Predicting spinal hypotension during cesarean delivery: what is being predicted, and when
- 1Department of Anesthesiology, Chongqing Wanzhou Health Center for Women and Children, Chongqing, China
- 2Department of Anesthesiology, Chongqing Three Gorges Medical College Affiliated People’s Hospital, Chongqing, China
Abstract
Spinal hypotension during cesarean delivery has generated a large prediction literature, but the term “prediction” is applied to signals obtained at very different points in the peri-spinal course. Most reviews group predictors by physiology or device. Here we organize them by when the signal becomes available and which clinical decision remains open. This changes how reported performance should be interpreted. A preoperative low-frequency/high-frequency heart rate variability threshold of 2.5, for example, showed only 35% sensitivity and discrimination around 0.60 in an independent cohort, whereas small development studies of other preoperative tools have reported areas under the receiver operating characteristic curve approaching 0.9. Pre-spinal provocation may improve discrimination while preserving time to adjust prophylaxis. Measurements obtained after intrathecal injection, and real-time algorithms operating minutes before hypotension, answer a different question because sympathetic blockade is already evolving and the decision window is narrower. Variation in hypotension definitions, treatment background, case mix, and small development samples further limits direct comparison. Routine vasopressor prophylaxis also changes what a useful predictor should do: rather than decide who receives prevention, it should help identify who needs earlier, stronger, or differently titrated treatment. Two randomized cesarean trials now support Hypotension Prediction Index-guided management, while treatment-impact evidence for true preoperative prediction remains limited.
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BibTeX
@article{zhang2026predicting,
title = {{Predicting spinal hypotension during cesarean delivery: what is being predicted, and when}},
author = {Yi Zhang and Shuang Guo and Qingjun Zeng and Chaowen Fu},
journal = {Frontiers in Medicine},
year = {2026},
month = oct,
doi = {10.3389/fmed.2026.1989191},
url = {https://doi.org/10.3389/fmed.2026.1989191},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Predicting spinal hypotension during cesarean delivery: what is being predicted, and when
AU - Yi Zhang
AU - Shuang Guo
AU - Qingjun Zeng
AU - Chaowen Fu
PY - 2026
DA - 2026/10/12
JO - Frontiers in Medicine
DO - 10.3389/fmed.2026.1989191
UR - https://doi.org/10.3389/fmed.2026.1989191
AB - Spinal hypotension during cesarean delivery has generated a large prediction literature, but the term “prediction” is applied to signals obtained at very different points in the peri-spinal course. Most reviews group predictors by physiology or device. Here we organize them by when the signal becomes available and which clinical decision remains open. This changes how reported performance should be interpreted. A preoperative low-frequency/high-frequency heart rate variability threshold of 2.5, for example, showed only 35% sensitivity and discrimination around 0.60 in an independent cohort, whereas small development studies of other preoperative tools have reported areas under the receiver operating characteristic curve approaching 0.9. Pre-spinal provocation may improve discrimination while preserving time to adjust prophylaxis. Measurements obtained after intrathecal injection, and real-time algorithms operating minutes before hypotension, answer a different question because sympathetic blockade is already evolving and the decision window is narrower. Variation in hypotension definitions, treatment background, case mix, and small development samples further limits direct comparison. Routine vasopressor prophylaxis also changes what a useful predictor should do: rather than decide who receives prevention, it should help identify who needs earlier, stronger, or differently titrated treatment. Two randomized cesarean trials now support Hypotension Prediction Index-guided management, while treatment-impact evidence for true preoperative prediction remains limited.
SN - 2296-858X
ER -