ANALG
2005;101:862–8
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