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The Consensus Bundle on Hypertension in Pregnancy and the

Anesthesiologist: Doing All the Right Things for All the Patients
All of the Time
Mihaela Podovei, MD; Brian T. Bateman, MD, MSc

Anesth Analg. 2017;125(2):383-385.

Abstract and Introduction

Introduction

Hypertensive disorders of pregnancy and their associated complications are a major source of maternal morbidity and
mortality in contemporary obstetrical practice in the United States, accounting for a substantial fraction of pregnancy-
related intensive care unit admissions, cardiac arrests, and deaths.[1–4] The prevalence of these disorders in
pregnancy are increasing, potentially driven by rising rates of obesity and increasing numbers of patients of advanced
maternal age.[1] It is thus timely that the National Partnership for Maternal Safety (NPMS) is publishing the obstetric
bundle on severe hypertension in this month's Anesthesia & Analgesia.

The NPMS is a multidisciplinary interprofessional collaboration between 19 core organizations, including the American
Society of Anesthesiologists and the Society for Obstetric Anesthesia and Perinatology. The partnership strives to
generate a culture of change by creating and disseminating patient safety bundles that promote development of
protocols and practices that should be implemented in all hospitals that provide obstetric care. The NPMS has
identified 3 major contributors to maternal morbidity and mortality amenable to interventions that can improve outcome:
hemorrhage, pulmonary embolism, and severe hypertension. Bundles focused on hemorrhage were published in
2015[5] and venous thromboembolism in 2016.[6]

The goal of the safety bundles is to facilitate doing "all the right things for all the patients all the time." Recognizing the
diverse characteristics of hospitals performing deliveries in the United States, the goal is to lay out a set of guidelines
to be adapted to local circumstances and create systems so that any hospital can optimally manage a condition. The
bundle is organized in 4 action domains: readiness, recognition, response, and reporting and system learning. Each
action domain describes key practices that should be put in place on labor and delivery units. Implementation of the
bundle on labor and delivery units will require multidisciplinary and intraprofessional collaboration between
anesthesiologists, obstetricians, midwives, and nurses. As such, the bundle is being simultaneously published in
Obstetrics and Gynecology, Journal of Midwifery and Women's Health, and Journal of Obstetric, Gynecologic and
Neonatal Nursing, in addition to Anesthesia & Analgesia.

Key Considerations for the Anesthesiologist

Publication of this bundle will prompt labor and delivery units across the country to develop new guidelines and
protocols for the treatment of severe hypertension. As these are developed and implemented, anesthesiologists should
take advantage of the opportunity to engage with or even lead this process. There are 6 areas that will be particularly
important for anesthesiologists to be attentive to as labor and delivery unit protocols are developed.

1. Management of hypertensive emergency: Systolic blood pressure of ≥160 mm Hg or a diastolic blood pressure of
≥110 mm Hg in pregnant or postpartum women accurately measured and persistent over 15 minutes is a hypertensive
emergency and requires prompt treatment (within 30–60 minutes). This threshold is based largely on data suggesting
that risk for hemorrhagic stroke increases when blood pressures exceed these values.[7]

The bundle recommends intravenous labetalol or hydralazine as first-line medications, with oral nifedipine as an
alternative if the patient does not have intravenous access or has contraindications to the other first-line agents. If
elevations in blood pressure are refractory to first-line agents, then anesthesiologists or intensivists may be consulted
to evaluate the patient for treatment with a second-line agent administered by infusion, such as nicardipine, esmolol, or
nitroprusside, potentially with invasive arterial blood pressure monitoring.[8] Prolonged use of nitroprusside should be
avoided due to the potential risk of cyanide and thiocyanate toxicity. In general, nitroglycerine infusions should also be

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avoided around the time of delivery due to the drug's effect on uterine tone and risk for postpartum hemorrhage.

2. Management of eclamptic seizures: Anesthesiologists have an important role in management of eclamptic seizure
given their expertise in airway and crisis management. Unit protocols for responding to eclamptic seizures should
include calling an anesthesiologist to the patient's bedside where they can immediately attend to the patient's airway,
breathing, and circulation.

The bundle appropriately identifies magnesium as the first line of treatment for eclamptic seizures (recommending a 4–
6 g bolus of magnesium sulfate), followed by a magnesium infusion. While magnesium is rarely harmful at these
doses, it may not be sufficient; optimal management depends on a timely and accurate diagnosis.

Not all seizures on the labor and delivery unit are due to eclampsia, and seizure is not the only serious complication of
preeclampsia. If a patient's seizure activity is refractory to repeat doses of magnesium, or if she demonstrates focal
neurologic deficits or her confusion extends beyond the postictal period, the differential diagnosis should be broadened
to consider other etiologies (). Emergency computerized tomography or magnetic resonance imaging in a postictal or
confused patient will require anesthesia services to ensure that she holds still, to protect her airway, and to monitor for
further decompensation.

Box. Differential Diagnosis of Peripartum Seizure

Decrease in cerebral oxygenation

Hypoxia

Hypotension

Amniotic fluid embolism

Infection

Sepsis

Meningitis

Drug effects

Cocaine

Methamphetamine

Local anesthetic systemic toxicity

Drug error

Cerebrovascular event

Central venous thrombosis

Intracranial hemorrhage

Intracranial thrombosis

Carotid or vertebral artery dissection

Thrombotic thrombocytopenic purpura

Epilepsy
Intracranial malignancy

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3. Promotion of the use of regional anesthesia: Protocols should encourage the use of regional anesthesia for
hypertensive patients whenever possible because preeclampsia increases the risks of general anesthesia. In
particular, airway edema may exacerbate difficult intubation, and an exaggerated hypertensive response to
laryngoscopy may lead to hemorrhagic stroke.[9,10] Nevertheless, coagulopathy must be excluded to ensure safe
neuraxial blockade. Units need processes in place to obtain frequent platelet counts for preeclamptic patients,
particularly for those with severe features, so that a count is available at a time point proximate to the placement of the
neuraxial block. Systems to obtain point-of-care viscoelastic monitoring or rapid coagulation studies, or both, are also
needed to facilitate optimal decision-making and clinical care for the rare patient with severe thrombocytopenia or
suspected abruption. Absent coagulopathy, spinal anesthesia is generally safe for this population,[11] despite historical
concerns about hemodynamic change and fetal perfusion.

4. Safe administration of general anesthesia when necessary: If general anesthesia is required either to facilitate
emergent delivery or due to coagulopathy, maternal blood pressure should be stabilized prior to the anesthetic
induction. The target systolic blood pressure should be between 140 and 160 mm Hg, recognizing that normotension
or hypotension may impair placental or maternal cerebral perfusion. Preparations should be made for a potential
difficult airway (eg, summoning additional providers, using videolaryngoscopes). A medication should be administered
to blunt the hypertensive response to laryngoscopy; a variety of drugs have been demonstrated to be effective in this
setting including remifentanil, esmolol, or nitroglycerin boluses.[12] Hemodynamic instability may also accompany
emergence, so careful attention to blood pressure at this time is also critical.

5. Management of magnesium in the peridelivery period: Unit protocols should recommend that magnesium be
continued during cesarean deliveries and not stopped out of concern for the impact on uterine tone or anesthetic drug
interactions. The half-life of magnesium sulfate is about 4 to 5 hours in women with normal renal function,[13] so
stopping at the time of incision will not significantly change the levels during the intraoperative period but will increases
the likelihood of subtherapeutic magnesium levels in the postpartum period, placing the patient at risk for eclampsia.
Magnesium infusions in the operating room increase risk for a drug error if other medications (eg, oxytocin,
phenylephrine, azithromycin) are also infused on pump, and systems are needed as part of the handoff process to
ensure safe transfer of responsibility for the magnesium infusion from the labor nurse to the anesthesiologist at the
time of transport to the operating room and from the anesthesiologist to the nurse in the postanesthesia care unit.

6. Postdelivery care: The postpartum period is a particularly vulnerable time for preeclamptic patients; over 50% of
strokes[7] and as many as 75% of deaths secondary to hypertension occur following delivery.[14] Protocols should
ensure that preeclamptic patients are carefully monitored well into the postpartum period. Anesthesiologists should be
involved in defining a safe disposition for the patient based on the degree of blood pressure control and respiratory
status.

Additionally, postdelivery analgesic regimens will need to be tailored for circumstances when nonsteroidal anti-
inflammatory medications or acetaminophen are contraindicated. Opioid monotherapy and magnesium infusions
increase the risk for respiratory depression, so appropriate systems for monitoring are advised.

Conclusions

The Consensus Bundle on Hypertension in Pregnancy was written for an intraprofessional audience and addresses
key actions that have the potential to reduce maternal morbidity and mortality associated with hypertensive diseases of
pregnancy. This editorial expands on the intraprofessional bundle to detail the specific role that anesthesiologists can
play in ensuring safe peripartum care for women with hypertensive disorders. Given that hemodynamic monitoring and
administration of cardiovascular drugs are so central to role of anesthesiologists, we should play a key role in
facilitating the implementation of the bundle on labor and delivery units and, with this, expand our role in the care of
these patients.

References

1. Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United
States. Obstet Gynecol. 2009;113:1299–1306.

2. Wanderer JP, Leffert LR, Mhyre JM, Kuklina EV, Callaghan WM, Bateman BT. Epidemiology of obstetric-related
ICU admissions in Maryland: 1999–2008*. Crit Care Med. 2013;41:1844–1852.

3. Mhyre JM, Tsen LC, Einav S, Kuklina EV, Leffert LR, Bateman BT. Cardiac arrest during hospitalization for
delivery in the United States, 1998–2011. Anesthesiology. 2014;120:810–818.

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4. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the
United States, 2006–2010. Obstet Gynecol. 2015;125:5–12.

5. Main EK, Goffman D, Scavone BM, et al; National Partnership for Maternal Safety; Council for Patient Safety in
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Anesth Analg. 2015;121:142–148.

6. D'Alton ME, Friedman AM, Smiley RM, et al. National Partnership for Maternal Safety: Consensus Bundle on
Venous Thromboembolism. Anesth Analg. 2016;123:942–949.

7. Martin JN Jr, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and
eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005;105:246–254.

8. Committee on Obstetric Practice. Committee Opinion No. 692: Emergent therapy for acute-onset, severe
hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2017;129:e90–e95.

9. Munnur U, de Boisblanc B, Suresh MS. Airway problems in pregnancy. Crit Care Med. 2005;33:S259–S268.

10. Huang CJ, Fan YC, Tsai PS. Differential impacts of modes of anaesthesia on the risk of stroke among
preeclamptic women who undergo Caesarean delivery: a population-based study. Br J Anaesth. 2010;105:818–
826.

11. Henke VG, Bateman BT, Leffert LR. Focused review: spinal anesthesia in severe preeclampsia. Anesth Analg.
2013;117:686–693.

12. Pant M, Fong R, Scavone B. Prevention of peri-induction hypertension in preeclamptic patients: a focused
review. Anesth Analg. 2014;119:1350–1356.

13. Lu JF, Nightingale CH. Magnesium sulfate in eclampsia and pre-eclampsia: pharmacokinetic principles. Clin
Pharmacokinet. 2000;38:305–314.

14. Zuleta-Tobón JJ, Pandales-Pérez H, Sánchez S, Vélez-Álvarez GA, Velásquez-Penagos JA. Errors in the
treatment of hypertensive disorders of pregnancy and their impact on maternal mortality. Int J Gynaecol Obstet.
2013;121:78–81.

Funding
None.

Anesth Analg. 2017;125(2):383-385. © 2017 International Anesthesia Research Society

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