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y Pregnancy induced hypertension
and anesthesia consideration
y Dr Asgher Niazi
PGR-II anesthesia
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contentscontents
y Definition
y diagnosis
y
Treatmenty Complication
y Anesthesia consideration
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Pregnancy induced HypertensionPregnancy induced Hypertension
Third leading cause of maternal mortality, after
thromboembolism and non-obstetric injuries
Maternal DBP > 110 is associated with risk of placental
abruption and fetal growth restriction
Superimposed preeclampsia cause most of the morbidity
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Definitions of Hypertensive DisordersDefinitions of Hypertensive Disorders
in Pregnancyin PregnancyType Blood Pressure Onset Proteinuria
Preeclampsia 140/90 After 20 weeks
gestation
>300 mg/24 h
Chronic hypertension 140/90 Before 20 weeks
gestation/withoutresolution PP
Absent
Preeclampsia withchronic hypertension
140/90 Before 20 weeksgestation/suddenincrease in HTN
Sudden increase inproteinuria
Gestationalhypertension
140/90 After mid-pregnancy Absent
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Pregnancy induced hypertensionPregnancy induced hypertension
y Risk factors
y greater trophoblastic mass for instance
in multiple pregnancy or molar pregnancy.
y Previous history of pre-eclampsia.
y family history of pre-eclampsia
y diabetes, obesity, advanced age, nulliparity
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Gestational hypertensionGestational hypertension
y 8-10 % all pregnancy
y Usual mild & self limiting
y
May develop pre eclampsiay Methyldopa ,labetolol and nefidipine
y Resolves 3months post partum
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EtiologyEtiology
y Pre-eclampsia is associated with widespread
endothelial dysfunction leading to placental ischaemia
and multi-organ dysfunction
Vasospasm
Hyper-responsive response to vasoactive hormones
(e.g. angiotensin II & epinephrine) Imbalance b/w prostacyclin and PG12
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PrePre--eclampsiaeclampsia
y In USA it is responsible for 15% of
premature deliveries & 17.6% of maternal
deaths.
y Preeclampsia and eclampsia are
estimated to be responsible for
approximately 14% of maternal deaths
per year
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PrePre--eclampsiaeclampsia
Maternal Risk Factors
First pregnancy
Age younger than 18 or older than 35
Prior h/o preeclampsia
Black race
Medical risk factors for preeclampsia - chronic HTN, renal
disease, diabetes, anti-phospholipid syndrome
Twins
Family history
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Features of Mild /moderate
Pre-Eclampsia Features of severe Pre-Eclampsia
Blood Pressure >140/90 Blood pressure >160/110 mm HgProteinuria >300mg/24h Proteinuria >5 g/24 h
Cerebral involvement
(headache, visual
disturbances)
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)
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Symptoms of preeclampsiaSymptoms of preeclampsia Visual disturbances
Headache
Epigastric pain
Rapidly increasing or nondependent edema
Rapid weight gain
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PathophysiologyPathophysiology
Airway edema
Laryngeal edema
Cardiac
Increased CO & SVR
CVP normal or slightly increased
Plasma volume reduced
Pulmonary edema .
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CNS disturbancesCNS disturbances
y Visual
y Photophobia,diplopia,blurring of vision
y Ischemia due to vasospasm of posterior cerebralarteries
y Cerebral edema in occipital regions
y OTHER
y headache,hyperrefexia,siezers
y Cerebral irritaion and ischemia
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Hematological changesHematological changes
Thrombocytopenia
Increased FDP
Hemoconcentration higher HCT %
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RenalRenal Decreased RBF
BUN increase, may correlate w/ severity
Adversely affected proteinuria
ARF w/ oliguria PIH, esp. w/ abruption, DIC,Hypovolemia
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HepaticHepatic
Elevated liver enzyme
hepatic swelling
epigastric pain
Risk of spontaneous rupture rareRisk of spontaneous rupture rare
Decreased metabolism of drugsDecreased metabolism of drugs
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UterineUterine
Activity increased
Hyperactive/hypersensitive to oxytocin
Preterm labor frequent
Uterine/placental blood flow decreased by 50-
70%
Abruption incidence increased
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Fetal complicationsFetal complicationsreduced uteroplacental blood flow
Abruptio placentae IUGR
Premature delivery
Intrauterine fetal death
Small fetuses more vulnerable to drug induced
depression
Meconium aspiration
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TreatmentTreatment
y Definitive treatment DELIVERY
y At term deliver
y Away from termrisk of neonatal
maturity balanced with risk to mother
and fetus of continuing pregnancy
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Management of preManagement of pre eclampsiaeclampsia
y General principles
Bed rest
Hydration
Monitoring of fetal heart rate
Monitoring of s. calcium ,s.Mg,BUN ,S.Cr
LFTs,CBC
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Antihypertensive therapyAntihypertensive therapy
y Goals
Maintain SBP between 130-160 mmHg
Maintain DBP between 80-110mmHg
Close monitoring of BP, urine output ,
Look for pulmonary edema ,fits and organ
failure
IBP necessary
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Antihypertensive therapyAntihypertensive therapy
HYDRALAZINE
y 5-10mg IV every 20-30 min or
y 5mg IV STAT then 5-20mg/hr IV as continues
infusion
LABETOLOL
y 100mg oral / or 50 mg IV
y 20-160mg/hr as continuous infusion
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ContdContd..
Nitroglycerine
y 10g/min iv titrated to response
Na nitroprusside
y 0.25 g/kg/min IV titratd to response
Fenoldopam
y 0.05-0.2g/kg/min until reached desired
response
y Average dose 0.25-0.5g/kg/min
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Seizers prophylaxisSeizers prophylaxis
y Mg 4-6 g IV followed by 1-2 g /hr IV as
continuous infusion
y Maintain serum Mg conc 2.0-3.5meq/l
y Relives spasm of cerebral vessels
y ECG and vital signs monitoring necessary
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Mg toxicityMg toxicity
y 4-6.5 meq /l ..
nausea vomiting ,diplopia,sedation,loss ofpateller reflex
y 6.5-8 meq /l .
skeletal muscle paralysis and apnea
y
> 10 meq /l .cardia arrest
y Toxic: 10 ml of 10% Ca Gluconate IV slowly
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yAnesthesia
consideration
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Pre anesthesia managementPre anesthesia management
y Airway assessment ..
Facial edema ,stridor, difficult intubation
y Risk of hypotension
more prone to develop hypotension
Hydration with 0.5-1L crystalloid
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y IBP
Refractory hypertension
Infusion of antihypertensive drugs
y CVP
Indicated in pulmonary edema
Oligourea not responsive to fluid
challange
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LABSLABS
CBC
Low platelet counts ..risk of epi
hematoma
Raised HCT %
LFTS
BUN and serum Cr
ABGs & Chest radiographs ..signs of
pulmonary edema
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Labor analgesiaLabor analgesia
y Vaginal delivery .. When no fetal distress
y C/section .. Fetal distress
y Continue fetal HR monitoring
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Labor analgesiaLabor analgesia contdcontd
y Maintain left uterine displacement and
fetal monitoring
y Risk of epidural hematoma if platelets are
low
y Risk of hypoension
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Anesthesia for C/sectionAnesthesia for C/section
y General anesthesia
Coagulopathy or
refusal to regional anesthesia
Sepsis
Consider difficult airway and risk of
aspiration of gastric contents
Potentiating of MR with use of Mg
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GA for C/sectionGA for C/section contdcontd
y Induction
y Restore blood volume and BP
Preferably with Thiopentol with SCh using rapid
seq technique
Larygeal edema ..use small ETT
Reduce CVS response to intubation
Maintenance
low dose volatile agents 0.5-1.0 MAC
Opiods after delivery
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Spinal anesthesia for CSpinal anesthesia for C--sectionsection
y Preferred method
y Risk of hypotension
y Hydrate with crystalloid upto 1L
y A block upto T-4 level
y Bupivacain 12-15mg
y Add opiods meperdine (10mg) or
morphine 0.1mg-0.2mg for PO analgesia
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Spinal anesthesia for C/sectionSpinal anesthesia for C/section
y hypotension
y Maintain SBP with in 30 % of pre-op value
y Left uterine displacement
y Leg elevation
y Rushing IV fluid
y IV ephedrine 5mg OR phenylepherine
0.1mg IV
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EclampsiaEclampsia
y Fits in parturient with other wise no
cause for siezers
y Usually follows pre-eclampsia
y Edema may be present
y Mortality 10 %
y Cause include cong cardiac failure and
cerebral hemmorage
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EclampsiaEclampsia
y Fits..
Secure airway ,oxygenation
Control fits using thiopental, diazpam,
midazolam ,or bolus of Mg sulfate
Continue Mg infusion
Check Mg level and dose adjusted
Early cesarean delivery
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HELLP
SyndromeHELLP
Syndrome Hemolysis
Elevated Liver enzymes
Low Platelets
20 % of parturient having sever pre eclampsia
< 36 wks Malaise (90%), epigastric pain (90%), N/V (50%)
Self-limiting
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HELLP syndromeHELLP syndrome
y COMPLICATION
Pleural effusion
Pulmonary edema
Cerebral edema
Hematuria
Oliguria
DIC
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Management of HELLP syndromeManagement of HELLP syndrome
y Early delivery via c-section
y Platelets transfusion necessary
y Urine output via catheter
y Organ support may be necessary
y RCC transfusion In case of anemia
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y Anesthetic management
y General anesthesia > regional anesthesia
y Reduced hepatic and renal clearance of
drugs
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y
Hypertensive diseases of pregnancyare still acommon cause of maternal death.
yMagnesium Sulphate is the anticonvulsant of
choice in prevention and treatment of eclampticfits.
y The main concerns to the anaesthetist are those
of an oedematous airwayand dysfunction of thecardiorespiratory, cerebro-vascular and
coagulation systems.
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y Reference
y Stoetling anesthesia and co existing
diseases
y Clinical anesthesia by barash 6th edition
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yQUESTIONS