Preeclampsia, HELLP and eclampsia

What the Anesthesiologist Should Know before the Operative Procedure (Cesarean Delivery)

When caring for the preeclamptic patient in the intrapartum period, the most important anesthetic implications for the anesthesiologist are 1) thrombocytopenia or other coagulopathy when a regional anesthetic is planned, and 2) blood pressure control and airway management when a general anesthetic is planned.

Preeclampsia without severe features is defined as systolic blood pressure ≥ 140 mmHg or diastolic ≥ 90 mmHg on two occasions at least 4 hours apart after 20 weeks gestation in a previously normotensive woman. Preeclampsia with severe features requires ≥ 160 mmHg systolic blood pressure or ≥ 110 mmHg diastolic blood pressute on two occasions at least 4 hours apart on bedrest unless antihypertensive therapy initiated. Other factors indicating severe features include thrombocytopenia (<100,000 per microliter), renal insufficiency (serum creatinine >1.1mg/dL or doubling), impaired liver function, pulmonary edema, and new onset cerebral or visual symptoms. Previously proteinuria (≥ 300 mg in 24 hours or a protein/creatinine ratio ≥ 0.3 mg/dL) was required for diagnosis, however, the diagnosis is no longer dependent on proteinurua in the presence of new onset thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, cerebral or visual symptoms.

1. What is the urgency of the surgery?

Induction of labor or cesarean delivery are rarely elective in the preeclamptic patient. Unless the patient presents in spontaneous labor, delivery is usually indicated for worsening maternal status (new onset or progressive hypertension and/or laboratory evaluations), or for fetal indications such as intrauterine growth restriction, oligohydramnios, or non-reassuring fetal status on monitoring. These indications can be urgent or emergent depending on the immediacy of the risk of maternal or fetal morbidity.

What is the risk of delay in order to obtain additional preoperative information?

There are risks to both the mother and to the fetus. The greatest risk to the mother involves progression of the disease, most specifically from preeclampsia to eclampsia, when a seizure occurs. Additionally, uncontrolled extreme hypertension can lead to pulmonary edema and cerebrovascular accident. HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a form of preeclampsia with severe features, might also develop which can lead to progressive hepatic dysfunction and hemorrhage due to thrombocytopenia. The greatest risk to the fetus is placental abruption or asphyxia resulting from progressive restriction of uteroplacental blood flow due to vasoconstriction.

Emergent- When cesarean delivery is emergent, there might not be time to perform a regional anesthetic. A true emergency implies that there is immediate grave risk to the mother and/or the fetus, and therefore the quickest possible method of inducing anesthesia must be sought. This almost always implies a general endotracheal anesthetic. However, there are circumstances in which a spinal anesthetic might be appropriate, for example when the mother and fetus are immediately stable, the airway exam is extremely worrisome, and a recent platelet count is deemed adequate.

2. Preoperative evaluation

When a neuraxial anesthetic is planned, the most important preoperative condition to evaluate is platelet count. Preeclampsia often involves a consumptive thrombocytopenia, and platelet counts can occasionally become dangerously low. Since epidural hematoma is extremely rare, the minimal platelet count at which neuraxial anesthesia remains safe is unknown. Each case must be evaluated individually, keeping multiple factors in mind. A traditional 100,000 platelet count cut-off is increasingly seen by many to be overly conservative, but the references for this come only in the form of case reports and editorials. The entire clinical picture must be taken into consideration. For instance, most clinicians would accept a lower platelet count in a patient with anticipated difficult airway management or a patient who is starting a potentially long induction of labor requiring analgesia. Also, preeclampsia with severe features and HELLP are dynamic diseases. The trend in platelet count might be an important consideration, i.e., a rapidly decreasing platelet count in a preeclamptic with severe features versus a patient with preeclampsia without severe features and stable platelet counts, with no clinical signs of bleeding. Several studies have shown that if platelet count is above 150,000 the risk of other coagulation abnormalities will be low or absent. Although the obstetric service will likely have sent a full coagulation panel, platelet count is most important to the anesthesiologist.

Medically unstable conditions warranting further evaluation include: poorly-controlled hypertension (i.e., severe range blood pressures > 160/110), pulmonary edema, severe thrombocytopenia < 50,000, mental status change or recurring seizures.

Delaying surgery may be indicated if: fetal condition is stable and improvement to maternal condition is feasible, e.g., blood pressure control.

3. What are the implications of co-existing disease on perioperative care?

b. Cardiovascular system

Acute/unstable conditions: Hypertension is the hallmark of the disease, and can sometimes become severe range. One study found that patients who had a stroke associated with preeclampsia all had systolic blood pressures > 155 mmHg. To prevent complications, a goal should be set to maintain systolic blood pressure < 160 mmHg and diastolic blood pressure around 100mmHg using labetalol, hydralazine, and/or nitroglycerine as needed. Acute pulmonary edema can occur peripartum due to high afterload / SVR and low oncotic pressure secondary to proteinuria. Treatment should include afterload reduction, diuresis and oxygen as needed. Most cases can be managed without the need for invasive central monitoring.

If intravenous medications such as labetolol and hydralazine prove ineffective at reducing blood pressure to an acceptable level, arterial line placement should be considered with initiation of a continuous infusion of carefully titrated antihypertensive drugs such as nicardipine. Rarely, placement of a pulmonary artery catheter can be considered if the patient does not respond appropriately.

Baseline coronary artery disease or cardiac dysfunction – Goals of management: Baseline cardiac disease would be highly unusual in a parturient.

c. Pulmonary

i
COPD: COPD would be unusual in a parturient.
ii
Reactive airway disease (Asthma): Clinical management of asthma would be no different in the parturient with preeclampsia. In the setting of uterine atony requiring uterotonics, the anesthesiologist would need to weigh the risks and benefits of usage of carboprost tromethamine (Hemabate®) as it is contraindicated in asthmatics due to the potential for bronchospasm versus methylergonovine (Methergine®) as it can precipitate further elevations in blood pressure.
iii
Pulmonary edema should be evaluated by clinical signs and symptoms (rales, hypoxemia, dyspnea) and treated as necessary. Prevention of pulmonary edema can be achieved by blood pressure control and judicious use of intravenous fluids.

d. Renal-GI:

Preeclampsia can lead to oliguria and renal insufficiency due to vasospasm and reduced renal blood flow. Proteinuria can be a feature of the disease, though not necessary for diagnosis, and an indication of its severity, i.e. the more protein spilled in the urine the more severe the preeclampsia. Normal creatinine in pregnancy is 0.4-0.6 mg/dL and values above 1.0 mg/dL are concerning. Preeclamptic patients with severe features and some without severe features will be receiving magnesium sulfate for seizure prophylaxis, and magnesium is only cleared by the kidneys, so renal insufficiency can rapidly lead to magnesium toxicity manifest as loss of deep tendon reflexes and respiratory insufficiency. The patient must be monitored closely for signs and symptoms of magnesium toxicity such as decreased deep tendon reflexes, altered mental status and difficulty with respiration. Magnesium levels may also be obtained.

GI concerns are similar to those in the healthy parturient in regards to aspiration risk from reflux and delayed gastric emptying in labor. Preeclamptic patients can also have liver dysfunction as part of the HELLP syndrome, which may manifest as epigastric pain or referred shoulder pain. Liver function tests should be evaluated when the patient presents and followed closely if they are elevated. In rare cases, hepatic dysfunction can be severe enough to cause problems with coagulation. INR should be followed if liver function tests are elevated.

e. Neurologic:

Acute issues: Preeclampsia progresses to eclampsia when a seizure occurs, and this neurologic complication can be prevented by using intravenous magnesium sulfate. Outside of the USA, benzodiazepines and barbiturates are frequently employed for this purpose. Magnesium sulfate is superior to placebo, dilantin, benzodiazepines, and nimodipine for seizure prophylaxis in preeclampsia with severe features, although the mechanism is uncertain. The dosing regimen is a 4-6 gram loading dose of 20-30 minutes followed by a 2 gram/hour infusion, and may be adjusted to account for renal dysfunction. Adequacy of magnesium level is followed clinically by deep tendon reflexes which should be depressed but not absent. About 80% of eclamptic patients will have visual changes and/or headache before their seizure.

Chronic disease: Parturients with a known seizure disorder should continue their usual medications in the peripartum period.

f. Endocrine:

No issues related to preeclampsia.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Hematologic: thrombocytopenia is common in preeclampsia, and should be evaluated frequently (at least every six hours) in the preeclamptic patient with severe features during labor.

4. What are the patient's medications and how should they be managed in the perioperative period?

The most common drug used for outpatient control of blood pressure in the preeclamptic patient is alpha methyldopa (Aldomet®). Once the patient requires hospitalization, oral antihypertensive control can be discontinued and intravenous medications used. ACOG recommends labetalol and hydralazine in their practice guidelines. Magnesium sulfate should be continued through delivery and for 24 hours postpartum while the risk of eclamptic seizure is high. Some centers use high-dose steroids (e.g., 10 mg dexamethasone q 12 hours) in patients with HELLP syndrome to improve laboratory studies and general patient condition, although multi-center confirmation of its benefits are lacking. One result of steroid therapy is that platelet count will rise, perhaps to a level acceptable for neuraxial anesthesia.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

N/A

i. What should be recommended with regard to continuation of medications taken chronically? All chronic medications that have been taken during pregnancy should be continued in the peripartum period with the exception of anticoagulants (discussed elsewhere).

Alpha methyldopa should be discontinued in favor of blood pressure control using intravenous agents such as labetalol, hydralazine, and nitroglycerine.

j. How to modify care for patients with known allergies –

There is nothing specific to preeclampsia.

k. Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

There is nothing specific to preeclampsia. The anesthetic equipment for neuraxial blocks is latex-free.

l. Does the patient have any antibiotic allergies? (common antibiotic allergies and alternative antibiotics)

N/A

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia:

Documented- avoid all trigger agents such as succinylcholine and inhalational agents:

i
Proposed general anesthetic plan: If general anesthesia is necessary for cesarean delivery, rapid sequence induction with propofol and high dose rocuronium can be used, followed by TIVA for maintenance. Magnesium interacts with non-depolarizing relaxants, and there may be prolonged weakness necessitating postoperative ventilation in the main operating room PACU or ICU.
ii
Insure MH cart available: [- MH protocol]
iii
Family history or risk factors for MH:

Local anesthetics/ muscle relaxants:

N/A

5. What laboratory tests should be obtained and has everything been reviewed?

Common laboratory normal values will be same for all procedures, with a difference by age and gender.

Hemoglobin levels: A baseline hemoglobin should be checked as these patients are at higher than normal risk of postpartum hemorrhage. HELLP syndrome can include hemolysis and declining hemoglobin.

Electrolytes: A baseline creatinine will evaluate adequacy of renal blood flow and help adjust magnesium sulfate infusion rate based on anticipated clearance.

Coagulation panel: Platelet count (especially trend) is most important, but if there is liver dysfunction or placental abruption, other coagulation studies including fibrinogen should be evaluated.

Imaging: Include stress tests, renal imaging tests, etc. Fetal ultrasound should be done to evaluate any growth restriction, presentation, and a biophysical profile to establish fetal well-being. If the patient has epigastric pain and/or elevated liver function testing, hepatic ultrasound may be done to look for subcapsular hematoma. Patients who have recurrent seizures or neurologic findings should have expedited delivery and head imaging to rule out intracerebral bleed or subarachnoid hemorrhage.

Other tests: Include thyroid tests, etc. A type-and-screen should be done to evaluate for antibodies and to make conversion to type-and-cross more efficient if hemorrhage occurs. Liver function tests should be evaluated at least once on admission.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

a. Regional anesthesia –

Neuraxial

Benefits

Neuraxial analgesia provides the most effective and least depressant pain relief for labor. The sympathectomy will help control hypertension during labor. If cesarean delivery is needed during labor, the block can be extended for surgical anesthesia. Neuraxial anesthesia allows the mother to be awake during a cesarean delivery to experience the birth of her child, and avoids general anesthesia, minimizing the potential risks associated with airway manipulation. Neuraxial anesthesia for cesarean delivery allows for the provision of spinal or epidural morphine, which is the gold standard for post cesarean delivery analgesia.

Drawbacks

Thrombocytopenia may increase the risk for epidural hematoma, and the platelet level at which neuraxial anesthesia becomes unsafe is not known. Even if a documented platelet count seems adequate, the platelet level can drop precipitously, especially when HELLP syndrome develops, and the actual level at the time of placement might be significantly lower than reflected in laboratory values. Platelet function may be abnormal, but we do not have a test to measure platelet function. Some patients might have pulmonary edema causing symptoms severe enough to prevent them from being able to lie down comfortably for the duration of the surgery, and some might simply fear neuraxial anesthesia and refuse it.

Issues

Once a neuraxial anesthetic is chosen, controversy persists over the best choice between a spinal and epidural anesthesia. Traditional thought favored the use of epidural anesthesia because of a theoretical concern of rapid sympathectomy using spinal anesthesia in a volume contracted preeclamptic may lead to profound hypotension and resultant fetal bradycardia. However, evidence supports the safety of spinal anesthesia in the preeclamptic patient, and it allows for the use of spinal morphine for postoperative analgesia, which may provide superior analgesia to epidural morphine, especially in the immediate postoperative period. Combined spinal-epidural anesthesia can be used if the surgery may be prolonged. To avoid postpartum pulmonary edema, fluid management should be conservative with minimal or no preload prior to neuraxial block. Hypotension is less common in preeclampsia than in healthy parturients, but if it occurs should be treat aggressively with vasopressors such as phenylephrine.

Peripheral Nerve Block

Nerve blocks have limited value during labor, although there have been reports or lumbar sympathetic blocks during the first stage of labor. Pudendal blocks can be used for the second stage of labor or for outlet forceps delivery if the obstetrician is trained to do an effective block. PNBs are not appropriate for cesarean delivery. TAP (transversus abdominis plane) block can be used for postoperative analgesia, but will not provide adequate anesthesia for surgery. Historically, a field block has been described as a way of providing anesthesia in an extreme emergency, but should only be considered as a last resort, or when there is no experienced anesthesia care provider available and the cesarean delivery is a dire emergency.

b. General Anesthesia

Benefits

When regional anesthesia is contraindicated due to a coagulopathy, or when there is not sufficient time to perform neuraxial anesthesia, general anesthesia becomes the most viable option. Even under ideal circumstances for each technique, the time from arriving in-room to skin incision will be quicker with general than with regional anesthesia.

Drawbacks

Airway concerns (below). Most patients want to be awake for the birth of their child, which of course is not possible with general anesthesia. Postoperative analgesia will require the use of parenteral opioids, which will provide analgesia inferior to neuraxial morphine with the potential for greater side effects. However, opioids can be supplemented with TAP blocks if the anesthesiologist is comfortable with the technique. There is a rare but real risk of awareness under general anesthesia for cesarean delivery. Rapid sequence induction can lead to wide swings in blood pressure, so adjuncts must be available to attenuate hypertension during laryngoscopy and prior to extubation. These might include opioids, lidocaine, beta blockers, or vasodilators such as nitroglycerin.

Other issues

Preeclamptics with severe features, and some without severe features, depending on their risk for seizure will be receiving a magnesium infusion in order to prevent an eclamptic seizure. These patients will have increased sensitivity to both depolarizing and nondepolarizing skeletal muscle relaxants. The effect is so profound that consideration should be given to not using a nondepolarizing relaxant after intubation, instead relying upon succinylcholine for tracheal intubation, and then the naturally occurring abdominal muscle laxity afforded by the pregnant state. Small (10 mg) doses of succinylcholine can be used during surgery if the patient is coughing or bucking on the endotracheal tube. Narcotics will also blunt the cough reflex. If the magnesium level is high, the patient may be too weak to meet criteria for extubation.

Airway concerns

The oropharynx will become swollen during a normal pregnancy, and this problem is compounded by preeclampsia. Full preparations must be made for a difficult intubation when a preeclamptic parturient presents for cesarean delivery – additional experienced help, fiberoptic laryngoscope, laryngeal mask airways, smaller endotracheal tubes, etc. The nasal mucosa in pregnancy becomes engorged and friable, so instrumentation of the nares should be avoided to prevent bleeding. If general anesthesia was chosen because thrombocytopenia was a contraindication to regional anesthesia, epistaxis could be even more severe.

c. Monitored Anesthesia Care:

If there is a contraindication for neuraxial labor analgesia, the patient will benefit from intravenous opioids via patient-controlled pump, for example fentanyl 50 μg with a 10-minute lockout and no basal rate. MAC is not appropriate for cesarean delivery.

Not an option for cesarean delivery.

6. What is the author's preferred method of anesthesia technique and why?

Combined spinal-epidural for labor analgesia can be initiated with 25 μg fentanyl or 5 μg sufentanil in the spinal dose to minimize sympathectomy and drops in blood pressure. The patient-controlled epidural infusion should contain low concentration local anesthetic plus an opioid, for example 0.0625% bupivacaine with 2 μg fentanyl/ml. The pump settings would be 8-12 ml/hour basal rate with a 8 ml bolus available every 10 minutes for a maximum of 3 boluses per hour. The patient should be monitored through labor for adequate analgesia and minimal motor block. If an instrumented delivery is necessary and the patient needs a top-up perineal dose, 10-15 ml of 0.5% bupivacaine, 1.5% lidocaine, or 2% 2-chloroprocaine can be used.

For cesarean delivery, the epidural catheter can be bolused with 15-20 ml of 3% 2-chloroprocaine for a fast onset, or 2% lidocaine with bicarb and epinephrine for a more intermediate onset. Be aware that theoretically intravenous epinephrine in the case of an unintentional intravenous injection could cause dangerous hypertension in the preeclamptic patients. A bolus of opioid can also be included: 100 μg fentanyl or 20 μg sufentanil to augment the neuraxial block improving the conversion to neuraxial anesthesia. At the time of delivery, bolus with 4 mg preservative-free morphine. If an epidural is not in place, a spinal (or combined spinal-epidural) should be chosen using 1.5 ml 0.75% hyperbaric bupivacaine plus 10-25 μg fentanyl and 0.1-0.25 mg morphine.

If general anesthesia is necessary for urgency, a rapid sequence induction with propofol or etomidate, 100 mg lidocaine, and succinylcholine can be used. Anti-hypertensives such as esmolol, labetalol or nitroglycerine should be available in case severe hypertension results. The remainder of the case can be done with combinations of nitrous oxide, 0.5 MAC volatile agent, and opioids. Try to avoid using non-depolarizing relaxants that may be difficult to reverse in the presence of magnesium.

What prophylactic antibiotics should be administered? ACOG has published a committee opinion that is used as a guideline for antibiotic prophylaxis as follows: One gram of intravenous cefazolin (more for larger women) ideally within 30 minutes and certainly within 60 minutes of incision time. For women with a significant allergy to beta lactam antibiotics such as cephalosporins and penicillins, clindamycin with gentamycin is a reasonable alternative.

What do I need to know about the surgical technique to optimize my anesthetic care? Most cesarean deliveries will occur using a low transverse (Pfannenstiel) incision, but occasionally a midline approach will be used, such as in the morbidly obese parturient with a large pannus. A neuraxial anesthetic level to the fourth thoracic dermatome will be adequate in almost all cases, with a T6 level being adequate for many cases as well, especially if the obstetrician can avoid exteriorizing the uterus.

What can I do intraoperatively to assist the surgeon and optimize patient care? During regional anesthesia, the patient usually has a dense motor block below the mid thoracic level, and intraoperative movement is not a problem. However, even thoracic and upper extremity movement can hinder safe and effective surgery. Crying, coughing, vomiting and moving the arms can all cause motion that is distracting to the surgeon, and can be mostly avoided with patient instruction, or with sedation when necessary. Uterotonic agents should be used after delivery to minimize blood loss. Examples include oxytocin, 15 methyl prostaglandin F2alpha (Hemabate®), and misoprostol (Cytotec®). Methylergonovine (Methergine®) should be avoided in preeclamptic patients because of its intense vasoconstrictive properties.

What are the most common intraoperative complications and how can they be avoided/treated? Prioritize them by urgency. There can be blood pressure swings during surgery with hypertension at induction and emergence of general anesthesia and hypotension with blood loss at delivery under all forms of anesthesia. Magnesium is a tocolytic agent, and theoretically may contribute to postpartum uterine atony and hemorrhage during vaginal or cesarean delivery. Uterotonics should be used aggressively, and calcium may also be given to try and counteract magnesium’s effects.

Cardiac complications – The most likely cardiac complication in the preeclamptic undergoing cesarean delivery with regional anesthesia is hypotension due to sympathectomy. First line treatment normally includes intravenous fluid administration, but in the preeclamptic patient crystalloid solutions should be used judiciously to prevent postpartum pulmonary edema. Vasopressor drugs should also be utilized with caution due to increased sensitivity, but fluids and pressors should not be withheld for patients who need them, especially if symptomatic.

Pulmonary – Pulmonary edema can occur at any time during labor or postpartum. Combined with an increase in oxygen consumption and decrease in FRC seen in all parturients, significant hypoxemia can occur. Amniotic fluid embolism syndrome, also known as anaphylactoid syndrome of pregnancy, is a very rare complication that occurs in the peripartum period. Actually a misnomer, rather than being embolic, the etiology consists of sudden and extreme pulmonary vasoconstriction, with resulting right heart failure if spontaneous resolution does not occur. Treatment consists of resuscitation and supportive therapy for respiratory and cardiac failure and coagulopathy. Anecdotal suggestions consist of therapy with inotropic drugs and pulmonary vasodilators, but evidence based treatment guidelines do not exist due to the acuity and rareness of the syndrome.

a. Neurologic:

Neurologic: The preeclamptic patient progresses to eclampsia when a seizure occurs. Ideally, a patient presenting to the operating room has therapeutic magnesium levels. Eclamptic seizures are equally likely to occur postoperatively, so the magnesium infusion should be continued during surgery and into the postoperative therapy.

b. If the patient is intubated, are there any special criteria for extubation?

Normal pregnancy involves edema of the entire airway, and preeclampsia can have even more dramatic swelling. Extra care must be taken to assure that the patient is fully awake and able to breathe spontaneously in order to reduce the risk of reintubation. Many preeclamptic patients will be on a magnesium infusion to prevent seizures, and therapeutic serum levels of magnesium will potentiate the effects of both depolarizing and nondepolarizing skeletal muscle relaxants. Therefore, extra caution must be used prior to extubation of the patient who has therapeutic (or higher) magnesium levels and has received a nondepolarizing muscle relaxant.

c. Postoperative management

What analgesic modalities can I implement? The ideal postoperative analgesic for cesarean delivery is spinal morphine, 150-250 mcg. If epidural anesthesia is utilized for the surgery, then epidural morphine will also be effective, with a typical dose 4 mg. When regional anesthesia is not selected, then an intravenous opioid PCA can be used to provide effective analgesia. NSAIDs should be avoided if creatinine is elevated or oliguria is present. Postoperative TAP block can also be used as an adjuvant.

What level bed acuity is appropriate? (Example: floor, telemetry, step-down, or ICU and justification): Preeclampsia itself does not warrant admission to a level higher than an L&D bed where the nursing staff is able to care for postpartum patients. Magnesium infusions will require a patient to be monitored for signs of toxicity, but does not increase the level of bed acuity required as long as the ward is sufficiently staffed with nurses who are familiar with the needs of the postpartum patient. If the patient manifests more severe features such as HELLP syndrome with critical liver injury, pulmonary edema requiring intubation and mechanical ventilation or profound renal dysfunction necessitating dialysis, an admission to the intensive care unit is warranted.

What are common postoperative complications, and ways to prevent and treat them? (Example: postop delirium, postop DVT/PE, reoperation for bleeding, functional decline, increased mortality) Maternal hemorrhage from uterine atony can occur postoperatively. A continuous infusion of oxytocin in the immediate postpartum period can help prevent this complication, and other drugs such as prostaglandins and misoprostol may be used in severe cases. Eclamptic seizures are just as likely to occur postoperatively as they are intrapartum. This postoperative complication can be prevented by continuing the magnesium infusion for 24 hours after delivery. Magnesium toxicity is also of concern. Postoperative respiratory depression is rarely clinically significant after typical doses of neuraxial morphine, but the ASA Guidelines for monitoring for this complication should be done for the 24 hour period after the patient receives the drug. The preeclamptic patient who is weak from magnesium may be more at risk for hypoventilation.

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