NEW YORK (Reuters Health) – A larger bolus of intravenous fluid given at the time of epidural placement in pregnant women with narrow pulse pressure reduces the risk of fetal heart rate (FHR) abnormalities, post-epidural hypotension and resuscitative intervention, according to a randomized controlled trial.
“Admission pulse pressure, as a peripheral surrogate of central volume status, may be used to individualize intrapartum fluid management at the time of initiation of neuroaxial labor analgesia,” Dr. Justin R. Lappen of Case Western University School of Medicine in Cleveland and colleagues state in their November 3 report in Obstetrics & Gynecology.
Hypotension occurs in 14% of women after the initiation of regional anesthesia, while abnormal FHR patterns occur in 30%, Dr. Lappen and his team note.
Intravenous fluid preload is widely used clinically, on the assumption that it can help restore normal hemodynamics after an epidural, the researchers add, but evidence for the benefit of this approach has been mixed.
Given that pulse pressure is an indicator of central volume status, the investigators hypothesized that giving women with a narrow pulse pressure more intravenous fluid could help reduce hemodynamic complications associated with regional anesthesia.
Dr. Lappen and colleagues randomly assigned 276 women with a pulse pressure <45 mmHg to an intravenous fluid bolus of 500 mL or 1,500 mL at epidural placement, while 138 women without narrow pulse pressure served as a reference group.
Category 2 or 3 FHR patterns occurred in 38.0% of the women who received the larger bolus, versus 51.8% of those given the smaller amount – a significant difference. The number needed to treat (with the larger bolus) to prevent a single abnormal FHR event was 7. (FHR abnormalities occurred in 17.8% of the reference group.)
Maternal systolic hypotension occurred in 10.2% of the 1,500-mL group and 34.5% of the 500-mL group. Patients given the larger bolus were also less likely to require post-epidural resuscitative interventions for FHR or hypotension (18.3% vs. 44.2%). Both differences were statistically significant.
Any maternal hypotension (systolic or diastolic) occurred in 40.6% of the reference group, 55.5% of the 1,500-mL group, and 75.5% of the 500-mL group (P<0.001).
“This trial demonstrates a physiology-based approach to fluid management at the initiation of neuroaxial labor analgesia and highlights the use of pulse pressure as a peripheral indicator of central volume status,” Dr. Lappen and his team write.
Dr. Lappen was not available for an interview by press time.
SOURCE: http://bit.ly/2hXm3qK
Obstet Gynecol 2017.
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