Anesthetic Management of Pregnant Patients with Hypertensive Disorders

  • Samina IsmailEmail author


Hypertensive disorders of pregnancy are one of the most common medical problems encountered during the management of obstetric patients. Preeclampsia is a type of hypertensive disorder, which is unique to human pregnancy and is a leading cause of maternal and fetal morbidity and mortality. The current widely accepted pathophysiology of preeclampsia is failure of placenta to embed adequately leading to hypoxia due to poor placental perfusion. As a result coagulation cascade is activated with the formation of microthrombi leading to end-organ damage. Preeclampsia therefore involves either one or more than one organ systems including the central nervous, cardiovascular, gastrointestinal, hematological, renal, and uteroplacental systems. Early diagnosis of the disease, accurate monitoring, and timely institution of treatment can prevent complication. In the absence of contraindication, neuraxial anesthesia and analgesia is recommended. Postpartum management includes continuation of monitoring, antihypertensive management, thromboprophylaxis, and analgesia. In the presence of multisystem organ involvement and its related complications, patients need to be managed postoperatively in the intensive care unit. Anesthesiologists being part of the multidisciplinary team are involved in the management of these patients for provision of analgesia/anesthesia and for subsequent management in the postpartum period.


Anesthesia management Hypertensive disorders Preeclampsia Pregnancy Obstetric patients 


  1. 1.
    Mammaro A, Carrara S, Cavaliere A, Ermito S, Dinatale A, Pappalardo EM, et al. Hypertensive disorders of pregnancy. J Prenat Med. 2009;3:1.PubMedPubMedCentralGoogle Scholar
  2. 2.
    National Institute for Health and Care Excellence (NICE). Hypertension in pregnancy: the management of hypertensive disorders during pregnancy. In:NICE CG 107. Manchester: National Institute for Health and Clinical Excellence; 2010. Available from Accessed 5 Jan 2018.Google Scholar
  3. 3.
    Bujold E, Morency AM, Roberge S, Lacasse Y, Forest JC, Giguere Y. Acetylsalicylic acid for the prevention or preeclampsia and intra-uterine growth restriction in women with abnormal uterine artery Doppler: a systematic review and meta-analysis. J Obstet Gynaecol Can. 2009;31:818–26.CrossRefGoogle Scholar
  4. 4.
    Regitz-Zagrosek V, Lundqvist CB, Borghi C, Cifkova R, Ferreira R, Foidart JM, et al. European Society of Cardiology Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147–97.CrossRefGoogle Scholar
  5. 5.
    Fitzpatrick K, Hinshaw K, Kurinczuk J, Knight M. Risk factors, management, and outcomes of hemolysis, elevated liver enzymes, and low platelets syndrome and elevated liver enzymes, low platelets syndrome. Obstet Gynecol. 2014;123:618–27.CrossRefGoogle Scholar
  6. 6.
    Gifford RW. Report of the national high blood pressure education program working group on high blood pressure in pregnancy. Am J Obstet Gynecol. 2000;183:1–22.CrossRefGoogle Scholar
  7. 7.
    Hauth JC, Ewell MG, Levine RJ, Esterlitz JR, Sibai B, Calcium for Preeclampsia Prevention Study Group, et al. Pregnancy outcomes in healthy nulliparas who developed hypertension. Obstet Gynecol. 2000;95(1):24–8.PubMedGoogle Scholar
  8. 8.
    Barton JR, O’Brien JM, Bergauer NK, Jacques DL, Sibai BM. Mild gestational hypertension remote from term: progression and outcome. Am J Obstet Gynecol. 2001;184(5):979–83.CrossRefGoogle Scholar
  9. 9.
    Polly LS. Hypertension disorders. In: Chestnut DH, Tsen LC, Polly LS, Wong CA, editors. Chesnut’s obstetric anesthesia: principles and practice. 4th ed. Philadelphia: Mosby Elsevier; 2004. p. 975–1008.Google Scholar
  10. 10.
    Giannubilo SR, Dell’Uomo B, Tranquilli AL. Perinatal outcomes, blood pressure patterns and risk assessment of superimposed preeclampsia in mild chronic hypertensive pregnancy. Eur J Obstet Gynecol Reprod Biol. 2006;126:63–7.CrossRefGoogle Scholar
  11. 11.
    Uzan J, Carbonnel M, Piconne O, Asmar R, Ayoubi JM. Preeclampsia: pathophysiology, diagnosis, management. Vasc Health Risk Manag. 2011;7:467–74.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Bell MJ. A historical overview of preeclampsia-eclampsia. J Obstet Gynecol Neonatal Nurs. 2010;39:510–8.CrossRefGoogle Scholar
  13. 13.
    Alladin AA, Harrison M. Preeclampsia: systemic endothelial damage leading to increased activation of the blood coagulation cascade. J Biotech Res. 2012;4:26–43.Google Scholar
  14. 14.
    Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005;45:142–61.CrossRefGoogle Scholar
  15. 15.
    Dennis AT. Management of pre-eclampsia: issues for anaesthetists. Anaesthesia. 2012;67:1009–20.CrossRefGoogle Scholar
  16. 16.
    Bacq Y. Liver diseases unique to pregnancy: a 2010 update. Clin Res Hepatol Gastroenterol. 2011;35:182–93.CrossRefGoogle Scholar
  17. 17.
    Healthcare Improvement Scotland. Scottish confidential audit of severe maternal morbidity, 7th annual report. Edinburgh; 2011. Accessed 3 Nov 2017.
  18. 18.
    Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The eighth report of the confidential enquiries into maternal deaths in the United Kingdom. BJOG. 2011;118:1–203.PubMedGoogle Scholar
  19. 19.
    Lewis G, editor. The confidential enquiry into maternal and child health (CEMACH). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer – 2003–2005. The seventh report on confidential enquiries into maternal deaths in the United Kingdom. London: CEMACH; 2007.Google Scholar
  20. 20.
    Dyer RA, Piercy JL, Reed AR. The role of the anaesthetist in the management of the pre-eclamptic patient. Curr Opin Anaesthesiol. 2007;20:168–74.CrossRefGoogle Scholar
  21. 21.
    Izci B, Riha RL, Martin SE, Vennelle M, Liston WA, Dundas KC, et al. The upper airway in pregnancy and preeclampsia. Am J Respir Crit Care Med. 2003;167:137–40.CrossRefGoogle Scholar
  22. 22.
    Hennessy A, Thornton CE, Makris A, Ogle RF, Henderson-Smart DJ, Gillin AG, et al. A randomized comparison of hydralazine and mini-bolus diazoxide for hypertensive emergencies in pregnancy: the PIVOT trial. Aust N Z J Obstet Gynaecol. 2007;47:279–85.CrossRefGoogle Scholar
  23. 23.
    Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2007;1:CD002252.Google Scholar
  24. 24.
    Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension. 2008;51:960–9.CrossRefGoogle Scholar
  25. 25.
    National Collaborating Centre for Women’s and Children’s Health. Hypertension in pregnancy. The management of hypertensive disorders during pregnancy. National Institute for Health and Clinical Excellence Guideline 107. August 2010 revised reprint January 2011 ed. London: RCOG; 2011. Accessed 30 Dec 2011.
  26. 26.
    Rowe T. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. J Obstet Gynaecol Can. 2008;30:1–48.CrossRefGoogle Scholar
  27. 27.
    Duley L, Gülmezoglu AM, Chou D. Magnesium sulphate versus lytic cocktail for eclampsia. Cochrane Database Syst Rev. 2010;9:CD002960.Google Scholar
  28. 28.
    Duley L, Henderson-Smart DJ, Walker GJA, Chou D. Magnesium sulphate versus diazepam for eclampsia. Cochrane Database Syst Rev. 2010;12:CD000127.Google Scholar
  29. 29.
    Duley L, Henderson-Smart DJ, Chou D. Magnesium sulphate versus phenytoin for eclampsia. Cochrane Database Syst Rev. 2010;10:CD000128.Google Scholar
  30. 30.
    The Collaborative Eclampsia Trial Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet. 1995;345:1455–63.CrossRefGoogle Scholar
  31. 31.
    Duley L, Gülmezoglu AM, Henderson-Smart DJ, Chou D. Magnesium sulphate and other anticonvulsants for women with preeclampsia. Cochrane Database Syst Rev. 2010;11:CD000025.Google Scholar
  32. 32.
    Alexander JM, McIntire DD, Leveno KJ, Cunningham FG. Selective magnesium sulfate prophylaxis for the prevention of eclampsia in women with gestational hypertension. Obstet Gynecol. 2006;108:826–32.CrossRefGoogle Scholar
  33. 33.
    Ganzevoort W, Rep A, Bonsel GJ, Fetter WP, van Sonderen L, De Vries JI, et al. A randomised controlled trial comparing two temporising management strategies, one with and one without plasma volume expansion, for severe and early onset pre-eclampsia. BJOG. 2005;112:1358–68.CrossRefGoogle Scholar
  34. 34.
    Duley L, Williams J, Henderson-Smart DJ. Plasma volume expansion for treatment of pre-eclampsia. Cochrane Database Syst Rev. 1999;4:CD001805.Google Scholar
  35. 35.
    Krishnachetty B, Plaat F. Management of hypertensive disorders of pregnancy. ATOTW Weekly. 2014;304:1–13.Google Scholar
  36. 36.
    Lucas MJ, Sharma SK, McIntire DD, Wiley J, Sidawi JE, Ramin SM, et al. A randomized trial of labor analgesia in women with pregnancy-induced hypertension. Am J Obstet Gynecol. 2001;185:970–5.CrossRefGoogle Scholar
  37. 37.
    Visalyaputra S, Rodanant O, Somboonviboon W, Tantivitayatan K, Thienthong S, Saengchote W. Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study. Anesth Analg. 2005;101:862–8.CrossRefGoogle Scholar
  38. 38.
    Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology. 2004;101:950–9.CrossRefGoogle Scholar
  39. 39.
    Valera MC, Parant O, Vayssiere C, Arnal JF, Payrastre B. Physiologic and pathologic changes of platelets in pregnancy. Platelets. 2010;21:587–95.CrossRefGoogle Scholar
  40. 40.
    Ginosar Y, Nadjari M, Hoffman A, Firman N, Davidson EM, Weiniger CF, et al. Antepartum continuous epidural ropivacaine therapy reduces uterine artery vascular resistance in pre-eclampsia: a randomized, dose-ranging, placebo-controlled study. Br J Anaesth. 2009;102:369–78.CrossRefGoogle Scholar
  41. 41.
    Reynolds F. Labour analgesia and the baby: good news is no news. Int J Obstet Anesth. 2011;20:38–50.CrossRefGoogle Scholar
  42. 42.
    Fettes PD, Moore CS, Whiteside JB, McLeod GA, Wildsmith JA. Intermittent vs. continuous administration of epidural ropivacaine with fentanyl for analgesia during labour. Br J Anaesth. 2006;97:359–64.CrossRefGoogle Scholar
  43. 43.
    Huang CJ, Fan YC, Tsai PS. Differential impacts of modes of anaesthesia on the risk of stroke among preeclamptic women who undergo caesarean delivery: a population-based study. Br J Anaesth. 2010;105:818–26.CrossRefGoogle Scholar
  44. 44.
    Sia AT, Fun WL, Tan TU. The ongoing challenges of regional and general anaesthesia in obstetrics. Best Pract Res Clin Obstet Gynaecol. 2010;24:303–12.CrossRefGoogle Scholar
  45. 45.
    Aya AG, Vialles N, Tanoubi I, Mangin R, Ferrer JM, Robert C, et al. Spinal anesthesia-induced hypotension: a risk comparison between patients with severe preeclampsia and healthy women undergoing preterm cesarean delivery. Anesth Analg. 2005;101:869–75.CrossRefGoogle Scholar
  46. 46.
    Berends N, Teunkens A, Vandermeersch E, Van de Velde M. A randomized trial comparing low-dose combined spinal-epidural anesthesia and conventional epidural anesthesia for cesarean section in severe preeclampsia. Acta Anaesthesiol Belg. 2005;56:155–62.PubMedGoogle Scholar
  47. 47.
    Dyer RA, Els I, Farbas J, Torr GJ, Schoeman LK, James MF. Prospective, randomized trial comparing general with spinal anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. Anesthesiology. 2003;99:561. Discussion 5A-6A.CrossRefGoogle Scholar
  48. 48.
    Dennis AT. Transthoracic echocardiography in obstetric anaesthesia and obstetric critical illness. Int J Obstet Anesth. 2011;20:160–8.CrossRefGoogle Scholar
  49. 49.
    Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM, Acute Pain Management: Scientific Evidence Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute pain management: scientific evidence. 3rd ed. Melbourne: Australian and New Zealand College of Anaesthetists and the Faculty of Pain Medicine; 2010.Google Scholar
  50. 50.
    Makris A, Thornton C, Hennessy A. Postpartum hypertension and nonsteroidal analgesia. Am J Obstet Gynecol. 2004;190:577–8.CrossRefGoogle Scholar
  51. 51.
    Ehrenberg HM, Mercer BM. Abbreviated postpartum magnesium sulfate therapy for women with mild preeclampsia: a randomized controlled trial. Obstet Gynecol. 2006;108:833–8.CrossRefGoogle Scholar
  52. 52.
    Isler CM, Barrilleaux PS, Rinehart BK, Magann EF, Martin JN Jr. Postpartum seizure prophylaxis: using maternal clinical parameters to guide therapy. Obstet Gynecol. 2003;101:66–9.PubMedGoogle Scholar
  53. 53.
    Magee L, Sadeghi S, von Dadelszen P. Prevention and treatment of postpartum hypertension. Cochrane Database Syst Rev. 2005;1:CD004351.Google Scholar
  54. 54.
    Norwitz ER, Hsu CD, Repke JT. Acute complications of preeclampsia. Clin Obstet Gynecol. 2002;45:308–29.CrossRefGoogle Scholar
  55. 55.
    Steyn DW, Steyn P. Low-dose dopamine for women with severe pre-eclampsia. Cochrane Database Syst Rev. 2007;1:CD003515.Google Scholar
  56. 56.
    Dennis A, Castro J. Transthoracic echocardiography in women with treated severe pre-eclampsia. Anaesthesia. 2014;69:436–44.CrossRefGoogle Scholar
  57. 57.
    Chappell L, Duckworth S, Seed P, Griffin M, Myers J, Mackillop L, et al. Diagnostic accuracy of placental growth factor in women with suspected preeclampsia. Circulation. 2013;128:2121–31.CrossRefGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of AnaesthesiologyAga Khan UniversityKarachiPakistan

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