What are the recommended preoperative, intraoperative, and postoperative management steps for a term pregnant woman with severe pre‑eclampsia (severe hypertension, low platelet count) requiring delivery?

Management of Severe Preeclampsia Requiring Delivery

Preoperative Management

Blood Pressure Control

Severe hypertension (≥160/110 mmHg) requires urgent treatment in a monitored setting to prevent maternal cerebrovascular complications. 1

• Initiate immediate antihypertensive therapy when BP reaches ≥160/110 mmHg using:

  • Oral nifedipine (first-line) 1
  • IV labetalol (20 mg bolus, then 40 mg after 10 minutes, followed by 80 mg every 10 minutes to maximum 220 mg) 2
  • IV hydralazine (second-line alternative) 1
  • IV nicardipine (start 5 mg/h, increase by 2.5 mg/h every 5-15 minutes to maximum 15 mg/h) 2

• Target diastolic BP of 85 mmHg and systolic BP <160 mmHg (some centers target 110-140 mmHg systolic) 1

Seizure Prophylaxis with Magnesium Sulfate

All women with severe preeclampsia (severe hypertension with proteinuria, or hypertension with neurological symptoms) must receive magnesium sulfate for eclampsia prophylaxis. 1

• Loading dose: 4-5 g IV over 5 minutes 2
• Maintenance infusion: 1-2 g/hour continuous IV 2
• Alternative IM regimen (when IV unavailable): 10 g IM total (5 g in each buttock) 2
• Monitor for toxicity: Check deep tendon reflexes, respiratory rate (must be >12/min), and urine output (>100 mL over 4 hours) 2
• Have calcium gluconate available to reverse magnesium toxicity 2

Laboratory Assessment

Obtain baseline labs before delivery including hemoglobin, platelet count, liver transaminases, serum creatinine, and uric acid 1, 2

Fluid Management

Restrict total fluid intake to 60-80 mL/hour to prevent pulmonary edema, as preeclamptic women have capillary leak and are at high risk for fluid overload 1, 2

• Replace insensible losses (30 mL/h) plus anticipated urinary output (0.5-1 mL/kg/h) 1
• Avoid plasma volume expansion and diuretics 1, 2

Fetal Assessment

Perform continuous fetal heart rate monitoring and assess fetal status with ultrasound (biometry, amniotic fluid, umbilical artery Doppler) 1, 2

Anesthesia Considerations

Continue oral antihypertensives at the start of labor/delivery 1

• Reduced gastrointestinal motility may decrease oral drug absorption, necessitating IV agents 1
• Avoid combining magnesium sulfate with calcium channel blockers due to severe hypotension risk 2

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Intraoperative Management

Blood Pressure Monitoring and Control

Maintain continuous BP monitoring throughout the procedure with immediate treatment if BP rises ≥160/110 mmHg 1, 2

• Use IV labetalol, hydralazine, or nicardipine for acute BP elevations 1, 2
• Target BP <160/110 mmHg to prevent cerebrovascular accidents 1, 2

Magnesium Sulfate Continuation

Continue magnesium sulfate infusion at 1-2 g/hour throughout delivery 2

• Recent evidence shows interrupting magnesium during cesarean is non-inferior for postpartum hemorrhage risk, but continuation remains standard practice 3
• Maintain therapeutic serum levels (4-7 mg/dL) 4

Fluid Restriction

Maintain strict fluid restriction of 60-80 mL/hour intraoperatively to avoid pulmonary edema 1, 2

Delivery Timing

Proceed with delivery after maternal stabilization (BP control and magnesium loading complete) 2

• Vaginal delivery is preferred unless cesarean indicated for obstetric reasons 2

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Postoperative Management

Magnesium Sulfate Duration

Continue magnesium sulfate for 24 hours postpartum or 24 hours after the last seizure, whichever is later. 1, 2

• The ISSHP and major guidelines recommend 24-hour postpartum continuation as standard 1, 2
• One Latin American study found no benefit to continuing beyond delivery in women who received ≥8 g predelivery, but this requires validation in other populations before changing practice 1, 5
• Alternative regimen: 5 g IM every 4 hours in alternating buttocks if IV unavailable 2

Blood Pressure Management

Monitor BP at least every 4-6 hours during the day for minimum 3 days postpartum 1, 6

• Continue or restart antihypertensive medications postpartum 1, 6
• Taper slowly only after days 3-6 postpartum unless BP falls <110/70 mmHg or patient becomes symptomatic 1, 6
• First-line agents: labetalol, nifedipine, methyldopa (all compatible with breastfeeding) 6
• Treat severe hypertension (≥160/110 mmHg) urgently 1, 6

Laboratory Monitoring

Repeat hemoglobin, platelets, creatinine, and liver transaminases the day after delivery 1, 6

• Continue every second day until stable if any were abnormal before delivery 1, 6
• Monitor for progression of HELLP syndrome 6

Neurological Monitoring

Assess neurological status regularly as 25-30% of eclampsia cases occur postpartum 1, 2

• Watch for headache, visual disturbances, right upper quadrant pain, and clonus 1, 6

Analgesia

Avoid NSAIDs in women with preeclampsia, especially with acute kidney injury 1, 6, 2

• NSAIDs can cause severe hypertension and worsen renal function 1
• Use alternative analgesics (acetaminophen, opioids) as first-line 1, 6

Discharge Planning

Most women can be discharged by day 5 postpartum if BP is controlled and they can monitor BP at home 1, 6

• Ensure access to home BP monitoring devices 6
• Schedule follow-up within 1 week if still requiring antihypertensives at discharge 1, 6

Short-Term Follow-Up

Review all women at 3 months postpartum to confirm normalization of BP, urinalysis, and laboratory tests 1, 6

• Persistent hypertension or proteinuria warrants investigation for secondary causes or underlying renal disease 1, 6
• Screen for depression, anxiety, and post-traumatic stress disorder 1

Long-Term Counseling

Counsel about increased lifetime cardiovascular risks: stroke, diabetes, venous thromboembolism, chronic kidney disease 6

• Recurrence risk: ~15% for preeclampsia and ~15% for gestational hypertension in future pregnancies 6
• Prescribe low-dose aspirin (75-162 mg daily) for future pregnancies, ideally started before 16 weeks 6
• Recommend annual medical review lifelong 6

Common Pitfalls to Avoid

• Do not abruptly discontinue antihypertensives—taper gradually after 3-6 days 1, 6
• Do not use NSAIDs as first-line analgesia 1, 6, 2
• Do not neglect long-term cardiovascular risk counseling 6
• Do not use diuretics—plasma volume is already reduced 1, 2
• Do not use sodium nitroprusside—risk of fetal cyanide toxicity 2