Anesthesia for the patient with preeclampsia
- Joy Hawkins, MD
Joy Hawkins, MD
- Professor of Anesthesiology
- University of Colorado School of Medicine
- Emily McQuaid-Hanson, MD
Emily McQuaid-Hanson, MD
- Instructor in Anesthesia
- Harvard Medical School
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".)
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.)
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- PREANESTHESIA EVALUATION
- Severity of preeclampsia
- Airway evaluation
- Hemodynamic status
- CARE SETTING: ICU VERSUS LABOR FLOOR
- HEMODYNAMIC MONITORING
- GOAL BLOOD PRESSURE
- INTRAVENOUS FLUID MANAGEMENT
- LABOR ANALGESIA
- Advantages of neuraxial labor analgesia
- Neuraxial analgesia versus systemic opioids
- Management of neuraxial labor analgesia
- - Timing of neuraxial analgesia
- - The epidural test dose
- - Vasopressors during neuraxial analgesia
- - Epidural catheter removal
- ANESTHESIA FOR CESAREAN DELIVERY
- Intravenous access
- Choice of anesthetic technique
- - General versus neuraxial anesthesia
- - Choice of neuraxial technique
- Anesthetic management of neuraxial anesthesia
- - Fluid administration
- - Vasopressors during cesarean delivery
- - Uterotonic medications
- General anesthesia
- - Airway management
- - Induction of anesthesia
- Intraoperative magnesium
- Postoperative pain control
- POSTPARTUM CARE
- SUMMARY AND RECOMMENDATIONS