Spinal Anaesthesia in Pre-Eclampsia

Dr Paul Howell
Consultant Anaesthetist
St Bartholomews & Homerton Hospitals, London
Spinal Anaesthesia in Pre-eclampsia
Dr Paul Howell
Consultant Anaesthetist
St Bartholomews & Homerton Hospitals, London
Pre-eclampsia kills ..
No. 2 Killer in Pregnancy in UK
No. 2 Killer in Pregnancy in UK
(also in USA & Australia)
Oedema Hypertension Proteinuria
Endothelial Dysfunction
Vasoconstriction
Vasoconstriction
Capillary Leak
Vasoconstriction
Capillary Leak Pulmonary Oedema
Vasoconstriction
Cerebral Haemorrhage
Vasoconstriction
Eclamptic Convulsions
Vasoconstriction
Coagulopathy DIC
Vasoconstriction
Coagulopathy DIC Renal Dysfunction
Vasoconstriction
Hepatic Dysfunction
Vasoconstriction
Hepatic Dysfunction
Vasoconstriction
HELLP Syndrome
Hepatic Dysfunction
Vasoconstriction
HELLP Syndrome
Poor Placentation
Hepatic Dysfunction
Vasoconstriction
HELLP Syndrome
10
Upper Abdominal Pain + Vomiting
Upper Abdominal Pain + Vomiting
Hepatic Involvement - BEWARE !!!

CEMD UK Data 1982-84 and 1997-99
11
PRE-ECLAMPSIA & ECLAMPSIA:
CEMD UK 1997-99
12
Mortality rate from PET & Eclampsia per million maternities

20 15 10 5 0 70-72 73-75 76-78 79-81 82-84 85-87 88-90 91-93 94-96 97-99
CEMD UK 1997-99

No. 2 Direct cause (n=15)
Mortality rate from PET & Eclampsia per million maternities
20 15 10 5 0 70-72 73-75 76-78 79-81 82-84 85-87 88-90 91-93 94-96 97-99
CEMD UK 1997-99
13

No. 2 Direct cause (n=15) Major cause of death = cerebral haemorrhage
CEMD UK 1997-99

CAUSE OF DEATH
PRE-ECLAMPSIA + ECLAMPSIA
1997-99
Pulmonary Other Cerebral
1 7
CEMD - UK Data
CEMD UK 1997-99
14

CAUSE OF DEATH
1982-84
CAUSE OF DEATH
1997-99
21
3 1
CEMD - England & Wales Data
1 7
CEMD - UK Data
CEMD UK 1997-99

CAUSE OF DEATH
1982-84
CAUSE OF DEATH
1991-93
CAUSE OF DEATH
1997-99
21
3 1
CEMD - England & Wales Data
11 4
1 7
CEMD - UK Data
CEMD - UK Data
CEMD UK 1997-99
15
FLUID MANAGEMENT
FLUID MANAGEMENT
Pre-Renal Failure
(too dry)
Pulmonary Oedema
(fluid overload)
16
PULMONARY OEDEMA
Colloid Oncotic Pressure

Benedetti & Carlson 1979, ian P 1986
PULMONARY OEDEMA
17

Pulmonary Capillary Leak

Benedetti TJ 1985, Belfort M 1993
PULMONARY OEDEMA


PULMONARY OEDEMA
CVP
PAOP
Strauss RG 1980, Cotton DB 1985
18


PULMONARY OEDEMA
CVP
PAOP
Strauss RG 1980, Cotton DB 1985
Left Ventricular Function

Benedetti TJ 1985, Desai DK 1996
OLIGURIA
.. is very common in PET
19
OLIGURIA
Pre-renal failure
OLIGURIA
Pre-renal failure Renal failure
20
OLIGURIA
Pre-renal failure Renal failure Appropriate in dry patient
OLIGURIA
Pre-renal failure Renal failure Appropriate in dry patient ? Benign oliguria of PET ?
21
OLIGURIA
Pre-renal failure Renal failure Appropriate in dry patient ? Benign oliguria of PET ?
OLIGURIA
If plasma urea and creatinine are normal If urinary concentration is high
22
OLIGURIA
If plasma urea and creatinine are normal If urinary concentration is high
DO NOT PANIC DO NOT PUSH IV FLUIDS
23
Labour Ward PET Protocol

Control of BP
24

Control of BP Invasive Monitoring

Control of BP Invasive Monitoring Labour Analgesia
25

Control of BP Invasive Monitoring Labour Analgesia Anaesthesia for C-section

Control of BP Invasive Monitoring Labour Analgesia Anaesthesia for C-section Fluid Management
26

Control of BP Invasive Monitoring Labour Analgesia Anaesthesia for C-section Fluid Management Oliguria Management

Control of BP Invasive Monitoring Labour Analgesia Anaesthesia for C-section Fluid Anticonvulsant Management Prophylaxis Oliguria Management
27

Control of BP Invasive Monitoring Labour Analgesia Anaesthesia for C-section Fluid Anticonvulsant Management Prophylaxis Oliguria Management
Eclampsia
Robson SC et al.
Int J Obstet Anesth, 1992
28

Individual Assessment

Individual Assessment Senior Anaesthetist / Obstetrician
29

Individual Assessment Senior Anaesthetist / Obstetrician High Dependency / ITU Nursing
CAESAREAN SECTION
30
CAESAREAN SECTION
GENERAL vs REGIONAL
CAESAREAN SECTION
GENERAL vs REGIONAL
Prefer REGIONAL
31
General Anaesthesia Emergency C-Section
Airway problems
32
Airway problems
Airway problems
33
GA Problems in PET
Pressor Response:
GA Problems in PET
Pressor Response:
Myocardial Ischaemia Cardiac Failure Cerebral Haemorrhage
BP Pulse Rate ICP
34
GA Problems in PET
Pressor Response:
BP Pulse Rate ICP
EPINEPHRINE
(pg/ml)
300
GA Epidural
200
100
Base
Incision
Delivery
Post-Op
Ramanathan J et al. Anesth Analg, 1991; 73: 772-9
35
GA Problems in PET
Pressor Response:
Lignocaine Alfentanil Fentanyl Labetolol Esmolol MgSO4
GA Problems in PET
Pressor Response:
Airway Oedema:
Difficult Intubation Hazardous Extubation
36
At extubation . . is it safe?
At extubation . . is it safe?
Airway Oedema Muscle Relaxant (NB: MgSO4)
37
Regional Anaesthesia . is it safe?
COAGULOPATHY
Regional Anaesthesia . is it safe?
38
COAGULOPATHY
Aspirin Platelets Hepatic dysfunction DIC
COAGULOPATHY
Aspirin
39
COAGULOPATHY
Aspirin
COAGULOPATHY
Aspirin Platelets
40
COAGULOPATHY
Aspirin Platelets
Thromboelastography
Orlikowski CEP et al. Br J Anaesth, 1996; 77: 157-61 Sharma SK et al. Anesthesiology, 1999; 90: 385-90
COAGULOPATHY
Aspirin Platelets
> 100 x 109.L-1 Thromboelastography
41
COAGULOPATHY
Aspirin Platelets
> 100 x 109.L-1 > 80 x 109.L-1 Thromboelastography
COAGULOPATHY
Aspirin Platelets
42
COAGULOPATHY
Aspirin Platelets Hepatic dysfunction
COAGULOPATHY
Aspirin Platelets Hepatic dysfunction
Coagulation defects (PT, PTT) only occur with low platelets : < 100 x 109/L
Barker P, Callander C. Anaesthesia, 1991; 46: 67-9. Schindler M et al. Anaesth Int Care, 1990; 18: 169-74
43
COAGULOPATHY
COAGULOPATHY
Ignore low-dose aspirin
44
COAGULOPATHY
Ignore low-dose aspirin Platelet Count for all PET
COAGULOPATHY
Ignore low-dose aspirin Platelet Count for all PET Clotting screen if platelets < 150 x 109.L-1
45
COAGULOPATHY
Ignore low-dose aspirin Platelet Count for all PET Clotting screen if platelets < 150 x 109.L-1 No ED if platelets < 80 x 109/L ???
COAGULOPATHY
Ignore low-dose aspirin Platelet Count for all PET Clotting screen if platelets < 150 x 109.L-1 No ED if platelets < 80 x 109/L ??? Consider TRENDS Relative Risk : Benefit
46
COAGULOPATHY
?? Spinal vs Epidural ??
Consider
TRENDS Relative Risk : Benefit
CAESAREAN SECTION
GENERAL vs REGIONAL
47
CAESAREAN SECTION
GENERAL vs REGIONAL
Prefer REGIONAL
CAESAREAN SECTION
GENERAL vs REGIONAL
Prefer REGIONAL EPIDURAL
48
EPIDURAL ADVANTAGES
Incremental doses
EPIDURAL ADVANTAGES
Incremental doses Smooth control of BP
49
EPIDURAL ADVANTAGES
Incremental doses Smooth control of BP Maintains utero-placental perfusion
EPIDURAL ADVANTAGES
Incremental doses Smooth control of BP Maintains utero-placental perfusion Optimises fetal outcome
50
EPIDURAL ADVANTAGES
Incremental doses Smooth control of BP Maintains utero-placental perfusion Optimises fetal outcome Avoids airway & CVS problems of GA
EPIDURAL ADVANTAGES
Incremental doses Smooth control of BP Maintains utero-placental perfusion Optimises fetal outcome Avoids airway & CVS problems of GA Avoids CVS problems of spinal
51
Incremental doses Smooth control of BP Maintains utero-placental perfusion Optimises fetal outcome Avoids airway & CVS problems of GA Avoids CVS problems of spinal
Are Spinals OK in PET??
52

Clark V Hood D ... Sharwood-Smith G ... Ahmed S ... Van Bogaert L Rout C Patel N ... Karinen J ... Wallace D ... Assali N ... (abstract) (abstract) (abstract) n = 20 n = 103 n = 11 n = 17 n = 24 n = 49 n = 50 n = 12 n = 27 n = 15 Int J Obstet Anesth 2000 Anesthesiology 1999
Int J Obstet Anesth 1999 J Indian Med Assoc 1999 East African Med J 1998 SOAP Meeting SOAP Meeting Br J Anaes Obstet Gynecol J Clin Invest 1998 1997 1996 1995 1950

53
Problems with Spinals:

Hypotension
54

Hypotension
Common (50 70%) Unpredictable Preload ineffective
Clark RB 1976, Rout C 1992/93, Jackson R 1995

Hypotension
Ephedrine
Cotton DB et al. AmJOG, 1988; 158: 523-9
55

Hypotension Bradycardia / Asystole

Hypotension Bradycardia / Asystole
Unpredictable (generally)
Scull & Carli 1996, Gratadour 1997
Baroreceptor Dysfunction in PET paradoxical bradycardia

Wasserstrum N 1989 + 1991
56
Maternal Haemodynamics:
Hypovolaemic
57
Hypovolaemic Vasoconstricted
Hypovolaemic Vasoconstricted Some have low cardiac output
Cotton DB 1988 Belfort M 1989 Mabie MC 1993 Desai DK 1996
58
Hypovolaemic Vasoconstricted Some have low cardiac output O2 Flux: Delivery dependent
Oxygen Transport
in Severe PET
OXYGEN CONSUMPTION Severe PET Normal pregnant
Oxygen Extraction: VO2

= Reduced = Delivery Dependent
(Non-pregnant)
OXYGEN DELIVERY
Belfort MA et al, 1993
59
PULMONARY OEDEMA
Risk of Pulmonary Oedema
CVP
PAOP
60
Aggressive Preloading
Pulmonary Capillary Leak CVP
PULMONARY OEDEMA
PAOP
Fetal Considerations:
61
Chronic Fetal Hypoxia + IUGR
62
Chronic Fetal Hypoxia + IUGR Elective LSCS: Spinal
Fetal acidosis
Mueller 1997, Roberts 1995, Ratcliffe 1993, Robson 1992
63
Fetal acidosis Cardiac Output

Robson 1992
Spinal
Robson SC et al, 1992
64
Elective C - Section Randomized, prospective ED (n = 16) or Spinal (n = 16) 1 Litre Preload Ephedrine IVI Non-invasive C. O. Monitoring
Preload C. O.
65
Preload C. O. SBP SBP UA pH
< 80 mmHg
Spinal
(n = 16)
in in in
5 2 2
> 5 mins
UA P. I.
(7.22
vs
7.27)
Preload C. O. SBP SBP UA pH
< 80 mmHg
Spinal
(n = 16)
in in in
5 2 2
> 5 mins
UA P. I.
(7.22
vs
7.27)
in in
C. O. C. O. > 1 l/min
12 9
66
UA pH
Cardiac Output
UA pH
Cardiac Output
NOT with BP
67
Slow Incremental Spinal

Stable Cardiac Output Stable UA P. I.
( Epidural)
68
Fetal acidosis Cardiac Output

Robson 1992
Spinal
?? Significance ...
69
?? Significance ...
.. to the stressed fetus ??
SPINAL FEARS
Severe PET
Cardiac Output
Spinal Anaesthesia
70
SPINAL FEARS
Severe PET
Cardiac Output
Spinal Anaesthesia
Cardiac Output
Spinals + PET Potential for Disaster
71
Do severe pre-eclamptics behave CONTRARY to prediction ?
in BP after spinal anaesthesia

Normal Pregnancy
>> PET
Assali & Prystowsky 1950
72
?? Spinals do not BP in PET ??


73
Comments: Clark V et al, 2000
Normotensive vs. PIH (n = 20 PIH) Ephedrine in Normotensive cf. PIH 28 mg vs. 16 mg (p<0.01)
Comments: Clark V et al, 2000
Normotensive vs. PIH (n = 20 PIH) Ephedrine in Normotensive cf. PIH 28 mg vs. 16 mg (p<0.01) Abstract only
74


75

Retrospective Analysis of Clinical Practice Non-randomised

Retrospective Analysis of Clinical Practice Non-randomised Small Numbers
76

Retrospective Analysis of Clinical Practice Non-randomised Small Numbers Variable Severity of PET

Retrospective Analysis of Clinical Practice Non-randomised Small Numbers Variable Severity of PET Dubious Conclusions
77

Consider individual responses .. not means !!
78
MAP mmHg SEM
120 110 100 90
Spinal n = 26 Epidural n = 27 General n = 27
Induction of anaesthesia
Skin Incision
TIME
Wallace DH et al, 1995

79
Comments: Karinen et al, 1996
n = 12 (6 = mild, 6 = severe PET) BP in 2

(to 51%, 71% baseline)
1 needed assisted ventilation P. I. (Uterine Artery) in 2 UA mean pH 7.29 (n = 7)
Abstract Rejected - SOAP 1989
80
Norris MC, Leighton BL, DeSimone CA
81
PET C-Section Spinal Anesthesia n=5
PET C-Section Spinal Anesthesia n=5
BP in 2
Fetal Acidosis
82
Anaesthetic Deaths in Michigan 1972-84:

4 of 15 2 of 4 spinal = = Spinal Anaesthesia PET + Obesity Hypotension ++ Cardiac Arrest
Endler GC et al. Am J Obstet Gynecol, 1988;159: 187-93
Anaesthetic Deaths in Michigan 1972-84:

4 of 15 2 of 4 spinal = = Spinal Anaesthesia PET + Obesity Hypotension ++ Cardiac Arrest
Endler GC et al. Am J Obstet Gynecol, 1988;159: 187-93
83

Clark V (abstract) n = 20 n = 103 n = 11 n = 17 n = 24 n = 49 n = 50 n = 12 n = 27 n = 15 Int J Obstet Anesth 2000 Anesthesiology 1999
Hood D & Curry R Sharwood-Smith G ... Ahmed S ... Van Bogaert L Rout C Patel N ... Karinen J ... Wallace D ... Assali N ... (abstract) (abstract)
Hood DD & Curry R
Anesthesiology 1999; 90: 1252-4
84
Hood DD & Curry R

Severe PET
n = 103 spinals, 35 epidurals Retrospective, 7 year review
Hood DD & Curry R

Severe PET
n = 103 spinals, 35 epidurals Retrospective, 7 year review No difference in lowest BP
85
MAP
mmHg S.D.
150 140 130 120 110 100 90 80 70 60 10 0
Spinal Epidural
n = 103 n = 35
Before Block
Up to Delivery
After Delivery
Hood DD, Curry R. Anesthesiology 1999; 90: 1276-82
Hood DD & Curry R

Severe PET
n = 103 spinals, 35 epidurals Retrospective, 7 year review No difference in lowest BP No difference in ephedrine use
IV fluids in spinal group
86
EDITORIALS
Howell P, 1998
Santos AC, 1999
CAESAREAN SECTION
EPIDURAL vs SPINAL
Prefer Epidural
87
CAESAREAN SECTION
EPIDURAL vs SPINAL
Prefer Epidural
? CSE: Sequential Spinal - Epidural ?
URGENT CAESAREAN SECTION
GENERAL vs SPINAL
88
GENERAL vs SPINAL
Balance of Risks
GENERAL vs SPINAL
Balance of Risks ?? Spinal may be the lesser evil ??
89
GENERAL vs SPINAL
Balance of Risks ?? Spinal may be the lesser evil ?? INDIVIDUAL ASSESSMENT
90

Spinal Anaesthesia in Pre-Eclampsia

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Spinal Anaesthesia in Pre-Eclampsia

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Dr Paul Howell

Spinal Anaesthesia in Pre-eclampsia

Spinal Anaesthesia in Pre-eclampsia

Spinal Anaesthesia in Pre-eclampsia

Spinal Anaesthesia in Pre-eclampsia

Spinal Anaesthesia in Pre-eclampsia

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Capillary Leak Pulmonary Oedema

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Capillary Leak Pulmonary Oedema

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Capillary Leak Pulmonary Oedema

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Capillary Leak Pulmonary Oedema

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Capillary Leak Pulmonary Oedema

Coagulopathy DIC Renal Dysfunction

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Capillary Leak Pulmonary Oedema

Coagulopathy DIC Renal Dysfunction

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Capillary Leak Pulmonary Oedema

Coagulopathy DIC Renal Dysfunction

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Capillary Leak Pulmonary Oedema

Coagulopathy DIC Renal Dysfunction

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Capillary Leak Pulmonary Oedema

Coagulopathy DIC Renal Dysfunction

Spinal Anaesthesia in Pre-eclampsia

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Upper Abdominal Pain + Vomiting

Oedema Hypertension Proteinuria

Spinal Anaesthesia in Pre-eclampsia

Upper Abdominal Pain + Vomiting

Oedema Hypertension Proteinuria

Hepatic Involvement - BEWARE !!!

Spinal Anaesthesia in Pre-eclampsia

Spinal Anaesthesia in Pre-eclampsia

PRE-ECLAMPSIA & ECLAMPSIA:

Spinal Anaesthesia in Pre-eclampsia

PRE-ECLAMPSIA & ECLAMPSIA:

Mortality rate from PET & Eclampsia per million maternities

Spinal Anaesthesia in Pre-eclampsia

PRE-ECLAMPSIA & ECLAMPSIA: