Cesarean Delivery in Severe Preeclampsia with Thrombocytopenia

Preferred plan: Single-shot spinal anesthesia if the platelet count is stable and there is no evidence of coagulopathy, with general anesthesia immediately available as a backup.

Reasoning:

• A platelet count of 72 × 10⁹/L is in the gray zone. Many obstetric anesthesia guidelines accept neuraxial anesthesia at 70–80 × 10⁹/L if the count is stable and there is no HELLP syndrome, coagulopathy, or falling trend. Other guidelines use 80 × 10⁹/L as a threshold.
• The decision must be individualized. Check a recent full blood count, fibrinogen, and coagulation screen; look for HELLP syndrome, which would make neuraxial anesthesia unsafe.
• A single-shot spinal is preferable to an epidural because it is a smaller needle, causes less bleeding risk, and is faster for urgent delivery. An epidural is useful if labor is planned, but this patient needs urgent cesarean delivery.
• General anesthesia is indicated if the platelet count is below 70 × 10⁹/L, falling rapidly, or if there is coagulopathy. It also carries risks of difficult airway from edema, hypertension at intubation, and neonatal depression.

Magnesium effect: Magnesium sulfate prolongs neuromuscular blockade. If general anesthesia is needed, reduce the rocuronium dose and monitor with a peripheral nerve stimulator. Do not omit magnesium, because seizure prophylaxis is essential.

Hemodynamic management:

• Insert an arterial line before induction for beat-to-beat blood pressure monitoring.
• Avoid both hypertension and hypotension. Severe hypertension risks maternal stroke; hypotension worsens uteroplacental perfusion.
• For spinal anesthesia, preload with a modest crystalloid co-load and use phenylephrine infusion or boluses to maintain systolic blood pressure near baseline.
• Continue magnesium sulfate throughout surgery.
• Monitor urine output, blood loss, and respiratory status; preeclamptic patients are at risk of pulmonary edema.

Uterotonic management:

• Avoid a rapid oxytocin bolus, which can cause profound hypotension and tachycardia.
• Use a dilute oxytocin infusion, for example 10 IU in 500 mL over 30–60 minutes, titrated to uterine tone.
• Avoid ergometrine because it causes hypertension.
• If uterine atony persists, use carboprost with caution or misoprostol, and involve a senior obstetrician.

Reasoning: The goal is to deliver the baby safely while preventing maternal stroke, pulmonary edema, and hemorrhage. Magnesium must continue because delivery does not immediately eliminate seizure risk.

Monitoring:

• Admit to a high-dependency or intensive care unit for at least 24 hours.
• Continue magnesium sulfate for 24 hours postpartum, with monitoring of respiratory rate, deep tendon reflexes, and urine output.
• Use continuous pulse oximetry, strict fluid balance, and regular blood pressure checks.
• Watch for postpartum hemorrhage, pulmonary edema, and worsening thrombocytopenia.

Analgesia:

• If spinal anesthesia was used, intrathecal morphine provides excellent analgesia but requires monitoring for respiratory depression.
• Use regular acetaminophen and, if renal function is normal, NSAIDs with caution. Avoid NSAIDs if platelets are falling or renal function is deteriorating.
• Avoid sedatives that could mask preeclampsia symptoms.

Thromboprophylaxis:

• Preeclampsia and cesarean delivery increase venous thromboembolism risk.
• Start mechanical prophylaxis immediately and low-molecular-weight heparin after hemostasis is confirmed, usually 12–24 hours postoperatively.
• Continue thromboprophylaxis for at least 6 weeks postpartum if risk factors persist.

Reasoning: The postoperative period is when most maternal complications occur. Structured monitoring and a clear escalation plan are essential.