Pre-eclampsia and Anaesthesia

Quick Answer

Pre-eclampsia affects 3-5% of pregnancies in Australia and is a leading cause of maternal morbidity and mortality, with higher incidence in Aboriginal and Torres Strait Islander women (5-8%). It is defined as new-onset hypertension (BP ≥140/90 mmHg) after 20 weeks gestation with proteinuria (≥300 mg/24 hours or ≥2+ on dipstick) or end-organ dysfunction (thrombocytopenia, renal insufficiency, impaired liver function, pulmonary oedema, visual or cerebral symptoms). Severe features include BP ≥160/110 mmHg, thrombocytopenia <100 × 10⁹/L, transaminitis >2× normal, creatinine >90 μmol/L, pulmonary oedema, persistent headache, visual disturbances, or epigastric pain. Anaesthetic management requires careful haemodynamic control (labetalol, hydralazine, or nifedipine), thrombocytopenia assessment (platelets >100 × 10⁹/L for neuraxial, >80 × 10⁹/L with caution), eclampsia prophylaxis with magnesium sulfate (4 g IV loading, 1-2 g/hour infusion, target serum Mg²⁺ 2-3.5 mmol/L), and fluid restriction (maintenance 80-100 mL/hour to prevent pulmonary oedema). Neuraxial anaesthesia is preferred if platelets adequate and coagulopathy absent, but hypotension risk is higher and may require phenylephrine infusion and cautious fluid loading. General anaesthesia risks include difficult airway (laryngeal oedema), exaggerated haemodynamic response to intubation, and aspiration. Indigenous women have higher incidence, greater severity, and reduced access to specialist care, requiring culturally safe management, early specialist referral, and coordination with Aboriginal health services. [1-10]

Pathophysiology

Pre-eclampsia Definition and Classification

Definition (ISSHP 2014/ACOG 2019):

Pre-eclampsia is new-onset hypertension after 20 weeks gestation with either proteinuria OR evidence of end-organ dysfunction.

Diagnostic Criteria:

• Hypertension: BP ≥140/90 mmHg on two occasions ≥4 hours apart
• Proteinuria: ≥300 mg/24 hours OR ≥2+ on urine dipstick OR protein/creatinine ratio ≥30 mg/mmol
• OR End-organ dysfunction:
  • Thrombocytopenia: Platelets <100 × 10⁹/L
  • Renal insufficiency: Creatinine >90 μmol/L (or doubling of baseline)
  • Liver dysfunction: Transaminases >2× upper limit of normal
  • Pulmonary oedema
  • Visual or cerebral symptoms (headache, scotomata, hyperreflexia)

Severity Classification:

Severe Features (Any ONE indicates severe pre-eclampsia):

1. Severe hypertension: BP ≥160/110 mmHg
2. Thrombocytopenia: Platelets <100 × 10⁹/L
3. Liver dysfunction: AST/ALT >2× upper limit of normal, severe persistent epigastric/right upper quadrant pain
4. Renal insufficiency: Creatinine >90 μmol/L
5. Pulmonary oedema: New-onset, not due to other causes
6. Cerebral/visual symptoms: Persistent headache, visual disturbances, altered mental status
7. Fetal compromise: Fetal growth restriction, abnormal Doppler studies, oligohydramnios

Pathophysiology:

1. Placental Pathology:

• Abnormal placentation: Failure of spiral artery remodelling in early pregnancy
• Shallow trophoblast invasion: Results in reduced placental perfusion
• Ischemia-reperfusion injury: Placental oxidative stress, inflammation
• Anti-angiogenic factors: Release of soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng)
• Pro-angiogenic factors reduced: Placental growth factor (PlGF) reduced

2. Maternal Endothelial Dysfunction:

• Generalized vasospasm: Increased vascular resistance, hypertension
• Endothelial injury: Proteinuria, oedema
• Platelet activation: Thrombocytopenia, coagulopathy
• Increased vascular permeability: Pulmonary oedema, ascites

3. Systemic Manifestations:

Cardiovascular:

• Increased SVR (afterload)
• Reduced intravascular volume (third spacing)
• Hemoconcentration
• Left ventricular hypertrophy, diastolic dysfunction
• Risk of pulmonary oedema (capillary leak + fluid overload)

Renal:

• Glomerular endotheliosis (pathognomonic lesion)
• Reduced GFR
• Proteinuria
• Sodium retention
• Oliguria (severe cases)

Hepatic:

• Hepatic periportal necrosis
• Transaminitis (AST/ALT elevation)
• Epigastric/RUQ pain (liver capsule distension)
• Risk of hepatic rupture (rare, catastrophic)
• HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets)

Haematological:

• Thrombocytopenia (consumption, platelet activation)
• Coagulopathy (DIC in severe cases)
• Haemolysis (microangiopathic)

Neurological:

• Cerebral oedema (vasogenic)
• Hyperreflexia, clonus
• Headache, visual disturbances
• Seizures (eclampsia)
• Risk of intracranial haemorrhage

Fetal:

• Placental insufficiency → IUGR
• Oligohydramnios
• Abnormal Doppler studies (umbilical artery, uterine artery)
• Preterm delivery
• Stillbirth (if severe, untreated)

Eclampsia

Definition: New-onset seizures in a pre-eclamptic patient, not attributable to other causes.

Incidence:

• 2-3% of severe pre-eclampsia cases
• Higher in developing countries, Indigenous populations

Timing:

• 40% antepartum
• 40% intrapartum
• 20% postpartum (usually within 48 hours)

Pathophysiology:

• Severe vasospasm → cerebral ischaemia
• Loss of cerebral autoregulation (upper limit of autoregulation decreased)
• Endothelial dysfunction → blood-brain barrier disruption
• Cerebral oedema
• Hypertensive encephalopathy

Risk Factors for Eclampsia:

• Severe pre-eclampsia
• Nulliparity
• Age extremes (<18 or >35)
• Multiple pregnancy
• Hydrops fetalis
• Molar pregnancy
• Chronic hypertension
• Renal disease
• Previous eclampsia

HELLP Syndrome

Definition: Haemolysis (H), Elevated Liver enzymes (EL), Low Platelets (LP).

Classification (Tennessee/Mississippi):

Clinical Features:

• Often presents without significant hypertension or proteinuria (20-30% of cases)
• "Silent" HELLP — diagnosis missed if only looking for classic pre-eclampsia
• Epigastric/RUQ pain (most common symptom)
• Nausea, vomiting
• Malaise, flu-like symptoms
• Hypertension and proteinuria may be absent or mild

Complications:

• DIC (20% of Class 1 HELLP)
• Abruptio placentae (15-20%)
• Acute kidney injury
• Liver failure, hepatic rupture
• Pulmonary oedema
• Fetal demise

Management:

• Delivery (definitive treatment)
• Supportive care
• Platelet transfusion if <20 × 10⁹/L or active bleeding
• Steroids for fetal lung maturity if preterm

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Clinical Presentation

Pre-eclampsia Assessment

History:

• Headache (frontal, persistent, not relieved by analgesia)
• Visual disturbances (scotomata, flashing lights, blurred vision)
• Epigastric or right upper quadrant pain (liver capsule distension)
• Nausea, vomiting
• Oedema (rapid weight gain, facial swelling)
• Reduced fetal movements

Physical Examination:

• Blood pressure: Hypertension (≥140/90, severe ≥160/110)
• Neurological: Hyperreflexia, clonus (ankle clonus >3 beats suggests severe features)
• Abdominal: Epigastric tenderness, hepatic tenderness, ascites
• Respiratory: Signs of pulmonary oedema (crackles, dyspnoea)
• Fetal: Fundal height, fetal position, fetal heart rate

Investigations:

Essential:

• Full blood count (platelets, haemoglobin)
• Coagulation screen (INR, APTT, fibrinogen)
• Renal function (creatinine, urea, electrolytes)
• Liver function tests (AST, ALT, bilirubin, albumin, LDH)
• Urine protein (24-hour collection or protein/creatinine ratio)
• Group and screen (crossmatch if delivery anticipated)

Additional:

• LDH, haptoglobin (haemolysis markers)
• Peripheral blood film (schistocytes in HELLP)
• ECG (left ventricular hypertrophy, ischaemia)
• Chest X-ray (pulmonary oedema)
• Fetal monitoring (CTG, ultrasound, Doppler studies)

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Management

General Management Principles

Definitive Treatment:

• Delivery is the only cure for pre-eclampsia
• Timing depends on gestational age and severity

Timing of Delivery:

Expectant Management (Non-severe pre-eclampsia, <37 weeks):

• Bed rest (limited evidence, but standard practice)
• BP monitoring (q4-6h)
• Fetal surveillance (CTG q12-24h, ultrasound for growth/Doppler weekly)
• Laboratory monitoring (FBC, LFTs, creatinine q2-3 days)
• Antihypertensives if BP ≥160/110 or symptoms
• Delivery if worsening

Acute Management (Severe pre-eclampsia, eclampsia, HELLP):

• Stabilize mother
• Control BP
• Prevent/treat seizures
• Prepare for delivery
• Monitor for complications

Antihypertensive Therapy

Indications:

• Severe hypertension (≥160/110 mmHg)
• Persistent hypertension with symptoms
• Chronic hypertension with superimposed pre-eclampsia

Target BP:

• 140-150/90-100 mmHg (avoid excessive reduction which may compromise uteroplacental perfusion)
• Gradual reduction (not >15-25% in first hour)

First-Line Agents:

1. Labetalol:

• Dose: 20 mg IV bolus, then 20-80 mg IV q10-20min (max 300 mg)
• Infusion: 1-2 mg/min IV
• Mechanism: Combined α and β-blockade
• Advantages: Fast onset, effective, maintains uteroplacental perfusion
• Contraindications: Asthma, bradycardia, heart block, decompensated heart failure

2. Hydralazine:

• Dose: 5 mg IV bolus, then 5-10 mg IV q20-30min (max 30 mg)
• Mechanism: Direct arteriolar vasodilation
• Advantages: Established safety in pregnancy, effective
• Disadvantages: Reflex tachycardia, headache, unpredictable response
• Caution: May worsen pulmonary oedema (increases preload)

3. Nifedipine (Immediate Release):

• Dose: 10 mg PO q15-30min (max 50 mg in 1 hour)
• Mechanism: Calcium channel blockade (arteriolar vasodilation)
• Advantages: Oral route, effective, rapid onset
• Disadvantages: Headache, flushing, tachycardia
• Caution: Avoid sublingual (rapid drop in BP)

Second-Line Agents:

4. Sodium Nitroprusside:

• Dose: 0.25-5 μg/kg/min IV infusion
• Use: Refractory hypertension, hypertensive emergency
• Caution: Cyanide/thiocyanate toxicity with prolonged use (>4 hours) or renal impairment
• Fetal risk: Potential (thiocyanate crosses placenta)

5. Magnesium Sulfate:

• Has mild antihypertensive effect
• Primary use is seizure prophylaxis, not BP control

Contraindicated:

• ACE inhibitors: Fetal toxicity (renal agenesis, oligohydramnios, growth restriction)
• ARBs: Similar fetal toxicity
• Diuretics: Reduce intravascular volume (already reduced in pre-eclampsia)

Magnesium Sulfate for Seizure Prophylaxis (Eclampsia Prevention)

Indications:

• Severe pre-eclampsia (seizure prophylaxis)
• Eclampsia (treatment and prevention of recurrence)

Regimen:

Loading Dose:

• 4 g IV over 20-30 minutes
• Can give additional 2 g if seizures persist

Maintenance Dose:

• 1-2 g/hour IV infusion
• Continue for 24 hours post-delivery or last seizure

Monitoring:

• Serum magnesium levels: Target 2-3.5 mmol/L (therapeutic)
  • 2-3 mmol/L: Therapeutic
  • 4-5 mmol/L: Patellar reflexes lost (warning sign)
  • 5-7 mmol/L: Respiratory depression

  • 7.5 mmol/L: Cardiac arrest

• Patellar reflexes: Check hourly (loss indicates toxicity)
• Respiratory rate: Check hourly (RR <12/min indicates toxicity)
• Urine output: Monitor (reduced excretion increases toxicity risk)

Side Effects:

• Flushing, warmth
• Nausea
• Muscle weakness
• Respiratory depression (if toxic levels)
• Cardiac arrest (if severe toxicity)

Toxicity Treatment:

• Stop magnesium infusion
• Calcium gluconate 10%: 10 mL IV over 2-3 minutes (antagonizes magnesium)
• Supportive care: Ventilation if respiratory depression, ACLS if cardiac arrest
• Consider: Furosemide 20-40 mg IV (increases magnesium excretion)

Contraindications:

• Myasthenia gravis (magnesium worsens condition)
• Severe renal impairment (reduced excretion, toxicity risk)
• Heart block
• Cardiac arrest (relative — can use in eclampsia)

Fluid Management

Rationale for Fluid Restriction:

• Pre-eclampsia is a state of vasospasm with reduced intravascular volume
• Increased capillary permeability (risk of pulmonary oedema)
• Risk of fluid overload with aggressive fluid therapy
• "Wet pre-eclampsia" — fluid shifts to extravascular space

Fluid Strategy:

Maintenance:

• 80-100 mL/hour crystalloid (isotonic)
• Avoid: Aggressive fluid loading, dextrose solutions (increased fluid retention)
• Monitor: Fluid balance, urine output, auscultation for pulmonary oedema

Preloading for Neuraxial Anaesthesia (Controversial):

• Limited evidence for efficacy in preventing spinal-induced hypotension
• Risk: Pulmonary oedema with aggressive preload
• Recommendation:
  • If used: 500-750 mL crystalloid over 15-30 minutes
  • Close monitoring for fluid overload
  • Consider colloids (Gelofusine 500 mL) if colloid osmotic pressure low
• Alternative: Phenylephrine prophylaxis (better safety profile)

Blood Product Replacement:

• Indications: Active bleeding (abruption, DIC), severe thrombocytopenia (<20 × 10⁹/L)
• Avoid: Routine FFP/cryoprecipitate unless coagulopathy present
• Platelets: Transfuse if <20 × 10⁹/L (or <50 × 10⁹/L with active bleeding or neuraxial planned)

Anaesthetic Management

Neuraxial Anaesthesia (Preferred if Feasible):

Advantages:

• Reduced risk of aspiration
• Avoids airway manipulation (laryngeal oedema risk)
• Better haemodynamic stability (gradual onset)
• Patient awake and aware
• Reduced fetal drug exposure

Contraindications:

• Absolute:
  • Patient refusal
  • Coagulopathy (thrombocytopenia <100 × 10⁹/L, INR >1.4)
  • Infection at insertion site
  • Severe hypovolaemia/shock
  • Increased intracranial pressure (eclampsia with cerebral oedema)
• Relative:
  • Thrombocytopenia 100-150 × 10⁹/L (individual assessment)
  • Platelet count declining (trend more important than single value)
  • Fetal distress requiring immediate delivery
  • Eclampsia (cerebral oedema, risk of herniation with dural puncture)

Considerations Specific to Pre-eclampsia:

1. Thrombocytopenia:

• Most important factor in deciding neuraxial vs. general
• Check trend: Platelet count often declining in pre-eclampsia
• Guidelines:
  • >100 × 10⁹/L: Safe for neuraxial
  • 80-100 × 10⁹/L: Individual assessment, consider risks/benefits
  • <80 × 10⁹/L: Contraindicated (general anaesthesia preferred)
• Additional tests: INR, APTT, fibrinogen if severe pre-eclampsia or HELLP

2. Hypotension Risk:

• Higher risk: Due to reduced intravascular volume
• More severe: Due to reduced cardiac reserve
• Management:
  • Phenylephrine infusion (50-100 μg/min) prophylaxis
  • Ephedrine (5-10 mg IV) as alternative
  • Fluid restriction (avoid overload)
  • Left uterine displacement (critical)

3. Airway Considerations (if general required):

• Laryngeal oedema: Common in pre-eclampsia (capillary leak)
• Difficult intubation risk: Higher than general population
• Management:
  • Smaller ETT (size 6.5-7.0 mm)
  • Gentle laryngoscopy (minimize trauma)
  • Videolaryngoscope
  • Cuff pressure monitoring (avoid excessive, reduces mucosal ischaemia)

Technique for Caesarean Section:

Spinal Anaesthesia (Preferred):

• Dose: Reduce local anaesthetic dose (reduced volume of distribution, more sensitive)
  • Hyperbaric bupivacaine 0.5%: 1.8-2.2 mL (9-11 mg, vs. 11-12.5 mg in healthy patient)
  • Fentanyl: 10-20 μg
  • Morphine: 100-150 μg (reduce dose, more sensitive to respiratory depression)
• Position: Sitting may be safer (reduces risk of high block)
• Monitoring: Aggressive BP monitoring (q2-3min initially)
• Vasopressor: Phenylephrine infusion starting with spinal injection

Epidural Anaesthesia:

• Indication: Labour epidural in situ (extension for caesarean)
• Advantage: Slow onset (more haemodynamic stability)
• Caution: Ensure platelet count stable (check recent FBC)

General Anaesthesia:

Indications:

• Thrombocytopenia <80 × 10⁹/L (contraindication to neuraxial)
• Eclampsia (increased ICP, risk of herniation)
• Coagulopathy (DIC)
• Severe fetal distress (insufficient time for neuraxial)
• Patient refusal of neuraxial
• Failed neuraxial block

Technique Modifications:

1. Aspiration Prophylaxis (Aggressive):

• Sodium citrate 0.3 M 30 mL PO (immediately pre-induction)
• Ranitidine 50 mg IV (30-60 min pre-op)
• Metoclopramide 10 mg IV

2. Haemodynamic Control:

• Avoidance of pressor response: Pre-eclamptics have exaggerated response to intubation
• Strategies:
  • Short-acting opioid (remifentanil 1 μg/kg or alfentanil 10-20 μg/kg) prior to intubation
  • Esmolol 1-2 mg/kg (short-acting beta-blocker)
  • Lidocaine 1.5 mg/kg IV
  • Deep anaesthesia (sevoflurane 2-3% or propofol TCI 4-6 μg/mL)
• Avoid: Long-acting agents (may worsen hypotension post-delivery)

3. Airway Management:

• Difficult airway anticipation: Higher risk due to laryngeal oedema
• Strategy:
  • Awake fibreoptic intubation if difficult airway predicted
  • Rapid sequence induction if not difficult
  • Smaller ETT (6.5-7.0 mm)
  • Cuff pressure monitoring (keep <30 cm H₂O)
  • Gentle technique (minimize mucosal trauma)

4. Maintenance:

• Volatile agents: Sevoflurane 0.5-1 MAC (avoid high doses, vasodilation worsens hypotension)
• Nitrous oxide: 50% after delivery (reduces volatile requirement)
• Remifentanil infusion: 0.1-0.2 μg/kg/min (provides analgesia, reduces haemodynamic response)
• Muscle relaxation: Rocuronium (rapid onset, sugammadex reversal available)

5. Emergence:

• Smooth emergence: Avoid coughing/straining (increases BP)
• Extubation: Deep extubation if airway not difficult
• Monitoring: Close BP monitoring (post-delivery fluid shifts)

Complications and Management

Pulmonary Oedema:

Incidence: 2-5% of severe pre-eclampsia

Pathophysiology:

• Capillary leak (increased permeability)
• Reduced colloid osmotic pressure (low albumin)
• Fluid overload (iatrogenic or third spacing)
• Left ventricular dysfunction (diastolic)
• Pulmonary vasospasm

Clinical Features:

• Dyspnoea, orthopnoea
• Tachypnoea
• Pink frothy sputum
• Hypoxaemia (SpO₂ <90%)
• Bilateral crackles on auscultation
• Bilateral infiltrates on CXR

Management:

1. Oxygen: 100% via face mask, CPAP if needed
2. Position: Upright (reduces preload)
3. Diuresis: Furosemide 20-40 mg IV (caution if hypovolaemic)
4. Vasodilators: If hypertensive
   • GTN infusion (0.5-2 μg/kg/min)
   • Hydralazine (if not already hypotensive)
5. Morphine: 2-5 mg IV (reduces preload, relieves anxiety)
6. Monitor: ABG, chest X-ray, ECG
7. Avoid: Further fluid loading, beta-blockers (worsen cardiac output)

Disseminated Intravascular Coagulation (DIC):

Incidence: 5-10% of severe pre-eclampsia/HELLP

Pathophysiology:

• Endothelial injury triggers coagulation cascade
• Consumption of platelets, clotting factors
• Fibrinolysis activation

Clinical Features:

• Bleeding from IV sites, surgical field
• Haematuria, GI bleeding
• Oozing from mucous membranes
• Petechiae, purpura

Laboratory Findings:

• Thrombocytopenia (progressive)
• Prolonged INR/APTT
• Hypofibrinogenaemia (<2 g/L)
• Increased D-dimer, FDPs
• Microangiopathic haemolytic anaemia (schistocytes)

Management:

1. Delivery: Definitive treatment (removes trigger)
2. Blood products:
   • Platelets: If <20 × 10⁹/L or active bleeding
   • FFP: If INR >1.5 or active bleeding
   • Cryoprecipitate: If fibrinogen <1.5 g/L
   • Red cells: If anaemic (maintain Hb >80 g/L)
3. Tranexamic acid: 1 g IV (reduces fibrinolysis)
4. Avoid: Heparin (unless chronic indication, increases bleeding)
5. Monitor: FBC, coagulation profile, fibrinogen q4-6h

Abruptio Placentae:

Incidence: 1-2% of pregnancies, 10-20% with severe pre-eclampsia

Pathophysiology:

• Vasospasm and endothelial dysfunction cause placental separation
• Concealed bleeding (retroplacental haematoma)
• Consumptive coagulopathy
• Fetal hypoxia/acidosis

Clinical Features:

• Vaginal bleeding (may be absent if concealed)
• Uterine tenderness, rigidity
• Fetal distress (tachycardia then bradycardia)
• Maternal shock (may be out of proportion to visible blood loss)
• Coagulopathy (DIC)

Management:

1. Resuscitation:
   • 2 large-bore IVs
   • Crystalloid/colloid resuscitation (may need massive transfusion)
   • Blood products (O-negative if crossmatch delayed)
2. Delivery:
   • Urgent caesarean section if fetal viable and distressed
   • Vaginal delivery if fetus dead or pre-viable
3. Coagulation management:
   • Massive transfusion protocol if bleeding severe
   • FFP, cryoprecipitate, platelets as indicated
4. Neonatal team: For resuscitation

Eclampsia:

Management of Acute Seizure:

1. Call for help:

   • Alert obstetric team, anaesthetic team, neonatal team
   • Crash caesarean section readiness

2. Airway protection:

   • Left lateral position (prevents aspiration, reduces aortocaval compression)
   • Suction oropharynx
   • Insert oral airway if needed
   • 100% oxygen via face mask
   • Prepare for intubation if seizures prolonged or recurrent

3. Seizure termination:

   • Magnesium sulfate: 4 g IV over 5-10 minutes (loading dose)
   • Benzodiazepines: If magnesium fails or unavailable
     • Diazepam 5-10 mg IV (caution: respiratory depression)
     • Lorazepam 2-4 mg IV
     • Midazolam 2-5 mg IV
   • Propofol: 1-2 mg/kg IV (if refractory, may need intubation)

4. Blood pressure control:

   • Treat if ≥160/110 mmHg
   • Labetalol, hydralazine, or nifedipine

5. Fetal monitoring:

   • CTG during and after seizure
   • Fetal bradycardia common during seizure (usually resolves)

6. Delivery:

   • Once stabilized (usually within 24-48 hours)
   • Caesarean section if not in labour or fetal compromise
   • Vaginal delivery if already in active labour

7. Post-seizure care:

   • Magnesium maintenance 1-2 g/hour IV for 24 hours
   • ICU monitoring if complications ( aspiration pneumonia, cerebral oedema)
   • Imaging if focal deficits or prolonged altered consciousness (MRI to exclude stroke, haemorrhage)

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Women:

Higher Risk:

• Incidence: 5-8% (vs. 3-5% non-Indigenous)
• Severity: More likely to develop severe features, eclampsia, HELLP
• Timing: Often presents later, more advanced disease at diagnosis
• Outcomes: Higher rates of maternal mortality, preterm birth, stillbirth

Contributing Factors:

• Higher rates of obesity, diabetes, chronic hypertension
• Reduced access to antenatal care (late presentation, limited visits)
• Geographic barriers (remote communities)
• Socioeconomic factors
• Systemic racism in healthcare

Cultural Safety:

• Involvement of Aboriginal midwives and health workers
• Communication strategies (plain language, visual aids, interpreter if needed)
• Family involvement in decision-making
• Respect for traditional birthing practices
• Avoidance of stereotyping or assumptions

Access and Equity:

• Early referral to specialist obstetric/anaesthetic care
• Telehealth consultations for remote monitoring
• Transport assistance for appointments
• Birthing on Country (where safe)
• Postpartum follow-up coordination with Aboriginal health services

Māori Health Considerations (New Zealand)

Higher Risk:

• Similar to Aboriginal women, higher incidence and severity
• Contributing factors include socioeconomic disparities, access issues

Cultural Safety:

• Whānau involvement in care decisions
• Tikanga (cultural protocols) around birth and medical interventions
• Karakia (prayer) may be requested
• Respect for tapu (sacredness) of birth
• Māori Health Worker involvement

Health Equity:

• Early identification and management
• Culturally safe communication
• Coordination with primary care and Māori health providers
• Address barriers to care

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ANZCA Final Exam Focus

SAQ Patterns

Pre-eclampsia anaesthesia appears regularly in ANZCA Final Written Examination. Common SAQ themes include:

Management-Focused Questions:

• "Describe the anaesthetic management of a patient with severe pre-eclampsia for emergency caesarean section." (2020)
• "How would you manage eclampsia in a labouring patient?" (2021)
• "What are the considerations for neuraxial anaesthesia in pre-eclampsia?"

Pharmacology-Focused Questions:

• "Explain the mechanism of action and monitoring requirements for magnesium sulfate in pre-eclampsia."
• "Compare labetalol, hydralazine, and nifedipine for BP control in pre-eclampsia."
• "What is the fluid management strategy in severe pre-eclampsia?"

Complication-Focused Questions:

• "How would you manage pulmonary oedema in a pre-eclamptic patient?"
• "Describe the management of HELLP syndrome."
• "What are the causes and management of DIC in pre-eclampsia?"

Indigenous Health Questions:

• "What specific considerations apply to pre-eclampsia management in Aboriginal women?"
• "How would you ensure culturally safe care for an Indigenous woman with severe pre-eclampsia?"

Marking Scheme Priorities:

• Diagnosis and severity assessment (BP, proteinuria, end-organ dysfunction)
• BP control (labetalol, hydralazine, nifedipine)
• Magnesium sulfate regimen and monitoring
• Fluid restriction rationale
• Neuraxial vs. general anaesthesia decision-making (platelets, coagulation)
• Haemodynamic management (phenylephrine, left uterine displacement)
• Complication management (eclampsia, HELLP, pulmonary oedema, DIC)
• Indigenous health considerations

Clinical Viva Themes

The Clinical Viva frequently includes pre-eclampsia scenarios:

Scenario Types:

• Severe pre-eclampsia for emergency caesarean section
• Eclampsia management
• Thrombocytopenia and anaesthetic decision-making
• HELLP syndrome
• Pulmonary oedema in pre-eclampsia
• Difficult airway in pre-eclamptic patient

Examiner Expectations:

• Systematic assessment approach (history, examination, investigations)
• Knowledge of severity criteria
• BP management strategies
• Magnesium sulfate dosing and monitoring
• Fluid management principles
• Neuraxial vs. general decision-making
• Complication recognition and management
• Indigenous health considerations

Common Viva Questions:

• "What are the diagnostic criteria for pre-eclampsia?"
• "What are the severe features of pre-eclampsia?"
• "How would you manage BP in severe pre-eclampsia?"
• "What is the magnesium sulfate regimen for eclampsia prophylaxis?"
• "How do you monitor for magnesium toxicity?"
• "When is neuraxial anaesthesia contraindicated in pre-eclampsia?"
• "How would you manage pulmonary oedema in pre-eclampsia?"
• "What is HELLP syndrome and how do you manage it?"

Key Points for Examination Success

1. Diagnosis requires BP + proteinuria OR end-organ dysfunction — know the criteria
2. Severe features — any one qualifies as severe (BP >160/110, thrombocytopenia <100, transaminitis >2×, creatinine >90, pulmonary oedema, cerebral symptoms)
3. Magnesium sulfate — 4 g IV loading, 1-2 g/hour infusion, monitor reflexes/RR/urine
4. BP control — labetalol, hydralazine, or nifedipine; target 140-150/90-100
5. Fluid restriction — 80-100 mL/hour, avoid overload
6. Thrombocytopenia — >100 for neuraxial, 80-100 with caution, <80 contraindicated
7. General anaesthesia modifications — laryngeal oedema, exaggerated pressor response, difficult airway risk
8. Complications — eclampsia (seizure protocol), HELLP (delivery, blood products), pulmonary oedema (diuretics, vasodilators), DIC (blood products, delivery)
9. Indigenous health — higher incidence/severity, cultural safety, access issues

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Assessment Content

SAQ Practice Question 1 (20 marks)

Question:

A 28-year-old primigravida (80 kg) at 36 weeks gestation presents with severe pre-eclampsia. Her blood pressure is 170/110 mmHg, she has 3+ proteinuria, and complains of severe headache and visual disturbances. Laboratory investigations show: Hb 115 g/L, platelets 75 × 10⁹/L, creatinine 105 μmol/L, AST 120 U/L (ref <40), ALT 140 U/L (ref <45), INR 1.3, fibrinogen 1.2 g/L.

(a) What are the severe features of pre-eclampsia present in this patient? (4 marks)

(b) Outline your immediate management priorities. (8 marks)

(c) The obstetric team plans urgent caesarean section. What anaesthetic technique would you choose and why? (8 marks)

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Model Answer:

(a) Severe Features Present (4 marks)

This patient has multiple severe features of pre-eclampsia:

1. Severe hypertension [1 mark]

• BP 170/110 mmHg (>160/110 threshold)
• Persistent hypertension despite rest

2. Thrombocytopenia [1 mark]

• Platelets 75 × 10⁹/L (<100 × 10⁹/L threshold)
• Indicates consumptive coagulopathy
• Contraindication to neuraxial anaesthesia

3. Cerebral/visual symptoms [1 mark]

• Severe headache (persistent, not relieved by analgesia)
• Visual disturbances (scotomata, flashing lights, blurred vision)
• Indicates cerebral involvement, risk of eclampsia

4. Liver dysfunction [0.5 marks]

• AST 120 U/L (3× upper limit of normal)
• ALT 140 U/L (3× upper limit of normal)
• Hepatic involvement

5. Renal dysfunction [0.5 marks]

• Creatinine 105 μmol/L (>90 μmol/L threshold)
• Reduced GFR

Additional Concern:

• Coagulopathy: Low fibrinogen (1.2 g/L) suggests developing DIC
• HELLP syndrome: Haemolysis (not confirmed without LDH/bilirubin), Elevated Liver enzymes, Low Platelets

(b) Immediate Management Priorities (8 marks)

1. Seizure Prophylaxis [1.5 marks]

• Magnesium sulfate loading dose: 4 g IV over 20-30 minutes
  • Patient has cerebral symptoms (headache, visual disturbances) — high risk of eclampsia
  • Prophylaxis reduces seizure risk by 50%
• Check reflexes and respiratory rate before loading dose (baseline)
• Prepare magnesium maintenance: 1-2 g/hour IV infusion

2. Blood Pressure Control [1.5 marks]

• Target: 140-150/90-100 mmHg (avoid excessive reduction)
• Labetalol: 20 mg IV bolus, repeat 20-40 mg q10-20min (max 300 mg)
  • First-line agent (fast onset, effective, maintains uteroplacental perfusion)
• Alternative: Hydralazine 5 mg IV bolus, repeat 5-10 mg q20-30min
• Avoid: Rapid reduction (compromise uteroplacental perfusion)

3. Fluid Management [1 mark]

• Restrict fluids: 80-100 mL/hour maintenance
• Rationale:
  • Patient has reduced intravascular volume (third spacing)
  • High risk of pulmonary oedema (capillary leak, diastolic dysfunction)
  • Avoid fluid overload
• Monitor: Fluid balance, auscultation for pulmonary oedema, SpO₂

4. Monitoring [1 mark]

• Continuous: ECG, SpO₂, BP (q5-15min initially)
• Fetal monitoring: CTG (fetal distress risk)
• Neurological: Reflexes (clonus, hyperreflexia), consciousness
• Respiratory: Auscultation for pulmonary oedema

5. Laboratory Monitoring [0.5 marks]

• FBC: Platelet trend (declining count concerning)
• Coagulation: INR, APTT, fibrinogen (DIC risk)
• Liver function: AST, ALT, bilirubin (worsening hepatic function)
• Renal function: Creatinine, urea, electrolytes
• LDH, haptoglobin: If HELLP suspected

6. Corticosteroids [0.5 marks]

• Betamethasone: 11.4 mg IM × 2 doses 24 hours apart
• Rationale: 36 weeks gestation — fetal lung maturity may not be complete
• Timing: If delivery can be delayed 24-48 hours for steroids to work

7. Delivery Planning [1 mark]

• Urgent caesarean section indicated:
  • Severe pre-eclampsia at 36 weeks
  • Multiple severe features
  • Thrombocytopenia (75 × 10⁹/L)
  • Unlikely to improve with expectant management
• Notify: Obstetric team, anaesthetic team, neonatal team, blood bank
• Crossmatch: 4 units red cells (potential for bleeding, DIC)

8. Aspiration Prophylaxis [0.5 marks]

• Sodium citrate: 0.3 M 30 mL PO (immediately pre-op)
• Ranitidine: 50 mg IV (30-60 min pre-op)
• Metoclopramide: 10 mg IV (prokinetic, anti-emetic)

9. Thromboprophylaxis Planning [0.5 marks]

• Mechanical: Compression stockings, IPC
• Pharmacological: LMWH post-delivery when safe (bleeding risk, neuraxial considerations)

(c) Anaesthetic Technique Choice (8 marks)

Decision: General Anaesthesia [1.5 marks]

Rationale:

1. Thrombocytopenia — Absolute Contraindication to Neuraxial [2 marks]

• Platelets 75 × 10⁹/L: Below safe threshold for neuraxial blockade
• Guidelines:
  • <100 × 10⁹/L: Generally avoid neuraxial
  • <80 × 10⁹/L: Absolute contraindication
• Epidural haematoma risk: High with this platelet count
• Additional concerns:
  • Trend: Platelet count likely declining (pre-eclampsia progression)
  • Fibrinogen low (1.2 g/L) — coagulopathy present
  • INR elevated (1.3) — coagulation abnormal

2. Coagulopathy [1 mark]

• Fibrinogen 1.2 g/L: Below normal (2-4 g/L)
• INR 1.3: Elevated (coagulation impaired)
• DIC risk: Pre-eclampsia with thrombocytopenia and coagulopathy
• Contraindication: Neuraxial blockade in coagulopathy

3. Severe Pre-eclampsia/Eclampsia Risk [1 mark]

• Cerebral symptoms: Headache, visual disturbances
• Cerebral oedema risk: Dural puncture could precipitate herniation
• Eclampsia prophylaxis: Magnesium sulfate already started
• Risk: Performing neuraxial block with increased ICP

4. General Anaesthesia Modifications for Pre-eclampsia [2 marks]

Aspiration Prophylaxis (Aggressive):

• Sodium citrate 0.3 M 30 mL PO immediately pre-induction
• Ranitidine 50 mg IV (already given)
• Metoclopramide 10 mg IV (already given)
• Rapid sequence induction mandatory

Haemodynamic Control (Critical):

• Pressor response to intubation: Pre-eclamptics have exaggerated response
• Pre-treatment options:
  • Remifentanil 1 μg/kg IV prior to intubation
  • Esmolol 1-2 mg/kg IV (short-acting beta-blocker)
  • Lidocaine 1.5 mg/kg IV
  • Deep anaesthesia (sevoflurane 2-3 MAC, propofol TCI 4-6 μg/mL)
• Avoid: Long-acting agents (labetalol, hydralazine) before delivery (worsen post-delivery hypotension)

Airway Management:

• Anticipate difficult airway: Laryngeal oedema common in pre-eclampsia
• Strategy:
  • Smaller ETT (6.5-7.0 mm)
  • Gentle laryngoscopy (minimize trauma to oedematous airway)
  • Videolaryngoscope available
  • Cuff pressure monitoring (keep <30 cm H₂O)
• Backup: Awake fibreoptic if difficult airway predicted

Fluid Management:

• Restrict fluids: Avoid fluid overload (pulmonary oedema risk)
• Blood products available: 4 units crossmatched (potential for bleeding, DIC)
• Monitor: Fluid balance, auscultation for pulmonary oedema

5. Alternative Considerations [0.5 marks]

Could Neuraxial Be Considered?

• No: Platelet count and coagulation parameters clearly contraindicated
• Even with platelet transfusion: High risk, not recommended
• Time: Urgent caesarean section — insufficient time for platelet transfusion anyway

6. Post-Operative Planning [0.5 marks]

• ICU/HDU admission: High-dependency monitoring
• Continue magnesium sulfate: 1-2 g/hour for 24 hours
• BP monitoring: Aggressive control post-delivery (risk of pulmonary oedema from fluid shifts)
• Fluid restriction: Continue 80-100 mL/hour initially
• Thromboprophylaxis: LMWH when safe (after bleeding risk assessed)

Total: 20 marks

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Viva Scenario (25 marks)

Opening Stem:

You are called urgently to the labour ward. A 26-year-old primigravida (70 kg) at 38 weeks gestation has been admitted with BP 165/105 mmHg, 2+ proteinuria, and severe headache. She is now having a tonic-clonic seizure lasting 2 minutes. The midwife has placed her in the left lateral position and applied oxygen. Platelet count is 120 × 10⁹/L. The obstetric registrar is present and the neonatal team has been called.

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Expected Viva Progression:

Examiner: What are your immediate priorities?

Candidate Response: [5 marks]

"This is eclampsia — a medical emergency. My immediate priorities follow the ABC approach with eclampsia-specific interventions:

Airway and Breathing [2 marks]

1. Airway protection:

• Left lateral position: Already done (prevents aspiration, reduces aortocaval compression)
• Suction: Immediate oropharyngeal suctioning to clear secretions
• Oral airway: Insert Guedel airway if needed to maintain patency
• Oxygen: 100% via face mask (already applied)
• Prepare for intubation: If seizures >5 minutes or recurrent, may need RSI

2. Breathing support:

• SpO₂ monitoring: Ensure >95%
• Auscultate: Check for aspiration (gastric contents in airway)
• Bag-mask ventilation: If respiratory depression post-seizure
• ETCO₂ monitoring: If available (capnography)

Seizure Termination [1.5 marks]

3. Magnesium sulfate:

• Loading dose: 4 g IV over 5-10 minutes (IV bolus)
  • Mechanism: CNS depressant, reduces seizure activity
  • First-line treatment for eclampsia
• Check: Patellar reflexes and respiratory rate before giving (baseline)
• Maintain: 1-2 g/hour IV infusion after seizure terminates

Circulation and BP Control [1 mark]

4. Blood pressure management:

• Treat if ≥160/110: Patient is 165/105 — treat
• Labetalol: 20 mg IV bolus (fast onset, effective)
• Monitor: BP q5min initially
• Avoid: Excessive reduction (maintain uteroplacental perfusion)

Fetal and Delivery Planning [0.5 marks]

5. Fetal assessment:

• CTG: Attach CTG once seizure terminates (fetal bradycardia common during seizure)
• Expect: Bradycardia during seizure (usually resolves with maternal resuscitation)

6. Delivery preparation:

• Urgent caesarean section likely: Once stabilized (within 24-48 hours)
• Notify: Obstetric consultant, anaesthetic team, neonatal team
• Prepare: Theatre, equipment, blood products

Monitoring and Support [0.5 marks]

7. Monitoring:

• Continuous: ECG, SpO₂, BP (q5min)
• Neurological: Consciousness, reflexes, signs of recurrent seizure
• Fluid balance: Urine output (catheterize to monitor)

Key Points:

• Seizure usually self-limiting: 1-2 minutes duration
• Magnesium sulfate: Loading dose immediately (don't wait for seizure to stop)
• Airway protection: Critical to prevent aspiration
• Team approach: Obstetrics, anaesthesia, neonatal teams working together"

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Examiner: The seizure terminates after 90 seconds. The patient is post-ictal but maintaining her airway. BP is now 170/110 mmHg. What is your ongoing management?

Candidate Response: [4 marks]

"Post-seizure management focuses on preventing recurrence, controlling BP, and preparing for delivery:

1. Magnesium Sulfate Maintenance [1 mark]

• Infusion: 1-2 g/hour IV continuous
• Duration: Continue for 24 hours post-delivery or last seizure
• Monitoring:
  • Patellar reflexes: Check hourly (loss indicates toxicity, stop infusion)
  • Respiratory rate: RR <12/min indicates toxicity (stop infusion)
  • Urine output: Monitor (reduced excretion increases toxicity risk)
  • Serum magnesium: Check if prolonged therapy or toxicity suspected (target 2-3.5 mmol/L)

2. Blood Pressure Control [1 mark]

• Target: 140-150/90-100 mmHg
• Labetalol infusion: 1-2 mg/min IV OR intermittent boluses 20-40 mg q10-20min
• Alternative: Hydralazine 5-10 mg IV q20-30min
• Avoid: Nifedipine if oral route not available (sublingual contraindicated)
• Gradual reduction: Avoid >15-25% reduction in first hour (compromise uteroplacental perfusion)

3. Fluid Management [0.5 marks]

• Restrict: 80-100 mL/hour maintenance
• Avoid: Aggressive fluid loading (pulmonary oedema risk)
• Monitor: Fluid balance, auscultation for pulmonary oedema, SpO₂
• Urinary catheter: Monitor urine output (oliguria suggests worsening renal function)

4. Monitoring [0.5 marks]

• Continuous: ECG, SpO₂, BP (q15min once stable)
• Neurological: Consciousness level (post-ictal confusion expected), reflexes, signs of recurrent seizure
• Respiratory: Auscultation for pulmonary oedema, aspiration pneumonia
• Fetal: Continuous CTG until delivery

5. Investigations [0.5 marks]

• FBC: Platelet count (trend), haemoglobin
• Coagulation: INR, APTT, fibrinogen (DIC risk)
• Liver function: AST, ALT, bilirubin (hepatic involvement)
• Renal function: Creatinine, urea (renal impairment)
• Group and screen: 4 units crossmatched (potential for bleeding)

6. Delivery Planning [0.5 marks]

• Urgent caesarean section: Once stabilized (usually within 24-48 hours)
• Rationale: Definitive treatment is delivery; expectant management risks recurrent seizures, worsening end-organ damage
• Timing: Allow maternal stabilization (BP control, seizure prophylaxis), then deliver

7. Complication Watch [0.5 marks]

• Recurrent seizures: Have magnesium ready, prepare for intubation if needed
• Pulmonary oedema: Auscultate lungs, monitor SpO₂ (common with fluid shifts, diastolic dysfunction)
• Abruption: Monitor for vaginal bleeding, uterine tenderness (pre-eclampsia increases abruption risk)
• DIC: Monitor platelet trend, coagulation studies"

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Examiner: The patient is stabilized after 6 hours. BP is now 145/95 mmHg on labetalol infusion. Platelet count is now 95 × 10⁹/L (was 120 × 10⁹/L). The obstetric team wants to proceed with caesarean section. How do you proceed?

Candidate Response: [5 marks]

"This patient now has worsening thrombocytopenia (120 → 95 × 10⁹/L), which is concerning and affects anaesthetic management:

Assessment of Thrombocytopenia [1.5 marks]

1. Trend analysis:

• Platelets 95 × 10⁹/L: Declining trend (was 120 × 10⁹/L 6 hours ago)
• Concerning: Pre-eclampsia progression, likely to continue declining
• Implication: High risk of continued fall, potential for DIC

2. Additional coagulation assessment:

• Need INR, APTT, fibrinogen before neuraxial decision
• If elevated INR or low fibrinogen → coagulopathy → general anaesthesia mandatory
• Even if normal now, trend suggests worsening

3. Clinical context:

• HELLP syndrome: Developing (thrombocytopenia + eclampsia + likely hepatic/renal involvement)
• DIC risk: With declining platelets and pre-eclampsia

Anaesthetic Decision: General Anaesthesia [1.5 marks]

Rationale:

Neuraxial Contraindicated:

• Platelets 95 × 10⁹/L: Below safe threshold (100 × 10⁹/L guideline)
• Declining trend: Likely to be <80 × 10⁹/L intraoperatively or post-op
• Eclampsia: Recent seizure, cerebral oedema risk (dural puncture could precipitate herniation)
• HELLP: Thrombocytopenia + hepatic involvement

General Anaesthesia Safer:

• Avoids risk of epidural haematoma
• Avoids risk of spinal cord compression from haematoma
• Faster (already time-sensitive with eclampsia)
• Allows better control of haemodynamics (BP swings with neuraxial unpredictable in this patient)

General Anaesthesia Technique Modifications [2 marks]

1. Aspiration Prophylaxis (Already Given):

• Sodium citrate 0.3 M 30 mL PO immediately pre-induction
• Ranitidine 50 mg IV (already given 6 hours ago — may repeat or give additional dose)
• Metoclopramide 10 mg IV

2. Haemodynamic Management:

• Pressor response to intubation: Pre-eclamptics have exaggerated response
• Pre-treatment:
  • Remifentanil: 1 μg/kg IV prior to intubation (short-acting, reduces pressor response)
  • Esmolol: 1-2 mg/kg IV (short-acting beta-blocker)
  • Deep anaesthesia: Sevoflurane 2-3 MAC, propofol TCI 4-6 μg/mL
• Avoid: Long-acting antihypertensives pre-intubation (worsen post-delivery hypotension)
• Maintain labetalol infusion intraoperatively for BP control

3. Airway Management:

• Anticipate difficult airway: Laryngeal oedema common in pre-eclampsia/eclampsia
• Strategy:
  • Awake fibreoptic intubation: If difficult airway predicted (Mallampati III/IV, short neck, obesity)
  • OR rapid sequence induction: If airway appears manageable
• Equipment:
  • Smaller ETT (6.5-7.0 mm)
  • Videolaryngoscope (C-MAC, Glidescope)
  • Difficult airway cart ready
  • LMA (supreme or proseal) as backup
• Technique:
  • Cricoid pressure (10 Newtons)
  • Gentle laryngoscopy (minimize trauma to oedematous airway)
  • Cuff pressure monitoring (keep <30 cm H₂O)

4. Fluid and Blood Management:

• Restrict fluids: 80-100 mL/hour maintenance (avoid pulmonary oedema)
• Blood products available: 4 units crossmatched
• Platelets on standby: If <50 × 10⁹/L or active bleeding
• FFP/cryoprecipitate: If INR >1.5 or fibrinogen <1.5 g/L

5. Magnesium Sulfate:

• Continue infusion: 1-2 g/hour throughout surgery and for 24 hours post-op
• Monitor: Reflexes, RR, urine output
• Have calcium gluconate ready: 10% 10 mL IV (antidote if toxicity)

6. Post-Operative Care:

• ICU/HDU admission: High-dependency monitoring
• Continue magnesium: 24 hours post-delivery or last seizure
• BP monitoring: Aggressive control (risk of pulmonary oedema post-delivery from fluid shifts)
• Fluid restriction: Continue initially, liberalize gradually
• Thromboprophylaxis: LMWH when safe (after bleeding risk assessed, usually 4-6 hours post-op)

Alternative Discussion [0.5 marks]

Could Platelet Transfusion Allow Neuraxial?

• Not recommended: Platelet transfusion for neuraxial is controversial
• Short-lived effect: Platelets consumed quickly in pre-eclampsia
• Risk still present: Underlying endothelial dysfunction and coagulopathy remain
• Time: Caesarean section is urgent — insufficient time for transfusion and reassessment
• Recommendation: Proceed with general anaesthesia"

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Examiner: How would your management differ if this patient was a Jehovah's Witness?

Candidate Response: [4 marks]

"Jehovah's Witness management requires modifications while respecting patient's religious beliefs:

Preoperative Discussion [1 mark]

1. Explicit refusal of blood products:

• Document: Clear documentation of refusal of red cells, plasma, platelets
• Witness signature: Patient, physician, witness signatures
• Specific products refused: Clarify which products (red cells definitely refused, may accept some fractions)
• Alternative options: Discuss cell salvage, acute normovolaemic haemodilution (ANH), perfluorocarbons
• Risks explained: Potential for severe haemorrhage, cardiac arrest, death

Preoperative Optimization [0.5 marks]

2. Maximize haemoglobin:

• Iron supplementation: IV iron sucrose or ferric carboxymaltose (if time permits)
• Erythropoietin (EPO): If several days available (increases red cell production)
• Folate, B12: If deficient
• Baseline Hb: Check and optimize

Intraoperative Management [1.5 marks]

3. Minimize blood loss:

• Tranexamic acid: 1 g IV at induction, then 1 g over 8 hours (reduces bleeding)
• Meticulous surgical technique: Minimize bleeding from uterine incision
• Uterotonics: Active management of third stage (oxytocin, ergometrine, carboprost)
• Cell salvage: If available and patient accepts (most Witnesses accept autologous blood)

4. Haemodynamic management without blood transfusion:

• Permissive hypotension: SBP 80-90 mmHg until bleeding controlled
• Aggressive crystalloid: Up to 5-6 L if needed (risk of pulmonary oedema in pre-eclampsia — balance carefully)
• Colloid use: Gelatin or starch solutions
• Vasopressors: Norepinephrine, vasopressin to maintain perfusion despite anaemia
• Inotropes: Dobutamine, milrinone for cardiac support

5. Alternative oxygen carriers (if available):

• Perfluorocarbon-based oxygen carriers: Artificial blood substitutes (acceptance varies)
• Haemoglobin-based oxygen carriers: Oxyglobin (bovine) — acceptance varies
• Clarify acceptance: Individual Witnesses may have different views

Platelet Management Specific [0.5 marks]

6. Platelet refusal implications:

• Thrombocytopenia (95 × 10⁹/L): Patient refusing platelets
• Risk: Higher bleeding risk, potential for DIC
• Management:
  • Avoid neuraxial (already decided — general anaesthesia)
  • Meticulous haemostasis at surgery
  • Tranexamic acid (reduces fibrinolysis)
  • If severe bleeding: May need to accept death rather than transfuse (patient autonomy)

7. Postoperative considerations:

• Accept lower Hb: Hb 70-80 g/L if haemodynamically stable
• EPO therapy: Stimulate red cell production (takes days to weeks)
• Iron supplementation: IV iron to support erythropoiesis
• Close monitoring: For end-organ hypoxia (lactate, ScvO₂, urine output)
• Minimize oxygen consumption: Sedation, paralysis, temperature control

Ethical Considerations [0.5 marks]

8. Respect for autonomy:

• Patient's right: To refuse treatment even if life-threatening
• Informed refusal: Ensure patient understands risks and consequences
• No coercion: Cannot force transfusion against wishes
• Alternative care: Provide best possible care within patient's constraints

9. Multidisciplinary approach:

• Ethics committee: Consult if concerns about patient understanding or capacity
• Religious liaison: Hospital chaplain or Witness liaison
• Family involvement: Discuss with family (with patient consent)
• Documentation: Thorough documentation of all discussions and decisions

Key Principles:

• Respect beliefs: Even if life-threatening
• Optimize alternatives: Maximize non-blood strategies
• Clear communication: Ensure understanding of risks
• Best possible care: Within patient's constraints
• Documentation: Protects patient and healthcare team"

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Examiner: What are the key considerations for managing pre-eclampsia in an Aboriginal woman?

Candidate Response: [4 marks]**

"Pre-eclampsia management in Aboriginal women requires culturally safe, individualized care:

Higher Risk Profile [1 mark]

1. Increased incidence and severity:

• Incidence: 5-8% (vs. 3-5% non-Indigenous)
• Severity: More likely to develop severe features, eclampsia, HELLP
• Outcomes: Higher rates of maternal mortality, preterm birth, stillbirth

2. Contributing factors:

• Higher rates of obesity, diabetes, chronic hypertension: Underlying risk factors
• Reduced access to antenatal care: Late presentation, limited visits
• Geographic barriers: Remote communities, transport challenges
• Socioeconomic factors: Poverty, housing instability, food insecurity
• Systemic racism: Historical and ongoing discrimination in healthcare

Cultural Safety [1.5 marks]

3. Communication strategies:

• Plain language: Avoid medical jargon, use visual aids
• Aboriginal Health Workers/Midwives: Essential for cultural mediation
• Interpreter services: If English not primary language
• Time: Allow extra time for questions and understanding
• Respect: For traditional knowledge and healing practices

4. Family involvement:

• Extended family: Include in decision-making (with patient consent)
• Cultural protocols: Respect for women's business, appropriate gender of care providers
• Traditional birth practices: Incorporate where safe and appropriate
• Support persons: Identify key family members patient wants present

Access and Equity [1 mark]

5. Service delivery:

• Early specialist referral: Obstetric medicine, anaesthesia
• Transport assistance: For appointments and delivery
• Accommodation: If need to stay near hospital
• Birthing on Country: Where medically safe
• Telehealth: For remote monitoring and consultation

6. Postpartum care:

• Cultural safety: In follow-up appointments
• Coordination: With Aboriginal health services
• Remote follow-up: Telehealth, RFDS if returning to community
• Traditional healing: Support integration with medical care

Specific Clinical Considerations [0.5 marks]

7. Higher complication rates:

• Diligent monitoring: For progression to severe features
• Lower threshold: For delivery (may need earlier delivery)
• HELLP/eclampsia risk: Higher likelihood — have magnesium ready
• Access to ICU/HDU: Ensure availability if complications arise

8. Communication about risks:

• Clear explanation: Of pre-eclampsia, risks to mother and baby
• Informed consent: Ensure understanding of treatment plan
• Ongoing dialogue: Regular updates and opportunity for questions

Key Principles:

• Cultural safety first: Respect and integrate cultural practices
• Equity: Address barriers to care
• Partnership: Work with patient, family, and Aboriginal health workers
• Holistic care: Medical + cultural + social support"

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Total: 25 marks

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