1. Preeclampsia and Eclampsia.Preeclampsia (pregnancy-induced hypertension) and eclampsia (seizures) are characterized by hypertension, proteinuria, and edema that may progress to oliguria, congestive heart failure, and seizures (eclampsia) (Table 40-8: Symptoms of Severe Preeclampsia).
   1. Many of the symptoms associated with preeclampsia may result from an imbalance between the placental production of prostacyclin and thromboxane.
   2. The HEELP syndrome is a form of severe preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelet count. In contrast to preeclampsia, elevations in blood pressure and proteinuria may be mild.
   3. General Management (Table 40-9: Considerations in the Management of Parturients with Preeclampsia or Eclampsia)
   4. Anesthetic Management
      1. Epidural anesthesia or combined spinal–epidural analgesia for labor and delivery is acceptable provided no clotting abnormality or plasma volume deficit is present. In volume-repleted parturients positioned with left uterine displacement, the institution of epidural anesthesia does not typically cause an unacceptable decrease in blood pressure and may result in significant improvements in placental blood flow.
      2. Spinal anesthesia may produce severe alterations in cardiovascular dynamics resulting from sudden sympathetic nervous system blockade.
      3. General anesthesia is often chosen for acute emergencies, but the practitioner should keep in mind the probable exaggerated blood pressure responses to induction of anesthesia and intubation of the trachea and possible interactions of muscle relaxants with magnesium sulfate therapy.
      4. Decreased doses of ephedrine are recommended to treat patients with hypotension because parturients with preeclampsia or eclampsia may exhibit increased sensitivity to vasopressors.
2. Obstetric hemorrhage is the leading cause of maternal mortality, causing 25% of peripartum deaths.
   1. Placenta previa (painless bright red bleeding after the seventh month of pregnancy) is the most common cause of postpartum hemorrhage.
   2. Abruptio placentae typically manifests as uterine hypertonia and tenderness with dark red vaginal bleeding. Maternal and fetal mortality rates are increased.
   3. General anesthesia (often with ketamine [0.75 mg/kg IV] induction of anesthesia) is used in view of the increased risk of hemorrhage and clotting disorders.
3. Heart Disease. Cardiac decompensation and death occur most commonly at the time of maximum hemodynamic stress. For example, cardiac output increases during labor, with the greatest increase immediately after delivery of the placenta. These changes in cardiac output are blunted by regional anesthesia.
   1. Congenital Heart Disease (Table 40-10: Congenital Heart Disease and the Parturient)
   2. Valvular Heart Disease (Table 40-11: Hemodynamic Goals with Valvular Lesions)
   3. Primary pulmonary hypertension is seen predominantly in young parturients, and pain during labor and delivery may further increase pulmonary vascular resistance. (Neuraxial analgesia is useful.)
   4. Cardiomyopathy of pregnancy is left ventricular failure in late pregnancy or in the first 6 weeks postpartum (occurs approximately one in 3,000 births and is associated with a maternal mortality of 25% to 50%). It is a diagnosis of exclusion and thought to be related to myocarditis or an abnormal immune response.
   5. Coronary artery disease and myocardial infarction are rare but are associated with high maternal and infant mortality rates.
   6. Sudden Arrhythmic Death Syndrome (SADS) is a sudden cardiac death in which all other causes have been eliminated (normal heart, no stimulant drugs).
4. Diabetes Mellitus. Gestational diabetes mellitus or glucose intolerance is first diagnosed during pregnancy. (There is an increasing incidence with obesity.)
5. Obesity is associated with antenatal comorbidities (hypertension, diabetes, preeclampsia) and an increasing need for cesarean delivery. Despite technical challenges, continuous neuraxial analgesia provides excellent pain relief during labor and delivery.
6. Advanced maternal age (older than 35 years of age) is associated with poorer outcomes and a higher incidence of maternal morbidities (gestational diabetes, preeclampsia, placental abruption, cesarean delivery) and chronic medical conditions.

Obstetrical Anesthesia

1. Physiologic Changes of Pregnancy
2. Placental Transfer and Fetal Exposure to Anesthetic Drugs
3. Anesthesia for Labor and Vaginal Delivery
4. Anesthesia for Cesarean Delivery
5. Anesthetic Complications
6. Management of High-Risk Parturients
7. Preterm Delivery
8. Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome
9. Substance Abuse
10. Fetal Monitoring
11. Newborn Resuscitation in the Delivery Room
12. Anesthesia for Nonobstetric Surgery in Pregnant Women