{
  "abstract": "Introduction Preeclampsia is a pregnancy complication characterized by the new onset of hypertension, defined as a blood pressure of ≥140/90 mmHg on at least two occasions separated by a minimum of four hours. It is often accompanied by proteinuria or organ dysfunction and typically develops after 20 weeks of gestation. The condition usually resolves within three months postpartum. Preeclampsia affects approximately 3–10% of pregnancies and is a leading cause of maternal mortality and morbidity, primarily due to haemorrhagic stroke, pulmonary oedema, respiratory insufficiency, and acute renal failure. 1 Additionally, preeclampsia is a significant contributor to preterm births, accounting for 15–20%, which can adversely impact neonatal health.2 Therefore, the key management goals in preeclampsia are blood pressure control to prevent haemorrhagic stroke, fluid management to prevent pulmonary oedema and respiratory failure, and maintaining adequate uteroplacental perfusion, considering disease severity and gestational age.2 Traditionally, preeclampsia was classified based on gestational age at onset: early-onset (before 34 weeks) or late-onset (after 34 weeks). However, current definitions now incorporate two categories: preeclampsia with or without severe features. Preeclampsia without severe features can progress to severe features, where organ dysfunction becomes more clinically significant than gestational age alone.1 2 This transition to severe features is often when an anaesthesiologist first becomes involved in the management of the patient.3 Preoperative Assessment and Anaesthetic Management of the Parturient With PreeclampsiaPreeclampsia with severe features usually prompts an urgent or emergent delivery. The decision to deliver involves multidisciplinary collaboration and shared decision-making. The delivery type depends on the maternal and foetal conditions, dilation of the cervix, gestational age, and foetal presentation.1–3 For patients with preeclampsia with severe features who are planned for vaginal delivery, neuraxial analgesia is recommended. It offers better blood pressure control, provides superior analgesia compared to systemic analgesics, and reduces the risk of intrapartum caesarean section and complications related to general anaesthesia. Regional anaesthesia also mitigates pain-induced hypertensive responses during uterine contractions by decreasing circulatory catecholamines, thereby reducing stress for both mother and foetus. However, in cases of severe thrombocytopenia, coagulopathy, or uncontrolled haemorrhage, general anaesthesia may be necessary.4 In cases requiring caesarean section, clinicians must decide between regional and general anaesthesia based on factors such as the urgency of delivery, maternal and foetal status, and the severity of preeclampsia (including coagulation status). Preoperative assessment, often conducted under urgent or emergent circumstances, typically includes obtaining a detailed history, physical examination, platelet count, coagulation profile, haemoglobin level, and blood type and screen. In severely preeclamptic patients, spinal anaesthesia-induced hypotension is readily managed, the risk of spinal or epidural hematoma is low, and there is no evidence suggesting adverse neonatal outcomes. Conversely, the potential complications of general anaesthesia—such as hypertensive crises, stroke, and difficult airway management—are leading causes of maternal morbidity and mortality in severe preeclamptic patients. Therefore, in most severely preeclamptic patients who are not coagulopathic or thrombocytopenic, the risks associated with difficult airway management and delayed recognition of maternal stroke during general anaesthesia are considered to outweigh the risk of spinal or epidural hematoma.2 5–10 A study comparing general anaesthesia to spinal anaesthesia in women with severe preeclampsia undergoing caesarean due to nonreasoning foetal heart rate found no differences in umbilical blood gases with base excess (BE) < 10.11 In a larger multicentre randomized controlled trial involving 100 parturient, spinal anaesthesia was associated with a higher incidence of hypotension (SBP < 100 mmHg) during the first 20 minutes after induction (51% vs. 23%, P < 0.001) and a greater need for vasopressor (ephedrine 12 mg vs. 6 mg, P < 0.025), compared to epidural analgesia. No significant differences in neonatal outcomes, as measured by Apgar scores and arterial pH, were observed between the groups.8 Fluid Management Women with preeclampsia are at greater risk of developing pulmonary oedema, especially if too much fluid is given. Excessive fluid can cause serious complications and may lead to ICU admission in up to 10% of severe cases. 2 The 2010 guidelines from the Royal College of Obstetricians and Gynaecologists recommend a cautious, restrictive approach to fluid administration.12 This helps prevent fluid overload, particularly in the early postpartum period when excess fluids are naturally mobilized, even if it means the patient produces less urine (oliguria). Some clinicians have suggested using invasive hemodynamic monitoring—like placing a pulmonary artery catheter—to guide fluid therapy more precisely, especially in patients with low urine output. However, a Cochrane review in 2012 found no strong evidence from clinical trials that this method is safe or effective for managing fluids in severe preeclampsia.13 A focus has shifted to the use of non- or minimally invasive methods to guide fluid therapy, such as pulse wave analysis, TTE or lung ultrasound (US).14 15 Lung, which detects B-lines or comet tails, provides a useful way to assess and quantify extravascular lung water caused by cardiac dysfunction, increased vascular permeability, and reduced colloid osmotic pressure—all common in preeclampsia.16 Nevertheless, studies suggest that cardiac dysfunction is a primary driver of pulmonary oedema in severe cases. Combining lung ultrasound with focused echocardiography to evaluate LV filling pressures allows clinicians to identify women at higher risk of pulmonary oedema, enabling more precise and safer fluid management.15 16 A study that employed pulse wave analysis found considerable variability in SV responsiveness in patients with severe preeclampsia given a colloid bolus before spinal anaesthesia for caesarean section.17 Such variability suggests that in the absence of monitoring of SV responsiveness; fluid restriction is safer.12 Recent insights have shifted the view of preeclampsia from a single disease to a spectrum of cardiovascular and hemodynamic changes. It is now understood to have two main phenotypes, which have important implications for perioperative fluid management14 15: 1. Type 1 (Placental preeclampsia): Characterized by high peripheral vascular resistance (PVR), low cardiac output (CO), and decreased blood volume. This pattern is often linked to placental dysfunction, severe imbalance of angiogenic factors, and foetal growth restriction.2 Type 2 (Maternal preeclampsia): Features low PVR, high CO, and volume overload, reflecting the maternal heart’s maladaptive response to pregnancy (usually associated with preexisting obesity and hypertension). This form tends to develop later and is less frequently associated with foetal growth issues. Around 74% of women with preeclampsia exhibit high PVR, with most having either low (58%) or normal (36%) CO. Recognizing these different hemodynamic profiles is crucial for tailoring management strategies, including fluid therapy and anaesthesia, to better support both mother and baby. Using TTE has revealed that the maternal heart often undergoes structural changes in response to these pressures, especially in severe cases. This can involve left ventricular (LV) hypertrophy, impaired diastolic function, and subtle systolic abnormalities. In women with high PVR, low CO, and foetal growth restriction, echocardiography frequently shows increased LV filling pressures, which raise the risk of pulmonary oedema. Both diastolic and systolic dysfunction contribute to increased extravascular lung water, making management more complex. For women with preeclampsia showing high PVR, low CO, and lung congestion, myocardial impairment with elevated LV filling pressures is likely, and these women require strict blood pressure control and cautious fluid replacement, typically limited to about 60–80 ml/hour. Conversely, women with low CO but no signs of lung fluid overload may benefit from small fluid boluses, around 300 ml, followed by careful infusion, as they tend to tolerate fluids better. On the other hand, women with a high CO and low vascular resistance can usually handle additional fluids, but if signs of pulmonary congestion appear, diuretics may be helpful.14–19 Management and prevention of eclampsia Eclampsia is associated with generalized tonic-clonic seizures, which are usually self-limited. It is a life-threatening complication of preeclampsia and one of the main causes of intracranial haemorrhage, long-term morbidity, and death in parturients, and it also leads to significant foetal morbidity and mortality. Eclampsia is associated with posterior reversible encephalopathy syndrome, with a prevalence of 100%. Clinical signs are hypertension with headache, altered mental status, vision loss, seizures, and radiographic vasogenic oedema, localized to the posterior cerebral white matter. Therapy includes prevention of secondary maternal injury with airway protection and oxygen administration, with left uterine displacement and administration of magnesium sulphate. The decision to deliver involves multidisciplinary collaboration and shared decision-making. Delivery type depends on the maternal and foetal conditions, dilation of the cervix, gestational age, and foetal presentation. Vaginal delivery is considered in a cooperative parturient without altered mental status.3 According to Moodley, RA could be undertaken if GCS is greater than or equal to 14, not needing rapidly acting anti-hypertensive medications, platelet count greater than 100.000 μ/l, cooperative, normal foetal heart rate, and no additional maternal or foetal complications.20 Coagulopathy In preeclampsia, endothelial dysfunction can stimulate excessive platelet activation and consumption, which may contribute to the increased incidence of thrombocytopenia. However, the incidence of spinal-epidural hematoma among preeclamptic patients undergoing neuraxial procedures is unknown. Large survey studies have found that the incidence of spinal-epidural hematoma after neuraxial anaesthesia is lower among parturients than the general population. 21–23 Nevertheless, evidence suggests that the incidence of spinal-epidural hematoma has increased since the 1990s.24 In large retrospective reviews and case reports, laboratory evidence of deranged haemostasis was found in a large proportion of pregnant and nonpregnant patients who developed spinal-epidural hematomas after neuraxial procedures.21 22 24 In 1 large retrospective study, the only 2 cases of obstetric spinal-epidural hematoma occurred in patients with the syndrome of haemolysis, elevated liver enzymes, and low platelets (HELLP).21 Spinal anaesthesia may confer a lower risk of spinal/epidural hematoma than CSE or epidural anaesthesia, since smaller calibres needles are associated with a lower incidence of spinal hematoma and single-shot spinal anaesthesia avoids the risks of an indwelling catheter.24 The Society for Obstetric Anesthesia and Perinatology consensus statement for neuraxial procedures in obstetric patients with thrombocytopenia provides risk-benefit guidelines for patients with preeclampsia and thrombocytopenia. If the patient does not have bleeding associated with thrombocytopenia, does not have an additional comorbidity of an underlying disorder of haemostasis, has normal coagulation, has no rapid rate of decline in platelet count, and has a platelet count of greater than or equal to 70,000 μ/l measured within 6 h, it may be reasonable to proceed with neuraxial analgesia.25 In patients with preeclampsia who are also on aspirin therapy, there is a paucity of evidence to guide clinical practice. Neuraxial procedures in the setting of a low but stable platelet count is likely to be safer than the same low but rapidly falling platelet count. In the setting of HELLP, siting an early epidural catheter may be indicated to prevent having to perform a neuraxial procedure once the platelet count has fallen. A thorough risk-benefit analysis should be undertaken and discussed with the patient before performing a neuraxial technique.25 Platelet count should be re-evaluated before removal of an epidural catheter when thrombocytopenia is present. The same factors used to assess the safety of placement of an epidural catheter should be considered when determining a safe time to remove the catheter. Although the risk of spinal epidural hematoma is low in healthy patients, the risks in patients with preeclampsia and thrombocytopenia is poorly defined.25 In all patients who have neuraxial techniques, monitoring for appropriate resolution of sensorimotor blockade and advising patients to report deviations from normal. Recovery is essential for early detection and management of complications indices should be considered. Clinical judgment is critical in selecting the anaesthetic approach for a preeclamptic patient with a marginal platelet count or coagulation profile. In conclusion, management of preeclampsia requires a comprehensive and multidisciplinary approach, with key considerations including vigilant blood pressure control, careful fluid management, and maintenance of uteroplacental perfusion. For vaginal delivery, neuraxial analgesia is preferred to systemic methods due to its superior blood pressure control and analgesic efficacy while reducing the risk of complications associated with general anaesthesia. In cases requiring caesarean section, the choice between neuraxial and general anaesthesia depends on factors such as urgency, maternal and foetal status, and the patient‘s coagulation profile. While spinal anaesthesia can be safely administered in many severely preeclamptic patients, clinicians must remain vigilant for the increased risks of cardiorespiratory adverse events. Fluid management should therefore be tailored to the to the individual patient with the aid of clinical assessment and where available, especially in complicated cases, non-invasive modalities such as lung ultrasound, TTE or pulse-wave monitors. In the absence of these, a fluid restriction as proposed by RCOG seems justified.References Gestational hypertension and preeclampsia: ACOG practice bulletin summary, number 222. Obstet Gynecol. 2020;135:1492–5. DOI: 10.1097/AOG.0000000000003892Brown MA, Magee LA, Kenny LC, et al. The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens. 2018;13:291–310. doi: 10.1016/j.preghy.2018.05.004.Dennis AT, Xin A, Farber MK. Perioperative management of patients with preeclampsia: a comprehensive review. Anesthesiology 2025;142(2):378–402. doi: 10.1097/ALN.0000000000005296.Henke VG, Bateman BT, Leffert LR. Focused review: spinal anesthesia in severe preeclampsia. Anesth Analg. 2013;117(3):686–693. doi: 10.1213/ANE.0b013e31829eeef5. Erratum in: Anesth Analg. 2013;117(5):1263.Aya AG, Vialles N, Tanoubi I, et al. Spinal anesthesia-induced hypotension: a risk comparison between patients with severe preeclampsia and healthy women undergoing preterm cesarean delivery. Anesth Analg. 2005;101(3):869–75. doi: 10.1213/01.ANE.0000175229.98493.2B.Aya AG, Mangin R, Vialles N, et al. Patients with severe preeclampsia experience less hypotension during spinal anesthesia for elective cesarean delivery than healthy parturients: a prospective cohort comparison. Anesth Analg. 2003;97(3):867–72. doi: 10.1213/01.ANE.0000073610.23885.F2.Clark VA, Sharwood-Smith GH, Stewart AV. Ephedrine requirements are reduced during spinal anaesthesia for caesarean section in preeclampsia. Int J Obstet Anesth. 2005;14(1):9–13. doi: 10.1016/j.ijoa.2004.08.002.Visalyaputra S, Rodanant O, Somboonviboon W, et al. Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study. Anesth Analg. 2005;101(3):862–8. doi: 10.1213/01.ANE.0000160535.95678.34.Sharwood-Smith G, Clark V, Watson E. Regional anesthesia for cesarean section in severe preeclampsia: spinal anesthesia is the preferred choice. Int J Obstet Anesth. 1999;8(2):85–9. doi: 10.1016/s0959-289x(99)80003-x.Chiu CL, Mansor M, Ng KP, et al. Retrospective review of spinal versus epidural anaesthesia for caesarean section in preeclamptic patients. Int J Obstet Anesth. 2003;12(1):23–7. doi: 10.1016/s0959-289x(02)00137-1.Dyer RA, Els I, Farbas J, et al. Prospective, randomized trial comparing general with spinal anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. Anesthesiology 2003;99(3):561–9. discussion 5A-6A. doi: 10.1097/00000542-200309000-00010.National Institute for Health and Care Excellence (NICE). Hypertension in pregnancy: diagnosis and management (NICE guideline NG133) [online]. 2019, last updated 2023. https://www.nice.org.uk/guidance/ng133Li YH, Novikova N. Pulmonary artery flow catheters for directing management in pre-eclampsia. Cochrane Database Syst Rev. 2012;2012(6):CD008882. doi: 10.1002/14651858.CD008882.pub2.Ambrozic J, Brzan Simenc G, Prokselj K, et al. Lung and cardiac ultrasound for hemodynamic monitoring of patients with severe pre-eclampsia. Ultrasound Obstet Gynecol. 2017;49(1):104–9. doi: 10.1002/uog.17331.Ambrožič J, Lučovnik M, Cvijić M. The role of lung and cardiac ultrasound for cardiovascular hemodynamic assessment of women with preeclampsia. Am J Obstet Gynecol MFM. 2024;6(3):101306. doi: 10.1016/j.ajogmf.2024.101306.Zieleskiewicz L, Contargyris C, Brun C, et al. Lung ultrasound predicts interstitial syndrome and hemodynamic profile in parturients with severe preeclampsia. Anesthesiology 2014;120(4):906–14. doi: 10.1097/ALN.0000000000000102.Dyer RA, Daniels A, Vorster A, et al. Maternal cardiac output response to colloid preload and vasopressor therapy during spinal anaesthesia for caesarean section in patients with severe preeclampsia: a randomised controlled trial. Anaesthesia 2018;73(1):23–31. doi: 10.1111/anae.14040.Korenc M, Zieleskiewicz L, Stopar Pintaric T, et al. The effect of vitamin C on pulmonary oedema in patients with severe preeclampsia: a single-centre, randomised, placebo-controlled, double-blind trial. Anaesth Crit Care Pain Med. 2021;40(1):100800. doi: 10.1016/j.accpm.2021.100800.Ambrožič J, Lučovnik M, Cvijić M. Evolution of cardiac geometry and function in women with severe preeclampsia from immediately post-delivery to 1 year postpartum. Int J Cardiovasc Imaging. 2021;37(7):2217–25. doi: 10.1007/s10554-021-02210-6.Moodley J, Jjuuko G, Rout C. Epidural compared with eneral anaesthesia for caesarean delivery in conscious women with eclampsia. BJOG. 2001;108(4):378–82. doi: 10.1111/j.1471-0528.2001.00097.x.Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology 2004;101(4):950–9. doi: 10.1097/00000542-200410000-00021.Bateman BT, Mhyre JM, Ehrenfeld J, et al. The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the multicenter perioperative outcomes group research consortium. Anesth Analg. 2013;116(6):1380–5. doi: 10.1213/ANE.0b013e318251daed.Cook TM, Counsell D, Wildsmith JA, Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the third national audit project of the royal college of anaesthetists. Br J Anaesth. 2009;102(2):179–90. doi: 10.1093/bja/aen360.Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American society of regional anesthesia and pain medicine evidence-based guidelines (third edition). Reg Anesth Pain Med. 2010;35(1):64–101. doi: 10.1097/aap.0b013e3181c15c70.Bauer ME, Arendt K, Beilin Y, et al. The society for obstetric anesthesia and perinatology interdisciplinary consensus statement on neuraxial procedures in obstetric patients with thrombocytopenia. Anesth Analg. 2021;132(6):1531–44. doi: 10.1213/ANE.0000000000005355.",
  "authors": [
    {
      "affiliations": [
        "Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Slovenia, Ljubljana, Slovenia"
      ],
      "name": "Tatjana Stopar Pintaric"
    },
    {
      "affiliations": [
        "Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Slovenia, Ljubljana, Slovenia"
      ],
      "name": "Pia Vovk Racman"
    }
  ],
  "title": "FT33 RA in preeclampsia",
  "uid": "06a2c320-c002-5a61-9ae3-a1d5b592ee17"
}