Pre- eclampsia & eclampsia : a case presentation

2. Pre-eclampsia & eclampsia:a case presentation By Dr/ Mohamed Sayed Shorbagy Lecturer of anesthesia & intensive care Faculty of medicine Ain Shams University 2012

3. A 26-year-old female, primi-gravidapresented with severe right upper quadrant pain • Vital data • Blood pressure is 160/110 mmHg • Heart rate is 75 B/Min. • Respiratory rate is 20 • Temperature is 36.6 °C

4. On examination Tenderness in her right hypochondrium with moderate pedal edema • She has Mallampati class III airway • Lab shows: Platelets 100,000 AST 156 ALT 174 Creatinine 1 • For urgent C.S.

5. Introduction • Preeclampsia is a disease with unknown etiology. It may be due to excess thromboxane over prostacycline with wide spread vasoconstriction, tissue hypoxia & endothelial damage. • Right hypochondrial pain may be secondary to sub-capsular hematoma of the liver & its rupture carries 80% mortality rate

6. It is a case of severe pre-eclampsia with HELLP syndrome (Hemolysis, elevated liver enzymes & low platelet count) • Take care that eclampsia “seizures” may occur before, during or after delivery • The only cure for pre-eclampsia/eclampsia is the delivery of the fetus & placenta

7. Pre-operative management • Establish & maintain the airway & provide O2 supplement. • Pulse Oximetry, ECG & blood pressure should be monitored . • Expand her IV volume with 500 ml fluid (crystalloids) with adequate UOP monitoring & fluid balance chart. • Aspiration prophylaxis as H2 blocker & non particulate antacid. • Magnesium sulfate prophylaxis by loading & maintenance doses.

8. Arterial line for invasive blood pressure monitoring in severe pre-eclampsia prior to neuroaxial blockade or GA. • Blood pressure control by Nitroglycerine, Hydralazine, labetalol, IV & sublingual Nifedipine, with continuous CTG monitoring during administration of the drugs. • In the face of difficult airway for an urgent C.S. Which is appropriate (neuroaxial blockade vs G.A.)??

9. Consider neuroaxial block for platelet count of 100,000 & platelet count of 50,000 may be safe provided that platelet function is normal, use platelet function tests as TEG, platelet function assay (PFA-100) • It is defensible to perform it down to platelet count of about 80,000, assuming no recent rapid decrease in platelet number & its function by (T.E.G) or (PFA-100) • HELLP syndrome: Dexamethazone ?? & platelet transfusion??

10. Intraoprative • For spinal : • be ready for blood pressure swings. • Treat hypotension by : • Left uterine displacement • Fluids • Ephedrine or phenylephrine • Remember that pre-eclampsia patients are more sensitive to vasopressor effects

11. Spinal versus epidural anesthesia: • Severe hypotension occurring in pre-eclampsia due to intravascular volume contraction with the onset of sympathectomy • Although we know that epidural has better control of sympathectomy, recent studies are showing no significant difference in hypotension between them • Spinal is better than epidural for emergency C.S. in order to avoid G.A.

12. GA: If there is contraindication to regional anesthesia • Aspiration prophylaxis • Preoxygenation& denitrogenation • Rapid sequence induction with smooth endotracheal intubation due to airway edema with pre induction nirtoglycerine or labetalol • Consider awake intubation for Mallampati III (the case) • DON’T FORGET • Mg++ potentiates muscle relaxant effect • Preinduction arterial line in severe preeclampsia • Never ergometrine

13. Postoperative • Postoperative analgesia & emptying of the bladder • Monitoring should be continued for 24-48 hours after delivery due to potential development of eclampsia as well as the risk associated with magnesium therapy • The location of management: labour & delivery, ICU or floor is the decision of the physician guided by the patient’s clinical status