The Effect of Anesthesia on Apgar Score
Question
What are the effects of general and spinal anesthesia during cesarean
delivery on the neonatal Apgar score?
Dr. Khademis
Response from Dena Goffman, MD, and Peter S. Bernstein, MD, MPH
Dena Goffman, MD, fellow in Maternal-Fetal Medicine, Albert Einstein College
of Medicine/Montefiore Medical Center, Bronx, New York
Peter S. Bernstein, MD, MPH, FACOG, Associate
Professor of Clinical Obstetrics and Gynecology and Women's Health, Albert
Einstein College of Medicine/Montefiore Medical Center, Bronx, New York;
Medical Director of Obstetrics and Gynecology, Comprehensive Family Care
Center, Montefiore Medical Center, Bronx, New York
An anesthetic plan for cesarean delivery must take into account maternal and
fetal well being, as well as the clinical situation at hand. General
anesthesia and regional anesthesias, including spinal, epidural, or combined
spinal-epidural, are available options. Regional anesthesia is well
recognized as safe and effective, and it allows the mother to be awake and
to participate in the birth of her child. A widely accepted benefit of
general anesthesia is the rapidity with which it can be induced. The
majority of cesarean deliveries in the United States are performed under
regional anesthesia, with the majority of planned cesareans performed under
spinal anesthesia.
The question posed regarding the effect of general vs regional anesthesia on
neonatal Apgar scores is an interesting one. This subject has been studied
by many investigators over the years, most commonly retrospectively and in
the setting of elective cases. Some have shown no difference in Apgar scores
between the groups. Some have reported lower Apgar scores and worse outcomes
with the use of general anesthesia, suggesting that these differences are a
result of transient sedation secondary to anesthetic agents.[1] Others have
suggested an increased degree of acidosis in neonates delivered under
regional anesthesia, possibly due to greater incidence of maternal
hypotension and need for ephedrine to support maternal blood pressure.[2]
One large retrospective review studied the effects of general and regional
anesthesia in infants delivered by elective and nonelective cesarean
section. The authors showed that when controlled for confounding factors,
general anesthesia was associated with lower Apgar scores at 1 and 5 minutes
and with greater requirements for intubation and artificial ventilation.
There were no differences in neonatal death rates.[1]
In recent years, prospective randomized trials have been undertaken
comparing general anesthesia with both spinal and epidural anesthesia for
cesarean delivery. In a comparison of spinal and general anesthesia for
elective cesarean delivery at term, no difference was demonstrated in
short-term neonatal outcomes, including Apgar scores, cord gas parameters,
creatine kinase, AST/ALT and cortisol levels, hospital stay, NICU
admissions, neonatal respiratory depression, or perinatal asphyxia.[3]
However, in another smaller randomized study comparing general anesthesia
with epidural anesthesia for cesarean delivery at term, the epidural group
had higher Apgar scores, higher Neurologic Adaptive Capacity scores at 2 and
24 hours of life, higher umbilical artery pH and pO2, and a shorter interval
to initiation of breastfeeding.[4] A recent large cohort study reported that
for both emergency and elective cesarean deliveries, significantly more
infants delivered under general anesthesia require resuscitation.[5]
It is well accepted that optimal anesthetic choice depends on the clinical
situation. Comparisons of general and regional anesthesia in the setting of
specific obstetric dilemmas such as prematurity, pre-eclampsia, and placenta
previa have been reported. The influence of general compared with epidural
anesthesia for cesarean delivery of preterm infants < 32 weeks has been
described using a prospective database. When controlled for confounders,
lower 1-minute Apgar scores were evident in the general anesthesia group[6];
however, the clinical significance of this in the setting of comparable
5-minute scores is unclear. Dyer and colleagues[2] published results from a
prospective randomized trial comparing general anesthesia with spinal
anesthesia for cesarean delivery in pre-eclamptic patients with a
nonreassuring fetal heart rate tracing. Both groups had acceptable
hemodynamic parameters. The spinal group received more ephedrine, had a
lower maternal pCO2, and umbilical artery parameters showed a greater base
deficit and lower pH. The general anesthesia group had lower 1-minute Apgar
scores, but 5-minute scores were comparable. It is unclear what conclusions
should be drawn from these results.
Finally, another recent prospective randomized trial evaluated the use of
general vs epidural anesthesia in the setting of placenta previa. Neonatal
Apgar scores did not differ between the groups; however, the general
anesthesia group had lower maternal postoperative hematocrits and more blood
transfusions, suggesting a maternal benefit with the use of regional
anesthesia in the setting of placenta previa.[7]
Varying data exist regarding the effect of anesthetic options on neonatal
Apgar scores and umbilical artery parameters, and the significance of small
differences in these numbers is unclear. Each situation must be evaluated
individually; however, in most cases maternal risk is greater with general
anesthesia. There is some suggestion that neonatal Apgar scores are lower
and resuscitation rates are higher in the setting of general anesthesia use,
although the long-term clinical significance of this observation is unclear.
Posted 01/10/2006
References
Ong BY, Cohen MM, Palahniuk RJ. Anesthesia for cesarean section -- effects
on neonates. Anesth Analg. 1989;68:270-275. Abstract
Dyer RA, Els I, Farbas J, Torr GJ, Schoeman LK, James MF. Prospective,
randomized trial comparing general with spinal anesthesia for cesarean
delivery in preeclamptic patients with a nonreassuring fetal heart trace.
Anesthesiology. 2003;99:561-569. Abstract
Kavak ZN, Basgul A, Ceyhan N. Short-term outcome of newborn infants: spinal
versus general anesthesia for elective cesarean section. A prospective
randomized study. Eur J Obstet Gynecol. 2001;100:50-54.
Sener EB, Guldogus F, Karakaya D, Baris S, Kocamanoglu S, Tur A. Comparison
of neonatal effects of epidural and general anesthesia for cesarean section.
Gynecol Obstet Invest. 2003;55:41-45. Abstract
Gordon A, Mckechnie EJ, Jeffrey H. Pediatric presence at cesarean section:
Justified or not? Am J Obstet Gynecol. 2005;193:599-605. Abstract
Rolbin SH, Cohen MM, Levinton CM, Kelly EN, Farine D. The premature infant:
anesthesia for cesarean delivery. Anesth Analg. 1994;78:912-917. Abstract
Hong JY, Jee HJ, Yoon S, Kim M. Comparison of general and epidural
anesthesia in elective cesarean section for placenta previa totalis:
maternal hemodynamics, blood loss and neonatal outcome. Int J Obstet Anesth.
2003;12:12-16. Abstract
Peter S. Bernstein, MD, MPH, has disclosed no relevant financial
relationships.
Dena Goffman, MD, has disclosed no relevant financial relationships.
Medscape Ob/Gyn & Women's Health. 2006;11(1) ©2006 Medscape
Leanne Wynne
Midwife in charge of "Women's Business"
Mildura Aboriginal Health Service Mob 0418 371862
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