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Dr. Mona Hypertension in pregnancy.

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1 Dr. Mona Hypertension in pregnancy

2 Dr. Mona Shroff Classification Gestational hypertension:>=140/90,>20 wks,no proteinuria,resolves PP Preeclampsia: above + proteinuria>=+1 Eclampsia : preeclampsia + convulsions Chronic HT : 12 wks PP, +/- proteinuria Chr HT + Superimposed preeclampsia : onset of proteinuria(if nonproteinuric),shootup of BP/proteinuria(if proteinuric)

3 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff RCOG Evidence level II Frequency of monitoring in SGA fetuses with normal Doppler need not generally be more than once every fortnight.

11 Dr. Mona Shroff 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 Dr. Mona Shroff 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.


14 Dr. Mona Shroff 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

15 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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)

18 Dr. Mona Shroff 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 Dr. Mona Shroff IV Labetolol Vs SL/Oral Nifedepine vs Oral hydrallazine

20 Dr. Mona Shroff SL NIFEDEPINE

21 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff RIFLE classification The RIFLE classification (ADQI group) of ARF: Risk (R) Risk (R) - Increase in serum creatinine level X 1.5 or UO <0.5 mL/kg/h for 6 hours Injury (I) Injury (I) - Increase in serum creatinine level X 2.0 or UO <0.5 mL/kg/h for 12 hours Failure (F) 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) Loss (L) - Persistent ARF, complete loss of kidney function >4 wk End-stage kidney disease (E) End-stage kidney disease (E) - Loss of kidney function >3 months

25 Dr. Mona Shroff 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 to judge? Role of diuretics ??? Role of renal dose dopamine ??? Dialysis … when,which type??? Delivery..when??


27 Dr. Mona Shroff Investigations BLOOD CBC Urea,creatinine,uric acid Electrolytes LFT S.proteins Coagulation profile ABG RBS OsmolalityURINE sp.gravity osmolality electrolytes proteins pigment casts c/s ECG

28 Dr. Mona Shroff 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.

29 Dr. Mona Shroff 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 2004;44: 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. 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 Dr. Mona Shroff 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: 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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-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 Dr. Mona Shroff 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

35 Dr. Mona Shroff Early Prophylactic Dialysis Allows more liberal fluid, protein & salt intake. Prevent hyperkalemic emergencies. Reduces infectious Cx. Improves comfort & survival

36 Dr. Mona Shroff Hemodialysis Vs Peritoneal dialysis Limited usefulness if hypotension C/I in actively bleeding pt. Controlled anticoagulation reqd Volume shifts- careful Faster correction 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

37 Dr. Mona Shroff Delivery Development of ARF in obs pt is indication of delivery in majority cases. Deliver if UOP 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

38 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff Cryoprecipitate ml per unit (bag) Fibrinogen 250 mg Factor VIII units Von Willebrand Factor 40-70% of FFP Factor XIII 20-30% of FFP Fibronectin mg

42 Dr. Mona Shroff Cryoprecipitate: Dosing 1-2 Units / 10 Kg Expect mg/dl rise in fibrinogen Goal: Fibrinogen 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 Dr. Mona Shroff Platelets: Risk of Spontaneous Hemorrhage Count Site > 40,000 Minimal 20-40,000GI Mucosa 5-20Skin,Mucus Membranes < 5 CNS, Lung

44 Dr. Mona Shroff 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 >20,000 If Major Bleed / invasive procedure

45 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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

48 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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?? Management options-

52 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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

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

57 Dr. Mona Shroff Classification less than 50,000 per mm3 class I, less than 50,000 per mm3 50,000 to less than 100,000 per mm3 class II, 50,000 to less than 100,000 per mm3 100,000 to 150,000 per mm3 class III, 100,000 to 150,000 per mm3 On the basis of platelet count

58 Dr. Mona Shroff Classification full HELLP syndrome partial HELLP syndrome Based on the number of abnormalities Audibert F, Friedman SA, Frangieh AY, Sibai BM. Am J Obstet Gynecol 1996; 175: considered for delivery within 48 hours candidates for more conservative management

59 Dr. Mona Shroff 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 Eligibility to conservative management

60 Dr. Mona Shroff Patients who undergo cesarean section should be transfused if their platelet count is less than 50,000 per mm3, 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.. 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. Patients with DIC should be given fresh frozen plasma and packed red blood cells. Vertical incision Vertical incision Eventration XX Eventration XX Dead space XX Dead space XX Drains Drains LSCS IN HELLP

61 Dr. Mona Shroff 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):

62 Dr. Mona Shroff 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 Dr. Mona Shroff 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 preeclampsia…tests… Prevention of preeclampsia….role of different drugs…evidence based recommendations..

64 Dr. Mona Shroff 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


66 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff Ultrasound Obstet Gynecol 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.

70 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff ANAESTHETIC & INTENSIVE CARE ASPECTS… Type of anaesthesia..precautions.. Fluid balance… Invasive haemodynamic monitoring.. PCWP vs CVP… criteria..indications Pulmonary oedema…prevention & Mx

78 Dr. Mona Shroff 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 Dr. Mona Shroff 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

80 Dr. Mona Shroff 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: 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

81 Dr. Mona Shroff 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 Dr. Mona Shroff Regional vs. General Anesthesia for C/S in Severe Preeclampsia General vs. spinal (CSE) vs. epidural Wallace, et al., Obstet Gynecol 1995;86:193-9 Prospective, randomized study All these types of anesthesia were used safely BP on laryngoscopy avoided by controlling hypertension pre- op with hydralazine; IV NTG & lidocaine immediately pre- intubation BP with regional avoided by 1000 cc LR pre-load & 5 mg boluses of ephedrine for SBP 100

83 Dr. Mona Shroff 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 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 Dr. Mona Shroff Epidural vs. Spinal Anesthesia for C/S in Severe Preeclampsia Hood, et al., Anesthesiology 1999;90: 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 Dr. Mona Shroff 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 Dr. Mona Shroff Regional vs. General Anesthesia in Preeclampsia General anesthesia is a well-known hazard in obstetric anesthesia: 16X more likely to result in anesthetic- related maternal mortality Mostly due to airway/respiratory complications, which would only be exaggerated in preeclampsia Hawkins, Anesthesiology 1997;86:273

87 Dr. Mona Shroff 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 K, <80K some would proceed (esp. spinal)

88 Dr. Mona Shroff 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

89 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff Preanesthetic assessment: Airway Aspiration prophylaxis Auscultation of lungs Fluid balance Hemodynamic status Left uterine displacement Renal function Coagulation status

93 Dr. Mona Shroff Analgesia for Labor Continuous lumbar epidural – Advantages: o Decreased circulating catecholamines Decreased uterine vascular resistance Improved uteroplacental blood flow Avoids risk of general anesthesia

94 Dr. Mona Shroff Epidural Placement R/O coagulopathy, LUD, oxygen, continuous fetal monitoring Careful crystalloid preload ( ml) Local anesthetic: Bupivicaine (slow onset) Epinephrine: consider avoiding Slow, incremental dosing Ephedrine (in smaller doses) for hypotension < 20% of baseline

95 Dr. Mona Shroff 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 Dr. Mona Shroff 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 Dr. Mona Shroff Pre-eclampsia Invasive monitoring CVP monitoring may NOT be helpful! poor correlation between CVP and PCWP PA catheters have risks! rare indications: pulmonary oedema resistant to diuretics oliguric renal failure despite volume expansion

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