Performance of non-invasive stroke volume variation during passive leg raising as a predictor of hypotension following induction of spinal anesthesia for elective cesarean delivery: a single cohort study

Published:December 29, 2021DOI:


      • Identifying risk factors might improve prevention of spinal-induced hypotension.
      • Baseline non-invasive stroke volume variation with passive leg raising was assessed.
      • Pre-spinal stroke volume change predicted hypotension after spinal anesthesia.
      • Assessment of change in stroke volume may help prevent hypotension.



      Spinal anesthesia for cesarean delivery is accompanied by hypotension in up to 70% of cases. To date, there is no gold standard for predicting hypotension after spinal anesthesia for cesarean delivery. The Clearsight™ device is a non-invasive system that uses a digital cuff to calculate stroke volume. We hypothesized that stroke volume variation induced with passive leg raising before spinal anesthesia for elective cesarean delivery could predict the occurrence of hypotension.


      We conducted a prospective observational study, including third trimester parturients undergoing elective cesarean delivery with spinal anesthesia. We analyzed the stroke volume variation performance for predicting hypotension. Stroke volume was collected in the semi-recumbent position (baseline) and during passive leg raising before spinal anesthesia. Systolic arterial blood pressure measurement was followed for 15 min after spinal anesthesia. Hypotension was defined as a ≥20% decrease from the baseline measurement. All parturients received appropriate hypotension prophylaxis.


      Data from 42 parturients were analyzed. Hypotension occurred in 45%. The area-under-the curve for predicting hypotension using the stroke volume variation was 0.83 (95% CI 0.68 to 0.98; P=0.001). The best cut-off value for predicting hypotension was 7%, having a sensitivity of 87% (95% CI 0.70 to 0.99) and a specificity of 83% (95% CI 0.69 to 0.97).


      In our study of third trimester parturients undergoing cesarean delivery and receiving appropriate hypotension prophylaxis, a digital non-invasive monitoring device of stroke volume variation analysis was useful for predicting the occurrence of hypotension after spinal anesthesia.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to International Journal of Obstetric Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Klöhr S.
        • Roth R.
        • Hofmann T.
        • Rossaint R.
        • Heesen M.
        Definitions of hypotension after spinal anaesthesia for caesarean section: literature search and application to parturients.
        Acta Anaesthesiol Scand. 2010; 54: 909-921
        • Kinsella S.M.
        • Carvalho B.
        • Dyer R.A.
        • et al.
        International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia.
        Anaesthesia. 2018; 73: 71-92
        • Robson S.C.
        • Boys R.J.
        • Rodeck C.
        • Morgan B.
        Maternal and fetal haemodynamic effects of spinal and extradural anaesthesia for elective caesarean section.
        Br J Anaesth. 1992; 68: 54-59
        • Roberts S.W.
        • Leveno K.J.
        • Sidawi J.E.
        • Lucas M.J.
        • Kelly M.A.
        Fetal acidemia associated with regional anesthesia for elective cesarean delivery.
        Obstet Gynecol. 1995; 85: 79-83
        • Langesæter E.
        • Dyer R.A.
        Maternal haemodynamic changes during spinal anaesthesia for caesarean section.
        Curr Opin Anaesthesiol. 2011; 24: 242-248
        • Langesæter E.
        • Gibbs M.
        • Dyer R.A.
        The role of cardiac output monitoring in obstetric anesthesia.
        Curr Opin Anaesthesiol. 2015; 28: 247-253
        • Zieleskiewicz L.
        • Noel A.
        • Duclos G.
        • et al.
        Can point-of-care ultrasound predict spinal hypotension during caesarean section? A prospective observational study.
        Anaesthesia. 2018; 73: 15-22
        • Allen T.K.
        • George R.B.
        • White W.D.
        • Muir H.A.
        • Habib A.S.
        A double-blind, placebo-controlled trial of four fixed rate infusion regimens of phenylephrine for hemodynamic support during spinal anesthesia for cesarean delivery.
        Anesth Analg. 2010; 111: 1221-1229
        • Mercier F.J.
        Cesarean delivery fluid management.
        Curr Opin Anaesthesiol. 2012; 25: 286-291
        • Mercier F.J.
        • Diemunsch P.
        • Ducloy-Bouthors A.-S.
        • et al.
        6% Hydroxyethyl starch (130/0.4) vs Ringer’s lactate preloading before spinal anaesthesia for Caesarean delivery: the randomized, double-blind, multicentre CAESAR trial.
        Br J Anaesth. 2014; 113: 459-467
        • Cornette J.
        • Laker S.
        • Jeffery B.
        • et al.
        Validation of maternal cardiac output assessed by transthoracic echocardiography against pulmonary artery catheterization in severely ill pregnant women: prospective comparative study and systematic review.
        Ultrasound Obstet Gynecol. 2017; 49: 25-31
        • Ameloot K.
        • Palmers P.-J.
        • Malbrain M.L.N.G.
        The accuracy of noninvasive cardiac output and pressure measurements with finger cuff: a concise review.
        Curr Opin Crit Care. 2015; 21: 232-239
        • Eeftinck Schattenkerk D.W.
        • van Lieshout J.J.
        • van den Meiracker A.H.
        • et al.
        Nexfin noninvasive continuous blood pressure validated against Riva-Rocci/Korotkoff.
        Am J Hypertens. 2009; 22: 378-383
        • Broch O.
        • Renner J.
        • Gruenewald M.
        • et al.
        A comparison of the Nexfin® and transcardiopulmonary thermodilution to estimate cardiac output during coronary artery surgery.
        Anaesthesia. 2012; 67: 377-383
        • Schraverus P.
        • Kuijpers M.M.
        • Coumou J.
        • et al.
        Level of agreement between cardiac output measurements using Nexfin(®) and thermodilution in morbidly obese patients undergoing laparoscopic surgery.
        Anaesthesia. 2016; 71: 1449-1455
        • Duclos G.
        • Hili A.
        • Resseguier N.
        • et al.
        ClearsightTM use for haemodynamic monitoring during the third trimester of pregnancy - a validation study.
        Int J Obstet Anesth. 2018; 36: 85-95
        • Youden W.J.
        Index for rating diagnostic tests.
        Cancer. 1950; 3: 32-35
        • Ray P.
        • Le Manach Y.
        • Riou B.
        • Houle T.T.
        Statistical evaluation of a biomarker.
        Anesthesiology. 2010; 112: 1023-1040
        • Coste J.
        • Pouchot J.
        A grey zone for quantitative diagnostic and screening tests.
        Int J Epidemiol. 2003; 32: 304-313
        • Ngan Kee W.D.
        • Khaw K.S.
        • Ng F.F.
        Prevention of hypotension during spinal anesthesia for cesarean delivery: an effective technique using combination phenylephrine infusion and crystalloid cohydration.
        Anesthesiology. 2005; 103: 744-750
        • Jozwiak M.
        • Mercado P.
        • Teboul J.-L.
        • et al.
        What is the lowest change in cardiac output that transthoracic echocardiography can detect?.
        Crit Care Lond Engl. 2019; 23: 116
        • Toyama S.
        • Kakumoto M.
        • Morioka M.
        • et al.
        Perfusion index derived from a pulse oximeter can predict the incidence of hypotension during spinal anaesthesia for Caesarean delivery.
        Br J Anaesth. 2013; 111: 235-241
        • Sun S.
        • Huang S.Q.
        Role of pleth variability index for predicting hypotension after spinal anesthesia for cesarean section.
        Int J Obstet Anesth. 2014; 23: 324-329
        • Xiao W.
        • Duan Q.
        • Zhao L.
        • et al.
        Goal-directed fluid therapy may improve hemodynamic stability in parturient women under combined spinal epidural anesthesia for cesarean section and newborn well-being.
        J Obstet Gynaecol Res. 2015; 41: 1547-1555
        • Messina A.
        • Dell’Anna A.
        • Baggiani M.
        • et al.
        Functional hemodynamic tests: a systematic review and a metanalysis on the reliability of the end-expiratory occlusion test and of the mini-fluid challenge in predicting fluid responsiveness.
        Crit Care Lond Engl. 2019; 23: 264