Severe preeclampsia, and HELLP syndrome, are hypertensive pregnancy diseases that occur at 20 weeks of pregnancy. The main manifestations are hypertension, protenuria, and multiple organs dysfunction. It is one of most common causes of maternal and fetal deaths.HELL syndrome manifestations as elevated liver enzymes, thrombocytopenia, renal impairment .CNS manifestations as convulsions, brain edema, hemorrhages or brain injury. , cardiovascular manifestations as heart failure, and pulmonary edema,High mortality in under developed countries is due to lack of anti natal care for early diagnosis, and management. Malnutrition, early age of marriage, or elderly marriage predisposes to increase mortality among patients.Anesthetist may face the challenge of anesthetic management of these patients. Anesthetist may has the challenge in preoperative management as controlling blood pressure , full stomach preparation for difficult intubation, management of Oliguria and renal impairment, convulsion by magnesium infusion, control of pulmonary edema. The second challenge is Intra operative management, selection of anesthesia the presence of coagulopathy is a contraindication for regional anesthesia. General anesthesia is the second anesthetic challenge .the proper selection inhalational, narcotics, and muscle relaxant is mandatory in the presence of the affected liver. Hemorrhage following abrubto placenta, coagulopathy, intrauterine fetal death and DIC blood transfusion, plasma, cryoprecipitate OR novo seven. The third challenge is Post operative care, mechanical ventilation, after ARDS syndrome, continuation of magnesium sulphate, sedation for controlling of convulsions.In this book I summarized some tips to overcome this great challenge, and deceases the rate of mortality when emergency cesarean section is facing the anesthesia especially in under developed countries.