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Effect of General Anesthesia with Thiopental Sodium and Propofol on the 1- and 5 Minute Apgar Newborns by Cesarean

The authors declare no conflicts of interest. *Corresponding author. E-mail address: shomia@ymail.com Copyright © 2021 Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/by-nc/4.0/). Noncommercial uses of the work are permitted, provided the original work is properly cited. Effect of General Anesthesia with Thiopental Sodium and Propofol on the 1and 5 Minute Apgar Newborns by Cesarean

aesarean section, is the use of surgery to deliver babies [1]. In 2012, about 23 million C-sections were done globally [2]. A C-section typically takes 45 minutes to an hour [3]. It may be done with a spinal block, where the woman is awake, or under general anesthesia [4]. Regional anesthesia may be preferred as it allows the mother to be awake and interact immediately with her baby [5]. Compared to general anesthesia, regional anesthesia is better at preventing persistent postoperative pain 3 to 8 months after caesarean section [6]. Other advantages of regional anesthesia may include the absence of typical risks of general anesthesia: pulmonary aspiration (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and esophageal intubation [7]. One trial found no difference in satisfaction when general anesthesia was compared with either spinal anesthesia [8]. Regional anesthesia is C Research Article used in 95% of deliveries, with spinal and combined spinal and epidural anesthesia being the most commonly used regional techniques in scheduled cesarean section [9]. Regional anesthesia during caesarean section is different from the analgesia (pain relief) used in labor and vaginal delivery [10]. The pain that is experienced because of surgery is greater than that of labor and therefore requires a more intense nerve block. General anesthesia may be necessary because of specific risks to mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia [11]. General anesthesia is also preferred in very urgent cases, such as severe fetal distress, when there is no time to perform a regional anesthesia [12]. Given the abdominal filling of patients during pregnancy, general anesthesia for cesarean section requires laryngoscopy and intra-tracheal intubation, both of which provide an extremely severe stimulus and increase the patient's heart rate and blood pressure. Thus, in general anesthesia, opiates -beta-blockers and nitroglycerin -lidocaine and deeper anesthesia are used to control this complication [13]. Thiopental sodium and propofol are among the drugs widely used to induce anesthesia [14]. In the usual cases, thiopental sodium is used, but propofol has also gained prominence in anesthesia in recent decade. Propofol improves the quality and recovery time, which is associated with a lower proportion of postoperative nausea and vomiting [15]. Rapid disposal, lack of cumulative effects of the drug and its bronchodilator effects are other notable properties of the drug [16]. On the other hand, Propofol can reduce the patient's blood pressure relatively. This property is particularly important in preeclampsia and can modulate the increase in blood pressure following intubation [17]. Propofol passes through the placenta in large quantities and rapidly. This may disrupt the neural function of the infant and reduces fetal blood flow with an effect on the mother's blood pressure [18]. The Apgar score is a method to quickly summarize the health of newborn children against infant mortality [19]. This score is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two, then summing up the five values thus obtained. This grading uses three criteria (breathing, heart rate and skin color) to decide how and when resuscitation begins and the other two components of Apgar (muscle tone and irritability reflex) determine neurological status. The resulting score ranges for every criterion from zero to 10 [20]. In this study the effect of general anesthesia with thiopental and propofol on neonatal Apgar score of first and fifth minutes in cesarean section was investigated.

Methods
This study, reviewed and approved by the Research Ethics Committee of Sabzevar University of Medical Sciences, with registration code of IR. MEDSAB.REC.1396.86.
In this double-blind clinical trial, 100 pregnant women with age range 18-35 years and being in ASA Class I or II, who were candidates for elective cesarean section were selected and randomly assigned to A and B groups (50 persons in each group). Any suffering from heart diseases, high blood pressure, diabetes, allergy to certain drugs of the study, eclampsia and preeclampsia diseases, gestational diabetes mellitus (GDM), placental abruption, oligohydramnios, placental disorders, coagulopathy, fetal disorders, addiction to drugs and cold made volunteers unqualified for this study. Limiting and matching techniques were used to control confounding variables, and demographic profiles of both groups were identical. To induce anesthesia, propofol (2.5 mg/ kg) was administered to patients in group A and thiopental sodium (4.5 mg / kg) to group B patients ( Figure 1). Succinylcholine was used to establish muscle relaxation for intubation in each group. However, anesthesia was maintained with 0.5% isoflurane and a mixture of oxygen and nitrous oxide. In each group, at thirty seconds after birth, 5 factors of heart rate, respiratory status, skin color, muscle tone and reflex responses by midwife unaware of medication were recorded and assessed in a checklist.

Results
In this study, for group propofol, the Apgar score at 1th minute was recorded 8 for a newborn and 9 for 49 newborns. The Apgar score at 5th minute was recorded 10 for all newborns. While, for thiopental group, the Apgar score at 1th minute was recorded 9 for all newborns. The Apgar score at 5th minute was recorded 10 for all 50 newborns (Table 1).
According to the results in )Table 2(, the groups had significant differences in the indices such as first systolic (P=0.00) and diastolic (P=0.00) pressure in recovery, last diastolic pressure in recovery (P=0.001) and duration of postoperative recovery (P=0.001), while the mean scores in the propofol group were significantly higher than the thiopental sodium group. The statistical analysis of nausea and vomiting in both groups made it clear that either nausea or vomiting in propofol group was meaningfully less than that in thiopental group (P=0.00).

Discussion
In this study, the Apgar score of cesarean infants at 1 and 5 minutes induced by propofol was approximately similar to those treated with thiopental; likewise, first systolic and diastolic pressure in recovery, last diastolic pressure in recovery and duration of postoperative recovery showed a meaningful difference. Incidence rate of nausea and vomiting in propofol treated group was less than those in thiopental treated group. In this study, the participants were matched and randomized regardless of whether they were primiparous or multiparous.
Studies on 40 Hong Kong women who had registered for the cesarean operation showed that Apgar scores of newborn babies, in both thiopental and propofol groups, who were born through elective cesarean, were similar. The study was enjoying a proper matching process and a sufficient fluid therapy has been practiced prior to inducing anesthesia, however, their results were similar to ours [21].
Celleno et al. studied 90 Italian women. The Apgar scores of cesarean babies who had been inducted with propofol were less than babies inducted with thiopental. Thus, their results were in contradiction to ours [22]. 32 Finnish women who had registered in hospital for cesarean operation were divided into two groups, each 16 women. The Apgar scores of the cesarean newborn babies who had been inducted with thiopental and propofol did not differ meaningfully; both groups were treated with propofol for maintaining anesthesia condition. Likewise, the results were similar to our results [23]. Ghodrati et al. reported in Ardabil's Alavi Hospital no meaningful difference among Apgar scores (at 1, 5, 10 and 15 minutes) of the cesarean newborn babies, who had been inducted with propofol and thiopental. Similarly, in this study, mothers' hemodynamic changes were found without meaningful difference for the two groups. In order to maintain the anesthesia condition, halothane had been used; however, regarding its effects on liver, recently it has been used very rarely. Using this anesthetic to maintain anesthesia condition for both groups, can justify similar results in both groups [24].
Djordoevi et al. studied 40 Serbian pregnant women who were inclined to give birth to their children through cesarean operation. They found that the Apgar score at 1 minute of the cesarean newborn baby who had been treated with thiopental, as the anesthesia induction, was higher. In this study, both elective cesarean and emergency cesarean were included and groups' matching has not been explained. Propofol was used to maintain anesthesia [25].

Conclusion
Although propofol and thiopental did not differ significantly in Apgar score, however with regard to advantages and disadvantages of these two drugs, it seems that propofol can be a better option to induce anesthesia for an elective cesarean operation when no certain risk threatens mother and fetus and there is not any contraindication.