Prediction of spinal anesthesia-induced hypotension during cesarean delivery: a narrative review

Spinal anesthesia-induced hypotension remains a major challenge in obstetric anesthesia, with significant maternal and fetal consequences despite prophylactic measures. Reliable prediction tools are essential to stratify risk and optimize management. This review narratively discusses evidence on clinical, hemodynamic, Doppler-derived, and pulse oximetry-based predictors of spinal anesthesia-induced hypotension in cesarean delivery. Clinical factors such as body mass index, maternal age, baseline blood pressure, and spinal anesthetic dose demonstrate variable predictive value. Hemodynamic markers, including heart rate variability and shock index, show promise but require further validation. Advanced monitoring techniques, such as stroke volume variation, subaortic velocity time integral, and femoral artery Doppler indices, exhibit high accuracy, while venous diameter-based measures (inferior vena cava, internal jugular vein, subclavian vein-axillary vein) yield inconsistent results. Pulse oximetry-derived indices, particularly the perfusion index, demonstrate moderate to good predictive ability across systematic reviews. Composite risk models integrating multiple parameters may enhance precision compared to single predictors. Overall, while several modalities show potential, translation into routine practice requires simplification, validation in larger cohorts, and integration into standard monitoring systems.