©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
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© 2018 EDIZIONI MINERVA MEDICA
Online version at http://www.minervamedica.it
EDITORIAL
Hypertension control during caesarean
section in patients with pre-eclampsia:
is dexmedetomidine an option?
Nicolas BROGLY *, Emilia GUASCH
Service of Anesthesia and Reanimation, University Hospital of La Paz, Madrid, Spain
*Corresponding author: Nicolas Brogly, Service of Anesthesia and Reanimation, University Hospital of La Paz, Paseo de la Castel-
lana 261, 28046 Madrid, Spain. E-mail: nicolas0brogly@hotmail.com
S evere pre-eclampsia remains a common com-
plication of pregnancy which raises special
attention among the obstetric anesthesiologists,
due to the risk of severe complications or death.1
A strict control of blood pressure is the corner-
stone of the management of these patients.2 Ther-
apeutic options before delivery include methyl-
dopa, labetalol or nifedipine,3 implemented with
intravenous labetalol and hydralazine in severe
cases. Vasodilators such as glyceryl trinitrate are
recommended for refractory hypertension,4 asso-
ciated with magnesium sulphate in prevention of
seizure.2
Caesarean section (CS) delivery is increased
in patients with pre-eclampsia,5 and general an-
esthesia (GA) is still commonly required.2 The
higher risk of hemodynamic instability espe-
cially at induction of GA and for tracheal intu-
bation must be considered, and remifentanil is
recommended by many authors for the induction
of GA in pre-eclamptic patients, to limit the sym-
pathetic stimulation of laryngoscopy, assuming a
depressor effect on the fetus.6
Recently, dexmedetomidine, a highly selec-
tive alpha-2 adrenergic receptor agonist has been
introduced in the field of anesthesia: its action on
pre- and post-synaptic receptors of the pons and
brainstem explains its hypotensive and sedative
effects, while its action on spinal and supra-spi-
nal sites permits to modulate nociceptive input.7
Vol. 84 - No. 12 Minerva Anestesiologica 1329
Minerva Anestesiologica 2018 December;84(12):1329-31
DOI: 10.23736/S0375-9393.18.12915-4
Its anti-shivering effect is probably explained by
an attenuation of sympathetic response to sur-
gical stress.8 It is also an interesting option for
premedication, anxiolysis, sedation and as an ad-
juvant of GA. It decreases perioperative require-
ments of opioids leading to a lower incidence of
postoperative nausea and vomiting (PONV), and
is a good option for opioid-free anesthesia.9
In the field of obstetric anesthesia, dexme-
detomidine has shown to be safe for the fetus,10
despite a relatively high placental transfer rate
of 0.68 to 0.76.11, 12 Its milk/plasma ratio and
relative infant dose, six hours after discontinu-
ation of the administration were (0.76;0.88) and
(0.040; 0.098) respectively, but the drug was un-
detectable in milk at 24 hours, suggesting that
dexmedetomidine is compatible with breastfeed-
ing. Sia et al.13 observed an in-vitro dose-depen-
dent effect of dexmedetomidine on myometrium
contraction, even though little evidence exists
concerning this potentially important effect.14, 15
Clinical effects of dexmedetomidine were
confirmed for delivery: Bao et al.16 confirmed
in a recent meta-analysis comparing intravenous
dexmedetomidine versus placebo in CS under
spinal anesthesia, a decrease of PONV and shiv-
ering, but also a higher incidence of maternal
bradycardia, even though episodes of hypoten-
sion were not more frequent.16
Intravenous dexmedetomidine administered
 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
BROGLY HYPERTENSION CONTROL DURING C-SECTION IN PRE-ECLAMPSIA
immediately after CS under spinal anesthesia
(loading dose of 0.5 µg/kg alone or associated
with a continuous infusion of 0.045 µg/kg/h)
provided a better pain relief compared with no
dexmedetomidine.17
El-Tahan et al.15 observed a higher suppres-
sion of hemodynamic and hormonal response to
tracheal intubation with the preoperative admin-
istration of infusions of 0.4 to 0.6 µg/kg/h dex-
medetomidine during CS under general anesthe-
sia (GA), compared with 0.2 µg/kg infusion or
placebo.
Li et al.18 compared dexmedetomidine (bolus
of 0.4 µg/kg in 10 minutes plus 0.4 µg/kg/kg in-
fusion) with remifentanil (bolus of 2 µg/kg in 10
minutes plus 2 µg/kg/h infusion) in GA for CS.
Compared with baseline value, patients in both
groups presented a significant mean arterial pres-
sure (MAP) drop after induction of GA, followed
by an increase of MAP one minute after tracheal
intubation. MAP was significantly higher in dex-
medetomidine group one minute after induction
of GA, but no other significant MAP difference
was seen. On the other hand, patients in dex-
medetomidine group required less propofol top
up doses during GA, and those in remifentanil
group presented a worse neonatal outcome, even
though these were not the primary outcomes of
the study.18
The scarce clinically relevant differences be-
tween dexmedetomidine and remifentanil on
hemodynamic response to induction of GA, re-
inforced by the better neonatal outcome of dex-
medetomidine, could convert this drug into an
ideal adjuvant for severe pre-eclamptic patients
scheduled for CS under GA.
Eskandr et al.12 recently performed a ran-
domized controlled study to evaluate the inter-
est of dexmedetomidine in the treatment of pre-
eclamptic patients submitted to CS under GA.
They compared the hemodynamic changes of a
preoperative administration of dexmedetomidine
(bolus of 0.1 µg/kg plus infusion of 0.4 or 0.6
µg/kg/h) with saline. As for non-pre-eclamptic
patients, they showed a better hemodynamic
control in dexmedetomidine groups in terms of
MAP and heart rate (HR). Three (4.6%) patients
in control group required a rescue hypotensive
treatment during surgery. Pain control was better
1330 Minerva Anestesiologica December 2018
in dexmedetomidine groups during the first five
postoperative hours. A dose dependent sedative
effect of dexmedetomidine was also observed
until 30 minutes after emergence of GA, but
there was no difference between groups after 45
minutes. Fetal wellness was not affected by dex-
medetomidine. They therefore recommended an
infusion of 0.6 µg/kg/h dexmedetomidine to be
employed for this indication.
In this issue of Minerva Anestesiologica, El-
Tahan et al.19 investigated deeper into the poten-
tial indication of dexmedetomine in pre-eclamp-
tic patients. They compared dexmedetomidine
(0.4 µg/kg/h infusion) versus remifentanil (0.1
µg/kg/h infusion) in a randomized controlled
study to assess hemodynamic changes during CS
under GA. They showed significant differences
of MAP and HR in both groups compared with
baseline. Patients in remifentanil group had low-
er MAP during all the procedure and a higher HR
drop one minute after induction. They required
more ephedrine administration, suggesting a bet-
ter hemodynamic stability with dexmedetomi-
dine than remifentanil. This better hemodynamic
profile was associated with a higher sedation
score until 15 minutes after emergence from GA
and a better postoperative pain control. Neonates
in remifentanil group also presented lower Apgar
scores at one minute, mainly due to respiratory
depression, but with no further complications, as
previously described.
This interesting article continues a new field
of investigation in blood pressure control in
pre-eclamptic patients. Further research will be
needed to confirm these results and provide more
evidence to recommend formally the use of dex-
medetomidine for the treatment of hypertensive
disorders in pregnant women during labor, de-
termine its safety profile and therapeutic dose
ranges.
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 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

HYPERTENSION CONTROL DURING C-SECTION IN PRE-ECLAMPSIA BROGLY

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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material
discussed in the manuscript.
Comment on: El-Tahan MR, El Kenany S, Abdelaty EM, Ramzy EA. Comparison of the effects of low doses of dexmedetomidine
and remifentanil on the maternal hemodynamic changes during caesarean delivery in patients with severe preeclampsia: a random-
ized trial. Minerva Anestesiol 2018;84:1343-51. DOI: 10.23736/S0375-9393.18.12312-1.
Article first published online: May 15, 2018. - Manuscript accepted: May 11, 2018. - Manuscript received: March 28, 2018.
(Cite this article as: Brogly N, Guasch E. Hypertension control during caesarean section in patients with pre-eclampsia: is dexme-
detomidine an option? Minerva Anestesiol 2018;84:1329-31. DOI: 10.23736/S0375-9393.18.12915-4)

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