Acls

PIH

• Classification of hypertensive disorders of pregnancy• Diagnosis of preeclampsia• Risk factors• Obstetric and Anaesthetic management• Complications of preeclampsia• Diagnosis and risk factors of Eclampsia• Obstetric and Anaesthetic management in Eclampsia• Complications of Eclampsia

CLASSIFICATION

• Gestational hypertension• Preclampsia- eclampsia• Chronic hypertension• Chronic hypertension with superimposed

preeclampsia

Gestational Hypertension

• Blood Pressure ≥ 140/90 on two or more occasions

- In a previously normotensive patient

- After 20 weeks gestation - Without proteinuria

- Returning to normal 12 weeks after delivery

Chronic Hypertension

• Blood Pressure ≥ 140/90 before 20 weeks of gestation

Or• Persistence of hypertension beyond 12 weeks

after delivery.

Preeclampsia superimposed on Chronic Hypertension

• New-onset proteinuria ≥ 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks’ gestation

• A sudden increase in proteinuria or blood pressure or platelet count <1 lakh/mm3 in women with hypertension and proteinuria before 20 weeks’ gestation

• More adverse outcome than preeclampsia alone

Preeclampsia

• New onset of hypertension & proteinuria in a previously normotensive woman – after 20 weeks of gestation– Returning to normal after 12 weeks of pregnancy.

• Edema not a part of diagnosis now.• A retrospective diagnosis• Eclampsia : new onset of seizures or unexplained coma during

pregnancy or postpartum period in patients with pre-existing

preeclampsia and without pre-existing neurological disorder.

• )

Epidemiology

• Pre eclampsia – primi (10%) , multi (5%)• Eclampsia – variable• Chronic hypertension – 2-4%

• Textbook of obstetrics (D.C.DUTTA)• Ref :J Prakash, Lk Pandey, Ak Singh, B Kar Hypertension In Pregnancy : Hospital Based Study• Kamala Dhall Md, Dgo, Epidemiology Of Preeclampsia And Eclampsia (Article First Published

Online: 24 May 2010 Doi: 10.1111/J.1447-0756.1984.Tb00033.X

Classification of Preeclampsia

Risk Factors

• Nulliparity• History of Preeclampsia in previous pregnancy• Advanced maternal age• Family history of Preeclampsia • History of placental abruptio, IUGR, fetal

death

• Obesity• Hypertension • Diabetes• Thrombotic vascular diseases• Multiple gestation• Molar pregnancy

• Abnormal placentation

• Stage1: Failure of trophoblastic invasion into myometrium

Penetrates only decidua ↓placental perfusion

• Stage2 : Endothelial damage Systemic manifestations of Preeclampsia

Prostanoid balance

• Prostacyclin (PGI2):Thromboxane (TXA2) balance shifted to favor TXA2

• TXA2 promotes: • Vasoconstriction • Platelet aggregation

• Inflammatory mediators

• Immunologic• Soluble fms-like

tyrosine kinase-1 (sFlt-1 or sVEGFR-1)

• activated auto antibodies to angiotensin receptor-1 AA-AT1 - activate AT1 receptors - increased sensitivity to angiotensins-

hypertension

Markers of Preeclampsia

• ↑ plasma Homocystiene• ↑ serum sFlt1(soluble fms-like tyosine kinase)• ↓serum and urinary Platelet Growth Factor• ↓ Vascular Endothelial Growth Factor

Pathophysiology

• Cardiovascular effects• Hematologic effects• Neurologic effects• Pulmonary effects• Renal effects• Fetal effects

• Vasospasm and exaggerated responses to catecholamines• Increased vascular permeability• ↓ Colloid Oncotic Pressure

• Ref :Zinaman M, Rubin J, Lindheimer MD , Serial plasma oncotic pressure levels and echoencephalography during and after delivery in severe pre-eclampsia.Lancet 1985 Jun 1;1(8440):1245-7.

• .

• Increased CO & SVR• CVP normal or slightly increased• Plasma volume reduced• Increase PWP and CVP

• Airway is edematous;• ↓ internal diameter of trachea• Pharyngolaryngeal edema• risk of pulmonary edema

• Headache.• Visual disturbances.• Hyper excitability, hyper reflexia. • Coma , seizures.

• Hemoconcentration (pts with anemia may appear to have normal hematocrit)

• Thombocytopaenia - most common• DIC due to activation of coagulation

cascadeoverconsumption of coagulants and platelets spontaneous haemorrhage.

• HELLP syndrome • Periportal haemorrhage • Subcapsular bleeding• Hepatic rupture: 30% maternal mortality•

• Decreased glomerular filtration rate• Glomerular endotheliosis• Proteinuria• Oliguria• Acute tubular necrosis

Fetal complications

• Hypoxia • IUGR• Prematurity• IUD• Placental abruptio

Management

• Maternal evaluation : • Hemoglobin and hematocrit • Platelet count • Coagulation profile • LFTs : indicated in all patients• RFTs : raised (REF PHY CHANGES) • Urine Routine : proteinuria

Fetal evaluation

• Fetal movement count • Ultrasound • Doppler ultrasound for fetal blood flow

Prediction of Preeclampsia

Various screening methods are:• Diastolic notch at 24weeks by doppler ultrasonography• Absence or reversal of end diastolic flow• Average mean arterial pressure ≥ 90 mmHg in second

trimester• Angiotensin infusion test: angiotensin infusion required

to raise the blood pressure >20 mm Hg from baseline• Roll over test: rise in blood pressure >20 mmHg from

baseline on turning supine at 28-32 weeks gestation is positive.

Hypertension

• GOALS• Prevent adverse maternal sequelae

Anti Hypertensive DrugsDRUGS MOA SIDE EFFECTS C/I & PREVENTION

Methyldopa 250mg-1g tds or 250-500mg iv

Central and pripheral anti adrenergic action

Maternal-postural hypotension, hemolytic anemia, sodium retention, excessive sedationFetal-intestinal ileus

Hepatic disorders, psychic pts., CCF

LabetalolOral-100mg tds till 800mg/dIv- 20 mg till desired effect (max. 220mg)

Alpha + beta blocker Maternal-tachycardia, hypotensionFetal-bradycardia, hypotension

Hepatic disorders

HydralazineOral-100mg/d in 4 divided doses

Peripheral vasodilation Maternal-hypotension, tachycardia, arrythmia, palpitations, lupus like syndromeFetal- safeNeonate- thrombocytopenia

Causes sodium retention so use diuretic

• Seizure Prophylaxis • Routinely used in severe PE• Magnesium sulphate: most commonly used• Initiated with onset of labor till 24h postpsrtum• For caesarean, started 2hrs before the section till

12hrs postpartum• Pritchard regime: 4 gm i.v over 3-5min f/b 5 gm in

each buttock with maintenance of 5 gm i.m in alternate buttock 4 hrly

Mg level monitoring

• Normal Serum levels- 1.7- 2.4 mg/dl• Therapeutic range- 5- 9mg/dl• Patellar reflex lost- >12mg/dl• Respiratory depression- 15-20 mg/dl• Cardiac arrest- >25mg/dl

MgSO4 cautions

• MgSO4 potentiate and prolong the action of both depolarizing non-depolarizing muscle relaxants

• At higher doses Mg2+ rapidly crosses the placental barrier, has been found to significantly ↓ FHR variability

• Should be given cautiously with Ca2+ as may antagonize the anticonvulsant effect of MgSO4

• Also be cautious in patients with renal impairment• May ↑ the possibility of hypotension during regional

block