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Hypertensive Disorders With Pregnancy

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Title: Hypertensive Disorders With Pregnancy


1
Hypertensive Disorders With Pregnancy
  • Amr Nadim, MD
  • Professor of Obstetrics Gynecology
  • Ain Shams Maternity and Womens Hospital
  • prof.amrnadim_at_gmail.com

2
  • C.G. is a 39 year old married white female
    gravida 2, para 0, with one spontaneous abortion
    who presented for prenatal care at 14 weeks
    gestation. Blood pressure at that time was
    130/80. The patient had no significant medical
    history and her gynecologic history was
    significant only for oral contraceptive use
    several years ago. The patient noted that her
    physician stopped the birth control pills after
    only two cycles, but the patient was not told
    why.
  • The pregnancy had been unremarkable until
    approximately one month ago when the patient
    noted increased swelling of her hands and feet. A
    6 Kg. weight gain in two weeks time was noted.
    Blood pressure at that time was 124/78. There was
    no urinary protein. On the day prior to
    admission, at 28 weeks, the patient presented
    with a blood pressure of 160/98 and had been sent
    home to bedrest with instructions to take a
    single baby aspirin daily. On the day following,
    the patient was noted at home to have a
    persistent blood pressure of 180/100.

3
Avant propos
  • Complicates 7-10 of pregnancies
  • 70 Preeclampsia-eclampsia
  • 30 Chronic hypertension
  • Eclampsia 0.05 incidence
  • 20 of Maternal Deaths
  • Cause of 10 of Preterm birth
  • Etiology unknown

4
  • Young female 3 fold increased risk
  • African American 2 fold increased risk
  • Multifetal pregnancies
  • Twins
  • Triplets
  • Hypertension
  • Diabetes Mellitus
  • Renal Disease
  • Collagen Vascular Disease

5
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6
Hypertension during Pregnancy Classification
  • Pregnancy-induced hypertension
  • Hypertension without proteinuria/edema
  • Preeclampsia
  • mild
  • severe
  • Eclampsia
  • Coincidental HTN preexisting or persistent
  • Pregnancy-aggravated HTN
  • superimposed preeclampsia
  • superimposed eclampsia
  • Transient HTN occurs in 3rd trimester, mild

7
Preeclampsia Definition
  • Hypertension
  • gt 140/90
  • relative ? no longer considered diagnostic
  • Proteinuria
  • gt 300 mg/24 hours or ? 1or 2 on urine dipstick
  • may occur late
  • Edema (non-dependent)
  • so common difficult to quantify it is rarely
    evoked to make or refute the diagnosis

8
Criteria for Severe Preeclampsia
  • SBP gt 160 mm Hg
  • DBP gt 110 mm Hg
  • Proteinuria gt 5 g/24 hr. or 3-4 on dipstick
  • Oliguria lt 500 cc/24 hr.
  • ? serum creatinine
  • Pulmonary edema or cyanosis
  • CNS symptoms (HA, vision changes)
  • Abdominal (RUQ) pain
  • Any feature of HELLP
  • hemolysis
  • ? liver enzymes
  • thrombocytopenia
  • IUGR or oligohydramnios

9
Preeclampsia Risk Factors
  • Nulliparity (or, more correctly, primipaternity)
  • Chronic renal disease
  • Angiotensinogen gene T235
  • Chronic hypertension
  • Antiphospholipid antibody syndrome
  • Multiple gestation
  • Family or personal history of preeclampsia
  • Age gt 40 years
  • African-American race
  • Diabetes mellitus

10
Etiology and Prevention
  • Etiology is unknown.
  • Many theories
  • genetic
  • immunologic
  • dietary deficiency (calcium, magnesium, zinc)
  • supplementation has not proven effective
  • placental source (ischemia)

11
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12
Etiology and Prevention
  • A major underlying defect is a relative
    deficiency of prostacyclin vs. thromboxane
  • Normally (non-preeclamptic) there is an 8-10 fold
    ? in prostacyclin with a smaller ? in thromboxane
  • prostacyclin salutatory effects dominate
  • vasodilation, ? platelet aggregation, ? uterine
    tone
  • In preeclampsia, thromboxanes effects dominate
  • ? thromboxane (from platelets, placenta)
  • ? prostacyclin (from endothelium, placenta)

13
Preeclampsia Prophylaxis Aspirin
  • Aspirin has been extensively studied as a
    targeted therapy to ? thromboxane production
  • CLASP study, A multicenter RCT
  • CLASP Collaborative Group, Lancet
    1994343619-29
  • 9364 women, risk factors for PIH or IUGR or who
    had PIH or IUGR
  • 60 mg ASA daily vs. placebo
  • Small reduction (12) in occurrence of PIH
  • Small reduction in preterm deliveries 20 vs 22
  • No difference in neonatal outcome

14
Preeclampsia Prophylaxis Aspirin
  • NIH study of high-risk patients, RCT, 60 mg
    aspirin daily vs. placebo Caritis, et al., N
    Engl J Med 1998338701-5
  • pre-gestational DM (471 patients)
  • chronic hypertension (774 patients)
  • multifetal gestations (688 patients)
  • prior history of preeclampsia (606 patients)
  • No reduction in development of preeclampsia in
    any subgroup or groups in aggregate
  • No difference in perinatal death, preterm
    delivery, IUGR, maternal or fetal hemorrhagic
    complications

15
Preeclampsia Mechanism
  • At this time the most widely accepted proposed
    mechanism for preeclampsia is
  • Global Endothelial Cell Dysfunction
  • Endothelial cell dysfunction is just one
    manifestation of a broader intravascular
    inflammatory response
  • present in normal pregnancy
  • excessive in preeclampsia
  • Proposed source of inflammatory stimulus placenta

16
Pathophysiology
  • Of importance, and distinguishing preeclampsia
    from chronic or gestational hypertension, is that
    preeclampsia is more than hypertension it is a
    systemic syndrome, and several of its
    non-hypertensive complications can be
    life-threatening when blood pressure elevations
    are quite mild.

17
Pathophysiology Cardiovascular
  • In severe preeclampsia, typically hyperdynamic
    with normal-high CO, normal-mod. high SVR, and
    normal PCWP and CVP.
  • Despite normal filling pressures, intravascular
    fluid volume is reduced (30-40 in severe PIH)
  • Variations in presentation depending on prior
    treatment and severity and duration of disease
  • Total body water is increased (generalized edema)

18
Pathophysiology Cardiovascular
  • Preeclamptic patients are prone to develop
    pulmonary edema due to reduced colloid oncotic
    pressure (COP), which falls further postpartum
  • Colloid oncotic pressure
  • Antepartum Postpartum
  • Normal pregnancy 22 mm Hg 17 mm Hg
  • Preeclampsia 18 mm Hg 14 mm Hg

19
Pathophysiology
  • Respiratory
  • Airway is edematous use smaller ET tube (6.5)
  • ? risk of pulmonary edema 70 postpartum
  • Renal
  • Renal blood flow GFR are decreased
  • Renal failure due to ? plasma volume or renal
    artery vasospasm
  • Proteinuria due to glomerulopathy
  • glomerular capillary endothelial swelling
    w/subendothelial protein deposits
  • Renal function recovers quickly postpartum

20
Pathophysiology Hepatic
  • RUQ pain is a serious complaint
  • warrants imaging, especially when accompanied by
    ? liver enzymes
  • caused by liver swelling, periportal hemorrhage,
    subcapsular hematoma, hepatic rupture (30
    mortality)
  • HELLP syndrome occurs in 20 of severe
    preeclamptics.

21
Pathophysiology
  • Coagulation
  • Generally hypercoagulable with evidence of
    platelet activation and increased fibrinolysis
  • Thrombocytopenia is common, but fewer than 10
    have platelet count lt 100,000
  • DIC may occur,
  • Acutely esp. with placental abruption
  • Neurologic
  • Symptoms headache, visual changes, seizures
  • Hyperreflexia is usually present
  • Eclamptic seizures may occur even w/out ??BP
  • Possible causes hypertensive encephalopathy,
    cerebral edema, thrombosis, hemorrhage, vasospasm

22
Hypertension during Pregnancy Classification
  • Pregnancy-induced hypertension
  • Hypertension without proteinuria/edema
  • Preeclampsia
  • mild
  • severe
  • Eclampsia
  • Coincidental HTN preexisting or persistent
  • Pregnancy-aggravated HTN
  • superimposed preeclampsia
  • superimposed eclampsia
  • Transient HTN occurs in 3rd trimester, mild

23
Classification
  • Chronic hypertension
  • Preeclampsia-eclampsia
  • Preeclampsia Superimposed upon chronic
    hypertension or Renal Disease
  • Gestational hypertension (only during pregnancy)
  • Transient hypertension (only after pregnancy)

24
Chronic Hypertension
  • Defined as hypertension diagnosed
  • Before pregnancy
  • Before the 20th week of gestation
  • During pregnancy and not resolved postpartum

25
Gestational Hypertension
  • Gestational Hypertension
  • Systolic gt140
  • Diastolicgt90
  • No Proteinurea
  • 25 Develop Pre-eclampsia

26
Gestational Hypertension
  • Diagnosis of gestational hypertension
  • Detected for first time after midpregnancy
  • No proteinuria
  • Only until a more specific diagnosis can be
    assigned postpartum
  • If
  • BP returns to normal by 12 weeks postpartum,
    diagnosis is transient hypertension.
  • BP remains high postpartum, diagnosis is chronic
    hypertension.
  • Proteinurea develops Superimposed Preeclampsia is
    diagnosed (25 incidence)

27
Preeclampsia-Eclampsia
  • Occurs after 20th week (earlier with
    trophoblastic disease)
  • Increased BP (gestational BP elevation) with
    proteinuria
  • LL Edema is NOT part of this definition

28
Diagnosis of Preeclampsia-Eclampsia
  • Gestational Hypertension
  • Systolic gt140
  • Diastolicgt90
  • Proteinuria is defined as urinary excretion
  • 0.3 g protein or greater in a 24-hour
  • 2 or greater on urine dip specimen

29
Blood Pressure Measurement
  • How would you measure the Blood Pressure for a
    pregnant lady?

30
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31
Preeclampsia-Eclampsia
  • Blood pressure
  • Measure blood pressure
  • in the sitting position,
  • with the cuff at the level of the heart.
  • Inferior vena caval compression by the gravid
    uterus while the patient is supine can alter
    readings substantially, leading to an
    underestimation of the blood pressure.
  • Blood pressures measured in the left lateral
    position similarly may yield falsely low values
    if the blood pressure is measured in the higher
    arm and the cuff is not maintained at heart
    level.
  • Allow women to sit quietly for 5-10 minutes
    before measuring the blood pressure.

32
Blood Pressure Assessment Patient preparation
and posture
  • Standardized technique
  • Patient
  • 1. No caffeine in the preceding hour.
  • 2. No smoking or nicotine in the preceding 15-30
    minutes.
  • 3. No use of substances containing adrenergic
    stimulants such as phenylephrine or
    pseudoephedrine (may be present in nasal
    decongestants or ophthalmic drops).
  • 4. Bladder and bowel comfortable.
  • 5. Quiet environment. Comfortable room
    temperature.
  • 6. No tight clothing on arm or forearm.
  • 7. No acute anxiety, stress or pain.
  • 8. Patient should stay silent prior and during
    the procedure.

33
Blood Pressure Assessment Patient preparation
and posture
  • Standardized technique
  • Posture
  • The patient should be calmly seated for at least
    5 minutes, with his or her back well supported
    and arm supported at the level of the heart. His
    or her feet should touch the floor and legs
    should not be crossed.
  • The patient should be instructed not to talk
    prior and during the procedure.

34
Recommended Technique for Measuring Blood
Pressure
  • Standardized technique
  • Use a mercury manometer or a recently calibrated
    aneroid or a validated electronic device.
  • Aneroid devices should only be used if there is
    an established calibration check every 6-12
    months.

35
Recommended Technique for Measuring Blood
Pressure
  • Electronic oscillometric devices
  • Use a validated electronic device according to
    BHS, AAMI or IP standards.
  • For self blood pressure measurement devices, a
    logo on the packaging ensures that this type of
    device and model meets the international
    standards for accurate blood pressure measurement.

AAMIAssociation for the Advancement of Medical
Instrumentation BHSBritish Hypertension
Society IP International Protocol.
36
Recommended Technique for Measuring Blood
Pressure (cont.)
  • Select a
  • cuff with the appropriate size

37
Cuff size
Arm circumference (cm) Size of Cuff (cm)
From 18 to 26 9 x 18 (child)
From 26 to 33 12 x 23 (standard adult model)
From 33 to 41 15 x 33 (large, obese)
More than 41 18 x 36 (extra large, obese)
38
Recommended Technique for Measuring Blood
Pressure (cont.)
  • Locate brachial and radial pulse
  • Position cuff at the heart level
  • Arm should be supported

39
Recommended Technique for Measuring Blood
Pressure (cont.)
  • To exclude possibility of auscultatory gap,
    increase cuff pressure rapidly to 20-30 mmHg
    above level of disappearance of radial pulse
  • Place stethoscope over the brachial artery

40
Recommended Technique for Measuring Blood
Pressure (cont.)
  • Drop pressure by 2 mmHg / sec
  • Appearance of sound (phase I Korotkoff)
    systolic pressure
  • Record measurement
  • Drop pressure by 2 mmHg / beat
  • Disappearance of sound (phase V Korotkoff)
    diastolic pressure
  • Record measurement
  • Take 2 blood pressure measurements, 1 minute apart

41
Recommended Technique for Measuring Blood
Pressure (cont.)
Systolic BP
Diastolic BP
42
Preeclampsia-Eclampsia
  • Blood pressure
  • Record Korotkoff sounds I (the first sound) and V
    (the disappearance of sound) to denote the
    systolic blood pressure (SPB) and DPB,
    respectively.
  • In about 5 of women, an exaggerated gap exists
    between the fourth (muffling) and fifth
    (disappearance) Korotkoff sounds, with the fifth
    sound approaching zero. In this setting, record
    both the fourth and fifth sounds (eg, 120/80/40
    with sound I 120, sound IV 80, sound V 40).

43
Recommended Technique for Measuring Blood
Pressure
  • Standardized technique
  • For initial readings, take the blood pressure in
    both arms and subsequently measure it in the arm
    with the highest reading.
  • Thereafter, take two measurements on the side
    where BP is highest.

44
Recommended Technique for Measuring Blood
Pressure (cont.)
Record the blood pressure to the closest 2 mmHg
on the manometer as well as the arm used and
whether the patient was supine, sitting or
standing.
45
Recommended Technique for Measuring Blood
Pressure (cont.)
  • Avoid digit preference for five (5) or zeros (0)
    by not rounding up or down.
  • Record the heart rate.

46
Recommended Technique for Measuring Blood
Pressure (cont.)
  • The seated blood pressure is used to determine
    and monitor treatment decisions.
  • The standing blood pressure is used to test for
    postural hypotension, if present, which may
    modify the treatment.

47
Blood Pressure Assessment Patient preparation
and posture
Standing position For patients over age 65,
diabetics and patients being treated with
antihypertensives, check if there are postural
changes while taking blood pressure reading, i.e.
after one to five minutes in the standing
position and under circumstances when the
patients complains of symptoms suggestive of
hypotension.
48
Classification of Preeclampsia-Eclampsia
  • Mild Pre-eclampsia
  • Severe Pre-eclampsia

49
Classification of Preeclampsia-Eclampsia
  • Criteria for Severe Preeclampsia (one or more)
  • Blood Pressure gt160 systolic, gt110 diastolic
  • Proteinurea gt5gm in 24 hours, over 3 urine dip
  • Oligurea less than 400ml in 24 hours
  • CNS Visual changes, headache, scotomata, mental
    status change
  • Pulmonary Edema
  • Epigastric or RUQ Pain Usually indicates liver
    involvement

50
Classification of Preeclampsia-Eclampsia
  • Criteria for Severe Preeclampsia (one or more)
  • Impaired Liver Function tests
  • Thrombocytopenia lt100,000
  • Intrauterine Growth Restriction With or without
    abnormal doppler assessment
  • Oligohydramnios

51
Classification of Preeclampsia Superimposed Upon
Chronic Hypertension
  • Hypertension and no proteinuria lt 20 weeks
  • New-onset proteinuria after 20 weeks
  • Hypertension and proteinuria lt 20 weeks
  • Sudden increase in proteinuria
  • Sudden increase in BP in women whose hypertension
    was well controlled
  • Thrombocytopenia (platelet count lt100,000
    cells/mm3)
  • Increase in ALT or AST to abnormal levels

52
Clinical Implications of Preeclampsia
  • Preeclampsia ranges from mild to severe.
  • Progression may be slow or rapid hours to days
    to weeks.
  • For clinical management, preeclampsia should be
    over diagnosed to prevent maternal and perinatal
    morbidity and mortality primarily through
    timing of delivery.

53
Symptoms of Preeclampsia
  • Visual disturbances typical of preeclampsia are
    scintillations and scotomata. These disturbances
    are presumed to be due to cerebral vasospasm.
  • Headache is of new onset and may be described as
    frontal, throbbing, or similar to a migraine
    headache. However, no classic headache of
    preeclampsia exists.
  • Epigastric pain is due to hepatic swelling and
    inflammation, with stretch of the liver capsule.
    Pain may be of sudden onset, it may be constant,
    and it may be moderate-to-severe in intensity.

54
Symptoms of preeclampsia
  • While mild lower extremity edema is common in
    normal pregnancy, rapidly increasing or
    nondependent edema may be a signal of developing
    preeclampsia. However, this signal theory remains
    controversial and recently has been removed from
    most criteria for the diagnosis of preeclampsia.
  • Rapid weight gain is a result of edema due to
    capillary leak as well as renal sodium and fluid
    retention.

55
Physical Findings in Preeclampsia
  • Blood Pressure
  • Proteinurea
  • Retinal vasospasm or Retinal edema
  • Right upper quadrant (RUQ) abdominal tenderness
    stems from liver swelling and capsular stretch

56
Physical findings in Preeclampsia
  • Brisk, or hyperactive, reflexes are common during
    pregnancy, but clonus is a sign of neuromuscular
    irritability that raises concern.
  • Among pregnant women, 30 have some lower
    extremity edema as part of their normal
    pregnancy. However, a sudden change in dependent
    edema, edema in nondependent areas such as the
    face and hands, or rapid weight gain suggests a
    pathologic process and warrants further evaluation

57
Differential Diagnosis
  • Documentation of HBP before conception or before
    gestational week 20 favors a diagnosis of chronic
    hypertension (essential or secondary).
  • HBP presenting at midpregnancy (weeks 20 to 28)
    may be due to early preeclampsia, transient
    hypertension, or unrecognized chronic
    hypertension.

58
Laboratory Tests
  • High-risk patients presenting with normal BP
  • Hematocrit
  • Hemoglobin
  • Serum uric acid
  • If 1 protein by routine urinalysis (clean catch)
    present obtain a timed collection for protein and
    creatinine
  • Accurate dating and assessment of fetal growth
  • Baseline sonogram at 25 to 28 weeks

59
Laboratory Tests
  • Patients presenting with hypertension before
    gestation week 20
  • Same tests as described for high-risk patients
    presenting with normal BP
  • Early baseline sonography for dating and fetal
    size

60
Laboratory Tests
  • Patients presenting with hypertension after
    midpregnancy
  • Quantification of protein excretion
  • Hemoglobin and hematocrit and platelet count
  • Serum creatinine, uric acid, and transaminase
    level
  • Serum albumin, LDH, blood smear, and coagulation
    profile

61
Preeclampsia Treatment
  • Goal is to prevent eclampsia and other severe
    complications.
  • Attempts to treat preeclampsia by natriuresis or
    by lowering BP may exacerbate pathologic changes.
  • Palliate maternal condition to allow fetal
    maturation and cervical ripening.

62
Preeclampsia Treatment
  • Maternal Evaluation
  • Goals
  • Early recognition of preeclampsia
  • Observe progression, both to prevent maternal
    complications and protect well-being of fetus.
  • Early signs
  • BP rises in late second and early third
    trimesters.
  • Initial appearance of proteinuria is important.

63
Fetal Monitoring
64
Preeclampsia Treatment
  • Maternal EvaluationWhen To Hospitalize?
  • Often, hospitalization recommended with new-onset
    preeclampsia to assess maternal and fetal
    conditions.
  • Hospitalization for duration of pregnancy
    indicated for preterm onset of severe
    gestational hypertension or preeclampsia.
  • Ambulatory management at home or at day-care unit
    may be considered with mild gestational
    hypertension or preeclampsia remote from term

65
Preeclampsia
66
Indication of Delivery
67
Preeclampsia
  • Antepartum Management of Preeclampsia
  • Little to suggest therapy alters the underlying
    pathophysiology of preeclampsia.
  • Restricted activity may be reasonable.
  • Sodium restriction and diuretic therapy appear
    to have no positive effect.

68
Obstetric Management
  • Classically stabilize and deliver

69
Obstetric Management
  • Medical management while awaiting delivery
  • use of steroids X 48 hours if fetus lt 34 wks
  • antihypertensives to maintain DBP lt 105-110
  • magnesium sulfate for seizure prophylaxis
  • monitor fluid balance, I/O, daily weights,
    symptoms, reflexes, HCT, plts, LFTs, proteinuria

70
Obstetric Management
  • Indications for expedited delivery
  • fetal distress
  • ? BP despite aggressive Rx
  • worsening end-organ function
  • development or worsening of HELLP syndrome
  • development of eclampsia

71
Antihypertensive Therapy
  • Most commonly, for acute control hydralazine,
    labetolol
  • Nifedipine may be used, but unexpected
    hypotension may occur when given with MgSO4
  • For refractory hypertension nitroglycerin or
    nitroprusside may be used
  • Nitroprusside dose and duration should be limited
    to avoid fetal cyanide toxicity
  • Usually require invasive arterial pressure mon
  • Angiotensin-converting enzyme (ACE) inhibitors
    contraindicated due to severe adverse fetal
    effects

72
Seizure Prophylaxis Treatment
  • Magnesium sulfate vs. phenytoin for seizure
    prophylaxis in preeclampsia
  • Lucas, et al., N Engl J Med 1995333201-5.
  • 2138 patients (75 had mild PIH)
  • Maternal fetal outcomes similar except 10
    seizures in the phenytoin group (0 in MgSO4)
  • Mg vs. diazepam Mg vs. phenytoin for preventing
    recurrent seizures in eclamptics
  • Eclampsia Trial Collaborative Group, Lancet
    19953451455
  • Mg pts were 52 or 67 less likely to have a
    recurrent seizure than diazepam or phenytoin pts

73
Seizure Prophylaxis
  • Evidence is strong that magnesium sulfate is
    indicated for
  • seizure treatment in eclamptics
  • seizure prophylaxis in severe preeclamptics
  • Role of magnesium prophylaxis in mild
    preeclamptics is less clear
  • awaits large, prospective, randomized,
    placebo-controlled trial

74
Magnesium Sulfate
  • Magnesium sulfate has many effects its mechanism
    in seizure control is not clear.
  • NMDA (N-methyl-D-aspartate) antagonist
  • vasodilator
  • Brain parenchymal vasodilation demonstrated in
    preeclamptics by Doppler ultrasonography
  • increases release of prostacyclin
  • Potential adverse effects
  • toxicity from overdose (respiratory, cardiac)
  • ? bleeding
  • ? hypotension with hemorrhage
  • ? uterine contractility

75
Magnesium Sulfate
  • Renally excreted
  • Preeclamptics prone to renal failure
  • Magnesium levels must be monitored frequently
    either clinically (patellar reflexes, urinary
    output) or by checking serum levels q 6-8 hours
  • Therapeutic level 4-7 meq/L
  • Patellar reflexes lost 8-10 meq/L
  • Respiratory depression 10-15 meq/L
  • Respiratory paralysis 12-15 meq/L
  • Cardiac arrest 25-30 meq/L
  • Treatment of magnesium toxicity
  • stop MgSO4, IV calcium, manage airway

76
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77
Treatment of Eclampsia
  • Seizures are usually short-lived.
  • If necessary, small doses of barbiturate or
    benzodiazepine (STP, 50 mg, or midazolam, 1-2 mg)
    and supplemental oxygen by mask.
  • If seizure persists or patient is not breathing,
    rapid sequence induction with cricoid pressure
    and intubation should be performed.
  • Patient may be extubated once she is completely
    awake, recovered from neuromuscular blockade, and
    magnesium sulfate has been administered.

78
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

79
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

80
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 199786273

81
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 anesthesia.

82
Hazards of General Anesthesia in Preeclampsia
  • Airway edema is common
  • Mandatory to reexamine the airway soon before
    induction
  • Edema may appear or worsen at any time during the
    course of disease
  • tongue facial, as well as laryngeal
  • Laryngoscopy and intubation may ? severe ?BP
  • Labetolol NTG are commonly used acutely
  • Fentanyl (2.5 mcg/kg), alfentanil (10 mcg/kg),
    lidocaine may be given to blunt response

83
Hazards of General Anesthesia in Preeclampsia
  • Magnesium sulfate potentiates depolarizing
    non-depolarizing muscle relaxants
  • Pre-curarization is not indicated.
  • Initial dose of succinylcholine is not reduced.
  • Neuromuscular blockade should be monitored
    reversal confirmed.

84
Invasive Central Hemodynamic Monitoring in
Preeclampsia
  • Usually reserved for patients with complications
  • oliguria unresponsive to modest fluid challenge
    (500 cc LR X 2)
  • pulmonary edema
  • refractory hypertension
  • may have increased CO or increased SVR
  • Poor correlation between CVP and PCWP in PIH
  • However, at most centers anesthesiologists would
    begin with CVP follow trend
  • not arbitrarily hydrate to a certain number
  • If poor response, change to PA catheter

85
Conclusions
  • Preeclampsia is a serious multi-organ system
    disorder of pregnancy that continues to defy our
    complete understanding.
  • It is characterized by global endothelial cell
    dysfunction.
  • The cause remains unknown.
  • There is no effective prophylaxis.

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Conclusions
  • Delivery is the only effective cure.
  • Magnesium sulfate is now proven as the best
    medication to prevent and treat eclampsia.
  • Epidural analgesia for labor pain management
    regional anesthesia for C/S have many beneficial
    effects are preferred.

87
Antihypertensive Therapy
  • Patients with chronic hypertension should
    continue on their pre-pregnancy medication if NOT
    contraindicated with pregnancy.
  • The usual cut off to prescribe Antihypertensives
    with pregnancy is 150/100.
  • Care should be taken NOT to compromise the fetal
    circulation by bringing the blood pression down
    to normal.

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Alpha-methyl Dopa
  • The most commonly used and presumably the safest
    with pregnancy.
  • The usual dose starts with 250mg tds to be
    increased up to 2 grams per day.
  • It blocks the adrenaline release at post synaptic
    sites.

89
Hydralazine
  • Dose 5-10 mg every 20 minutes
  • Onset 10-20 minutes
  • Duration 3-8 hours
  • Side effects headache, flushing, tachycardia,
    lupus like symptoms
  • Mechanism peripheral vasodilator

90
Labetalol
  • Dose
  • IV20mg, then 40, then 80 every 20 minutes, for a
    total of 220mg
  • Oral 100 mg bid to be increased up to 200 mg qid.
    ( maximum 2400mg daily)
  • Onset 1-2 minutes
  • Duration 6-16 hours
  • Side effects hypotension
  • Mechanism Alpha and Beta block

91
Nifedipine
  • Dose 10 mg po, not sublingual
  • Onset 5-10 minutes
  • Duration 4-8 hours
  • Side effects chest pain, headache, tachycardia
  • Mechanism CA channel block

92
Clonidine
  • Dose 1 mg po
  • Onset 10-20 minutes
  • Duration 4-6 hours
  • Side effects unpredictable, avoid rapid
    withdrawal
  • Mechanism Alpha agonist, works centrally

93
Nitroprusside
  • Dose 0.2 0.8 mg/min IV
  • Onset 1-2 minutes
  • Duration 3-5 minutes
  • Side effects cyanide accumulation, hypotension
  • Mechanism direct vasodilator

94
Preeclampsia
  • Indications for Delivery in Preeclampsia
  • Maternal
  • Gestational age 38 weeks
  • Platelet count lt 100,000 cells/mm3
  • Progressive deterioration in liver and renal
    function
  • Suspected abruptio placentae
  • Persistent severe headaches, visual changes,
    nausea, epigastric pain, or vomiting

Delivery should be based on maternal and fetal
conditions as well as gestational age.
95
Preeclampsia
  • Indications for Delivery in Preeclampsia
  • Fetal
  • Severe fetal growth restriction
  • Nonreassuring fetal testing results
  • Oligohydramnios

96
Preeclampsia
  • The cure for preeclampsia is delivery
  • The cure is always beneficial for the mother,
    although c-section might be needed
  • The cure may be deleterious for the fetus

97
Preeclampsia
  • Route of Delivery
  • Vaginal delivery is preferable.
  • Aggressive labor induction (within 24 hours).
  • Neuraxial (epidural, spinal, and combined
    spinal-epidural) techniques offer advantages.
  • Hydralazine, nitroglycerin, or labetalol may be
    used as pretreatment to reduce significant
    hypertension during delivery.

98
Preeclampsia
  • Anticonvulsive Therapy
  • Indicated to prevent recurrent convulsions in
    women with eclampsia or to prevent convulsions in
    women with preeclampsia.
  • Parenteral magnesium sulfate reduces the
    frequency of eclampsia and maternal death.
    (Caution in renal failure.)

99
Treatment of Acute Severe Hypertension in
Pregnancy
  • SBP gt 160 mm Hg and/or DBP gt 105 mm Hg
  • Parenteral hydralazine is most commonly used.
  • Parenteral labetalol is second-line drug (avoid
    in women with asthma and CHF.)
  • Oral nifedipine used with caution.
    (Short-acting nifedipine is not approved by FDA
    for managing hypertension.)
  • Sodium nitroprusside may be used in rare cases.

100
Postpartum Counseling and Followup
  • Counseling for Future Pregnancies
  • Risk of recurrent preeclampsia increases with
  • Preeclampsia before 30 weeks (40)
  • Multiparas as compared with nulliparas or new
    father
  • Risk of recurrent preeclampsia may be
    substantially greater in African Americans.

101
Remote Prognosis
  • Preeclampsia-Eclampsia
  • The more certain the diagnosis of preeclampsia,
    the lower the prevalence of remote cardiovascular
    disorders.
  • Preeclampsia-eclampsia in subsequent pregnancies
    helps define future risk.
  • Gestational hypertension in any pregnancy
    increases remote cardiovascular risk.

102
Eclampsia
  • Women older than 40 years with preeclampsia have
    4 times the incidence of seizures compared to
    women in their third decade of life.
  • Twenty-five percent of eclampsia cases occur
    before labor (ie, antepartum).
  • Fifty percent of eclampsia cases occur during
    labor (ie, intrapartum).
  • Twenty-five percent of eclampsia cases occur
    after delivery (ie, postpartum).
  • Patients with severe preeclampsia are at greater
    risk to develop seizures.
  • Twenty-five percent of patients with eclampsia
    have only mild preeclampsia prior to the seizures

103
Causes
  • The cause of the seizures is not clear, although
    several processes have been implicated in their
    development.
  • Areas of cerebral vasospasm may be severe enough
    to cause focal ischemia, which may in turn lead
    to seizures.
  • Pathologic alterations in cerebral blood flow and
    tissue edema induced by vasospasm may result in
    headaches, visual disturbances, and hypertensive
    encephalopathy, resulting in a seizure.

104
  • Prior to the seizures, Symptoms include the
    following
  • Headache (82.5)
  • Hyperactive reflexes (80)
  • Marked proteinuria (52)
  • Generalized edema (49)
  • Visual disturbances (44.4)
  • Right upper quadrant pain or epigastric pain
    (19)
  • Sometimes, there is
  • Lack of edema (39)
  • Absence of proteinuria (21)
  • Normal reflexes (20)

105
Eclamptic seizure
  • The patient may have 1 or more seizures.
  • Seizures generally last 60-75 seconds.
  • The patient's face initially may become
    distorted, with protrusion of the eyes.
  • The patient may begin foaming at the mouth.
  • Respiration ceases for the duration of the
    seizure.

106
  • The seizure may be divided into 2 phases
  • Phase 1 lasts 15-20 seconds and begins with
    facial twitching. The body becomes rigid, leading
    to generalized muscular contractions.
  • Phase 2 lasts approximately 60 seconds. It starts
    in the jaw, moves to the muscles of the face and
    eyelids, and then spreads throughout the body.
    The muscles begin alternating between contracting
    and relaxing in rapid sequence.
  • A coma or a period of unconsciousness follows
    phase 2.
  • Unconsciousness lasts for a variable period.
  • Following the coma phase, the patient may regain
    some consciousness.
  • The patient may become combative and very
    agitated.
  • The patient has no recollection of the seizure.
  • A period of hyperventilation occurs after the
    tonic-clonic seizure. This compensates for the
    respiratory and lactic acidosis that develops
    during the apneic phase.
  • Seizure-induced complications may include tongue
    biting, head trauma, broken bones, or aspiration.

107
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