PIH and Eclampsia Anaesthetic implications

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PIH and EclampsiaAnaesthetic implications

• Speaker Dr. Praveen Talawar
• Moderator Dr Anjan Trikha

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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Multidisciplinary team approach

• 18 deaths from pre-eclampsia eclampsia
• 10- from intracranial haemorrhage
• 2- from cerebral infarction
• 2- from multi-organ failure (ARDS)
• 1 - from massive liver infarction, and
• 3- from other causes
• Intracranial haemorrhage
• Single most common cause of death
• Failure of effective anti-hypertensive therapy ,
  most common source of sub-standard care
• No deaths from pulmonary edema - better fluid
  management in PIH
• (Confidential Enquiries into Maternal Deaths in
  the United Kingdom , 2007 )

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Multidisciplinary team approach

• Systolic blood pressures over 160 mm Hg must be
  treated
• Ergometrine
• Should not be given for active management of 3rd
  stage if the mother is hypertensive, or her blood
  pressure has not been checked
• Early referral and involvement of the
  anesthesiologist
• The anaesthesiologist should be given as much
  time as possible to try to prevent the pressor
  effects of intubation in the pre-eclamptic woman,
  even when there are pressing fetal reasons for
  urgent caesarean section under general anaesthesia

4

• Role of Anesthesiologist in PIH
• Vaginal delivery
• Operative delivery
• Control of convulsions
• ICU management
• Definitive treatment of PIH
• Delivery of fetus

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Medical Management While
awaiting delivery.

• AIMS to reduce maternal and fetal complications
• Fetal and maternal surveillance
• Treatment of hypertension
• Control of convulsions
• Fluid therapy and treatment of oliguria
• Decision when to deliver
• Management of coagulation abnormalities
• Steroids x 48 hrs if fetus lt 34 weeks

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Maternal and fetal surveillance

• Maternal surveillance
• Indicated for all pre-eclamptic women
• Early detection of severe disease
• Severe headache
• Visual disturbances
• Altered mentation
• Dyspneoa
• Right upper quadrant/epigastric pain
• Nausea and vomiting
• Decreased urine output and
• CNS hyperexcitability

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Initial lab investigations for pregnant women in
whom HTN develops after 20 weeks of gestation
Test Rationale
Hemoglobin hematocrit Hemoconcentration support diagnosis of PIH ?- Hemolysis
Platelet count Thrombocytopenia- severe PIH
Serum creatinine Abnormal or rising creat- severe PIH
Serum transaminase ?- severe PIH, hepatic involvement
Serum uric acid ?- diagnosis of preeclampsia
Quntification of protein excretion Pregnancy associated HNT with proteinuria should be considered PIH until proved otherwise
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Treatment of hypertension

• Non-severe HTN- BP 140-159/90-109 mmHg
• Antihypertensive therapy (Cochrane Database Syst
  Rev 2007)
• No evidence of improved perinatal outcome
• Does not delay/prevent PIH/its associated
  problems
• Risk of haemorrhagic stroke (Martin et al 2005)
• Most guidelines recommend lowering BP

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Rx of chronic rise in B.P. Methyldopa - Most
commonly used agent Labetalol Hydralazine
Clonidine ß adrenergic antagonists - risk of
fetal bradycardia Calcium channel blocker
MgSo4 potentiates. ACE inhibitors not
recommended (Teratogenic) Diuretic not
preferred
Treatment of non severe hypertension
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Treatment of severe hypertension (gt 160/110)
Drug Action Onset Regimen Comments/SE
Hydralazine Direct arterial vasodilator 20 min 5 mg every 20 min or infusion Ist line drug Tachycardia, headache, nausea, vomiting
Labetalol Non selective a ß blocker 5 min 5-10 mg IV every 5 min upto total dose -1mg/kg Individual variability in ß blockade- 13 to 17 Fetal bradycardia
Nifedipine CCB 10-20 min 10 mg oral or 5 mg SL (ACOG FDA) Headache Severe hypotension MI, complete heart block and death,
MgSo4 Direct vasodilator Catecholamine blocker 2 min 4 gm bolus, 1-3gm/hr infusion Nausea, vomiting, flushing, weakness, resp depression
NTG Direct arterial venous vasodilator 2 min 0.5-1µg/kg/min Headache, nausea, vomiting, restlessness
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Volume Management

• Correction of i/v fluid volume deficit before
  antihypertensive
• Crystalloid solutions 1-2 ml/kg/hr with
  adjustments based on patients clinical
  condition urine output
• CVP Pulmonary artery catheter- in selected
  cases
• Colloid solutions Limited role
• - improves colloidal osmotic pressure.
  - Risk of increased CVP and Pulm.edema. -
  No evidence of improved outcome
• (Cochrane Database of Systematic Review
  1999)

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Oliguria

• Normal urine output to be maintained
• Persistent oliguria
• Fluid challenge of 500ml crystalloids
• If no effect - dopamine infusion
• Avoid Repetitive unmonitored fluid admn
• Acute pulmonary edema- frequent cause of ICU
  admission
• CVP monitoring

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Indications for Invasive Monitoring?

• Sepsis with refractory hypotension/oliguria
• Unexplained pulmonary edema, heart
  failure/decompensation, severe hypertension with
  pulmonary edema or oliguria
• Massive blood loss
• ARDS
• Shock of unknown etiology
• NYHA Class III or IV cardiac status
• CAD with ischemia or infarction
• Chestnut, DH. Obstetric Anesthesia, 2nd Ed.
  Mosby, St. Louis, MO. 1999. P. 898.

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Control of seizures

• Magnesium Sulphate
• Diazepam
• Phenytoin
• Chlorpromazine
• Phenobarbitone
• Thiopentone

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MgSo4 Mechanism of action

• Mechanism of action - not clearly understood
• Possibilities
• Vasodilatation of the cerebral vasculature
• Inhibition of platelet aggregation
• Protection of endothelial cells from damage by
  free radicals
• Prevention of calcium ion entry into ischemic
  cells
• Decreasing the release of acetylcholine at motor
  end plates within the neuromuscular junction
• Competitive antagonist to NMDA receptor
  (epileptogenic)

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Indications for treatment with MgSo4

• Anticonvulsant Rx
• To prevent 1st seizure in severe PIH
• Mild preeclampsia 
• Role of MgSo4 is controversial
• NNT -100, Side effects are more common
• Increase in caesarean birth in MgSo4 group

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MgSo4

• Magpie Trial , Lancet 2002.
• (Magnesium sulfate for prevention of
  eclampsia trial)
• 10,000 women (pregnant or within 24 hours of
  delivery)
• Blood pressure 140/90 mmHg on two occasions
• Proteinuria of at least 1
• Magnesium sulfate or placebo for 24 hours
• MgSo4- 4 gm IV as a loading dose , 1 g/h, or
• 5 gm IM into each buttock ? 5 gm IM every four
  hours
• Mild preeclampsia was present in 75 percent of
  women, the remainder had severe disease

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Magpie trial -Results

• ??? reduced risk of eclamptic convulsions (0.8
  versus 1.9 percent, relative risk RR 0.42, 95
  CI 0.29-0.60)
• To prevent one convulsion
• 63 women with severe PIH or
• 109 women with mild PIH would need to be treated
• Magnesium sulfate therapy was associated with
• Trend toward a reduced rate of maternal death
• Maternal /neonatal morbidity, perinatal mortality
  - Similar in both groups
• ??? lower rate of abruption in treated women

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Magnesium sulfate

• No agreement in the published randomized trials
• Optimal time, dose , route of admn,
  duration of therapy.
• Women with imminent eclampsia are the best
  candidates to receive magnesium sulfate
  prophylaxis.
• Magnesium sulfate might prevent complications
  related to seizures (status epileptics, maternal
  trauma, or aspiration)
• May not affect serious maternal complications of
  severe PIH,
• Pulmonary edema, stroke, liver hematoma, or renal
  failure.

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MgSo4 Regimens

• Sibai regimen
• Loading bolus -6 gm IV slowly over 5-10 min
• Followed by 2 gm/hr infusion
• Pritchard regimen
• Loading bolus 4gm IV slowly over 5-10
  minfollowed by- 10 gm IM (5 gm in each
  buttock)Subsequently- 5 gm IM in alternate
  buttocks -4th hrly
• Zuspan regimen
• Loading dose - 4gm IV slowly over 5-10 min
• Maintenance 1-2 gm/hour IV infusion
• Start before the onset of labor continue 24 hrs
  after delivery/last seizure
• Additional 2 gm IV bolus of MgSo4 for recurrent
  seizure
• In AIIMS- OBG deptt- Pritchard and Zuspan regimen

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Side effects of MgSo4

• Nausea, headache, flushing, weakness
• Decreased uterine tone
• Augmentation of neuromuscular blockade
• Toxicity
• Loss of deep tendon reflexes
• Respiratory depression
• Cardiovascular collapse

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Serum Magnesium levels (1 mmol/L 2 meq/L for Mg ) Serum Magnesium levels (1 mmol/L 2 meq/L for Mg ) Serum Magnesium levels (1 mmol/L 2 meq/L for Mg )
Normal 1.8 2.4 meq/l
Therapeutic 4 -7
ECG changes 5 10
Patellar reflex 8 -10
Respiratory depression 10 -15
Cardiac arrest gt20
In AIIMS Mg levels can be get done in Casualty ABG machine
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How to avoid Mg toxicity?

• Urine flow of at least 100ml during last 4hrs
  before administering next dose
• Patellar reflexes present
• No Respiratory depression
• Mg levels - To be measured in suspected toxicity

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Rx of MgSo4 toxicity

• Immediate discontinuation of MgSo4
• Cal gluconate 1gm IV over 10 min
• In the event of respiratory compromise
• Endotracheal intubation
• Mechanical ventilation

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MgSo4 Anaesthetic concerns

• Clinically significant potentiation of both
  depolarising nondep. - Careful
  titration of doses of muscle relaxants.
  - Neuromuscular monitoring
• Potentiates sedatives and opioids, ? Dose
• Potentiation of Ca channel blockers
• Post Partum uterine relaxation excessive blood
  loss
• Neonatal Transient loss of fetal beat to
  beat variability ? Neonatal skeletal Ms tone
  hypoventilation (Ca may be given to
  overcome the problem)

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Diazepam

• Still widely used as -first line agent to
  terminate a convulsion
• Given in 5-10 mg increments until effective
• Diazepam infusions of 10 mg/h
• Excessive sedation, consequent risks to airway
• Fetal depression (especially premature infant)
• Magnesium sulphate- now the preferred agent

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• Phenytoin. 
• Recent evidence no longer supports its use.

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Efficacy of MgSo4 Versus Phenytoin in Seizure
Control Prophylaxsis in Patients of Eclampsia
Severe Pre eclampsia

JK science 2008

• 50 pts - eclampsia 50 had severe preeclampsia
  
• Eclamptic pts (p 0.033).
• Rx with MgSo4, No recurrence of convulsions
• Rx with phenytoin, 24 had recurrence of
  convulsions
• Severe preeclamptic pts
• Rx with phenytoin,- 2 pts progressed to
  eclampsia,
• No preeclamptic pt allocated MgSo4 progressed to
  eclampsia

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MgSo4

• MgSO4 -The treatment of choice for eclampsia
  (Duley Gülmezoglu 2000,
  Duley Henderson-Smart 2003)
• MgSO4- reduces mortality when compared with
  diazepam (Duley Henderson-Smart 2003,
  Level I)
• MgSO4- superior to diazepam, phenytoin lytic
  cocktail (chlorpromazine, promethazine,
  pethidine) in reducing risk of seizure recurrence
  
  (Duley
  Gülmezoglu 2000)
• Morbidity related to pneumonia, mechanical
  ventilation admission to ICU - significantly
  reduced with the use of MgSO4 compared with
  phenytoin
  (Duley Henderson-Smart 2003)

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Labor analgesia

• Mild or moderate pre-eclampsia
• Allowed to proceed with normal labor, provided
  coagulation is normal
• Lumbar epidural and CSE preferred methods of
  pain management during labor in PIH

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• Early institution of neuraxial block recommended
• To avoid GA possibility of airway catastrophe
  in the event of emergency cesarean delivery
  
  ( Moore et al 1985, Newsome et al 1986, )
• To optimize the timing of epidural catheter
  placement in the setting of declining platelet
  count
• Lumbar epidural -(Lucas et al 2001)
• Appropriate in absence of contraindications
• If regional Contraindicated (Head et al 2002
  Lucas et al 2001)
• IV opioids has been employed to good effect

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Labor analgesia- Neuraxial block

• Advantages
• Controls blood pressure, vasodilatation
• Reduce stress response and catecholamine release
• Improves placental intervillous blood flow
• Prevent complications of preeclampsia-cerebral
  hemorrhage, renal failure, pulm oedema
• Excellent pain relief
• Concomitant MgSo4 infusion
• May increase the degree of hypotension
• Unlikely to be severe to compromise placental
  blood flow

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Labor analgesia

• Considerations neuraxial blocks
• Selection of local anesthetic not affected by
  PIH
• (bupi 0.125 , fentanyl 2µg/ml- 10-12ml/hr)
• Coagulation status/ Thrombocytopenia
• Preloading ?
• Treatment of hypotension
• Use of epinephrine
• Use of test Dose

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Coagulation status

• Platelets- contributes to coagulation
  hemostasis
• Severe PIH Thrombocytopenia, DIC
• Risk of bleeding into epidural/spinal space with
  neuraxial tq
• Platelet count gt 100x103- No change in TEG
  (sharma et al 1999)
• Platelet count lt 100x103 - PT, aPTT fibrinogen
  levels
• Documentation of- admission platelet count
• Trend in the platelet count
• Platelet count every 6th hrly
• Platelet count within the last 1-3 hrs

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Platelet count RA

• gt1,00,000 SAFE
• gt75,000-80,000 Perhaps Safe
• 50,000-75000 Significant
• (grey zone) reluctance
  
• lt50,000 Unsafe

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Preloading during regional anaesth/analg?

• Vasculature in PIH
• Contracted porous - endothelial damage, but
  not underfilled
• Colloid osmotic pressure
• Low in pregnancy, even lower in preeclamptic
  patients with proteinuria
• Crystalloids colloids readily leak - risk of
  pulmonary edema
• Weak benefit of preloading in preventing
  hypotension during obstetric regional anesthesia
• No preload for labor analgesia in PIH
• Conservative preload for surgical regional
  anesthesia

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Treatment of hypotension

• The incidence of hypotension
• Decreased with the use of low conc of LA
• PIH exaggerated response to vasopressors
• Titrated doses of ephedrine or phenylephrine

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Vasopressor
Ephedrine Meph Phenylep Metaraminol Methoxamine
Receptors Directly ß1 ß2 Indirectly a1 Mixed action Directly-a1 Mixed Predom- a1 Pure a1
Actions ?BP HR ?BP ? BP Reflex brady ? BP CO Less likely to cause reflex bradycardia ?BP Reflex brady
Dose 3-10 mg bolus until effective 3 -6 mg bolus 0.1-0.5 mg IV, 20-50µg/min 1 mg IV bolus 1-20mg/hr 2-4mg iv bolus
UBF? Does not affect UBF fetal asphyxia Preserve UBF No evidence of fetal/maternal distress ?UBF ?UBF fetal asphyxia, uterine hypertonia fetal distress
Neonatal acidosis Tachyphylaxis
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? Vasopressor

• Ephedrine
• Less effective than a- adrenergic agents
• Foetal acidosis
• Maternal tachycardia and reactive hypertension
• Alpha agonists
• More effective than ephedrine
• Better foetal acid base status but maternal
  bradycardia
• Recent study supports the use of phenylephrine
  during regional anesthesia in uncomplicated term
  pregnancy
• Ephedrine increases uterine and placental
  circulation after epidural anesthesia-induced
  hypotension more than phenylephrine.

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• Because feto-placental circulation may be
  compromised in severe pre-eclampsia, ephedrine
  might have more benefit to the newborn than
  phenylephrine
• Ephedra- containing dietary supplements(asthma
  hey fever) - convulsions
• No evidence suggests that treating
  anesthetic-induced hypotension with ephedrine
  increases the risks of seizures in patients with
  pre-eclampsia
• Considering the potential benefits to
  feto-placental circulation, It seems that
  ephedrine is the drug of choice to treat
  hypotension in severe pre-eclampsia.
• Anesth Analg 2006103 1584

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• Phenylephrine in Spinal Anesthesia in
  Preeclamptic Patients (2006)
• Still recruiting participants
• Verified on February 2011 by Northwestern
  University

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Epinephrine

• PIH increased sensitivity to vasopressors
  (angiotensin II, norepinephrine
  epinephrine)
• Smaller doses of ephedrine phenylephrine
  required to restore BP during SAB in PIH
• Hypertensive crisis- with 2 lig with Adr (Case
  report)
• No adverse effects in some case series
• No randomized controlled trials
• Epinephrine - unlikely to pose significant risk
  of hypertensive crisis

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• Anaesthesia for Cesarean section
• General or Regional ?
• Choice Determined By.
• Maternal and fetal condition
• The indication for caesarean
• The urgency
• Facilities equipment available
• Experience of the anaesthesiologist

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Indications for emergency delivery

• Fetal distress
• Increase in BP despite aggressive Rx
• Worsening end organ function
• HELLP syndrome
• Development of eclampsia

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GA / Regional?

• Leading cause of death in PIH intracranial
  hemorrhage
• GA- Intracranial hemorrhage
• Hypertensive response to intubation
• Difficult airway- airway edema
• Neuraxial anesthesia - preferred

46

• Regional anesthesia
• Be used in pre-eclamptic pts without coagulopathy
  in order to decrease need for GA should an
  emergent procedure become necessary
• ACOG Practice bulletin Diagnosis and management
  of preeclampsia and eclampsia. Obstet
  Gynecol. 200299(1)159167
• Practice guidelines for obstetric anesthesia An
  updated report by the ASA Task Force on Obstetric
  Anesthesia 2010.

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• In severe cases- Insertion of an epidural
  catheter may precede the onset of labor or a
  patients request for labor analgesia. 
•  
• ASA guidelines- spinal catheters placed early
  ( high-risk patients)
• More likely to fail, difficult removal, when
  compared to epidural
• Not been studied for use in the pre-eclamptic
  patients
• With availability of fast-acting LA(3
  chloroprocaine) for epidural use
• Epidural catheters have a better safety profile
  than spinal catheters in pre-eclamptic patients

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Pre operative assessment- Detailed History-
Examination Frequent BP
determination. Fundoscopic
examination Neurological examination
for knee reflex Fluid balance,
Airway assessment Detailed CVS
resp. examination Obstetric fetal
evaluation. Lab Tests
hematological studies Coagulation
profile Urine studies
R.F.T., L.F.T. Foetal well being
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Lumbar epidural is the technique of choice-
provided

• Coagulation profile is acceptable
• Circulating volume is maintained adequate
• Maternal B.P. is controlled
• Aortocaval compression is avoided
• No obvious contraindications to R.A
• ADVANTAGES
• Protection against pain related maternal foetal
  complications
• Safeguards against
• Exaggerated hemodynamic responses
• Difficult / failed intubation
• Pulm.aspiration related morbidity mortality in
  PIH patients with GA.

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Lumbar epidural

• All considerations as for any obstetric patient
• Modest prehydration
• ?Dose of antihypertensive agent before epidural
  and before each top-up dose
• Addition of epidural opioids to reduce LA dose
• F.H.R. monitoring.
• Small doses of ephedrine for persistent
  hypotension Increased
  sensitivity to vasopressors

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Spinal anaesthesia

• Traditional view spinal anesthesia
• Contraindicated in severe PIH (marked
  hypotension)

52
Spinal Anesthesia for Cesarean Delivery

• Aya et al. Patients with severe preeclampsia
  experience less hypotension during spinal
  anesthesia for elective cesarean delivery than
  healthy parturients A prospective cohort
  comparison. Anesth Analg 2003.
• Severe PIH pts - 6 times less likely to develop
  hypotension
• Criticized on
• Reduced gestational age(32 vs 38 wks) lower
  fetal weight (1.9 vs 3kg)
• Less aortocaval compression ? decreased
  hypotension in PIH patients

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Spinal Anesthesia for Cesarean Delivery

• Aya et. al Spinal anesthesia-induced
  hypotension A risk comparison between patients
  with severe preeclampsia and healthy women
  undergoing preterm cesarean delivery. Anesth
  Analg 2005
• Compared PIH women with severe disease with a
  control group of preterm mothers undergoing
  cesarean delivery
• The control group was chosen
• Fetuses were matched in terms of fetal wt
  (1,1001,900 g)
• Control for uterine mass between the groups and
  therefore aortocaval compression

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Spinal Anesthesia for Cesarean Delivery

• Reduced frequency of hypotension in preeclamptic
  group (24.6 vs. 40.8)
• Decrease in blood pressure was similar between
  groups
• PIH patients needed less ephedrine to return to
  baseline BP
• Concluded that PIH-associated factors may ?
  reduced spinal hypotension instead of smaller
  uterine mass
• PIH- associated factors may increased vascular
  resistance and sensitivity to vasoconstrictors ?
  decrease BP drop

55
Spinal versus Epidural anesthesia for Cesarean
delivery

• Visalyaputra et al. Spinal versus epidural
  anesthesia for cesarean delivery in severe
  preeclampsia A prospective randomized,
  multicenter study. Anesth Analg 2005
• Hemodynamic effects of Spinal vs Epidural
  anesthesia for C-section of severe preeclampsia
• Spinal anesthesia was associated with
• Greater incidence of hypotension (51 vs. 23)
• Greater use of ephedrine (mean difference only 10
  mmHg)

56
Spinal versus Epidural anesthesia for Cesarean
delivery

• Hypotension
• Short duration
• Easily treated in all patients
• Neonatal outcome
• Measured by Apgar score and blood pH
• No difference b/w groups
• Conclusion
• Hemodynamic differences - little clinical
  significance
• Spinal anesthesia was a safe technique for severe
  preeclampsia

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GA - Indications

• Suspected placental abruption
• Coagulopathy
• Platelet count less than 80,000100,000/µL
• Severe pulmonary edema
• Eclampsia, and
• Severe fetal distress

58
GA - Concerns

• Hypertensive response to laryngoscopy
  intubation
• Loss of airway- Failed airway management
• Risk of aspiration
• Transient neonatal depression
• Maternal mortality approx 7-fold greater than for
  regional
• Drug interactions - Mg So4 NDMRs-? sensitivity
  to NDMRs

59

• Careful pre-anaesthetic evaluation prepn.
• Exaggerated haemodynamaic responses to lx
  intubation prophylactic admn.of labetolol ,
  fentanyl , lignocaine
• Rapid sequence induction intubation
• Airway edema Smaller size ETT
  Gentle instrumentation
• Titrate the dose of muscle relaxants.
• Use NM monitor
• Intra op HTN- Hydrallazine, esmolol, NTG SNP
• Continue MgSo4 during intraoperative and post op
  period
• Careful extubation ( L. edema )

60

• Perioperative monitoring of PIH patients
• N.I.B.P., (I.B.P ), E.C.G, SpO2 ETCO2
• NM monitoring
• Temperature
• Mg levels
• Uterine Contraction monitoring
• Continuous FHR monitoring.
• Coagulation profile monitoring serial estimation
  of platelet
• Urine output Fluid balance
• C.V.P - Diastolic gt 105 mmHg with persistent
  oliguria - Extended use of oxytocin
  gt10 mu/min. - Difficulty in fluid
  management.
• PCWP monitoring - P. edema. -
  - chronic HT with impending CHF

61
Comparison of GA vs. regional anaesthesia in
pre-eclampsia
Regional anaesthesia Regional anaesthesia GA GA
Advantages Dis advant Advantages Dis advant
Airway No intubation response. No risk of failed intubation No control Control Exaggerated intubation response. Increased risk of failed intubation
Convulsions Nil. No active control. Risk of convulsion. Control
Drugs Technique No sedative drugs Risk of convulsions.Risk of high block. Maternal awareness.Fetal depression
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Comparison of GA vs. regional anaesthesia in
pre-eclampsia
Regional anaesthesia Regional anaesthesia GA GA
Advantages Dis advant Advantages Dis advant
Speed Spinals quick5-10 mins. Epidural slow20-30 mins. Fastlt5 mins.
Blood Pressure Control Lower catecholamines.Less instability. Risk of hypotension. Less hypotension. Increased catecholamines.Increases in BP, PAWP, CVP with intubation.
Coagulation No airway instrumentation. Risk of haematoma. Avoid spinal haematoma. Risk of airway haemorrhage.
63
Oxytocin, Ergometrine, NSAIDs

• Oxytocin- should be given slowly
• Systemic vasodilatation, pulmonary
  vasoconstriction
• Ergometrine- should be avoided
• Vasoconstriction, may precipitate eclampsia
• NSAIDs should be avoided
• Coagulopathy, thrombocytopenia, oliguria, renal
  dysfunction

64

• Post partum care of pre-eclamptic patients
• O2 , Continuous post partum monitoring
• Continue MgSo4 for 24 hrs.
• Eclamptics for 24 hrs after last post partum
  convulsion
• Continue antihypertensive agents.
• Pain mangement
• Epidural opioids can provide sustained post
  operative analgesia.
• Maintain i/v fluids.
• Blood transfusion if excessive blood loss.
• Comfortable quiet environment

65
Eclampsia

• Stop convulsion
• Establish patent airway
• Prevent major complications
• Hypoxemia and aspiration
• Antihypertensive therapy

66
ABCs of seizure control

• Airway
• Turn patient to left side, apply jaw thrust
• Attempt bag mask ventilation(FiO2-1)
• Insert soft nasopharyngeal airway SOS
• Breathing
• Continue bag mask ventilation (FiO2-1)
• Apply pulse oximeter monitor SpO2
• Circulation
• Secure IV access
• Check BP at frequent intervals
• Monitor ECG
• Drugs
• MgSo4- 4-6 gm over 20 min, 1-2gm/hr
• 2gm IV over 10 min for recurrent seizure
• Antihypertensive agents
• Labetalol- 10-20mg or Hydralazine 5-10 mg IV SOS

67
Pre-anaesthetic evaluation in eclampsia

• Assessment of seizure control neurological
  function
• Review of fluid balance
• Blood pressure control
• Monitoring- SpO2, FHR
• Lab investigations

68
Eclampsia

• Labor analgesia
• Epidural analgesia
• Opioids possible ? ICP from resp depression
• Cesarean section
• Regional anaesthesia
• Conscious eclamptic patient
• No evidence of ? ICP
• Seizure well controlled
• General anaesthesia
• Neuroanaesthetic technique
• Propofol, thiopentone- ? CMRO2, ?CBF
• Avoid hypoxia, hyperthermia, hyperglycemia
• Mechanical ventilation ICU care

69
ICU management of PIH patient

• Pts requiring admission in ICU
• Severe Hypertension with neurological symp
• Severe oliguria requiring dialysis
• Rptd convulsions
• DIC, HELLP,severe PPH
• Cerebral Hmg edema
• Intra abd. Catastrophe liver rupture hematoma
• Pulmonary edema, CHF

70
Management of HELLP Syndrome

• Stabilize mother control BP, prevent seizures
• Evaluate fetus
• Determine optimal timing and route for delivery
• Provide continued monitoring and management
  during postpartum period
• All women should receive MgSO4

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• Expeditious delivery usually warranted
• Poor maternal and fetal outcome if delivery
  delayed
• Infants gt 28 weeks gestation are routinely
  delivered 48 hrs after first maternal dose of
  dexamethasone
• Dexamethasone 10 mg IV q12hr when platelets lt
  100,000
• Platelets for active bleeding, or if lt 20,000
• Plasmapheresis limited success, but not
  routinely recommended

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• Thank you

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Labor analgesia studies

• 738 women, randomized to IV PCA or epidural
• Cesarean delivery rates were similar
• IV PCA group- Neonates required more naloxone
  (12 versus 1)
• Epidural group
• Pain relief was superior
• Longer second stage of labor, More forceps
  deliveries
• Required ephedrine more often (11 versus 0)
• 
  American J Obstet Gynecol 2001
• 116 laboring women with PIH, epidural/PCA opioid
• There was no difference in cesarean delivery
  rates
• Opioid group Neonates - received naloxone (54
  versus 9)
• Epidural patients
• Significantly better pain relief
• Required more ephedrine (9 versus 0).
• No differences in preeclampsia-related
  complications
• 
  Obstet Gynecol 2002

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Spinal Anesthesia for Cesarean Delivery 11,29

• Aya et. al Spinal anesthesia-induced
  hypotension A risk comparison between patients
  with severe preeclampsia and healthy women
  undergoing preterm cesarean delivery. Anesth
  Analg 2005 10186975

76
Spinal Anesthesia for Cesarean Delivery 11,29

• Aya et. al Spinal anesthesia-induced
  hypotension A risk comparison between patients
  with severe preeclampsia and healthy women
  undergoing preterm cesarean delivery. Anesth
  Analg 2005 10186975

77
Spinal versus Epidural anesthesia for Cesarean
delivery 11,31

• Hypotension
• Short duration
• Easily treated in all patients
• Neonatal outcome
• Measured by Apgar score and blood pH
• No difference b/w groups
• Conclusion
• Hemodynamic differences with little clinical
  significance
• Spinal anesthesia was a safe technique for severe
  preeclampsia

78
Visalyaputra et al. Spinal versus epidural
anesthesia for cesarean delivery in severe
preeclampsia A prospective randomized,
multicenter study. Anesth Analg 2005 1018628

• Changes in mean SAP and mean DAP in the epidural
  group (n 47) and the spinal group (n 53)
  during 1st 30 min of regional anesthesia
• Significant differences in SAP at 1 to 15 min (P
  lt 0.0001) and at 16 to 20 min (P lt 0.005) and in
  DAP at 1 to 15 min (P lt 0.0001) and at 16 to 20
  min (P lt 0.01) between the 2 groups
• No significant differences in SAP and DAP at 22
  to 30 min between groups. Pre ind the baseline
  SAP, DAP in preinduction period delivery time
  time from local anesthetic administration to
  delivery. Data are mean sd

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• Ephedrine
• Ephedrine acts directly on b1 and b2 receptors,
  and indirectly on a1 receptors by causing
  noradrenaline release.
• Action It causes a rise in blood pressure and
  heart rate, and some bronchodilation.
• Side effects May cause tachycardia and
  hypertension. Possible arrhythmias if used with
  halothane.
• Preparation 3 or 5 solution 1 ml ampoules.
• Indications Low blood pressure due to
  vasodilation e.g. following spinal or epidural
  anaesthesia and drug overdoses. Best vasopressor
  to use in pregnancy as it does not reduce
  placental blood flow.
• Dose 3-10 mg boluses iv, repeat until effective.
  Maximum dose is 60mg.
• Length of action 5-15 minutes, repeated doses
  less effective (i.e. it demonstrates
  tachyphylaxis). 
• . 
• Phenylephrine
• Acts directly on a1 receptors.
• Action Hypertension and a reflex decrease in
  heart rate.
• Dose 2-5mg im or sc, 0.1-0.5mg iv, by infusion
  20-50mcg/min. 

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• Methoxamine
• Methoxamine acts on a1 receptors.
• Actions Increases blood pressure. There may be a
  reflex decrease in heart rate, and therefore it
  is good for hypotension with tachycardia. Useful
  during spinal anaesthesia.
• Side effects May produce bradycardia
• Dose 2-4mg boluses IV, repeated as necessary. 
• Metaraminol
• Acts directly on a1 receptors and also causes
  noradrenaline and adrenaline release.
• Actions Increases blood pressure and cardiac
  output. Less likely to cause a reflex bradycardia
  than methoxamine or phenylephrine.
• Dose - 1mg boluses iv, 2-10mg s/c or im, by
  infusion at 1-20mg/hr

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