Ephedrine, a long time was considered the safest drug for both mother and fetus during the
treatment of hypotension in Caesarean section. However, recent evidence shows that contrary
to what was thought, ephedrine appears to increase fetal metabolism, decreasing the pH and
excess base.
Recently, phenylephrine has been used in the treatment of hypotension during cesarean
delivery with better results in relation to acid-base parameters in umbilical cord blood.
However, few data are available on the use of phenylephrine in high-risk pregnancy, the
majority of studies in healthy pregnant women for elective caesarean section.
Although little scientific evidence regarding the use of metaraminol for treatment of
hypotension in Caesarean section, recent study demonstrated superiority of this drug compared
to ephedrine, checking a lower incidence of neonatal acidosis and better control of blood
pressure. The researchers also found differences in blood gases from the umbilical cord
between the ephedrine and metaraminol groups larger than those already found in previous
studies comparing ephedrine and phenylephrine.
The pathophysiological changes in patients with pre-eclampsia can lead to intrauterine growth
restriction with chronic fetal distress, due to the limited uteroplacental flow, which, in
certain situations, may be reduced by 50% to 70%. Added to this, spinal anesthesia may cause
sudden hypotension and fetal acidosis more often, even in elective operations, compared to
epidural or general anesthesia, and that these changes may not have clinical significance in
healthy fetuses at term, but may be critical in situations where arterial insufficiency
uteroplacental and fetal distress already to present. It is believed, therefore, important
that treat or prevent hypotension in patients with severe preeclampsia under spinal
anesthesia.
Prevention of hypotension in patients with severe preeclampsia does not require large amounts
of intravenous fluids, but careful prophylaxis of postural hypotensive syndrome. Despite the
care, if hypotension occurs, aggressive treatment is mandatory in these patients and fast in
order to avoid worsening fetal distress and neonatal depression. Such patients are more
sensitive to vasopressors, therefore, small doses should be administered.
However, the biggest challenge of the anesthesiologist is to determine the ideal vasopressor
in pregnant women at high risk, able to adequately restore blood pressure levels without
determining deterioration of fetal status.
30 Reynolds and Seed in 2005 showed that ephedrine, administered in large doses, has
contributed to the adverse effects of spinal anesthesia (greater degree of fetal metabolic
acidosis), supporting the idea that ephedrine is not the vasopressor of choice for treatment
of maternal hypotension during cesarean section.
As a result, this study is to fill this knowledge gap, taking on great importance to evaluate
maternal and perinatal outcomes of pregnant women with severe preeclampsia to receive
ephedrine or metaraminol for treatment of maternal hypotension during caesarean section under
spinal anesthesia. Considering the importance of creating a protocol, since the metaraminol,
unlike phenylephrine, is widely available at our facility.