Care of the Parturient with Pre-eclampsia
This PBLD was peer-reviewed by a panel of experts from the Society of Obstetric Anesthesia and Perinatology (SOAP) and has been endorsed by the SOAP Education Committee.
Required Pre-work
Reading List
- Bateman BT, Polley LS. Hypertensive Disorders. Chestnut’s Obstetric Anesthesia: Principles and Practice. Ed. David H. Chestnut, Cynthia A. Wong, Lawrence C. Tsen, Warwick D. Ngan Kee, Yaakov Beilin, and Jill M. Mhyre. 6th ed. PA: Philadelphia, 2019. 358-79.
- Henke VG, Bateman BT, Leffert LR. Focused review: spinal anesthesia in severe pre-eclampsia. Anesth Analg. 2013;117(3):686-93.
- Orlando B, Epstein, J. Peripheral Nerve Injury Associated with Labor.Clinical Anesthesiology Guide: Obstetric Anesthesia. Ed. Alan C. Santos, Jonathan N. Epstein, and Kallol Chaudhuri. 1st ed. 2015. 213-20.
Videos: OB Fellows Webinars in OpenAnesthesia
Obstetric Anesthesia section page, OpenAnesthesia
- Expectant Management of the Patient with Preeclampsia – OpenAnesthesia
- Post-Dural Puncture Headache and Epidural Blood Patch – OpenAnesthesia
- Neurologic Complications in Obstetric Anesthesia – OpenAnesthesia
Learning Objectives
Upon the conclusion of this session, the fellow will be able to:
- Assess the risks and benefits of regional anesthesia vs. general anesthesia in a pre-eclamptic patient
- Recognize the types of peripheral nerve injury associated with labor
- Identify and treat post-dural puncture headache
Case Stem
A 38-year-old G1P0 at 38 weeks and 2 days gestational age is admitted to the labor and delivery floor for induction of labor (IOL) for severe pre-eclampsia (PEC). Upon admission, the patient is complaining of a mild frontal headache. She is not in labor, so she has no pain. In the fetal evaluation unit, her blood pressure (BP) ranges between 140/85-195/114 mmHg, and she is therefore admitted on the labor and delivery floor for IOL for PEC with severe features. The anesthesia team is immediately consulted regarding the possibility of an epidural for IOL. However, her past medical history is still unknown to the OB team at this time since the patient has just arrived on the floor.
List 5-10 elements of history, physical exam, or additional workup that will aid you in building your anesthetic plan.
- Laboratory work., including platelet count and coagulation studies.
- Prior laboratory values for comparison
- Obstetric plan for management of PEC (including administration of antihypertensives or magnesium)
- Patient’s additional comorbidities, including obesity or significant cardiac or pulmonary disease
- Airway evaluation
Which of the following criteria are required for diagnosing PEC with severe features?
Which of the following criteria are required for diagnosing PEC with severe features?
According to the American College of Obstetrics and Gynecology (ACOG) guidelines,1 the diagnosis of pre-eclampsia no longer requires the detection of any level of proteinuria. Evidence shows end-organ damage (kidneys, liver, eyes) can occur without proteinuria and that the amount of protein in the urine does not predict how severely the disease will progress.2 Pre-eclampsia is now diagnosed by persistent hypertension that develops during pregnancy or during the postpartum period associated with at least one of the following: new onset of thrombocytopenia, impaired liver or kidney function, pulmonary edema, or neurological sequelae such as seizures and/or visual disturbances. Elevated levels of urine protein are frequently present but not required for the diagnosis.
Of note, in the setting of a clinical presentation similar to preeclampsia but at gestational ages earlier than 20 weeks, alternative diagnoses should be considered, including but not limited to thrombotic thrombocytopenic purpura, hemolytic–uremic syndrome, molar pregnancy, renal disease or autoimmune disease.1
References
1) Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020;135(6):e237-e260. doi:10.1097/AOG.0000000000003891. PubMed.
2) Homer CS, Brown MA, Mangos G, Davis GK. Non-proteinuric pre-eclampsia: a novel risk indicator in women with gestational hypertension. J Hypertens. 2008;26(2):295-302. doi:10.1097/HJH.0b013e3282f1a953. PubMed.
List 5 risk factors for preeclampsia:
- Nulliparity
- Multifetal gestations
- Preeclampsia in a previous pregnancy
- Chronic hypertension
- Pregestational diabetes
- Gestational diabetes
- Thrombophilia
- Systemic lupus erythematosus
- Prepregnancy body mass index greater than 30
- Antiphospholipid antibody syndrome
- Maternal age 35 years or older
- Kidney disease
- Assisted reproductive technology
- Obstructive sleep apnea
Continue with the case:
The patient is diagnosed with PEC with severe features. She is started on magnesium and her induction is initiated. The patient reports 9/10 pain with contractions and requests neuraxial analgesia.
The rest of your anesthesia assessment is as follows: morbid obesity with a body mass index (BMI) of 44, short neck, large tongue, class IV airway, and diet-controlled gestational diabetes. The pregnancy was uneventful until now, except for fetal macrosomia. The patient has 2 large-bore peripheral intravenous (IV) catheters and is type and crossed.
Admission laboratory results are still pending. Her previous labs from 2 weeks ago showed a platelet count of 215K and normal coagulation values.
What are some of the side effects of magnesium administration?
What are some of the side effects of magnesium administration?
Magnesium sulfate is used as a tocolytic and anticonvulsant in parturients with pre-eclampsia/eclampsia. It is also a powerful sedative medication, inducing maternal drowsiness and floppy baby. In addition, anesthetic requirements are reduced when magnesium has been utilized. This results from decreased release of presynaptic acetylcholine and decreased motor end-plate sensitivity to acetylcholine. This end-plate effect results in an increased sensitivity to both depolarizing and non-depolarizing muscle relaxants. Neuromuscular blocking agents have a reduced ED50 and onset time and increased duration of action. Magnesium administration does not cause seizures but rather is used to prevent their occurrence.
Reference
3) Walton JR, Grobman WA. Preterm Labor and Delivery. Chestnut’s Obstetric Anesthesia: Principles and Practice. Ed. David H. Chestnut, Cynthia A. Wong, Lawrence C. Tsen, Warwick D. Ngan Kee, Yaakov Beilin, and Jill M. Mhyre. 5th ed. PA: Philadelphia, 2014. 787-808.
List 5-10 concerns you have about this patient:
- The difficult airway anticipated by your clinical evaluation
- Association of gestational diabetes and large babies increasing the risk of shoulder dystocia and potential for emergent cesarean delivery
- Ability to obtain informed consent for anesthesia in a drowsy patient
- Inability to offer regional anesthesia if the patient’s repeat laboratory values are abnormal
- The possibility of urgent or STAT cesarean delivery occurring before further workup can be completed.
Continue with the case:
A half-hour later, once the laboratory results are back, you reassess the patient. She is not as drowsy as on the initial evaluation since the magnesium has been held, but she is now complaining of increased pain. Unfortunately, the results of her PEC labs show marked thrombocytopenia of 85,000, coagulopathy with an international normalized ratio (INR) of 1.6, and elevated AST and ALT at twice the normal values. At this point, the patient is diagnosed with HELLP syndrome.
In this case, what are the contraindications to neuraxial placement?
In this case, what are the contraindications to neuraxial placement?
According to guidelines published by the American Society of Regional Anesthesia and Pain Medicine (ASRA),4 the only real contraindication to neuraxial anesthesia in the choices given is an elevated INR above 1.5.
Isolated thrombocytopenia with normal INR, depending on the etiology of the low platelets and the trend, might not be an absolute contraindication, especially in the context of a difficult airway, as presented in this case. You might consider a spinal for cesarean delivery or even neuraxial anesthesia for labor.
Different diagnostic benchmarks have been proposed for HELP syndrome. Many clinicians use the following criteria to make the diagnosis:
- lactate dehydrogenase (LDH) elevated to 600 IU/L or more.
- aspartate aminotransferase (AST) and alanine aminotransferase (ALT) elevated more than twice the upper limit of normal.
- platelets count less than 100,000 × 109/L.5
Although HELLP syndrome is mostly a third-trimester condition, in 30% of cases, it is first expressed or progresses postpartum. Furthermore, HELLP syndrome may have an insidious and atypical onset, with up to 15% of the patients lacking either hypertension or proteinuria.5 In HELLP syndrome, the main presenting symptoms are right upper quadrant pain and generalized malaise in up to 90% of cases and nausea and vomiting in 50% of cases.5
References
4) Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):64-101. doi:10.1097/aap.0b013e3181c15c70. PubMed.
5) Martin JN Jr, Rinehart BK, May WL, Magann EF, Terrone DA, Blake PG. The spectrum of severe preeclampsia: comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification. Am J Obstet Gynecol. 1999;180(6 Pt 1):1373-1384. doi:10.1016/s0002-9378(99)70022-0. PubMed.
Continue with the case:
Because this patient is not considered a candidate for the placement of neuraxial analgesia, you decide to offer her a remifentanil patient-controlled analgesia (PCA) for the treatment of labor pain.
List 3 side effects of remifentanil administration:
- Itchiness
- Nausea
- Drowsiness
- Respiratory depression
List specific risks and benefits of intravenous remifentanil PCA during labor:
Remifentanil, administered intravenously by patient-controlled analgesia, seems to provide better pain relief during labor than other opioids (although less so than epidural analgesia), and has become increasingly popular as an option during labor.6 Some institutions prefer a continuous infusion without bolus or a combination of both infusion and bolus, which must be tailored to your patient and her comorbidities.
- Pro: Remifentanil provides better pain relief than intermittent pushes of longer-lasting opioids because of its short half-life and can be administered to patients with a contraindication to regional anesthesia. Remifentanil PCA with a bolus dose in the range of 0.15-0.5 µg/kg and a lockout time of 2 min appears to be a safe and effective option for use in labor with patient‐controlled analgesia systems.7 The risk of respiratory depression is increased if you combine remifentanil with other medications, such as magnesium that can alter the mental status.
- Con: Additional monitoring and closer observation are required during the therapy. This option requires continuous pulse oximetry, respiratory rate monitoring and PCA pumps
that can be programed as needed, as well as a designated nursing staff.
References
6) Van de Velde M, Carvalho B. Remifentanil for labor analgesia: an evidence-based narrative review. Int J Obstet Anesth. 2016;25:66-74. doi:10.1016/j.ijoa.2015.12.004. PubMed.
7) Blair JM, Hill DA, Fee JP. Patient-controlled analgesia for labour using remifentanil: a feasibility study. Br J Anaesth. 2001;87(3):415-420. doi:10.1093/bja/87.3.415. PubMed.
8) Stocki D, Matot I, Einav S, Eventov-Friedman S, Ginosar Y, Weiniger CF. A randomized controlled trial of the efficacy and respiratory effects of patient-controlled intravenous remifentanil analgesia and patient-controlled epidural analgesia in laboring women. Anesth Analg. 2014;118(3):589-597. doi:10.1213/ANE.0b013e3182a7cd1b. PubMed.
Continue with the case:
After pushing for 2 hours, the patient has arrested at 10cm. A new set of labs was just sent, and the platelets are back up to 110K with INR at 1.3. Unfortunately, after another hour, the OB attending has to call for an emergency cesarean delivery for nonreassuring fetal heart tracing and arrest of descent.
What is your anesthetic plan? List factors that might prevent you from using neuraxial anesthesia at this point.
- Patient refusal
- Severe coagulopathy and/or thrombocytopenia
- Persistent fetal bradycardia and no time for spinal
- Eclamptic seizure, altered mental status, and need to protect the airway
- Pulmonary edema with desaturation
- Hemodynamic instability due to bleeding (placental abruption more frequent in PEC)
References
9) Henke VG, Bateman BT, Leffert LR. Focused review: spinal anesthesia in severe preeclampsia [published correction appears in Anesth Analg. 2013 Nov;117(5):1263]. Anesth Analg. 2013;117(3):686-693. doi:10.1213/ANE.0b013e31829eeef5. PubMed.
10) Visalyaputra S, Rodanant O, Somboonviboon W, Tantivitayatan K, Thienthong S, Saengchote W. Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study. Anesth Analg. 2005;101(3):862-868. doi:10.1213/01.ANE.0000160535.95678.34. PubMed.
Continue with the case:
After explaining all the risks and benefits to your patient, you decide to do a single-shot spinal. The spinal is successful, and the cesarean delivery goes well. Two days later, you visit your patient on the postpartum floor, and she informs you that her right leg has been very weak and she cannot stand up. “It feels like my leg is giving up. Do you think I am having the complications you were telling me about? I am so anxious now…”
If you want to rule out an epidural hematoma, what additional features will you look for/ask the patient about?
- Urinary or rectal incontinence
- Severe back pain
- Worsening progression of symptoms
- No specific dermatomal distribution
- Mix of both motor and sensory deficits
- Onset 0-2 days
Which of the following is the most likely cause of this patient’s symptoms?
Which of the following is the most likely cause of this patient’s symptoms?
This patient’s symptoms are most consistent with nerve injury secondary to prolonged pushing with hyperflexion of the hips. This injury is more likely with a large baby compressing the obturator and femoral nerve inside the pelvis. Generally, this complication carries a good prognosis, with total recovery within 6 weeks. Physical therapy is considered first line treatment9.
Reference
11) Santos AC, Esptein JN, Chaudhuri K. Obstetric Anesthesia. Peripheral Nerve Injury Associated with Labor. 213-220.
Continue with the case:
After a few days on the floor, your patient’s neurologic symptoms are improving and she is finally able to walk around but now she says her head hurts a lot and she has blurry vision. She is not very happy and tells you this is “the last pregnancy she will have.”
Which of the following is NOT a symptom of post-dural puncture headache (PDPH)?
Which of the following is NOT a symptom of post-dural puncture headache (PDPH)?
The etiology of PDPH is the inadvertent puncture of the dura by the Tuohy needle (but can also be seen after dural puncture with smaller-size needles such as 25G). Its diagnosis requires the demonstration of a postural component of the headache or the neck pain/stiffness. It can be associated with other neurologic symptoms such as diplopia or tinnitus, but the presence of fever is inconsistent with the diagnosis and should be investigated further.
Reference
12) Macarthur A. Postpartum Headache. Chestnut’s Obstetric Anesthesia: Principles and Practice. Ed. David H. Chestnut, Cynthia A. Wong, Lawrence C. Tsen, Warwick D. Ngan Kee, Yaakov Beilin, and Jill M. Mhyre. 5th ed. PA: Philadelphia, 2014. 713-738. PubMed
List other potential etiologies which could be consistent with this presentation and should be included in your differential diagnosis:
- Elevated blood pressure as a result of ongoing pre-eclampsia
- Cerebral hemorrhage secondary to elevated blood pressure
- Cerebral edema
- Posterior reversible encephalopathy syndrome (PRES)
Posterior reversible encephalopathy syndrome is a complication of nonpregnancy-related reversible cerebral vasoconstriction syndrome, preeclampsia, and eclampsia.13 Posterior reversible encephalopathy syndrome results from posterior cerebral endothelial dysfunction and increased vascular permeability, leading to vasogenic edema. Symptoms of posterior reversible encephalopathy syndrome include occipital headache and cortical blindness. Although the clinical course of preeclampsia or eclampsia usually improves rapidly after delivery, the clinical course of reversible cerebral vasoconstriction syndrome does not, with resolution usually requiring treatment for 3–6 months with medication to decrease cerebral vascular tone.14
References
13) Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(8):494-500. doi:10.1056/NEJM199602223340803. PubMed.
14) Lenger SM, Barrier BF. Recumbent thunderclap headache in the postpartum period. Obstet Gynecol. 2014;123(2 Pt 2 Suppl 2):477-479. doi:10.1097/AOG.0b013e3182a7f20d. PubMed.
Complete List of References:
- Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020;135(6):e237-e260. doi:10.1097/AOG.0000000000003891. PubMed.
- Homer CS, Brown MA, Mangos G, Davis GK. Non-proteinuric pre-eclampsia: a novel risk indicator in women with gestational hypertension. J Hypertens. 2008;26(2):295-302. doi:10.1097/HJH.0b013e3282f1a953. PubMed.
- Walton JR, Grobman WA. “Preterm Labor and Delivery.” Chestnut’s Obstetric Anesthesia: Principles and Practice. Ed. David H. Chestnut, Cynthia A. Wong, Lawrence C. Tsen, Warwick D. Ngan Kee, Yaakov Beilin, and Jill M. Mhyre. 5th ed. PA: Philadelphia, 2014. 787-808.
- Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):64-101. doi:10.1097/aap.0b013e3181c15c70. PubMed.
- Martin JN Jr, Rinehart BK, May WL, Magann EF, Terrone DA, Blake PG. The spectrum of severe preeclampsia: comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification. Am J Obstet Gynecol. 1999;180(6 Pt 1):1373-1384. doi:10.1016/s0002-9378(99)70022-0. PubMed.
- Van de Velde M, Carvalho B. Remifentanil for labor analgesia: an evidence-based narrative review. Int J Obstet Anesth. 2016;25:66-74. doi:10.1016/j.ijoa.2015.12.004. PubMed.
- Blair JM, Hill DA, Fee JP. Patient-controlled analgesia for labour using remifentanil: a feasibility study. Br J Anaesth. 2001;87(3):415-420. doi:10.1093/bja/87.3.415. PubMed.
- Stocki D, Matot I, Einav S, Eventov-Friedman S, Ginosar Y, Weiniger CF. A randomized controlled trial of the efficacy and respiratory effects of patient-controlled intravenous remifentanil analgesia and patient-controlled epidural analgesia in laboring women. Anesth Analg. 2014;118(3):589-597. doi:10.1213/ANE.0b013e3182a7cd1b. PubMed.
- Henke VG, Bateman BT, Leffert LR. Focused review: spinal anesthesia in severe preeclampsia [published correction appears in Anesth Analg. 2013 Nov;117(5):1263]. Anesth Analg. 2013;117(3):686-693. doi:10.1213/ANE.0b013e31829eeef5. PubMed.
- Visalyaputra S, Rodanant O, Somboonviboon W, Tantivitayatan K, Thienthong S, Saengchote W. Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study. Anesth Analg. 2005;101(3):862-868. doi:10.1213/01.ANE.0000160535.95678.34. PubMed.
- Santos AC, Esptein JN, Chaudhuri K. Obstetric Anesthesia. Peripheral Nerve Injury Associated with Labor. 213-220.
- Macarthur, Alison. “Postpartum Headache.” Chestnut’s Obstetric Anesthesia: Principles and Practice. Ed. David H. Chestnut, Cynthia A. Wong, Lawrence C. Tsen, Warwick D. Ngan Kee, Yaakov Beilin, and Jill M. Mhyre. 5th ed. PA: Philadelphia, 2014. 713-738.
- Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(8):494-500. doi:10.1056/NEJM199602223340803. PubMed.
- Lenger SM, Barrier BF. Recumbent thunderclap headache in the postpartum period. Obstet Gynecol. 2014;123(2 Pt 2 Suppl 2):477-479. doi:10.1097/AOG.0b013e3182a7f20d. PubMed.
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