The inferior vena caval compression theory of hypotension in obstetric spinal anaesthesia: studies in normal and preeclamptic pregnancy, a literature review and revision of fundamental concepts
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Three clinical investigations together with a combined editorial and review of the cardiovascular physiology of spinal anaesthesia in normal and preeclamptic pregnancy form the basis of a thesis to be submitted for the degree of Doctor of Medicine at the University of St Andrews. First, the longstanding consensus that spinal anaesthesia could cause severe hypotension in severe preeclampsia was examined using three approaches. The doses of ephedrine required to maintain systolic blood pressure above predetermined limits were first compared in spinal versus epidural anaesthesia. The doses of ephedrine required were then similarly studied during spinal anaesthesia in preeclamptic versus normal control subjects. The principal outcome of these studies, that preeclamptic patients were resistant to hypotension after a spinal anaesthetic, was then further investigated by studying pulse transit time (PTT) changes in normal versus preeclamptic pregnancy. PTT was explored both as beat-to-beat monitor of cardiovascular function and also as an indicator of changes in arterial stiffness. The cardiovascular physiology of obstetric spinal anaesthesia was then reviewed in the light of the three clinical investigations, developments in reproductive vascular biology and the regulation of venous capacitance. It is argued that the theory of a role for vena caval compression as the single cause of spinal anaesthetic induced hypotension in obstetrics should be revised.
Thesis, MD Doctor of Medicine
DescriptionFull metadata records and copyright statements for publications contained in this portfolio thesis are available at the identifiers listed
Description of related resources*Sharwood-Smith G, Clark V Watson E. Regional anaesthesia for caesarean section in severe preeclampsia: spinal anaesthesia is the preferred choice. Int J Obstet Anaesth 1999; 8: 85-9 (http://hdl.handle.net/10023/1817)
*Clark V A, Sharwood-Smith GH , Stewart AVG. Ephedrine requirements are reduced during spinal anaesthesia for caesarean section in preeclampsia. Int J Obstet Anesth 2005; 14: 9-13 (http://hdl.handle.net/10023/1818)
*Bruce J, Sharwood-Smith G, Drummond G. Pulse transit time: a new approach to haemodynamic monitoring in obstetric spinal anaesthesia. Int J Obstet Anaesth 2002; 11, Supplement 1, 1- 38 (http://hdl.handle.net/10023/1819)
*Sharwood-Smith G, Drummond G, Bruce J. Pulse transit time confirms altered haemodynamic response to spinal anaesthesia in pregnancy induced hypertension. Hypertension in Pregnancy 2002; 21 suppl 1: 31 (http://hdl.handle.net/10023/1820)
*Sharwood-Smith G, Drummond G, Bruce J. Pulse transit time confirms altered response to spinal anaesthesia in pregnancy induced hypertension. (poster annex to the above abstract) (http://hdl.handle.net/10023/1821)
*Sharwood-Smith G, Bruce J and Drummond G. Assessment of pulse transit time to indicate cardiovascular changes during obstetric spinal anaesthesia. Br J Anaesth 2006; 96: 100-5 (http://hdl.handle.net/10023/1822)
*Sharwood-Smith G, Drummond G B. Hypotension in obstetric spinal anaesthesia: a lesson from preeclampsia. Br J Anaesth 2009; 102: 291-4 (http://hdl.handle.net/10023/1823)
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Regional anaesthesia for caesarean section in severe preeclampsia: spinal anaesthesia is the preferred choice Sharwood-Smith, Geoffrey H.; Clark, V.; Watson, E. (Elsevier Ltd, 1999-04) - Journal articleStandard textbooks advocate epidural rather than spinal anaesthesia for caesarean section in severe preeclampsia. The basis for this recommendation is the theoretical risk of severe hypotension but no published scientific ...
Sharwood-Smith, Geoffrey H.; Drummond, G. B. (Oxford University Press, 2009-03) - Journal item
Pulse transit time confirms altered haemodynamic response to spinal anaesthesia in pregnancy induced hypertension Sharwood-Smith, Geoffrey H.; Drummond, G.; Bruce, J. (Informa Healthcare, 2002) - Conference item