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Lower limb compression halved epidural-associated hypotension
SAN DIEGO – Use of sequential compression devices reduced by half cases of epidural-associated hypotension in laboring women in a small real-world, randomized controlled trial.
The results showed that patients who received sequential compression devices (SCD) and kept them on for at least an hour after epidural analgesia placement had half the hypotension of patients who had no lower limb compression (33.3% vs. 66.7%; P .022).
“Lower limb compression using SCDs significantly decreased the incidence of maternal hypotension in laboring patients receiving epidural anesthesia,” said Margaret Steinmetz, MD, a third-year resident at the State University of New York at Buffalo.
The study, which was presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, was a multisite, randomized controlled trial that used a randomized block design to assign women to three groups. The control group received no intervention; the remainder of patients received either thromboembolic deterrent (TED) stockings or sequential compression devices (SCDs) set to intermittent compression and applied before receiving epidural anesthesia.
The facilities’ usual protocols were followed both for epidural placement and for patient management, except for the lower limb compression and the study’s timed blood pressure checks.
Pregnant women who were at term and had requested epidural anesthesia were included if they had a singleton pregnancy; no history of hypertension, cardiovascular disease; and no contraindication to lower limb compression.
Hypotension – defined as at least one decrease in either systolic or diastolic blood pressure of more than 20% from baseline – was tracked by obtaining sequential blood pressure readings. A baseline was established with an average of three readings obtained before epidural placement. Following the epidural bolus, blood pressures were measured at minutes 1, 5, 15, 30, 45, and 60.
The investigators used an intention-to-treat analysis, meaning that they included patients allocated to each group whether or not they actually received lower limb compression. Patients with missing data were excluded.
A total of 82 patients were randomized:
- 28 to the control arm (no lower limb compression); 1 had missing data.
- 26 to receive TEDs (6 of whom did not don the stockings); 5 were excluded from analysis because of missing data or no epidural placement.
- 28 patients to receive SCDs (8 of whom did not have SCDs applied); 5 were excluded from analysis because of missing data or no epidural placement.
While the SCDs cut the incidence of hypotension in half, compared with no compression, women in the TEDs group saw an intermediate result, with a 52.4% incidence of hypotension.
Dr. Steinmetz noted that knee-high TEDs were used. The choice was made in part because the labor and delivery nursing staff were not enthusiastic about the prospect of placing thigh-high TEDs on a woman in labor, she added.
Patient age, mean body mass index, and gestational age did not differ significantly between the study arms. Logistic regression analysis performed to control for clinical site, method of delivery, gestational age, and maternal age and body mass index did not affect the analysis, Dr. Steinmetz added.
Older data showed that about 30% of women getting epidurals in labor experience hypotension, though Dr. Steinmetz said that she believes that the 66.7% seen in this study is probably closer to an accurate estimate.
SUNY Buffalo is looking at changing the labor and delivery protocol to include lower limb compression with epidurals, Dr. Steinmetz said, adding “When I’m on labor and delivery, I definitely encourage the placement of SCDs.”
Some facilities also use lower limb compression to reduce hypotension when patients receive regional anesthesia for cesarean deliveries. Dr. Steinmetz said that there are studies that support that practice, but the literature is not conclusive. Still, it makes sense in this setting too, she said. “C-section patients sit up, they get their spinal, then we lay them down and put in a Foley, and they’re vomiting as we put in the Foley because they’re hypotensive from that spinal. ... For me, myself, when I go into practice in 2 months, yes; I will be wanting to do this.”
Dr. Steinmetz reported no relevant disclosures.
[email protected]
On Twitter @karioakes
SAN DIEGO – Use of sequential compression devices reduced by half cases of epidural-associated hypotension in laboring women in a small real-world, randomized controlled trial.
The results showed that patients who received sequential compression devices (SCD) and kept them on for at least an hour after epidural analgesia placement had half the hypotension of patients who had no lower limb compression (33.3% vs. 66.7%; P .022).
“Lower limb compression using SCDs significantly decreased the incidence of maternal hypotension in laboring patients receiving epidural anesthesia,” said Margaret Steinmetz, MD, a third-year resident at the State University of New York at Buffalo.
The study, which was presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, was a multisite, randomized controlled trial that used a randomized block design to assign women to three groups. The control group received no intervention; the remainder of patients received either thromboembolic deterrent (TED) stockings or sequential compression devices (SCDs) set to intermittent compression and applied before receiving epidural anesthesia.
The facilities’ usual protocols were followed both for epidural placement and for patient management, except for the lower limb compression and the study’s timed blood pressure checks.
Pregnant women who were at term and had requested epidural anesthesia were included if they had a singleton pregnancy; no history of hypertension, cardiovascular disease; and no contraindication to lower limb compression.
Hypotension – defined as at least one decrease in either systolic or diastolic blood pressure of more than 20% from baseline – was tracked by obtaining sequential blood pressure readings. A baseline was established with an average of three readings obtained before epidural placement. Following the epidural bolus, blood pressures were measured at minutes 1, 5, 15, 30, 45, and 60.
The investigators used an intention-to-treat analysis, meaning that they included patients allocated to each group whether or not they actually received lower limb compression. Patients with missing data were excluded.
A total of 82 patients were randomized:
- 28 to the control arm (no lower limb compression); 1 had missing data.
- 26 to receive TEDs (6 of whom did not don the stockings); 5 were excluded from analysis because of missing data or no epidural placement.
- 28 patients to receive SCDs (8 of whom did not have SCDs applied); 5 were excluded from analysis because of missing data or no epidural placement.
While the SCDs cut the incidence of hypotension in half, compared with no compression, women in the TEDs group saw an intermediate result, with a 52.4% incidence of hypotension.
Dr. Steinmetz noted that knee-high TEDs were used. The choice was made in part because the labor and delivery nursing staff were not enthusiastic about the prospect of placing thigh-high TEDs on a woman in labor, she added.
Patient age, mean body mass index, and gestational age did not differ significantly between the study arms. Logistic regression analysis performed to control for clinical site, method of delivery, gestational age, and maternal age and body mass index did not affect the analysis, Dr. Steinmetz added.
Older data showed that about 30% of women getting epidurals in labor experience hypotension, though Dr. Steinmetz said that she believes that the 66.7% seen in this study is probably closer to an accurate estimate.
SUNY Buffalo is looking at changing the labor and delivery protocol to include lower limb compression with epidurals, Dr. Steinmetz said, adding “When I’m on labor and delivery, I definitely encourage the placement of SCDs.”
Some facilities also use lower limb compression to reduce hypotension when patients receive regional anesthesia for cesarean deliveries. Dr. Steinmetz said that there are studies that support that practice, but the literature is not conclusive. Still, it makes sense in this setting too, she said. “C-section patients sit up, they get their spinal, then we lay them down and put in a Foley, and they’re vomiting as we put in the Foley because they’re hypotensive from that spinal. ... For me, myself, when I go into practice in 2 months, yes; I will be wanting to do this.”
Dr. Steinmetz reported no relevant disclosures.
[email protected]
On Twitter @karioakes
SAN DIEGO – Use of sequential compression devices reduced by half cases of epidural-associated hypotension in laboring women in a small real-world, randomized controlled trial.
The results showed that patients who received sequential compression devices (SCD) and kept them on for at least an hour after epidural analgesia placement had half the hypotension of patients who had no lower limb compression (33.3% vs. 66.7%; P .022).
“Lower limb compression using SCDs significantly decreased the incidence of maternal hypotension in laboring patients receiving epidural anesthesia,” said Margaret Steinmetz, MD, a third-year resident at the State University of New York at Buffalo.
The study, which was presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists, was a multisite, randomized controlled trial that used a randomized block design to assign women to three groups. The control group received no intervention; the remainder of patients received either thromboembolic deterrent (TED) stockings or sequential compression devices (SCDs) set to intermittent compression and applied before receiving epidural anesthesia.
The facilities’ usual protocols were followed both for epidural placement and for patient management, except for the lower limb compression and the study’s timed blood pressure checks.
Pregnant women who were at term and had requested epidural anesthesia were included if they had a singleton pregnancy; no history of hypertension, cardiovascular disease; and no contraindication to lower limb compression.
Hypotension – defined as at least one decrease in either systolic or diastolic blood pressure of more than 20% from baseline – was tracked by obtaining sequential blood pressure readings. A baseline was established with an average of three readings obtained before epidural placement. Following the epidural bolus, blood pressures were measured at minutes 1, 5, 15, 30, 45, and 60.
The investigators used an intention-to-treat analysis, meaning that they included patients allocated to each group whether or not they actually received lower limb compression. Patients with missing data were excluded.
A total of 82 patients were randomized:
- 28 to the control arm (no lower limb compression); 1 had missing data.
- 26 to receive TEDs (6 of whom did not don the stockings); 5 were excluded from analysis because of missing data or no epidural placement.
- 28 patients to receive SCDs (8 of whom did not have SCDs applied); 5 were excluded from analysis because of missing data or no epidural placement.
While the SCDs cut the incidence of hypotension in half, compared with no compression, women in the TEDs group saw an intermediate result, with a 52.4% incidence of hypotension.
Dr. Steinmetz noted that knee-high TEDs were used. The choice was made in part because the labor and delivery nursing staff were not enthusiastic about the prospect of placing thigh-high TEDs on a woman in labor, she added.
Patient age, mean body mass index, and gestational age did not differ significantly between the study arms. Logistic regression analysis performed to control for clinical site, method of delivery, gestational age, and maternal age and body mass index did not affect the analysis, Dr. Steinmetz added.
Older data showed that about 30% of women getting epidurals in labor experience hypotension, though Dr. Steinmetz said that she believes that the 66.7% seen in this study is probably closer to an accurate estimate.
SUNY Buffalo is looking at changing the labor and delivery protocol to include lower limb compression with epidurals, Dr. Steinmetz said, adding “When I’m on labor and delivery, I definitely encourage the placement of SCDs.”
Some facilities also use lower limb compression to reduce hypotension when patients receive regional anesthesia for cesarean deliveries. Dr. Steinmetz said that there are studies that support that practice, but the literature is not conclusive. Still, it makes sense in this setting too, she said. “C-section patients sit up, they get their spinal, then we lay them down and put in a Foley, and they’re vomiting as we put in the Foley because they’re hypotensive from that spinal. ... For me, myself, when I go into practice in 2 months, yes; I will be wanting to do this.”
Dr. Steinmetz reported no relevant disclosures.
[email protected]
On Twitter @karioakes
AT ACOG 2017
Key clinical point:
Major finding: The rate of hypotension for women in labor who received epidurals was 66.7% with no lower limb compression, compared with 33.3% when sequential compression devices were used (P –.02).
Data source: Multisite randomized controlled trial of 82 patients who received epidurals while in labor.
Disclosures: The study authors reported no outside sources of funding, and reported no conflicts of interest.
Periconception smoking found to affect birth defect risk
SAN DIEGO – Smoking during the period of fetal organogenesis, during the first trimester of pregnancy, is associated with increased risk of some birth defects, results from a large retrospective analysis demonstrated.
Ms. Perry, a second-year medical student at the University of Cincinnati and her associates conducted a population-based retrospective cohort analysis of 1,436,036 live births in Ohio during 2006-2015. They compared the rates of major defects between births to nonsmoking mothers and those who smoked only during the 3-month preconception period and not in the first trimester; and in the preconception period plus throughout the first trimester. They used multivariate logistic regression to quantify the relationship between smoking and birth defects after adjustment for maternal race, age, pregestational diabetes, and socioeconomic factors.
The researchers observed that 23.3% of women smoked during pregnancy; 6.0% during preconception only and 17.3% smoked through the first trimester, as well. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis (adjusted risk ratio, 1.4), but no other individual birth defects. However, smoking through the first trimester was associated with a modest but significantly increased risk of several defects, including gastroschisis (adjusted RR, 1.9), limb reduction (adjusted RR, 1.6), congenital diaphragmatic hernia (adjusted RR, 1.4), and cleft palate (adjusted RR, 1.2), even after adjustment for coexisting factors.
“It was surprising to see that, even when women stop smoking when they find out they are pregnant, and therefore are not smoking during the period of fetal organogenesis, there is still an increased risk of some congenital birth defects to the fetus,” Ms. Perry said. “My hope is that this study serves as a launching point for future research and public health efforts. It’s important to encourage smoking cessation in women of reproductive age, whether pregnant or not. Furthermore, it’s valuable to be able to explain to patients that along with adverse effects to their own health, smoking even before conception poses a risk to the fetus.”
She acknowledged certain limitations of the study, including its observational design. “There could exist unmeasurable influences that we were unable to adjust for,” Ms. Perry said. She reported having no financial disclosures.
SAN DIEGO – Smoking during the period of fetal organogenesis, during the first trimester of pregnancy, is associated with increased risk of some birth defects, results from a large retrospective analysis demonstrated.
Ms. Perry, a second-year medical student at the University of Cincinnati and her associates conducted a population-based retrospective cohort analysis of 1,436,036 live births in Ohio during 2006-2015. They compared the rates of major defects between births to nonsmoking mothers and those who smoked only during the 3-month preconception period and not in the first trimester; and in the preconception period plus throughout the first trimester. They used multivariate logistic regression to quantify the relationship between smoking and birth defects after adjustment for maternal race, age, pregestational diabetes, and socioeconomic factors.
The researchers observed that 23.3% of women smoked during pregnancy; 6.0% during preconception only and 17.3% smoked through the first trimester, as well. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis (adjusted risk ratio, 1.4), but no other individual birth defects. However, smoking through the first trimester was associated with a modest but significantly increased risk of several defects, including gastroschisis (adjusted RR, 1.9), limb reduction (adjusted RR, 1.6), congenital diaphragmatic hernia (adjusted RR, 1.4), and cleft palate (adjusted RR, 1.2), even after adjustment for coexisting factors.
“It was surprising to see that, even when women stop smoking when they find out they are pregnant, and therefore are not smoking during the period of fetal organogenesis, there is still an increased risk of some congenital birth defects to the fetus,” Ms. Perry said. “My hope is that this study serves as a launching point for future research and public health efforts. It’s important to encourage smoking cessation in women of reproductive age, whether pregnant or not. Furthermore, it’s valuable to be able to explain to patients that along with adverse effects to their own health, smoking even before conception poses a risk to the fetus.”
She acknowledged certain limitations of the study, including its observational design. “There could exist unmeasurable influences that we were unable to adjust for,” Ms. Perry said. She reported having no financial disclosures.
SAN DIEGO – Smoking during the period of fetal organogenesis, during the first trimester of pregnancy, is associated with increased risk of some birth defects, results from a large retrospective analysis demonstrated.
Ms. Perry, a second-year medical student at the University of Cincinnati and her associates conducted a population-based retrospective cohort analysis of 1,436,036 live births in Ohio during 2006-2015. They compared the rates of major defects between births to nonsmoking mothers and those who smoked only during the 3-month preconception period and not in the first trimester; and in the preconception period plus throughout the first trimester. They used multivariate logistic regression to quantify the relationship between smoking and birth defects after adjustment for maternal race, age, pregestational diabetes, and socioeconomic factors.
The researchers observed that 23.3% of women smoked during pregnancy; 6.0% during preconception only and 17.3% smoked through the first trimester, as well. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis (adjusted risk ratio, 1.4), but no other individual birth defects. However, smoking through the first trimester was associated with a modest but significantly increased risk of several defects, including gastroschisis (adjusted RR, 1.9), limb reduction (adjusted RR, 1.6), congenital diaphragmatic hernia (adjusted RR, 1.4), and cleft palate (adjusted RR, 1.2), even after adjustment for coexisting factors.
“It was surprising to see that, even when women stop smoking when they find out they are pregnant, and therefore are not smoking during the period of fetal organogenesis, there is still an increased risk of some congenital birth defects to the fetus,” Ms. Perry said. “My hope is that this study serves as a launching point for future research and public health efforts. It’s important to encourage smoking cessation in women of reproductive age, whether pregnant or not. Furthermore, it’s valuable to be able to explain to patients that along with adverse effects to their own health, smoking even before conception poses a risk to the fetus.”
She acknowledged certain limitations of the study, including its observational design. “There could exist unmeasurable influences that we were unable to adjust for,” Ms. Perry said. She reported having no financial disclosures.
AT ACOG 2017
Key clinical point:
Major finding: Smoking during only the preconception period was associated with a 40% increased risk of gastroschisis (adjusted RR, 1.4), while smoking during the first trimester of pregnancy was associated with a significantly increased risk of gastroschisis (adjusted RR, 1.9) and several other birth defects.
Data source: A retrospective cohort analysis of 1,436,036 live births in Ohio during 2006-2015.
Disclosures: Ms. Perry reported having no financial disclosures.