Anesthesia for the Preeclamptic Patient
Shane Yates, M.D. MAJ, MC
From the Greek meaning ³to shine forth´ implying a µsudden development¶. ³Fits´ occurring during pregnancy recorded as early as 4th century BC by Hippocrates.
Definition of Preeclampsia
Remains nebulous since exact etiology is still unknown Onset of systemic hypertension and proteinuria with or without edema occurring after the 20th wk of gestation. Preeclampsia + seizures = eclampsia. Disease can occur before the 20th week in the presence of trophoblastic disease.
SBP >140 or DBP >90 mmHg on two readings 6 hrs apart. (ACOG.
ISSHP (International Society for the Study of Hypertension in Pregnancy) 1988 Single DBP >110 mmHg or two readings >90 mmHg 4 hrs apart. 1996). Proteinuria either 1+ or greater on dipstick or >300 mg in a 24hr urine.
HA. Pulmonary edema or cyanosis. Neurologic sxs.Severe Preeclampsia
SBP >160 mmHg. Epigastric or RUQ pain. or 3+/4+ on dipstick. blurred vision. altered LOC. DBP >110 mmHg on more than one reading (ACOG). Hepatic insufficiency or rupture Thrombocytopenia HELLP syndrome
. Proteinuria >5g in 24 hrs. Oliguria with UOP <400cc in 24 hrs.
1/3 of seizures occur before diagnosis of preeclampsia is made.
.5% of pregnant women. Incidence is significantly higher in developing countries presumably due to lack of prenatal care.Incidence
Hypertensive d/o¶s complicate 10% pregnancies Preeclampsia . Eclampsia complicates about 1:2000 pregnancies. 30% of all seizures post-partum.
Nulliparity Family History High body mass Multiple gestation (or any condition where there is an incr¶d placental tissue) Chronic HTN There is no test to predict pre-eclampsia
Leads to placental insufficiency and ischemia Injured placenta releases toxins which damage the vascular endothelium. Spiral arteries maintain their adrenergic innervation. results in a systemic microvascular disease
Exact pathophysiology is not known 20th wk.failure of the trophoblastic cells to invade the spiral arteries supplying the placenta.
Capillaries become leaky with movement of protein to the interstitial space. Autoimmune theory vs. VonWillebrands) Activated platelets produce TXA2 and 5HT which promote vasospasm. PGI2/TXA2 imbalance theory
. Injured endothelial cells produce decreased amounts of PGI2 Activates platelets and procoagulants (VIIIc.
Pathology by System
MAP. SVR(?) May be signif disparity btwn PAOP and CVP Plasma vol reduced in concert with severity COP (colloid oncotic pressure) reduced
HTN is an early sign Responses to catecholamines are exaggerated. Increased sensitivity to angiotensin II No consistency among CO.
Predisposed to pulmonary edema due to alterations in Starling forces.
. About 70% of pulm edema episodes occur in the post-partum period. Pulmonary edema complicates about 3% of pre-eclampsia cases.
EEGs incr theta and delta wave activity. Vasospasm.
.Central Nervous System
Mechanism of seizures is unknown. blurry vision.HA (retroorbital). photophobia. No correlation between HTN and onset of seizures. hyperreflexia. Signs. edema and microinfarct. CNS Sx.clonus. scotomata. altered LOC CNS signs signify increased cerebral irritation Seizures can develop without CNS Sxs. diplopia.
increase in serum Cr.Renal
Non-selective proteinuria Decr¶d RBF and GFR. Oliguria common Overt renal failure rare (ATN) Cortical necrosis cause of irreversible ARF (rare)
. Nl uric acid is inconsistent with severe disease. Glomerular swelling. narrowing of glomerular capillary and fibrin deposition. Decr urate clearance.
Thrombocytopenia is common. low plts)
± hemolysis dx by peripheral blood smear. LDH >600 U/L ± platelet count <100K/mm3
DIC in a small subset etiology unclear
. inc bili ± AST >70 U/L. <100K in 15% Antiplatelet IgG(support for autoimmune theory). inc LFTs. Von Willebrand factor Reduced AT3 Hypercoagulable state HELLP (hemolysis. Incr¶d factor VIIIc.
but lethal ± preceded by subcapsular edema or hemorrhage
Abnormal LFTs may signify HELLP Ascites
Elevation of liver enzymes
± periportal endothelial damage ± can lead to dec clearance of drugs
Spontaneous liver rupture
Placental insufficiency Higher incidence of emergent Csection for fetal distress. Higher incidence perinatal mortality Often forced to deliver fetus prematurely Placental abruption more common
Treatment is symptomatic The only cure for preeclampsia is delivery of the fetus AND the placenta.
labetolol.hydralazine. nitrates. ACE inhibitors are contraindicated Goals. nifedipine. Acute control.methyldopa. nifedipine. DBP 90-110 mmHg Invasive monitoring if BP is difficult to control or if nitrates are being used
.Blood Pressure Control
Chronic control.SBP 130-170 mmHg.
Prehydrate before anesthesia? Repeated fluid boluses should not be given without invasive monitoring No proven benefit of colloid over crystalloid.
Goal: organ perfusion w/o pulmonary edema.
.Treatment of Oliguria
Rule out postrenal Treat initially with fluid bolus Invasive monitoring if fluid bolus unsuccessful Loop diuretics can be used after prerenal causes are eliminated DA shown to be safe and effective for increasing UOP.
Seizure prophylaxis and Tx
Mg++ mainstay for seizure prophylaxis
± not an anticonvulsant ± inhibition of cerebral vasoconstriction ± toxicity . hypotension ± toxicity treated with calcium ± Ca++ tx can reverse anticonvulsant effects ± predisposes pt to neuromuscular blocker sensitivity
. resp depression.hyporeflexia.
benzodiazepine. barbituates 3. ABCs 2. rule out other causes -LA toxicity -preexisting seizure disorder
If a seizure occurs.
Must weigh maternal risks with fetal risks (prematurity)
. rarely after this.Delivery of Fetus
Only ³cure´ for pre-eclampsia Mother at risk for seizures for 48 hrs after delivery.
Anesthesia and Analgesia Management in the Preeclamptic Patient
gradual onset of sympathectomy. Larger fall in BP compared to normal pt. 2CP all safe
Preferred for labor and operative delivery Analgesia. bupivicaine. Smaller HD and neuroendocrine responses compared to GA for C-section. Prehydrate? ephedrine safe if titrated in small doses avoid epinepherine lidocaine. BP control. conversion to surg anesthesia. ropivicaine.
. Accepted form of anesthesia for C-section Evidence of coagulopathy (thrombocytopenia) is a contraindication Must weigh risks of epidural hematoma with risk of GA.Spinal Anesthesia
Speed and degree of sympathectomy may be greater compared to epidural.
³Randomized Comparison of General and Regional Anesthesia for C-section in pregnancy complicated by severe pre-eclampsia´. no signif comorbid problems.. No diff btwn SAB and Epid No severe maternal or fetal complications Conc: SAB is safe reg anesth for C-sec in severe pre-E
. ramdomized trial comparing HD and outcomes of GA vs. Wallace et al. SAB Inclusion: severe pre-E by BP Exclusion: no fetal probs. More fluid & ephed w/regional. no plt<100K. Ob&Gyn. Lower BP with reg. Aug 1995 Prospective. Epid vs.
³Spinal vs. Epidural Anesth for C-section in Severely Preeclamptic Patients´. Anesthesiology. May 1999 Retrospective review of 138 women w/severe pre-e undergoing c/s under either SAB or Epid. Hood et. Did not include women in labor Indication worsening pre-e in all cases No diff in HD btwn groups No diff in ephedrine use More Cx in SAB group No diff in incidence of pulm edema or ICU admits No diff in fetal outcome
emergent C-sections absolute contraindication for regional.
increased pharyngeal and laryngeal edema observe for stridor or hoarseness difficult airway equipment should be available Na Citrate RSI with cricoid pressure
laryngeal edema may worsen during surgery see if patient can breath around cuff hypertensive response to extubation If signs of pulm edema. consider postoperative mechanical ventilation
extubation CVAs.Hemodynamic Control
exaggerated andrenergic response to intubation. uteroplacental insufficiency. incision. pulmonary edema labetolol and hydralazine -> NTP Lidocaine pretreatment
Ketamine should be avoided Pentothal may be agent of choice
± documented safety in parturient ± anticonvulsant properties ± vasodilating properties
Etomidate and propofol may also be used
may not see fasciculations with Mg++ All neuromuscular blockers are potentiated by Mg++
Sux safe to use.
Remember« to avoid trouble
Evaluate and examine the patient as soon as possible Have a preformulated plan (and backup plan) for ± fetal complications ± maternal complication ± emergent C-section
? Questions ?