This retrospective study of the blood pressure effects of spinal vs epidural anesthesia in severely preeclamptic patients requiring cesarean section cannot exclude the possibility that selection bias contributed significantly to the study outcome. That is, it is possible that "sicker" patients were managed with epidurals. The author attempts to address this concern by suggesting that the starting blood pressure of patients in each group was similar. However, blood pressure is not always a true surrogate for severity of preeclampsia. Also, the increased use of antihypertensive agents in the epidural group suggests that if they were not "sicker", at least their blood pressure was more difficult to manage. Then Hood refers to a study by Wallace in 1995, a prospective randomized clinical trial that supports the conclusions of this study, in which there was no difference in the blood pressure effects of spinal vs epidural anesthesia for cesarean section in severely preeclamptic patients.

Practice is changing so that many anesthesiologists now prefer epidural to general anesthesia for this patient group, where time permits. If time to cesarean section is limited and an epidural has not been placed, spinal anesthesia is becoming a more frequent option, while general anesthesia is reserved for patients with absolute contraindications to regional anesthesia and where the obstetric team feels that there is absolutely no time for the regional to be placed.

This is not to suggest that spinal anesthesia is now the "standard of care" for severe preeclamptic patients who require a cesarean section. But the severe and frequent hypotension that might be intuitively expected with spinal anesthesia, compared to epidural anesthesia, has not appeared in these early, small, studies. If you will be changing your practice and starting to use spinals for this patient population I would suggest that you choose cases that are more straightforward to allow yourself to become more comfortable with spinal technique in this new setting. As well, this will allow time for larger prospective randomized trials which will more clearly define the place of spinal anesthesia for this particular patient population. Finally, it is still accepted practice to establish epidural analgesia early in labor for patients with severe preeclampsia, especially as they are at greater risk for the need for urgent cesarean section.