A randomized study of maternal serum cytokine levels following cesarean section under general or neuraxial anesthesia. Prospective, randomized trial comparing general with spinal anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. Comparison of general and epidural anesthesia in elective cesarean section for placenta previa totalis: maternal hemodynamics, blood loss and neonatal outcome. General versus spinal anaesthesia for elective caesarean sections: effects on neonatal short-term outcome. A prospective randomised study. Comparison of general and regional anesthesia for cesarean section: success rate, blood loss and satisfaction from a randomized trial. Comparison of neonatal effects of epidural and general anesthesia for cesarean section. General anaesthesia versus epidural anaesthesia for primary caesarean section--a comparative study. Anaesthetic technique for elective caesarean section and neurobehavioural status of newborns. Systemic and pulmonary blood pressure during caesarean section in parturients with gestational hypertension. Randomized comparison of general and regional anesthesia for cesarean delivery in pregnancies complicated by severe preeclampsia. Neurologic activity of infants following anesthesia for cesarean section. The effect of epidural and general anesthesia on newborn rectal temperature at elective cesarean section. The effect of delivery on umbilical arterial cord blood gases and lipid peroxides: comparison of vaginal delivery and cesarean section. Frequency of electrocardiographic changes indicating myocardial ischemia during elective cesarean delivery with regional and general anesthesia: detection based on continuous Holter monitoring and serum markers of ischemia. Short-term outcome of newborn infants: spinal versus general anesthesia for elective cesarean section. A prospective randomized study. Impact of intrapartum factors on oxidative stress in newborns.
Cytokines are significant mediators of the immune response to surgery and also play a role in parturition. The aim of the study was to investigate the impact of the anesthetic technique for cesarean section on plasma levels of cytokines IL-6 and TNF-alpha.
                Thirty-five parturients scheduled for elective cesarean section were randomly assigned to general (n=18) or neuraxial (n=17) anesthesia. The general anesthesia group received thiopental 4 mg/kg, succinylcholine 1-1.5 mg/kg and 1% end-tidal concentration of sevoflurane in nitrous oxide and 50% oxygen. The neuraxial anesthesia group received intrathecal 0.5% levobupivacaine 1.8-2.2 mL and epidural fentanyl 1 microg/kg. Blood samples were taken for IL-6 and TNF-alpha immediately after positioning the parturient on the operating table, after uterine incision and before the umbilical cord clamping and 24h after surgery (T(1), T(2) and T(3) respectively).
                The two groups did not differ in IL-6 (P=0.15) or TNF-alpha (P=0.73) serum concentrations at any time point. In the general and neuraxial anesthesia groups, IL-6 serum concentrations were significantly higher in the third blood sample, T(3) (12.2+/-5.0 and 15.2+/-4.3 pg/mL), than in T(1) (0.41+/-0.38 and 0.29+/-0.10 pg/mL) and T(2) (0.37+/-0.47 and 0.24+/-0.05) respectively (P<0.001). Within each group, serum TNF-alpha concentrations did not differ significantly over time (P=0.44).
                Under the present study design anesthetic technique did not affect IL-6 or TNF-alpha concentrations in parturients undergoing elective cesarean section. Serum IL-6 levels increased 24 h postoperatively independently of anesthetic technique. There are no randomized studies on neonatal outcome after spinal versus general anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. This study examined both markers of neonatal hypoxia and maternal hemodynamics.
                Seventy patients were randomized to general (n = 35) or spinal anesthesia (n = 35). The general anesthesia group received thiopentone, magnesium sulfate, and suxamethonium intravenously before intubation, followed by 50% nitrous oxide in oxygen, 0.75-1.5% isoflurane, and morphine after delivery. The target end-tidal partial pressure of carbon dioxide (Pco2) was 30-34 mmHg. The spinal anesthesia group received 1.8 ml hyperbaric bupivacaine plus 10 microg fentanyl at the L3-L4 interspace. Heart rate and blood pressure were measured at specific time points. Hypotension was treated with ephedrine. Maternal arterial and neonatal umbilical arterial blood gas samples were taken at delivery. Resuscitation requirements were recorded.
                In both groups, hemodynamic measures remained within acceptable limits. Spinal anesthesia patients required more ephedrine (13.7 vs. 2.7 mg). Maternal Paco2 was lower in the spinal group (28.9 vs. 32.4 mmHg). One-minute Apgar scores were lower after general anesthesia. Base deficit was greater (7.13 vs. 4.68 mEq/l) and neonatal umbilical arterial pH was lower (7.20 vs. 7.23) after spinal anesthesia. Post hoc analysis showed that if maternal diastolic blood pressure on admission was greater than 110 mmHg, neonatal umbilical arterial base deficit was greater after spinal anesthesia. There was no difference in the number of patients with Apgar scores less than 7 at 1 or 5 min or umbilical arterial pH less than 7.2 or in the requirements for resuscitation.
                In preeclamptic patients with a nonreassuring fetal heart trace, spinal anesthesia for cesarean delivery was associated with a greater mean neonatal umbilical arterial base deficit and a lower median umbilical arterial pH. The clinical significance remains to be established. Maternal hemodynamics were similar and acceptable with either anesthetic technique. There are few consistent guidelines in choosing anesthesia for cesarean section for a parturient with placenta previa. This prospective randomized trial was organized to compare the maternal hemodynamics, blood loss and neonatal outcome of general versus epidural anesthesia for cesarean section with the diagnosis of grade 4 placenta previa. After giving informed consent, 12 patients received general anesthesia and 13 received epidural. Intraoperative blood pressures demonstrated a more stable course in the epidural group than in the general group. Blood loss did not differ significantly between the groups (1622 +/- 775 mL vs. 1418 +/- 996 mL). General anesthesia resulted in lower immediate postoperative hematocrit level (28.1 +/- 3.5% vs. 32.5 +/- 5.0%, P < 0.05). The patients in the general group received a significantly larger transfusion than the epidural group (1.08 +/- 1.6 vs. 0.38 +/- 0.9 units, P < 0.05). The Apgar scores at 1 and 5 min were similar in the two groups (8 [4-9] vs. 8 [7-9] and 10 [6-10] vs. 9 [9-10], respectively). We concluded that epidural anesthesia is superior to general anesthesia in elective cesarean section for grade 4 placenta previa with regard to maternal hemodynamics and blood loss. There was no difference in neonatal outcome. To compare neonatal short-term outcome in patients who underwent spinal, general anaesthesia and conversion from spinal to general anaesthesia.
                One hundred seventy-nine pregnant women undergoing elective caesarean section were allocated randomly to general (n=89) or spinal anaesthesia (n=90) and compared with 63 patients who required conversion to general anaesthesia. Umbilical cord artery pH, Apgar score as well as its individual parameter and need for assisted ventilation were evaluated.
                No differences were found in pH values (p=0.35), while the need for assisted ventilation differed significantly (p=0.001). The rate of depressed newborns was 1.1% in the spinal group, 25.9% in the general group and 12.7% in the conversion group with a significant difference for all comparisons. At 5-min, all newborns were vigorous. At 1 min, a higher score for each parameter was found in spinal group with respect to general group, while 'activity', 'grimace' and 'respiration' showed a higher score in conversion group than in general group. At 5 min, a difference was found only for 'activity'.
                All kinds of anaesthesia seem to be safe, but loco-regional blockade shows more advantages on the neonatal outcome also when a conversion is necessary. A prospective randomized trial was organized to compare the effectiveness of general and regional anesthesia for cesarean section (C/S).
                Three hundred and forty-one patients were randomized into the general anesthesia group (GA), epidural anesthesia group (EA) and spinal anesthesia group (SA). The effectiveness of interest was success rate, blood loss and patient satisfaction.
                We found that the success rates of EA and SA were lower than GA. Success in EA should be improved by using an epidural catheter to add more local anesthetic drug instead of a single shot; and the surgeon should allow more time for the block to work adequately. Success in SA should be improved by using bupivacaine instead of lidocaine. GA resulted in significantly more blood loss, lower postoperative hematocrit, and higher proportion of patients who had postoperative hematocrit < 30 per cent than EA and SA. The patients' satisfaction scores were not different among the 3 techniques. This meant that, given adequate explanation and perioperative care, Thai women were satisfied with regional anesthesia.
                Regional anesthesia is a better choice of anesthesia for C/S than general anesthesia. However, the availability of different techniques and ability to change the technique when needed were very useful and important. If GA is chosen, all safety procedures must be followed. Oxygen supplement and endotracheal intubation facilities must be available in all techniques. Guidelines of anesthesia for C/S at a national level should be agreed upon, including the type of personnel, monitoring equipment and postoperative care. We assessed the influence of anesthetic technique for cesarean section on neonatal outcome. Thirty parturient women (ASA I/II) were randomly allocated into two groups. In Group GA general anesthesia was induced with 4 mg.kg(-1) thiopental and 1.5 mg.kg(-1) succinylcholine. In group EA epidural anesthesia was performed with 20 ml 0.375% bupivacaine through L(3-4) inter-space. 1-min Apgar scores were significantly higher in group EA (p < 0.001). Neurologic and Adaptive Capacity scores at 2 and 24 h were higher in group EA (p < 0.001). In terms of blood gas values, umbilical arterial pH and pO(2) values were higher in group EA (p < 0.05 and p < 0.001, respectively). The first breast-feeding intervals were found to be shorter in group EA (p < 0.001). We conclude that in terms of better Apgar and NAC scores, acid-base status and earlier initiation of breast-feeding, the epidural anesthesia may be preferred to general anesthesia in cesarean section.
                Copyright 2003 S. Karger AG, Basel Forty-seven healthy parturients undergoing elective Caesarean section were randomly allocated to either general anaesthesia (n = 24) or epidural anaesthesia (n = 23) under standardized anaesthetic and surgical conditions. Seven women of the epidural group required additional systemic analgesia or sedation following delivery of the neonate. Nine of 24 newborns obtained 1-min Apgar scores below 7 after general anaesthesia compared to only 3/23 after epidural anaesthesia. The time period to establish normal colour in the babies was 2.2 min after epidural and 4.9 min after general anaesthesia. Three of the 24 general-anaesthesia newborns demonstrated a tendency to hypotonia compared to only one in the epidural group. Twenty-four hours and 7 days after delivery all infants of both groups were completely normal. At the time of delivery maternal PO2 was higher in the general anaesthesia compared to the epidural group, due to higher inspired oxygen concentrations. Comparable results were obtained in umbilical PO2 venous values; lower pH values, however, were observed in the umbilical artery after general anaesthesia. There were no significant differences in the glucose levels between the groups. A significant correlation was established between uterine incision-delivery interval and 1-min neonatal Apgar scores in the general-anaesthesia group, but not in the epidural group. Our investigation did not show either the incision-delivery interval or the start of operation-delivery interval to play a role in neonatal outcome. Epidural anaesthesia is superior to general anaesthesia in Caesarean section under normal conditions with regard to neonatal outcome. Whether this is also true for critical conditions cannot be concluded from this study. Ninety healthy parturients undergoing elective caesarean section were randomly allocated to receive either general (n = 30), epidural (n = 30) or spinal (n = 30) anaesthesia. Acid-base status, Apgar score and neurobehavioural status, using the neurologic and adaptive capacity scoring (NACS) system, were studied in the newborn. Apgar scores and acid-base parameters were similar in all the three groups. NACS testing revealed significantly more vigorous babies in the spinal anaesthesia group than in the other two groups at 15 min and 2 h interval after delivery, despite a higher incidence of maternal hypotension. We conclude that newborns tend to have a better neurobehavioural status in the early post-delivery period if their mothers receive spinal anaesthesia rather than general or epidural anaesthesia for caesarean section. nan To evaluate the maternal and fetal effects of three anesthetic methods used randomly in women with severe preeclampsia who required cesarean delivery.
                Eighty women with severe preeclampsia, who were to be delivered by cesarean, were randomized to general (26 women), epidural (27), or combined spinal-epidural (27) anesthesia. The mean preoperative blood pressure (BP) was approximately 170/110 mmHg, and all women had proteinuria. Anesthetic and obstetric management included antihypertensive drug therapy and limited intravenous (IV) fluid and drug therapy.
                The mean gestational age at delivery was 34.8 weeks. All infants were born in good condition as assessed by Apgar scores and umbilical arterial blood gas determinations. Maternal hypotension resulting from regional anesthesia was managed without excessive IV fluid administration. Similarly, maternal BP was managed without severe hypertensive effects in women undergoing general anesthesia. There were no serious maternal or fetal complications attributable to any of the three anesthetic methods.
                General as well as regional anesthetic methods are equally acceptable for cesarean delivery in pregnancies complicated by severe preeclampsia if steps are taken to ensure a careful approach to either method. Elective cesarean section was performed in a consecutive series of 30 patients with full-term pregnancies who were not in labor. Epidural (lidocaine, 1.5 per cent, with epinephrine, 1:200,000) and general anesthesia (thiopental, nitrous oxide-oxygen, succinylcholine infusion) was used alternately. Neonatal acid-base values and Apgar scores showed no significant difference between the two anesthetic groups, and most infants were vigorous at birth. The neurologic recoveries of the infants showed no significant difference between the two groups. In the group receiving epidural anesthesia, there was a significant correlation between maternal hypotension and weak rooting and sucking reflexes of the infants during the first two days. All infants of high-risk obstetric patients in the series, independent of anesthetic technique used, had abnormal neurologic activity, as evidenced by either depression of muscle tone and the reflexes or all the tested variables. Neurologic assessment as followed in this series is a sensitive indicator of the effects of fetal stress factors acting during cesarean section. Both epidural and general anesthesia can impair thermoregulatory mechanisms during surgery. However, there is lack of information about the effects of different methods of anesthesia on newborn temperature. The purpose of this study was to determine whether there are differences in newborn rectal temperature related to type of anesthesia. Sixty-three pregnant women were randomly assigned to receive general or epidural anesthesia. Maternal core temperature was measured three times with a rectal probe just before anesthesia, at the beginning of surgery and at delivery. In addition, umbilical vein blood was sampled for pH. The rectal temperatures of the babies were recorded immediately after delivery, and Apgar scores were determined 1, 5, and 10 min after birth. The duration of anesthesia and the volume of intravenous fluid given during the procedure (833 +/- 144 vs 420 +/- 215 mL) were significantly higher in the epidural group than in the general anesthesia group (P < 0.0001). Maternal rectal temperatures were not different in both groups at all measurements. In contrast, newborn rectal temperatures were lower in the epidural anesthesia group than in the general anesthesia group (37.4 +/- 0.3 vs 37.6 +/- 0.3 degrees C; P < 0.05) immediately after birth. Furthermore, the umbilical vein pH value (7.31 +/- 0.05 vs 7.33 +/- 0.01; P < 0.05) and Apgar scores at the 1st-min measurement (8.0 +/- 0.9 vs 8.5 +/- 0.7; P < 0.05) were lower in the epidural anesthesia group than in the general anesthesia group. Since epidural anesthesia requires more iv fluid infusion and a longer time for cesarean section, it involves a risk of a mild temperature reduction for the baby which, however, did not reach the limits of hypothermia. Umbilical arterial blood gas analysis is the most objective method to assess fetal well being at birth, is the gold standard assessment of uteroplacental function and fetal oxygenation/acid-base status at birth, and it excludes the diagnosis of birth asphyxia in approximately 80% of depressed newborns at term. This study was designed to determine the effect of the type of delivery on umbilical cord blood gases and on free radical activity together with antioxidation in the fetus. Ninety-six pregnant women between 37 and 42 weeks of gestation were included to the study and randomly assigned to the one of three groups: Group 1 (n = 40) were vaginally delivered, Group 2 (n = 26) had cesarean section with epidural anaesthesia, and Group 3 (n = 30) had cesarean section under general anaesthesia. Umbilical artery blood gas analysis was performed just after the delivery of the fetus together with melondealdehyde and glutathione. The umbilical arterial PO2 was found to be higher in Group 3, and malondealdehyde and glutathione levels were lower in newborns of Group 2. It can be concluded that cesarean section with epidural anaesthesia is safer when lipid peroxides are concerned. To determine the frequency of electrocardiographic (ECG) changes and to assess the occurrence of myocardial ischemia during elective cesarean delivery with either regional or general anesthesia.
                Randomized, prospective, single-blinded clinical trial.
                Large referral hospital.
                40 ASA physical status I and II term parturients.
                Patients were divided randomly into two groups as follows: the regional anesthesia group (group 1, n = 20) and the general anesthesia group (group 2, n = 20).
                In each case, continuous ECG was done using a 7-lead Holter monitor in the operating room, continuing for 24 hours after surgery. All Holter traces were analyzed by a study-blinded cardiologist. Blood samples were collected preoperatively (baseline) and at one, 5, and 24 hours postoperatively. Serum troponin T, creatinine kinase-MB, and myoglobin levels were measured.
                Two patients in group 1 (10%) and one patient in group 2 (5%) showed one mm ST-segment depression for two to 5 minutes. In all 40 cases, troponin T levels were in the normal range at all time points studied. In both groups, mean serum creatinine kinase-MB and myoglobin levels at one and 5 hours postoperatively were significantly higher than at baseline (P < 0.05). These high CK-MB and myoglobin levels were returned to normal ranges at the end of the study period; none of these women showed ST-segment changes.
                The ST-segment changes are not frequent in healthy women undergoing elective cesarean delivery during either regional or general anesthesia, and we found no evidence of myocardial injury. To compare general and spinal anesthesia with respect to the short-term outcome of newborns born by elective cesarean deliveries.
                Pregnant women admitted to our hospital from January 1999 to July 2000, for whom elective repeat cesareans were planned after 37 weeks gestation, were allocated randomly after their informed consent to spinal anesthesia or general anesthesia. Maternal age, gestational age, birth weight, Apgar's score, hospital stay duration, and duration of cesarean section time were all noted. The rate of the neonatal respiratory depression, perinatal asphyxia, and admittance to the neonatal intensive care unit of the infants were documented. We also studied arterial samples withdrawn from the cord for the pH, bicarbonate, PaO(2) (oxygen pressure, arterial), and PaCO(2) (carbon dioxide pressure, arterial). The serum levels of creatine kinase with myocardial-specific isoform, aspartate aminotransferase, alanine aminotransferase, and total cortisol levels of the newborns were measured and served in ruling out perinatal stress and in confirming the diagnosis of perinatal asphyxia (and of myocardial damage). Statistical analyses was performed with the use of an unpaired Student's t-test, Chi-square test, and a power calculation was done.
                From the randomly selected patients, we had 38 (45.2%) infants for general anesthesia and 46 (54.8%) for spinal anesthesia. None of our primary endpoints favored any of the study groups, and the clinical short-term outcome of the infants was similar in the neonates born both by spinal and general anesthesia (P>0.05). The biochemical assays did not rule out or confirm any differences in the occurrence of perinatal stress (P>0.05).
                Anesthesia type does not seem to influence the short-term outcome of the newborn infants for the elective cesarean deliveries. We believe that both spinal and general anesthesia could be performed in elective term cesarean deliveries without any risk to the newborn infants. To determine the impact of the method of delivery and type of obstetric anesthesia on oxidative stress in neonates.
                The trial included 164 women in two groups of elective cesarean delivery (CD) and uncomplicated vaginal delivery (VD) at term. The CD group was randomized to either a spinal or general anesthesia and the VD group was randomized to either a local or a spinal saddle block. The main outcome measures were the umbilical venous blood glutathione and malondialdhyde (MDA).
                Neonates of CD had significantly higher levels of MDA and pO(2) and lower glutathione levels than VD. However, in regression analysis, the mode of delivery and type of anesthesia were independent factors that determine the level of MDA but not the level of glutathione. Gestational age was a significant predictor of the glutathione level while birth weight was a significant predictor of the MDA level.
                The oxidative status of the newborn is not simply a reflection of the mode of delivery and type of anesthesia. The impact of gestational age and birth weight appears to be crucial. This must be considered when planning elective delivery.
There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes. Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful.