Pre-eclampsia: key issues. Robin Russell Nuffield Department of Anaesthetics John Radcliffe Hospital Oxford

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1 Robin Russell Nuffield Department of Anaesthetics John Radcliffe Hospital Oxford

2 Antenatal Issues Labour Analgesia Anaesthesia for Delivery High Dependency Care

3 Hypertension systolic >140 mmhg or diastolic >90 mmhg severe: systolic >160 mmhg or diastolic >110 mmhg Chronic hypertension pre-pregnancy or diagnosed before 20 weeks Gestational hypertension new-onset after 20 weeks no proteinuria Pre-eclampsia new onset after 20 weeks proteinuria >300 mg / 24 h regression 3/12 post delivery

4 Maternal deaths Maternal Deaths from Pre-eclampsia & Eclampsia

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6 Presentation cardiovascular central nervous respiratory haematology hepatic renal fetus

7 Presentation cardiovascular central nervous respiratory haematology hepatic renal fetus hypertension cardiac output SVR loss of autoregulation cerebral haemorrhage avoid ergometrine future risk

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9 Presentation cardiovascular central nervous respiratory haematology hepatic renal fetus hypertension cardiac output SVR loss of autoregulation cerebral haemorrhage avoid ergometrine future risk

10 Presentation cardiovascular central nervous respiratory haematology hepatic renal headache visual disturbance nausea & vomiting photophobia clonus / hyperreflexia eclampsia fetus

11 Presentation cardiovascular central nervous respiratory haematology hepatic fluid management breathlessness pulmonary oedema laryngeal oedema difficult intubation renal fetus

12 Presentation cardiovascular central nervous respiratory haematology hepatic thrombocytopenia haemolysis fibrinolysis coagulopathy thrombosis renal fetus

13 Presentation cardiovascular central nervous respiratory haematology hepatic periportal oedema liver enzymes epigastric pain subcapsular haemorrhage rupture renal fetus

14 Kinthala et al. IJOA 2012

15 Presentation cardiovascular central nervous respiratory haematology hepatic renal glomerular filtration proteinuria creatinine / urea urate acute renal failure no NSAIDs fetus

16 Presentation cardiovascular central nervous respiratory haematology hepatic placental perfusion growth restriction preterm delivery abruption intrauterine death renal fetus

17 Risk factors nulliparity age <20 or >40 years previous pre-eclampsia family history multiple pregnancy obesity hypertension, diabetes, renal disease autoimmune disease assisted reproduction

18 Diagnosis blood pressure proteinuria urinary protein : creatinine ratio creatinine uric acid liver enzymes Sflt1 : PlGF ratio

19 Predicting adverse outcomes in pre-eclampsia Rana et al. Circulation 2012

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25 Women with severe pre-eclampsia need effective team care based on clear communication and common understanding. There should be early involvement of intensive care specialists where appropriate.

26 Antenatal Issues Labour Analgesia Anaesthesia for Delivery High Dependency Care

27 % Increase in flow Epidural analgesia & intervillous blood flow in pre-eclampsia Jouppila et al. Obstet Gynecol 1982

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29 Tests of Coagulation bleeding time platelet count clotting studies TEG / ROTEM

30 Thromboelastography

31 Thromboelastography & pre-eclampsia Sharma et al. Anesthesiology 1999

32 Antenatal Issues Labour Analgesia Anaesthesia for Delivery High Dependency Care

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35 Hypertensive response to laryngoscopy Hodgkinson et al. Can Anaesth Soc J 1980

36 Middle cerebral artery blood flow & pre-eclampsia Ramanathan et al. Anesth Analg 1999

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39 Anaesthetists should anticipate an additional rise in BP at intubation in women with severe pre-eclampsia who are undergoing caesarean section under GA and take measures to avoid a speed that compromises maternal wellbeing, even when there are concerns about fetal wellbeing.

40 Drugs to attenuate pressor response Booth et al. IJOA 2010

41 no of patients 10 Attenuation of pressor response Systolic BP > 180 mmhg Lidocaine Mg Alfentanil L + I time after intubation (min) Allen et al. BJA 1991

42 Remifentanil & pressor response Yoo et al. BJA 2009

43 Remifentanil & pressor response Yoo et al. IJOA 2013

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46 General vs. regional anaesthesia Wallace et al. Obstet Gynecol 1995

47 Spinal v epidural anaesthesia Hood & Curry Anesthesiology 1999

48 Spinal vs. epidural anaesthesia Visalyaputra et al. Anesth Analg 2005

49 Spinal vs. epidural anaesthesia 47 epidural ml 2% lidocaine + adrenaline 53 spinal 11 mg hyperbaric bupivacaine hypotension with spinal ephedrine requirements with spinal no difference in Apgar scores no difference in cord gases intraoperative pain with epidural Visalyaputra et al. Anesth Analg 2005

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51 Spinal anaesthesia & cardiac output Dyer et al. Anesthesiology 2008

52 Spinal anaesthesia & vasopressors

53 Spinal anaesthesia & vasopressors Pre-eclamptic group IV fluid bupivacaine frequency hypotension severity hypotension ephedrine requirement

54 Antenatal Issues Labour Analgesia Anaesthesia for Delivery High Dependency Care

55 Pulmonary oedema pulmonary capillary leak colloid osmotic pressure left ventricular dysfunction excess iv fluid administration inadequate monitoring

56 Indications for invasive monitoring severe refractory hypertension pulmonary oedema oliguria unresponsive to fluid therapy anaesthesia haemorrhage

57 CVP or PCWP? poor correlation after treatment complication rates effects on outcome experienced personnel alternative cardiac output monitoring

58 Cardiac Output Monitoring Pulse waveform analysis Ultrasound Electrical resistance Others LiDCO PiCCO FloTrac-Vigileo Oesophageal Doppler Suprasternal Doppler Transthoracic echocardiography Oesophageal echocardiography Bioimpedence Bioreactance Electrical velocimetry Modelflow Pleth variability index Dye densitometry Pulmonary artery catheter

59 Cardiac Output Monitoring Accuracy & precision Applicability Dynamic vs. static Cost Training Complications

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61 Conclusions In women with pre-eclampsia, inability to increase stoke index at the moment of delivery may suggest dysfunction of the left ventricle to adapt to volume load caused by delivery and prompts concern for the increased risk of pulmonary oedema.

62 Antenatal Issues Labour Analgesia Anaesthesia for Delivery High Dependency Care