More tilt, less drug: treating severe compression of inferior vena cava during caesarean section.


The case presented by Bouvet et al. highlights the potential severe haemodynamic consequences of unrelieved inferior vena cava (IVC) compression in pregnancy but also the limitations of managing these consequences by the use of vasopressors alone. Their patient developed severe sustained hypotension after being laid supine from a sitting position after her spinal injection for an elective caesarean section. The maternal hypotension remained refractory to escalating vasopressor therapy doses of phenylephrine, ephedrine and norepinephrine and may have contributed to the poor neonatal condition of the baby at birth. Although the authors stated that their patient was tilted to the left using the table tilt they make no comment how much tilt was used and they do not comment on whether they increased the tilt when the supine hypotension occurred and persisted. It is recognized that anaesthetists overestimate the angle of tilt. Increased tilt can significantly relieve inferior vena caval compression although the tilt may have to be in excess of 30 degrees that may be impossible to achieve using table tilt alone. Lateral position has been shown to offset IVC compression. In the case presented by Bouvet et al. the simple remedy of immediately turning the patient into the lateral position may have quickly resolved the hypotension without having a detrimental effect on the evolution of the spinal anaesthetic. Obviously if surgery has commenced this may not be possible but manual displacement of the uterus by the surgeons can be applied until haemodynamic stability has been achieved. Radiological investigations, which have continued after the original work by Kerr et al. demonstrate clearly the mechanical nature of inferior vena cava compression. Compensation for the reduced venous return by collateral blood flow may not be possible in all patients. A mechanical problem may be better managed by a mechanical solution.

DOI: 10.1016/j.ijoa.2016.11.005

Cite this paper

@article{Kamath2017MoreTL, title={More tilt, less drug: treating severe compression of inferior vena cava during caesarean section.}, author={Padmanabh K. Kamath and J H Bamber}, journal={International journal of obstetric anesthesia}, year={2017}, volume={29}, pages={92} }