Wisconsin Anesthesia Professionals

Considerations for Obstetric Anesthesia with Preeclampsia

Preeclampsia

Preeclampsia is a pregnancy complication characterized by proteinuria, high blood pressure, and other symptoms that can lead to organ damage and risk the life of both the mother and child [1]. It affects millions of women worldwide each year; as a result, it should be considered a healthcare priority [2]. Because preeclampsia can develop during obstetric surgery, anesthesia providers must learn how to manage the condition effectively, including the considerations relating to the type of anesthesia used, prevention, and resource constraints.

While it was once the primary technique used during obstetric surgery, general anesthesia has fallen out of favor [3]. This is because general anesthesia carries the risk of complications, such as failed tracheal intubation or aspiration and consequent pneumonitis, that pose particular dangers to preeclamptic women [3]. Despite deaths associated with general anesthesia during obstetric surgery having decreased significantly in the last fifty years, the relatively high occurrence of mortality after failed intubation discourages practitioners from using it, especially with the elevated risks associated with preeclampsia [3].

Instead, the preferred technique is neuraxial anesthesia [4]. Of course, neuraxial anesthesia carries its own set of complications, the primary one being bleeding [4]. Nevertheless, bleeding is rare and can be addressed by opting for a single-shot spinal when the patient has a lower platelet count, for instance [4].

Neuraxial anesthesia is not always preferable to general anesthesia for obstetric patients with preeclampsia. Patients with coagulopathy, altered mentation, and thrombocytopenia may benefit from general anesthesia, as well as those with persistent reduced consciousness warranting emergency delivery [5]. If medical professionals decide to administer general anesthesia, they can rely on various strategies to minimize its risks [5]. For one, they should take precautions in anticipation of a difficult airway [6]. This can involve using a channeled laryngoscope to improve vision and ease entry of the endotracheal tube [5]. Another strategy to consider is using high-flow nasal oxygen delivery to maintain oxygenation, as well as administering multimodal anesthesia wherever possible [5].

Beyond their choice of anesthesia, medical professionals should also make use of preventative techniques to avoid the occurrence of eclampsia wherever possible. For instance, biomarker tests for early diagnosis and better surveillance of eclampsia can be helpful and have been shown to lead to a reduced incidence of adverse outcomes in mothers [6]. As of now, the tyrosine kinase receptor-1 (sFlt-1)/placental growth factor (PlGF) ratio appears to be the most telling marker for diagnosing preeclampsia [6]. Among preventative therapies, aspirin, administered at a dose of between 7 and 150 mg/day, seems to be the most effective [6].

Lastly, practitioners must bear in mind that care does not end after surgery. The risk of eclampsia persists following the operation, and close monitoring of the mother’s platelet count, blood pressure, urine output, liver function, and serum creatinine should continue [6]. Importantly, one should avoid administering non-steroidal analgesics while making sure to continue anti-hypertensive therapy [6]. While preeclampsia is a dangerous condition, medical practitioners can lessen the risk of adverse outcomes by bearing in mind preventative strategies, appropriate techniques for obstetric anesthesia, and post-delivery practice. 

References

[1] “Preeclampsia,” Mayo Clinic. [Online]. Available: https://www.mayoclinic.org/diseases-conditions/preeclampsia/symptoms-causes/syc-20355745.

[2] S. Sobhy et al., “Type of obstetric anesthesia administered and complications in women with preeclampsia in low- and middle-income countries: A systematic review,” Hypertension in Pregnancy, vol. 36, no. 4, pp. 326-36, July 2017. [Online]. Available: https://doi.org/10.1080/10641955.2017.1389951.

[3] C. Delgado, L. Ring, and M.C. Mushambi, “General anaesthesia in obstetrics,” BJA Education, vol. 20, no. 6, pp. 201-07, June 2020. [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7807964/.

[4] L. R. Leffert, “What’s new in obstetric anesthesia? Focus on preeclampsia,” International Journal of Anesthesia, vol. 24, no. 3, pp. 264-71, August 2015. [Online]. Available: https://doi.org/10.1016/j.ijoa.2015.03.008.

[5] R. Hofmeyr, M. Matjila, and R. Dyer, “What’s new in obstetric anesthesia? Focus on preeclampsia,” Best Practice & Research Clinical Anaesthesiology, vol. 31, no. 1, pp. 264-71, March 2017. [Online]. Available: https://doi.org/10.1016/j.bpa.2016.12.002.

[6] L. McGarey, K. Bhatia, and W. Ross Macnab, “Pre-eclampsia and the anaesthetist,” Anaesthesia & Intensive Care Medicine, vol. 23, no. 6, pp. 331-35, June 2022. [Online]. Available: https://doi.org/10.1016/j.mpaic.2022.02.028