DECLARATION

I, TSAMO NDOMO Vigny hereby declare that this research work is original (except where

acknowledgements indicate otherwise) and that neither the work nor any part of it has been

submitted for the award of a degree in higher education or any institute of learning.

Signature: ______________________ Date: ________________________

i
~ ii ~
 TABLE OF CONTENTS

DECLARATION ............................................................................................................................. i

CERTIFICATION .........................................................................Error! Bookmark not defined.

DEDICATION .......................................................................................................................... vii

ACKNOWLEDGEMENTS ..................................................................................................... viii

ABSTRACT .................................................................................................................................. xv

RESUME .................................................................................................................................... xvii

Lists of tables ............................................................................................................................. xviii

Lists of figures ............................................................................................................................. xix

List of acronyms ........................................................................................................................... xx

CHAPTER I: INTRODUCTION ................................................................................................... 1

I.1- Background ....................................................................................................................... 1

I.2- Problem statement ................................................................................................................ 2

I.3- Rationale ............................................................................................................................... 3

I.4- Research question ................................................................................................................. 3

I.5- Objectives ............................................................................................................................. 3

I.5.1- General objective ........................................................................................................... 3

I.5.2- Specific objectives ......................................................................................................... 3

I.6- Hypothesis ............................................................................................................................ 4

CHAPTER II- LITERATURE REVIEW ....................................................................................... 5

~ iii ~
 II.1- Introduction ......................................................................................................................... 5

II.2- General overview of pregnancy and its complications. ...................................................... 5

II.3- Generalities on Cesarean section......................................................................................... 7

II.4- Clinical applications and indications of spinal anesthesia .................................................. 8

II.5- Advantages of spinal anesthesia in cesarean section .......................................................... 8

II.6- Contraindications of spinal anesthesia ................................................................................ 9

II.7- Definition and classification of spinal anesthesia induced hypotension ............................. 9

II.8- Pathophysiology of spinal anesthesia induced hypotension. .............................................. 9

II.9- Risk factors of hypotension induced spinal anesthesia ..................................................... 10

II.10- Consequences of hypotension on the mother and fetus .................................................. 11

II.10- Management of spinal anesthesia induced hypotension ................................................. 12

II. 11- Prevention of spinal anesthesia induced hypotension .................................................... 13

CHAPTER III- MATERIALS AND METHODS ........................................................................ 14

III.1- Study design ..................................................................................................................... 14

III.2- Study setting..................................................................................................................... 14

III.3 - Study Population ............................................................................................................. 14

III.4 – Inclusions and Exclusions criteria .................................................................................. 15

III.4.1 - Inclusion criteria ....................................................................................................... 15

III.4.2 - Exclusion criteria...................................................................................................... 15

III.5 - Study Procedure .............................................................................................................. 15

~ iv ~
 III.6- Study variables ................................................................................................................. 17

III.6.1- sociodemographic characteristics .............................................................................. 17

III.6.2- Preoperative assessment. ........................................................................................... 18

III.6.3- Operative data ........................................................................................................... 18

III.6.4- Anesthetic data .......................................................................................................... 19

III.6.5- Diagnosis of hypotension .......................................................................................... 20

III.7- Quality control ................................................................................................................. 20

III.7 - Data analysis. .................................................................................................................. 21

III.8 - Ethical Considerations .................................................................................................... 21

CHAPTER IV- RESULTS and DISCUSSIONS .......................................................................... 23

IV.1- Socio demographic characteristics of the study participants ........................................... 23

IV.1- Incidence and level of Hypotension ................................................................................ 31

IV.3- Risk factors for spinal anesthesia induced hypotension in cesarean section. .................. 33

IV.4- Consequences of hypotension.......................................................................................... 35

V- Discussion ............................................................................................................................ 36

V.1- Sociodemographic factors. ............................................................................................ 36

V.2- Incidence of hypotension. ................................................................................................. 38

V.3- Risks factors of hypotension. ........................................................................................ 38

V.3- APGAR score and hypotension ..................................................................................... 39

Limitations .................................................................................................................................... 40

~v~
CONCLUSIONS........................................................................................................................... 40

RECOMMENDATIONS. ............................................................................................................. 41

REFERENCES ............................................................................................................................. 42

APPENDIXES .............................................................................................................................. 50

Appendix A: Ethical Clearance Form ....................................................................................... 51

Appendix B: Authorization letter from the Director of Yaoundé Central

Hospital. .............................................................................................................................. 52

Appendix c- Questionnaire........................................................................................................ 53

~ vi ~
 DEDICATION

TO MY BELOVED LATE GRANDMOTHER

SONNA JULIENNE
WHO HAVE EVER DREAMT OF HAVING A DOCTOR IN HER FAMILY.

~ vii ~
 ACKNOWLEDGEMENTS

My sincere gratitude goes to;

My supervisor Professor PISOH TANGNYIN CHRISTOPHER, for his support, collaboration

and supervision of the work, and my Supervisors Dr SAMJE MOSES and Dr TEMKOU SERGE

for their thorough supervision, advices and support which led to the completion of this work.

My appreciation goes to all Professionals of the Yaoundé Central Hospital Maternity especially

those of the anesthesia and reanimation unit and theater.

Special thanks also go to my dad NDOMO MARTIN, my mum NDOMO OLIVE, who

permitted me to be here today and for their continuous and everlasting encouragements and

support since the beginning of my medical studies. My uncle KENFACK DESIRE, for his

presence and assistance all through my studies. My uncle NGUEFACK ROGER, my late uncle

ZANE MAURICE, grandmother NGUEPI COLLETE , my elder brother WAMBA

TARCISSUIS, DJOUKENG ANDELYS, my elder sister NDOMO EDWIGE, all my brothers

and sisters, my Godfather NANTIA AKONO, my uncle KENFACK Jules, my aunt Sonfack

Clementine, DJATSA Rose, for their continuous support and encouragements throughout my

studies.

Special thanks to all those whose identity have not been revealed here, for the list is long

and endless.

Thanks to the Almighty God for the strength He has given me to successfully complete my

medical studies and for his continuous blessings and abundant grace.

~ viii ~
 REPUBLIC OF CAMEROON
Peace – Work – Fatherland
----------
MINISTRY OF HIGHER EDUCATION
UNIVERSITY OF BAMENDA
--------
FACULTY OF HEALTH SCIENCES
OFFICE OF THE DEAN
Tel/Fax: 22 81 60 39
THE ADMINISTRATIVE STAFF OF THE UNIVERSITY OF
BAMENDA
Prof Theresia Akenji
Prof Suh Cheo Emmanuel
Prof Agwara Moise Ondoh
Prof Roselyn Jua
Prof Banlilon Victor Tani
Prof Ghogomu Julius Numbonui
Dr Mbifi Richard
~ ix ~
REPUBLIQUE DU CAMEROUN
Paix – Travail -Patrie
--------
MINISTERE DE L’ENSEIGNEMENT SUPERIEUR
UNIVERSITE DE BAMENDA
-----------
FACULTE DES SCIENCES DE LA SANTE
DECANAT
B.P. 39 Bambili
Vice-Chancellor
Deputy Vice-Chancellor in charge of
Teaching, Professionalization and
Development of Information and
Communication Technologies
Deputy Vice-Chancellor in charge of
Internal Control and Evaluation
Deputy Vice-Chancellor in charge of
Research, Cooperation and relationship
with the Business world
Registrar
Director of Academic Affairs
Director of Administrative Affairs
Prof Anong Damian Nota Director Students’ Affairs

Mr Giyoh Yerima Peter Director of Finance

Mme Bongnda Winifred B. Beriliy Director of Library

THE ADMINISTRATIVE AND TEACHING STAFF OF THE FACULTY

OF HEALTH SCIENCES (FHS), THE UNIVERSITY OF BAMENDA

2018/2019 Academic Year

1. Administrative staff

Prof Dora Mbanya Dean

Prof Christopher Tangnyin Pisoh Vice-Dean in charge of Academic Affairs

Prof Helen Kuokuo Kimbi Vice-Dean in charge of Admissions and Records

Prof Henri Lucien F. Kamga Vice-Dean in charge of Research & Cooperation

Mr Jacob Titafan Voma Faculty Officer

Dr Gerald Ngo Teke Chief of Service, Programmes, Teaching & Research

Dr Moses Samje Chief of Service, Administration and Personnel

Mr Zaccheus Aweneg Chief of Service, Finance

Mr Humphrey Njoamomoh Chief of Service, Admissions and Records

Mr Leonard Peyechu Chief of Service, Materials and Maintenance

~x~
Dr Mary Garba Chief of Service, Internships

Mr Cyprien Bongwong Stores Accountant

2. Heads of Departments

Prof Frederic Agem kechia Biomedical Sciences

Prof Christopher Tangnyin Pisoh Clinical Sciences

Prof Bih Suh Mary Atanga Nursing/Midwifery

Dr Esther Etengeneng Agbor Medical Laboratory Sciences

3. Teaching staff

a) Professors

1. Christopher Kuaban Internal Medicine/Chest Medicine

2. Helen Kuokuo kimbi Medical Parasitology

3. Dora Mbanya Haematology

b) Associate Professors

1. Bih Suh Mary Atanga Nursing/Midwifery

2. Henri Lucien F. Kamga Medical Parasitology

3. Frederic Agem Kechia Medical Mycology

4. Christopher Tangnyin Pisoh General Surgery

~ xi ~
c) Senior Lecturers

1. Esther Etengeneng Agbor Nutritional Biochemistry

2. Marie Ebob Bissong Medical Microbiology

3. Flore Ngoufo Nguemaim Medical Parasitology

4. Gerald Ngo Teke Pharmacology

5. Omarine Nfor Njimanted Medical Parasitology

6. Moses Samje Biochemistry

7. William Ako Takang Obstetrics/Gynaecology

d) Assistant Lecturer

Jacob Titafan Voma Physics

e) Instructors

1. Kwende Odelia Nursing

2. Foba Marcelline Nursing

~ xii ~
THE HIPPOCRATIC (PHYSICIAN’S) OATH

Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland,

September 1948

and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968

and the 35th World Medical Assembly, Venice, Italy, October 1983

and the 46th WMA General Assembly, Stockholm, Sweden, September 1994

and editorially revised by the 170th WMA Council Session, Divonne-les-Bains, France, May

2005

and the 173rd WMA Council Session, Divonne-les-Bains, France, May 2006

and the WMA General Assembly, Chicago, United States, October 2017

AS A MEMBER OF THE MEDICAL PROFESSION:

• I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;

• THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;

• I WILL RESPECT the autonomy and dignity of my patient;

• I WILL MAINTAIN the utmost respect for human life;

• I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin,

gender, nationality, political affiliation, race, sexual orientation, social standing, or any other

factor to intervene between my duty and my patient;

• I WILL RESPECT the secrets that are confided in me, even after the patient has died;

• I WILL PRACTISE my profession with conscience and dignity and in accordance with good

medical practice;

• I WILL FOSTER the honor and noble traditions of the medical profession;

• I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their

~ xiii ~
due;

• I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of

healthcare;

• I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the

highest standard;

• I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even

under threat;

I MAKE THESE PROMISES solemnly, freely, and upon my honor.

~ xiv ~
 ABSTRACT

Introduction: Pregnancy is a physiologic condition during which the body undergoes

physiological changes affecting in almost various systems in the body. These changes can affect
the outcome of medical procedures such as spinal anesthesia. Pregnancy can complicate and end
up in a cesarean section which can be life saving for both the mother and the baby. Spinal
anesthesia is the most common method of anesthesia with a prevalence of 80-90 % in cesarean
section and hypotension is the most common complication with an incidence of 60-70%. The
persistent high incidence of hypotension urges us to know more about its risk factors with the
aim of preventing it thus making its practice safer though our study.

Objective: Determine the incidence and associated risk factors of spinal anaesthesia induced
hypotension in women undergoing caesarean section in Yaoundé Central Hospital.

Materials and Methods: A retrospective cohort study was carried out in Yaoundé Central
Hospital. Data were extracted from anesthetic files of women who underwent cesarean section
under spinal anesthesia from March 2018 to March 2019 using a questionnaire. Data were
analyzed using EPI INFO 7.2.2.6TM.

Results: a total of 519 participants were recruited. The incidence of hypotension was found to be
70 % (361). There was statistically significant association between hypotension and Body Mass
Index >30 (p = 0.001), Baseline Systolic Blood Pressure of >139 (p = 0.018), an American
Society of Anesthesiologists score of II (p value 0.02), duration of surgery of <60 min (p =
0.006), preoperative fluid load of 1000-2000 (p = 0.017), and practitioner being a nurse (p value
0.0015). There was also a statistically significant association between hypotension and low
APGAR score at birth (p = 0.04).

Conclusion and recommendations: The incidence of hypotension was found to be 70%. Risks
factors included modifiable one: BMI>30, the amount of fluid loaded prior to the procedure and
the practitioner administering the anesthesia and the non-modifiable one: ASA score, surgery
duration and the baseline systolic blood pressure which was associated with severe hypotension.
women developing hypotension were at risk of delivering a baby with a poor APGAR score at
birth.

~ xv ~
We recommend that women undergoing spinal anesthesia for cesarean section should be
assessed for risk factors, women with baseline SBP >139 shouldn’t undergo spinal anesthesia,
other strategies for preoperative fluids loading should be put in place and continuous training
should be organized for practitioner performing spinal anesthesia.

~ xvi ~
 RESUME

Introduction : La grossesse est un état physiologique au cours duquel l’organisme subit

plusieurs changements physiologiques lequel affecte Presque tous les systèmes de l’organisme.
Ces changements peuvent avoir un impact sur les procédures médicales telles que la rachi
anesthésie. La grossesse peut avoir des complications qui en fin de terme peuvent conduire à la
pratique d’une césarienne pour sauver la vie de la mère et/ou du fœtus. Le rachis anesthésie est le
type d’anesthésie la plus pratiqué durant la césarienne avec une prévalence de 60-70%. La rachi
anesthésie présente des complications parmi lesquelles l’hypotension est tune des plus
communes. La persistance du taux de prévalence élevé de ce dernier nous empresse d’identifier
ses facteurs de risque pouvant nous aider à le prévenir et à réduire ses complications rendant sa
pratique plus sure, d'où notre étude.
Objectif : Déterminer l’incidence et les facteurs de risques associe de l’hypotension chez les
patients ayant subi une césarienne sous rachis anesthésie.
Matériels et Méthodes : Nous avons conduit une étude de cohorte rétrospectif Durant laquelle
nous avons étudié les dossiers anesthésiques des patients ayant été opérées à la maternité de
l'Hôpital Central de Yaoundé pour une césarienne sous rachi anesthésie sur une période d’un an
allant de Mars 2018 à Mars 2019, en utilisant un questionnaire. Les données ont été analysés
avec le logiciel EPI INFO 7.2.2.6 TM.
Résultats : L’incidence de l’hypotension fut de 70 %. Une association statisticallement
significatif fut établit entre l’hypotension et l’Indice de Masse Corporel >30 (p value ≈ 0.001),
un score de la Société Américaine d’Anesthésie de II (p value 0.02), pression systolique de base
>139 (p value 0.006), remplissage préopératoire avec 1000-2000ml de cristalloïdes (p value
0.017), infirmier comme praticien de la procédure (p value 0.0015). Une association fut établit
entre hypotension et un score APGAR moyen a la naissance (p value 0.04).

Conclusions et recommandations : Au vu de notre analyse, l’incidence de l’hypotension fut de

70 %. Les facteurs de risques modifiables comprennent, l’indice de masse corporelle >30, la
quantité de liquides reçu au pré remplissage, le praticien pratiquant la procédure. Et las facteurs
non modifiables comprennent : le score ASA II, la durée de la chirurgie et la pression systolique
de base >139 qui est aussi associe au développement d’une hypotension sévère. Les femmes
ayant subi une hypotension étaient à risque d’avoir un bébé avec un score d’APGAR moyen. De
ce fait, nous recommandons que toutes les femmes sur le point de subir un rachis anesthésie pour
une césarienne soient bien investiguer pour la recherche de facteurs de risques. Les femmes avec
une pression artérielle systolique supérieure à 139 ne doivent pas subir une rachis anesthésie, de
Nouvelles stratégies sur la réhydratation préopératoire doit être mise en place et les praticiens
opérant une rachis anesthésie pour césarienne doivent être mieux formes et recyclés.

~ xvii ~
 LISTS OF TABLES

Table1: Sociodemographic characteristics of participants. ------------------------------------page 23

Table2: Distribution of operative data among participants -------------------------------------page 26

Table3: Distribution of Anesthetic data among participants------------------------------------page 28

Table4: Distribution of level of hypotension among study participants-----------------------page 32

Table05: Univariate analysis of risks factors for hypotension ----------------------------------page 34

Table 06: association between severe hypotension and Baseline SBP -----------------------page 33.

Table07: Multiple logistic regression analysis for risks factors ------------------------------ page 34

Table08: Association between hypotension and APGAR score 4-6 --------------------------page35

~ xviii ~
 LISTS OF FIGURES

Figure 1: Distribution of Baseline Systolic Blood Pressure among participants ------------ page 24

Figure 2: Distribution of ASA score among participants. ---------------------------------------page 25

Figure 3: Distribution of APGAR score at birth of baby born from study participants ---- page 29

Figure 4: Incidence of hypotension among study participants --------------------------------- page 30

~ xix ~
 LIST OF ACRONYMS

ASA: American Society of Anesthesiologists

BMI: Body Mass Index

BP: Blood Pressure

BRH: Bamenda Regional Hospital

CI: Confidence Interval

CS: Cesarean Section

CSF: Cerebrospinal Fluid

DBP: Diastolic Blood Pressure

HR: Heart Rate

HTN: Hypertension

OR: Odds Ratios

SA: Spinal Anesthesia

SBP: Systolic Blood Pressure

T3: Triiodothyronine

TBG: Thyroxine Binding Globulin

T4: Thyroxine

YCH: Yaoundé Central Hospital

~ xx ~
 CHAPTER I: INTRODUCTION

I.1- BACKGROUND

Pregnancy is from the first day of the last menstrual cycle until the delivery of the baby.

[1] During this period, the body undergo several changes which basically are aimed to prepare

the body of the woman to receive the baby, to favor his growth and delivery. These changes

affect almost all of the body system mainly the cardiovascular system with peripheral

vasodilation, increased in cardiac output [2] , in renal function by vasodilation of renal arteries,

[3] renal blood flow and glomerular filtration rate,[4] in the respiratory system by increased

oxygen demand and in the endocrine system by increased hormonal levels such as thyroid

hormones [5], adrenal cortex [6,7] and pituitary hormones. [8,9] During pregnancy, many life-

threatening conditions can occur depending on the trimester of pregnancy and towards term, can

end up in cesarean delivery. Cesarean delivery is mostly done under spinal anesthesia which is

more difficult and riskier in pregnant women due to the aforementioned physiological changes.

Spinal anesthesia is induced by injecting small amounts of local anesthetic into the

cerebro-spinal fluid (CSF). Since its first use in 1885 [10] its use has been progressively

increasing with time, and this mostly in cesarean section with 80-90% of cesarean deliveries are

done under spinal anesthesia [11]. These are mainly due to the numerous advantages of spinal

anesthesia over general anesthesia mainly: decreased in surgical time, in blood loss,

intraoperative transfusions [12], decreased incidence of thrombotic phenomena [13] and it allows

the mother to be awake, minimizes maternal aspiration pneumonitis and problems with difficult

intubation [14] Finally, it facilitates effective postoperative pain relief and avoids the neonatal

depression associated with general anesthesia.[15,16]

1
 Spinal anesthesia has many complications, namely hypotension 33% in no obstetric

patients [17] and 60-70% in obstetric patients [18] with incidence of cardiac arrest from 0.04–

1/10,000.23,24 [19,20] bradycardia, [19,20] post-dural puncture headache,[32] and transient

neurologic symptoms.[33] Knowned risks factors for hypotension in women undergoing spinal

anesthesia include patient’s height, baseline systolic blood pressure and level of blockade and for

non-obstetric populations include block height T5 or greater, age 40 year or greater, baseline

systolic blood pressure less than 120 mmHg, and spinal puncture above L3–L4 [19].

I.2- P ROBLEM STATEMENT

Despite the amelioration of the method of spinal anesthesia, its more often use, and

preventive measures, much remain unknown on it [21] though the persistence of its

complications of which one of the most common during cesarean section is hypotension. As far

as risk factors are concerned, despite the current knowledge of some of them, it’s still difficult to

predict with certainty patients at risk of hypotension during spinal anesthesia evidenced by the

persistence of high incidence of hypotension in cesarean section. Added to this, the severity of

the side effects of hypotension in spinal anesthesia in general and during cesarean section in

particular needs us to identify preventives measure to make its practice safe though the need of

our study.

To contextualize the aforementioned analysis, very few data are available concerning

spinal anesthesia and its relatively high incidence and severity of his side effects needs us to

identify preventive measures. Therefore, to increase its safety in our community more data are

needed especially concerning its most frequent complication which is hypotension through the

~2~
research of the incidence and associated risk factors of hypotension in patients undergoing spinal

anesthesia for cesarean section in Yaoundé Central Hospital.

I.3- R ATIONALE

The determination of the incidence of hypotension in patients undergoing spinal

anesthesia helped us to know the burden of the problem in our community through its incidence

and the identification of its risk factors will help us to prevent it in our community for us to be

able to decrease the morbidity of the condition and also to increase our data and overall

knowledge in spinal anesthesia as a whole and of hypotension secondary to spinal anesthesia in

cesarean section in particular.

I.4- R ESEARCH QUESTION

What is the incidence and associated risk factors of hypotension in patients undergoing spinal

anesthesia for cesarean section in Yaoundé Central Hospital?

I.5- O BJECTIVES
I.5.1- GENERAL OBJECTIVE

To determine the incidence of spinal anesthesia induced hypotension in women undergoing

cesarean section in Yaoundé Central Hospital and identify its risk factors.

I.5.2- SPECIFIC OBJECTIVES

• To determine the incidence of hypotension in patients undergoing spinal anesthesia for

cesarean section in Yaoundé Central Hospital.

• To determine the risk factors of hypotension in the above-mentioned patients.

~3~
 • To determine the effect of hypotension on the baby.

I.6- HYPOTHESIS

There’s no association between hypotension and age, gravidity, BMI, baseline systolic

blood pressure, ASA score, type of surgery, duration of surgery, patient position, level of

puncture, drug used, amount of drug used and the practitioner in women undergoing spinal

anesthesia for caesarean section in Yaoundé Central Hospital.

~4~
 CHAPTER II- LITERATURE REVIEW

II.1- I NTRODUCTION

Pregnancy in medical terminology is considered as a physiologic condition. Nevertheless,

complications can arise and end up in a cesarean section which is mostly done nowadays under

spinal anesthesia. Since its discovery in 1885 [2], Spinal anesthesia use has been increasing until

nowadays when it’s the most common used anesthetic technic for cesarean section with 80-90%

of cesarean sections done under spinal anesthesia. Hypotension which is a decrease in BP of

more than 10% of its baseline value or a systolic blood pressure value of less than 100mmHg

[22], is a very common consequence of the sympathetic vasomotor block caused by spinal

anesthesia for caesarean section with an incidence of 60-70 % [8,9]. Maternal symptoms such as

nausea, vomiting and dyspnea frequently accompany severe hypotension, and adverse effects on

the fetus, including depressed Apgar scores and umbilical acidosis, have been correlate with

severity and duration of hypotension [23].

II.2- G ENERAL OVERVIEW OF PREGNANCY AND ITS

COMPLICATIONS .

Pregnancy is a physiologic condition divided into 3 trimesters, lasting 40 weeks (280

days), Starting from the 1st day of last menstrual cycle end by the delivery of the baby. [1]

During pregnancy, the body undergo some physiological changes in various body system such

as:

• Cardiovascular system: [2]

~5~
 o Increase in the cardiac output by 20%.

o Peripheral vasodilation, that will lead to a fall in total peripheral

resistance.

o Increase in heart rate and stroke volume.

o Dilatation of the heart and increased myocardial contractility.

o Increase in blood and stroke volume.

• In renal function, we have a renal vasodilation due to the increase secretion of

relaxin that will cause a vasodilation of renal arteries [4] causing an increase in

renal blood flow and glomerular filtration rate all leading to an increase in renal

size [3].

• Respiratory system, there’s an increased in oxygen demand. [2]

• Endocrine system

o Increased level of thyroxine binding globulin. (TBG)

o Increased level of T3 and T4. [5]

o Increased in adrenal cortex hormones. [6,7]

o Increased pituitary gland size due to the increased production of prolactin.

and increased oxytocin level with a peak at term. [8,9]

Throughout pregnancy, various complications exist according to the trimester namely in

the first trimesters, they’re mainly abortion, ectopic pregnancy and gestational trophoblastic

diseases [24] and at the end of pregnancy, the most serious and challenging issues are

hypertensive disorders, preterm labor and birth and bleeding disorders. [25] All these conditions

can threaten the life of either the mother or the child and therefore ending up in a cesarean

delivery, therefore making it to be about 13.3% [31] in some area in Cameroon.

~6~
 II.3- G ENERALITIES ON C ESAREAN SECTION

Cesarean delivery defines the birth of a fetus via laparotomy and then hysterotomy. [26]

WHO recommend cesarean section to be 5-15 % of all deliveries. [27,28] The most common

Complications of pregnancy leading to cesarean section include [29]:

• Cephalo-pelvic disproportion.

• Fetal distress.

• Previous cesarean delivery.

• Breech delivery, foetal macrosomia.

• Placenta previa.

• Eclampsia and severe pre-eclampsia.

• Multiple pregnancies.

• Placenta abruptio.

Cesarean section can be done either under general anesthesia or spinal anesthesia which

is the most commonly used with a prevalence of 80-90. [2] Complications of cesarean section are

numerous and can either be secondary to the procedure itself or to the anesthesia. Some

complications of cesarean section include hysterectomy, transfusion, hypovolemic shock, cardiac

arrest, venous thromboembolism, puerperal infection, wound disruption and wound hematoma.

[18] Some complications due to the anesthesia (spinal anesthesia) include: hypotension, [8,9]

bradycardia, [8,9] post-dural puncture headache [30], transient neurologic symptoms. [31]

~7~
 II.4- C LINICAL APPLICATIONS AND INDICATIONS OF
SPINAL ANESTHESIA

Spinal anesthesia provides excellent operating conditions for surgery below the

umbilicus. To be more explicit, indications of spinal anesthesia include: ambulatory anesthesia

[23] all operations below the diaphragm where a general or local anesthetic is contraindicated, In

intestinal obstruction with regurgitant vomiting, when great shock is feared, such as amputation

or disarticulation of hip joint, operations upon the rectum necessitating its dilatation, Patients

who are fearful of being rendered unconscious and will not consent to the use of a general

anesthetic, Nephritis and catheterization of ureters as spinal does not inhibit renal excretion,

Anemia where the hemoglobin is below 50%, and in cachexia, in patients with bronchitis,

phthisis and pulmonary disorders, Diabetes, advanced arteriosclerosis, cardiac degeneration, and

advanced valvular disease of the heart, Septic conditions tax the secreting function of the kidneys

to such an extent that spinal anesthesia comes as a boon to these overworked organs [32].

Among these, cesarean section remains one of the most common indication of spinal anesthesia.

II.5- A DVANTAGES OF SPINAL ANESTHESIA IN CESAREAN

SECTION

Spinal anesthesia avoids the problems associated with general anesthesia in the pregnant

patient, notably risks of difficult airway, awareness, and aspiration. Maternal blood loss has been

found to be lower with spinal compared with general anesthesia [33], decrease in maternal

mortality rate, allows a mother to be awake for childbirth, lower risk of fetal distress [34], which

can be jeopardized by hypotension [35, 36], preventing the antidepressant drug from reaching the

fetus. [37]

~8~
 II.6- C ONTRAINDICATIONS OF SPINAL ANESTHESIA

Basically, the first contraindication of spinal anesthesia is any operation above the

diaphragm, but also for patient suffering from spinal trouble, Children or young adults generally

due to the risk of failure, in cases where the asepsis necessary to safely place a needle into the

subarachnoid space cannot be carried out, Nervous and hysterical patients [17].

II.7- D EFINITION AND CLASSIFICATION OF SPINAL

ANESTHESIA INDUCED HYPOTENSION

Hypotension occur when there’s a decrease in BP of more than 10% of its baseline value or a

systolic blood pressure value of less than 100mmHg [38]. It’s the most common complication of

spinal anesthesia. [2] Guidelines for blood pressure measurement in general medical practice

suggest, for accuracy, a 5-min period without movement or speaking, [39] although this is

unlikely to be achieved in the situation of impending surgery. Repeat measurements every 1–2

min until three consecutive values of SAP were achieved with a difference of < 10% between

them before considering it. [40] Hypotension can be classified as [29]:

• Mild hypotension: drop of ≥10% and ≤20% in baseline SBP

• Moderate hypotension: drop of >20% and ≤30% in baseline SBP

• Severe hypotension: drop of >30% in baseline SBP

II.8- P ATHOPHYSIOLOGY OF SPINAL ANESTHESIA

INDUCED HYPOTENSION .

Hypotension fall under the cardiovascular effects of spinal anesthesia which typically

include a decrease in arterial blood pressure and central venous pressure [41] with only minor

~9~
decreases in heart rate. Spinal anesthesia causes a sympathetic block which in turns causes

hypotension via its effects on preload (Preload is decreased by sympathetic block-mediated

venodilation, resulting in pooling of blood in the peripheries and decreased venous return [42],

afterload (a decreased in afterload is due to a decreased in arterial vasomotor tone, a vasodilation

and thus a decreased in systemic vascular resistance [43,44] and heart rate (decrease in heart rate

due to blockade of the upper thoracic sympathetic nerves. [45] With a high spinal block

to cervical levels, the pre-ganglionic sympathetic cardiac accelerator fibers may be blocked

resulting in a failure of compensatory tachycardia. However, heart rate does not correlate well

with block height; a pattern of sudden bradycardia, secondary to vasovagal (also termed Bezold-

Jarisch) reflex activation, is well recognized. [46]

II.9- R ISK FACTORS OF HYPOTENSION INDUCED SPINAL

ANESTHESIA

Known risk factors for spinal anesthesia induced hypotension in patients undergoing

cesarean section include [47]:

• Increasing age: hypothetically explained by reduction in cardiac reserve and changes in

baroreceptor and sympathetic nervous system responses may play certain roles in

increasing the risk of hypotension in older patients. [48]

• Body Mass Index (BMI) ≥25 kg/m2: This might be explained by the decrease in CSF

volume due to elevated abdominal pressure and compression of the subarachnoid cavity,

as in obesity or pregnancy. [49]

• Weight gain >10 kg during pregnancy,

• History of one previous normal vaginal: Due to the reduction in peripheral vascular tone

during a healthy pregnancy. [50]

~ 10 ~
• History of ≥2 previous CS.

• History of previous hypotension: it might be attributed to the fact that history of

hypotension represents more changes in the regulation of autonomic nervous system

during pregnancy. Thus, pregnant women would be more susceptible to sympathectomy

due to SA.

• Hypotension: prior history of hypotension can predict hypotension.

• Baseline SBP <120 mmHg, baseline DBP <80 mmHg: might be explained by the fact

that patients with low baseline SBP may have low baseline systemic vascular resistance

thus after spinal anesthesia, vasodilatation was increased.

• Baseline HR >80 beats/min: patients with increased HR secondary to preoperative

fear or anxiety would experience more hypotension after induction of SA. [51]

• Sensory block over T4: the higher level of sensory blockade, the more autonomic

blockade causing more vasodilatation and more hypotension. Level of T1-T4 is the

location of cardio accelerate nerve fibers. Blockade above T4 level may lead to negative

inotropic and chronotropic heart function and causes more hypotension. [52]

II.10- C ONSEQUENCES OF HYPOTENSION ON THE

MOTHER AND FETUS

• Nausea and vomiting: they are significantly more frequent during spinal

anesthesia for caesarean section than during non-obstetric surgery. Acute

hypotension reduces cerebral perfusion, induces transient brainstem ischemia and

activates the vomiting center. Transient cerebral hypoxia may occur, as studies

using near-infrared spectroscopy (NIRS) show that hypotension is accompanied

by a significant decrease in maternal regional cerebral blood volume, cerebral

~ 11 ~
 oxygen saturation and oxygenation. This is consistent with the observation that

supplemental oxygen may relieve this nausea. [54]

• Dizziness and decreased levels of consciousness may follow severe and prolonged

maternal hypotension, but are uncommon when blood pressure is treated

promptly. [53]

• Neonates of women with spinal-induced hypotension had significant acidosis, and

hypotension of more than 2 min duration was associated with a significant

Increase in umbilical venous oxypurines and lipid peroxides, suggestive of

ischemia–reperfusion injury.[54]

II.10- M ANAGEMENT OF SPINAL ANESTHESIA INDUCED

HYPOTENSION

The management of spinal anesthesia induced hypotension is somehow tricky because

maternal and fetal health are concerned here making the choice of therapeutic regimen more

specific. Non pharmacologic methods include:

• Placing the patient in the left lateral position after spinal injection [54],

• Mechanical compression of the lower limb using elastic or pneumatic stockings or

wrappings. [55]

As pharmacologic methods, we can use:

• Vasopressors increase blood pressure by increasing the systemic vascular

resistance and by increasing the cardiac output and are generally given

intravenously, intramuscularly or rarely orally [25] the vasopressor of choice in

obstetric patients is ephedrine because it causes less effect in placenta blood flow

~ 12 ~
 [56]. As second drug of choice, phenylephrine can be use. Metaraminol can also

be use and has better fetal acid base status than ephedrine [57] but is not available

in all countries.

• Intravascular fluids loading Crystalloid coloading may be more effective at

decreasing hypotension and vasopressor requirements than pre-loading or no

fluid. [55] Colloids are more effective than crystalloids, with 500 ml pre-load of

colloids appears as effective as 1000 ml of crystalloids. [58]

II. 11- P REVENTION OF SPINAL ANESTHESIA INDUCED

HYPOTENSION

Since hypotension is a frequent complication of spinal anesthesia and in obstetric can be

deleterious for both the mother and the fetus, it’s more or less imperative to prevent it. This can

be achieved using:

• Prehydration with crystalloid or colloid with crystalloid being more effective [59].

• Prophylactic administration of vasopressors [60], using a side port spinal needle

such as Whitacre 61,using a small dose of local anesthetic [62].

• Keeping the patient in the lateral position for 6–20 min [63].

The non-standardization of these methods, the non-availability of material/resources and

eventually the emergency of the surgery usually may reduce the use of these preventive

measures.

~ 13 ~
 CHAPTER III- MATERIALS AND METHODS

III.1- S TUDY DESIGN

A descriptive retrospective cohort study was used. Since files of operated patients from

March 2018 to March 2019 have been used to collect data from the beginning to the end of the

surgery.

III.2- S TUDY SETTING

The study took place in Yaoundé Central Hospital. Yaoundé Central Hospital is a referral

hospital located in the center of Yaoundé the political capital of Cameroon, and is the second

most populated town of the country. It’s one of the biggest government hospitals of the country

receiving patients from all over the country mostly from the center region. The study took place

in the archives of the anesthesia and reanimation department of the maternity of the hospital

since that is where files were being kept.

III.3 - S TUDY P OPULATION

All women of the Yaoundé Central Hospital who underwent cesarean section under spinal

anesthesia from May 2018 to May 2019.

~ 14 ~
 III.4 – I NCLUSIONS AND E XCLUSIONS CRITERIA

III.4.1 - INCLUSION CRITERIA

• Properly filled anesthetic Files of patients who underwent spinal anesthesia for cesarean

section from March 2018 to March 2019.

III.4.2 - EXCLUSION CRITERIA

• Not properly filled files.

• Files of patients who didn’t respond to the spinal anesthesia.

• Patients to whom the cesarean section was followed by other procedures.

• Patients receiving any treatment which could affect the BP.

III.5 - S TUDY P ROCEDURE

• Sample size: The sample size was equal to all the women who underwent spinal

anesthesia for cesarean section in Yaoundé Central Hospital from March 2018 to March

2019 and who meet the selection criteria. This was equal to 519 patients.

• Sampling technique: consecutive non probability sampling technique was used. We

went to the archives of the anesthesia and reanimation unit of the maternity of YCH. Files

were stored according to years, so we sorted out the files of patients operated in 2018

from March to December, then among those of 2019 from January to February. Files of

March 2019 were collected from the office anesthetic nurses. Out of these selected files,

files of patients who underwent cesarean section were selected and those who underwent

spinal anesthesia sorted out.

~ 15 ~
• Data collection tools:

1. A questionnaire: was used to collect data prior to analysis. The questionnaire

(Appendix B) was made up of 5 sections containing specific data namely:

o Sociodemographic data: This section was containing data relative to the

identification of the woman, her gravidity, her BMI, marital status and level of

education, religion and occupation.

o Preoperative assessment data: This section was made up of 2 variables, the

baseline systolic blood pressure, and ASA status.

o Anesthetic data: This section contained all the information related to the

anesthesia namely the patient position, level of puncture, fluids, and drugs used.

o Operative data: This section contained data related to the surgery weather the

surgery is elective or emergency one and its duration.

o Diagnostic data: this section was containing information related to the diagnosis

of hypotension and the eventual outcome on the baby.

~ 16 ~
 III.6- STUDY VARIABLES

III.6.1- SOCIODEMOGRAPHIC CHARACTERISTICS

1. Age: This was a quantitative discrete variable. It was recorded during analysis

into age range in years as follow: minimum <20 years and maximum 60-70 years,

with an interval of 10

2. Gravida: This was a quantitative discrete variable. It was recorded during the

analysis into consecutive numbers from 1 to >8.

3. Parity: This was a quantitative discrete variable. It was recorded during the

analysis into consecutive numbers from 1 to >9.

4. BMI (Body Mass Index): This was a quantitative continuous variable. It was

recorded during the analysis by calculating it’s value from the patient weight and

height using the following formula:

Body Mass Index = Weight (kg)/Height2 (m) ; and the answer selected from a

range of possibilities containing various Body Mass Index

5. Marital status: This was a categorical nominal variable. It was recorded during

the analysis by selecting the corresponding patient matrimonial status from a

preset list containing various marital status.

6. Occupation: this was a categorical nominal variable. It was recorded during the

analysis by selecting the corresponding occupation from a preset list containing

various occupations.

~ 17 ~
III.6.2- PREOPERATIVE ASSESSMENT.

1. Baseline systolic blood pressure: This was a quantitative continuous variable. It

was recorded during the analysis by choosing the patient corresponding blood

pressure from a list of preset blood pressure.

2. ASA score: This was a quantitative discrete variable. It was recorded during the

analysis by choosing the patient corresponding ASA score from a list of preset

ASA scores.

3. Previous spinal anesthesia: This was a categorical binary variable. It was

recorded during the analysis by choosing the patient corresponding history of

previous spinal anesthesia from a list of preset 2 values which could either be yes

or no.

III.6.3- OPERATIVE DATA

1. Type of surgery: This was a categorical binary variable. It was recorded during

the analysis by choosing the patient corresponding surgery type from a list of

preset 2 values which could either be elective or emergency.

2. Duration of surgery: This was a quantitative discrete variable. This was recorded

during the analysis by choosing the corresponding duration from a list of time of

surgery arranged in rage in minutes with the lowest value being <60 minutes and

the greatest one > 120.

~ 18 ~
III.6.4- ANESTHETIC DATA

1. Patient position: This was a categorical nominal variable. this was recorded

during the analysis by selecting the patient position from the list of positions

proposed.

2. Level of puncture: This was a categorical nominal variable. this was recorded

during the analysis by selecting the patient level of puncture from the list

proposed.

3. Preoperative fluids loading: This was a categorical binary variable. This was

recorded during the analysis by answering either yes or no if the patient has

received fluids.

4. Type of fluids: This was a categorical binary variable. This was recorded during

the analysis by answering if the patient received either crystalloids or colloids.

5. Amount of fluids: This was a quantitative discrete variable. This was recorded

during the analysis by selecting the patient amount of fluids received from a list of

values.

6. Drug used: This was a categorical nominal variable. This was recorded during

the analysis by selecting the drug used on the patient from the list of drugs

proposed.

7. Drug dosage: this was a quantitative continuous variable. This was recorded

during the analysis by selecting the drug dosage corresponding to the drug used

from the list of propositions.

8. Opioids: This was a categorical binary variable. This was recorded during the

analysis by answering either yes or no if the patient has received opiods.

~ 19 ~
 9. Practitioner: This was a categorical binary variable. This was recorded during

the analysis by answering either a nurse or medical doctor has practiced the

anesthesia on the patient.

III.6.5- DIAGNOSIS OF HYPOTENSION

1. Hypotension: This was a categorical binary variable. This was recorded during

the analysis by answering either yes or no if the patient had hypotension.

2. Level of hypotension: This was a categorical ordinal variable. This was recorded

during the analysis by choosing the level of hypotension of the patient from the

list of propositions after calculating the difference in percentage from the initial

systolic blood pressure.

3. Apgar score at birth: This was a quantitative continuous variable. This was

recorded during the analysis by selecting the baby APGAR score at birth from the

list proposed.

III.7- Q UALITY CONTROL

Quality issues were addressed through the following measures to ensure that data generated were

complete, reliable, accurate and reproducible using the same method.

• Pretesting the data collection tool: This was done using 05 files in Bamenda Regional

Hospital, which has a same technical plateau and patients representatives as Yaoundé

Central Hospital since patients all over the region are being referred there for better

management. This exercise helped to improve the data collection tools in terms of

contents and order of the questions in relation to the study objectives and necessary

adjustments were made prior to data collection.

~ 20 ~
 • Checking for completeness and accuracy of the data collection form: This was done

at the end of each data collection. Gaps were identified such as missing age or

hypotension values, and values like BMI and hypotension values recalculated prior to

entry into the data analysis software. This was possible with the use of the patient file

identification code

III.7 - D ATA ANALYSIS .

All parameters were recorded in EPI INFOTM 7.2.2.6 using a form designed for the

purpose in the software. Categorical variables were presented as frequencies and percentages.

Meanwhile, continuous variables were presented as means and standard deviations (SD). Chi-

square test was used in order to determine the association between categorical variables. Finally,

multivariate analysis was performed via multiple logistic regression and result of logistic

regression was expressed as adjusted odds ratio and 95% CI. A two-sided p value of <0.05 was

considered as statistically significant.

The software Microsoft excel 2016 was used to design the different tables and figures for

the presentation of the results.

III.8 - E THICAL C ONSIDERATIONS

• Ethical clearance: The authorization to conduct the study was obtained from: The

Faculty of Health Science ethical committee of the University of Bamenda. (see appendix

A)

• Administrative authorizations: Was obtained from the Director Yaoundé Central

Hospital. (see appendix B)

~ 21 ~
• Patients confidentiality was respected as participants identity wasn’t revealed and the

information collected kept secret.

~ 22 ~
 CHAPTER IV- RESULTS AND DISCUSSIONS

IV.1- S OCIO DEMOGRAPHIC CHARACTERISTICS OF THE

STUDY PARTICIPANTS

The age of participants varied from 16 years to 45 years. Most participants age range

was 20-30 years, with the mean age being 25 years. Participants BMI was calculated

from their weight and height using the formula: Body Mass Index = Weight (kg)/Height 2

(m). Most of the participants had a BMI ranging between 25 to 29.9 kg/m2. The majority

of women who files were recruited were married women (58%), followed by single

women.

Table01 summarize the data mentioned above.

~ 23 ~
Table1: Sociodemographic characteristics of participants.

Frequency (n=519) Percentages (%)

Age

<20 48 9

20-30 288 55

30-40 170 33

40-50 13 3

BMI

<18.5 0 0

18.5-24.9 81 16

25-29.9 236 46

≥30 196 38

Marital status

Married 300 58

Single 159 31

divorced 50 10

widow 9 2

• Baseline Systolic BP: In our study, the majority of participants had a baseline systolic

blood pressure of less than 120 mmHg. The data are presented in the figure 1 below.

~ 24 ~
 119 (23%)

201 (39%)
<120
90 (17%)
120 - 129
130-139
>139
107 (21%)

Fig1: Distribution of Baseline Systolic Blood Pressure among participants.

• American Society of Anesthesiologists score (ASA): The ASA score of participants was

extracted from their files and revealed that the majority (81 %) of participants had an

ASA score of II. Data are showed in figure 2 below.

~ 25 ~
 500 417 (81%)
400

300

200
71 (14%)
100 29 (6%)
0
0
ASA I ASA II ASA III ASA IV

Fig2: Distribution of ASA score among participants.

• Surgery type: During the study, we evaluated whether the surgery was an emergency of

elective one. Emergency surgery were more common (81%) than elective surgery (19%).

• Duration of surgery: The duration of surgery was reported from the patient file. It was equal

to the time from the injection of the drug into the subarachnoid space until the time of

closure. Table 2 below summarizes the abovementioned findings.

~ 26 ~
Table 2: Distribution of operative data among participants.

Frequencies (n=519) Percentages (%)

Type of surgery

Emergency 419 81

Elective 100 19

Duration of surgery

(in minutes)

<60 158 30

60-89 250 48

90-119 90 17

≥120 21 4

• Patient position: The patient position during the administration of the anesthesia was

recorded. All patients were sited during the administration of the anesthesia.

• Level of puncture: Level of puncture for the spinal anesthesia where recorded as the

spine level where the needle was inserted. The majority of participants (77%) were

puncture at L4-L5 level.

• Preoperative fluids loading: All participants (100%) in the study received fluids prior to

the surgery.

• Type of fluids: All fluids used for preoperative loading were crystalloids (100%).

~ 27 ~
• Amount of fluids: This correspond to the amount of fluid the participant has received

prior to the injection of the spinal anesthesia. The majority of participants prior to the

induction of anesthesia were loaded with 1000-2000 ml of fluids.

• Opioids usage: All participants to our study received opioids (100%) with the local

anesthesia.

• Drugs used: All participants to the study received BUPIVACAINE as local anesthetic

during the spinal anesthesia.

• Bupivacaine dosage: The amount of bupivacaine given to the patient was recorded.

Most patients (91%) received 5-7.5mg of the drug.

• Practitioner: The grade of the medical personnel who performed the spinal anesthesia

was recorded, whether a nurse or a medical doctor. Findings revealed that 83 % of spinal

anesthesia were done by nurses. Table 03 summarizes the findings above.

~ 28 ~
Table03: Distribution of Anesthetic data among participants.

Frequencies (n=519) Percentages (%)

Level of puncture

Below L4-L5 10 2

L4-L5 399 77

Above L4-L5 109 21

Amount of preoperative

fluids

500-1000 29 6

1000-2000 380 73

>2000 109 21

Bupivacaine dosage

<5 0 0

5-7.5 474 91

7.6-10 39 8

>10 6 1

Practitioner

Nurse 430 83

Medical doctor 89 17

~ 29 ~
 • APGAR score: The APGAR score at birth only (since only the APGAR at birth was

present in the files) was recorded. Most of the babies had a score more than 7 (87%).

Figure 3 summarize the above-mentioned data.

APGAR Score at birth

453 (87%)
500
450
400
350
300
250
200
150
100
49 (9%)
16 (3%)
50 Score
0
<3 04 to 06 ≥7

Fig3: Distribution of APGAR score at birth of baby born from study participants.

~ 30 ~
 IV.1- I NCIDENCE AND LEVEL OF H YPOTENSION

• Incidence of hypotension: The patient Blood Pressure all along the surgery was checked

and a fall in the BP from at least 10% of the initial value was recorded as a hypotension,

thus giving us an incidence of 70%. Highest level of hypotension was observed among

participants aged within 20-30 years old, with a BMI > 30, and among married woman.

Figure 04 represent the above-mentioned data.

Incidence of hypotension

361 (70%)

400

300
157(30%)

200

100

0
No hypotension Hypotension

Fig4: Incidence of hypotension among study participants.

• Level of hypotension: Files of participants with hypotension were further classified as

either mild, moderate or severe hypotension based on the drop in the BP during the

surgery respectively by 10 to 20%, from 21% to 30% and > 30%. According to our study,

the majority of hypotension case were severe hypotension (51%). See table4 below

~ 31 ~
 Table4: Distribution of level of hypotension among study participants

Level of Hypotension
Mild Moderate Severe No Hypotension
Age
<20 7(15%) 12(26%) 16(34%) 12(26%)
20-30 38(13%) 65(23%) 86(30%) 99(34%)
30-40 24(14%) 29(17%) 77(46%) 39(23%)
40-50 1(8%) 1(8%) 6(46%) 5(3%)
ASA score
ASAI 7(10%) 11(15%) 20(28%) 33(46%)
ASA II 60(14%) 88(21%) 155(37%) 113(27%)
ASA III 3(10%) 8(28%) 9(31%) 9(31%)
Baseline Systolic Blood Pressure
<120 33(17%) 38(19%) 52(26% 77(39%
≥139 9(8%) 27(23%) 65(55%) 18(15%)
120-129 16(15%) 20(19%) 35(33%) 36(34%)
130-139 12(13%) 22(24%) 32(36%) 24(27%)
Duration of Surgery
<60 20(13%) 24(15%) 54(34%) 59(38%)
>120 6(29%) 3(14%) 7(33%) 5(24%)
60-90 33(13%) 56(22%) 88(35%) 72(29%)
90-120 11(12%) 24(27%) 36(40%) 19(21%)
Preoperative fluid load
>2000 18(17%) 21(19%) 47(43%) 23(21%)
1000-2000 49(13%) 83(22%) 125(33%) 122(32%)
250-500 3(10%) 3(10%) 13(45%) 10(34%)
Practitioner
Medical Doctor 13(15%) 11(13%) 27(32%) 34(40%)
Nurse 56(13%) 96(22%) 157(37%) 121(28%)
Total 184(35.4%) 107(20.6%) 70(13.5%) 158 (30.4%)

~ 32 ~
 IV.3- RISK FACTORS FOR SPINAL ANESTHESIA INDUCED
HYPOTENSION IN CESAREAN SECTION .

Following analysis, risk factors were identified following univariate analysis, namely BMI>30,

ASA Status II, Baseline Systolic Blood Pressure of > 139, surgery duration of <60%,

preoperative fluid load ranging between 1000-2000, practitioner being a nurse. Among these, a

SBP>139 was associated with severe hypotension. Table 05 illustrate the findings above.

Table05: Univariate analysis of risk factors for hypotension.

Hypotension Crude OR (95% CI) p-value

Yes No

BMI
>30 142 84 1.9898 (1.29-3.06) 0.002
ASA status
ASA II 285 115 2.15 (1.28-3.59) 0.004
Baseline systolic BP
SBP >139 99 18 2.09 (1.05-4.16) 0.01
Duration of surgery
<60 min 66 19 2.11 (1.15-3.86) 0.01
Preoperative fluid load
1000-2000 248 124 1.71 (1.02-2.86) 0.04
Practitioner
Nurse 301 122 2.16 (1.30-3.56) 0.002

• BMI: In our study, 196 (38%) of our participants had a BMI> 30 and 142 of them had a

hypotension. There was a statistically significant association between a BMI of >30 and

~ 33 ~
 hypotension with a p value of 0.00081, an OR of 1.98 and a 95%confidence interval of

1.29-3.07. see table 07.

• ASA score: Following our analysis, 417(81%) of students had an ASA score of II, and

285 of them had hypotension. There was a statistically significant association between an

ASA score of II and hypotension, with a p value of 0.002, an OR of 2.14 and a 95%

Confidence Interval of 1.28-3.59. see table 07.

• Baseline systolic BP: During the course of our study, 119 (23%) of participants had a

baseline systolic blood pressure of >139, out of them 99 had hypotension. There was

statistically significant association between a baseline SBP>139 and hypotension with a p

value of 0.018, an OR of 2.08 and a 95% confidence interval of 1.04-4.21. see table 7

During the study, it was also noticed that a baseline SBP was associated with severe

hypotension, p value 0.008. see table 06.

Table 06: Association between severe hypotension and Baseline SBP.

Severe hypotension OR (95%CI) P value

Values Percentages

SBP<120 52 28.26 - -

SBP120-129 35 19 - -

130-139 32 17.4 - -

>139 65 35.3 1.75(0.95-3.24) 0.008*

• Duration of surgery: Following our analysis, 157 (30%) of participants surgery lasted

for <60 minutes and 66 of them had hypotension. There was a statically significant

~ 34 ~
 association between a surgery lasting less than 60 minutes and hypotension; with a p

value of 0.006, an OR of 2.1 and 95% confidence interval of 1.15-3.92. see table 07

• Practitioner: During the course of our analysis, 430 (83%) of spinal anesthesia have

been administered by nurses and 301 of them had hypotension. There was a statistically

significant association between a nurse administering the anesthesia and hypotension

with a p value of 0.0015, an OR of 2.15 and a 95% confidence interval of 1.30-3.56. see

table 07.

• Table 07: Multiple logistic regression analysis for risk factors

P value Adjusted OR Adjusted 95% CI

BMI
≥30 0.000809 1.9865 1.29-3.07
ASA status
ASA II 0.002 2.14 1.27-3.60
Baseline systolic BP
SBP >139 0.018 2.08 1.04-4.21
duration of surgery
<60 min 0.006 2.1 1.15-3.92
Preoperative fluid load
1000-2000 0.017 1.71 1.03-2.91
practitioner
Nurse 0.0015 2.15 1.30-3.56

IV.4- C ONSEQUENCES OF HYPOTENSION

During the course of our study, 453 (87%) of participants had their baby with APGAR score

more or equal to 7 and 49 (9%) had an APGAR score in between 4 and 6 with 40 of them

presenting hypotension and 9 presenting no hypotension. There was a statistically significant

association between hypotension and poor APGAR score (4-6), p value of 0.04. data presented in

table8.

~ 35 ~
Table 08: Association between hypotension and APGAR score 4-6.

No hypotension (%) Hypotension (%) OR 95% CI P value

<3 6(3.77%) 12(3.33%) - - -

4-6 6(3.77%) 40(11.11%) 4.02 1.55-10.42 0.04*

≥7 147(92.45%) 308(85.55%) - - -

V- D ISCUSSION

V.1- SOCIODEMOGRAPHIC FACTORS.

We studied 519 anesthetic files during the study period. Among these participants files,

288 (55%) of them were aged between 20-30 years. It’s similar to the results obtained by

Saowapark C et Al in which the mean age of his participants was 29 years old. [14] It’s

also similar to the results obtained by Tanyi T et Al, where most participant age was

between 25-34 years. [28] this can be explained by the fact that 20-30 years is the range

in which fall the most common reproductive age in Cameroon. [61]

Out of the 519 participants anesthetic files studied, the majority of them 236 (46%) of

them had a BMI value between 25-30. This result is similar to the one obtained by Bernd

H et Al who had a mean BMI value of 26.2, [65] and to the study of saowapark C et Al

who had a mean BMI of 27.6. [14] This can be explain by the fact that most women who

deliver have a BMI ranging between 25-29.9. [68]

~ 36 ~
Out of participants files studied, most of them had an ASA score of I (14%) and II (81%)

which is the same with the study of Bernd H et Al where the dominant score was ASA II

[62] and similar to the findings of the study of Saowapark C et Al.[14] This can be

explain by the fact that the majority of participants were relatively young during the study

period and relatively had less co morbidity which could affect their ASA classification.

During the course of our study, the majority of our participants 201(39%) had a baseline

SBP of < 120. It’s similar to the findings of saowpark C et Al, who had a mean baseline

systolic blood pressure of 120± 15. This can be explained by the fact that most women

aged 25-34 years have a baseline SBP of 114. [63]

Following the results of our study, most surgeries 250 (58%) lasted between 60-89

minutes and 157 (30 %) less than 60 min. this is the same with the study of saowapark C

et Al who find it to be 60 min ± 20.47 min, [14] and similar to the findings in the research

of Bernd H et Al who find it to be 51.8 min.[62]

In the course of our analysis, 380 (73%) of participants have been loaded with 1000-2000

ml of crystalloids prior to the surgery. This can be explained by the fact that 1000-2000

cc of fluids is believed to be the most cost-effective prevention of spinal anesthesia

induced hypotension.

In the course of our study, the majority of spinal anesthesia 430 (83%) were done by

nurses. This can be explained by the fact that they’re few medical doctors as compare to

the number of surgeries thus the nurses are assisting in performing some other

surgeries.[67]

~ 37 ~
 V.2- INCIDENCE OF HYPOTENSION .

Following our analysis, the incidence of hypotension was found to be 70 % (see table 05). This is

close to the results of Saowapark C et Al. [14] which is a little higher than ours which can be

explained by the fact that they used two definitions of hypotension that is a fall in SBP in of at

least 10% and a BP reading of <100mmhg during the surgery. This later value will pick more

cases than our study since we circumscribed our definition to a fall in at least 10%. Our results

are a little higher than the one of kuwata S which was 64%.[64] This can be explained by the fact

that in the aforementioned study, the sample size was low [50] and more importantly, their

criteria for diagnosis of hypotension was more restrictive than ours that is a fall in SBP of >20%

from the baseline value unlike ours that was a fall in at least 10%.

V.3- RISKS FACTORS OF HYPOTENSION.

During the course of our study we found a statistically significant association between a

BMI > 30 and hypotension, p value 0.00081 and adjusted OR 1.98. Which is close to the

result obtained by Bernd H et Al which was 28.2.[62] This can be explained by the fact

that obese individuals have substantially less CSF, which is partly caused by compression

of the neural foramina. [20]

A statistically significant association was found between ASA score of II and

hypotension p value of 0.002 and adjusted OR of 2.14. This can be explained by the fact

that patients with ASA score of II is associated with anxiety which predispose to

hypotension. [65]

We found a statistically significant association between a baseline SBP of >139 and

hypotension p value 0.018 adjusted OR 2.14. This is different from the result obtained by

~ 38 ~
 saowpark C et Al who had an association between a baseline SBP 120-130 and

hypotension. [14] This can be explained by the fact that one of the exclusion criteria was

files of patients with pregnancy induced hypertension, and preeclampsia. Added to this,

there was a statistically significant association between baseline SBP of more than 139

and severe hypotension p value of 0.023.

There was a statistically significant association between surgery lasting less than 60

minutes and hypotension. P value 0.006, adjusted OR 2.1. This can be explained by the

fact that most hypotension occurs during the first 15 min following the induction of the

spinal anesthesia which correspond to the peak effect of the local anesthetic. [14]

There was a statistically significant association between preoperative fluid load of 1000-

5000 ml of crystalloids and hypotension. This can be explained by the fact that the type

of fluid used here was crystalloids, has a shorter half-life in the intravascular

compartment and thus less effective as opposed to colloids which are more effective. [66]

A statistically significant association was found between a nurse administering the spinal

anesthesia and hypotension. This can be explained by the fact that only 40% of nurses

performing the act have not been trained on it. [67]

V.3- APGAR SCORE AND HYPOTENSION

During our analysis, a statistically significant association was found between hypotension and

low APGAR score p value of 0.04. this is similar to the study of OLANG P et Al who find an

association between maternal hypotension and low APGAR score only when the hypotension

lasted for more than 2 minutes. [68]

~ 39 ~
 LIMITATIONS

Many participants files couldn’t be assessed because of lack of some information.

Some parameters couldn’t be assessed like their behavior before and during the surgery, the

speed at which the anesthetic was administered, … Due to their absence from the files.

CONCLUSIONS

• The incidence of hypotension in patients undergoing spinal anesthesia for cesarean

section in Yaoundé Central Hospital was found to be 70%.

• Risks factors for spinal anesthesia induced hypotension in patient undergoing spinal

anesthesia could be separated in 2 groups mainly:

• Modifiable one namely:

o BMI >30

o Amount of fluid loaded prior to the procedure of 1000-2000 ml

o Practitioner administering the anesthesia being a nurse

• Non-modifiable one namely:

o ASA score II

o Surgery duration <60 min

o Baseline systolic blood pressure which was associated with severe hypotension.

>139 mmHg

• It was also found that women developing hypotension were at risk of delivering a baby

with a poor APGAR score at birth.

~ 40 ~
 RECOMMENDATIONS.

To health care workers practicing spinal anesthesia.

1. Women undergoing spinal anesthesia should be carefully assessed for the risk factors

before the choice of spinal anesthesia is being made.

2. Women with baseline systolic blood pressure of more than 139 (as in pregnancy induced

hypertension and preeclampsia) shouldn’t receive spinal anesthesia as it’s a risk factor for

severe hypotension.

3. Preloading with colloids too have to be envisage as it might be better in preventing

hypotension.

4. Hypotension during spinal anesthesia should be prevented as much as possible and

treated as soon as possible to reduce its effect on the baby.

To the responsible of anesthesia and reanimation units.

1. All personnel administering spinal anesthesia should be well trained and updated as often

as possible to increase their skills on performing spinal anesthesia and caution should be

place in respecting the procedure.

~ 41 ~
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2013;20(3):209–214

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mineralocorticoids and glucocorticoids throughout human pregnancy. J Clin Endocrinol

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1885;42:483–485.

~ 42 ~
11. N. J. McDonnell, M. J. Paech, N. A. Muchatuta, S. Hillyard, and E. A. Nathan, “A

randomised double-blind trial of phenylephrine and metaraminol infusions for prevention

of hypotension during spinal and combined spinal-epidural anaesthesia for elective

caesarean section,” Anaesthesia, vol. 72,no. 5, pp. 609–617, 2017..

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vein thrombosis. A comparison of subarachnoid and general anaesthesia. Br J Anaesth

1985; 57:853.

14. Saowapark Chumpathong , Thitima Chinachoti ,Shusee Visalyaputra , Thongporn

Himmunngan, Incidence and risk Factors of Hypotension During Spinal Anesthesia for

Cesarean Section at Siriraj Hospital, J Med Assoc Thai 2006; 89 (8): 1127-32.

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~ 43 ~
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Analgesia 2016; 122: 1120–9

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~ 46 ~
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~ 49 ~
 APPENDIXES

Appendix A: Ethical clearance form

Appendix B: Authorization from the Yaoundé Central Hospital

Appendix C: Questionnaire

~ 50 ~
Appendix A: Ethical Clearance Form

~ 51 ~
Appendix B: Authorization letter from the Director of
Yaoundé Central Hospital.

~ 52 ~
A PPENDIX C - Q UESTIONNAIRE

~ 53 ~
~ 54 ~
~ 55 ~
69

1 - Chamberlain G. Obstetrics by ten teachers: Normal pregnancy. 16ed. London: Edward Arnold; 1995
2- Priya SP, Piercy CN, Heli T, Mebazaa A. physiological changes in pregnancy.CVJAFRICA.2016:27(2):89-93
3- Conrad KP. Emerging role of relaxin in the maternal adaptations to normal pregnancy: implications for
preeclampsia. Semin Nephrol. 2011;31(1):15–32.
4 - Cheung KL, Lafayette RA. Renal physiology of pregnancy. Adv Chronic Kidney Dis. 2013;20(3):209–214
5 - Glinoer D. The regulation of thyroid function in pregnancy: pathways of endocrine adaptation from physiology
to pathology. Endocr Rev. 1997;18:404.
6- Dorr HG, Heller A, Versmold HT. et al. Longitudinal study of progestins, mineralocorticoids and glucocorticoids
throughout human pregnancy. J Clin Endocrinol Metabol. 1989;68:863.
7- Elsheikh A, Creatsas G, Mastorakos G. et al. The renin-aldosterone system during normal and hypertensive
pregnancy. Arch Gynecol Obstet. 2001;264:182.
8- Gordon MC. 6th edn. Philadelphia: Saunders, Elsevier; 2012. Maternal Physiology in Obstetrics: Normal and
Problem pregnancies.
9- Linheimer MD, Barron WM, Davison JM. Osmotic and volume control of vasopressin release in pregnancy. Am J
Kidney Dis. 1991;17:105.
10- Corning JL: Spinal anaesthesia and local medication of the cord. NY Med J 1885;42:483–485.
11- N. J. McDonnell, M. J. Paech, N. A. Muchatuta, S. Hillyard, and E. A. Nathan, “A randomised
double-blind trial of phenylephrine and metaraminol infusions for prevention of hypotension
during spinal and combined spinal-epidural anaesthesia for elective caesarean section,”
Anaesthesia, vol. 72,no. 5, pp. 609–617, 2017..
12- Maurer SG, Chen AL, Hiebert R, et al. Comparison of outcomes of using spinal versus general
anesthesia in total hip arthroplasty. Am J Orthop (Belle Mead NJ) 2007; 36:E101.
13- McKenzie PJ, Wishart HY, Gray I, Smith G. Effects of anaesthetic technique on deep vein
thrombosis. A comparison of subarachnoid and general anaesthesia. Br J Anaesth 1985; 57:853.
14- Saowapark Chumpathong , Thitima Chinachoti ,Shusee Visalyaputra , Thongporn Himmunngan,
Incidence and risk Factors of Hypotension During Spinal Anesthesia for Cesarean Section at Siriraj
Hospital, J Med Assoc Thai 2006; 89 (8): 1127-32.
15- Marx GF, Rabin JM. Anesthesia for cesarean section and neonatal welfare. In: Raynols F, ed. The
effects on the baby of maternal analgesia and anesthesia. London: WB Saunders, 1993: 237-51
16- Abboud TK, Nagappala S, Murakawa K, David S,Haroutunian S, Zakarian M, et al. Comparison of the
effects of general and regional anesthesia for cesarean section on neonatal neurologic and adaptive
capacity scores. Anesth Analg 1985; 64:996-1000
17- Carpenter RL, Caplan RA, Brown DL, Stephenson C, Wu R: Incidence and risk factors for side effects
of spinal anesthesia. ANESTHESIOLOGY 1992; 76:906–16
18- F. J. Mercier, M. Auge, C. Hoffmann, C. Fischer, and A. Le `Gouez, “Maternal hypotension during
spinal anesthesia for caesarean delivery,” Minerva Anestesiologica, vol. 79, no. 1, pp.62–73, 2013.
19- Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K: Serious complications related to regional
anesthesia: Results of a prospective survey in France.ANESTHESIOLOGY 1997; 87:479–86
20- Aromaa U, Lahdensuu M, Cozanitis DA: Severe complications associated with epidural and spinal
anaesthesias in Finland 1987-1993: A study based on patient insurance claims. Acta Anaesthesiol Scand
1997; 41:445–52
21- Spencer S. Liu. ,Susan B. McDonald, Current Issues in Spinal Anesthesia, Anesthesiology 2001;
94:888–906.
22- Klohr S, Roth R, Hofmann T, Rossaint R, Heesen M. Definitions of hypotension after spinal
anaesthesia for caesarean section: literature search and application to parturients. Acta
Anaesthesiologica Scandinavica 2010; 54: 909–21.

~ 56 ~
23- S. M. Kinsella, B. Carvalho,R. A. Dyer,R. Fernando,N. McDonnell,F. J. Mercier, A. Palanisamy,A. T. H.
Sia,M. Van de Velde, A. Vercueil and the Consensus Statement Collaborators International consensus
statement on the management of hypotension with vasopressors during caesarean section under spinal
anaesthesia, Anaesthesia 2018, 73, 71–92
24- Martonffy A, Rindfleisch K, Lozeau AM, Potter B. first trimester complications. jpop. 2012:39(1);95-113.
25- Newfield E. third-pregnancy complications.jpop.2012:39(1);95-113.
26- Cunningham FG, Leveno KJ, Bloom SL, Spong SY, Dashe JS, Hoffman BL, et AL. Williams obstetrics:
delivery.24ed.USA: McGraw-Hill Education; 2014.

28- UNDP/UNFPA/WHO/World Bank Special Programme of Research (2008). Highlights of achievements, 1990-2001.Geneva, World
Health Organization, Department of Reproductive Health and Research, Family and Community Health. 2008; 14(124):470-83.
29- TanyiJT, Atashili J, Nde FP, Tchounzou R, Koki NP. Caesarean delivery in the Limbé and
the Buea regional hospitals, Cameroon:frequency, indications and outcomes. Pamj.
2016:24(227):1-8.
30- Ghaleb A, Khorasani A, Mangar D. Post-dural puncture headache. IJGM. 2012:5:45-51.
31- Hiller A, Karjalainen K, Balk M, Rosenberg PH: Transient neurological symptoms after spinal
anaesthesia with hyperbaric 5% lidocaine or general anaesthesia. Br J Anaesth 1999; 82:575–9
32- ASA W. COLLINS, INDICATIONS AND CONTRAINDICATIONS FOR THE USE OF SPINAL ANESTHESIA,
CALIFORNIA STATE JOURNAL OF MEDICINE Vol. VIII, No. 1O, 1910, 329-330
33- Afolabi BB, Lesi FE, Merah NA: Regional versus general anaesthesia for caesarean section. Cochrane
Database Syst Rev 2006(4):CD004350
34- Reynolds F, Seed PT: Anaesthesia for Caesarean section and neonatal acid-base status: A meta-
analysis. Anaesthesia 2005;60(7):636–653
35- Mitra JK, Roy J, Bhattacharyya P, Yunus M, Lyngdoh NM.Changing trends in the management of
hypotension following spinal anaesthesia in cesarean section. J Postgrad Med 2013;59:121-6.
36- Reynolds F, Seed PT. Anaesthesia for caesarean section and neonatal acid-base status: A meta-
analysis. Anaesthesia 2005;60:636-53
37- Miller RD, Eriksson LI,Fleisher LA,Wiener- KronishJp, Young WL. Miller’s Anesthesia.
7thed.philadelphia:Churchill Livingstone, 2010:2203-41.

39
- British Hypertension Society. How to measure blood pressure. 2012. http://bhsoc.org/resources/how-to-measureblood-pressure/
(accessed 01/08/2017).
40
- Ngan Kee WD, Lee SWY, Ng FF, Tan PE, Khaw KS. Randomized double-blinded comparison of norepinephrine and phenylephrine for
maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesthesiology 2015; 122:736–45.
41- Kuhn JC, Hauge TH, Rosseland LA, Dahl V, Langesaeter E.Hemodynamics of phenylephrine infusion
versus lower extremity compression during spinal anesthesia for cesarean delivery: a randomized,
double-blind, placebo-controlled study. Anesthesia and Analgesia 2016; 122: 1120–9
42- Khaw KS, Ngan Kee WD, Lee SW: Hypotension during spinal anaesthesia for Caesarean section:
Implications, detection, prevention and treatment. Fetal Matern Med Rev 2006;17(2):157–183.
43- Langesaeter E, Dyer RA. Maternal haemodynamic changes during spinal anaesthesia for caesarean
section. Current Opinion in Anesthesiology 2011; 24: 242–8
44- Rabow S, Olofsson P. Pulse wave analysis by digital photoplethysmography to record maternal
hemodynamic effects of spinal anesthesia, delivery of the baby, and intravenous oxytocin during
cesarean section. Journal of Maternal-Fetal and Neonatal Medicine 2017; 30: 759–66
45- Mark JB, Steele SM: Cardiovascular effects of spinal anesthesia. Int Anesthesiol Clin 1989;27(1):31–
39
46
- Kinsella SM, Tuckey JP. Peri-operative bradycardia and asystole: relationship to vasovagal syncope and the Bezold-Jarisch reflex.
British Journal of Anaesthesia 2001; 86: 859–68.

~ 57 ~
47- Fakherpour A, Ghaem H, Fattahi Z, Zaree S.Maternal and anaesthesia-related risk factors and
incidence of spinal anaesthesia-induced hypotension in elective caesarean section: A multinomial
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