Preeclampsia and pulmonary edema

1
Preeclampsia and pulmonary edema

• Report by R2 Lan,Cheng-Yen
• Supervisor VS Geng, Ya-Rung
• Department of Anesthesiology
• National Taiwan University Hospital

2
Patient history

• ?x?,30 y/o F,4576088
• Chief complain Twin pregnancy at 32 gestational
  weeks with elevated BP and vaginal watery
  discharge since 8/8 1200am
• Past historydenied any systemic disease, such as
  HTN, DM, CAD, pulmonary dx
• Allergy historydenied
• Drug use historydenied
• OP and anesthesiology historydenied

3

• Family history

4
Present pregnancy history and menstrual history

• G1P0, got this pregnancy by ET
• MC I/D28/7, LMP94-12-26, EDC95-10-12
• Routine pregnancy exam. in ???? no abnormality
  was told such as GDM, PIH before 8/2

5
Symptom and sign

• 8/2 8/3 8/4 8/5 8/6
  8/7 8/8

Proteinuria
Abdominal edema at lower abdomen
Epiphora
Fetal movement decrease in right side
Dyspnea, orthopnea
Insomnia, urinary frequency
6
Events at 8/8

• 12am 4pm
  5pm 18am

watery discharge ????
refer to our ER
BT37.6 HR120 BP181/102 RR22/min
BP210/100mmHg BT130, CT140 WBC8.4x103/ul R
BC3.19x106/ul Hb10g/dl, Hct29 Plt9.7K/µL
BT37.6 HR129 BP198/118 SpO2100 RR27/min
540pm BP161/104 HR110 SaO2100
O2, adalate, trandate(5mg)
Admission to 5FD
MgSO410ml/hr
7

• 6pm 630
  640

????,????
??DR
O2 mask 3L, SaO293 room air, SaO297
?70 ?97
BP232/148,HR105
????,dyspnea ????, edema ,????
??????,
cough with frothy sputum
?????

ASA VE
Induction Etomidate20mg
laryngoscopy Trandate15mg
LMA Cisatracurium10mg laryngoscopy
ENT standby ?fiber
8
Endo6.5mm fix 21cm

• 640 700
  800

Maintenance
Sevoflurane0.2-0.3MAC add N2O
Lasix40mg
Morphine10mg
midazolam5mg bicarbonate5amp
ventilation volume control ,PEEP8 cmH2O
???suction
On A-line
ABG7.05/77.3/162/21.5/-9.4/12.3/37/98.4/193/5.2/1
44/4.4/112.8/1.03
642 ?? 647 twin A F 1510g,1?7 twin B F
1698g,4?8
745??,IV150ml blood loss200ml ?ICU
9
(No Transcript)
10
Lab data 8/8 pre OP

• PT11sec
• PTT29.5sec
• INR0.93

• WBC11.55 K/uL
• RBC3.75M/uL
• Hb11.1 g/dL
• HCT34.4
• PLT107K/uL

11
Lab data

• AST36U/l
• ALT18U/l
• CRP0.52mg/dl
• Alb2.67g/dL
• D-Bil0.1mg/dl
• Na140mmole/l
• K3.5mmole/l
• Cl110mmole/l
• Mg0.74mmole/l
• BUN6.4mg/dl
• Cre0.8mg/dl

• FDP53.2ug/mL
• D-Dimer2978
• Random urine
• Sp.Gr.1.01
• pH5.5
• protein1 (70mg/dL)
• Glu.-

12
ICU course
BP176/110 mmHg HR112 SaO297 BT37.2

• 8/8 8/9 8/10 8/11 8/12 8/13 8/14

MgSO4-----I Trandateadalat-----------------------
------------------------------ Laxis--------------
----------------------I
BP130-180/87-95------121-180/90-100-----120-140/7
0-90
CVP14---12-----13---------11--------10-------11
mmH2O
I/O negative----------------------------positive-
----negative-----
BW67.3?66.9?63.1?62.3?61.3?61.1?60.8?60.3
Re-on endo
extubation
13
Cardiac echo 8/9

• Normal LA and LV size
• Borderline LV contractility
• MR, moderate
• TR, mild

14
Pulmonary edema and Pregnancy Preeclampsia with
pulmonary edemaAnesthesia consideration
15
Pulmonary edema

• Clinical diagnosis
• Dyspnea, orthopnea
• Signs of respiratory compromise (tachypnea,
  auditory crackles and rales, hypoxemia)
• Arterial blood gas and chest x-ray may assist in
  the diagnosis

16
Mechanism--Starling equation

• FK(Pinside-Poutside)-(?inside- ?outside)
• Fnet transcapillary flow of fluid out of
  pulmonary capillaries
• Pinsidepulmonary capillary hydrostatic pressure
• Poutsideinterstitial fluid hydrostatic pressure
• ?inside capillary colloid oncotic pressure
• ?outside interstitial colloid oncotic pressure
• Kconstant capillary permeability

17
Pulmonary edema-classification

• Cardiogenicincreased pulmonary cap. P
• pv P ?without LV failureMS
• pv P ?secondary to LV failure
• pv P ?secondary to pa P ?(pul blood flow?)L-R
  shunts,hypervolemia,severe anemia, exercise
• Noncardiogenic

18
Noncardiogenic pulmonary edema

• Imbalance of Starling forces
• Plasma oncotic p?hypoalbuminemia
• Negativity of interstitial p ?airway obs
• Altered alveolar-capillary membrane
  permeability(ARDS)
• Infectious pneumonia
• Inhaled toxins
• Aspiration
• Endogenous vasoactive substances
• DIC
• Immunologic
• Lymphatic insufficiency
• Unknown or incompletely understood

19
Pulmonary edema in pregnancy

• Ventricular dysfunction
• Permeability edema from alveolar-capillary injury
  or beta-mimetic tocolytic therapy
• Combination of these two problems

20

• Sciscione reported ?25
• Cardiac failure
• Ttocolytic therapy
• Iatrogenic fluid overload
• Preeclampsia

21
Cardiogenic pulmonary edema

• Diastolic heart failure caused by chronic
  hypertension
• Obesity leading to left ventricular hypertrophy
• In many instances, heart failure is precipitated
  acutely by superimposed preeclampsia, excessive
  blood loss, anemia, and puerperal sepsis.

22
Respiratory failure

• ARDS (acute respiratory distress syndrome)
• Pathophysiological diagnosis
• Radiographic pulmonary infiltrates
• PaO2 FiO2lt 200 mm Hg
• Sepsis and diffuse infectious pneumonia are the
  two most common single-agent causes
• Severe preeclampsia, aspiration, and obstetrical
  hemorrhage are also commonly found

23
Management of acute pulmonary edema-- LMNOP

• Lasix(furosemide)
• Morphine sulfate 2 to5 mg in an attempt to
  reduce the adrenergic vasoconstrictor stimuli
  to the pulmonary arteriolar and venous beds
• Naand water restriction
• Oxygen supplementation and capillary leak
  syndrome has been breathed by mechanical
  ventilation and PEEP 5-15 cmH2O
• Positioning (elevation) by reducing pulmonary
  capillary wedge pressure

24
Treatment of cardiogenic pulmonary edema

• Improve LV function
• Correct fluid overload
• Positive airway pressure
• Diuretics,morphine,vasodilators,ACEI,inotropes

25
Treatment of noncardiogenic pulmonary edema

• FIO2lt0.5
• PEEP
• Avoid high peak inflation pgt35cmH2O, high
  VTgt8-10ml/kg
• Inhaled NO
• Inhaled PGE1
• Ventilation in prone position
• Steroidsday 4-10

26
Preeclampsia
27
Mild and severe preeclampsia
mild severe
SAP lt160mmHg gt160
DAP lt110mmHg gt110
Urinary protein lt5g/24hr 1or2 gt5 3or4
Urine output gt500ml/24hr lt500
headache No Yes
Visual disturbances No Yes
Epigastric pain No Yes
RUQ pain No Yes
Pulmonary edema No Yes
cynosis No Yes
HELLP No Yes
Platelet count gt100000/mm3 lt100000
28
Mechanism

• Reduced organ perfusion secondary to vasospasm
  and endothelial activation
• Abnormal trophoblastic invasion of uterine
  vessels
• Immunological intolerance between maternal and
  fetoplacental tissues
• Maternal maladaptation to cardiovascular or
  inflammatory changes of normal pregnancy
• Dietary deficiencies
• Genetic influences

29
Maternal vascular disease
Excessive trophoblast
Faulty placentation Genetic, immunologic,
inflammatory factors
Reduced uteroplacental perfusion
Vasoactive agents Prostaglandins nitric
oxide endothelins
Noxious agents Cytokines Lipid peroxidases
Endothelial activation
Activation of coagulation
Capillary leak
Vasospasm
liver ischemia
HTN
proteinuria
edema
thrombocytopenia
oliguria
hemoconcentration
seizures
abruption
30
Risk factor

• Nulliparous women
• Chronic hypertensions
• Mutifetal gestation
• Maternal age over 35 years
• Obesity
• African-American ethnicity

31
Acute complication of preeclampsia

• Eclampsia
• HELLP syndrome
• Liver rupture
• Pulmonary edema
• Renal failure
• DIC
• Hypertensive emergencies
• Hypertensive encephalopathy and cortical blindness

32
Preeclampsia and pulmonary edema
33
Severe preeclampsia and pulmonary edema

• 2.9
• Etiology
• high LA and pul. capillary wedge pressure
• Low plasma colloid and osmotic pressure
• Increased capillary permeability
• 30 before delivery, 70 after delivery
• Risk factorchronic HTN, multiparous, advanced
  maternal age
• Labalbumin(antipartum edema3 0.36 gm/dl,
  postpartum edema 2.560,46)
• Perinatal mortality rate530/1000

34
Anesthesia for severe preeclampsia

• Wallace and colleagues -- a randomized trial in
  women with severe preeclampsia who were to be
  delivered to general anesthesia or epidural or
  combined spinal-epidural analgesia
• General as well as regional anesthetic methods
  are equally acceptable if steps are taken to
  ensure a careful approach to either method

35
Anesthesia consideration

• A detailed preanesthetic assessment (severity of
  the condition, associated features and systemic
  involvement, evaluation of the airway, fluid
  status, and blood pressure control )
• Airway edema
• Although water and sodium retention are
  accompanied, hypovolemia may be present
• CVP is needed for careful fluid management
• PAC for assessing left ventricular filling
  pressure

36

• Hypertension at laryngoscopy, at tracheal
  intubation, during emergence and extubation --
  blocked by appropriate pre-treatment with
  hydralazine, nitroglycerin, or labetalol.
• MgSO4, potentiate succinylcholine ,
  non-depolarizing muscle relaxants, blunts the
  response to vasoconstrictors and inhibits
  catecholamine release after sympathetic
  stimulation

37
What happen in our case?What can we do better?

• Acute onset of hypertensive crisis?acute
  pulmonary edema
• There was no good management to the hypertension
• Delayed delivery

38
Reference

• 1. Cunningham G, MacDonald PCWilliams obstetrics
  22 ed, p761-98,p900-3
• 2. Baha M. Sibai,Bill C.Mabie,Carol J.Harvey
  Pulmonary edema in severe preeclampsia-eclampsia
  Analysis of thirty-seven consecutive cases. Am J
  Obstet Gynecol 1561174-9,1987
• 3. Zlantnik MG Pulmonary edemaEtiology and
  treatment. Semin Perinatol 21298-306,1997
• 4. Benedetti TJ, Kates R, Williams V.
  Hemodynamic observations in severe pre-eclampsia
  complications in severe pre-eclampsia complicated
  by pulmonary edema. Am J Obstet Gynecol
  152330-4,1985
• 5.Øian P, Maltau JM, Noddleland H, et al
  Transcapillary fluid balance in preeclampsia.
  Br.J.Obstec Gynaecol 93235,1986

39

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  Gynecol 102181,2003

40

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