Efficacy and safety of combined spinal: Epidural versus epidural technique for labor analgesia in parturients with rheumatic valvular heart disease

Background: Hemodynamic changes induced by labor pain and apprehension in addition to physiological changes may pose risk to parturients with rheumatic heart disease (RHD). Therefore, it is important to provide adequate pain relief during labor in these patients. We planned this study to compare the efficacy and safety of epidural (E) versus combined spinal - epidural (CSE) for labor analgesia in parturients with rheumatic valvular heart disease. Methods: Twenty-five parturients with RHD included in this study were randomized to one of the two groups - E group (n = 12), received 6 mL of 0.0625% bupivacaine with 25 μg fentanyl or CSE group (n = 13), received 25 μg of fentanyl with 1.25 mg bupivacaine diluted to 1 mL in subarachnoid space. Afterward, a continuous infusion of 0.1% bupivacaine with 2 μg/mL fentanyl was started at 6-8 mL/h. Primary outcome, analgesic efficacy, was assessed by visual analog scale (VAS) for pain. VAS ≤ 3 was considered as effective analgesia. Rescue analgesia in the form of epidural bolus was given if VAS > 3. Results: Demographic characteristics of the patients were comparable. Mitral stenosis was the predominant valvular lesion. The VAS at which the parturients received analgesia was comparable. The mean time to achieve effective analgesia was significantly faster in CSE group (4.46 ± 0.87 min) compared with group E (15.09 ± 5.7 min) (P < 0.001). Significantly lower median pain scores were recorded until the initial 15 min in CSE group. Afterward, median VAS for pain was comparable between the groups. VAS for pain was significantly low at all time intervals than baseline in both the groups. Maternal satisfaction and incidence of cesarean rate and complication were comparable between the groups. Conclusion: Both epidural and CSE are equally effective and safe for labor analgesia in parturients with rheumatic valvular heart disease. However, CSE technique provides a faster onset of analgesia.