Can Maternal Pulse Pressure be Used to Determine the Need for Fluid Bolus Prior to Epidural?
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
Randomized controlled trial (RCT)
Presented for either spontaneous or induction of labor
Narrow pulse pressure (systolic BP–diastolic BP) <45 mm Hg on admission
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
Category 2 or 3 FHR within 60 minutes after epidural test dose
Composite resuscitative interventions to correct FHR and maternal hypotension
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
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
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