General versus Regional anesthesia for preeclapmtic Patient undergoing cesarean section.

Abstract

Pregnancy produces profound physiological changes that alter the usual response to anesthesia, many of these changes are useful to the mother in tolerating the stresses of pregnancy and delivery. Preeclampsia has been defined as hypertension developing after 20 weeks’ gestation or in the early postpartum period and returning to normal within 3 months after delivery. The classic triad of preeclampsia includes hypertension, proteinuria, and edema. The exact etiology of preeclampsia is unknown and probably complex, However, Many theories center on problems of placental implantation and the level of trophoblastic invasion. The anesthesiologist must perform a thorough preanesthetic evaluation, including a history and physical examination, with careful attention to the airway examination due to the increased risk of pharyngolaryngeal edema, and assessment of the patient’s cardiopulmonary, fluid, and coagulation status.

The rate of eclamptic seizures in women with mild preeclampsia is less than 1%. Use of magnesium sulfate to prevent eclamptic seizures in women with mild preeclampsia is controversial. Medications commonly used by obstetricians to treat hypertension associated with severe preeclampsia include hydralazine, labetalol, and nifedipine (or other calcium channel blockers) with a goal diastolic BP of 90–105 mmHg and systolic BP of 140–155 mmHg or a mean arterial pressure of 105–125 mmHg. Magnesium sulfate is the drug of choice for prevention of seizures in the preeclamptic woman, or prevention of recurrence of seizures in the eclamptic woman Laboratory tests include: a complete blood count with platelets; bilirubin, aspartate transaminase, and alanine transaminase in order to identify potential HELLP syndrome; electrolyte, urea, and creatinine assessment to check for acute renal failure or uremia; 24-hour proteinuria; prothrombin, activated thrombin time, and fibrinogen (microangiopathic hemolytic anemia); blood group Women with HELLP should be delivered regardless of gestational age, but if expectant management is planned, it should only occur at a tertiary care hospital with close maternal and fetal monitoring due to the severe nature of the disease The choice of a safe anesthetic and maintenance of intraoperative stability to ensure the delivery of a healthy neonate, and to minimize maternal morbidity and mortality, is of particular concern. Studies that compared regional and general anesthesia in patients with preeclampsia have also shown varying results. Some reported poorer maternal and neonatal outcomes in the general anesthetic group, while others indicated similar maternal and neonatal outcomes when a comparison was made between the two groups In preeclampsia, spinal anesthesia is generally considered for cesarean delivery when there is no indwelling epidural catheter or there is a contraindication to neuraxial anesthesia (e.g., coagulopathy, eclampsia with persistent neurologic deficits). Spinal anesthesia affords quicker onset of anesthesia than epidural or Combined Spinal Epidural anesthesia. General anesthesia is indicated in severe preeclampsia with HELLP syndrome, eclampsia, coagulopathy, cerebral edema and in patients who refuse regional anesthesia. In postpartum, close monitoring is done of vital signs, fluid intake and output, and symptoms for at least 48 hours. Management should be done in high dependency unit or transferred to intensive care unit (ICU) if required. The patients with severe preeclampsia are prone to convulse or develop pulmonary edema within 24 h of delivery.