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PIH and Eclampsia Anaesthetic implications

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PIH and Eclampsia Anaesthetic implications Speaker: Dr. Praveen Talawar Moderator: Dr Anjan Trikha www.anaesthesia.co.in anaesthesia.co.in_at_gmail.com – PowerPoint PPT presentation

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Title: PIH and Eclampsia Anaesthetic implications


1
PIH and Eclampsia Anaesthetic implications
  • Speaker Dr. Praveen Talawar
  • Moderator Dr Anjan Trikha

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
2
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 )

3
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

5
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

6
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

7
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
8
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

9
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
10
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
11
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)

12
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

13
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.

14
Control of seizures
  • Magnesium Sulphate
  • Diazepam
  • Phenytoin
  • Chlorpromazine
  • Phenobarbitone
  • Thiopentone

15
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)

16
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

17
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

18
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

19
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.

20
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
    min followed 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

21
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

22

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
23
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

24
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

25
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)

26
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

27
  • Phenytoin. 
  • Recent evidence no longer supports its use.

28
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

29
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)

30
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

31
  • 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

32
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

33
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

34
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

35
Platelet count RA
  • gt1,00,000 SAFE
  • gt75,000-80,000 Perhaps Safe
  • 50,000-75000 Significant
  • (grey zone) reluctance
  • lt50,000 Unsafe

36
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

37
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

38
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
39
? 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.

40
  • 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

41
  • Phenylephrine in Spinal Anesthesia in
    Preeclamptic Patients (2006)
  • Still recruiting participants
  • Verified on February 2011 by Northwestern
    University

42
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

43
  • 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

44
Indications for emergency delivery
  • Fetal distress
  • Increase in BP despite aggressive Rx
  • Worsening end organ function
  • HELLP syndrome
  • Development of eclampsia

45
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.

47
  • 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

48
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
49
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.

50
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

51
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

53
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

54
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

57
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
62
Comparison of GA vs. regional anaesthesia in
pre-eclampsia
Regional anaesthesia Regional anaesthesia GA GA
Advantages Dis advant Advantages Dis advant
Speed Spinals quick 5-10 mins. Epidural slow 20-30 mins. Fast lt5 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

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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

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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

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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

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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

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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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