CASE PRESENTATION PREECLAMPSIA

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CASE PRESENTATIONPREECLAMPSIA

• PRESENTED BY Avneep Aggarwal
• MODERATOR Anjan Trikha

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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HISTORY

• Name Savita
• Age 27 yrs
• Resident of New delhi
• Date of admission 11/08/08
• Presenting complaint Missed periods for 8
  months

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History of present illness

• Primipara, second gravida (G2P1)
• LMP 17/01/08
• EDD 23/10/08
• Gestational period 34 weeks 3 days

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ANTENATAL HISTORY

• FIRST TRIMESTER
• Registered at an antenatal clinic at a pvt
  hospital
• Started on iron and folic acid tablets
• No history of severe vomiting or any other
  signficant illness in the first trimester.

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• SECOND TRIMESTER
• Quickening 5th month .
• Tetanus toxoid .
• First visit AIIMS 21st week of gestation
• High BP (150/96)mm Hg.
• Admitted to ward .
• Treatment Aldomet 500mg qid and tab depin 20 mg
  bd
• Discharged after 1 week .
• Advice BP monitoring
• Information regarding preeclampsia
  .
• No further visits to ANC in the second trimester
  .

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• THIRD TRIMESTER
• Visit to antenatal clinic at 34 wks of gestation
• High BP(174/ 100) mm Hg detected,
• Urine albumin 1
• FHR
• No history of headache, visual disturbances,
  epigastric pain, jaundice, decreased urine
  output, seizures .
• No history of bleeding per vaginum

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• Admitted in ward .
• BP monitored hourly .
• Antihypertensives continued .
• Magnesium sulfate started .
• Urine albumin monitored 4 hourly .
• Inj Betamethasone 12 mg im od for 2 days .
• Next day
• BP 180/112 mmHg
• Urine albumin 3
• Fundoscopy gr 2 hypertnsive retinopathy
• FHR monitoring- fetal distress .
• Emergency caesarean section planned .

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PAST HISTORY

• Past medical history No history of any chronic
  illness.
• Drug history no history of any drug allergy.
• Family history- not significant

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PAST OBSTETRIC HISTORY

• Married for 4 yrs
• Previous pregnancy complicated with severe
  preeclampsia
• Emergency LSCS was done at 35th wk of pregnancy
• ?Spinal anaesthesia ( records NA )
• Baby healthy , 2.5 kg , cried at birth

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• MENSTRUAL HISTORY
• Previous menstrual cycles regular,
• Normal flow
• 3-4/ 30 days
• PERSONAL HISTORY-No addiction-Housewife

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EXAMINATION

• Weight 65 kg
• Height 150 cm
• BMI 28.9 kg/m2
• Afebrile,
• pallor- / Jaundice-/ Cyanosis-/ clubbing- /
• B/L pedal edema
• Neck veins not engorged
• Pulse 110/min, regular, normal volume , all
  peripheral pulses felt
• B.P.-176/110 mmHg in (R) upper arm in supine
  position.
• No bleeding manifestation

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• RESPIRATORY SYSTEM
• Respiratory rate 20/min
• B/l air entry equal
• Normal vesicular breath sounds
• CARDIOVASCULAR SYSTEM
• Apex beat lt 4th intercostal space, 1 cm lateral
  to mid clavicular line
• S1 S2 (N)
• No murmur

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• ABDOMINAL EXAMINATION
• INSPECTION
• Abdomen distended
• Umblicus inverted
• Previous caesarian scar present
• PALPATION
• Fundal height 32 wks
• Vertex presentation
• No epigastric tenderness
• AUSCULTATION
• FHR, 130/ min

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• AIRWAY EXAMINATION
• Mouth opening gt3 fb
• Teeth no loose tooth
• Thyromental distance 7cm
• Sternomental distance 13cm
• Neck movements
• Flexion - adequate
• Extension - adequate
• Mallampatti class II
• BHT-26 sec

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• CENTRAL NERVOUS SYSTEM
• Conscious , oriented to time place and person
• Motor function muscle tone, power and DTR
  within normal limits
• Sensory function within normal limits
• Fundus examination ( gr 2 hypertensive
  retinopathy)
• -flame shaped hge
• -macula normal
• -no pappiloedema

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PROVISIONAL DIAGNOSIS

• A 27 yr old , G2P1 at 34 weeks of gestation with
  severe preeclampsia .

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Investigations

• Hb-11.5
• Hct-36
• Platelet Count 120,000/cumm
• TLC-8600
• PT 13/16
• RBS-89mg/dl
• Urea-21
• Uric acid 8.0 mg/dl
• Creatinine 1.2mg/dl

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• Ca2-9.4
• Phosphate-5.3
• Na/K - 149/4.8
• Total Bilirubin 0.8
• Total Protein 7.6 Albumin-4.5 Globulin 3.1
• SGOT/PT 34/45
• ALP-521
• BT Normal
• Urine Albumin 3, sugar nil
• CXR PA view
• No bony / parenchymal abnormalities
• Cardiac Shadow Normal
• B/L CP angle Clear

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• Plan spinal anaesthesia
• Preparation
• -equipment
• -drugs
• -monitors
• N.I.B.P., I.B.P as required.
• E.C.G.,
• pulse oximetry
• Respiratory rate
• Urine output
• Uterine Contraction monitoring
• Continuous foetal heart rate monitoring.

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• Aspiration prophylaxis.
• Made sure that blood and blood products are
  available
• Started a second peripheral intravenous line.
• Preloaded with 500 mL of crystalloid (RL)
• Monitoring the fetal heart rate until the
  beginning of surgery.
• Oxygen by face mask .
• Spinal anaesthesia with 1.5ml of 0.5 bupivacaine
  with 25 micgm of fentanyl was given .
• Maintain left uterine displacement .

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• Surgery completed w/o complication .
• Female child, 1.9 kg, cried at birth .
• Fluids LR 500 ml, EBL 700, UOP 250.

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POSTOP COURSE

• Persistent high BP (150 160 / 90- 100 mmHg) on
  postpartum day 1
• Started on
• -tab.ramipril 5 mg od
• -tab hydrochlorthiazide 12.5 mg od
• No seizures, breathlessness
• Postop analgesia
  
• -inj tramadol 50mg iv tds
• -tab.Paracetamol 1g orally 6 hourly

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• To maintain strict I/O charting for atleast 24
  hrs.
• Magnesium sulfate to continue for atleast 24 hrs.

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CLASSIFICATION

• Preeclampsia(6- 8)
• Eclampsia (0.05 )
• Gestational Hypertension(6-7)
• Chronic Hypertension(3-5)
• Chronic Hypertension with
  
  
  superimposed P.I.H

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A.C.O.G Criteria

• Mild pre-eclampsia
• B.P. ? 140/90 (2 occasions,6 hrs.Apart)
• Proteinuria gt 0.3 gm/24hrs. Severe
  pre-eclampsia
• B.P. ? 160/110
• Proteinuria ? 5 gm /24 hrs
• ?S. Creatinine gt1.6.
• Oliguria lt 500 ml./24 hrs.
• Thrombocytopenia
• CerebraL involvement headache, visual
  disturbances
• Rt. Upper quadrant epigastric pain
• Elevated liver enzyme(HELLP)
• Pulmonary edema, CHF
• Seizures Eclampsia

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?vasopressor

• Ephedrine less effective than alpha adrenergic
  agents associated with foetal acidosis,
  maternal tachycardia and reactive hypertension.
• Alpha agonists more effective than ephedrine,
  better foetal acid base status but maternal
  bradycardia.
• Although a recent study supports the use of
  phenylephrine during regional anesthesia in
  uncomplicated term pregnancy , ephedrine
  increases uterine and placental circulation after
  epidural anesthesia-induced hypotension more than
  phenylephrine.

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

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?Spinal vs GA

• When compared with healthy parturients incidence
  of
• hypotension which is defined as 30 decrease
  in
• mean BP, is less in patients with severe
  preeclampsia
• undergoing spinal anesthesia for cesarean
• delivery.
• The use of spinal anesthesia in severe
  preeclamptic patients has no significant
  differences in maternal blood pressure or
  neonatal Apgar scores compared to epidural
  anesthesia in this retrospective study with
  limited number of patients
• Retrospective study (Hood Curry, 1999) found
  no difference in hemodynamic changes after spinal
  or epidural anesthesia

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• References
• 1 Howell P. Spinal anesthesia in severe
  preeclampsia time for
• reappraisal, or time for caution? Int J Obstet
  Anesth
• 199872179.
• 2 Aya AGM, Mangin R, Vialles N, Ferrer JM,
  Robert C, Ripart J,
• 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 200397867 72.
• 3 Hood DD, Curry RN. Spinal versus epidural
  anesthesia for
• cesarean section in severely preeclamptic
  patients a
• retrospective survey. Anesthesiology
  1999901276 82
• Gatt SP. Clinical management of established
  pre-eclampsia
• and gestational hypertension an anaesthetists
  perspective.
• Baillieres Best Pract Res Clin Obstet Gynaecol
  199913
• 95 105.

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?Aspirin Prophylaxis

• The role of aspirin in prevention of APO is still
  controversial.
• The CLASP study did not support the routine
  prophylactic or
• therapeutic administration of LDA to all women at
  increased
• risk of preeclampsia or fetal growth retardation.
  
• However,the study did suggest the role of LDA in
  women at increased
• risk of early onset severe preeclampsia.
• A systematic review of 39 randomized controlled
  trials of LDA for
• prevention of preeclampsia found an overall
  reduction in PE of
• 15,along with reductions in the rate of IUGR.

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Magnesium sulfate

• There is no agreement in the published randomized
  trials
• regarding the optimal time to initiate magnesium
  sulfate,
• the dose to use (both loading and maintenance),
  the
• route of administration (i.m. or intravenous
  i.v.), as
• well as the duration of therapy.
• Women with imminent eclampsia are the best
  candidates to receive
• magnesium sulfate prophylaxis.
• Even then, magnesium sulfate might
• prevent complications related to seizures (status
  epileptics,
• maternal trauma, or aspiration), but it may not
• affect serious maternal complications of severe
  preeclampsia,
• such as pulmonary edema, stroke, liver,
• hematoma, or renal failure.

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Magnesium levels
Therapeutic range 4-6 meq. / L Normal
levels 1.5 -2 meq. /L Monitoring
Knee jerk Mg. Levels (if possible)
respiration, urine output (gt100 ml. in 4 hrs.).
Toxicity 6-8 meq./ L -
Nausea, Vomiting, diplopia,
somnolence decrease
myometrial contractility.
5-10 meq./L - Increase PQ interval,
wide QRS 10 meq. / L - Loss of
deep tendon reflexes. 15 meq./L -
SA AV block
respiratory paralysis. 25 meq./L
- Cardiac arrest
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Magpie Trial Lancet, July 2002

• gt10 000 women
• world-wide co-ordinated from Oxford UK
• BP ?140/90 and proteinuria (30 mg/100 ml)
• 4g Mg i.v. over 10-15 min, 1g/hr for 24 hr
• or placebo
• EclampsiaMg 0.8 (40/5055) vs placebo 1.9
  (96/5055)
• NNT 91
• Maternal deaths 11 Mg, 20 placebo p 0.11
• Few attributed to eclampsia

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Magpie Trial Lancet, July 2002

• Mg neither antihypertensive nor tocolytic
• No adverse events with nifedipine Mg
• No serum monitoring
• tendon reflexes, respiratory rate, urine output
• Side effects
• 24 of women on Mg, 5 on placebo
• flushing, nausea/vomiting
• 5 Mg vs 2 placebo respiratory arrests
• 10 Mg vs 6 placebo MI or cardiac failure

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EVE Use in preeclampsia

• Historically spinal anaesthesia has been
  considered hazardous in patients with
  preeclampsia, although conventional dose
  single-shot spinals have been shown to be safe
  and Modest falls of mean arterial pressure
  (122-103 mmHg) in severe preeclampsia have been
  demonstrated using low-dose CSE for caesarean
  section, but this study lacked a control group. A
  retrospective chart analysis of patients with
  preeclampsia undergoing caesarean section under
  epidural or low-dose CSE concluded that low-dose
  CSE appeared to be a safe technique for
  preeclamptic women. However the study was
  retrospective, with many more patients receiving
  epidural anaesthesia than CSE (62 vs. 15). A
  recent case report described good haemodynamic
  stability when a low-dose CSE using intrathecal
  hyperbaric levobupivacaine 5 mg with fentanyl 25
  µg and EVE with saline 10 mL was used.
• Epidural volume extension and low-dose
  sequential combined spinal- epidural blockade
  two ways to reduce spinal dose requirement for
  caesarean section
• International Journal of Obstetric
  AnesthesiaVolume 16, Issue 4, October 2007,
  Pages 346-353

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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

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• The status of central hemodynamic monitoring is
  controversial.
• There may be a poor correlation between CVP LAP
  in pre-eclamptic patients
• ASA obstetric practice anaesthesia guidelines
  report insufficient data demonstrating the use of
  CVP / PA catheter.
• Guidelines suggest that it is not neceesary to
  use invasive central hemodynamic monitoring
  routinely in severe pre eclamptic pts. unless
  there are clear cut indications due to assoc. med
  problems .

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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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HELLP Syndrome

• Hemolysis
• Abnormal peripheral smear
• Total bilirubin gt 1.2 mg/dl
• LDH gt 600 IU/L
• Liver Enzymes
• AST (SGOT) gt 70 IU/L
• Platelet count
• lt 100,000

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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
• Diagnosis occasionally missed as some patients
  present without triad of preeclampsia

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• 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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