Cesarean — Preeclampsia / HELLP
Patient phenotype
Preeclampsia: BP ≥ 140/90 + proteinuria or end-organ dysfunction after 20 wk gestation. Severe features: SBP ≥ 160, DBP ≥ 110, plt < 100k, LFTs 2× upper, Cr > 1.1, pulmonary edema, headache, visual changes, RUQ pain. HELLP: hemolysis + elevated liver enzymes + low platelets.
Procedure
Cesarean delivery. Often urgent for fetal/maternal indications. Spinal vs epidural vs CSE vs GA depending on platelets, urgency, airway. Mag sulfate infusion typically running for seizure prophylaxis.
Anesthetic plan
Neuraxial preferred when platelets adequate (often > 70-80k accepted in HELLP per local protocol; > 100k traditional). GA reserved for emergent + thrombocytopenia + airway-permitting. Strict BP control: SBP < 160 / DBP < 105. Mag continued through delivery + 24h postpartum.
Setup
- ·A-line if severe HTN + difficult NIBP cuffing
- ·2× PIV
- ·Antihypertensive ready: labetalol, hydralazine, nicardipine drip
- ·Magnesium infusion continuing (verify level, reflexes, RR)
- ·Calcium gluconate 1g (mag toxicity reversal)
- ·Difficult airway cart (airway edema common)
- ·Type & cross 2 units PRBC (HELLP coagulopathy)
- ·Coag panel + platelets recent (within 6h)
Biggest concerns by phase
BP control + agent choice
Goal: SBP < 160, DBP < 105. Labetalol 10-20 mg IV q10 min (avoid if asthma/HF), hydralazine 5-10 mg IV (slow onset, watch reflex tachy), nicardipine 5-15 mg/h IV (titratable). Avoid: ACE/ARB (fetal harm), nitroprusside prolonged (cyanide).
Magnesium status + interactions
Therapeutic Mg 4-7 mEq/L. Toxicity: > 7 lose DTRs, > 10 respiratory depression, > 12 cardiac arrest. Mag potentiates NMB (use 1/3 dose roc/cis). Treat toxicity with calcium gluconate 1g IV. Don't stop Mg perioperatively (seizure risk).
Platelet count + neuraxial decision
> 100k: spinal/epidural fine. 70-100k: case-by-case (trend matters; falling = avoid neuraxial). < 70k: avoid neuraxial OR proceed with caution + experienced provider per local protocol. < 50k: GA (most institutions).
GA induction — hypertensive response to laryngoscopy
If GA needed: blunt response with fentanyl 1-2 mcg/kg, lidocaine 1.5 mg/kg, labetalol 10-20 mg, MgSO4 already onboard helps. Avoid ketamine. RSI standard. Anticipate difficult airway (edema, weight gain, full dentition).
Neuraxial hypotension management
Preeclampsia is volume-contracted despite edema — neuraxial drops BP fast. Phenylephrine infusion preferred (norepinephrine increasingly used). Avoid aggressive fluid bolus (pulmonary edema risk). Left uterine displacement throughout.
Uterine atony + PPH
Mag is a tocolytic — uterine atony more likely. Oxytocin 20-40 U in 1L LR over 30 min after cord clamp. Methylergonovine contraindicated (BP spike). Carboprost contraindicated if asthma/pulmonary HTN. Misoprostol 800-1000 mcg PR safe.
Postpartum eclampsia + HELLP progression
Eclampsia risk extends 24-48h postpartum. Continue Mg 24h. HELLP can worsen postpartum (peak LFTs day 2-3). Strict BP control + Mg + plt monitoring. ICU disposition often warranted.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
32-yo G2P1 at 33 wks, severe preeclampsia, BP 175/110 on IV labetalol, plt 85k trending down, fetal decels. Surgery decision: cesarean now. Spinal, epidural, or GA?
What an examiner probes for
- ▹Reviews falling platelet trend + neuraxial risk
- ▹Considers urgency vs ability to delay for second platelet
- ▹Discusses spinal vs CSE vs GA tradeoffs
- ▹Plans BP control during whatever technique chosen
- ▹Anticipates uterotonic choice + airway
Sources
- Chestnut's OB Anesthesia 6e
- ACOG Hypertension in Pregnancy Practice Bulletin 222
- SOAP Consensus Statement 2022
Anatomy reference
Sourced reference images. 4 matches for "uterus pregnant pelvic obstetric".
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