Maternal Lateral Tilt and Cardiac Output in Caesarean Section

Background: Left uterine displacement (LUD) has been questioned as an effective strategy to prevent aortocaval compression after spinal anesthesia (SA) for cesarean delivery (CD). The investigators tested if LUD has a significant impact on cardiac output (CO) in patients undergoing CD under SA during continuous non-invasive hemodynamic monitoring.

Methods: Forty-six patients were included in the final analysis. The investigators considered 4 timepoints of 5 minutes each: T1=baseline with LUD; T2=baseline without LUD; T3=after SA with LUD; T4=after SA without LUD. LUD was then repositioned for CD. Primary outcome was to test if CO decreased from T3 to T4. We also compared CO between T1 and T2 and other hemodynamic variables: mean, systolic and diastolic blood pressure (respectively MAP, SAP and DAP), heart rate (HR), stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), contractility (dP/dt), dynamic arterial elastance (Eadyn) at the different timepoints. Data on fetal Apgar scores and umbilical arterial and venous pH were collecte

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Key information

Conditions

Hypotension Drug-Induced Cardiovascular Diseases Hypotension Vascular Diseases

Age range

18 year and older

Sex eligibility

Female

Study type

Observational

Primary location

IRCCS Fondazione Policlinico Universitario Agostino Gemelli

Rome, 00168, Italy

About this study

The primary outcome was to test if CO decreases significantly after LUD removal in patients under SA for CD. This is a prospective observational study.

Data were gathered from pregnant patients who, in addition to standard monitoring, underwent perioperative non-invasive hemodynamic monitoring by ClearSight system on the Edwards Lifesciences HemoSphere platform (Edwards Lifesciences, Irvine, CA).

The parameters were recorded at 20 seconds-intervals. The investigators considered 4 timepoints. T1 were the baseline values recorded for 5 minutes, after initial stabilization of parameters, with the patient laying down on the operating table with LUD. At T2, LUD was removed and we considered for the analysis hemodynamic data of the subsequent 5 minutes. The investigators indicated as T3 the 5 minutes following SA with a satisfactory sensory block and as T4 the subsequent 5 minutes following LUD removal. Figure 1 summarizes the timepoints of our analysis. LUD was accomplished by positioning a wooden wedge wrapped with cotton, to make it comfortable, and medical sheets with a measured angle of 15° under the right flank of the laying down patient. In all patients, after T4 the 15° wooden wedge was positioned again and surgery was performed with LUD.

Anesthesia was standard spinal procedure, fluid management was left to the attending anesthesiologist.

The attending anesthesiologist was blinded to the advanced hemodynamic parameters from the ClearSight system except for the continuous BP values. The investigators defined hypotension as an absolute value of MAP < 65 mmHg. This value was considered as trigger for the attending anesthesiologist for the administration of norepinephrine 5 mcg. Norepinephrine boluses were repeated to reach a MAP>65mmHg. Bradycardia was defined as a heart rate of < 60 bpm. Atropine 0.5 mg was administered for the treatment of bradycardia combined with hypotension, or for an absolute value of heart rate < 45 bpm. After delivery, Oxytocin was administered to facilitate the uterine contraction.

We also evaluated the impact of maternal blood pressure and CO on fetal outcome collecting neonatal Apgar scores at 1 and 5 minutes after birth, and umbilical cord arterial and venous pH.

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

pregnant patients at term (36th to 40th week of gestation) scheduled for elective caesarean section under spinal anesthesia.

Exclusion criteria

age <18 years
American Society of Anesthesiologists score >3
cardiac arrhythmias or aortic regurgitation
pregnancy-induced hypertension
pre-eclampsia
body mass index (BMI) > 35 kg/m2
foetal complications
coagulation disorders or contraindication to neuraxial block
emergency surgery
preoperative infection
patient's refusal

Treatment and study plan

Left Lateral Uterine Displacement

Procedure

a wooden wedge wrapped with cotton, to make it comfortable, and medical sheets with a measured angle of 15° under the right flank of the laying down patient

Primary outcomes

Cardiac Output (l/min) measured by non-invasive hemodynamic monitoring

Time frame: at 5 minutes from left lateral uterine tilt removal under spinal anesthesia

Does cardiac output decrease significantly after left lateral uterine displacement removal in patients under spinal anesthesia for caesarean delivery?

Sponsors and collaborators

Lead sponsor

Fondazione Policlinico Universitario Agostino Gemelli IRCCS

Other

Registry information

Official study title

Impact of Maternal Lateral Tilt on Cardiac Output During Caesarean Section Under Spinal Anaesthesia: A Prospective Observational Study

Important dates

Study start: 2020
Primary completion: 2020
Study completion: 2020
First posted: Dec 3, 2021
Registry last updated: Dec 3, 2021

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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