preg induced hypertension

8/7/2019 Preg Induced Hypertension

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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

preg induced hypertension

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