A parturient at 34 weeks gestation with severe pre-eclampsia (BP 168/112, proteinuria 3+, headache) requires emergency caesarean section. The obstetric anaesthetist elects spinal anaesthesia. Regarding epidural/spinal drug dosing in this patient, which statement is correct?

• A Higher doses of local anaesthetic are needed in pre-eclampsia due to resistance
• B Spinal anaesthesia is contraindicated because it causes excessive hypotension in pre-eclampsia
• C General anaesthesia with succinylcholine is always preferred in pre-eclampsia to avoid hypotension
• D Pre-eclamptic patients are more sensitive to intrathecal bupivacaine and may need dose reduction; spinal is the preferred option if no coagulopathy ✓

Explanation

Pre-eclamptic patients are known to be more sensitive to neuraxial blockade — hypotheses include peripheral oedema reducing epidural/subarachnoid space volume (increasing spread) and augmented blockade from elevated progesterone. They are therefore at higher risk of hypotension from spinal anaesthesia and lower doses of bupivacaine should be considered. Spinal anaesthesia is PREFERRED over general anaesthesia in pre-eclampsia because: (1) airway oedema makes GA more dangerous (difficult intubation); (2) laryngoscopy triggers a severe hypertensive surge that can cause ICH; (3) spinal avoids this if coagulation studies are normal (platelets >75–80 × 10^9/L by most guidelines).

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.