Cesarean section for patient with pre eclampsia need mre attention focus and direct consideration. Here is the highlight.

1. Dr. Ibrahim Elkathiri

2.  36-year-old G1P0 at 37 weeks’ gestation
presents to ER complaining of a severe
headache and blurry Vision. Her vital signs
include T 37.8, HR 84, RR 28, and BP
190/114. Her laboratory evaluation is
Significant for proteinuria and shows a
platelet count of 86 000/mm 3 with normal
coagulation studies.
 Q.Anesthesia consideration.

3.  Difficult intubation,
 Aspiration,
 ↓ time to desaturation,
 aortocaval compression,
 2 patients)

4.  Airway: edema → even more difficult
 CNS: seizures, intracranial hemorrhage (ICH),
cerebral edema, ↑ ICP
 Respiratory: pulmonary edema (secondary to
hypoalbuminemia & hypertension)
 CVS: relatively hypovolemic, ↑ SVR,
hyperdynamic, hypertensive crisis, LV
dysfunction
 Renal dysfunction: oliguria, ATN
 Coagulopathy: thrombocytopenia, MAHA, risk of
DIC
 HELLP (Hemolysis, Elevated Liver enzymes, Low
Platelets)

5.  ↓ uteroplacental perfusion, IUGR, placental
abruption, premature labour& delivery
 Medications: antihypertensive/anticonvulsant
therapy (including risk of MgSO4 toxicity)

6.  Potential delivery & resuscitation of
premature infant:
 Steroids if gestational age < 34+6
 MgSO4 for neuroprotection if gestational age
< 31+6

7.  Consider delivery:
 If severe preeclampsia at any gestational age
 If non-severe preeclampsia > 37 wks
gestational age

8.  BP control (sBP<160 mmHg, dBP<110 mmHg)
(SOGC 2014)
 Prevent end-organ complications (seizures,
ICH, ischemia)
 Optimize fluid status
 Optimize uteroplacental perfusion
 Excellent labour analgesia to mitigate
adverse effects of pain
 Prevent complications if general anesthesia:
 Failed airway
 Hypertensive crisis

9.  Anesthetic technique depends on:
 Fetal distress
 Airway assessment
 Platelets/coagulation profile

10.  Preferred technique
 Allows for titration of local anesthetic & IV
fluids (minimizes risk of BP fluctuations &
pulmonary edema)
 If using for cesarean, consider not adding
epinephrine (may decrease uteroplacental
perfusion)

11.  Traditionally relatively contraindicated in
severe preeclampsia for fear of marked
hypotension, but recent studies (as per
Chestnut) suggest spinal may be appropriate

12.  Least desirable
 Risk of ICH from hypertension secondary to
intubation & ↑ possibility of difficult
intubation secondary to airway edema

13.  Chestnut suggests the following for platelets:
 < 50: neuraxial technique contraindicated
 50-80: risk vs benefit (consider trend, function,
other coagulation investigations)
 80: likely safe
 SOGC 2014 guidelines suggest > 75 is safe unless
coagulopathy, falling platelet count or other
antiplatelet agents

14.  SOGC 2014 guidelines:
 Primary immediate goals:
 Stop convulsions with MgSO4 (4g bolus over 20min, then
1g/hr)
 Establish a patent airway
 Prevent major complications (e.g., hypoxemia, aspiration)
 Phenytoin & benzodiazepines should NOT be used for
eclampsia prophylaxis or treatment, unless there is a
contraindication to MgSO4 or it is ineffective

15.  Further obstetric management:
 Antihypertensive therapy (labetolol 10-20mg IV
or hydralazine 5-10mg IV)
 Induction or augmentation of labor
 Expeditious (preferably vaginal) delivery
 Fetal bradycardia typically occurs during &/or
immediately after a seizure but does not
mandate immediate delivery unless it is
persistent

16.  Interaction with NdMRs (nondepolarizing muscle relaxants):
 Increases the potency & duration of NdMRs (titrate/reduce dose)
 Directly inhibits acetylcholine release &postmembrane sensitivity
to acetylcholine
 No change in succinylcholine (onset & duration unchanged, use
standard dose)
 Effects on uterine tone:
 Potential PPH as a tocolytic agent; however, studies demonstrate
no increase in blood loss
 Have uterotonics available, group & screen completed
 Interaction with calcium channel blockers (specifically
nifedipine)
 Possibly greater hypotensive effects