Anesthesia for the Parturient with Pre-eclampsia

By August 3, 2018Uncategorized

Expectant mothers can rejoice in knowing that healthcare advances have eradicated many preventable and rare diseases and improved their comfort and care. Last year, an estimated 4.5 million females in the United States conceived and gave birth. [1] Indeed, it has never been easier for a baby to reach the finish line of their term pregnancy, taking their first breath of our worldly air and completing a loving family. However, the bodily changes that accompany pregnancy are much the same regardless of the era in which we live.  The heart must pump blood for two, and the mother’s circulatory system must adjust to share blood and oxygen to the fetus. In turn, many changes in blood pressure can occur during pregnancy, and monitoring and follow-up for obvious blood pressure abnormalities is indicated over and above routine pre-natal care.

In 3-8% of pregnancies, some women may present with severe hypertension, or very high blood pressure (systolic blood pressure > 160 mmHg) along with significant amounts of protein in the urine. These findings are characteristics of pre-eclampsia, a disorder that typically presents in the third trimester and is due to compromised blood flow from the placenta to the developing baby. While some may report “frothy” urine after using the bathroom, it may also catch the obstetrician’s eye after providing a urine sample during routine prenatal visits. Headaches and edema, which is fluid accumulation in the legs and hands, are non-specific symptoms reported during pregnancy. However, they may be worse in patients with pre-eclampsia. In 10% of patients with poorly managed pre-eclampsia, seizures may occur around the time of labor, requiring continuous monitoring to prevent further harm to the baby. [2]

Parturient with pre-eclampsiaAs an anesthesiologist, I am often asked by my pre-eclamptic patients approaching their due date about the available choices for pain control during labor. It is a valid question, considering that either an epidural approach for labor or spinal approach for cesarean section (“C-Section”) will itself affect (i.e. decrease) blood pressure. Other similar options are available for pre-eclamptic patients. If you are a patient with pre-eclampsia, please make sure to discuss the following items with your anesthesiologist ahead of time.

  1. Hydration – Your anesthesiologist will mention that you will need extra fluids prior to receiving an epidural or spinal. Hydration is decreased in pre-eclamptic patients, and you will need a “bolus” or continuous infusion of fluid through an IV ahead of time.
  2. Blood profile – A nurse will draw a sample of your blood to send off to the lab to check the levels of electrolytes, blood cells, and platelets (specialized cells that help to form a clot and stop bleeding). This level is low and can further decrease around the time of labor, thereby increasing the risk of bleeding with epidural procedures and complicating anesthetic management. Levels and function of our clotting system are also measured during this study. Your doctor may order for extra platelets or other related products if your levels are too low.
  3. Seizure prevention – Your obstetrician may administer magnesium around the time of labor to prevent seizures. This requires a planned hospitalization during the routine monitoring of magnesium levels.
  4. Blood pressure control – Pre-eclamptic patients are given medications to control their blood pressure while maintaining blood flow via the placenta. A beta-blocker (labetalol) and smooth muscle relaxant (hydralazine) have been thoroughly studied. However, your obstetrician and healthcare team monitoring your blood pressure can provide you with individualized treatment and monitoring plans after a diagnosis has been established.

Because of these considerations, many pre-eclamptic patients will receive their labor care, and even pre-natal care, at a hospital or center specializing in patients with similar hypertensive or other pregnancy-related disorders.

 

REFERENCES

  1. Curtin SC, Abma JC, Ventura SJ, Henshaw SK. Pregnancy rates for U.S. women continue to drop. NCHS data brief, no 136. Hyattsville, MD: National Center for Health Statistics. 2013.
  2. Ronsmans C, Graham WJ on behalf of the Lancet Maternal Survival Series steering group, “Maternal mortality; who, when, where and why.” The Lancet, Maternal Survival, September 2006.

 

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