Hypertension in pregnancy

1
Hypertension in pregnancy
2
Classification

• Gestational hypertensiongt140/90,gt20 wks,no
  proteinuria,resolves PP
• Preeclampsia above proteinuriagt1
• Eclampsia preeclampsia convulsions
• Chronic HT lt 20 wks,ct gt 12 wks PP, /-
  proteinuria
• Chr HT Superimposed preeclampsia onset of
  proteinuria(if nonproteinuric),shootup of
  BP/proteinuria(if proteinuric)

3
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)
•   Pathogenesis. Current concepts ..
• Management Role of antihypertensives??
• Role of bed rest,SRD,
  sedatives tranquilisers?
• Role of antioxidants??
• Corticosteroids?
• Monitoring
• When to deliver?

4
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..

5
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

6
CASE 1b

• Mrs. A on routine 2D USG at 31 wks show IUGR on
  biometry with AFI6.
•  
• 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

7

• 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

8
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 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

9
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

10
RCOG Evidence level II

• Frequency of monitoring in SGA fetuses with
  normal Doppler need not generally be more than
  once every fortnight.

11
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

12
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.

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14
Some forms of intervention

• There is not enough evidence to assess the value
  of
• oxygen therapy,
• nutrient therapy,
• hospitalisation and bedrest,
• betamimetics,
• calcium channel blockers,
• hormonal therapy
• and plasma volume expansion
• in treating growth restriction.

The Cochrane Library, Issue 3, 2003
15
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.

16

• 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 ??

17
Features of severe Pre-Eclampsia

•  
• Blood pressure gt160/110 mm Hg
• Proteinuria gt5 g/24 h
• Cerebral involvement (hyper-reflexia, seizures)
• Oliguria lt 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)

18
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

19

• IV Labetolol
• Vs
• SL/Oral Nifedepine
• vs
• Oral hydrallazine

20

• SL NIFEDEPINE

21
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.

22
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.

23
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?

24

• The RIFLE classification (ADQI group) of
  ARF
• Risk (R) - Increase in serum creatinine level X
  1.5 or UO lt0.5 mL/kg/h for 6 hours
• Injury (I) - Increase in serum creatinine level X
  2.0 or UO lt0.5 mL/kg/h for 12 hours
• Failure (F) - Increase in serum creatinine level
  X 3.0 or serum creatinine level gt 4 mg/dL UO
  lt0.3 mL/kg/h for 24 hours, or anuria for 12 hours
  
• Loss (L) - Persistent ARF, complete loss of
  kidney function gt4 wk
• End-stage kidney disease (E) - Loss of kidney
  function gt3 months

25

• In next 12 hrs UOP is 100 ml.Total 400 ml/24 hrs.
• 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??

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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

28
Prerenal failure

• Adequately replace fluid losses,maintain BP.
• Lasix challenge trial to d/d b/w reversible
  prerenal
• failure established ATN (provided oliguria
  lt48 hrs
• UP osmolality gt 1.05)
• If diuresis (gt50ml/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.

29
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,
Esnault VL. High-dose furosemide for established
ARF a prospective, randomized, double-blind,
placebo-controlled, multicenter trial. Am J
Kidney Dis 200444402-9. Kellum JA.
Systematic review The use of diuretics and
dopamine in acute renal failure a systematic
review of the evidence. Critical
Care19971(2)539.
30
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
2001291526-31. 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 1996504-14.
31
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

32
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

33
Nutrition

• INTAKE
• 1500 cal (protein free)
• Oral/parenteral
• If vol limitation-50D via central vein
• Essential L-aminoacids K,Mg,PImprove wound
  healing, hasten recovery
• Protein intake of 0.6 g per kg per day

34
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
  gt100 mg per dL 36 mmol per L)
• Significant bleeding
• Uremic pericarditis
• Volume overload

35
Early Prophylactic Dialysis

• Allows more liberal fluid, protein salt intake.
• Prevent hyperkalemic emergencies.
• Reduces infectious Cx.
• Improves comfort survival

36
Hemodialysis Vs Peritoneal dialysis

• Can be used in preg/PP pt.
• Easily available
• Simple,inexpensive
• Lower Cx rate
• Minimises rapid metabolic pertubations fluid
  shifts
• Insert cath high direct vision

• Limited usefulness if hypotension
• C/I in actively bleeding pt.
• Controlled anticoagulation reqd
• Volume shifts-careful
• Faster correction

37
Delivery

• Development of ARF in obs pt is indication of
  delivery in majority cases.
• Deliver if UOPlt20 ml/hr gt2hrs 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

38
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 40PT 25 ,
  control 15Fibrinogen 60 mg/dl. Hb 8.5,
•  
• Haematopathology ..
• MANAGEMENT FFPCRYOPPTPLATELETS ????
• How much of above required? Target
  values??
• Monitoring
• Other Mx options..
• Expected complications??

39

• 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

40
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

41
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

42
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.

43
Platelets Risk of Spontaneous Hemorrhage

• Count Site
• gt 40,000 Minimal
• 20-40,000 GI Mucosa
• 5-20 Skin,Mucus Membranes
• lt 5 CNS, Lung

44
Prophylactic Platelet TX Guidelines

• Platelet Count/µl Recommendation
• 0-5,000 Always
• 5-10,000 If Febrile or Minor Bleeding
• 11-20,000 If coagulopathy / minor
  procedure
• gt20,000 If Major Bleed / invasive
  procedure

45
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?

46
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

47
Laboratory Findings in HELLP

• Hemolysis
• Abnormal peripheral smear
• Total bilirubin gt 1.2 mg/dl
• LDH gt 600 IU/L
• Liver Enzymes
• AST (SGOT) gt 70 IU/L
• Platelet count
• lt 100,000

48
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

49
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.

50
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.
51
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??
•  

52
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

53

• 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
19941711148-53.
54
HELLP Treatment

• Dexamethasone 10 mg IV q12hr when platelets lt
  100,000
• Platelets for active bleeding, or if lt 20,000
• Plasmapheresis limited success, but not
  routinely recommended

55

• 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.

56

• Patients with HELLP syndrome should be treated
  prophylactically with magnesium sulfate to
  prevent seizures, whether hypertension is present
  or not.

57
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
58
Classification
Based on the number of abnormalities
full HELLP syndrome
partial HELLP syndrome
considered for delivery within 48 hours
candidates for more conservative management
Audibert F, Friedman SA, Frangieh AY, Sibai BM.
Am J Obstet Gynecol 1996 175460-4.
59
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 IIIII .(platelet count).gt50000
• Partial HELLP

60
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

61
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 1991164(6 pt
  1)1500-9.

62

• 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

63
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.
•  
• Recurrence risk??
• Special investigations? Whycriteria for
  APLA testing?
• Prediction of preeclampsiatests
• Prevention of preeclampsia.role of different
  drugsevidence based recommendations..
•  

64
APLA SYNDROME

• CLINICAL CRITERIA
• One or more unexplained deaths gt10 wk
• One or more pre-eclampsia/ placental
• insufficiency lt 34wk
• 3 or more unexplained consecutive
• spontaneous abortions lt 10 wk
• Exclude other causes

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66
SCREENING

• BP
• MAP(midtrimester)
• Roll over test
• Isometric hand grip test
• Forearm venous tone
• URINE
• Microalbuminuria
• Fasting urinary albumin creatinine ratio
• 24 hr urinary calcium excretion
• U.calcium creatinine ratio
• U. kallikrein creatinine ratio

67

• BLOOD
• Pl. urate
• Platelet count
• Fibronectin
• Beta thromboglobulin
• AT 3 /Factor 8
• Cytokines
• Placental peptides
• Markers of oxidative stress
• ANGITENSIN SENSITIVITY TESTS
• DOPPLER ULTRASOUND

68

• 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 20052048-53

69
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.

70

• 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
  globulin-treated pregnancies may warrant
  expansion of the study.
• The Cochrane Central Register of Controlled
  Trials (CENTRAL) 2008 Issue 2

71
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.

72
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.

73
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

74
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.

75
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 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.

76
CASE 4

• Mrs D ,k/c/o HT ,uninvestigated,primi,26
  yrs,comes with 10 wks pregnancy.
•  
• Causes
• Evaluation
• Prognosis risks
• Mx .Brief outline

77
ANAESTHETIC INTENSIVE CARE ASPECTS

• Type of anaesthesia..precautions..
• Fluid balance
• Invasive haemodynamic monitoring.. PCWP vs
  CVP criteria..indications
• Pulmonary oedemaprevention Mx

78
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

79
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 19866531-6
• 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 19917720-6

80
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 198259158-61.
• 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 199889A1033

81
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

82
Regional vs. General Anesthesia for C/S in Severe
Preeclampsia

• General vs. spinal (CSE) vs. epidural
• Wallace, et al., Obstet Gynecol 199586193-9
• 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

83
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

84
Epidural vs. Spinal Anesthesia for C/S in Severe
Preeclampsia

• Hood, et al., Anesthesiology 1999901276-82
• 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

85
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

86
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 199786273

87
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
  gt100K, many would proceed at 80-100K, lt80K some
  would proceed (esp. spinal)

88
Platelets Regional Anesthesia in Preeclampsia

• When placing a regional block in a patient with a
  platelet count lt 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
  1990161-30
• Low-dose aspirin is not a contraindication to
  regional anesthesia in preeclampsia
• CLASP study 1422 women on aspirin received
  epidurals without any bleeding complications

89
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

90
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.

91
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

92

• Preanesthetic assessment
• Airway
• Aspiration prophylaxis
• Auscultation of lungs
• Fluid balance
• Hemodynamic status
• Left uterine displacement
• Renal function
• Coagulation status

93
Analgesia for Labor

• Continuous lumbar epidural
• Advantages
• Decreased circulating catecholamines
• Decreased uterine vascular resistance
• Improved uteroplacental blood flow
• Avoids risk of general anesthesia

94
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 lt
  20 of baseline

95
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

96

• 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

97
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