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CME Released: 11/21/2012; Valid for credit through 11/21/2013
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Target Audience
This article is intended for primary care clinicians, anesthesiologists, obstetricians, and other specialists who care for patients
with preeclampsia or eclampsia.

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The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to
enhance patient care.

Learning Objectives
Upon completion of this activity, participants will be able to:
1. Describe principles of blood pressure and seizure management in patients with preeclampsia and eclampsia.
2. Describe principles of anesthesia and postpartum management in patients with preeclampsia and eclampsia.

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Author(s)
Steven Fox

Steven Fox is a freelancer for Medscape.

Disclosure: Steven Fox has disclosed no relevant financial information.

Editor(s)
Brande Nicole Martin, MA

CME Clinical Editor, Medscape, LLC

Disclosure: Brande Nicole Martin, MA, has disclosed no relevant financial relationships.

CME Author(s)
Laurie Barclay, MD

Freelance writer and reviewer, Medscape, LLC

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)
Sarah Fleischman

CME Program Manager, Medscape, LLC

Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

From Medscape Education Clinical Briefs

Anesthesiologists' Role in Treating Preeclampsia

News Author: Steven Fox
CME Author: Laurie Barclay, MD
CME Released: 11/21/2012; Valid for credit through 11/21/2013

Clinical Context
Preeclampsia is a leading cause of maternal morbidity and mortality. Many deaths attributed to preeclampsia may be preventable,
as care for preeclampsia is often substandard. Causes of death include intracranial hemorrhage, cerebral infarction, acute
pulmonary edema, respiratory failure, and hepatic failure or rupture. Other severe maternal complications include antepartum
hemorrhage caused by placental abruption, eclampsia, cerebrovascular accidents, organ failure, and disseminated intravascular
coagulation.
The objective of this evidence-based review for anesthesiologists by Dennis was to summarize key management issues regarding
preeclampsia.

Study Synopsis and Perspective

A new review article published in the September issue of Anaesthesia provides useful, up-to-date advice for anesthesiologists
treating patients with preeclampsia.
Anesthesiologists often work along with multidisciplinary teams to treat women who are critically ill with eclampsia.

"This article was developed as there was a need to provide a current succinct summary of the anaesthetic issues relating to the
case of women with pre-eclampsia relevant for anaesthetists," Alicia T. Dennis, MD, director of anaesthesia research at The Royal
Women's Hospital Parkville, and clinical associate professor, Department of Pharmacology, University of Melbourne, Victoria,
Australia, writes.
Dr. Dennis compiled the review using several databases, including Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, and
literature published in languages other than English.
Factors of Preeclampsia
Preeclampsia exists within a wide range of hypertensive diseases associated with pregnancy.
"Pre-existing or chronic hypertension is present before and often during pregnancy, and gestational hypertension is defined as
hypertension arising after 20 weeks' gestation, without any other organ system involvement," she writes.
In contrast, patients with preeclampsia exhibit elevated blood pressure plus the involvement of 1 or more organ systems, and such
problems usually surface after the 20th week of gestation. Symptoms generally resolve within 3 months postpartum.
Preeclampsia should be considered in the differential diagnosis of pregnant women who present with elevated blood pressure,
severe headache, or new-onset epigastric pain, Dr. Dennis emphasizes.
Hypertension that occurs during pregnancy can be caused by a variety of problems. "These include renal disease,
phaeochromocytoma, drug usage such as cocaine and amphetamines and cardiovascular diseases such as coarctation,
subclavian stenosis, aortic dissection and vasculitis," the study author writes. Given this broad range of possible causes, it is
imperative to consider all possible causes when evaluating patients with elevated blood pressure.
Managing Hypertension
"Due to the risk of haemorrhagic stroke in the presence of systolic hypertension, most guidelines recommend lowering of nonsevere blood pressure to a systolic level of 140150 mmHg and a diastolic of 90100 mmHg, using oral labetalol as the drug of
choice," Dr. Dennis writes.
Clinicians should keep any existing comorbidities in mind when determining the recommended blood pressure endpoints.
For severe hypertension (systolic 160 mm Hg; diastolic 110 mm Hg), the author suggests using oral or intravenous labetalol.
Alternatives are oral nifedipine or intravenous hydralazine. However, comparative studies of those agents for the treatment of
hypertension linked to preeclampsia are lacking. "The choice should be made depending on the experience of the clinician with a
particular agent," Dr. Dennis writes.
Although reducing blood pressure in patients is important, it is also prudent to avoid instituting therapies that can cause
precipitous decreases in blood pressure because such situations can trigger maternal and/or fetal complications.
Comorbidities and Complications
Seizures are a serious and potentially life-threatening aspect of preeclampsia and are associated with a mortality rate of more
than 3%.
On the basis of these findings, magnesium sulfate is the drug of choice in treating patients with seizures (eclampsia) and
recurrent seizures, and magnesium sulfate vs diazepam has been shown to reduce the risk for mortality. Magnesium sulfate also
appears to reduce the risk for recurrent seizures more effectively than diazepam, phenytoin, and lytic cocktail (consisting of
chlorpromazine, promethazine, and pethidine).
A severe form of preeclampsia involves a syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP). The
review did not find any sufficient evidence either to refute or support the adjuvant use of corticosteroids with dexamethasone,
betamethasone, or prednisolone in treating such patients.
Administration of Analgesia and Anesthetics

Among pregnant women in general, the incidence of complications after neuraxial procedures is approximately 1 in 20,000 to
30,000 for spinal anesthesia and 1 in 25,000 for epidural analgesia.
For women with symptoms of preeclampsia, Dr. Dennis writes: "In the absence of contraindications, lumbar neuraxial analgesia is
appropriate for women with pre-eclampsia during labour ... and neuraxial anaesthesia is the preferred method for anesthesia for
caesarean birth in women with pre-eclampsia."
Regarding the use of analgesia during labor, the review of the literature suggests that lumbar neuraxial analgesia helps reduce
hypertensive responses to pain and that having an epidural catheter in place facilitates titration of local anesthetics for surgical
procedures.
Dr. Dennis cautions that intravenous fluid loading should not be used in women with severe eclampsia until low-dose analgesia,
including combined-spinal epidural analgesia, has been established.
Neuraxial anesthesia is the preferred method for patients delivering via cesarean delivery. "Single-shot spinal, combined-spinal
epidural, and epidural anaesthesia have all been used effectively," Dr. Dennis writes. "There is no evidence that one technique has
an advantage over the other."
For women with preeclampsia who require general anesthesia, the review indicates that "extreme vigilance should be given to
ablating the hypertensive response to intubation, as this has been identified as a cause of direct maternal mortality." Agents that
have been used in this setting include alfentanil, fentanyl, remifentanil, magnesium sulfate, lidocaine, and esmolol.
During labor, blood pressure should be monitored hourly in patients with mild to moderate hypertension, and continuously in
women with severe hypertension. "Intra-arterial blood pressure measurement enables continuous blood pressure recording and
facilitates repeated blood sampling for assessment of respiratory function, electrolytes, acid-base balance and haematological
and liver abnormalities as well as the monitoring of cardiac output by minimally invasive cardiac output monitors," Dr. Dennis
writes.
Postpartum Monitoring
Treatment of women with preeclampsia should continue throughout the postpartum period. Pulmonary edema may occur in 2.9%
of such patients, with more than two thirds of cases occurring after delivery.
Oliguria in the immediate postpartum period may also be a problem. However, if renal and respiratory functions are normal, this
condition usually requires no treatment.
Some women who have experienced preeclampsia during gestation may go on to have severe hypertension in the immediate
postpartum period, the author notes. "Although it is clear that antenatal hypertension may persist in the postpartum period, it is
not clear what leads to new onset hypertension in this period," according to the review. Agents commonly used to manage this
complication include hydralazine, nifedipine, frusemide, and methyldopa.
A final challenge in treating patients with preeclampsia is choosing drugs that are safe to use during breast-feeding. Ideal drugs,
Dr. Dennis notes, have low milk-to-maternal plasma ratios. Drugs that may be useful in this regard include methyldopa, adrenoceptor blockers with high plasma protein binding (eg, oxprenolol), angiotensin-converting enzyme inhibitors (eg, captopril,
enalapril), and some dihydropyridine calcium channel blockers (eg, nifedipine).
Dr. Dennis has disclosed no relevant financial relationships.
Anaesthesia. 2012;67:1009-1020.

Study Highlights
The reviewer systematically searched the literature in electronic databases including MEDLINE, EMBASE, and the
Cochrane Library, as well as relevant college and society Web sites for pertinent guidelines.
Key search terms were obstetrics, pregnancy, pregnancy complications, maternal, pre-eclampsia, preeclampsia, cardiac
function, haemodynamics, haemolysis, elevated liver enzymes, low platelets (HELLP), eclampsia, anesthesia,

anaesthesia, and neuraxial.

Preeclampsia is defined as a hypertensive disease.
Early recognition of preeclampsia and its complications is important, as well as multidisciplinary expert team
management.
Early referral to the anesthesiologist facilitates stabilization of severe preeclampsia before delivery.
The use of transthoracic echocardiography allows accurate monitoring and recording of observations.
Oral labetalol is the drug of choice for lowering of nonsevere blood pressure to 140 to 150 mm Hg systolic and 90 to 100
mm Hg diastolic.
Other safe agents include methyldopa, nifedipine, or isradipine, and some -adrenoceptor blockers (eg, metoprolol,
pindolol, propranolol) and low-dose diazoxide.
Atenolol is not recommended because of fetal growth restriction, and angiotensin-converting enzyme inhibitors and
angiotensin type-2 receptor blockers are contraindicated.
For severe hypertension (systolic pressure 160 mm Hg or diastolic 110 mm Hg), drugs that can be safely used include
labetalol (oral or intravenous), nifedipine (oral), and hydralazine (intravenous).
Drugs that should be avoided to reduce blood pressure are high-dose diazoxide, ketanserin, nimodipine, and magnesium
sulfate, as well as labetalol in women with severe asthma.
It is important to treat systolic blood pressure of more than 180 mmHg, using intravenous antihypertensive medication
when needed.
Parenteral magnesium sulfate can be used to treat and prevent eclampsia (seizures). It is the first-line drug treatment of
eclampsia and recurrent seizures.
Other helpful interventions are intravenous fluid restriction and avoidance of ergometrine for uterine contraction.
The review also summarizes principles of neuraxial analgesia and anesthesia, as well as general anesthesia for birth.
Lumbar neuraxial analgesia is appropriate for women with preeclampsia during labor, in the absence of contraindications.
Neuraxial anesthesia is preferred for cesarean birth in women with preeclampsia.
Syntocinon is the drug of choice for uterine contraction in the setting of severe hypertension, and it should be carefully
titrated to hemodynamic responses.
Postpartum management includes analgesia, thromboprophylaxis, management of acute pulmonary edema, and use of
pharmacologic agents in the setting of breast-feeding.
Treatment of acute pulmonary edema is similar to that in nonobstetric patients.
Ideal antihypertensive drugs in the breast-feeding mother have low milk-to-maternal plasma ratios.
These include methyldopa, -adrenoceptor blockers with high plasma protein binding (eg, oxprenolol), angiotensinconverting enzyme inhibitors (eg, captopril, enalapril), and some dihydropyridine calcium channel blockers (eg, nifedipine).

Clinical Implications
A review of anesthesia management in patients with preeclampsia notes that it is important to treat systolic blood pressure
of more than 180 mm Hg, using intravenous antihypertensive medication when needed. Parenteral magnesium sulfate is
the first-line drug treatment of eclampsia and recurrent seizures.
In the absence of contraindications, lumbar neuraxial analgesia is appropriate for women with preeclampsia during labor.
Neuraxial anesthesia is also preferred for cesarean birth in women with preeclampsia. Postpartum management includes
analgesia, thromboprophylaxis, management of acute pulmonary edema, and use of pharmacologic agents in the setting of
breast-feeding.

CME Test
To receive AMA PRA Category 1 Credit, you must receive a minimum score of 70% on the post-test.

Your patient is a 24-year-old woman with preeclampsia. According to the systematic review by Dennis, which of
the following statements about management of blood pressure and seizures is correct?
Atenolol is the drug of choice for lowering of nonsevere blood pressure
Safe antihypertensive agents for lowering of nonsevere blood pressure include methyldopa, nifedipine or

isradipine, some -adrenoceptor blockers, and low-dose diazoxide

No oral agents have been recommended for treatment of severe hypertension
Parenteral magnesium sulfate is not recommended for recurrent seizures
According to the review by Dennis, which of the following statements about anesthesia and postpartum
management in patients with preeclampsia and eclampsia is correct?
Lumbar neuraxial analgesia is contraindicated for women with preeclampsia
Neuraxial anesthesia is preferred for cesarean birth in women with preeclampsia
Dose titration is not needed when syntocinon is used for uterine contraction in women with severe
hypertension
Treatment of acute postpartum pulmonary edema in women with preeclampsia differs dramatically from
that in nonobstetric patients
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