Neural Damage and Anesthetic Treatment in the Preeclamptic Parturient; a Prospective Observational Cohort Study.

Scientific background:

Preeclampsia is an idiopathic maternal, multi organ, specific pregnancy disorder, associated with significant maternal and perinatal morbidity and mortality. Preeclampsia complicates approximately 2-8% of all pregnancies. The disorder is characterized by new-onset of hypertension and proteinuria developing after gestational week 20. While the pathogenesis of the disease remains not completely understood, a possible explanation is endothelial cell dysfunction in which placenta-derived mediators causes multisystem organ dysfunction .

Preeclampsia increases the risk for acute cerebrovascular complications such as intracerebral hemorrhage, cerebral edema and eclampsia. Treatment with magnesium sulfate reduces the risk for seizures and treatment with antihypertensive therapy reduces the risk for a stroke , however the only effective treatment for the syndrome is prompt delivery of the fetus .

When considering the optimal anesthetic method for a preeclamptic parturient undergoing cesarean delivery, neuraxial anesthetic techniques, when feasible, are strongly preferred to general anesthesia (GA) . Spinal anesthesia (SA) is favored over general anesthesia since it is associated with increased benefits and reduced risks compared with general anesthesia. Increased benefits of SA include higher patient satisfaction, decreased pain and favorable neonatal outcomes. GA has been associated with increased risk for aspiration, unstable hemodynamics and difficult airway management . In addition GA has been shown to increase the risk for a stroke in women with preeclampsia . Nevertheless GA is sometime used in the preeclamptic parturient due to maternal or fetal indications with an incidence as high as 44% in some European countries .

Accumulative evidence from animal studies indicate that general anesthetic agents are neurotoxic and can induce subsequent behavioral abnormalities in the developmental mind . However the fetal and pediatric implications remain inconclusive. In a population-based birth cohort study fetal exposure to general anesthesia during cesarean delivery was not associated with increased risk for learning disabilities compared to delivering vaginally . In contrast in a population-based birth cohort study conducted in Taiwan the incidence of autism was increased in neonates who were delivered by cesarean delivery under general anesthesia compared with regional anesthesia .