Aortocaval compression syndrome (Supine hypotension syndrome) in pregnancy occurs after 20 weeks. What is the immediate anaesthetic management for a pregnant patient who develops sudden hypotension and bradycardia in the supine position during spinal anaesthesia for Caesarean section?

• A Administer atropine 0.6 mg IV only
• B Raise both legs 30° to increase venous return from lower limbs
• C Left lateral uterine displacement (tilt 15–30° left), IV fluid bolus, and vasopressor (phenylephrine or ephedrine) to restore uteroplacental perfusion ✓
• D Increase spinal anaesthetic dose to block T2 and improve cardiac sympathectomy

Explanation

From 20 weeks onwards, the gravid uterus compresses the inferior vena cava in the supine position, reducing venous return and cardiac output. Combined with sympathetic blockade from spinal anaesthesia, this produces significant hypotension impairing uteroplacental blood flow. Immediate management: (1) manual left uterine displacement or left lateral tilt of the operating table (15–30°), (2) IV fluid bolus (co-load with crystalloid), and (3) vasopressor — phenylephrine (100–200 µg bolus or infusion) is preferred over ephedrine in obstetrics as it maintains fetal acid-base balance better, though ephedrine remains appropriate for bradycardia-associated hypotension.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.