Transcript Hypertension in pregnancy

Hypertension in pregnancy
Dr. Mona Shroff
www.obgyntoday.info
Classification
Gestational hypertension:>=140/90,>20 wks,no proteinuria,resolves PP
Preeclampsia: above + proteinuria>=+1
Eclampsia : preeclampsia + convulsions
Chronic HT : < 20 wks,ct > 12 wks PP, +/- proteinuria
Chr HT + Superimposed preeclampsia : onset of proteinuria(if nonproteinuric),shootup of BP/proteinuria(if
proteinuric)
Dr. Mona Shroff
www.obgyntoday.info
Dr. Mona Shroff
www.obgyntoday.info
Dr. Mona Shroff
www.obgyntoday.info
CASE 1a:
Mrs. A, 2O yr old primigravida,under your ANC, develops mild preeclampsia at 30 wks of pregnancy.(BP 150/94 mm Hg ,Urine proteins- +1 on random dipstick sample)
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Pathogenesis…. Current concepts ..
 Management :Role of antihypertensives??
Role of bed rest,SRD, sedatives &
tranquilisers?
Role of antioxidants??
Corticosteroids?
Monitoring……
When to deliver?
Dr. Mona Shroff
www.obgyntoday.info
Antihypertensive drug therapy for mild to
moderate hypertension during pregnancy.
Antihypertensive drugs are often used to lower blood pressure in the belief that they will prevent this
progression. The review of 46 trials, involving 4282 women, found there was not enough evidence to show the
benefit of antihypertensive drugs for mild to moderate hypertension during pregnancy. More research is
needed.
Cochrane Database of Systematic Reviews
Abalos E, Duley L, Steyn DW, Henderson-Smart DJ..
Dr. Mona Shroff
2007, Issue 1
www.obgyntoday.info
Bed rest with or without
hospitalisation for hypertension
during pregnancy.
At present, there is insufficient evidence to provide clear
guidance for clinical practice. Therefore, bed rest should
not be recommended routinely for hypertension in pregnancy
Meher S, Abalos E, Carroli G Cochrane Database of Systematic Reviews 2005, Issue 4
Dr. Mona Shroff
www.obgyntoday.info
CASE 1b:
 Mrs. A on routine 2D USG at 31 wks show IUGR on
biometry with AFI=6.
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Further testing?? Primary screening tool -DOPPLER vs BPP vs NST ??
In Doppler ---uterine a. /umbilical/MCA/venous
as primary value screen for fetal well being??
If umbilical flow N –What next? How freq
monitoring??
If abN – What next ? Delivery timing & options ??
Role of various Rx options for oligohydramnios ….
recommendations…
 A study comparing fetal
heart-rate monitoring,
biophysical profile and
umbilical artery Doppler
found that only umbilical
artery Doppler had value in
predicting poor perinatal
outcomes in SGA
Grade A(RCOG)
 Use umbilical artery Doppler as the
primary surveillance tool.
 A systematic review with metaanalysis has provided evidence that
the use of umbilical artery Doppler
to monitor high-risk fetuses reduces
perinatal morbidity and mortality.
 In addition, there was a significant
reduction in the number of
antenatal admissions and inductions
of labour
RCOG Evidence level II
 A variety of indices of umbilical
arterial Doppler waveform, such
as:Resistance index,
systolic/diastolic ratio,
pulsatility index and diastolic
average ratio, is used for
predicting perinatal outcome.
 Resistance index had the best
ability to predict abnormal
outcomes
RCOG Evidence level II
Frequency of monitoring
in SGA fetuses with
normal Doppler need not
generally be more than
once every fortnight.
RCOG Evidence level Ia
 Grade A
 The biophysical profile has not been
shown to improve perinatal outcome but
sufficient data do not exist to rule out
its value.
 However, there is evidence from
uncontrolled observational studies that
biophysical profile in high-risk women has
good negative predictive value, i.e. fetal
death is rare in women with a normal
biophysical profile
Evidence level Ib
 The absence of benefit from randomised trials and
since it is a time-consuming test, So it cannot be
recommended for routine monitoring in low risk
pregnancies or for primary surveillance in SGA
 When primary surveillance with umbilical artery
Doppler is found to be abnormal, biophysical profile
is likely to be useful given its good negative
predictive value in high-risk populations.
 This recommendation is further supported by
evidence that, in high-risk women, the biophysical
profile was rarely abnormal when Doppler findings
were normal.
Some forms of intervention
There is not enough evidence to assess
the value of
1. oxygen therapy,
2. nutrient therapy,
3. hospitalisation and bedrest,
4.
betamimetics,
5. calcium channel blockers,
6. hormonal therapy
7. and plasma volume expansion
in treating growth restriction.
The Cochrane Library, Issue 3, 2003
Maternal hydration for increasing amniotic fluid
volume in oligohydramnios
 Simple maternal hydration (two litres of
water/Intravenous hypotonic hydration) appears to
increase amniotic fluid volume and may be beneficial
in the management of oligohydramnios and prevention
of oligohydramnios during labour or prior to external
cephalic version. Controlled trials are needed to
assess the clinical benefits and possible risks of
maternal hydration for specific clinical purposes
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Hofmeyr GJ, Gülmezoglu AM. Cochrane Database of
Systematic Reviews 2002, Issue 1.
 Mrs .A develops sev preeclampsia at 32
wks.BP 160/110, urine protein +2, Admitted
& Ix sent.
Started on antihypertensives. Fetal
Doppler N.
 Criteria for severe preeclampsia…
 Which antihypertensive would you prefer &
why ??
 Delivery ?
 Prophylactic MgSO4 ??
Features of severe Pre-Eclampsia
 Blood pressure >160/110 mm Hg
 Proteinuria >5 g/24 h
 Cerebral involvement (hyper-reflexia, seizures)
 Oliguria < 500 ml /24hr
 Increased serum creatinine level
 Pulmonary oedema
 Epigastric or right upper quadrant abdominal pain
 Evidence of hepatic injury (HELLP)
 Thrombocytopenia or disseminated intravascular
coagulation
 Evidence of fetal compromise (IUGR or oligohydramnios)
Drugs for treatment of very high blood
pressure during pregnancy.
Until better evidence is available, the
choice of antihypertensive should depend on
the clinician's experience and familiarity
with a particular drug, and on what is known
about adverse effects. Exceptions are
diazoxide, nimodipine , which are probably
best avoided.
Duley L, Henderson-Smart DJ, Meher S.
Cochrane Database of Systematic Reviews: Reviews 2006
Issue 3
IV Labetolol vs SL Nifedepine
care for severe pre-eclampsia
before term.
 There are insufficient data for
any reliable recommendation
about which policy of care
should be used for women with
severe early onset preeclampsia. Further large trials
are needed.
 Churchill D, Duley L.
Cochrane Database of
Systematic Reviews 2002, Issue 3.
Magnesium sulphate and other anticonvulsants
for women with pre-eclampsia
 Magnesium sulphate more than halves the
risk of eclampsia, reduces risk of abruptio
placenta and probably reduces the risk of
maternal death. It does not improve
outcome for the baby, in the short term. A
quarter of women have side effects,
particularly flushing.
Duley L, Gülmezoglu AM, Henderson-Smart DJ..
Cochrane Database of Systematic Reviews 2003,
Issue 2.
CASE 1d:
 After 12 hrs of admission her UOP is
300 ml/12 hrs. Bld urea is 40,s
creatinine is 1.0 mg/dl,electrolytes are
N.Wt :60 kgs
Criteria for renal failure…..can we call
this as “renal failure”?
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The RIFLE classification (ADQI group) of ARF:
 Risk (R) - Increase in serum creatinine level X
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1.5 or UO <0.5 mL/kg/h for 6 hours
Injury (I) - Increase in serum creatinine level
X 2.0 or UO <0.5 mL/kg/h for 12 hours
Failure (F) - Increase in serum creatinine level
X 3.0 or serum creatinine level > 4 mg/dL; UO
<0.3 mL/kg/h for 24 hours, or anuria for 12
hours
Loss (L) - Persistent ARF, complete loss of
kidney function >4 wk
End-stage kidney disease (E) - Loss of kidney
function >3 months
 In next 12 hrs UOP is 100 ml.Total 400 ml/24 hrs.
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Pathogenesis of ARF in preeclampsia & clinical
correlation….Prerenal vs ATN vs CAN
Investigations.
Role of fluid challenge.
Nutrition,fluid & electrolyte balance.how to judge?
Role of diuretics ???
Role of renal dose dopamine ???
Dialysis … when ,which type???
Delivery..when??
Investigations
BLOOD
CBC
Urea,creatinine,uric acid
Electrolytes
LFT
S.proteins
Coagulation profile
ABG
RBS
Osmolality
URINE
sp.gravity
osmolality
electrolytes
proteins
pigment casts
c/s
ECG
Prerenal failure
 Adequately replace fluid losses,maintain BP.
 Lasix challenge trial to d/d b/w reversible
prerenal failure & established ATN (provided
oliguria <48 hrs & U:P osmolality > 1.05)
 If diuresis (>50ml/hr or doubling) established
within 3 hrs,maintain NS infusion acc to UOP &
replace electrolytes acc to urinary loss
estimations.
 If unsuccessful –objective is to support the
functionally anephric pt till kidneys recover.
Diuretics
 Diuretics commonly have been given in an attempt to
convert the oliguric state to a nonoliguric state.
However, diuretics have not been shown to be
beneficial, and they may worsen outcomes.
 In the absence of compelling contradictory data from
a randomized, blinded clinical trial, the widespread
use of diuretics in critically ill patients with acute
renal failure should be discouraged.
 Useful only in management of fluid-overloaded
patients
Cantarovich F, Rangoonwala B, Lorenz H,Verho M, EsnaultVL. High-dose furosemide for established ARF: a prospective,
randomized, double-blind, placebo-controlled, multicenter trial. Am J Kidney Dis 2004;44:402-9.
Kellum JA. Systematic review:The use of diuretics and dopamine in acute renal failure: a systematic review of the evidence.
Critical Care1997;1(2):53–9.
DOPAMINE
 Dopamine traditionally has been used to promote
renal perfusion(1-5 mcg/kg/min )
 However, systematic reviews of dopamine
treatment in critically ill patients and in patients
with sepsis do not support the use of dopamine
to prevent renal insufficiency, morbidity, or
mortality. In the majority of ARF studies,
dopamine was associated only with an increase in
urine output.
Kellum JA, Decker MJ. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med
2001;29:1526-31.
Denton MD, Chertow GM, Brady HR. "Renal-dose" dopamine for the treatment of acute renal
failure: scientific rationale, experimental studies and clinical trials. Kidney Int 1996;50:4-14.
Low-dose dopamine for women with
severe pre-eclampsia.
 It is unclear whether low-dose
dopamine therapy for preeclamptic women with oliguria is
worthwhile. It should not be
used other than in prospective
trials.
 Steyn DW, Steyn P.
Cochrane Database of
Systematic Reviews 2007, Issue 1
Management
 Restore or maintain fluid balance
 The maintenance of electrolytes and acid base
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balance
The maintenance of nutritional support
Prevention of infection
Avoid renal toxins (including NSAIDS)
Instigate renal replacement therapies
Nutrition
INTAKE
1500 cal (protein free)
Oral/parenteral
If vol limitation-50%D via
central vein
Essential L-aminoacids:
K,Mg,P:Improve wound
healing, hasten recovery
Protein intake of 0.6 g
per kg per day
Indications for Renal Replacement Therapy
 Acidosis unresponsive to medical therapy
 Acute, severe, refractory electrolyte
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changes (e.g., hyperkalemia)
Encephalopathy
Significant azotemia (blood urea nitrogen level
>100 mg per dL [36 mmol per L])
Significant bleeding
Uremic pericarditis
Volume overload
Early “Prophylactic” Dialysis
 Allows more liberal
fluid, protein & salt
intake.
 Prevent hyperkalemic
emergencies.
 Reduces infectious
Cx.
 Improves comfort &
survival
Hemodialysis
Vs
Peritoneal
dialysis
 Limited usefulness
 Can be used in
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if hypotension
C/I in actively
bleeding pt.
Controlled
anticoagulation reqd
Volume shiftscareful
Faster correction
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preg/PP pt.
Easily available
Simple,inexpensive
Lower Cx rate
Minimises rapid
metabolic
pertubations & fluid
shifts
Insert cath high
direct vision
Delivery
 Development of ARF in obs pt is indication of
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delivery in majority cases.
Deliver if UOP<20 ml/hr >2hrs despite
adequate vol expansion & immediate delivery
not expected
Redistribution of CO – better renal perfusion.
Remove fetus from hostile environment.
Neonate increased urea –osmotis diuresis dehydration
KYA AAP PAANCHVI PAAS SE
TEZ HAI??
CASE 1e:
 Decision of LSCS taken. Coagulation profile N . Intraop
retroplacental haematoma 100 gms .Rest
uneventful.Post op after 4 hrs continuous trickling p/v
present .Rpt coagulation profile sent.
 PC : 70000/cumm… APTT 70 ,control 40…PT 25 ,
control 15…Fibrinogen 60 mg/dl. Hb 8.5,
 Haematopathology …..
 MANAGEMENT— FFP…CRYOPPT…PLATELETS ????
How much of above required? Target values??
Monitoring…
Other Mx options..
Expected complications??
Base treatment on need to:–
Maintain fibrinogen level above
1 g/l.
 – Maintain PT and APPT less
than 1.5 times control value
 – Stop persistent active
bleeding
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Guidelines: FFP Use
 Usual dosing: 10-15ml/Kg
 15-20% rise in factor levels
 Usually does not correct
laboratory coagulation
status to “normal”
 Evidence for its use as prophylaxis
in nonbleeding patients, is limited
Cryoprecipitate
 10-15 ml per unit (bag)
 Fibrinogen 250 mg
 Factor VIII
80-120 units
 Von Willebrand Factor 40-70%
of FFP
 Factor XIII 20-30% of FFP
 Fibronectin
20-40 mg
Cryoprecipitate: Dosing
 1-2 Units / 10 Kg
 Expect 60-100 mg/dl rise in fibrinogen
 Goal: Fibrinogen 70-100 mg/dl
 Patients on massive transfusion protocol and
receiving greater than 10 units of FFP generally do
not need additional cryoprecipitate, having received
an adequate bolus of fibrinogen in the large
quantity of FFP.
Platelets: Risk of Spontaneous
Hemorrhage
Count
> 40,000
20-40,000
5-20
< 5
Site
Minimal
GI Mucosa
Skin,Mucus Membranes
CNS, Lung
Prophylactic Platelet TX Guidelines
Platelet Count/μl
0-5,000
5-10,000
11-20,000
>20,000
Recommendation
Always
If Febrile or Minor Bleeding
If coagulopathy / minor
procedure
If Major Bleed / invasive
procedure
Transfused Platelets/Survival
 6 units = 1 single donor unit (SDP);
available as ¼, ½ and full SDP
 Dose:
adult 1 unit/8-10 kg
 Lifespan: 7-10 Days Native
2-3 Days Transfused
 Factors shortening Lifespan:
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Fever, Sepsis
HLA, Platelet Specific Abs
DIC
Product Age?
CASE 2:
 26 yr primi,32 wks pregnancy ,mild
preeclampsia,comes with vague symptoms –
malaise,epigastric pain,vomiting, giddiness. On Ix-- Hb 9.5,PCV 30, PC 80000,S.Br 2.8, SGPT
45,SGOT 80, RFT N, Coagulation profile N
 Probable Diagnosis?? Differential diagnosis??
 Would you ask for any other Ix??
 Pathophysiology …
Laboratory Findings in HELLP
 Hemolysis
 Abnormal peripheral smear
 Total bilirubin > 1.2 mg/dl
 LDH > 600 IU/L
 Liver Enzymes
 AST (SGOT) > 70 IU/L
 Platelet count
 < 100,000
Etiology and Pathogenesis
 The
hemolysis
in HELLP syndrome is a
microangiopathic hemolytic anemia. Red blood cells
become fragmented as they pass through small
blood vessels with endothelial damage and fibrin
deposits.
 The peripheral smear may reveal spherocytes,
schistocytes, triangular cells and burr cells.
 Increase in Bilirubin and lactic dehydrogenase
levels.
 Haptoglobin
Etiology and Pathogenesis
 The
elevated liver enzyme levels
in the syndrome are thought to be
secondary to obstruction of hepatic
blood flow by fibrin deposits in the
sinusoids. This obstruction leads to
periportal necrosis and, in severe
cases, intrahepatic hemorrhage,
subcapsular hematoma formation or
hepatic rupture.
Etiology and Pathogenesis
 The
thrombocytopenia has been
attributed to increased consumption
and/or destruction of platelets.
With platelet activation, thromboxane A
and serotonin are released, causing
vasospasm, platelet agglutination and
aggregation, and further endothelial
damage.
 Management options---
Role of hydration/Plasma vol expansion…
Role of corticosteroids…
Role of aspirin etc…
Transfusion??
Plasmapheresis??
Antihypertensives??
Anticonvulsants??
Conservative vs delivery???
CS vs Vaginal?? Precautions in CS….
Postpartum recovery ??? Mx..
Hepatic imaging ..When??
Corticosteroids for HELLP syndrome in
pregnancy.
 There is insufficient evidence to determine
whether adjunctive steroid use in HELLP
syndrome decreases maternal and perinatal
mortality, major maternal and perinatal
morbidity
 Corticosteroids may be able to normalise some
of the abnormal biochemical changes caused by
HELLP, as well as reduce hypertension
Matchaba P, Moodley J. Cochrane Database of Systematic
Reviews: Reviews 2004 Issue 1
The antenatal administration of dexamethasone in a high dosage
of 10 mg intravenously every 12 hours has been shown to
markedly improve the laboratory abnormalities associated with HELLP
syndrome.
Steroids given antenatally do not prevent the
typical worsening of laboratory abnormalities after
delivery. However, laboratory abnormalities resolve
more quickly in patients who continue to receive
steroids postpartum.
Magann EF, Bass D, Chauhan SP, Sullivan DL, Martin RW, Martin JN Jr.
Am J Obstet Gynecol 1994;171:1148-53.
HELLP: Treatment
 Dexamethasone 10 mg IV
q12hr when platelets <
100,000
 Platelets for active bleeding,
or if < 20,000
 Plasmapheresis: limited
success, but not routinely
recommended
Antihypertensive
therapy should be initiated
if blood pressure is
consistently greater than
160/110 mm hg . The goal
is to maintain diastolic blood
pressure between 90 and
100 mm hg.
Patients with HELLP
syndrome should be
treated prophylactically
with magnesium sulfate
to prevent seizures,
whether hypertension is
present or not.
Classification
Based on the number of
abnormalities
full HELLP
partial HELLP
considered
for delivery
within 48
hours
candidates
for more
conservative
management
syndrome
syndrome
Audibert F, Friedman SA, Frangieh AY, Sibai BM. Am J Obstet Gynecol
1996; 175:460-4.
Classification
On the basis of platelet count
class I, less than 50,000 per mm3
class II, 50,000 to less than 100,000 per mm3
class III, 100,000 to 150,000 per mm3
Eligibility to conservative management
Hypertension is controlled at less than
160/110 mm hg,
Oliguria responds to fluid management .
Elevated liver function values are not
associated with right upper quadrant or
epigastric pain.
Class II–III .(platelet count).>50000
Partial HELLP
LSCS IN HELLP
Patients who undergo cesarean section should be
transfused if their platelet count is less than 50,000
per mm3 ,
Prophylactic transfusion of platelets at delivery
does not reduce the incidence of postpartum
hemorrhage or hasten normalization of the platelet
count. .
Patients with DIC should be given fresh frozen
plasma and packed red blood cells.
Vertical incision
Eventration XX
Dead space XX
Drains
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POSTPARTUM
 The laboratory abnormalities
in HELLP syndrome typically
worsen after delivery and
then begin to resolve by
three to four days
postpartum
 Martin JN Jr, Blake PG, Perry KG Jr, McCaul JF, Hess LW,
Martin RW. The natural history of HELLP syndrome: patterns
of disease progression and regression. Am J Obstet Gynecol
1991;164(6 pt 1):1500-9.
 Patients with HELLP syndrome
who complain of severe right
upper quadrant pain, neck pain
or shoulder pain should be
considered for hepatic imaging
regardless of the severity of
the laboratory abnormalities, to
assess for subcapsular
haematoma or rupture
CASE 3 :
 Mrs .C ,8 wks pregnant, G4P1A2L0, comes for
ANC. H/O 1PTVD with IUFD,sev oligo,sev
preeclampsia at 27 wks,1early fetal demise at
10 wks,1 early fetal demise at 8 wks.
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Recurrence risk??
Special investigations? Why—criteria for
APLA testing?
Prediction of preeclampsia…tests…
Prevention of preeclampsia….role of different
drugs…evidence based recommendations..
APLA SYNDROME
CLINICAL CRITERIA
 One or more unexplained deaths >10 wk
 One or more pre-eclampsia/
insufficiency < 34wk
placental
 3 or more unexplained consecutive
spontaneous abortions < 10 wk
 Exclude other causes
SCREENING
 BP
 MAP(midtrimester)
 Roll over test
 Isometric hand grip test
 URINE
 Forearm venous tone
 Microalbuminuria
 Fasting urinary albumin : creatinine
 24 hr urinary calcium excretion
 U.calcium :creatinine ratio
 U. kallikrein : creatinine ratio
ratio
 BLOOD
 Pl. urate
 Platelet count
 Fibronectin
 Beta thromboglobulin
 AT 3 /Factor 8
 Cytokines
 Placental peptides
 Markers of oxidative stress
 ANGITENSIN SENSITIVITY TESTS
 DOPPLER ULTRASOUND
 The combination of serum
markers(BHCG & AFP) and abnormal
uterine Doppler ultrasound improves
the identification of women at risk
for subsequent pregnancy
complications. However, the
sensitivity of these tests is too low
to provide an efficient generalized
screening.
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Fetal Diagn Ther 2005;20:48-53
Ultrasound Obstet Gynecol. 2006-Jun; vol 27 (issue 6)
 Prediction of pre-eclampsia by uterine artery
Doppler ultrasonography and maternal serum
pregnancy-associated plasma protein-A, free
beta-human chorionic gonadotropin, activin A
and inhibin A at 22 + 0 to 24 + 6 weeks'
gestation.
 Screening by a combination of uterine artery
mean PI and maternal serum activin A and
inhibin A could detect 75% and 92% of patients
who subsequently developed pre-eclampsia, for
false positive rates of 5% and 10%,
respectively.
 In this pilot study intravenous immune globulin
did not improve obstetric or neonatal outcomes
beyond those achieved with a heparin and lowdose aspirin regimen. Although not statistically
significant, the findings of fewer cases of
fetal growth restriction and neonatal intensive
care unit admissions among the intravenous
immune globulin-treated pregnancies may
warrant expansion of the study.
 The Cochrane Central Register of Controlled Trials (CENTRAL)
2008 Issue 2
Antiplatelet agents for preventing preeclampsia and its complications.
 Antiplatelet agents, largely low-dose
aspirin, have moderate benefits when
used for prevention of pre-eclampsia
and its consequences. Further
information is required to assess
which women are most likely to
benefit, when treatment is best
started, and at what dose.
Duley L, Henderson-Smart DJ, Meher S, King JF Cochrane
Database of Systematic Reviews 2007, Issue 2.
Calcium supplementation during pregnancy for
preventing hypertensive disorders and related
problems.
 Calcium supplementation appears to
almost halve the risk of pre-eclampsia,
and to reduce the rare occurrence of
the composite outcome 'death or
serious morbidity'. There were no other
clear benefits, or harms.
 The effect was greatest for high-risk
women and those with low baseline
calcium intake .
 Hofmeyr GJ, Atallah AN, Duley L
Cochrane Database of
Systematic Reviews 1998, Issue 3.
Antioxidants for preventing pre-eclampsia
 Evidence from this review does not
support routine antioxidant
supplementation during pregnancy
to reduce the risk of preeclampsia and other serious
complications in pregnancy.
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Rumbold A, Duley L, Crowther CA, Haslam RR.
Cochrane Database of Systematic Reviews 2008,
Issue 1
Nitric oxide for preventing preeclampsia and its complications.
 There is insufficient evidence to draw reliable
conclusions about whether nitric oxide donors
and precursors prevent pre-eclampsia or its
complications.
The review of trials found too few women had
been studied, so it was not possible to say if
nitric oxide drugs help prevent pre-eclampsia.
However, these drugs did cause headaches,
often sufficiently severe for women to stop
taking the drugs. Future studies needed
 Meher S, Duley L
Cochrane Database of Systematic
Reviews 2007, Issue 2.
precursor, supplementation for
pregnancy .
 There is not enough evidence to
support the routine use of marine
oil, or other prostaglandin
precursor, supplements during
pregnancy to reduce the risk of
pre-eclampsia, preterm birth, low
birthweight or small-for-gestational
age.
 Makrides M, Duley L, Olsen SF.
Cochrane
Database of Systematic Reviews 2006, Issue 3.
CASE 4:
 Mrs D ,k/c/o HT ,uninvestigated,primi,26
yrs,comes with 10 wks pregnancy.
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Causes …
Evaluation…
Prognosis & risks…
Mx .Brief outline…
ANAESTHETIC & INTENSIVE CARE
ASPECTS…
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Type of anaesthesia..precautions..
Fluid balance…
Invasive haemodynamic monitoring..
PCWP vs CVP… criteria..indications
Pulmonary oedema…prevention & Mx
Anesthetic Goals of Labor Analgesia
in Preeclampsia
 To establish & maintain hemodynamic stability
(control hypertension & avoid hypotension)
 To provide excellent labor analgesia
 To prevent complications of preeclampsia
 intracerebral hemorrhage
 renal failure
 pulmonary edema
 eclampsia
 To be able to rapidly provide anesthesia for
C/S
Benefits of Regional Analgesia for
Labor in Preeclampsia
 Superior pain relief over parenteral narcotics
 Beneficial hemodynamic effects: 20% reduction in
blood pressure with a small reduction in SVR &
maintenance of CI
Newsome, Anes Anal 1986;65:31-6
 Doppler velocimetry shows epidural analgesia
reduces the S-D flow ratio in the uterine artery by
25% to levels seen in non-preeclamptics
Ramos-Santos, et al., Obstet Gynecol 1991;77:20-6
Benefits of Regional Analgesia for
Labor in Preeclampsia
 Epidural analgesia  intervillous blood flow 77% in
severe preeclamptics without maternal BP or
FHR abnormalities
Jouppila, et al., Obstet Gynecol 1982;59:158-61.
 Large series (385) preeclamptic patients; labor
epidural analgesia vs. PCIA meperidine
 No difference in FHR abnormalities or C/S
  forceps in epi group but 0.125% bupi infusion
  naloxone use,  umb artery pH,  1 min Apgar in
PCIA group
Lucas, et al., Anesthesiology 1998;89:A1033
Regional Anesthesia & Preeclampsia
 One of the most important advantages of labor
epidural analgesia is that it provides a route
for rapid initiation of anesthesia for
emergency C/S.
 In the past there were concerns re: use of
regional anesthesia for C/S in preeclamptics
 possibility of severe  BP 2° sympathectomy in
patient with volume contraction
 risk of pulmonary edema due to excessive fluid
administration with regional block
 risk with use of pressor agents to treat  BP
Regional vs. General Anesthesia for
C/S in Severe Preeclampsia
 General vs. spinal (CSE) vs. epidural
Wallace, et al., Obstet Gynecol 1995;86:193-9
 Prospective, randomized study
 All these types of anesthesia were used safely
  BP on laryngoscopy avoided by controlling
hypertension pre-op with hydralazine; IV NTG &
lidocaine immediately pre-intubation
  BP with regional avoided by 1000 cc LR pre-load & 5
mg boluses of ephedrine for SBP  100
Regional vs. General Anesthesia for
C/S in Severe Preeclampsia
 BP 20% lower in regional vs general groups at skin
incision only; no difference in min pressures
 Regional pts received 800 cc more IV fluid
 2200 cc vs. 1500 cc
 No associated pulmonary edema
 Infant outcomes were similar
 Caveat: cases were not urgent; none for non-
reassuring FHR pattern
 In an urgent situation there might not be time to
adequately control hypertension pre-op prior to
inducing general anesthesia
Epidural vs. Spinal Anesthesia for
C/S in Severe Preeclampsia
 Hood, et al., Anesthesiology 1999;90:1276-82
 Retrospective study
 Lowest intraoperative blood pressures not different
 Total ephedrine use was small & not different
 Spinal group received 400 cc more IV fluid
 No pulmonary edema attributable to intraop fluid
 Maternal & infant outcomes were similar
Regional vs. General Anesthesia in
Preeclampsia
 Epidural anesthesia would probably be preferred
by many anesthesiologists in a severely
preeclamptic pt in a non-urgent setting
 For urgent cases it is reassuring to know that
spinal is also safe
 This allows us to avoid general anesthesia with
the potential for encountering a swollen, difficult
airway and/or labile hypertension
Regional vs. General Anesthesia in
Preeclampsia
 General anesthesia is a well-known
hazard in obstetric anesthesia:
 16X more likely to result in anesthetic-
related maternal mortality
 Mostly due to airway/respiratory
complications, which would only be
exaggerated in preeclampsia
Hawkins, Anesthesiology
1997;86:273
Platelets & Regional Anesthesia in
Preeclampsia
 Prior to placing regional block in a preeclamptic it
is recommended to check the platelet count.
 No concrete evidence at to the lowest safe
platelet count for regional anesthesia in
preeclampsia
 Any clinical evidence of DIC would contraindicate
regional
 In the absence of such signs, most
anesthesiologists would proceed at plt count
>100K, many would proceed at 80-100K, <80K
some would proceed (esp. spinal)
Platelets & Regional Anesthesia in
Preeclampsia
 When placing a regional block in a patient with a
platelet count < 100K, the most important thing is
to monitor resolution of block closely
 Bleeding time has been discredited as an indicator
of epidural bleeding risk and is not indicated.
Channing-Rogers, Semin Thromb Hemost 1990;16:;1-30
 Low-dose aspirin is not a contraindication to
regional anesthesia in preeclampsia
 CLASP study: 1422 women on aspirin received
epidurals without any bleeding complications
Hazards of General Anesthesia
in Preeclampsia
 Airway edema is common
 Mandatory to reexamine the airway soon before
induction
 Edema may appear or worsen at any time during the
course of disease
 tongue & facial, as well as laryngeal
 Laryngoscopy and intubation may  severe
BP
 Labetolol & NTG are commonly used acutely
 Fentanyl (2.5 mcg/kg), alfentanil (10 mcg/kg),
lidocaine may be given to blunt response
Hazards of General Anesthesia
in Preeclampsia
 Magnesium sulfate potentiates
depolarizing & non-depolarizing muscle
relaxants
 Pre-curarization is not indicated.
 Initial dose of succinylcholine is not
reduced.
 Neuromuscular blockade should be
monitored & reversal confirmed.
Invasive Central Hemodynamic
Monitoring in Preeclampsia
 Usually reserved for patients with
complications
 oliguria unresponsive to modest fluid challenge (500
cc LR X 2)
 pulmonary edema
 refractory hypertension
 may have increased CO or increased SVR
 Poor correlation between CVP and PCWP in
PIH
 However, at most centers anesthesiologists would
begin with CVP & follow trend
 not arbitrarily hydrate to a certain number
 If poor response, change to PA catheter
 Preanesthetic assessment:
 Airway
 Aspiration prophylaxis
 Auscultation of lungs
 Fluid balance
 Hemodynamic status
 Left uterine displacement
 Renal function
 Coagulation status
Analgesia for Labor
 Continuous lumbar epidural –
Advantages:
o Decreased circulating catecholamines
 Decreased uterine vascular resistance
 Improved uteroplacental blood flow
 Avoids risk of general anesthesia
Epidural Placement
 R/O coagulopathy, LUD, oxygen, continuous




fetal monitoring
Careful crystalloid preload (250-500 ml)
Local anesthetic: Bupivicaine (slow onset)
Epinephrine: consider avoiding
Slow, incremental dosing
 Ephedrine (in smaller doses) for hypotension < 20%
of baseline
Anesthesia for Delivery
 Non-emergent C-section:
 Epidural anesthesia: thought to allow for
incremental dosing, potentially avoiding
precipitous hypotension
 Spinal anesthesia: recent retrospective study
(Hood & Curry, 1999) found no difference in
hemodynamic changes after spinal or epidural
anesthesia
 Conclusion: spinal is safe alternative to
epidural w/ added advantage of quicker onset
and better quality of sensory blockade
especially in urgent situations
 Emergent C-section
 Epidural – previously placed, well
functioning
 Spinal – if no epidural placed and if
FHR stable
 General anesthesia:
 Coagulopathy
 Patient refusal of regional
 Fetal bradycardia prohibits placement
in time
Pre-eclampsia
Invasive monitoring
 CVP monitoring may NOT be helpful!
 poor correlation between CVP and PCWP
 PA catheters have risks!
 rare indications:
 pulmonary oedema resistant to diuretics
 oliguric renal failure despite volume
expansion
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