Prevention of hypotension during spinal anesthesia for cesarean section avoids maternal and fetal side effects. The aim of this study is to compare the effects of prehydration with crystalloid and prehydration with Hydroxyethyl starch on maternal blood pressure and neonatal outcome during cesarean section under spinal anesthesia. We enrolled 72 full term women weighting between 50 and 85 Kg, classified as ASA I, scheduled for elective caesarean section under spinal anesthesia. Participants were randomly allocated equally to one of crystalloid or Hydroxyethyl starch (Voluven) groups. After arrival in the operating room and intravenous (IV) access, 500 ml of ringer solution was infused within 10-15 min before the initiation of the spinal block in the crystalloid group, but in the Voluven group, 500 ml of 6% Hydroxyethyl starch solution was infused to the patients. Hypotension occurred in 47.2% of patients in crystalloid group and 25% of patients in Voluven  group and the statistical difference between two groups was meaningful.(P = 0.008). The incidence of nausea was %41.6 (15 patients) in crystalloid group vs %22.2 (8 patients) in Voluven group. Apgar scores in newborns in both groups were above 8. As conclusion, prophylactic prehydration with Hydroxyethyl starch was more effective than prehydration with crystalloid in the prevention of hypotension during spinal anesthesia for elective caesarean section

Heidary, Matineh

Khooshideh, Maryam

Shahriari, Ali

English

Medical Hypothesis, Discovery & Innovation (MEHDI) Journals

 
 
Med Hypothesis Discov Innov Interdisciplinary 2014 Spring;1(2)  
 
 
 
Original Article 
Medical Hypothesis, Discovery &Innovation  
Interdisciplinary Journal 
   
 
 
Prevention of Hypotension During Spinal Anesthesia for 
Caesarean Section:  Preload with Crystalloids or Hydroxyethyl 
Starch 
 
Ali Shahriari ¹; Maryam Khooshideh ², Matineh Heidari³ 
¹ Department of Anesthesiology, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.  ² Department of Obstetrics and 
Gynecology,  Arash Hospital, Tehran University of Medical Sciences, Tehran, Iran. ³ Tehran University of Medical Sciences, Tehran, Iran 
 
 
ABSTRACT 
Prevention of hypotension during spinal anesthesia for cesarean section avoids maternal and fetal side 
effects. The aim of this study is to compare the effects of prehydration with crystalloid and prehydration 
with Hydroxyethyl starch on maternal blood pressure and neonatal outcome during cesarean section under 
spinal anesthesia. We enrolled 72 full term women weighting between 50 and 85 Kg, classified as ASA I, 
scheduled for elective caesarean section under spinal anesthesia. Participants were randomly allocated 
equally to one of crystalloid or Hydroxyethyl starch (Voluven) groups. After arrival in the operating room 
and intravenous (IV) access, 500 ml of ringer solution was infused within 10-15 min before the initiation of 
the spinal block in the crystalloid group, but in the Voluven group, 500 ml of 6% Hydroxyethyl starch 
solution was infused to the patients. Hypotension occurred in 47.2% of patients in crystalloid group and 
25% of patients in Voluven  group and the statistical difference between two groups was meaningful.(P = 
0.008). The incidence of nausea was %41.6 (15 patients) in crystalloid group vs %22.2 (8 patients) in 
Voluven group. Apgar scores in newborns in both groups were above 8. As conclusion, prophylactic 
prehydration with Hydroxyethyl starch was more effective than prehydration with crystalloid in the 
prevention of hypotension during spinal anesthesia for elective caesarean section. 
KEY WORDS 
Spinal anesthesia; Hydroxyethyl starch; Crystalloid; Hypotension. 
©2013, Med Hypothesis Discov Innov Interdisciplinary 
This is an open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 
License (CC BY-NC 3.0), which allows users to read, copy, distribute and make derivative works for non-commercial 
purposes from the material, as long as the author of the original work is cited properly. 
 
Correspondence to: Maryam Khooshideh, Email:Khooshide@yahoo.com 
 
 
INTRODUCTION 
Spinal anesthesia is often selected for cesarean delivery 
due to its rapid, reliable, and profound sensory and 
motor blockade. Spinal block causes peripheral 
vasodilation and venous pooling, which may result in 
maternal hypotension. Hypotension and bradycardia are 
common side effects of spinal anesthesia. The incidence 
of hypotension in the supine pregnant patient after 
spinal anesthesia may be as high as 90% (1).  
 
 
Med Hypothesis Discov Innov Interdisciplinary 2014 Spring;1(2)  
 
 
Prevention of  hypotension with crystalloids or Hydroxyethyl starch  
 The aim of fluid infusion is to neutralize the hypovolemia 
induced by spinal anesthesia, and for this purpose, 
various fluids infusion protocols, including crystalloids 
and colloids, have been used for preloading before spinal 
anesthesia for cesarean section. Many studies have been 
reported the effects of volume preload, using various 
fluids, with different volumes and speeds for treatment 
or prevention of hypotension induced by spinal 
anesthesia (2-4). 
The aim of this study is to compare the effects of 
prehydration with crystalloid with prehydration with 
Hydroxyethyl starch on maternal blood pressure and 
neonatal outcome during cesarean section under spinal 
anesthesia. 
 
METHODS 
The present prospectively designed study was approved 
by the ethics and clinical studies committee of Tehran 
University of Medical Sciences and informed and signed 
consent was obtained from all the patients who were 
enrolled in the study.  
We enrolled 72 full term women in Arash Hospital, 
weighting between 50 and 85 Kg, classified as ASA I, 
scheduled for elective caesarean section under spinal 
anesthesia. Parturient who had obstetric complications 
or evidence of fetal compromise were excluded. All 
patients were fasted overnight and received 
premedication with ranitidine 150 mg orally the night 
before and 2 h prior to surgery. 
Participants were randomly allocated equally to one of 
crystalloid or Voluven groups. After arrival in the 
operating room and intravenous (IV) access, 500 ml of 
ringer solution was infused within 10-15 min before the 
initiation of the spinal block, but in the Voluven group 
500 ml of 6% Hydroxyethyl starch solution was infused to 
the patients. Spinal anesthesia was performed in the 
sitting position with a 25 gauge whitacre needle, using a 
midline approach at L4-5 interspace. Once free flow of 
CSF had been recognized the intrathecal anesthetic 
solution (12 mg of 0.5% bupivacaine) was injected over 
15 s, aspirating CSF at the end of injection to confirm 
needle position. After intrathecal injection, the patients 
were turned in supine position with left uterine 
displacement. Surgery was started when a sensory block 
up to T5 dermatome was obtained. 
Baseline maternal heart rate and arterial blood pressure 
were measured by an automatic non-invasive monitor 
and recorded before the induction, every 2 minutes 
before delivery, and every 5 minutes until discharge from 
recovery room.  Hypotention  (defined by a decrease in 
systolic blood pressure to less than 90 mm Hg  or less 
than 20 mm Hg from baseline value was treated IV 
ephedrine 5 mg and incremented doses as required and 
additional ringer solution.  Maternal bradycardia (defined 
as heart rate less than 60 beats/min) was treated with IV 
atropine 0.5 mg. Nausea was defined as thesubjectively 
unpleasant sensation associated with awareness of the 
urge to vomit. Vomiting was defined as the forceful 
expulsion of gastric contents from the mouth. 
If a nausea who was not related to hypotention occured, 
or after intervention for hemodynamics parameters 
correction, midazolam 2 mg IV was administered for 
patient satisfaction. The height of block was recorded as 
the highest dermatome with loss of pinprick sensation at 
20 min post spinal. 
Times of skin incision, delivery of baby and completion of 
surgery were recorded. The surgical technique was 
uniform for all patients. Apgar scores were obtained at 1 
and 5 min. 
Statistical test were performed using SPSS 11 for 
Windows. Results are reported as absolute value, mean ± 
SD. Continuous variables were analyzed using Student's T 
test. Nominal or ordinal variables were analyzed by Chi 
square test and Fisher exact test or Mann-Whitney U 
test. P< 0.05 was considered statistically significant.  
 
RESULTS 
No significant differences were detected in maternal 
demographic data between the groups (Table 1). 
Intraoperative data are shown in Table 2 and 3. 
Anesthesia levels were similar in the two groups. 
Hypotension occurred in 47.2% of patients in crystalloid 
group and 22.2% of patients in Voluven group and the 
statistical difference between two groups was 
meaningful.(p=0.008) No patient received more than one 
dose of ephedrine (5 mg) for treatment of the 
hypotension. There were no significant difference 
between the mean systolic pressure between groups 
(109.39±8.92in crystalloid group vs 116.20 ±9.72 in 
 
 
Med Hypothesis Discov Innov Interdisciplinary 2014 Spring;1(2)  
 
 
Prevention of  hypotension with crystalloids or Hydroxyethyl starch  
 Voluven group). The incidence of nausea was %41.6 (15 
patients) in crystalloid group vs %22.2 (8 patients) in 
Voluven group (p=0. 12). No severe hypotension and 
bradycardia and occurred among the patients in our 
study.   
Neonatal outcome was similar in the two groups and all 
the neonates have Apgar scores    8 at one and five 
minutes.  
 
DISCUSSION 
Spinal anesthesia for cesarean delivery may cause severe 
maternal hypotension, and a decrease in cardiac output 
and blood flow to the placenta (5). 
The current study has shown that prophylactic 
prehydration with  Hydroxyethyl starch was more 
effective than prehydration with crystalloid for 
preventing hypotension in healthy parturient  
undergoing spinal anesthesia for elective cesarean  
delivery. We demonstrated a higher incidence of 
hypotension in the crystalloid group, 47.2% compared 
with 22.2% in the Voluven group (p=0.008).  
Multiple studies fail to show persistent blood pressure 
maintenance after prophylactic crystalloid administration 
(6,7). Blood pressure and cardiac indices transiently 
increase, but these effects are short-lived because 
crystalloid solutions remain intravascular for only a 
limited time. Fluid preloading with crystalloid is 
ineffective due to its rapid redistribution (8). 
A well prehydration protocol is known to augment 
intravascular volume, maintain stable hemodynamics 
parameters and improve microcirculatory organ 
perfusion. Many different fluid protocols have been tried 
by various studies to minimize the severity hypotension 
induced by spinal anesthesia in obstetric patients and it 
seems that Colloid preload provides a sustained increase 
in central blood volume (9,10). 
Malthru et al found no hypotension when patients 
received 15 mL/kg of 5% albumin prior to spinal 
anesthesia for cesarean section. The control group, 
which received 15 mL/kg of 5% dextrose in LR, had a 29% 
incidence of hypotension (11). 
Sharma et al. recently observed that patients given 500 
mL of hetastarch had a 21% incidence of hypotension 
after spinal anesthesia with lidocaine for postpartum 
tubal ligation compared to a 55% incidence in patients 
given 1000 mL of LR (12). 
Extravascular redistribution of crystalloids may be so 
rapid that it may be impossible to infuse them fast 
enough to maintain intravascular volume and avoid 
hypotension during spinal anesthesia. Colloid solutions 
contain large molecules that do not immediately 
redistribute throughout the extracellular fluid 
compartment (13,14). 
Neonatal outcome was good in both groups in our study, 
and it can be due to a rapid treatment of hypotention  
with intravenous ephedrine, and also due to the rapid 
treatment of hypotention in our study, the incidence of 
nausea in both groups was low.  
CONCLUSION 
Prophylactic prehydration with  Hydroxyethyl starch was 
more effective than prehydration with crystalloid for 
preventing hypotension in healthy parturient  
undergoing spinal anesthesia for elective cesarean  
delivery. 
 
DISCLOSURE 
Conflicts of Interest: None declared. 
 
 
 
 
 
 
Table 1. Characteristics of patients receiving 
prehydration with Crystalloid or Voluven infusion.
a
  
 
 Crystalloid Voluven p-value 
Age (years) 28 ±5.4 27 ± 3.9 0.06 
Weight (kg) 78.4 ± 9.8 86.5 ± 8.5 o.4 
Height (cm) 170±8.8 171 ± 6.9 0.8 
Gestational age 38.2 ±0.8 38.5 ±0.6 0.9 
a
There was no significant differences between the 
groups. 
 
 
Table 2. Intraoperative characteristics of patients in 
crystalloid or Voluven group. 
 
 
Med Hypothesis Discov Innov Interdisciplinary 2014 Spring;1(2)  
 
 
Prevention of  hypotension with crystalloids or Hydroxyethyl starch  
                                           Crystalloid     Voluven                p-value  
SBPb 1-10 min                   97.89±9.84    105.61 ±8.16        0.2 
SBPb 11-60 min                     109.39±8.92 116.20± 9.72   0.6 
Heart Rate before OP        92.22 ±10.75 88.39 ±6.89 0.01 
Heart Rate along OPc       115.75 ±21.34 104.34 ±13.56 0.008 
Level of sensory block         T4± 1    T4± 1 1.0 
a
P< 0.05; 
b
SBP: Systolicblood pressure; 
c
OP: Operation 
 
Table 3. Intraoperative adverse effects among patients in 
crystalloid or Voluven group. 
 Crystalloid 
N (%) 
Voluven 
N (%) 
P value 
Hypotention 17 (47.2) 9 (25) 0.008
a
 
Nausea 15 (41.6) 8 (22.2) 0.12 
a
 P< 0.05 
 
REFERENCES 
1. Sen I, Hirachan R, Bhardwaj N, Jain K, Suri V, Kumar P. e Colloid 
cohydration and variable rate phenylephrine infusion effectively 
prevents postspinal hypotension in elective Cesarean deliveries. J 
Anaesthesiol Clin Pharmacol. 2013 Jul;29(3):348-55. PMID: 24106360 
2. Jabalameli M, Soltani HA, Hashemi J, Behdad S, Soleimani B. 
Prevention of post-spinal hypotension using crystalloid, colloid and 
ephedrine with three different combinations: A double blind 
randomized study. Adv Biomed Res. 2012;1:36. PMID: 23326767  
3. Marciniak A, Wujtewicz M, Owczuk R. The impact of colloid infusion 
prior to spinal anaesthesia for caesarean section on the condition of a 
newborn--a comparison of balanced and unbalanced hydroxyethyl 
starch 130/0.4. Anaesthesiol Intensive Ther. 2013 Jan-Mar;45(1):14-9. 
PMID: 23572302 
4. Mitra JK, Roy J, Bhattacharyya P, Yunus M, Lyngdoh NM. Changing 
trends in the management of hypotension following spinal anesthesia 
in cesarean section. J Postgrad Med. 2013 Apr-Jun;59(2):121-6. PMID: 
23793313  
5. McDonald S, Fernando R, Ashpole K, Columb M. Maternal cardiac 
output changes after crystalloid or colloid coload following spinal 
anesthesia for elective cesarean delivery: a randomized controlled trial. 
Anesth Analg. 2011 Oct;113(4):803-10. PMID: 21890886  
6. Mercier FJ. Fluid loading for cesarean delivery under spinal 
anesthesia: have we studied all the options?  Anesth Analg. 2011 
Oct;113(4):677-80. PMID: 21948275 
7. Turker G, Yilmazlar T, Mogol EB, Gurbet A, Dizman S, Gunay H. The 
effects of colloid pre-loading on thromboelastography prior to 
caesarean delivery: hydroxyethyl starch 130/0.4 versus succinylated 
gelatine. J Int Med Res. 2011;39(1):143-9. PMID: 21672316 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
8. Singh J, Ranjit S, Shrestha S, Sharma R, Marahatta SB. Effect of 
preloading on hemodynamic of the patient undergoing surgery under 
spinal anaesthesia. Kathmandu Univ Med J (KUMJ). 2010 Apr-
Jun;8(30):216-21. PMID: 21209539 
9. Mitra JK.  Prevention of hypotension following spinal anaesthesia in 
caesarean section--then and now. Kathmandu Univ Med J (KUMJ). 2010 
Oct-Dec;8(32):415-9. PMID: 22610772 
10. Kaya S, Karaman H, Erdogan H, Akyilmaz A, Turhanoglu S. Combined 
use of low-dose bupivacaine, colloid preload and wrapping of the legs 
for preventing hypotension in spinal anaesthesia for caesarean section. 
J Int Med Res. 2007 Sep-Oct;35(5):615-25. PMID: 17900401 
11. Mathru M, Rao TL, Kartha RK, Shanmugham M, Jacobs HK. 
Intravenous albumin administration for prevention of spinal 
hypotension during cesarean section. Anesth Analg. 1980 
Sep;59(9):655-8. PMID: 7191222  
12. Riley ET, Cohen SE, Rubenstein AJ, Flanagan B. Prevention of 
Hypotension after Spinal Anesthesia for Cesarean Section: Six Percent 
Hetastarch Versus Lactated Ringer's Solution. Anesth Analg. 1995 
Oct;81(4):838-42. PMID: 7574020  
13. Dahlgren G, Granath F, Wessel H, Irestedt L. Prediction of 
hypotension during spinal anesthesia for Cesarean section and its 
relation to the effect of crystalloid or colloid preload. Int J Obstet 
Anesth. 2007 Apr;16(2):128-34. PMID: 17276668  
14. Davies P, French GW. A randomised trial comparing 5 mL/kg and 10 
mL/kg of pentastarch as a volume preload before spinal anaesthesia for 
elective caesarean section. Int J Obstet Anesth. 2006 Oct;15(4):279-83. 
PMID: 16945514 


Prevention of Hypotension During Spinal Anesthesia for Caesarean Section:  Preload with Crystalloids or Hydroxyethyl Starch

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Prevention of Hypotension During Spinal Anesthesia for Caesarean Section: Preload with Crystalloids or Hydroxyethyl Starch

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