HEREFORD HOSPITALS NHS TRUST

GUIDELINES FOR THE MANAGEMENT OF SEVERE PRE-ECLAMPSIA

(GUIDELINES FOR ANAESTHESIA AND ANALGESIA)
Introduction
Genuine pre-eclamptics tend to maintain their blood pressure, despite regional
blockade. When this happens fluid load is unnecessary and may complicate fluid
balance. For this reason fluid loading in pre-eclampsia should never be done
prophylactically or routinely, and should always be considered and controlled.
Hypotension, when it occurs, can be easily controlled with very small doses of
ephedrine. General anaesthesia can add to the risks of delivery since intubation and
extubation can lead to increases in systolic and diastolic blood pressure, as well as
heart rate, so should be avoided where possible. In women with pre-eclampsia, fluid
requirements at caesarean section should be carefully considered and the use of
more than 500mls of fluid, unless to replace blood loss, should be exceptional.
Analgesia for Labour
Lumbar epidurals using the low dose regime (0.1% Bupivacaine/Fentanyl 2mcg/ml)
is the preferred method of analgesia in the absence of contra-indications.
All the usual contra-indications apply but particularly
platelet count < 80 x 109/l
abnormal clotting prolonged PT or APTT
maternal refusal
The patient should have platelet count and clotting screen performed one hour or
less prior to receiving an epidural. The rate of fall of platelet count should be taken
into account.
Concurrent Aspirin therapy should be taken into account when considering
suitability for epidural.
Besides providing pain relief, the epidural reduces blood pressure swings and
improves placental perfusion in the absence of hypotension.
No fluid preload should be given. Fluid maintenance is with Hartmanns solution at
80 ml/hour. (A brief fluid bolus may be required if the patient is hypotensive. This
should be given with great care (risk of pulmonary oedema)). Ephedrine 3mg 6mg
iv bolus(es) may be required to treat hypotension, remembering that these patients
may be more sensitive to vasopressor agents.
The epidural will contribute to the control of blood pressure and anti-hypertensive
medication may have to be reduced or stopped whilst the block is in use.
Epidural catheter removal post-delivery must be timed safely according to
acceptable platelet count/clotting results. If an epidural is contra-indicated,

alternative methods of analgesia must be used, e.g. parenteral opiate (e.g. Fentanyl
PCA, to be set up by anaesthetist according to the guidelines).

Anaesthesia for Caesarean Section

Regional anaesthesia is the preferred method of anaesthesia in the absence of
severe fetal distress, abnormal clotting, platelet count <80x10 9/L and the other
usual contra-indications.
Communication with the obstetrician is vital to ascertain the urgency of caesarean
section so that a decision can be made promptly as to the most suitable type of
anaesthesia (with mothers agreement).
Careful consideration must be taken with administration of IV fluids. The use of more
than 500ml of fluid should be exceptional other than to replace blood loss. Very
small iv Ephedrine boluses can be used to treat hypotension.
Elective LSCS:
For spinal anaesthesia: 0.5% Bupivacaine heavy + Fentanyl 15-25 mcg
For epidural anaesthesia:

0.5% Bupivacaine plain + 50 100 mcg Fentanyl

Very small boluses of iv Ephedrine to treat hypotension.

Emergency LSCS
If there is a working epidural in situ, it may be extended incrementally without
futher iv fluids.
Bupivacaine 0.5% plain + Fentanyl 50 100 mcg
Or Bupivacaine 0.5% plain + Lignocaine 2% plain (without Adrenaline) + Fentanyl
50 100 mcg is used according to the urgency of the operation.
Spinal anaesthesia as for elective caesarean section. Remember that BP may fall
more rapidly with a spinal anaesthetic. The anaesthetist must be prepared to treat
hypotension promptly.
Very small boluses of iv Ephedrine to treat hypotension.
Regional anaesthesia avoids intubation, which may be difficult in the presence of
laryngeal oedema. Facial oedema and/or husky voice may indicate the presence of
laryngeal oedema.
Continuous fetal heart monitoring whilst regional anaesthesia is being established
will give early indication of fetal compromise (discuss with obstetrician).

Removal of an epidural catheter post-operatively must be timed safely according to

acceptable platelet count and clotting results.
General anaesthesia is indicated if there is a coagulopathy or signs/symptoms of
impending eclampsia (e.g. severe headache). The on-call consultant anaesthetist
should be informed. It is essential to obtund the pressor response to intubation. This
may be done with Alfentanil 30-40 mcg/kg, or Fentanyl 2-4 mcg/kg, +/- Labetolol iv
(in increments of 5 mg up to a total of 15 mg according to BP response) or
Magnesium Sulphate 30 40 mg/kg given prior to induction. (NOT Esmolol fetal
bradycardia). This is followed by the standard technique of rapid sequence induction
with
Thiopentone and Suxamethonium.
If Thiopentone is contra-indicated,
Etomidate is a suitable alternative.
Following Suxamethonium, a non-depolarising muscle relaxant of short/intermediate
length of action such as Rocuronium or Atracurium is used.
Isoflurane and Sevoflurane are suitable as the volatile agents.
Magnesium sulphate potentiates the effect of muscle relaxants. The usual dose of
Suxamethonium is used but fasciculations may be absent. The dose of nondepolarising agents should be reduced to approximately one-fifth the usual dose.
Use of a nerve stimulator is helpful.
The pressor response to extubation may need to be obtunded using Labetolol 10
20 mg. Ensure airway reflexes and consciousness have returned prior to extubation.
Where laryngeal oedema is present, the patient should be electively ventilated on
ITU post-operatively until there is a leak around the ET tube.
DO NOT use Labetolol in asthmatic patients.
A paediatrician should be present for neonatal resuscitation and should be
forewarned if any opiate drug has been given to the mother prior to delivery
because of the risk of neonatal depression.
Direct arterial line BP monitoring should be considered if unstable CVS. However,
this should be removed before returning to labour ward post-operatively. Continued
use of an arterial line +/- a CVP line (usually long line via antecubital fossa) will
require subsequent transfer to ITU for monitoring. It is not safe to leave an arterial
line or CVP line in situ on labour ward. Check chest x-ray if CVP line inserted.
Post-operative Analgesia
IM Morphine is used following caesarean section. If there is abnormal clotting,
morphine via PCA may be appropriate. If an epidural is already in situ this may be
used post-operatively whilst the patient is on the labour ward.
NSAIDs are contra-indicated because of anti-platelet and adverse renal effects.
Paracetamol or Co-codamol (8/500) are suitable oral analgesics.

Remember some patients may need analgesia following vaginal delivery.

Post-operative oxygen is used routinely after GA and may be required after regional
anaesthesia. Duration and flow rate according to patients condition.
Criteria for ITU Transfer

Recurrent seizures
Persistent poorly controlled hypertension (MAP > 125 despite iv Hydrallazine)
Oliguria requiring CVP monitoring
Pulmonary oedema
Compromised airway
Reduced level of consciousness
Continued bleeding
Compromised myocardial function

Some patients will require respiratory support in the form of mechanical ventilation.
This decision is made according to the patients condition at the time.
Monitoring Equipment for Labour Ward HDU Room
ECG monitor
Pulse oximeter
NIBP monitor
Urimeter/bags
HDU charts

References
Yorkshire Regional Severe Pre-eclampsia Guidelines. March 2005
Anaesthesia for Obstetrics and Gynaecology. Russell.BMJ Books 2000
Analgesia, Anaesthesia and Pregnancy. A Practical Guide. Yentis et al. WB Saunders
2001
Handbook of Obstetric Anaesthesia. Palmer et al BMJ 2002
Emergency Caesarean Section : Best Practice. DM Levy.Anaesthesia 2006,61. 786791
Use of Sevoflurane during Elective Caesarean Section Birth: a comparison with
Isoflurane and Spinal Anesthesia. Gambling DR, Sharma SK, White PF< Van Beveren
T, Bala AS, Gouldson R. Anesth Analg 1995;81: 90-95

Dr. Nigel Salmon

Consultant Anaesthetist
Dr. Seng Yeo
Consultant Anaesthetist

Reviewed : July 2006

Review Date : July 2008