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Can Maternal Pulse Pressure be Used to Determine the Need for Fluid Bolus Prior to Epidural?

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the study design that was used to test the hypothesis if narrow pulse pressure can be used to determine fluid bolus amount prior to epidural anesthesia
2. List the benefits of using a larger fluid bolus in pregnant women with a narrow pulse pressure on admission to labor floor

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Sema4, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from March 4 2018 through March 3 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

BACKGROUND AND PURPOSE: 

  • Epidural anesthesia can be associated with maternal hypotension and consequent changes in fetal status 
    • Fetal heart rate (FHR) can be abnormal in 14-30% of cases following an epidural  
  • No set guidelines exist as to necessity of a fluid bolus 
  • Literature exists that low maternal pulse pressure, indicating hypovolemia, may be a helpful guide in determining requirement for fluid bolus  
  • Lappen et al. (Obstetrics & Gynecology, 2017) sought to determine whether increasing the IV fluid bolus volume at the time of epidural placement in women with narrow pulse pressure would reduce adverse fetal cardiac events   

METHODS: 

  • Randomized controlled trial (RCT) 
  • Inclusion Criteria 
    • Normotensive 
    • Presented for either spontaneous or induction of labor 
    • Narrow pulse pressure (systolic BP–diastolic BP) <45 mm Hg on admission 
    • Nonanomalous fetus 
  • Eligibility for randomization at epidural request if within 6 hours of admission and FHR category 1
  • Patients were randomized into 2 arms, both receiving lactated Ringer’s over 30 minutes initiated with patient epidural request and with preparation for or initiation of epidural placement by the anesthesiology team  
    • 500-mL (institutional standard) with programmed infusion pump (rate 999 mL/h) 
    • 1,500-mL intravenous fluid bolus using a pressure bag over 30 minutes  
  • A reference group with admission pulse pressure ≥50 mm Hg or greater was also evaluated 
  • Primary outcome  
    • Category 2 or 3 FHR within 60 minutes after epidural test dose 
  • Secondary outcomes 
    • Maternal hypotension  
    • Composite resuscitative interventions to correct FHR and maternal hypotension 

RESULTS: 

  • 139 women received 500-mL and 137 women received 1,500-mL fluid bolus 
  • 138 women were evaluated in the reference group 
  • Demographic, obstetric, and labor characteristics were generally similar between groups 
    • 1,500-mL arm had higher rate of admission for induction  
  • Comparing the 1,500-mL group to the 500-mL group, there were  
    • Fewer FHR abnormalities (38.0% vs 51.8%) with relative risk (RR) of 0.73, 95% CI 0.56–0.96; P=.02 
    • Fewer episodes of maternal systolic hypotension (10.2% vs 34.5%) with RR of 0.30, 95% CI 0.17–0.51; P<.001 
    • Fewer composite interventions (18.3% vs 44.2%) with RR of 0.42, 95% CI 0.28–0.62; P<.001 
  • FHR abnormalities remained significantly less frequent in the reference group than among women with a narrow pulse pressure on admission for delivery 

CONCLUSION: 

  • An 1,500-mL intravenous fluid bolus in women with a narrow pulse pressure decreases FHR abnormalities, frequency of postepidural hypotension, and need for interventions to reverse maternal hypotension and abnormal FHR patterns  
  • Admission maternal pulse pressure can be used as a surrogate for central volume status and may identify women who would benefit from a larger IV bolus prior to epidural  

Learn More – Primary Sources:  

Maternal Pulse Pressure and the Risk of Postepidural Complications: A Randomized Controlled Trial 

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What is the Optimal Blood Pressure Target When Treating Hypertension?

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