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
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 ..
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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
2007, Issue 1
Abalos E, Duley L, Steyn DW, Henderson-Smart DJ..
Dr. Mona Shroff
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.
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…
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Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
Grade A(RCOG)
Use umbilical artery Doppler as the
primary surveillance tool.
A systematic review with meta-analysis
has provided evidence that the use of
umbilical artery Doppler to monitor highrisk fetuses reduces perinatal morbidity
and mortality.
In addition, there was a significant
reduction in the number of antenatal
admissions and inductions of labour
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
RCOG Evidence level II
Frequency of monitoring in
SGA fetuses with normal
Doppler need not generally be
more than once every
fortnight.
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Hofmeyr GJ, Gülmezoglu AM. Cochrane Database of Systematic
Reviews 2002, Issue 1.
Dr. Mona Shroff
www.obgyntoday.info
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 ??
Dr. Mona Shroff
www.obgyntoday.info
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)
•
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
IV Labetolol
Vs
SL/Oral Nifedepine
vs
Oral hydrallazine
Dr. Mona Shroff
www.obgyntoday.info
SL NIFEDEPINE
Dr. Mona Shroff
www.obgyntoday.info
Interventionist versus expectant 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 pre-eclampsia.
Further large trials are needed.
Churchill D, Duley L. Cochrane Database of
Systematic Reviews 2002, Issue 3.
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
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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Dr. Mona Shroff
www.obgyntoday.info
The RIFLE classification (ADQI group) of ARF:
Risk (R) - Increase in serum creatinine level X
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
Dr. Mona Shroff
www.obgyntoday.info
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??
Dr. Mona Shroff
www.obgyntoday.info
Investigations
BLOOD
CBC
Urea,creatinine,uric acid
Electrolytes
LFT
S.proteins
Coagulation profile
ABG
RBS
Osmolality
Dr. Mona Shroff
URINE
sp.gravity
osmolality
electrolytes
proteins
pigment casts
c/s
ECG
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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.
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
Low-dose dopamine for women
with severe pre-eclampsia.
It is unclear whether low-dose
dopamine therapy for pre-eclamptic
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
Dr. Mona Shroff
www.obgyntoday.info
Management
•Restore or maintain fluid balance
•The maintenance of electrolytes and acid
base balance
•The maintenance of nutritional support
•Prevention of infection
•Avoid renal toxins (including NSAIDS)
•Instigate renal replacement therapies
Dr. Mona Shroff
www.obgyntoday.info
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
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
Dr. Mona Shroff
www.obgyntoday.info
Early “Prophylactic” Dialysis
Allows more liberal
fluid, protein & salt
intake.
Prevent hyperkalemic
emergencies.
 Reduces infectious
Cx.
Improves comfort &
survival
Dr. Mona Shroff
www.obgyntoday.info
Hemodialysis
Vs
•Limited usefulness
if hypotension
•C/I in actively
bleeding pt.
•Controlled
anticoagulation reqd
•Volume shiftscareful
•Faster correction
Dr. Mona Shroff
Peritoneal dialysis
 Can be used in
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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
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Delivery
Development of ARF in obs pt is indication of
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
Dr. Mona Shroff
www.obgyntoday.info
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??
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
Platelets: Risk of Spontaneous
Hemorrhage
Count
Site
> 40,000
Minimal
20-40,000
GI Mucosa
5-20
Skin,Mucus Membranes
< 5
CNS, Lung
Dr. Mona Shroff
www.obgyntoday.info
Prophylactic Platelet TX Guidelines
Platelet Count/μl
0-5,000
5-10,000
11-20,000
>20,000
Dr. Mona Shroff
Recommendation
Always
If Febrile or Minor Bleeding
If coagulopathy / minor
procedure
If Major Bleed / invasive
procedure
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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:
Fever, Sepsis
HLA, Platelet Specific Abs
DIC
Product Age?
Dr. Mona Shroff
www.obgyntoday.info
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 …
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
Etiology and Pathogenesis
hemolysis
The
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
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
Management optionsRole 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??
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
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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.
Dr. Mona Shroff
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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
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
Patients with HELLP
syndrome should be treated
prophylactically with
magnesium sulfate to
prevent seizures, whether
hypertension is present or
not.
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
full HELLP
Based on the number of
abnormalities
Classification
syndrome
considered for
delivery within 48
hours
partial HELLP
syndrome
candidates for
more conservative
management
Audibert F, Friedman SA, Frangieh AY, Sibai BM. Am J Obstet Gynecol
1996; 175:460-4.
Dr. Mona Shroff
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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
Dr. Mona Shroff
www.obgyntoday.info
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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Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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..
Dr. Mona Shroff
www.obgyntoday.info
APLA SYNDROME
CLINICAL CRITERIA
One or more unexplained deaths >10 wk
One or more pre-eclampsia/ placental
insufficiency < 34wk
3 or more unexplained consecutive
spontaneous abortions < 10 wk
Exclude other causes
Dr. Mona Shroff
www.obgyntoday.info
SCREENING
BP
URINE
MAP(midtrimester)
Roll over test
Isometric hand grip test
Forearm venous tone
Microalbuminuria
Fasting urinary albumin : creatinine ratio
24 hr urinary calcium excretion
U.calcium :creatinine ratio
U. kallikrein : creatinine ratio
Dr. Mona Shroff
www.obgyntoday.info
BLOOD
Pl. urate
Platelet count
Fibronectin
Beta thromboglobulin
AT 3 /Factor 8
Cytokines
Placental peptides
Markers of oxidative stress
ANGITENSIN SENSITIVITY TESTS
DOPPLER ULTRASOUND
Dr. Mona Shroff
www.obgyntoday.info
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.
Fetal Diagn Ther 2005;20:48-53
Dr. Mona Shroff
www.obgyntoday.info
Prediction of pre-eclampsia by uterine artery Doppler
ultrasonography and maternal serum pregnancyassociated 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.
Ultrasound Obstet Gynecol. 2006-Jun; vol 27 (issue 6)
Dr. Mona Shroff
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In this pilot study intravenous immune globulin did
not improve obstetric or neonatal outcomes beyond
those achieved with a heparin and low-dose
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 globulintreated pregnancies may warrant expansion of the
study.
The Cochrane Central Register of Controlled Trials (CENTRAL)
2008 Issue 2
Dr. Mona Shroff
www.obgyntoday.info
Antiplatelet agents for preventing
pre-eclampsia 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.
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
Antioxidants for preventing pre-eclampsia
Evidence from this review does not
support routine antioxidant
supplementation during pregnancy to
reduce the risk of pre-eclampsia and
other serious complications in
pregnancy.
Rumbold A, Duley L, Crowther CA, Haslam RR. Cochrane
Database of Systematic Reviews 2008, Issue 1
Dr. Mona Shroff
www.obgyntoday.info
Nitric oxide for preventing pre-eclampsia 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.
Dr. Mona Shroff
www.obgyntoday.info
Marine oil, and other prostaglandin
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 preeclampsia, preterm birth, low birthweight
or small-for-gestational age.
Makrides M, Duley L, Olsen SF. Cochrane Database of
Systematic Reviews 2006, Issue 3.
Dr. Mona Shroff
www.obgyntoday.info
CASE 4:
Mrs D ,k/c/o HT ,uninvestigated,primi,26
yrs,comes with 10 wks pregnancy.




Causes …
Evaluation…
Prognosis & risks…
Mx .Brief outline…
Dr. Mona Shroff
www.obgyntoday.info
ANAESTHETIC & INTENSIVE CARE ASPECTS…
Type of anaesthesia..precautions..
Fluid balance…
Invasive haemodynamic monitoring..
PCWP vs CVP…
criteria..indications
• Pulmonary oedema…prevention &
Mx
•
•
•
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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 preop with hydralazine; IV NTG & lidocaine immediately preintubation
 BP with regional avoided by 1000 cc LR pre-load & 5 mg
boluses of ephedrine for SBP  100
Dr. Mona Shroff
www.obgyntoday.info
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 nonreassuring FHR pattern
In an urgent situation there might not be time to adequately control
hypertension pre-op prior to inducing general anesthesia
Dr. Mona Shroff
www.obgyntoday.info
Epidural vs. Spinal Anesthesia for C/S in Severe
Preeclampsia
Hood, et al., Anesthesiology 1999;90:127682
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
Regional vs. General Anesthesia in Preeclampsia
General anesthesia is a well-known
hazard in obstetric anesthesia:
16X more likely to result in anestheticrelated maternal mortality
Mostly due to airway/respiratory
complications, which would only be
exaggerated in preeclampsia
Hawkins, Anesthesiology 1997;86:273
Dr. Mona Shroff
www.obgyntoday.info
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)
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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.
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
Preanesthetic assessment:
Airway
Aspiration prophylaxis
Auscultation of lungs
Fluid balance
Hemodynamic status
Left uterine displacement
Renal function
Coagulation status
Dr. Mona Shroff
www.obgyntoday.info
Analgesia for Labor
Continuous lumbar epidural –
Advantages:
o Decreased circulating
catecholamines
• Decreased uterine vascular
resistance
• Improved uteroplacental blood flow
• Avoids risk of general anesthesia
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info
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
Dr. Mona Shroff
www.obgyntoday.info