What is the appropriate order and dosing of albumin infusion for a pregnant patient with preeclampsia undergoing Caesarean delivery?

Albumin Infusion in Preeclampsia During Cesarean Delivery: Not Routinely Recommended

Albumin infusion is not routinely recommended for pregnant patients with preeclampsia undergoing Caesarean delivery, as current evidence does not support its use for improving maternal or neonatal outcomes in this setting. 1, 2

Fluid Management During Cesarean Delivery with Preeclampsia

General Principles

Perioperative euvolemia is the primary goal during cesarean delivery, with careful attention to avoid fluid overload, which is a significant risk in preeclamptic patients due to capillary leak and potential for pulmonary edema. 1

• Total fluid intake should be limited to 60-80 mL/hour during labor and delivery to prevent pulmonary edema while maintaining adequate perfusion. 1

• Fluid balance should aim for euvolemia by replacing insensible losses (30 mL/h) plus anticipated urinary losses (0.5-1 mL/kg/hour). 1

• There is no rationale to "run dry" a preeclamptic patient, as they are already at risk for acute kidney injury. 1

Albumin Use: Limited Indications

The 2024 International Collaboration for Transfusion Medicine Guidelines found insufficient evidence to support albumin use in most clinical settings, including routine perioperative care. 1

Albumin is NOT indicated for:

• Routine volume expansion in preeclampsia 3, 4
• Standard preloading before regional anesthesia in preeclamptic patients 1
• Blood pressure management in preeclampsia 3

Albumin MAY be considered only in specific circumstances:

• Severe hypovolemia with inadequate response to crystalloids during hemorrhage, where it should supplement (not replace) blood product transfusion. 5

• HELLP syndrome with severe hypoalbuminemia (albumin <33 g/L) and evidence of intravascular volume depletion, though this remains controversial. 1

• Massive ascites removal (≥5L) in cirrhotic patients, but this is not a typical preeclampsia scenario. 1, 6

Evidence Against Routine Albumin Use

Historical studies suggesting benefit of albumin before spinal anesthesia 7 are contradicted by modern guidelines that emphasize euvolemia rather than aggressive preloading. 1

• Albumin infusion in preeclampsia neither decreases blood pressure nor increases uterine blood flow. 3

• Volume expansion with albumin in severe preeclampsia causes unchanged or slightly reduced mean arterial pressure but significantly increases pulmonary arterial pressure, raising concerns for pulmonary edema. 4

• The 2018 Enhanced Recovery After Surgery Society guidelines for cesarean delivery recommend perioperative euvolemia without specifying colloid use. 1

Appropriate Fluid Orders for Preeclamptic Cesarean Delivery

Standard Crystalloid Approach

Order balanced crystalloid solutions (Lactated Ringer's or Plasmalyte) at maintenance rates:

• Intraoperative rate: 60-80 mL/hour 1
• Avoid boluses unless treating documented hypotension with hemodynamic instability
• Monitor urine output targeting 0.5-1 mL/kg/hour 1

Blood Pressure Management (Primary Focus)

Antihypertensive medications, NOT volume expansion, are the cornerstone of preeclampsia management during cesarean delivery:

• Continue oral antihypertensives at the start of labor 1

• Treat urgently if BP ≥160/110 mmHg with: 1

  • IV labetalol: 20 mg bolus, then 40 mg after 10 minutes, then 80 mg every 10 minutes (max 220 mg) 1
  • IV hydralazine: 5 mg bolus, then 10 mg every 20-30 minutes (max 25 mg) 1
  • Oral nifedipine immediate-release: 10 mg, repeat every 20 minutes (max 30 mg) - use with caution if receiving magnesium sulfate due to risk of precipitous hypotension 1

Magnesium Sulfate for Seizure Prophylaxis

All patients with severe preeclampsia should receive magnesium sulfate for eclampsia prophylaxis, not albumin. 1

• Standard dosing regimens from the MAGPIE trial should be used 1
• Continue for 24 hours postpartum (or minimum 8g total if given before delivery) 1

Critical Pitfalls to Avoid

Do not order albumin as routine preloading before neuraxial anesthesia in preeclamptic patients - this outdated practice increases risk of pulmonary edema. 1, 4

Do not use albumin to treat hypertension - it is ineffective and potentially harmful. 3, 4

Avoid aggressive fluid boluses - preeclamptic patients have capillary leak and are at high risk for pulmonary edema despite appearing intravascularly depleted. 1, 4, 2

Monitor for fluid overload carefully - albumin 25% is hyperoncotic and can rapidly expand plasma volume by 3-4 times the infused amount, risking circulatory overload. 5

If albumin is used for hemorrhage, it must be accompanied by blood products to treat relative anemia from hemodilution. 5