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 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 , Issue Abalos E, Duley L, Steyn DW, Henderson-Smart DJ..
5 Bed rest with or without hospitalisation for hypertension 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 pregnancyMeher 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 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…
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 IIA 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 IIFrequency 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 IbThe 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 SGAWhen 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.
14 Some forms of intervention There is not enough evidence to assess the value ofoxygen therapy,nutrient therapy,hospitalisation and bedrest,betamimetics,calcium channel blockers,hormonal therapyand plasma volume expansionin 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 purposesHofmeyr GJ, Gülmezoglu AM. Cochrane Database of Systematic Reviews 2002, Issue 1.
16 Started on antihypertensives. Fetal Doppler N. 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 >160/110 mm HgProteinuria >5 g/24 hCerebral involvement (hyper-reflexia, seizures)Oliguria < 500 ml /24hrIncreased serum creatinine level Pulmonary oedema Epigastric or right upper quadrant abdominal painEvidence 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 LabetololVsSL/Oral NifedepinevsOral hydrallazine
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 Duley L, Gülmezoglu AM, Henderson-Smart DJ.. Magnesium sulphate and other anticonvulsants for women with pre-eclampsiaMagnesium 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 kgsCriteria for renal failure…..can we call this as “renal failure”?
24 Loss (L) - Persistent ARF, complete loss of kidney function >4 wk 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 hoursInjury (I) - Increase in serum creatinine level X 2.0 or UO <0.5 mL/kg/h for 12 hoursFailure (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 hoursLoss (L) - Persistent ARF, complete loss of kidney function >4 wkEnd-stage kidney disease (E) - Loss of kidney function >3 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 CANInvestigations.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??
28 Prerenal failure Adequately replace fluid losses,maintain BP. Lasix challenge trial to d/d b/w reversible prerenalfailure & established ATN (provided oliguria <48 hrs& U:P osmolality > 1.05)If diuresis (>50ml/hr or doubling) established within 3hrs,maintain NS infusion acc to UOP & replaceelectrolytes acc to urinary loss estimations.If unsuccessful –objective is to support thefunctionally anephric pt till kidneys recover.
29 DiureticsDiuretics 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 patientsCantarovich 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 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.
30 DOPAMINEDopamine 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: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.
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 balanceThe maintenance of nutritional supportPrevention of infectionAvoid renal toxins (including NSAIDS)Instigate renal replacement therapies
33 NutritionINTAKE 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
34 Indications for Renal Replacement Therapy Acidosis unresponsive to medical therapyAcute, severe, refractory electrolyte changes (e.g., hyperkalemia)EncephalopathySignificant azotemia (blood urea nitrogen level >100 mg per dL [36 mmol per L])Significant bleedingUremic pericarditisVolume 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 availableSimple,inexpensiveLower Cx rateMinimises rapid metabolic pertubations & fluid shiftsInsert cath high direct visionLimited usefulness if hypotensionC/I in actively bleeding pt.Controlled anticoagulation reqdVolume shifts- carefulFaster correction
37 DeliveryDevelopment 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 expectedRedistribution 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 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??
39 – Maintain PT and APPT less than 1.5 times control value 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 15-20% rise in factor levels Guidelines: FFP UseUsual dosing: ml/Kg15-20% rise in factor levelsUsually 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 unitsVon Willebrand Factor 40-70% of FFPFactor XIII 20-30% of FFPFibronectin mg
42 Cryoprecipitate: Dosing 1-2 Units / 10 KgExpect mg/dl rise in fibrinogenGoal: Fibrinogen mg/dlPatients 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> 40, Minimal20-40,000 GI Mucosa5-20 Skin,Mucus Membranes< CNS, Lung
44 Prophylactic Platelet TX Guidelines Platelet Count/μl Recommendation0-5, Always5-10, If Febrile or Minor Bleeding11-20, If coagulopathy / minor procedure>20, If Major Bleed / invasive procedure
45 Transfused Platelets/Survival 6 units = 1 single donor unit (SDP); available as ¼, ½ and full SDPDose: adult 1 unit/8-10 kgLifespan: 7-10 Days Native2-3 Days TransfusedFactors shortening Lifespan:Fever, SepsisHLA, Platelet Specific AbsDICProduct 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 NProbable Diagnosis?? Differential diagnosis??Would you ask for any other Ix??Pathophysiology …
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 morbidityCorticosteroids may be able to normalise some of the abnormal biochemical changes caused by HELLP, as well as reduce hypertensionMatchaba 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 1994;171:
54 HELLP: TreatmentDexamethasone 10 mg IV q12hr when platelets < 100,000Platelets for active bleeding, or if < 20,000Plasmapheresis: 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 On the basis of platelet count ClassificationOn the basis of platelet countclass I, less than 50,000 per mm3class II, 50,000 to less than 100,000 per mm3class III, 100,000 to 150,000 per mm3
58 Based on the number of abnormalities ClassificationBased on the number of abnormalitiesfull HELLP syndromepartial HELLP syndromeconsidered for delivery within 48 hourscandidates for more conservative managementAudibert F, Friedman SA, Frangieh AY, Sibai BM. Am J Obstet Gynecol 1996; 175:460-4.
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 II–III .(platelet count).>50000Partial HELLP
60 LSCS IN HELLPPatients 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 incisionEventration XXDead space XXDrains
61 POSTPARTUMThe laboratory abnormalities in HELLP syndrome typically worsen after delivery and then begin to resolve by three to four days postpartumMartin 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):
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? Why—criteria for APLA testing?Prediction of preeclampsia…tests…Prevention of preeclampsia….role of different drugs…evidence based recommendations..
64 APLA SYNDROME CLINICAL CRITERIA One or more unexplained deaths >10 wkOne or more pre-eclampsia/ placentalinsufficiency < 34wk3 or more unexplained consecutivespontaneous abortions < 10 wkExclude other causes
66 SCREENING BP MAP(midtrimester) Roll over test Isometric hand grip test Forearm venous toneURINEMicroalbuminuriaFasting urinary albumin : creatinine ratio24 hr urinary calcium excretionU.calcium :creatinine ratioU. kallikrein : creatinine ratio
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 2005;20:48-53
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 to 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 Jun; vol 27 (issue 6)
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) 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 neededMeher 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..indicationsPulmonary oedema…prevention & Mx
78 Anesthetic Goals of Labor Analgesia in Preeclampsia To establish & maintain hemodynamic stability (control hypertension & avoid hypotension)To provide excellent labor analgesiaTo prevent complications of preeclampsiaintracerebral hemorrhagerenal failurepulmonary edemaeclampsiaTo be able to rapidly provide anesthesia for C/S
79 Benefits of Regional Analgesia for Labor in Preeclampsia Superior pain relief over parenteral narcoticsBeneficial hemodynamic effects: 20% reduction in blood pressure with a small reduction in SVR & maintenance of CINewsome, Anes Anal 1986;65:31-6Doppler velocimetry shows epidural analgesia reduces the S-D flow ratio in the uterine artery by 25% to levels seen in non-preeclampticsRamos-Santos, et al., Obstet Gynecol 1991;77:20-6
80 Benefits of Regional Analgesia for Labor in Preeclampsia Epidural analgesia intervillous blood flow 77% in severe preeclamptics without maternal BP or FHR abnormalitiesJouppila, et al., Obstet Gynecol 1982;59:Large series (385) preeclamptic patients; labor epidural analgesia vs. PCIA meperidineNo 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 groupLucas, et al., Anesthesiology 1998;89:A1033
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 preeclampticspossibility of severe BP 2° sympathectomy in patient with volume contractionrisk of pulmonary edema due to excessive fluid administration with regional blockrisk with use of pressor agents to treat BP
82 Regional vs. General Anesthesia for C/S in Severe Preeclampsia General vs. spinal (CSE) vs. epiduralWallace, et al., Obstet Gynecol 1995;86:193-9Prospective, randomized studyAll 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 pressuresRegional pts received 800 cc more IV fluid2200 cc vs ccNo associated pulmonary edemaInfant outcomes were similarCaveat: cases were not urgent; none for non-reassuring FHR patternIn 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 1999;90:Retrospective studyLowest intraoperative blood pressures not differentTotal ephedrine use was small & not differentSpinal group received 400 cc more IV fluidNo pulmonary edema attributable to intraop fluidMaternal & 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 settingFor urgent cases it is reassuring to know that spinal is also safeThis 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 mortalityMostly due to airway/respiratory complications, which would only be exaggerated in preeclampsiaHawkins, Anesthesiology 1997;86:273
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 preeclampsiaAny clinical evidence of DIC would contraindicate regionalIn the absence of such signs, most anesthesiologists would proceed at plt count >100K, many would proceed at K, <80K some would proceed (esp. spinal)
88 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 closelyBleeding time has been discredited as an indicator of epidural bleeding risk and is not indicated.Channing-Rogers, Semin Thromb Hemost 1990;16:;1-30Low-dose aspirin is not a contraindication to regional anesthesia in preeclampsiaCLASP study: 1422 women on aspirin received epidurals without any bleeding complications
89 Hazards of General Anesthesia in Preeclampsia Airway edema is commonMandatory to reexamine the airway soon before inductionEdema may appear or worsen at any time during the course of diseasetongue & facial, as well as laryngealLaryngoscopy and intubation may severe BPLabetolol & NTG are commonly used acutelyFentanyl (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 relaxantsPre-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 complicationsoliguria unresponsive to modest fluid challenge (500 cc LR X 2)pulmonary edemarefractory hypertensionmay have increased CO or increased SVRPoor correlation between CVP and PCWP in PIHHowever, at most centers anesthesiologists would begin with CVP & follow trendnot arbitrarily hydrate to a certain numberIf poor response, change to PA catheter
92 Preanesthetic assessment: AirwayAspiration prophylaxisAuscultation of lungsFluid balanceHemodynamic statusLeft uterine displacementRenal functionCoagulation status
93 Analgesia for Labor Continuous lumbar epidural – Advantages: Decreased circulating catecholaminesDecreased uterine vascular resistanceImproved uteroplacental blood flowAvoids risk of general anesthesia
94 Epidural PlacementR/O coagulopathy, LUD, oxygen, continuous fetal monitoringCareful crystalloid preload ( ml)Local anesthetic: Bupivicaine (slow onset)Epinephrine: consider avoidingSlow, incremental dosingEphedrine (in smaller doses) for hypotension < 20% of baseline
95 Anesthesia for Delivery Non-emergent C-section:Epidural anesthesia: thought to allow for incremental dosing, potentially avoiding precipitous hypotensionSpinal anesthesia: recent retrospective study (Hood & Curry, 1999) found no difference in hemodynamic changes after spinal or epidural anesthesiaConclusion: 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 stableGeneral anesthesia:CoagulopathyPatient refusal of regionalFetal bradycardia prohibits placement in time
97 Pre-eclampsia Invasive monitoring CVP monitoring may NOT be helpful!poor correlation between CVP and PCWPPA catheters have risks!rare indications:pulmonary oedema resistant to diureticsoliguric renal failure despite volume expansion