Lecturer of anesthesia & intensive care
Faculty of medicine
Ain Shams University
2012
• A 26-year-old female, primi-gravida presented
with severe right upper quadrant pain
Vital data
• Blood pressure is 160/110 mmHg
• Heart rate is 75 B/Min.
• Respiratory rate is 20
• Temperature is 36.6 °C
• On examination
Tenderness in her right hypochondrium with
moderate pedal edema
• She has Mallampati class III airway
• Lab shows:
Platelets 100,000
AST 156
ALT 174
Creatinine 1
• For urgent C.S.
Introduction
• Preeclampsia is a disease with unknown
etiology. It may be due to excess
thromboxane over prostacycline with wide
spread vasoconstriction, tissue hypoxia &
endothelial damage.
• Right hypochondrial pain may be secondary
to sub-capsular hematoma of the liver & its
rupture carries 80% mortality rate
• It is a case of severe pre-eclampsia with HELLP
syndrome (Hemolysis, elevated liver enzymes
& low platelet count)
• Take care that eclampsia “seizures” may occur
before, during or after delivery
• The only cure for pre-eclampsia/eclampsia is
the delivery of the fetus & placenta
Pre-operative management
1. Establish & maintain the airway & provide O2
supplement.
2. Pulse Oximetry, ECG & blood pressure should
be monitored .
3. Expand her IV volume with 500 ml fluid
(crystalloids) with adequate UOP monitoring &
fluid balance chart.
4. Aspiration prophylaxis as H2 blocker & non
particulate antacid.
5. Magnesium sulfate prophylaxis by loading &
maintenance doses.
6. Arterial line for invasive blood pressure
monitoring in severe pre-eclampsia prior to
neuroaxial blockade or GA.
7. Blood pressure control by Nitroglycerine,
Hydralazine, labetalol, IV & sublingual
Nifedipine, with continuous CTG monitoring
during administration of the drugs.
8. In the face of difficult airway for an
urgent C.S. Which is appropriate
(neuroaxial blockade vs G.A.)??
9. Consider neuroaxial block for platelet count
of 100,000 & platelet count of 50,000 may be
safe provided that platelet function is
normal, use platelet function tests as TEG,
platelet function assay (PFA-100)
• It is defensible to perform it down to platelet
count of about 80,000, assuming no recent
rapid decrease in platelet number & its
function by (T.E.G) or (PFA-100)
10.HELLP syndrome: Dexamethazone ?? &
platelet transfusion??
Intraoprative
For spinal :
• be ready for blood pressure swings.
• Treat hypotension by :
 Left uterine displacement
 Fluids
 Ephedrine or phenylephrine
• Remember that pre-eclampsia patients
are more sensitive to vasopressor effects
Spinal versus epidural anesthesia:
• Severe hypotension occurring in preeclampsia due to intravascular volume
contraction with the onset of
sympathectomy
• Although we know that epidural has better
control of sympathectomy, recent studies
are showing no significant difference in
hypotension between them
• Spinal is better than epidural for
emergency C.S. in order to avoid G.A.
 GA: If there is contraindication to regional
anesthesia
• Aspiration prophylaxis
• Preoxygenation & denitrogenation
• Rapid sequence induction with smooth
endotracheal intubation due to airway edema
with pre induction nirtoglycerine or labetalol
• Consider awake intubation for Mallampati III
(the case)
o DON’T FORGET
• Mg++ potentiates muscle relaxant effect
• Preinduction arterial line in severe
preeclampsia
• Never ergometrine
Postoperative
• Postoperative analgesia & emptying of the
bladder
• Monitoring should be continued for 24-48
hours after delivery due to potential
development of eclampsia as well as the risk
associated with magnesium therapy
• The location of management: labour &
delivery, ICU or floor is the decision of the
physician guided by the patient’s clinical
status