Clinical management of established pre-eclampsia and gestational hypertension: an anaesthetist’s perspective

Expert and aggressive pre-operative preparation of the woman with severe pre-eclampsia will ultimately determine her intraoperative outcome. Such considerations as the effect of endotracheal manipulation on intracranial pressure, of thrombocytopenia on the potential to produce a compressive epidural haematoma following epidural or combined spinal–epidural neuraxial block and of adequacy of invasive monitoring for Caesarean section loom large in the eyes of an anaesthetist preparing such a patient for surgery. Time spent pre-operatively in fluid volume optimization, in assessment of ventricular function, filling pressures and systemic vascular resistance, on aspiration pneumonitis and seizure prophylaxis, on control of hypertension, on correction of coagulopathy and on attenuation of pressor responses is time well spent and will have profound effects on the peri-operative course. The choice of agents and techniques for control of hypertension and reduction of vascular resistance, for induction and maintenance of general anaesthesia, for eclampsia prophylaxis and for regional anaesthesia or analgesia for operative or spontaneous delivery is, likewise, important and, at times, problematic.