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CASE PRESENTATION PREECLAMPSIA

CASE PRESENTATION PREECLAMPSIA. PRESENTED BY : Avneep Aggarwal MODERATOR : Anjan Trikha. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. 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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CASE PRESENTATION PREECLAMPSIA

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  1. CASE PRESENTATIONPREECLAMPSIA PRESENTED BY : Avneep Aggarwal MODERATOR : Anjan Trikha www.anaesthesia.co.inanaesthesia.co.in@gmail.com

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

  3. History of present illness • Primipara, second gravida (G2P1) • LMP : 17/01/08 • EDD : 23/10/08 • Gestational period – 34 weeks + 3 days

  4. 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.

  5. 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 .

  6. 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

  7. 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 .

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

  9. 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

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

  11. 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

  12. 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

  13. 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

  14. AIRWAY EXAMINATION • Mouth opening – >3 fb • Teeth – no loose tooth • Thyromental distance – 7cm • Sternomental distance – 13cm • Neck movements • Flexion - adequate • Extension - adequate • Mallampatti class – II • BHT-26 sec

  15. 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 h’ge • -macula normal • -no pappiloedema

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

  17. 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

  18. 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

  19. 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.

  20. 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 .

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

  22. 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

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

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

  25. A.C.O.G Criteria Mild pre-eclampsia • B.P.  140/90 (2 occasions,6 hrs.Apart) • Proteinuria > 0.3 gm/24hrs.Severe pre-eclampsia • B.P.  160/110 • Proteinuria  5 gm /24 hrs • S. Creatinine >1.6. • Oliguria < 500 ml./24 hrs. • Thrombocytopenia • CerebraL involvement; headache, visual disturbances • Rt. Upper quadrant & epigastric pain • Elevated liver enzyme(HELLP) • Pulmonary edema, CHF • Seizures Eclampsia

  26. ?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.

  27. 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 2006;103: 1584

  28. ?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

  29. References [1] Howell P. Spinal anesthesia in severe preeclampsia: time for reappraisal, or time for caution? Int J Obstet Anesth 1998;7:217–9. [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 2003;97:867– 72. [3] Hood DD, Curry RN. Spinal versus epidural anesthesia for cesarean section in severely preeclamptic patients: a retrospective survey. Anesthesiology 1999;90:1276– 82; Gatt SP. Clinical management of established pre-eclampsia and gestational hypertension: an anaesthetist’s perspective. Baillieres Best Pract Res Clin Obstet Gynaecol 1999;13: 95– 105.

  30. ?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.

  31. 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.

  32. 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 (>100 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

  33. Magpie Trial: Lancet, July 2002 • >10 000 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 • Eclampsia:Mg 0.8% (40/5055)vs placebo1.9% (96/5055) • NNT 91 • Maternal deaths: 11 Mg, 20 placebo p = 0.11 • Few attributed to eclampsia

  34. 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

  35. 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

  36. 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

  37. 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 .

  38. 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

  39. HELLP Syndrome • Hemolysis • Abnormal peripheral smear • Total bilirubin > 1.2 mg/dl • LDH > 600 IU/L • Liver Enzymes • AST (SGOT) > 70 IU/L • Platelet count • < 100,000

  40. 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

  41. Expeditious delivery usually warranted • Poor maternal and fetal outcome if delivery delayed • Infants > 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

  42. Dexamethasone 10 mg IV q12hr when platelets < 100,000 • Platelets for active bleeding, or if < 20,000 • Plasmapheresis: limited success, but not routinely recommended www.anaesthesia.co.inanaesthesia.co.in@gmail.com

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