Indications for emergency caesarean section
Operative delivery is performed regardless of gestational age if life-threatening conditions develop. Absolute indications include:
- Eclampsia and its severe consequences (acute renal failure, pulmonary or cerebral edema, intracranial hemorrhage, DIC syndrome, placental abruption).
- Lack of response to therapy for severe and critical preeclampsia.
- Oliguria (less than 30 mL of urine over 2 hours) or rising creatinine $\ge 90$ µmol/L.
- Respiratory failure (oxygen saturation below 94%, pulmonary edema).
- Progressive platelet drop (less than 100,000/mm³), development of HELLP syndrome or subcapsular hepatic hematoma.
- Acute fetal hypoxia.
At 28–30 weeks or more, the presence of complications also dictates the need for urgent cesarean section. If the patient is diagnosed with hypocoagulation (aPTT prolonged more than 1.5 times, fibrinogen < 1 g/L), the surgery is performed exclusively under general anesthesia.
Conditions for vaginal delivery
Inducted labor is possible if the condition of the woman and fetus is stable. This requires the simultaneous fulfillment of several criteria:
- Gestational age of 36–37 weeks or more.
- Absence of clinical signs of severe preeclampsia.
- Controlled blood pressure (ranging from 130/80 to 150/90 mm Hg).
- Preserved diuresis (more than 30–50 mL/h).
- Proteinuria does not exceed 1 g/L.
- Cephalic presentation with a ripe cervix.
Labor management and analgesia
In the first stage of labor, basic therapy continues: administration of magnesium sulfate (Magnesii sulfas) and antihypertensive agents. The volume of intravenous infusions is strictly limited, using them mainly as a preload before anesthesia. The gold standard of pain relief is continuous epidural anesthesia, which is used throughout the first and second stages.
In the second stage, oxytocin can be used to prevent secondary arrest of labor. Completion of labor must be accompanied by a perineal incision (episiotomy or perineotomy).
If the condition of the mother or fetus worsens during labor, the tactics depend on the position of the fetal head:
- Head in the broad cavity of the pelvis $\rightarrow$ emergency cesarean section.
- Head in the narrow cavity of the pelvis $\rightarrow$ obstetric forceps or vacuum extraction.
Intensive care in HELLP syndrome
The development of HELLP syndrome requires immediate stabilization of hemostasis and vital organ functions in the perioperative and postpartum periods:
- Hemostasis correction: fresh frozen plasma transfusion (15–20 mL/kg), cryoprecipitate, vitamin K, and tranexamic acid. Platelet concentrate is transfused when platelets drop below $50 \times 10^3$.
- Detoxification and diuresis: crystalloid infusion, diuresis stimulation (up to 200–250 mL/h), sodium bicarbonate for metabolic acidosis. Oliguria is an indication for renal replacement therapy.
- Drug support: broad-spectrum antibiotics (3rd–4th generation cephalosporins, carbapenems), proton pump inhibitors, and nutritional support.
Prediction and prevention
There are no specific drugs for preeclampsia, therefore preconception care for risk groups (women with hypertension, renal pathology, APS, multiple pregnancy) plays a key role.
Screening is performed at 12–13 weeks. Risk is assessed using a set of markers:
- Mean arterial pressure.
- Pulsatility index in the uterine arteries.
- PAPP-A protein level.
- Ratio of sFlt1 to placental growth factor (an increase in sFlt1 against the background of a decrease in growth factor is considered pathological).
Prevention includes salt restriction (up to 4 g/day), hemostasis correction (antiplatelet agents in hypercoagulation), and treatment of background diseases under strict laboratory control.
Briefly: answers to topical questions
Which antihypertensive drugs are first-line agents for managing severe arterial hypertension in pregnant women?
To manage severe arterial hypertension (hypertensive crisis) in pregnant women, the following oral medications are used:
- Methyldopa — initially prescribed at a dose of 10 mg, repeated if necessary.
- Nifedipine — sustained-release preparation, prescribed according to the regimen: 10 mg initially, then 10 mg after 60 and 120 minutes (total dose is 30 mg).
In severe forms of preeclampsia, combination therapy with two or three drugs is indicated, selected strictly considering their effect on the fetus.
What is the dosage regimen of magnesium sulfate (loading and maintenance doses) for the prevention of eclampsia?
The magnesium sulfate dosing regimen for the prevention of eclampsia includes intravenous administration of loading and maintenance doses.
- Loading dose — 4–6 g IV slowly over 10–20 minutes. If no effect is observed, an additional dose of 2 g can be administered over 3–5 minutes.
- Maintenance dose — 1–3 g/h IV via an infusion pump.
The infusion is continued for at least 24–48 hours after delivery or the last seizure episode.
What instrumental methods are used to monitor fetal condition in preeclampsia?
To assess fetal condition in preeclampsia and during therapy, the following instrumental methods are used:
- Cardiotocography — mandatory during magnesium sulfate infusion, used to assess the functional state of the fetus and detect signs of chronic hypoxia.
- Ultrasound examination — used to detect fetal growth restriction, assess the severity of oligohydramnios, as well as the size and structure of the placenta.
- Dopplerometry — used to study blood flow in the uterine arteries, umbilical artery, middle cerebral artery, and fetal ductus venosus.
For quick memorization of the conditions for vaginal delivery in preeclampsia, use the "Five NORMS" rule: NORMal pressure (up to 150/90), NORMal diuresis (>30 mL/h), NORMal protein (<1 g/L), NORMal gestational age (>36 weeks), and NORMal (ripe) cervix.
Class and exam questions
Which anesthesia method should be chosen for cesarean section in preeclampsia?
The choice depends on the state of the hemostatic system. In hypocoagulation (platelets less than 75–100×10⁹/L, fibrinogen less than 1 g/L, prolonged aPTT), general anesthesia is indicated.
How to manage the second stage of labor in vaginal delivery?
Episiotomy or perineotomy must be performed. In case of secondary arrest of labor, oxytocin is prescribed, and if the condition worsens, obstetric forceps are applied or vacuum extraction is performed (if the head is already in the narrow cavity of the pelvis).
How to prevent postpartum hemorrhage?
Prophylaxis is performed at the end of the second stage of labor or after delivery of the fetus during cesarean section. 5 IU of oxytocin or 100 mcg of carbetocin is administered intravenously.
What else to study on this topic
- Pathogenesis and Clinical Manifestations of Preeclampsia
- Criteria for the Severity of Preeclampsia and Eclampsia
- Types of Gestational Toxicosis and Indications for Termination of Pregnancy
- Maternal and Fetal Complications of Preeclampsia
- Physician Management During an Eclamptic Seizure
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