Part 2 book “The clinical anaesthesia vivabook” has contents: The short cases (intracranial pressure, major obstetric haemorrhage, myasthenia gravis, myasthenia gravis, obstructive sleep apnoea, previous anaphylaxis, ), the long cases. | P Pre-medication 205 time, then optimisation of hypertension, anti-convulsant therapy and fluid balance is indicated prior to delivery. Anaesthetic techniques for delivery If an urgent caesarean section is required, and there is no time to establish an epidural, then the choice is limited to spinal or general anaesthesia. Spinal anaesthesia theoretically may result in hypotension and uteroplacental insufficiency although several publications in the recent literature describe its successful use and safety. If a regional block is contra-indicated, for example, because of coagulopathy, or there is no time because of severe fetal distress, then general anaesthesia will have to be undertaken. Factors making GA in pre-eclampsia particularly hazardous include a higher chance of difficult intubation and a marked pressor response at laryngoscopy and intubation. There is a significant risk of intracerebral haemorrhage secondary to severe hypertension. Invasive monitoring should be established pre-induction if there is time. Post-delivery care Convulsions can occur up to 23 days after delivery. In the UK, up to 44% of fits occur in the puerperium. Fluid balance can remain difficult in the post-operative period. The most common time for pulmonary oedema to occur is in the first 48–72 hours post-delivery. This is probably as a result of large volumes of fluid given peri-operatively (in the face of oliguria and capillary-leak syndrome) mobilising from the extravascular space as the patient improves. Platelet count is lowest in the 24–48 hours post-delivery and HELLP presents after delivery in 30% of cases. This demonstrates that, although delivery of the baby is the ‘cure’, it may not be the end of the problem. The decision to send a patient to intensive care is made on the basis of her clinical condition (a patient may also be considered for intensive care pre-operatively). Bibliography Brodie H, Malinow AM. (1999). Anaesthetic management of pre-eclampsia/eclampsia. .
