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Dr. Mona Shroffwww.obgyntoday.info Hypertension in pregnancy Slide 2 www.obgyntoday.info 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) Slide 3 www.obgyntoday.info 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? Slide 4 www.obgyntoday.info 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.. Slide 5 www.obgyntoday.info 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 Slide 6 www.obgyntoday.info 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 Slide 7 www.obgyntoday.info 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 Slide 8 www.obgyntoday.info 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 Slide 9 www.obgyntoday.info 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 Slide 10 www.obgyntoday.info 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. Slide 11 www.obgyntoday.info 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 Slide 12 www.obgyntoday.info 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. Slide 13 Slide 14 www.obgyntoday.info 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 Slide 15 www.obgyntoday.info 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, Glmezoglu AM. Cochrane Database of Systematic Reviews 2002, Issue 1. Slide 16 www.obgyntoday.info 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 ?? Slide 17 www.obgyntoday.info 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) Slide 18 www.obgyntoday.info 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 Slide 19 www.obgyntoday.info Dr. Mona Shroff IV Labetolol Vs SL/Oral Nifedepine vs Oral hydrallazine Slide 20 www.obgyntoday.info Dr. Mona Shroff SL NIFEDEPINE Slide 21 www.obgyntoday.info 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. Slide 22 www.obgyntoday.info 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, Glmezoglu AM, Henderson-Smart DJ.. Cochrane Database of Systematic Reviews 2003, Issue 2. Slide 23 www.obgyntoday.info 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? Slide 24 www.obgyntoday.info 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 3 months Slide 25 www.obgyntoday.info 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 balance.how to judge? Role of diuretics ??? Role of renal dose dopamine ??? Dialysis when,which type??? Delivery..when?? Slide 26 Slide 27 www.obgyntoday.info 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 Slide 28 www.obgyntoday.info 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 oliguria1.05) 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. Slide 29 www.obgyntoday.info 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;44:402-9. Kellum JA. Systematic review: The use of diuretics and dopamine in acute renal failure: a systematic review of the evidence. Critical Care1997;1(2):539. Kellum JA. Systematic review: The use of diuretics and dopamine in acute renal failure: a systematic review of the evidence. Critical Care1997;1(2):539. Slide 30 www.obgyntoday.info 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;29:1526-31. Denton MD, Chertow GM, Brady HR. "Renal-dose" dopamine for the treatment of acute renal failure: scientific rationale, experimental studies and clinical trials. Kidney Int 1996;50:4-14. Slide 31 www.obgyntoday.info 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 Slide 32 www.obgyntoday.info 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 Slide 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 Slide 34 www.obgyntoday.info 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 Slide 35 www.obgyntoday.info Dr. Mona Shroff Early Prophylactic Dialysis Allows more liberal fluid, protein & salt intake. Prevent hyperkalemic emergencies. Reduces infectious Cx. Improves comfort & survival Slide 36 www.obgyntoday.info 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 Slide 37 www.obgyntoday.info 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 Slide 38 www.obgyntoday.info 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 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?? Slide 39 www.obgyntoday.info 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 Slide 40 www.obgyntoday.info 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 Slide 41 www.obgyntoday.info Dr. Mona Shroff Cryoprecipitate 10-15 ml per unit (bag) Fibrinogen 250 mg Factor VIII80-120 units Von Willebrand Factor 40-70% of FFP Factor XIII 20-30% of FFP Fibronectin 20-40 mg Slide 42 www.obgyntoday.info Dr. Mona Shroff 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. Slide 43 www.obgyntoday.info Dr. Mona Shroff Platelets: Risk of Spontaneous Hemorrhage Count Site > 40,000 Minimal 20-40,000GI Mucosa 5-20Skin,Mucus Membranes < 5 CNS, Lung Slide 44 www.obgyntoday.info Dr. Mona Shroff Prophylactic Platelet TX Guidelines Platelet Count/l 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 Slide 45 www.obgyntoday.info Dr. Mona Shroff Transfused Platelets/Survival 6 units = 1 single donor unit (SDP); available as , 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? Slide 46 www.obgyntoday.info 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 Slide 47 www.obgyntoday.info 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 Slide 48 www.obgyntoday.info 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 Slide 49 www.obgyntoday.info 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. Slide 50 www.obgyntoday.info 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. Slide 51 www.obgyntoday.info 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- Slide 52 www.obgyntoday.info 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 Slide 53 www.obgyntoday.info 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;171:1148-53. Slide 54 www.obgyntoday.info 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 Slide 55 www.obgyntoday.info 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. Slide 56 www.obgyntoday.info Dr. Mona Shroff Patients with HELLP syndrome should be treated prophylactically with magnesium sulfate to prevent seizures, whether hypertension is present or not. Slide 57 www.obgyntoday.info 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 Slide 58 www.obgyntoday.info 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; 175:460-4. considered for delivery within 48 hours candidates for more conservative management Slide 59 www.obgyntoday.info 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 IIIII.(platelet count).>50000 Partial HELLP Eligibility to conservative management Slide 60 www.obgyntoday.info 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 Slide 61 www.obgyntoday.info 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):1500-9. Slide 62 www.obgyntoday.info 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 Slide 63 www.obgyntoday.info 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 preeclampsiatests Prevention of preeclampsia.role of different drugsevidence based recommendations.. Slide 64 www.obgyntoday.info 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 Slide 65 Slide 66 www.obgyntoday.info 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 Slide 67 www.obgyntoday.info 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 Slide 68 www.obgyntoday.info 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 Slide 69 www.obgyntoday.info Dr. Mona Shroff 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. Slide 70 www.obgyntoday.info 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 Slide 71 www.obgyntoday.info 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. Slide 72 www.obgyntoday.info 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. Slide 73 www.obgyntoday.info 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 Slide 74 www.obgyntoday.info 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. Slide 75 www.obgyntoday.info 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. Slide 76 www.obgyntoday.info 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 Slide 77 www.obgyntoday.info Dr. Mona Shroff ANAESTHETIC & INTENSIVE CARE ASPECTS Type of anaesthesia..precautions.. Fluid balance Invasive haemodynamic monitoring.. PCWP vs CVP criteria..indications Pulmonary oedemaprevention & Mx Slide 78 www.obgyntoday.info 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 Slide 79 www.obgyntoday.info 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 Slide 80 www.obgyntoday.info 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;59:158-61. Large series (385) preeclamptic patients; labor epidural analgesia vs. PCIA meperidine No difference in FHR abnormalities or C/S forceps in epi group but 0.125% bupi infusion naloxone use, umb artery pH, 1 min Apgar in PCIA group Lucas, et al., Anesthesiology 1998;89:A1033 Slide 81 www.obgyntoday.info 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 Slide 82 www.obgyntoday.info 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 Slide 83 www.obgyntoday.info 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. 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 Slide 84 www.obgyntoday.info Dr. Mona Shroff Epidural vs. Spinal Anesthesia for C/S in Severe Preeclampsia Hood, et al., Anesthesiology 1999;90:1276- 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 Slide 85 www.obgyntoday.info 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 Slide 86 www.obgyntoday.info 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 Slide 87 www.obgyntoday.info 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 80-100K,