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Summary of PET

Introduction

• Preeclampsia is a multisystem disorder unique to human pregnancy, characterised by new‑onset hypertension and organ dysfunction after 20 weeks of gestation. Hypertensive disorders affect approximately 5–10% of all pregnancies worldwide, contributing significantly to maternal and perinatal morbidity and mortality.

Incidence and Impact

• Global prevalence: Hypertensive disorders complicate 5–10% of pregnancies; preeclampsia accounts for 2–8%.
• Maternal mortality: Responsible for ~14% of maternal deaths globally and up to 20% in low‑resource settings.
• Long‑term risks: Women with a history of preeclampsia have a twofold increase in future hypertension and cardiovascular disease, and a threefold increase in end‑stage renal disease.
• Neonatal outcomes: Associated with fetal growth restriction, preterm delivery, perinatal mortality and increased lifetime cardiovascular risk in offspring.

Classification of Hypertensive Disorders

1. Chronic hypertension: Present before pregnancy or diagnosed before 20 weeks; may be complicated by superimposed preeclampsia (new endorgan dysfunction as below.)
   • Or persistent hypertension for >12 weeks post partum
2. Gestational hypertension: New‑onset hypertension (systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg) after 20 weeks without proteinuria or end‑organ dysfunction; 15–25% progress to preeclampsia.
   • Not recommended to start treatment for hypertension unless >160/110 mmHg.
     • Does not prevent progression to preeclampsia
3. Preeclampsia: Gestational hypertension with one or more of:
   • Proteinuria (≥ 300 mg/24 h or protein/creatinine ratio ≥ 0.3).
   • Other organ dysfunction (e.g. renal insufficiency, liver enzyme elevation, neurological features, haematological disturbances).
4. Severe features: Any of:
   • Severe hypertension (systolic ≥ 160 mmHg or diastolic ≥ 110 mmHg).
   • Thrombocytopenia (platelets < 100 × 10⁹/L).
   • Impaired liver function (transaminases > × 2 normal).
   • Progressive renal insufficiency (creatinine > 90 µmol/L).
   • Pulmonary oedema or new neurological signs.

Anaesthetic Implications

1. Blood pressure control: Aim for systolic 140–150 mmHg and diastolic 90–100 mmHg; first‑line agents include labetalol and hydralazine, with nitroprusside reserved for emergencies.
2. Monitoring: Invasive arterial line for continuous blood pressure monitoring in severe disease; central venous access if significant haemodynamic instability suspected.
3. Neuraxial anaesthesia: Platelet count ≥ 75 × 10⁹/L generally acceptable; avoid if < 70 × 10⁹/L or with coagulopathy.
4. Airway management: Anticipate difficult airway due to oropharyngeal oedema; prepare for smaller endotracheal tube and difficult extubation.
5. Seizure prophylaxis: Magnesium sulphate regime: loading dose 4 g IV over 20 min followed by infusion 1 g h⁻¹ for at least 24 h postpartum.
6. Fluid management: Avoid excessive crystalloids; judicious use guided by invasive monitoring to reduce risk of pulmonary oedema.

Pathophysiology

• A two‑stage model:
  1. Abnormal placentation: Inadequate cytotrophoblast invasion leads to high‑resistance uteroplacental circulation.
  2. Maternal syndrome: Release of antiangiogenic factors (sFlt‑1, soluble endoglin) induces widespread endothelial dysfunction, vasoconstriction and capillary leak.

Systemic Manifestations

System	Manifestations
Neurological	Headache, visual disturbance, hyperreflexia, eclampsia
Respiratory	Pulmonary oedema, reduced functional residual capacity
Cardiovascular	Severe vasospasm, left ventricular dysfunction
Renal	Proteinuria, oliguria, rising creatinine
Hepatic	RUQ pain, transaminase elevation, HELLP syndrome
Haematological	Thrombocytopenia, haemolysis, DIC
Feto‑placental	Growth restriction, abnormal Dopplers, risk of abruption

Complications

Acute

• Maternal: abruptio placentae; pulmonary oedema; acute kidney injury; liver failure; intracerebral haemorrhage or infarction secondary to loss of autoregulation and increased capillary permeability; progression to eclampsia with cytotoxic and/or vasogenic cerebral oedema (commonest cause of mortality).
• Neonatal: preterm birth; fetal growth restriction; hypoxic‑ischaemic encephalopathy; perinatal death.
• Risk factors for eclampsia: primiparity; young maternal age (<20 years) or >35y; low body mass index; high diastolic at booking, previous PET

Chronic

• Persistent left ventricular diastolic and/or systolic dysfunction may continue for ≥1 year after early‑onset disease.
• ↑ long‑term risk of chronic hypertension (11–14% within 10 years), ischaemic heart disease, cerebrovascular events, venous thromboembolism, white matter lesions and end‑stage renal disease.
• Cognitive deficits (impaired memory and verbal learning) may persist >15 years.

HELLP Syndrome

• Hemolysis evidence (any of):
  • Serum LDH > 600 U L⁻¹ or total bilirubin > 1.2 mg dL⁻¹ 
  • Peripheral-blood smear showing schistocytes or burr cells
  • Low haptoglobin (<25 mg dL⁻¹) or rising reticulocyte count 
• Elevated liver enzymes: aspartateor alanine-aminotransferase (AST/ALT) ≥ 70 IU L⁻¹ or ≥ 2 × upper-limit-of-normal
• Low platelet count: < 100 × 10⁹ L⁻¹
• Diagnostic rule: Complete HELLP = all three triad components present; partial HELLP = severe pre-eclampsia plus one or two components (e.g., ELLP, EL)

Cardiac Complications in Preeclampsia

Overview

• Spectrum: heart failure (HFpEF > HFrEF), pulmonary oedema, myocardial ischaemia, myocardial oedema, pericardial effusion.
• HFpEF: commonest (up to 10% in severe disease); often iatrogenic (excess fluid load); key contributor to ICU admissions and mortality.
• HFrEF: less frequent; presents with hypotension, tachycardia; high risk of decompensation.

Assessment

• Echocardiography: transthoracic echo for systolic/diastolic function, ventricular dimensions, pericardial fluid; use rapid obstetric screening echo (ROSE) for bedside evaluation.
• Biomarkers: NT‑proBNP (upper limit 200 pg/mL in 1st–2nd trimester, 150 pg/mL in 3rd); BNP (<50 pg/mL).
• Differential: distinguish from peripartum cardiomyopathy (EF < 45% without hypertension) to guide prognosis and counselling.

Echo Findings in Preeclampsia

• Global left-ventricular systolic function: visually estimated or Simpson biplane EF; normal adult range ≈ 53–73 %
• Diastolic dysfunction patterns: elevated E/e′ > 14, E/A < 0.8 (grade I) or > 2 (grade III), DT < 160 ms, TR ≥ 2.8 m s⁻¹
• Regional wall-motion abnormality (RWMA): hypo/akinesia or dyskinesia in a coronary territory → acute ischaemia or infarction
• Left-ventricular hypertrophy: septal or posterior wall thickness > 12 mm (concentric) or end-diastolic diameter > 58 mm (eccentric)
• Left-atrial enlargement: volume index > 34 mL m⁻² or antero-posterior diameter > 4.0 cm suggests chronic pressure/volume load
• Right-ventricular dilatation & “D-shaped” LV: basal RV diameter > 42 mm plus septal flattening → pulmonary hypertension or RV pressure overload
• TR jet velocity ≥ 3.4 m s⁻¹: echoes a systolic pulmonary-artery pressure > 50 mm Hg
• Pericardial effusion/tamponade: anechoic space > 15 mm plus right-atrial systolic or right-ventricular diastolic collapse and plethoric IVC

Management

HFpEF

• BP reduction: IV glyceryl trinitrate 5 µg/min, titrate q3–5 min to max 100 µg/min.
• Diuresis: IV furosemide 20–40 mg IV bolus over 2 min; repeat to total 120 mg/h as needed.
• Symptom relief: morphine 2–5 mg IV.
• Respiratory support: CPAP/BiPAP or high‑flow nasal oxygen; invasive ventilation if indicated.
• Fluid restriction: limit to maintenance rates to prevent overload.

HFrEF

• Inotropes: dobutamine or milrinone as per haemodynamic indices.
• Cardiac arrest: follow Also algorithm; consider perimortem Caesarean section ≤5 min post‑arrest.

Multidisciplinary Care

• Collaborative team: obstetrician, anaesthetist, cardiologist, intensivist, neonatologist.
• Early echo, ICU transfer, and joint planning optimise outcomes.

Treatment Options

Drug / Route (typical indication)	Guideline dose & escalation	Maximum dose	Common maternal side-effects	Key contraindications / cautions
Labetalol IV (acute severe HTN)	10–20 mg bolus → 20–80 mg every 10–30 min; or 1–2 mg min⁻¹ infusion	300 mg cumulative	Bradycardia, nausea, scalp tingling	Asthma, ≥1° heart block, decompensated HF, severe bradycardia
Labetalol oral (maintenance)	Start 200 mg 12-hourly; double every 12 h as needed	2 400 mg day⁻¹	Fatigue, fetal/neonatal bradycardia, hepatotoxicity (rare)	Same as IV; monitor LFTs in prolonged use
Nifedipine IR oral (acute severe HTN)	10–20 mg; repeat in 20 min; then 10–20 mg every 2–6 h	180 mg day⁻¹	Headache, flushing, reflex tachycardia	Severe aortic stenosis; cautious co-administration with MgSO₄ (hypotension)
Nifedipine MR oral (chronic/post-partum)	30–60 mg daily (XR); titrate q7 days	120 mg day⁻¹	Peripheral oedema, dizziness	Same as above
Hydralazine IV (acute severe HTN)	5–10 mg bolus (IV/IM); repeat every 20–40 min; infusion 0.5–10 mg h⁻¹	20 mg cumulative	Maternal hypotension, tachycardia, headache, drug-induced lupus	Tachycardia-induced myocardial ischaemia, systemic lupus erythematosus flare
Methyldopa oral (chronic)	250 mg 8–12-hourly for 48 h; titrate by 250 mg every 2 days	3 g day⁻¹	Sedation, dry mouth, positive Coombs test, hepatotoxicity	Active hepatitis, autoimmune haemolytic anaemia, depression
Nicardipine IV infusion (refractory severe HTN)	2–6 mg h⁻¹, weight-based titration	15 mg h⁻¹ (institutional)	Headache, flushing, hypotension, pulmonary oedema	Significant LV failure; caution in pulmonary oedema risk
Nitroglycerin IV infusion (HTN + pulmonary oedema)	Start 5–10 µg min⁻¹; ↑ by 5 µg min⁻¹ q3–5 min	200 µg min⁻¹ (short term)	Severe headache, hypotension, reflex tachycardia	RV infarction, hypertrophic cardiomyopathy, PDE-5 inhibitor use within 24 h
Sodium nitroprusside IV (last-resort)	0.5–4 µg kg⁻¹ min⁻¹; titrate to effect	10 µg kg⁻¹ min⁻¹ (≤10 min)	Cyanide/thiocyanate toxicity, reflex tachycardia, hypotension	Pregnancy generally contraindicated—fetal cyanide toxicity; avoid in renal/hepatic impairment

• First-line choices: Start with IV labetalol, IV hydralazine, or oral immediate-release nifedipine for acute BP ≥ 160/110 mm Hg; choose based on maternal comorbidities (e.g., avoid labetalol in asthma). For chronic or postpartum control, oral labetalol, modified-release nifedipine, or methyldopa are preferred.
• Escalation: If BP remains uncontrolled after two first-line boluses/infusion titrations, proceed to continuous nicardipine.
• Special situations: Add nitroglycerin when pulmonary oedema complicates pre-eclampsia; reserve nitroprusside for life-threatening, refractory crises under ICU and foetal monitoring with concurrent sodium thiosulphate

Perioperative Management

Perioperative Management

Preoperative

• Aspirin prophylaxis: 75–150 mg daily from 12–16 weeks until 36 weeks; not a contraindication to neuraxial anaesthesia.
• Calcium: 1 000 mg daily if dietary intake <1 000 mg/day; not routine in high‑income settings.
• Glucocorticoids: betamethasone or dexamethasone for fetal lung maturation if <34 weeks.
• Multidisciplinary planning: determine optimal timing, location and team composition for delivery.
• Blood testing interval
  • 6 hourly: Preeclampsia
  • 2 hourly: Preeclampsia with severe features/ HELLP
• Optimize BP to less than 150/80-100 prior to anaesthetic (slow reduction)

Intraoperative

Monitoring

• Arterial line: beat‑to‑beat BP; blood sampling.
• Echo-guided volume: transthoracic or TOE for volume/resistance assessment.
• Avoid routine CVP/PA catheters: limited benefit in PET.

Anaesthesia Choice

• Neuraxial: spinal, epidural or CSE preferred; platelet ≥80 × 10⁹/L; treat hypotension with phenylephrine (25–50 µg) or ephedrine (2.5–5 mg).
• General: indicated for coagulopathy, thrombocytopenia <70 × 10⁹/L, haemodynamic instability, refusal; plan RSI with video‑laryngoscope, minimise hypertensive surges during laryngoscopy and extubation.

Fluid & Haemorrhage

• Fluid: restrict to 80 mL/h maintenance or 1ml/kg/hour; guided by pulse pressure variation, urine output or echo.
• Haemorrhage risk: ~25% in PET; correct anaemia; use oxytocin/carbetocin; viscoelastic testing for coagulopathy.

Seizure Management

• Load Mgs04 as per guideline
• Give 2g after each seizure

Conversion to GA

• Preparation: anticipate and mitigate airway oedema; ensure resuscitation (fluids, blood) complete; team support; clear communication.

Decision Algorithm for Spinal Vs General Anaesthesia (SA Guideline)

Recommendations for Anaesthesia in Eclampsia

Indications for Spinal Anaesthesia

• GCS ≥ 14; platelets >75 × 10⁹/L; no airway/ICP concerns.

Clear-Cut Indications for General Anaesthesia

• HELLP with platelets <75 × 10⁹/L; GCS <14; ≥2 seizures or focal signs; suspected coagulopathy (abruption, hepatic haematoma); pulmonary oedema with hypoxaemia.

Decision Pathway

1. Any GA indication → GA
2. No GA indication → check platelets:
   • <50 × 10⁹/L → GA
   • 50–75 × 10⁹/L → GA unless neuraxial benefit clearly outweighs risk
   • More than 75 × 10⁹/L → spinal if no other contraindications
3. Reassess maternal–fetal status; non‑reassuring → GA

Magnesium Protocol

• Magnesium sulfate (MgSO₄) is the first-line anticonvulsant for severe pre-eclampsia and eclampsia. A full course begins with a 4 g IV loading dose (or 10 g IM split 5 g per buttock) followed by a 1 g h⁻¹ continuous infusion—or 5 g IM every 4 h—for 24 h after the last seizure or delivery.
• Randomised data show the 1 g h⁻¹ rate is as effective as higher rates with fewer adverse effects.
• If a convulsion recurs, give an extra 2–4 g IV bolus over 5 min and continue the same maintenance. Monitor patellar reflexes, respiratory rate > 12 min⁻¹, and urine output > 25 mL h⁻¹; treat toxicity with 1 g (10 mL) IV calcium gluconate.
• Post-partum blood pressure often peaks on days 3–6, so keep antihypertensives, continue seizure prophylaxis for at least 24 h, and provide clear “red-flag” instructions before discharge.

Loading (initial) Regimen

Route	Dose & rate	Practical preparation	Key points
IV (preferred)	4 g (8 mL of 50 % MgSO₄) diluted to 20 mL; give over 5–15 min via pump or slow push	Draw 8 mL (4 g) from a 50 % ampoule (500 mg mL⁻¹) and add 12 mL 0.9 % NaCl	Rapid control, easy titration
IM (if no pump / poor IV access)	10 g total: 5 g (10 mL of 50 %) deep IM each buttock with 1 mL 2 % lignocaine	Use a 21-G, 38-mm needle; massage site	Painful; ensure ambulation safety
Combined (Pritchard)	4 g IV as above plus 10 g IM (5 g each side)	Gives rapid serum level and depot	Standard in many low-resource protocols

When to Repeat a Loading Bolus

• Give 2–4 g IV over 5 min if the woman convulses again during maintenance, or if serum Mg²⁺ < 2 mmol L⁻¹ and clinical signs permit.

2. Maintenance Infusion

Regimen	Preparation example	Administration	Evidence
1 g h⁻¹ IV (Zuspan)	Add 20 g MgSO₄ (40 mL of 50 %) to 1 L RL = 20 mg mL⁻¹ (2 %) → 50 mL h⁻¹ delivers 1 g h⁻¹	Infuse for 24 h after last fit/delivery; adjust to 0.5–2 g h⁻¹ if renal impairment or obesity	1 g h⁻¹ non-inferior to 2 g h⁻¹, with fewer hot flushes and respiratory depression
5 g IM q4 h (Pritchard)	5 g (10 mL 50 %) + 1 mL lignocaine each buttock alternately	Start 4 h after loading; continue for 24 h	Use where pumps are unavailable

• Stop the infusion only if: reflexes disappear, RR < 12 min⁻¹, urine output < 25 mL h⁻¹, or Mg²⁺ ≥ 3.5 mmol L⁻¹. Restart when parameters normalise.

3. Monitoring and Toxicity

Parameter	Target / action	Rationale
Patellar (or biceps) reflex	Present	First sign of excess drug
Respiratory rate	≥ 12 min⁻¹	Respiratory-centre suppression precedes arrest
Urine output	≥ 25–30 mL h⁻¹	Renal clearance prevents accumulation
Serum Mg²⁺ (if available)	2.0–3.5 mmol L⁻¹ (therapeutic range)	> 5 mmol L⁻¹ → risk of apnoea or cardiac block
Antidote	10 mL 10 % Ca-gluconate IV over 3 min	Reverses respiratory or cardiac toxicity

• Signs of toxicity include loss of reflexes (Mg²⁺ ≈ 3.5 mmol L⁻¹), respiratory depression (≈ 5 mmol L⁻¹), and cardiac arrest (≈ 6 mmol L⁻¹).

Management of a Post-eclampsia Fit (post-partum or antenatal)

1. Call for help; place the woman in left lateral tilt and protect airway.
2. Give oxygen 10–15 L min⁻¹ via NRB mask and secure IV access.
3. Administer MgSO₄ loading (see Section 1). If on maintenance, give an extra 2 g IV
4. Control severe hypertension (SBP ≥ 160 or DBP ≥ 110 mm Hg) with IV labetalol 10–20 mg or hydralazine 5–10 mg.
5. Check glucose, electrolytes, FBC, creatinine, and consider CT/MRI if neuro-deficit persists (exclude intracranial bleed or PRES).
6. Continue maintenance infusion for 24 h after the last fit (not the first).

Post-partum (“fourth-trimester”) Considerations

• Hypertension rebounds on days 3–6; arrange home BP monitoring and maintain antihypertensives for at least 7 days.
• Seizures can occur up to 6 weeks; advise urgent review for headache, visual aura, epigastric pain, or dyspnoea.
• Breast-feeding is safe; infant Mg²⁺ exposure is minimal.

Postoperative Management

Immediate Monitoring and Location of Care

• Care Setting: Transfer to high‑dependency or ICU for severe preeclampsia; enhanced obstetric unit for mild–moderate cases
• Vital Signs: BP, HR, RR, SpO₂ hourly for first 24 h, then 4‑hourly if stable.
• Neurological Observations: GCS, deep tendon reflexes, headache/visual changes every 4 h for 48 h
• Urine Output: Hourly monitoring; target ≥0.5 mL/kg/h.
• Fluid Balance: Strict input/output charting; cumulative balance review every 8 h.
• Laboratory: Platelets, renal/liver function, coagulation profile 6 h postoperative and daily until stable.

Pain Management

• Neuraxial Analgesia:
  • Intrathecal morphine 50–100 µg for spinal; epidural morphine 2–3 mg.
  • Monitor sedation and respiratory rate hourly for 12 h.
• Systemic Analgesia:
  • Paracetamol 1 g QDS.
  • NSAIDs (ibuprofen 400 mg QDS or ketorolac 15 mg IV Q6h) if BP <140/90 mmHg and renal function normal.
  • Opioids: Oxycodone 5–10 mg PO Q4–6h PRN; avoid tramadol in seizure history.
• Regional Blocks:
  • TAP or QL block with ropivacaine 0.2% 20 mL each side for additional analgesia.

Postoperative Hypertension Management

• Antihypertensives: Continue labetalol or nifedipine targeting DBP <85 mmHg.
• Monitoring: BP every 4 h for 72 h, then twice daily until discharge.
• Oral Therapy Transition: Switch to oral labetalol 100–200 mg TDS or nifedipine SR 30–60 mg OD as patient tolerates.

Fluid Management and Oliguria

• Fluid Restriction: Limit to 1 000 mL IV fluids over 24 h; allow clear fluids orally.
• Oliguria (<0.5 mL/kg/h):
  • Exclude hypovolaemia, AKI, pulmonary oedema.
  • If pulmonary oedema risk high, avoid bolus; consider furosemide 20 mg IV
• Diuresis Goal: Maintain euvolaemia; avoid precipitous fluid shifts.

Thromboprophylaxis

• Mechanical: Thromboembolism stockings + intermittent pneumatic compression on arrival.
• Pharmacologic:
  • Enoxaparin 40 mg SC OD ≥12 h post neuraxial block or ≥4 h after catheter removal.
  • Increase to 40 mg BD if BMI >40 kg/m² or weight >120 kg.
• Duration: At least 7 days; extend to 6 weeks if additional VTE risk factors.

Breastfeeding and Medication Safety

• Safe Agents: Labetalol, nifedipine, methyldopa, enalapril—compatible with breastfeeding.
• Avoid: Atenolol (bradycardia risk in infant), ACEi with high milk transfer.
• Resources: Refer to LactMed for up‑to‑date compatibility.

Mental Health and Well‑being

• Screening: Use Edinburgh Postnatal Depression Scale (EPDS) and anxiety inventories before discharge.
• Support: Trauma‑informed care; involve partner or support person; offer counselling referrals.
• Follow‑Up: Arrange mental health review at 6 weeks postpartum.

Postpartum Follow‑Up

• Cardiovascular: Clinic at 6–12 weeks for BP, renal function, lipid profile and glucose tolerance test.
• Long‑Term Risk Counselling: Advise on cardiovascular risk reduction (diet, exercise, smoking cessation).
• Family Planning: Discuss optimal interpregnancy interval and prophylactic aspirin in future pregnancies.

4th Trimester

• The “fourth trimester” (birth → 12 weeks) is the danger zone where up to 60 % of maternal deaths from hypertensive disorders occur; blood-pressure can spike or present de novo, magnesium levels fall, airway and pulmonary oedema may persist, and analgesic/antihypertensive choices still shape maternal outcomes. Anaesthetists must therefore keep treating the parturient with pre-eclampsia as “high-risk” even after placental delivery

Persistent Pathophysiology

Issue	Why it matters in weeks 0-12	Practical actions
Hypertension & end-organ risk	New-onset or rebound hypertension peaks days 3-6 postpartum and can trigger stroke, HELLP, pulmonary oedema.	Continue in-hospital BP checks ≥72 h; home monitoring until 7 days; treat ≥150/100 mm Hg with labetalol, nifedipine or hydralazine as inpatient.
Seizure threat	Eclamptic fits reported up to 6 weeks after delivery.	Maintain MgSO₄ for ≥24 h after last seizure or delivery; give rescue diazepam/lorazepam if seizures recur.
Airway and laryngeal oedema	Edema and difficult laryngoscopy can linger 48 h+ postpartum.	If GA needed (e.g., uterine curettage), use smaller ETT, ramped position; keep difficult-airway devices ready.
Autotransfusion & fluid shifts	Uterine involution returns 500–800 mL to circulation, risking flash pulmonary oedema in stiff LV.	Restrict crystalloids, give low-dose furosemide if symptomatic; avoid ergometrine in severe HTN.
Thrombocytopenia / coagulopathy	Platelets may remain < 100 × 10⁹ L⁻¹ for days	Safe neuraxial if platelets ≥ 70 × 10⁹ L⁻¹, normal coagulation and no trend down; otherwise delay or use GA with airway plan above.
Analgesia & NSAIDs debate	NSAIDs can raise BP but recent RCTs show ibuprofen non-inferior to paracetamol for BP control, though data are mixed.	Prefer paracetamol ± opioid until BP controlled; if using NSAID, monitor BP q4 h; avoid if platelets < 100 or creatinine ↑.

Anaesthetic Considerations for Common Postpartum Procedures

Neuraxial Techniques

• Tubal ligation or curettage: Offer spinal (≤ 8 mg bupivacaine + opioid) to blunt hypertensive surges and avoid airway concerns; confirm platelets first.
• Epidural blood patch: Possible if platelets stable and BP controlled; rule out PRES before treating “headache.”

General Anaesthesia

• Induction: Propofol/etomidate + remifentanil or short-acting opioid to blunt pressor response; have nitroglycerin ready for severe surges.
• Extubation: Fully awake, head-up, consider IV labetalol 10 mg or nicardipine infusion to smooth emergence.

Post-discharge Safety Net

• Give the patient and family a “red flag” list: severe headache, visual change, epigastric pain, SOB.
• Arrange a BP check within 7 days and again at 6 weeks.
• Communicate anaesthetic course and any airway/platelet issues to primary-care team for future pregnancies.

Links

• Hypertension
• Obstetric haemorrhage
• Obstetric emergencies
• Obstetric physiology
• Amniotic fluid embolism and PE
• Stroke

Past Exam Questions

Anaesthetic Considerations in a Parturient with Severe Hypertension

A 25-year-old parturient at term in her third pregnancy presents with a blood pressure of 155/115 mmHg.
a) What other parameters are required to make a diagnosis of pre-eclampsia? (5)
The parturient goes into labour overnight and presents for a caesarean section.
b) What features on pre-operative evaluation would make you consider general rather than neuraxial anaesthesia? (5)

Test You Knowledge

1. Define preeclampsia and list the two key diagnostic criteria required after 20 weeks’ gestation.
2. Compare and contrast chronic hypertension, gestational hypertension and preeclampsia in terms of timing, proteinuria and end-organ dysfunction.
3. Describe four severe features of preeclampsia and give the threshold values or findings for each.
4. Outline the two-stage model of preeclampsia pathophysiology, naming the placental abnormality and the circulating factors involved.
5. List five acute maternal complications of preeclampsia and briefly explain the mechanism or consequence of each.
6. Explain your anaesthetic plan for a patient with severe preeclampsia and a platelet count of 80 × 10⁹/L who requires an emergency caesarean section.
7. Discuss the fluid management strategy in preeclampsia, including how and why you would use invasive monitoring to guide therapy.
8. Describe the regimen for seizure prophylaxis in preeclampsia, including dosing and duration.
9. Identify three echocardiographic findings you would look for in a preeclamptic patient with suspected HFpEF, and name the relevant biomarker thresholds.
10. Compare the intraoperative anaesthetic choices (neuraxial vs general) in preeclampsia, giving at least two indications and two contraindications for each.
11. Outline your postoperative thromboprophylaxis plan, including timing relative to neuraxial blockade and duration.
12. Summarise the key elements of postpartum follow-up for cardiovascular risk reduction after a preeclamptic pregnancy.

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References:

1. Melchiorre K, et al. Cardiovascular function in women with a history of early onset preeclampsia. Hypertension. 2020;75(4):1128–1136.
2. McDonald SD, Malinowski A. Long-term hypertension post preeclampsia. BJOG. 2019;126(3):338–347.
3. Wu P, et al. Long-term risk of cardiovascular disease in women with preeclampsia. JAMA Cardiol. 2017;2(8):778–785.
4. Proudfoot NR, et al. Neurocognitive sequelae of preeclampsia. Am J Obstet Gynecol. 2021;225(1):110.e1–110.e12.
5. Rolnik DL, et al. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med. 2017;377(7):613–622.
6. Hofmeyr GJ, et al. Calcium supplementation to prevent preeclampsia: meta-analysis. BJOG. 2014;121(10):1181–1190.
7. National Institute for Health and Care Excellence. Hypertension in pregnancy: diagnosis and management. CG132. 2020.
8. Royal College of Obstetricians and Gynaecologists. Postpartum care. Green-top Guideline No.37. 2018.
9. American College of Obstetricians and Gynecologists. Practice Bulletin No.207: Thromboembolism in pregnancy. Obstet Gynecol. 2020;135(2):e1–e13.
10. Moore D, ed. Drugs in Lactation. Larvol. 2023.
11. Howard LM, et al. Perinatal mental health. Lancet. 2014;384(9956):1775–1788
12. Dyk, D. v., Dyer, R. A., & Fernandes, N. (2021). Preeclampsia in 2021—a perioperative medical challenge for the anesthesiologist. Anesthesiology Clinics, 39(4), 711-725. https://doi.org/10.1016/j.anclin.2021.08.005
13. POLLEY, LINDA S. MD. Anesthetic Management of Hypertension in Pregnancy. Clinical Obstetrics and Gynecology 46(3):p 688-699, September 2003.
14. Sharma DD, Chandresh NR, Javed A, Girgis P, Zeeshan M, Fatima SS, Arab TT, Gopidasan S, Daddala VC, Vaghasiya KV, Soofia A, Mylavarapu M. The Management of Preeclampsia: A Comprehensive Review of Current Practices and Future Directions. Cureus. 2024 Jan 2;16(1):e51512. doi: 10.7759/cureus.51512. PMID: 38304688; PMCID: PMC10832549.
15. Seymour, Lisa M. MBChB; Fernandes, Nicole L. FCA(SA); Dyer, Robert A. FCA(SA), PhD,†; Smit, Maretha I. FCA(SA); van Dyk, Dominique FCA(SA); Hofmeyr, Ross FCA(SA), FAWM. General Anesthesia for Cesarean Delivery for Thrombocytopenia in Hypertensive Disorders of Pregnancy: Findings From the Obstetric Airway Management Registry. Anesthesia & Analgesia 136(5):p 992-998, May 2023. | DOI: 10.1213/And.0000000000006217
16. FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/
17. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/
18. The Calgary Guide to Understanding Disease. (2024). Retrieved June 5, 2024, from https://calgaryguide.ucalgary.ca/

Summaries
[PET
MGS04
PET Calgary guide

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