Eur J Anaesthesiol 2014; 31:183–189

REVIEW ARTICLE

Preeclampsia: pathophysiology, old and new strategies

for management
Gary Stocks

Preeclampsia continues to be a leading cause of maternal protocols all have common management goals which are to
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and foetal mortality and morbidity worldwide. It is defined as treat hypertension, prevent seizures, control fluid intake and
hypertension and proteinuria after 20 weeks’ gestation, optimise the timing of delivery. Hypertension can be treated
which resolves after delivery. It is complicated by intracer- with a range of antihypertensive drugs, but labetalol is
ebral haemorrhage, pulmonary oedema and respiratory and regarded as first-line therapy. Magnesium sulphate is the
hepatic failure, which form the commonest causes of death. treatment of choice for eclampsia because it reduces the risk
There is a genetic and immunological element to the patho- of seizures by more than 50%. A fluid restriction policy
physiology of the disease, which is still not completely should be used to prevent iatrogenic pulmonary oedema.
understood, but the underlying cause is an abnormality of Effective anaesthetic management relies on neuraxial tech-
placentation and placental hypoxia. This is thought to result in niques. Epidural, combined spinal-epidural and single-shot
an imbalance of angiogenic and antiangiogenic proteins that spinal anaesthetic techniques are all perfectly acceptable
leads to systemic endothelial disruption and multiorgan and should be actively promoted to the mother unless contra-
involvement. Successful treatment requires delivery of the indications such as thrombocytopaenia exist.
placenta and management should be undertaken by a multi-
disciplinary team, aiming primarily to stabilise the condition of
the mother before delivery is contemplated. Guidelines and Published online 31 December 2013

Preeclampsia and maternal death

Preeclampsia is a hypertensive disorder of pregnancy and overview of the medical and anaesthetic management of
is a multisystem disease that affects 5 to 8% of pregnancies. the condition.
It is defined as the new onset of hypertension and protei-
nuria after 20 weeks’ gestation. Although haemorrhage
continues to be the leading cause of maternal death world- Risk factors: a role for genetics and
wide, in some geographical areas such as Latin America immunology?
and the Caribbean, hypertensive disorders are the most The question of what is the cause of preeclampsia has had
common cause of maternal death.1 Data from the most many answers; the known risk factors are as follows3:
recent UK confidential enquiry into maternal and child
health2 confirm that deaths from preeclampsia occur prim- (1) Age 40 years or older
arily due to intracranial haemorrhage, although other fatal (2) Nulliparity
complications can include acute pulmonary oedema, and (3) Pregnancy interval of more than 10 years
respiratory and hepatic failure. The condition not only (4) Family history of preeclampsia
affects the mother, but it is also a leading cause of foetal (5) Previous history of preeclampsia
growth restriction, intrauterine foetal death and preterm (6) BMI of 30 kg m!2 or above
delivery. This article is intended to provide an update (7) Preexisting vascular disease such as hypertension
on the pathophysiology of preeclampsia and a current (8) Preexisting renal disease

From the Queen Charlotte’s & Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
Correspondence to Gary Stocks, Queen Charlotte’s & Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0HS, UK
Tel: +44 203 313 3991; fax: +44 203 313 5373; e-mail: Gary.Stocks@imperial.nhs.uk

0265-0215 ! 2014 Copyright European Society of Anaesthesiology DOI:10.1097/EJA.0000000000000044

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 184 Stocks

(9) Diabetes mellitus Endothelial dysfunction is associated with

(10) Multiple pregnancy antiangiogenic protein
In normal pregnancy, vascular endothelial growth factor
They suggest that there is both a genetic and an immuno- (VEGF) and placental growth factor (PlGF) are two
logical component to the development of the disease in potent angiogenic substances in the circulation, which
addition to a contribution from preexisting maternal seem to exert some control over endothelial function.
diseases such as obesity and renal impairment. Support An antiangiogenic protein called soluble fms-like tyro-
for a genetic link comes from the higher incidence in sine kinase-1 (sFlt-1) blocks the transmembrane receptor
pregnant women with a maternal history of the disorder. for VEGF and inhibits PlGF. High concentrations of
The immune system also appears to play a major role in sFlt-1 have been demonstrated in preeclampsia, and this
the development of preeclampsia with epidemiological has been associated with decreased concentrations of
evidence suggesting that nulliparity and a new partner are VEGF and PlGF in blood. Furthermore, in vitro studies
both important risk factors, although long-term exposure have demonstrated that the endothelial dysfunction
to paternal antigens in sperm is protective.4 caused by high levels of sFlt-1 can be rescued by admin-
istration of exogenous VEGF and PlGF.
Pathophysiology
Preeclampsia is a disease of abnormal placentation It would appear therefore that sFlt-1 made by the placenta
There are two excellent reviews of the pathophysiology of women with preeclampsia results in lower concen-
of preeclampsia which are recommended for a more trations of VEGF and PlGF, leading to an antiangiogenic
comprehensive overview.5,6 Similar to risk factors, the state and the maternal syndrome of preeclampsia.
pathogenesis is complex and incompletely understood.
However, there is consensus that the primary disease is Reduced haem oxygenase-1 activity
an abnormality of placentation. In order to understand Haem oxygenase-1 (HO-1) is an anti-inflammatory
the part that this plays, it is important to have some enzyme that inhibits sFlt-1 release. Women who go on
knowledge of normal placentation. to develop preeclampsia have been shown to have
decreased HO-1 mRNA expression at 11 weeks’
With normal placentation, maternal uterine spiral arteries gestation. This might result in an excessive elevation
run through the myometrium and into the endometrium, of sFlt-1 with corresponding endothelial dysfunction.
which in pregnancy is replaced by the decidua. Tropho- HO-1 might also have a role as a therapeutic target in
blasts of foetal origin invade these spiral arteries resulting the treatment of preeclampsia. Statins, commonly used in
in a loss of elasticity and vascular smooth muscle tone. cardiovascular disease, stimulate HO-1 expression and
Consequently, these arteries are remodelled into low inhibit sFlt-1 release both in vivo and in vitro, and so may
resistance capacitance vessels, which provide sufficient have the potential to ameliorate early-onset preeclamp-
placental perfusion to sustain the growing foetus. sia. Trials are currently under way to explore this
However, in preeclampsia, trophoblastic invasion is much exciting possibility.
shallower, affecting only the spiral arteries in the decidua.
The myometrial sections remain small and constricted, The origin of cardiovascular changes
resulting in a defective uteroplacental circulation with a The underlying mechanisms for hypertension in pree-
higher resistance. This gives rise to subsequent placental clampsia remain unknown. The commonly held view is
ischaemia. Why this should happen to a minority of that hypertension occurs because of increased systemic
individuals is unknown, but genetic and immunological vascular resistance (SVR) with a concomitant reduction in
mechanisms are thought to be important contributors. cardiac output. However, others believe that the hyper-
tension of preeclampsia arises from an increased cardiac
output state but with only a modest increase in SVR.
Preeclampsia is a two-stage disease characterised by Dennis et al.7 compared haemodynamic changes in
endothelial dysfunction untreated preeclamptics with healthy parturients and
Preeclampsia is a two-stage disorder. The asymptomatic nonpregnant controls using transthoracic echocardiogra-
first stage occurs early in pregnancy and corresponds to phy. They demonstrated that the untreated preeclamptic
the period of abnormal placentation. Some women have group had increased cardiac output due primarily to an
abnormal placentation but do not go on to develop increase in left ventricular fractional shortening and
preeclampsia, for example those with intrauterine growth increased inotropy. There was only mild peripheral vaso-
restriction or spontaneous preterm birth. However, others constriction (Fig. 1). However, one criticism of that study
go on to the symptomatic second stage of preeclampsia is that the mean arterial pressures in women in the
and develop the maternal syndrome, characterised by preeclamptic group were too low to represent a severe
hypertension, proteinuria and multiorgan involvement. disorder. Before new treatment options for the cardio-
The underlying cause of the maternal syndrome is vascular changes emerge, further research is needed to
thought to be systemic endothelial dysfunction. clarify the picture.

Eur J Anaesthesiol 2014; 31:183–189

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 Pathophysiology and management of preeclampsia 185

Fig. 1 risk of developing preeclampsia. The rationale for this is

based on some of the factors listed in the section ‘Risk
MAP mmHg CO ml min–1
HR beats per min factors: a role for genetics and immunology?’.
SVR dyn s cm–5
SV ml
120 6000
Medical management
100 5000 Distinguishing preeclampsia from other causes of hyperten-
80 4000 MAP sion in pregnancy can be difficult. However, clear diagnostic
HR
60 3000 SV criteria are now available. Chronic hypertension is hyper-
CO tension that is present before 20 weeks’ gestation. Gesta-
40 2000 SVR
tional hypertension is new-onset hypertension presenting
20 1000
after 20 weeks’ gestation without significant proteinuria.
0 0 Preeclampsia is new-onset hypertension presenting after 20
Non-pregnent Healthy pregnent Pre-edamptic
weeks’ gestation with significant proteinuria that resolves
Haemodynamic changes in women with untreated preeclampsia. CO,
after delivery.11 Hypertension in its mildest form is defined
cardiac output; HR, heart rate; MAP, mean arterial pressure; SV, stroke as a blood pressure of at least 140/90 mmHg taken with a
volume; SVR, systemic vascular resistance. Data from Dennis et al.7. manual device. Significant proteinuria is defined as more
than 0.3 g protein excreted in 24 h, or more than
30 mg mmol!1 in a spot urinary protein:creatinine sample.
Preeclampsia can be further classified into mild, moder-
Prediction by B-type natriuretic peptides
ate or severe, and typically, worsening severity is associ-
The knowledge that derangements in serum proteins can
ated with more abnormalities in other organ systems of
occur in preeclampsia has opened up the possibility of using
the body (Table 1).
sFlt-1 and PlGF, and other proteins, as biomarkers for the
prediction of disease, but at present, their incorporation into The management of preeclampsia is reviewed in an
some form of screening test remains investigational. More excellent article by Dennis.12 Management should be
recently, there has been interest in the possibility that B- undertaken with a multidisciplinary team approach.
type natriuretic peptides may be used to predict compli- Delivery of the placenta is the only cure. Many units
cations in preeclampsia. In a systematic review, Afshani have developed guidelines and protocols, and although
et al.8 concluded that preeclampsia is associated with elev- they may vary slightly in their content, they all have
ated natriuretic peptide concentrations, but larger prospec- common management goals which are to treat hyperten-
tive trials are required to determine whether elevated sion, prevent seizures, control fluid intake and optimise
concentrations predict development of severe preeclampsia the timing of delivery. When protocols and guidelines for
and its complications. management are implemented, there is evidence to
suggest that this is associated with less mortality and
fewer complications for preeclamptic mothers. However,
Prevention
it is not clear whether this is due to specific management
Other avenues have also been explored to aid in preven-
recommendations within the protocol or, more likely,
tion of preeclampsia. The observation that preeclampsia
because protocols are often introduced as part of a pack-
was associated with a low dietary calcium intake led to a
age of improved healthcare involving better education,
multicentre trial studying the addition of elemental
communication and multidisciplinary team working.13
calcium to the daily diet, but this failed to reduce the
Much of the treatment for preeclampsia lacks an
incidence of preeclampsia in the treatment group.9 Sim-
evidence base.
ilarly, the knowledge that preeclampsia may be a result of
oxidative stress led to investigations into the possibility of
antioxidant supplementation of the diet to prevent or Hypertension
treat preeclampsia. Again however, a large multicentre The purpose of treating acute hypertension in preeclamp-
study using dietary supplementation with Vitamins C and sia is to prevent serious complications such as intracerebral
E failed to show any benefit.10 haemorrhage and stroke, hypertensive encephalopathy,
myocardial ischaemia and cardiac failure.
Consequently, current UK National Institute for Health
and Clinical Excellence (NICE) guidelines11 for redu- Worldwide, there is no consensus yet about what the target
cing the risk of preeclampsia do not recommend the use blood pressure should be and which drugs to use to achieve
of nutritional supplements such as calcium, folic acid, it. In the USA, targeted values are less than 150/
vitamins C and E, fish oils or garlic. Nor do they recom- 100 mmHg; in Canada and Australia, the target is a DBP
mend the use of pharmaceutical agents such as nitric of 90 to 109 mmHg, and 90 to 105 mmHg in Germany. All
oxide donors, progesterone, diuretics or low-molecular are higher than the UK recommendation, which is to aim
weight heparin. The guidelines do recommend that for a DBP of 80 to 100 mmHg. This is important because a
women should take low-dose aspirin if they are at a high balance has to be achieved between accepting higher

Eur J Anaesthesiol 2014; 31:183–189

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 186 Stocks

Table 1 Features of severe preeclampsia in many countries, hydralazine is no longer the first-line
Cardiovascular system Hypertension BP "160/110 mmHg drug of choice.
Papilloedema
" SVR
Labetalol
# Plasma circulating volume
Hyperdynamic circulation Labetalol is a combined a-receptor and b-receptor
Central nervous system Seizures/eclampsia antagonist. It is currently the first-line drug in the UK
Severe headache where UK NICE guidelines11 recommend that moderate
Visual disturbances (blurring/flashing)
Hyperreflexia/clonus
hypertension (150/100 to 159/109 mmHg) and severe
Intracranial haemorrhage hypertension (160/110 mmHg or higher) are treated
Respiratory system Upper airway obstruction and oedema initially with oral labetalol with the aim of reducing
Pulmonary oedema
SBP to less than 150 mmHg and DBP to between 80
Renal system # GFR
Proteinuria >5 g in 24 h and 100 mmHg. Its efficacy is similar to that of hydrala-
3 þ protein dipstick zine, but it is associated with fewer maternal side-effects
Protein/creatinine >0.5 g mmol!1 such as tachycardia and palpitations. However, it should
Hyperuricaemia
Oliguria <400 to 500 ml in 24 h
be avoided in the presence of asthma or congestive
Gastrointestinal system Epigastric pain cardiac failure.
Liver tenderness
Elevated liver enzymes (ALT or AST >70 IU l!1) Nifedipine
Hepatic rupture
Haematological system Thrombocytopaenia <100 $ 109 l!1 This calcium channel blocker lowers blood pressure by
Haemolysis arterial smooth muscle relaxation. It is given orally and,
Disseminated intravascular coagulation when given in the enteral rather than sublingual form, it
Uteroplacental system Impaired uteroplacental blood flow
Intrauterine growth restriction
has been shown to be more effective than hydralazine at
Placental abruption reducing blood pressure to the target range, with less
hypotension. However, its slower onset of action than
GFR, glomerular filtration rate; SVR, systemic vascular resistance. Adapted from
Dennis.12
other antihypertensives can lead to overtreatment. Sub-
lingual nifedipine capsules are no longer recommended
because they are associated with myocardial infarction
blood pressure in an attempt to prolong the pregnancy but and cerebral ischaemia. In theory, nifedipine can interact
with possible adverse consequences to the mother, and the with magnesium to produce hypotension and neuromus-
possible consequences of failure to achieve a more exact- cular blockade, but in practice, the combination can be
ing blood pressure value resulting in increased preterm used safely.
delivery rates. However, there is agreement that when
embarking upon the acute control of hypertension, great Urapidil
care must be taken to avoid precipitous decreases in blood Urapidil is a sympatholytic antihypertensive drug. It acts
pressure, as this can adversely affect uteroplacental as an a1-adrenoceptor antagonist and has been shown to
perfusion. be as effective as hydralazine but gives better control and
is better tolerated. It has a minimal effect on maternal
The current Cochrane review14 does not support the
heart rate. Urapidil is currently not approved by the US
choice of any one antihypertensive over another, con-
Food and Drug Administration, but it is used widely
cluding that the choice should depend on the clinician’s
in Europe.
experience with a specific drug. Consequently, around
the world, there is a variety of antihypertensive agents in
Methyldopa
use. Drugs that are in common use are hydralazine,
Methyldopa continues to be a popular choice of antihy-
labetalol, nifedipine, urapidil and methyldopa.
pertensive in pregnancy, with a good safety profile. It is
an a2-adrenergic agonist, reducing blood pressure
Hydralazine through a sympatholytic action. In some countries, it is
There is great familiarity with hydralazine, which is a still regarded as a first-line medication, but in many
direct-acting vasodilator. It is potent and there is a risk of others, it has been superseded by the drugs outlined
maternal hypotension that can be avoided by the careful above, which are often much better tolerated.
use of a 500-ml infusion of crystalloid prior to its admin-
istration. It is considered well tolerated in pregnancy, but Magnesium sulphate for seizure treatment and
nevertheless there are side-effects such as maternal prophylaxis
tachycardia and palpitations. A systematic review of Eclampsia is the manifestation of end-organ damage in
randomised controlled trials of severe hypertension the brain from severe preeclampsia. It is associated with
showed hydralazine to be associated with poorer maternal intracerebral haemorrhage, cardiac arrest and death.
and perinatal outcomes than other antihypertensive There is clear evidence that magnesium sulphate is
agents and to be more poorly tolerated.15 Consequently, the treatment of choice for eclamptic seizures.16 A

Eur J Anaesthesiol 2014; 31:183–189

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 Pathophysiology and management of preeclampsia 187

loading dose of 4 g should be given over 5 min, followed treat oliguria in women with normal renal function is not
by an infusion of 1 g h!1 for 24 h. Given in this way, it is recommended.18
better than phenytoin, diazepam or lytic cocktail in
A requirement for invasive central venous pressure
reducing the risk of subsequent seizures. The mechanism
monitoring is not common and tends to be reserved for
of action of magnesium sulphate is unclear. Initially,
women with oliguria and also to monitor responses to
eclampsia was thought to occur as a result of cerebral
fluid administration. Several maternal deaths have been
vasospasm. Magnesium sulphate is a known vasodilator
reported as a result of complications from central line
and was thought to reduce seizures by relieving this
insertion,19,20 and one regional study13 found that the use
vasospasm. However, it is more likely that eclampsia
of central venous pressure monitoring did not add sig-
occurs as a result of sustained hypertension causing
nificantly to the management of severe preeclampsia.
cerebral hyperperfusion and oedema. Magnesium sul-
More recently, there has been interest in cardiac output
phate may possess a direct anticonvulsant activity
monitoring to help guide management in preeclampsia
because it has been shown to be a N-methyl-D-aspartate
using invasive intra-arterial techniques and transthoracic
(NMDA) antagonist. Stimulation of NMDA receptors
echocardiography, but this still remains experimen-
may lead to convulsant activity. In addition, magnesium
tal.21,22
is a calcium antagonist and may act at the site of cellular
membranes to oppose factors that promote cerebral
Timing of delivery
oedema and seizure activity. Magnesium sulphate does
Obstetricians decide on the timing of delivery having
not appear to be an effective antihypertensive drug and
weighed up the benefits of continuing a pregnancy for the
this is not thought to be a reason why it is protective
foetus against the risk of maternal morbidity and
against seizures.17
mortality rising with increasing gestation. There is gen-
For prevention of seizures in women with preeclampsia, eral agreement that women with severe preeclampsia
there is now clear evidence that magnesium sulphate after 34 weeks’ gestation should be delivered but only
reduces the risk of eclampsia by more than half.17 How- after blood pressure has been controlled and, if appro-
ever, despite this obvious beneficial effect, there is no priate, a course of corticosteroids completed to aid foetal
evidence that it improves maternal morbidity rates or lung maturation. For women with mild or moderate
perinatal outcomes. Magnesium sulphate therapy is not preeclampsia between 34 and 37 weeks’ gestation, the
without side-effects, such as chest pain, palpitations, timing of delivery should be determined by the maternal
nausea and vomiting, sedation and respiratory weakness. and foetal condition. For any woman with mild to mod-
These are more likely in patients with renal impairment erate preeclampsia after 37 weeks’ gestation, delivery
and should be monitored clinically using patellar reflex should be planned within the next 24 to 48 h.
testing. Worldwide, there is no consensus about when to
For women who develop preeclampsia before 34 weeks’
start magnesium therapy in women with preeclampsia.
gestation, the pregnancy should be managed conserva-
UK NICE guidelines suggest starting magnesium sul-
tively up to 34 weeks. However, delivery may be required
phate if a woman has severe preeclampsia and has had, or
if severe hypertension develops and is refractory to
has a history of, an eclamptic seizure, and also when a
treatment or if other significant maternal and foetal
woman has severe preeclampsia and birth is planned
indications develop.11
within 24 h. The infusion is commonly continued for
24 h postpartum.11
Anaesthesia
Neuraxial anaesthesia during labour
Fluid management Epidural or combined spinal-epidural techniques are
Pulmonary oedema is a recognised cause of death in recommended for preeclamptic women in labour.11,23,24
women with preeclampsia. It occurs because the combi- This is because they provide high-quality analgesia that
nation of low colloid osmotic pressure from loss of smoothes out hypertensive surges due to pain and
protein, increased capillary permeability and high hydro- reduces circulating catecholamine concentrations. In
static pressure from hypertension all make preeclamptic addition, there may be a possible improvement in uter-
women more susceptible to side-effects of fluid therapy. oplacental flow to the foetus and of course the presence of
Despite this, preeclampsia is regarded as a pathological the epidural catheter allows for anaesthesia for Caesarean
state of intravascular volume depletion, and acute renal delivery, thus avoiding the requirement for general
failure secondary to acute tubular necrosis is another well anaesthesia. However, hypotension can be a problem
recognised, albeit rare, complication. Consequently, most for preeclamptic women in labour with regional analgesia.
units now have a fluid management protocol to guide In a retrospective labour cohort study with epidural
intravenous fluid replacement so that the risks of pul- analgesia comparing 100 women with preeclampsia with
monary oedema and renal failure are minimised, and this 100 normotensive women, Vricella et al.25 reported sig-
usually takes the form of a fluid restriction protocol. The nificantly more episodes of hypotension that were also
use of intravenous fluids to increase plasma volume or more severe, had a higher vasopressor requirement and

Eur J Anaesthesiol 2014; 31:183–189

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 188 Stocks

were associated with more frequent foetal heart rate remifentanil can be used in addition to antihypertensives
abnormalities in the preeclamptic group. Consequently, such as labetalol or esmolol; magnesium sulphate has also
although epidural analgesia has advantages compared been used in this role. Finally, consideration should also
with no analgesia, it is important to remain vigilant with be paid to the interaction between magnesium sulphate
regard to hypotension. and nondepolarising muscle relaxants, whose action can
be prolonged in the presence of a magnesium infusion;32
Neuraxial anaesthesia for Caesarean delivery magnesium inhibits acetylcholine release at the neuro-
For Caesarean delivery, neuraxial techniques are also muscular junction, decreases sensitivity to acetylcholine
preferred to general anaesthesia. However, the traditional and depresses excitability of muscle fibre membranes.
view that epidural anaesthesia should be the neuraxial Sometimes, this leads to the requirement for prolonged
method of choice has now been rejected. Concerns that ventilation.
spinal anaesthesia might produce severe hypotension in
this subgroup have dissipated as a result of familiarity HELLP syndrome
with the technique and the evidence from clinical HELLP syndrome is considered to be an extreme form of
research. It has been shown that women with severe severe preeclampsia. It is characterised by haemolysis,
preeclampsia experience less hypotension under spinal elevated liver enzyme concentrations and a low platelet
anaesthesia than normotensive patients.26 Wallace et al.27 count (HELLP), and is associated with disseminated
showed that there was no significant difference in the intravascular coagulation, placental abruption, pulmonary
incidence of hypotension in severely preeclamptic oedema, acute renal failure, liver failure and acute respir-
women having spinal as compared with epidural anaes- atory distress syndrome. As with preeclampsia, it can
thesia. Other studies have shown that there was only a occur in the antepartum or postpartum period. Clinical
mild clinically insignificant difference in the lowest mean management is similar to that of preeclampsia and
arterial pressure between preeclamptic women having includes seizure prophylaxis and antihypertensive medi-
spinal and epidural anaesthesia.28,29 In growth-restricted cation. The initial priority is to stabilise the mother and to
foetuses with impaired Doppler flow, differences in correct coagulopathy, which may include the need for
neonatal biochemistry and Apgar scores when compared platelet transfusion. An assessment of the foetal con-
with general anaesthesia are clinically unimportant.30 dition should be made and, if appropriate, corticosteroids
should be prescribed to accelerate foetal lung maturity.
Coagulopathy There is controversy about the role of corticosteroids for
One well recognised complication of preeclampsia is the treatment of HELLP. Some believe that they might
thrombocytopaenia, and a low platelet count is a relative be of benefit to induce biochemical remission, but cur-
contraindication to regional blockade because of concerns rent UK guidelines do not recommend steroids to treat
regarding epidural haematoma formation. When consid- HELLP syndrome.11 A decision for delivery should be
ering this risk for Caesarean delivery, it must be balanced considered only when the maternal condition is more
against the risks of general anaesthesia. There is no stable.
threshold for platelet count that divides high risk and
low risk for epidural haematoma, and it is necessary to Improved strategies for preeclampsia
rely on expert and consensus opinion. A common view is In the developed world, there has certainly been a
that a stable platelet count of more than 75 $ 109 l!1 in reduction in morbidity and mortality from preeclamp-
the absence of other coagulation abnormalities should be sia/eclampsia. Several factors have led to this improve-
well tolerated and should provide no greater risk than ment. Better antenatal care with an understanding of risk
performing a general anaesthetic for a preeclamptic factors and pathogenesis has led to improved surveillance
woman in labour with a full stomach.31 and better treatment. Lessons concerning when to deli-
ver and mode of delivery have been learned, with an
General anaesthesia appreciation of the importance of stabilising the mother
Occasionally, it is necessary to provide general anaesthe- before embarking with undue haste upon Caesarean
sia for Caesarean delivery. This may be appropriate for delivery. We now manage blood pressure much more
women with contraindications to regional anaesthesia effectively using appropriate antihypertensives and con-
such as coagulopathy, or for those who have developed sistent blood pressure targets. The use of magnesium
severe complications such as pulmonary oedema or sulphate to prevent and manage convulsions is now
depressed consciousness following eclamptic seizures. standard practice. The early use of epidural analgesia
If general anaesthesia is chosen, particular attention in labour not only helps to control blood pressure but also
should be paid to the airway because tracheal intubation avoids the need for general anaesthesia for Caesarean
can be difficult. It is also extremely important to reduce section, with its inherent risks. However, if general
the hypertensive response to laryngoscopy, which can be anaesthesia is required, we now understand the import-
severe and has been identified as a cause of maternal ance of preventing the pressor response to laryngoscopy.
mortality. Opioids such as fentanyl, alfentanil or Finally, the role of consensus guidelines and protocols

Eur J Anaesthesiol 2014; 31:183–189

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 Pathophysiology and management of preeclampsia 189

cannot be overstated in providing an overall package of 14 Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high
blood pressure during pregnancy. Cochrane Database Syst Rev 2006;
care to improve outcomes for newborns and their mothers 3:CD001449.
with this life-threatening condition. 15 Magee LA, Ornstein MP, von Dadelszen P. Fortnightly review: management
of hypertension in pregnancy. Br Med J 1999; 318:1332–1336.
16 The Eclampsia Trial Collaborative Group. Which anticonvulsant for women
Acknowledgements relating to this article with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet
Assistance with the article: Dr Gordon Lyons helped with prep- 1995; 345:1455–1463.
aration of the manuscript. 17 Duley L, Gulmezoglu AM, Henderson-Smart DJ, Chou D. Magnesium
sulphate and other anticonvulsants for women with preeclampsia.
Financial support and sponsorship: none. Cochrane Database Syst Rev 2010; 11:CD000025.
18 Duley L, Williams J, Henderson-Smart DJ. Plasma volume expansion for
Conflicts of interest: none. treatment of preeclampsia. Cochrane Database Syst Rev 1999;
4:CD001805.
Presentation: this review is based on a Refresher Course lecture at 19 Department of Health, Welsh Office, Scottish Office Department of Health
Euroanaesthesia 2013 in Barcelona. Department of Health and Social Services Northern Ireland. Report on
confidential enquiries into maternal deaths in the United Kingdom 1991–
1993. London: HMSO; 1996.
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