Perioperative management of patients with preeclampsia

Preeclampsia is a progressive hypertensive disorder of pregnancy that can have life-threatening complications for both the mother and the newborn. It is characterized by new-onset hypertension after 20 weeks of gestation, along with evidence of organ dysfunction. Affecting approximately 5% of pregnancies worldwide, preeclampsia is responsible for nearly 4.9% of maternal deaths in the United States. Maternal complications can range from stroke and heart failure to liver rupture and renal impairment, while newborns may experience growth restrictions, prematurity, and lifelong metabolic risks. Given its significant impact on maternal and fetal outcomes, perioperative management of patients with preeclampsia, particularly during cesarean delivery, is of critical importance. The review of Dennis et al. 2024 in Anesthesiology focuses on the role of anesthesiologists in optimizing care, mitigating risks, and improving perioperative outcomes for this high-risk population.

Perioperative considerations for preeclampsia

Anesthesiologists are integral to the management of preeclampsia in cesarean delivery, the most common major surgical procedure worldwide. Their role extends beyond intraoperative care to include:

• Preoperative risk assessment and optimization
• Intraoperative management of hypertension and hemodynamics
• Postoperative recovery, rehabilitation, and long-term follow-up
• Collaborative decision-making in a multidisciplinary care team

Preoperative assessment and management

A thorough preoperative evaluation is essential to assess disease severity and determine the safest anesthetic approach. Key considerations include:

• Hypertension severity: Preeclampsia can present with systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg. Severe hypertension is defined as BP ≥ 160/110 mmHg and requires immediate treatment.
• Organ dysfunction: Complications such as cerebral edema, cardiac failure, renal impairment, hepatic dysfunction, and coagulopathy must be assessed.
• Diagnostic challenges: Other conditions, such as chronic hypertension, gestational hypertension, thrombotic microangiopathies, and acute fatty liver of pregnancy, can mimic preeclampsia and must be ruled out.

Blood pressure management

• Nonsevere hypertension (140–159/90–109 mmHg): Treated with oral antihypertensives like labetalol, nifedipine, or methyldopa.
• Severe hypertension (≥160/110 mmHg): Requires urgent treatment within 60 minutes using intravenous (IV) antihypertensive therapy such as IV labetalol, IV hydralazine, or calcium channel blockers.
• Hypertensive emergencies: BP should be carefully lowered to avoid maternal cerebrovascular events and fetal hypoxia.

Eclampsia prevention and management

Seizures in patients with preeclampsia characterize eclampsia and require urgent magnesium sulfate administration for seizure control and prevention.

• Prophylaxis: IV magnesium sulfate (4–6 g loading dose, then 1–2 g/hour infusion) is recommended for high-risk patients.
• Seizure management: Additional 2 g IV bolus of magnesium sulfate for recurrent seizures.
• Magnesium toxicity: High serum levels (>9 mg/dL) can cause respiratory depression and cardiac arrest, requiring calcium gluconate as an antidote.

Intraoperative management

The choice of anesthesia for cesarean delivery in patients with preeclampsia must balance maternal and fetal safety.

Neuraxial vs. general anesthesia

• Neuraxial anesthesia (spinal or epidural): Preferred due to stable hemodynamic profile, reduced maternal morbidity, and better neonatal outcomes.
• General anesthesia (GA): Reserved for emergencies, eclampsia, severe coagulopathy, or airway difficulties.

Considerations for neuraxial anesthesia

• Spinal hypotension: Less common in preeclamptic patients but still requires vigilant BP monitoring.
• Vasopressor management: Phenylephrine is preferred for spinal hypotension. Norepinephrine is contraindicated due to risks of critical hypertension.
• Epidural conversion: If a labor epidural is in place, it can be “topped up” for surgical anesthesia using 2% lidocaine or 3% 2-chloroprocaine.
• Thrombocytopenia management: Neuraxial anesthesia is generally safe if platelets are ≥70,000/µL and coagulation is normal.

Considerations for general anesthesia

• Airway management: Higher risk of difficult intubation due to airway edema.
• Hypertensive response to intubation: Requires pre-induction IV antihypertensives and opioids to blunt BP spikes.
• Postoperative extubation: This must be done cautiously, as extubation-induced hypertension can trigger intracranial hemorrhage.

Postoperative care and long-term considerations

Postoperative hemodynamic and analgesia Management

• Monitoring: Close hemodynamic monitoring in an intensive care setting is often required.
• Analgesia: Multimodal analgesia is recommended, including:
  • Neuraxial opioids (e.g., intrathecal morphine)
  • Acetaminophen
  • NSAIDs (with caution in renal dysfunction)
  • Regional anesthesia techniques (e.g., transversus abdominis plane block).

Cardiac complications

• Heart failure: Increased risk of heart failure with preserved ejection fraction (HFpEF) and pulmonary edema.
• Echocardiography: This should be performed preoperatively if heart failure is suspected.
• Postoperative cardiometabolic risk: Patients with preeclampsia are at long-term risk of hypertension, ischemic heart disease, and stroke.

Coagulation and thromboprophylaxis

• Risk of venous thromboembolism (VTE): Due to hypercoagulability and prolonged bed rest, requiring low-molecular-weight heparin prophylaxis.
• Epidural catheter removal: Must be timed carefully based on platelet count and anticoagulant use.

Conclusion

Preeclampsia presents significant perioperative challenges, requiring multidisciplinary collaboration, individualized anesthesia planning, and close postoperative monitoring to reduce maternal and neonatal morbidity and mortality. Anesthesiologists are critical in optimizing patient outcomes through early risk stratification, precise hemodynamic management, and tailored analgesia strategies. By implementing evidence-based perioperative management protocols, clinicians can reduce complications, improve surgical outcomes, and enhance mothers’ and newborns’ long-term health.

For more information, refer to the full article in Anesthesiology.

Dennis AT, Xin A, Farber MK. Perioperative Management of Patients with Preeclampsia: A Comprehensive Review. Anesthesiology. 2025 Feb 1;142(2):378-402.

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