6/10/2018 Anesthesia for the patient with preeclampsia - UpToDate

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Anesthesia for the patient with preeclampsia

Authors: Joy Hawkins, MD, Emily McQuaid-Hanson, MD

Section Editor: David L Hepner, MD
Deputy Editor: Marianna Crowley, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2018. | This topic last updated: Jun 15, 2018.

INTRODUCTION — Preeclampsia is a multisystem disorder with unique concerns for the anesthesiologist in the
peripartum period. This topic will discuss the anesthetic management of labor and delivery for preeclamptic
patients, including labor analgesia, cesarean delivery, fluid management, and invasive monitoring. The
pathogenesis, clinical features and diagnosis, and obstetric management of patients with preeclampsia are
discussed separately. (See "Preeclampsia: Clinical features and diagnosis" and "Preeclampsia: Management
and prognosis" and "Preeclampsia: Pathogenesis".)

PREANESTHESIA EVALUATION — Preeclamptic patients should be evaluated by an anesthesia clinician early

in labor, with the expectation that an emergency delivery may be required at any time. Women with preeclampsia
are at an increased risk for life-threatening events, including placental abruption, cerebral hemorrhage,
pulmonary edema, acute kidney injury, hepatic failure or rupture, disseminated intravascular coagulation, and
progression to eclampsia. (See "Preeclampsia: Clinical features and diagnosis".)

The preanesthesia evaluation of these patients should focus on severity of disease, the airway examination,
hemodynamic status, and coagulation parameters, all of which may change over time.

Severity of preeclampsia — Preeclampsia may be classified as severe (also called preeclampsia with severe
features) or preeclampsia without severe features (table 1). (See "Preeclampsia: Management and prognosis".)

In general, peripartum anesthesia for patients with preeclampsia without severe features is managed as it would
be for patients without preeclampsia, recognizing that severity may increase at any time. Patients with
preeclampsia without severe features may or may not receive magnesium for seizure prophylaxis. (See
"Preeclampsia: Management and prognosis", section on 'Seizure prophylaxis' and 'Intraoperative magnesium'
below.)

Airway evaluation — Airway management may be particularly difficult in preeclamptic patients who are prone to
edema and bleeding with airway instrumentation. Airway edema may worsen over the course of labor, and may
be present even with a reassuring airway examination. Airway evaluation is discussed separately. (See "Airway
management of the pregnant patient at delivery" and "Management of the difficult airway for general anesthesia
in adults".)

Equipment necessary for difficult and emergency airway management should be available on the labor floor;
urgent or emergent airway intervention may be required not only for general anesthesia for cesarean delivery,
but also for airway protection if eclamptic seizures occur, or in the setting of magnesium toxicity or overdose.
(See "Airway management of the pregnant patient at delivery", section on 'Available airway equipment'.)

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Hemodynamic status — Hypertension is generally the earliest clinical finding in preeclampsia, and may be
treated in the peripartum period with oral and/or intravenous vasodilators (eg, nifedipine, labetalol, hydralazine),
which may affect the choice of vasoactive drugs administered during analgesia and anesthesia. (See
"Management of hypertension in pregnant and postpartum women", section on 'Choice of drug and dose'.)

With severe preeclampsia, patients may develop cardiac dysfunction, myocardial damage, and pulmonary
edema, which may affect the choice and dose of anesthetic medications, and the need for invasive monitoring.
(See "Preeclampsia: Clinical features and diagnosis", section on 'Pulmonary edema'.)

Coagulation — Patients with severe preeclampsia and/or HELLP syndrome (Hemolysis, Elevated Liver
enzymes, Low Platelet count) may develop thrombocytopenia, which increases the risk of spinal epidural
hematoma with neuraxial anesthesia techniques. Both the absolute platelet count, and the trend in the count
over time are important considerations for the timing and advisability of neuraxial procedures. The platelet count
necessary to safely perform neuraxial anesthesia is unknown [1], and practice varies. In the absence of other
coagulation abnormalities, we usually perform neuraxial anesthesia procedures for patients with a platelet count
>75,000/microL, with close followup for signs of spinal epidural hematoma [2]. (See "Adverse effects of neuraxial
analgesia and anesthesia for obstetrics", section on 'Neuraxial analgesia and low platelets'.)

Use of low dose aspirin should not affect the decision to use neuraxial techniques. This is of interest because the
United States Preventive Services Task Force [3] and the American College of Obstetricians and Gynecologists
[4] recommend use of low-dose aspirin for prevention of preeclampsia in women deemed high-risk, including
those with prior preeclampsia requiring preterm delivery and those with preeclampsia in multiple prior pregnancy.
(See "Preeclampsia: Prevention", section on 'Low-dose aspirin'.)

Other coagulopathies may develop, including disseminated intravascular coagulation, as well as liver function
abnormalities, and may also preclude the use of neuraxial techniques. Coagulation testing, other than a platelet
count, should be individualized based on patient factors (eg, liver function test abnormalities, abruption).
Changes in prothrombin time (PT), partial thromboplastin time (PTT) and fibrinogen do not occur in most
preeclamptic patients with a normal platelet count [5,6].

We do not transfuse patients with platelets solely to allow neuraxial anesthesia. However, if the obstetrician
administers platelet transfusion prior to cesarean delivery, there may be an opportunity for spinal anesthesia.
Indications for platelet transfusion and correction of coagulopathy are discussed separately. (See "Preeclampsia:
Management and prognosis", section on 'Management of thrombocytopenia'.)

CARE SETTING: ICU VERSUS LABOR FLOOR — Patients with preeclampsia may require invasive monitoring
and intensive care during the peripartum period. The decision to care for these patients on the labor floor, or in
the intensive care unit (ICU), should be institution specific, collaborative between anesthesia, obstetric, and
nursing teams, and based on available resources and clinical expertise.

Advantages of care on the labor floor include:

● Proximity of the obstetric, neonatal, and obstetric anesthesia teams, for rapid response to changing clinical
situations

● Familiarity of the nursing staff with intrapartum assessment of labor, fetal monitoring, and the drugs,
procedures, and interventions frequently used during labor and delivery

Advantages of the intensive care unit for these patients include:

● Familiarity with invasive monitoring and vasoactive infusions

● Superior resources for maternal resuscitation

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In some institutions, the best compromise may be to cross cover, with obstetric and ICU nurses sharing patient
care in the most appropriate unit.

HEMODYNAMIC MONITORING — Blood pressure may be labile, and change rapidly in patients with
preeclampsia, due to disease progression, administration of vasoactive medications, the pain of labor, or
anesthetic interventions. Invasive hemodynamic monitoring (ie, arterial catheterization, central venous catheter
placement) is not routine for these patients, but may be indicated in some circumstances.

● Arterial catheterization – A radial artery catheter should be considered prior to induction of general
anesthesia for patients with severe preeclampsia based on blood pressure, if time permits, to provide
continuous blood pressure monitoring and rapid response to adverse changes, especially during rapid
sequence induction and during emergence. (See 'General anesthesia' below and 'Goal blood pressure'
below.)

Radial artery catheters are not routinely placed for hemodynamic monitoring during labor for patients with
preeclampsia. However, radial artery catheterization is a low-risk procedure [7] that may be beneficial for
continuous blood pressure monitoring, and facilitates blood sampling [8]. Placement of an arterial line should
be considered in the following situations:

• Persistent, severe hypertension (eg, systolic blood pressure >160 or diastolic blood pressure >110)
refractory to treatment

• Use of vasoactive infusions to control blood pressure

• Need for frequent blood sampling (eg, patients with coagulopathy, hemorrhage, severe renal or hepatic
dysfunction), particularly for patients with difficult peripheral venous access

• Need for frequent arterial blood gas monitoring (eg, patients with pulmonary edema and hypoxia)

• For use of a minimally invasive cardiac output monitor to guide hemodynamic management [9] (see
"Intraoperative fluid management", section on 'Dynamic hemodynamic parameters')

● Central venous catheterization – Central venous catheters (CVCs) and pulmonary artery catheters (PACs)
are rarely used in parturients with preeclampsia. Indications for placement are similar to those for patients
without preeclampsia, including difficult peripheral venous access, central administration of vasoactive
infusions, and measurement of cardiac function and/or preload. (See "Monitoring during anesthesia", section
on 'Other monitors of circulation'.)

However, complication rates for central line placement are relatively high in patients with severe
preeclampsia [10,11], and there are no randomized trials to support the use of CVCs [12]. Placement of a
CVC or PAC takes time, and should not delay delivery for patients with severe preeclampsia.

Central venous pressure correlates poorly with pulmonary capillary wedge pressure in patients with
preeclampsia [13-15]. Therefore, a PAC should be placed if measurement of preload is the primary
objective.

● Transthoracic echocardiography – Transthoracic echocardiography (TTE) is safe in pregnancy [16] and

may be useful in assessing cardiac function in the setting of hypertension, hemodynamic instability, or
respiratory failure [17]. TTE may also be used to assess volume status and guide therapeutic management
in obstetric patients with preeclampsia [18]. TTE requires specialized training and frequent use to maintain
competency.

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GOAL BLOOD PRESSURE — For preeclamptic patients, we aim to keep the patient's blood pressure close to
her baseline, rather than normal blood pressures, to preserve uteroplacental perfusion, but always less than
systolic 160 mmHg and diastolic 110 mmHg. Blood pressures >160/110 mmHg should be lowered aggressively,
while monitoring the fetus to be sure that uteroplacental perfusion is maintained and late decelerations do not
develop. The medications and doses used for treatment of acute, severe hypertension are shown in a table
(table 2).

Though specific blood pressure targets are not supported by data, goals for blood pressure management for
preeclamptic patients should include:

● Avoidance of severe hypertension to reduce the risk of stroke and intracranial hemorrhage – Severe
systolic hypertension is associated with stroke in these patients in the peripartum period. A review of 28
patients with stroke associated with severe preeclampsia found that 100 percent of the patients had systolic
blood pressure (BP) greater than 155 mmHg before the stroke [8]. Ninety-three percent of the strokes were
hemorrhagic events, 54 percent of the women died, and all but three of those who survived suffered
permanent disability.

● Avoidance of hypotension to maintain uteroplacental perfusion – Uteroplacental perfusion may be

compromised in patients with preeclampsia, and may increase the risk of fetal compromise with
hypotension. (See "Preeclampsia: Clinical features and diagnosis", section on 'Overview of
pathophysiology'.)

INTRAVENOUS FLUID MANAGEMENT — Peripartum fluid administration should be monitored closely, since
patients with severe preeclampsia are at risk for pulmonary edema. The etiology of pulmonary edema in these
patients may be multifactorial, including myocardial dysfunction as a result of acutely increased systemic
vascular resistance, low colloid oncotic pressure with capillary leak, and iatrogenic fluid administration. (See
"Preeclampsia: Management and prognosis", section on 'Fluids' and "Preeclampsia: Clinical features and
diagnosis", section on 'Pulmonary edema'.)

Current obstetric practice is to limit total fluid administration in patients with severe preeclampsia to 80 to 100
mL/hour IV, including oxytocin and magnesium infusions. Restrictive volumes of fluid should also be
administered during initiation of neuraxial labor analgesia or neuraxial anesthesia, and during anesthesia for
cesarean delivery. (See 'Fluid administration' below.)

In most patients who receive low dose local anesthetic with opioid solutions for neuraxial labor analgesia (eg,
0.0625 to 0.125% bupivacaine with fentanyl), no intravenous bolus is required or advised to prevent hypotension
[19-21]. (See "Neuraxial analgesia for labor and delivery (including instrumented delivery)", section on 'Goals for
neuraxial drug choice' and "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on
'Hypotension'.)

The limited available data do not indicate an absolute maternal or fetal benefit of colloids over crystalloids for
obstetric patients in general [22,23], or for preeclamptic patients in particular [24-26].

LABOR ANALGESIA — In the absence of other contraindications, neuraxial analgesia is the preferred form of
labor analgesia for women with preeclampsia [20].

For patients in whom neuraxial analgesia is contraindicated (eg, severe coagulopathy), other options include
systemic analgesics and nitrous oxide. (See "Pharmacologic management of pain during labor and delivery",
section on 'Opioid analgesia' and "Pharmacologic management of pain during labor and delivery", section on
'Nitrous oxide'.)

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Advantages of neuraxial labor analgesia — Some advantages of neuraxial labor analgesia are particularly
relevant for patients with preeclampsia.

● Superior pain relief, compared with systemic analgesics [27]

● Attenuation of the hypertensive response to labor pain

● Reduction of circulating catecholamines [28]

● Possible improvement in placental blood flow [29,30]

● Provision of a means for rapid conversion to surgical neuraxial anesthesia, with avoidance of general
anesthesia

Neuraxial analgesia versus systemic opioids — For patients without preeclampsia, the effects of neuraxial
labor analgesia on the progress and outcome of labor, and on maternal and fetal outcomes, have been studied
extensively. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on
the progress and outcome of labor'.)

Several randomized trials have reported no difference in the mode of delivery or neonatal outcomes for patients
with preeclampsia who received epidural labor analgesia, compared with systemic analgesia.

● In one study, 200 preeclamptic parturients were randomly assigned to epidural analgesia (0.125%
bupivacaine with tramadol, administered by intermittent bolus) or intramuscular tramadol for labor analgesia
[31]. There were no differences in hypotension, cesarean delivery rates, or neonatal apgar scores.

● In another study, 116 parturients with severe preeclampsia were randomly assigned to epidural analgesia
(bolus of 0.25% bupivacaine, followed by infusion of 0.125% bupivacaine with fentanyl) or intravenous
meperidine [32]. There were no differences in the cesarean delivery rate or neonatal outcomes. Infants of
patients who received meperidine were more likely to require naloxone, and parturients who received
epidural analgesia were more likely to require ephedrine for hypotension.

● In one small study, 30 preeclamptic patients were randomly assigned to epidural analgesia (bolus of 0.25%
bupivacaine, followed by infusion of 0.125% bupivacaine with fentanyl) or remifentanil patient controlled
intravenous analgesia [33]. There were no differences in maternal vital signs, neonatal outcomes, or mode
of delivery.

● In a single center trial, 738 parturients with pregnancy-induced hypertension (diastolic blood pressure ≥90
mmHg, with or without other features of preeclampsia) were randomly assigned to epidural analgesia (bolus
of 0.25% bupivacaine followed by infusion of 0.125% bupivacaine with fentanyl) or intravenous meperidine
for labor analgesia [34]. Epidural analgesia was associated with an increase in forceps delivery (14 versus 7
percent) but no difference in the cesarean delivery rate or in neonatal outcomes.

Management of neuraxial labor analgesia — Techniques for neuraxial labor analgesia for preeclamptic
patients are the same as for patients without preeclampsia, and are discussed separately. Differences in
management for preeclamptic parturients are discussed here. (See "Neuraxial analgesia for labor and delivery
(including instrumented delivery)".)

Timing of neuraxial analgesia — We place an epidural catheter early in labor, or prior to the induction of
labor, for patients with preeclampsia. Early placement is especially important for patients with declining platelet
counts before severe thrombocytopenia occurs, and for patients with expected difficulty with airway
management. (See 'Advantages of neuraxial labor analgesia' above.)

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The epidural test dose — The administration of a test dose with epinephrine after epidural catheter
placement in obstetrics is controversial, and practice varies. (See "Neuraxial analgesia for labor and delivery
(including instrumented delivery)", section on 'The epidural test dose in obstetrics'.)

For preeclamptic patients, alternative test dose solutions, without epinephrine, may be used (eg, fentanyl, or air),
since epinephrine test doses may be unreliable (eg, for patients who have received beta blockers), or may cause
severe hypertension if inadvertent intravascular injection occurs. One author avoids an epinephrine test dose for
preeclamptic patients, and tests the epidural catheter by administering a dilute epidural solution of local
anesthetic and opioid, assessing for the onset of appropriate block. The other author administers an epinephrine
containing test dose (eg, 3 cc of lidocaine 1.5% with epinephrine 1:200,000).

Vasopressors during neuraxial analgesia — Blood pressure may be labile during labor, and after
administration of labor analgesia. Vasodilators, vasopressors, and beta blockers are commonly required in
preeclamptic patients.

When needed, vasopressors (eg, ephedrine, phenylephrine) should be administered in small doses (eg,
ephedrine 2.5 to 5 mg IV, phenylephrine 25 to 50 mcg IV) to preeclamptic patients, and titrated to effect, as their
responses to these medications may be unpredictable. Preeclamptic patients are more sensitive to various
vasopressors, including norepinephrine [35] and epinephrine [36] and require lower doses of ephedrine and
phenylephrine to reverse spinal hypotension [37-39].

Epidural catheter removal — Removal of the epidural catheter may cause epidural blood vessel injury and
spinal epidural hematoma. The catheter should not be removed unless the platelet count and coagulation studies
are at a level that would allow neuraxial needle insertion. (See 'Coagulation' above.)

ANESTHESIA FOR CESAREAN DELIVERY — Cesarean delivery may be performed with neuraxial anesthesia
(ie, spinal, combined spinal epidural, or epidural) or general anesthesia.

Intravenous access — We place two intravenous catheters, including at least one large bore catheter (ie, 18
gauge or larger), to facilitate administration of vasoactive infusions, intravenous fluid, and blood products.

Choice of anesthetic technique

General versus neuraxial anesthesia — Neuraxial anesthesia is preferred for preeclamptic patients who
undergo cesarean delivery, rather than general anesthesia, whenever possible. The most important advantage to
neuraxial anesthesia is that it avoids the severe hypertension, which may be life threatening, that may occur
during induction of and emergence from anesthesia. (See 'Goal blood pressure' above.)

Other considerations include the following:

● Neuraxial anesthesia avoids the need for endotracheal intubation, which may be difficult in these edematous
patients.

● Neuraxial anesthesia avoids the need for administration of neuromuscular blocking agents, which are
potentiated by magnesium. (See 'Intraoperative magnesium' below.)

● Neuraxial anesthesia may cause more hypotension than general anesthesia, but it is usually transient and
easily treated, without a difference in neonatal outcome [40,41].

Choice of neuraxial technique — The choice of neuraxial anesthetic technique (ie, spinal, epidural, or
combined spinal epidural [CSE]) should be based on patient factors and the clinical context. Spinal and CSE are
often used when a labor epidural catheter has not been in place.

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Historically, spinal anesthesia was avoided in patients with severe preeclampsia because of the possibility of
profound hypotension related to the rapid onset of sympathetic block. (See "Adverse effects of neuraxial
analgesia and anesthesia for obstetrics", section on 'Hypotension'.)

A number of studies have refuted these concerns, including the following:

● In one trial, 80 patients with severe preeclampsia were randomly assigned to general, epidural, or CSE for
cesarean delivery [41]. There were no differences in mean highest or lowest blood pressures, or neonatal
outcomes, with any of the anesthetic techniques.

● In another trial, 100 severely preeclamptic patients were randomly assigned to epidural or spinal anesthesia
for cesarean delivery [42]. Hypotension was more common in the spinal group (51 versus 23 percent).
However, the duration of significant hypotension (systolic blood pressure [BP] ≤100) was brief (≤1 minute) in
both groups and was easily treated with small doses of ephedrine.

● A retrospective review of 140 severely preeclamptic patients who underwent cesarean delivery reported no
difference in lowest blood pressures between spinal and epidural anesthesia, with no difference in maternal
or fetal outcomes [43].

Patients with preeclampsia may be at lower risk for spinal induced hypotension than patients without
preeclampsia. Two prospective case controlled studies of severely preeclamptic patients who underwent
cesarean delivery at term [38] and preterm [37] reported lower incidences of spinal hypotension and ephedrine
requirement in the preeclamptic patients.

Anesthetic management of neuraxial anesthesia — The techniques and doses of neuraxial medications for
preeclamptic patients are similar to those for parturients without preeclampsia, and are discussed separately.
(See "Anesthesia for cesarean delivery", section on 'Neuraxial anesthesia'.)

Concerns specific to preeclamptic patients are discussed here.

Fluid administration — Intravenous fluid co-loading during placement of neuraxial anesthesia should be
avoided or minimized (ie, <500 mL crystalloid solution IV) for patients with severe preeclampsia. Intraoperative
fluid administration should be conservative as well. (See 'Intravenous fluid management' above.)

Vasopressors during cesarean delivery — Vasopressors (eg, phenylephrine and/or ephedrine) are
routinely administered during initiation of spinal anesthesia to prevent spinal hypotension. These medications
should initially be administered in low, incremental doses, titrated to effect, in patients with preeclampsia, aiming
for a blood pressure close to baseline. The choice of vasopressor should be based on maternal hemodynamics,
since the selection of specific vasopressors has not been show to affect maternal or fetal outcomes in patients
with preeclampsia [44,45]. (See 'Vasopressors during neuraxial analgesia' above.)

A reasonable strategy to prevent neuraxial anesthesia-induced hypotension for patients with preeclampsia
includes prophylactic, titrated administration of low-dose phenylephrine infusion (ie, starting at <50 mcg/min) with
rescue boluses of either phenylephrine (eg, 25 to 50 mcg IV) or ephedrine (2.5 to 5 mg IV), aiming for a blood
pressure close to baseline, or systolic <160 mmHg. For patients with baseline bradycardia, ephedrine (5 to 10
mg IV bolus, or 1 to 5 mg/min IV infusion) may be administered as an alternative. The choice of vasopressors for
treatment of spinal hypotension is discussed in more detail separately. (See "Anesthesia for cesarean delivery",
section on 'Vasopressors'.)

Uterotonic medications — Uterotonic medications are routinely administered after delivery of the fetus
during both vaginal and cesarean delivery. Oxytocin is the first line medication, followed by other uterotonics if

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bleeding persists. (See "Postpartum hemorrhage: Medical and minimally invasive management", section on
'Administer additional uterotonic drugs'.)

Methylergonovine can cause severe hypertension, and should not be administered to patients with preeclampsia
[46].f For postpartum hemorrhage unresponsive to oxytocin administration, prostaglandins (ie, misoprostol or
carboprost) should be administered. Carboprost should be avoided in patients with asthma.

General anesthesia — General anesthesia may be indicated for emergent cesarean delivery with a reassuring
airway examination, or for patients with severe coagulopathy such that neuraxial anesthesia is contraindicated.
The basic management technique for general anesthesia for cesarean delivery is discussed separately.
Concerns specific to preeclamptic patients are discussed here. (See "Anesthesia for cesarean delivery", section
on 'General anesthesia'.)

Airway management — In most patients, including those with preeclampsia, endotracheal intubation is
performed after rapid sequence induction of anesthesia. Difficulty with airway management must always be
anticipated, with equipment and personnel available to manage a difficult or failed airway. (See 'Airway
evaluation' above and "Management of the difficult airway for general anesthesia in adults" and "Airway
management of the pregnant patient at delivery".)

Induction of anesthesia — Induction of anesthesia should always include steps to minimize or eliminate the
hypertensive response to laryngoscopy and intubation. This hemodynamic response may be exaggerated in
preeclamptic patients, and may result in intracranial hemorrhage and/or pulmonary edema [47,48]. We place an
arterial catheter in patients with severe range blood pressures for continuous blood pressure monitoring prior to
induction of general anesthesia, if time permits, to facilitate rapid response to changes in blood pressure.

In addition to the usual anesthesia induction agents, a variety of medications may be administered during
induction to blunt the hemodynamic response to intubation, with a target blood pressure of systolic <160 mmHg
and diastolic <110 mmHg [49]. In general, drugs with rapid onset and short duration of action are preferred. The
literature on the choice of medication and optimal doses in this setting is limited [50]. Thus, medications are
chosen based on patient factors, and clinician preference.

Our usual drug regimen for induction of anesthesia is as follows:

● Preinduction, labetalol 10 mg IV boluses, titrated to achieve systolic blood pressure <160 mmHg, if time
permits.

● Lidocaine 1.5 mg/kg IV

● Propofol 2 mg/kg IV

● Succinylcholine 1 mg/kg IV

● Nitroglycerin infusion, or Nicardipine (100 mcg/mL, 1 to 2 mL bolus), as needed during induction, with goal
systolic blood pressure <160 mmHg.

Medications that may be used to blunt the hypertensive response to intubation include the following:

● Lidocaine 1 to 1.5 mg/kg IV during induction

● Labetalol 20 mg IV, titrated 10 mg IV boluses up to 1 mg/kg prior to induction [51]

● Esmolol 2 mg/kg IV during induction, or 1 mg/kg IV with lidocaine [52]

● Nitroglycerin 1.5 to 2.5 mcg/kg IV [53,54]

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● Nicardipine 15 to 30 mcg/kg IV, or 100 to 200 mcg bolus during induction [55]

● Remifentanil 1 mcg/kg IV during induction [56,57], crosses the placenta and may cause transient neonatal
respiratory depression

● Fentanyl 1 to 3 mcg/kg IV [58]

The neonatal resuscitation team should be notified of all medications administered to the mother during induction
of general anesthesia.

Intraoperative magnesium — Magnesium sulfate is routinely administered in the intrapartum and postpartum
period to patients with preeclampsia to prevent seizures, and should be continued in the operating room during
cesarean delivery [20]. (See "Preeclampsia: Management and prognosis", section on 'Seizure prophylaxis'.)

Magnesium causes muscle relaxation, potentiates the effect of nondepolarizing neuromuscular blocking agents
(NMBAs), and can prolong the duration of action of rocuronium [59], cisatracurium [60], and vecuronium [61].
Since nondepolarizing NMBAs are rarely necessary during cesarean delivery, they should be avoided if possible
for patients who are receiving magnesium. Magnesium does not potentiate the effects of succinylcholine, and the
usual rapid sequence induction dose (ie, succinylcholine 1 to 1.5 mg/kg IV) should be administered.

For the unusual cesarean delivery in which muscle relaxation is required, succinylcholine 10 to 20 mg IV (for a
brief effect), or deeper anesthesia may be sufficient. If necessary, small doses of NMBA (ie, rocuronium 10 mg IV
or cisatracurium 2 mg IV) should be administered, titrated to effect using a twitch monitor with the goal of one
twitch in the train of four twitches.

Postoperative pain control — Multimodal strategies for pain control are routinely used for all patients after
cesarean delivery, including those with preeclampsia, to promote rapid recovery and ambulation and to minimize
the need for postoperative opioids. Pain control strategies include neuraxial morphine or hydromorphone for
patients who have neuraxial anesthesia, transverse abdominis plane blocks, quadratus lumborum blocks,
acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), and systemic opioids. (See "Anesthesia for
cesarean delivery", section on 'Post-cesarean delivery analgesia'.)

NSAIDs are opioid sparing, and are especially effective for relief of uterine cramping. However, these
medications interfere with platelet function, and in doses adequate to reduce pain can increase blood pressure to
a variable degree in both normotensive and hypertensive patients. (See "NSAIDs and acetaminophen: Effects on
blood pressure and hypertension", section on 'Effect of NSAIDs on blood pressure'.)

The report from the American Congress of Obstetricians and Gynecologists Task Force on Hypertension in
Pregnancy suggests that alternative analgesics should be used, rather than NSAIDs, for patients who remain
hypertensive for more than one postpartum day [20]. Other work suggests that postpartum use of NSAIDs is not
associated with increased rates of persistent postpartum hypertension [62].

We routinely administer NSAIDs (ketorolac 30 mg IV every six hours as needed, or ibuprofen 600 to 800 mg
orally every six hours as needed) for 48 hours after cesarean delivery, and avoid NSAIDs for patients with
thrombocytopenia or other risk factors for bleeding.

POSTPARTUM CARE — The risks for complications of preeclampsia continue into the postpartum period.
These patients may remain hypertensive and are at risk for seizures, pulmonary edema, stroke, venous
thromboembolism, and airway obstruction due to airway edema. (See "Preeclampsia: Management and
prognosis", section on 'Postpartum care'.)

For patients who undergo cesarean delivery, postoperative disposition (eg, post anesthesia recovery unit,
intensive care unit) should be determined by the intraoperative course, patient factors, the need for ongoing
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invasive monitoring, and available resources.

ECLAMPSIA — Eclampsia refers to the occurrence of new-onset, generalized, tonic-clonic seizures or coma in a
woman with preeclampsia. The precise etiology of seizures in eclampsia is not clearly understood, and may
involve brain edema and/or ischemia. Obstetric management of eclampsia is discussed separately. (See
"Eclampsia".)

Anesthesia clinicians may be called to manage the airway during an eclamptic seizure, or to provide anesthesia
for vaginal or cesarean delivery [63]. Cesarean delivery should be delayed to allow maternal assessment and
stabilization if a seizure occurs. Women who do not improve promptly following control of hypertension and
seizures and those who develop localizing neurologic signs should be evaluated by a neurologist for possible
imaging to rule out stroke.

Seizures may rarely occur during cesarean delivery with neuraxial anesthesia. Treatment priorities in this setting
are the same as the priorities for patients without anesthesia, as follows (see "Eclampsia", section on 'Prevention
of recurrent seizures' and "Eclampsia", section on 'Management'):

● Airway protection and prevention of hypoxia — Supplemental oxygen should be provided and the airway
supported until the seizure ends.

● Control of hypertension — Blood pressure control should be meticulously maintained at <160 mmHg
systolic

● Prevention of recurrent seizures — Magnesium is the drug of choice for prevention of seizures. A loading
dose of magnesium sulfate 4 to 6 g IV should be administered over 15 to 20 minutes, followed by 2 g per
hour as a continuous infusion. (See "Eclampsia", section on 'Administration of magnesium sulfate'.)

For recurrent seizures in patients already receiving magnesium, an additional dose of 2 g magnesium
sulfate over 5 to 10 minutes should be administered, with frequent monitoring for signs of magnesium
toxicity. If necessary, a seizure may be terminated with benzodiazepines, most commonly midazolam 1 to 2
mg IV, repeated every five minutes until the seizure stops. (See "Eclampsia", section on 'Prevention of
recurrent seizures' and "Eclampsia", section on 'Management of recurrent seizures'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries
and regions around the world are provided separately. (See "Society guideline links: Hypertensive disorders of
pregnancy".)

SUMMARY AND RECOMMENDATIONS

● Anesthesia clinicians should evaluate patients with preeclampsia early in the peripartum period, with the
expectation that emergency delivery may be required at any time. The evaluation should focus on the
airway, hemodynamic status, and coagulation abnormalities. (See 'Preanesthesia evaluation' above.)

● Patients with preeclampsia are at risk for airway edema and difficulty with airway management. Airway
edema may worsen during labor and delivery. (See 'Airway evaluation' above.)

● Thrombocytopenia and other coagulopathies may develop with severe preeclampsia, and may preclude
neuraxial anesthesia techniques because of the risk of spinal epidural hematoma. We place epidural
catheters early in labor, especially for patients with falling platelet counts. In the absence of other
coagulopathies, we place epidural catheters for patients with a platelet count >75,000/microL, do not
perform neuraxial techniques if the platelet count is ≤50/microL, and make individualized decisions for
patients with a platelet count between 50 and 75 microL. (See 'Coagulation' above.)

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● Intravenous fluid administration should be restricted for patients with preeclampsia to avoid pulmonary
edema. No fluid bolus is required for initiation of labor analgesia, and fluid co-loading with neuraxial
anesthesia for cesarean delivery should be avoided or limited to <500 mL. (See 'Intravenous fluid
management' above.)

● We suggest the use of neuraxial analgesia for labor for patients with preeclampsia (Grade 2C). Continuous
neuraxial analgesia attenuates the hypertensive response to labor pain and circulating catecholamines, and
provides a means for rapid conversion to surgical neuraxial anesthesia and avoidance of general
anesthesia. (See 'Advantages of neuraxial labor analgesia' above.)

● For patients with preeclampsia, we target a blood pressure at the patient's baseline, but always systolic
<160 mmHg and diastolic <110 mmHg. Vasopressors should be administered in small doses (eg, ephedrine
2.5 to 5 mg IV, phenylephrine 25 to 50 mcg IV). (See 'Goal blood pressure' above.)

● We recommend neuraxial anesthesia rather than general anesthesia for patients with preeclampsia, for
cesarean delivery (Grade 1B), primarily because it avoids the risk of severe, possibly life threatening
hypertension during induction of anesthesia or during emergence. Endotracheal intubation may be difficult in
these edematous patients. Spinal, epidural, and combined spinal epidural may all be used safely. (See
'Choice of anesthetic technique' above.)

● For prevention of neuraxial anesthesia-induced hypotension for patients with preeclampsia, we administer a
prophylactic, titrated administration of low-dose phenylephrine infusion (ie, starting at <50 mcg/min) with
phenylephrine rescue boluses (eg, 25 to 50 mcg IV). For patients with bradycardia, ephedrine (5 to 10 mg IV
bolus, or 1 to 5 mg/min IV infusion) should be administered as an alternative. (See 'Vasopressors during
neuraxial analgesia' above.)

● When time permits, we consider placement of an arterial catheter prior to induction of general anesthesia for
patients with severe preeclampsia. Induction of general anesthesia for these patients should always include
steps to minimize or eliminate the hypertensive response to intubation. A variety of medications may be
administered during induction for this purpose, with a target systolic blood pressure <160 mmHg (eg,
labetalol, esmolol, lidocaine, nitroglycerine, nicardipine). (See 'Induction of anesthesia' above.)

● Magnesium is routinely administered to prevent seizures in preeclamptic patients. We recommend

continuing magnesium in the operating room during cesarean delivery (Grade 1A). Magnesium potentiates
nondepolarizing neuromuscular blocking agents (NMBAs); nondepolarizing NMBAs should be avoided. If
NMBAs are absolutely necessary, they should be administered in small, incremental doses, and the effect
should be monitored with a peripheral nerve stimulator. (See 'Intraoperative magnesium' above.)

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54. Safavi M, Honarmand A, Azari N. Attenuation of the pressor response to tracheal intubation in severe
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Topic 94369 Version 12.0

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GRAPHICS

In a patient with preeclampsia, the presence of one or more of the following

indicates a diagnosis of "preeclampsia with severe features"

Severe blood pressure elevation:

Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg on two occasions at least four hours
apart while the patient is on bedrest (antihypertensive therapy may be initiated upon confirmation of severe
hypertension, in which case criteria for severe blood pressure elevation can be satisfied without waiting until four
hours have elapsed)

Symptoms of central nervous system dysfunction:

New-onset cerebral or visual disturbance, such as:
Photopsia, scotomata, cortical blindness, retinal vasospasm
Severe headache (ie, incapacitating, "the worst headache I've ever had") or headache that persists and
progresses despite analgesic therapy
Altered mental status

Hepatic abnormality:
Severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by an
alternative diagnosis or serum transaminase concentration ≥2 times the upper limit of the normal range, or both

Thrombocytopenia:
<100,000 platelets/microL

Renal abnormality:
Progressive renal insufficiency (serum creatinine >1.1 mg/dL [97.2 micromol/L] or a doubling of the serum creatinine
concentration in the absence of other renal disease)

Pulmonary edema

In contrast to older criteria, the 2013 criteria do not include proteinuria >5 g/24 hours and fetal growth restriction as
features of severe disease.

Adapted from: Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force on
Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.

Graphic 76975 Version 19.0

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Treatment of acute severe hypertension in pregnancy
Drug Initial dose
Labetalol 20 mg IV gradually over 2 minutes.
A continuous IV infusion of 1 to 2 mg/minute
can be used instead of intermittent therapy or
started after 20 mg IV dose.
Requires use of programmable infusion pump
and continuous noninvasive monitoring of
blood pressure and heart rate.
Hydralazine 5 mg IV gradually over 1 to 2 minutes.*
Adequate reduction of blood pressure is less
predictable than with IV labetalol.
Nifedipine immediate 10 mg orally.
release ¶ May be associated with a precipitous drops in
BP in some women, with associated FHR
decelerations for which emergency cesarean
delivery may be indicated. As such, this
regimen is not typically used as a first-line
option and is usually reserved only for women
without IV access. If used, FHR should be
monitored while administering short-acting
nifedipine.
Nifedipine extended 30 mg orally.
release
Nicardipine A continuous IV infusion of 3 to 9 mg/hour.
(parenteral) Onset of action is delayed by 5 to 15 minutes;
in general, rapid titration is avoided to
minimize risk of overshooting dose.
Requires use of a programmable infusion
pump and continuous noninvasive monitoring
of blood pressure and heart rate.
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Follow-up
Repeat BP measurement at 10-minute
intervals:
If BP remains above target level at 10
minutes, give 40 mg IV over 2 minutes.
If BP remains above target level at 20
minutes, give 80 mg IV over 2 minutes.
If BP remains above target level at 30
minutes, give 80 mg IV over 2 minutes.
If BP remains above target level at 40
minutes, give 80 mg IV over 2 minutes.
Cumulative maximum dose is 300 mg. If
target BP is not achieved, switch to another
agent.
Adjust dose within this range to achieve target
blood pressure.
Cumulative maximum dose is 300 mg. If
target BP is not achieved, switch to another
agent.
Repeat BP measurement at 20-minute
intervals:
If BP remains above target level at 20
minutes, give 5 or 10 mg IV over 2
minutes, depending on the initial response.
If BP remains above target level at 40
minutes, give 10 mg IV over 2 minutes,
depending on the previous response.
Cumulative maximum dose is 20 mg. If target
BP is not achieved, switch to another agent.
Repeat BP measurement at 20-minute
intervals:
If BP remains above target at 20 minutes,
give 10 or 20 mg orally ¶, depending on the
initial response.
If BP remains above target at 40 minutes,
give 10 or 20 mg orally ¶, depending on the
previous response.
If target BP is not achieved, switch to another
class of agent.
If target BP is not achieved in 1 to 2 hours,
another dose can be administered.
If target BP is not achieved, switch to another
class of agent.
Adjust dose within this range to achieve target
BP.
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IV: intravenous; BP: blood pressure; FHR: fetal heart rate.

* If IV access is not immediately available, hydralazine may be given intramuscularly (IM) at a dose of 10 mg.
¶ Capsules should be swallowed whole and not punctured or otherwise given sublingually.

Data from: American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee Opinion No.
623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol
2015; 125:521.

Graphic 110261 Version 2.0

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Contributor Disclosures
Joy Hawkins, MD Nothing to disclose Emily McQuaid-Hanson, MD Nothing to disclose David L Hepner,
MD Nothing to disclose Marianna Crowley, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

Conflict of interest policy

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