Comparative effectiveness of ephedrine and norepinephrine for hypotension in cesarean section under spinal anesthesia: A systematic literature review

Abstract

Background : High-risk deliveries are generally managed via cesarean section. Spinal anesthesia is frequently chosen due to its rapid onset and sufficint  duration of action. However, hypotension remains a major complication that may comprmise maternal hemodynamics stability and fetal perfusion. Vasopressors such as ephedrine and norepinephrine are used to address this condition. Ephedrine is associate with increased tachycardia and higher rates of placental abruption, whereas norepinephrine is considered more stable in maintaining maternal hemodynamics without an increase in heart rate and with minimal placental abruption, although evidence of its effectiveness remains limited. Therefore, the researchers conducted a systematic review comparing the effectiveness of ephedrine and norepinephrine in managing hypotension in patients undergoing cesarean section under spinal anesthesia.

Method : This study utilized a PICO-based literature review and the PRISMA protocol, with inclusion criteria for quantitative studies (RCTs, cohort studies, and retrospective comparative studies) examining the use of ephedrine and norepinephrine in patients undergoing cesarean section with spinal anesthesia, published between 2015 and 2025 and written in English. Databases: Google Scholar, PubMed, and ScienceDirect. Article quality was assessed using the JBI Critical Appraisal Tools with narrative data synthesis.

Results : Based on 9 studies (8 RCTs and 1 comparative clinical study) involving a total of 1,006 patients (ages 18–46 years, ASA I and II), it was reported that norepinephrine was 55.6% more effective in maintaining maternal hemodynamics without inducing tachycardia and was associated with lower rates of placental abruption. A total of 22.2% reported no significant difference between the two groups, while another 22.2% stated that ephedrine was more effective despite a higher risk of tachycardia. Maternal effects (nausea, vomiting, chills, dizziness, palpitations) as well as umbilical artery pH and APGAR scores were generally similar across groups.

Conclusion : Norepinephrine is effectively maintains maternal hemodynamic stability while being associated with a reduced occurrence of tchycardia, along with a favorable neonatal profile and minimal maternal adverse effects. Therefore, it may be considered as an alternative vasopressor in patients undergoing cesarean section with spinal anesthesia.