Speaker : Dr omar kamal

Name: Mrs. Nagalakshmi B D

Age: 33 yrs

W/O: Mr. Harish

IP No.: 98870

Place : bangalore

Occupation : Housewife

Date of Admission :18/10/13

Date of surgery 18/10/13

Chief complaints :

h/o 8 months of amenorrhoea

h/o Swelling of B/l lower limbs since 15 days

HOPI :

Patient with 8 months of amenorrhea appreciating fetal movements well, was apparently normal 15 days back, when she started noticing swelling of both lower limbs, aggravated by work , no diurnal or postural variation, present through out day

No H/o headache, blurring of vision, epigastric pain, bowel/bladder disturbances, fever, rashes, bleeding

Obstetric History: ML: 12 years NCM G2P1L1

1st Pregnancy: in 2006 , FTVD of live male baby of weight 2.5kg at Bangalore hospital. No antenatal/ Intrapartum/Postpartum complications . Breast fed for 6 months . H/o using male barrier contraception .

2nd pregnancy: Present pregnancy, spontaneous conception

1st Trimester : Pregnancy diagnosed by UPT ; +ve after 5 week of LMP. Started on Folic acid supplementation . Blood investigations and scan done on 17/4/13 showed SLIUG . No H/o fever, rashes, excessive vomiting, pain abdomen, bleeding/spotting PV.

2nd trimester: Quickening felt at 4th month of gestation. Continued folic acid. Started on Iron/Calcium supplementation. Immunised with 2 doses of Inj.T.T. Scan on 14/6/13 showing SLIUG of 18+2 weeks at 18+2 weeks by LMP, fetal dopplernormal.

3rd trimester: Appreciates fetal movements well, continued iron/calcium/ folic acid. Patient had increased readings of BP since 30 weeks .Tab. Methyldopa 250 mg BD started.

now referred to hospital with above complaints for further management

Menstrual History: PMC: 3-4/ 24-25 days, regular, normal flow, no clots

LMP- 8/2/13 EDD- 15/11/13 POG- 36 wks

Past History : No H/o Diabetes/hypertension/ Tuberculosis/ epilepsy/ Thyroid disorders.

Family History: No H/o Diabetes/ Tuberculosis/ epilepsy/ Thyroid disorders.

O/E

Moderately built and nourished. conscious and cooperative

Vitals :

PR 88/min and regular

BP 150/90 mmHg measured in sitting position

Afebrile

B/l pedal edema

No pallor ,icterus cyanosis ,clubbing or lymphadenopathy

Facies No abnormality

Upper incisors no loose or protruding teeth

Nose both nares patent no nasal airflow obstruction

Mallampati Class 2

Thyromental distance >3fingers

Mouth opening adequate

Movement at atlanto occipetal joint normal

No obvious external pathology

RS : B/L air entry equal NVBS

CVS : S1S2 heard, no murmur

P/A-Uterus 32-34 size, relaxed, cephalic lower pole , non tense, non tender , FHS+ 148 bpm regular

PROVISIONAL DIAGNOSIS

33 yrs female, G2P1L1 with 36 wks of gestation with SLIUG, with mild pre eclampsia

In 2000, National High Blood Pressure Education Program classified hypertensive disorders complicating pregnancy as:

Gestational hypertension

Preclampsia- eclampsia

chronic hypertension

chronic hypertension with superimposed preeclampsia

Blood Pressure ≥ 140/90 on two or more occasions

- in a previously normotensive patient

- after 20 weeks gestation

- without proteinuria

- returning to normal 12 weeks after delivery

Almost half of these develop preeclampsia syndrome

Blood Pressure ≥ 140/90 before 20 weeks of gestation

Or

Persistence of hypertension beyond 12 weeks after delivery

New-onset proteinuria ≥ 300 mg/24 hours in chronc hypertensive women but no proteinuria before 20 weeks gestation

A sudden increase in proteinuria or blood pressure or platelet count <1 lakh/mm3 in women with hypertension and proteinuria before 20 weeks’ gestation

New onset of hypertension & proteinuria in a previously normotensive woman

after 20 weeks of gestation

Returning to normal after 12 weeks of delivery.

Edema not a part of diagnosis now.

Eclampsia :

New onset of seizures or unexplained coma during pregnancy or postpartum period in patients with pre-existing preeclampsia and without pre-existing neurological disorder

The NHBPEP has recommended that clinicians consider the diagnosis of preeclampsia in the absence of proteinuria when any of the following findings are present:

1) Persistent epigastric or right upper quadrant pain,

2) Persistent cerebral symptoms,

3) Fetal growth restriction,

4) Thrombocytopenia,

5) Elevated serum liver enzyme concentrations

• Preconception- Partner related Nulliparity

limited exposure to paternal sperms

Partner who fathered a preeclamptic pregnancy in another women

-Non partner related History of Preeclampsia in previous pregnancy

Advanced maternal age

Family history of Preeclampsia

History of placental abruptio, IUGR, fetal death

-Maternal disease related Obesity, BMI>35 doubles the risk

Hypertension

Diabetes

Thrombotic vascular diseases

-Behaviour-

Smoking :

-Pregnancy associated- Multiple gestation

Molar pregnancy

Exact mechanism unknown, disease of theories.

1. ABNORMAL PLACENTATION

Stage1: failure of trophoblastic invasion into myometrium

Penetrates only decidua

superficial placentation ↓placental perfusion

stage2 : endothelial damage

systemic manifestations of Preeclampsia

Family history of pre eclampsia: genetic origin

Mutations in Complement Regulatory Protein gene

Genes assoc.:

MTHFR, F5 leiden, AGT, HLA, NOS3, F2(prothrombin), ACE

Exposure to sperms of different partner

long term exposure to paternal antigen in sperms of same partner- protective

activated auto antibodies to angiotensin receptor-1 AA-AT1activate AT1 receptorsincreased sensitivity to angiotensins

hypertension

↑ plasma Homocystiene

↑ serum sFlt1(soluble fms-like tyosine kinase)

↓serum and urinary Platelet Growth Factor

↓ Vascular Endothelial Growth Factor

1. Respiratory Airway is edematous;

↓ internal diameter of trachea due to capillary engorgement

Pharyngolaryngeal edema visualization difficult

Subglottic edema – airway obstruction

CNS manifestations include:

headache,

visual disturbances,

hyperexcitability, hyperreflexia,

coma, seizures

Cause: cerebral edema and hypoperfusion

Vasospasm and exaggerated responses to catecholamines

Characteristically, blood pressure and SVR are elevated

Severe preeclampsia is usually a hyperdynamicstate

Pulmonary edema is a severe complication – 3 %

Plasma colloid osmotic pressure is diminished and increased vascular permiability influences PE

T3 POST PARTUM

NORMAL 22 17

PRE ECLAMPSIA 18 14

Hemoconcentration

Thombocytopaenia most common

Platelet count correlates with disease severity and incidence of abruptio placentae

DIC due to activation of coagulation cascadeoverconsumption of coagulants and platelets spontaneous haemorrhage

HELLP syndrome

Periportal haemorrhage

subcapsular bleeding

hepatic rupture: 32% maternal mortality

Decreased GFR 34 % than normal

- oliguria

- renal failure

- uric acid, creatinine is elevated

Glomerulopathy

- proteinuria

The characteristic renal histologic lesion is glomerular capillary endotheliosis

Uteroplacental insufficiency

Fetal complications:

- hypoxia

-IUGR

-Prematurity

-IUD

-Placental abruptio

No screening test is really helpful

Various screening methods are:

Diastolic notch at 24weeks by doppler ultrasonography

Absence or reversal of end diastolic flow

Average mean arterial pressure ≥ 90 mmHg in second trimester

Angiotensin infusion test: angiotensin infusion required to raise the blood pressure >20 mm Hg from baseline

Roll over test: rise in blood pressure >20 mmHg from baseline on turning supine at 28-32 weeks gestation is positive.

Regular Antenatal checkup:rapid gain in weightrising blood pressureedemaproteinuria/deranged liver or renal profile

Low dose Aspirin in High risk group: ↑PGs and↓TXA2 Calcium supplementation: no effects unless women

are calcium deficient Antioxidants- Vitamin C and E Nutritional supplementation: zinc, magnesium, fish

oil, low salt diet

Maternal

Gestational age 38 weeks*

Platelet count <100,000/mm3

Progressive deterioration in hepatic function

Progressive deterioration in renal function

Suspected placental abruption

Persistent severe headaches or visual changes

Persistent severe epigastric pain, nausea, or

vomiting

Fetal

Severe intrauterine growth restriction

Nonreassuring fetal status

Oligohydramnios

Obstetric Management

. Maternal evaluation :

Hemoglobin and hematocrit

platelet count : decreased, if < 1 lakh coagulation profile

LFTs : indicated in all patients

KFTs : raised (S.urea creatinine is decresaed in Normal pregnancy)

Urine Routine : proteinuria

Fetal evaluation :

Daily fetal movement count

Ultrasound

Doppler ultrasound for fetal blood flow

Velocimetry

. Seizure Prophylaxis

Routinely used in severe PE

Magnesium sulphate: most commonly used

Initiated with onset of labor till 24h postpartum

For caesarean, started 2hrs before the section till 12hrs postpartum

Delivery

The only definitive treatment

Preeclamptic patients divided into 3 categories

A- Preeclampsia features fully subside

B- partial control, but BP maintains a steady high level

C- persistently increasing BP to severe level

Gp A: can wait till spontaneous onset of labor

don’t exceed Expected Date of Delivery

Gp B: >37wk terminate w/o delay

<37wk, expectant management at least till 34wks

Gp C: terminate irrespective of POG,

start seizure prophylaxis and

steroids if<34wks

Anaesthetic management

Is the diagnosis correct

Condition of mother before the start of anaesthetic

Evidence of end organ damage

Airway

Haemodynamic monitoring

Fluid status: volume depleted patients

BP control

Coagulation status

Choice of anesthetic technique for LSCS

Evidence of recent bleeding causing hemodynamic instability.

Drug history and status of the fetus

Laboratory investigations

Hematocrit

Platelet count /PT/PTT

Abnormal liver enzymes

Signs of Hemolysis (elevated LDH, Bilirubin)

Uric acid, Urea , Creatinine ,Proteinuria

MEDICAL

General Measures-

Good rest , Salt restricted diet in severe cases,regularfollow up ,identification of risk factors and use of predictors.

Specific Measures

Antihypertensive drug therapy

To establish & maintain hemodynamic stability (control hypertension & avoid hypotension)

To provide excellent labor analgesia

To prevent complications of preeclampsia

To be able to rapidly provide anesthesia for Caesarean Section

Neuraxial analgesia:

Lumbar Epidural-

gradual onset of sympathetic blockade

cardiovascular stability

↓ stress response

maintains uteroplacental circulation

avoids neonatal depression

extended analgesia if cesarean required

excellent post op analgesia

Combined Spinal Epidural AnalgesiaAdvantages

(1) provision of high-quality analgesia, which attenuates the hypertensive response to pain

(2) reduction in levels of circulating catecholamines(3) improvement in intervillous blood flow(4) Provision of anesthesia through catheter for

emergency cesarean deliveryDisadvantage epidural catheter function cannot be fully evaluated until

after resolution of the intrathecal analgesia

special considerations in pre eclampsia

(1) assessment of coagulation status,

(2) intravenous hydration prior to the epidural administration of LA

(3) treatment of hypotension,

(4) use of an epinephrine-containing LA solution

Acid aspiration prophylaxis given

1. H2 blockers

2. non particulate antacid

3. metoclopramide

Routine

Heart rate ,

Blood pressure ,

Pulse oximetry ,

Temperature monitoring ,

Urine output ,

Neuromuscular monitoring and

Capnography

Invasive central blood pressure monitoring not routinely indicated

Does not improve patient outcome

Indications:-Oliguria patients-Unresponsive or refractory hypertension-Persistent arterial desaturation-Pulmonary edema- massive hemorrhage-frequent ABG measurement

Begins with the securing of a good IV access and

rapid fluid administration , An 18G is provided .

Choice of fluid should be isotonic saline or isotonic solution containing electrolytes.

Only dextrose containing solutions should be avoided as oxytocin infusions are known to have an antidiuretic effect and can result in water intoxication

Patient transfers should be in left lateral position and positioned same on table

Spinal anaesthesia

Epidural anaesthesia

Combined Spinal Epidural Anaesthesia

General anaesthesia

Spinal anesthesia is a generally preferred anesthetictechnique in emergency

Simple to perform, provides rapid onset and a dense block

spinal anesthesia can be safely used with 0.5 % bupivacaine (5 – 10mg) along with 20 micg fentanyl

Epidural anesthesia considered the optimal anesthetic technique for cesarean delivery

Advantages

relatively stable maternal BP

Increased uteroplacental blood flow

ability to titrate the administration of LA and intravenous fluids

reduce the possibility of fluid overload and pulmonary edema.

post op analgesia

Extension of an existing continuous lumbar epidural aneshesia

Injection of 8 to 10 ml of 1.5 to 2 % lidocaine with epinephrine 1 : 200000, 0.5 % bupivacaine , or 0.5 % ropivacaine provides level of T 10 analgesia

Addition of 25 – 50 micg fentanyl to LA will

• speed up the onset of block

• improve the quality and duration

• decrease visceral discomfort associated with uterine exteriorization, interiorization, peritoneal retraction

platelet count lower than 50,000/mm3 precludes the administration of neuraxial anesthesia.

For women with a platelet count between 50,000/mm3 and 80,000/mm3, the risks and benefits of neuraxialanesthesia must be weighed against the risks of general anesthesia

A platelet count of 75,000/mm3 to 80,000/mm3 for epidural catheter removal

Indications

- coagulopathy

-sustained fetal bradycardia with reassuring maternal airway

- severe ongoing maternal hemorrhage

- patients refusal

- contraindications to neuraxial technique

1.Difficult intubation--smaller size tube-difficult airway cart ready

2. Exaggerated and prolonged hypertensive response to laryngoscopy and intubation: -risk of intracranial hemorrhage.

-labetalol(10 mg), esmolol( 2mg/kg ), nitroglycerine (0.1 mg/kg/min), nitroprusside(0.5mcg/kg/min)remifentanyl (1mcg/kg)

3.MgSO4 prolong action of both depolarising and NDMR , as it inhibits calcium facilitated presynaptic transmitter release

4. Impairs uterine and intervillous blood flow

5. Acid aspiration prophylaxis followed

1. Induction :

Denitrogenation for 3 mins of 100 % oxygen

rapid sequence induction

induced with thiopentone(4-5 mg/kg) and Sch(1-1.5mg/kg)

2. Intubation :

small size cuffed ETT 6 to 6.5

difficult airway cart should be ready

3. Maintenance :

Maintained with 50 % N20 in O2 and volatile halogenated agent ( isolflurane, desflurane )

after delivery, inhalational agent decreased

ratio of N2O: O2 increased to 70 : 30

narcotics, BZD administered

4. Extubation :

exaggerated CVS response should be avoided by pre treating with lignocaine or esmolol

5. Post operative pain relief :

Intravenous or epidural opioids like fentanyl

Neonate of PIH mother is at higher risk for

prematurity

SGA

asphyxiation

drug depression

meconium aspiration

Immediate complications in neonate

respiratory distress

instability of body temperature

poor feeding

hypoglycemia

hypocalcemia

Severely PIH prone to

pulmonary edema

convulsions within 24 hrs of delivery

1. Analgesia

2. Fluid balance - strict I/O chart,restrict intake 75ml/hr

3. Haemodynamic control

4. MgSO4 - atleast 24 hrs postpartum or until

diuresis ( 200 ml/hr for atleast 3 hrs )

CVA: main leading cause of death in pts with PE

Pulmonary edema, pleural effusion, ARDS

laryngeal edema

Placental abruptio’

Renal failure: oliguria most common

Liver:

Subcapsular liver hematoma

HELLP Syndrome,

hepatic rupture with shock

DIC

Eclampsia

Maternal death

Diagnosis:

1. Hemolysis:

Peripheral smear - schistocytes, burr cells, and echinocytes ↑bilirubin >1.2mg/dL,

LDH>600 IU/L

1. Elevated liver enzymes:

SGOT> 70 IU/L

LDH>600 IU/L

2. Low platelets: <1 lakh /mm3

Immediate hospitalisation

Stabilise mother

antihypertensives

anti seizure prophylaxis

correct coagulation abnormalities

Assess fetal condition- FHR, doppler ultrasound, biophysical profile

Ultimate goal:

>34 wks gestation deliver

<34wks expectant management if stable maternal and fetal conditions

Platelet transfusion if: <40,000/mm3 before cesarean

<20,000/mm3 before delivery

Rupture of a subcapsular hematoma of the liver is a life-threatening complication of HELLP syndrome

manifest as abdominal pain, nausea and vomiting, and headaches

pain worsens over time and becomes localized to the epigastric area

Hypotension and shock typically develop, and the liver is enlarged and tender

Treatment consisting of intravascular volume resuscitation, blood and plasma transfusions, and emergency laparotomy

Eclampsia

Is the new onset of seizures or unexplained coma during pregnancy or postpartum period in patients with pre-

existing PE and without pre-existing neurological disorder.

0.1- 5.5 per 10,000 pregnancies

Antepartum(50%): mostly in third trimester

Intrapartum(30%):

Postpartum(20%): usually within 48hours

Maternal age less than 20 years

Multigravida

Molar pregnancy

Triploidy

Pre-existing hypertension or renal disease

Previous severe Preeclampsia or Eclampsia

Nonimmune hydrops fetalis

Systemic Lupus Erythematosus

Eclamptic convulsions are epileptiform and consist of four stages

Premonitory stage: twitching of muscles of face, tongue, limbs and eye. Eyeballs rolled or turned to one side, 30s

Tonic stage: opisthotonus, limbs flexed, hands clenched, 30s

Clonic stage: 1-4 min, frothing, tongue bite, stertorousbreathing

Stage of coma: variable period.

Sustained rise in blood pressure Tachycardia, Tachyponea Rales Mental status changes Hypereflexia Clonus Papilloedema Oliguria or anuria Right upper quadrant or epigastric abdominal tenderness Generalized edema Small fundal height for the estimated gestational age

Loss of normal cerebral auto regulatory mechanisms

cerebral hyperperfusion

Edema & ↓cerebral blood flow

Early detection and judicious treatment with termination of pregnancy in Preeclamptic patients

Adequate sedation, Anti hypertensives and prophylactic Anticonvulsant in peripartum period

Observe for 24-48 hrs postpartum

1. Prevention of seizures

2. Control of seizures

3. correction of hypoxia and acidosis

4. Blood pressure control

5. Delivery after maternal stabilization

MgSO4 therapy:

DOC for prophylaxis of eclamptic convulsions

M.O.A:

blocks Ca2+ ion influx into neurons leading to cerebral VD

Other actions: -lowers endothelin-1 levels

- ↑ production of PG I2

- tocolytic action

- attenuates the release of Ach and

sensitivity to Ach at myoneuronal junction

Turn patient head to one side,

- apply jaw thrust if airway compromised

- nasopharyngeal airway

- Adequate oxygenation

- ensure adequate breathing , bag and mask ventilation

- secure an i.v line

- Drugs- Antiepileptics

Antihypertensives

- Delivery

1. Zuspan or sibai regime( iv regimen )

4-6 gm i.v over 15 min f/b infusion of 1-2 gm/hr

2. Pritchard regime( im regimen)

4 gm i.v over 3-5min f/b 5 gm in each buttock ( 14 gmtotal )

maintenance of 5 gm i.m in alternate buttock 4 hrly

Normal Serum levels- 1.7- 2.4 mg/dl

Therapeutic range- 5- 9mg/dl

Patellar reflex lost- >1omg/dl

Respiratory depression- 15-20 mg/dl

Cardiac arrest- >25 – 30 mg/dl

Stop infusion

Intravenous Calcium 10 ml 10% over 10 minutes

Endotracheal intubation in respiratory depression

o MgSO4 potentiate and prolong the action of both

depolarizing non-depolarizing muscle relaxants

o At higher doses Mg2+ rapidly crosses the placental barrier,

has been found to significantly ↓ FHR variability

o given cautiously with Ca2+ as may antagonize the

anticonvulsant effect of MgSO4

o cautious use in patients with renal impairment

o May ↑ the possibility of hypotension during regional block

Indications for cesarean section -

Fetal distress

Placental abruption

Extreme prematurity

Unfavorable cervix

Failed induction of labor

Recurrent seizures

Neuraxial: -indications

- seizures controlled- no coagulopathy- patient cooperative

GA: -Indications

-seizures not controlled-coagulopathy-reassuring airway-uncooperative patients

Preeclampsia is a multisystem disorder.

Management is supportive, delivery is the only definitive.

Preeclampsia patients: High risk for difficult intubation.

Hypertensive response to laryngoscopy intracranial hemorrhage.

Spinal Anaesthesia not contraindicated in severe Preeclampsia

Eclampsia can be prevented by prophylactic MgSO4 therapy

Eclamptic patients should be monitored for at least 24 hrspost partum.