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Morbidity Eclampsia.pptx
- 2. SITUATION • A. O. • 26/Female • Single • Brgy. Magallanes, Limasawa, Southern Leyte • Admitted for the 1st time in our institution last January 20, 2023 • CC: Elevated BP, Difficulty breathing
- 3. SITUATION HPI • 8 hours PTA • Nape pain • Headache • Dizziness • Blurring of vision • Dyspnea • Bipedal edema • BP: 180/100 mmHg
- 4. SITUATION HPI • 6 hours PTA • BP: 210/110 mmHg • HR: 144 bpm • RR: 44 cpm • Dyspneic
- 5. SITUATION PAST MEDICAL HISTORY (-) HPN (-) DM (-) Asthma (-) Non-smoker (-)Non-alcoholic (-) allergies to food and medications
- 6. SITUATION FAMILY AND SOCIAL HISTORY (+) HPN- both paternal and maternal side (-) DM (-) Asthma (-)cancer
- 7. SITUATION MENSTRUAL HISTORY • Menarche – 12 yrs old • Duration: 3 days • 4 pads soaked per day • No associated symptoms • Subsequent menses: irregular • Duration: 5-6 days • 3 pads soaked per day • No associated symptoms Obstetric History: G2P1 (1001)
- 8. SITUATION ADMITTING DIAGNOSIS G2P1 (1001), PU 41 6/7 WEEKS AOG, CEPHALIC IN LABOR, INTRAPARTUM PREECLAMPSIA WITH SEVERE FEATURES, NRFHRP CATEGORY II (RECURRENT LATE DECELERATION)
- 9. PROPOSED PROCEDURE FOR “E” PRIMARY CS
- 10. DIAGNOSTICS • CBC (1/20/23) • Hgb 150 • Hct 0.43 • RBC 5.23 • WBC 29.09 • Platelet 361 • Creatinine 68.13 • Sodium 141.56 • Potassium 2.99 • Chloride 99.32 • PT control 10.82 • PT 9.10 • % Activity 100 • INR 0.85 • APTT Control 31.10 • APTT 26.10 • ECG: Sinus Rhythm
- 11. AT THE OR • Received patient intubated • In supine position • Attached to the monitor • Noted elevated BP, Sinus tachycardia and O2 sat of 80% • Patient eventually arrested ( No BP, HR, RR, asystole) • No anesthetic agent given yet • Started CPR and Anesthesiologist instructed to start the procedure and the baby was delivered • CPR was done while on-going operation
- 12. AT THE OR • Patient was revived after 2 epinephrine • BP:200/125, HR: 180, O2 sat 90% • Fentanyl (1mcg/kg), Rocuronium 0.6mg/kg and sevoflurane at 2.5% was given • Oral secretions suctioned • Chest auscultated noted to have unequal breath sounds and crackles on all lung fields • ET tube noted to be at lip level 23 • Tube placement adjusted at lip level 19, noted to have equal breath sounds
- 13. AT PACU • Patient was then transferred to PACU attached to Mechanical ventilator • Settings: AC mode, TV: 475, BUR: 14, FiO2: 100%, PEEP • On moderate high back rest • BP: 190/105mmHg • HR: 120 bpm • Tonic- Clonic seizure noted then arrested ( BP:0, HR: 0, O2 sat 0) • CPR was again initiated • Patient was revived after 2 epinephrine • Patient was then subsequently transferred to ICU
- 15. PREECLAMPSIA • gestational hypertension plus proteinuria developing after 20 weeks of gestation • can be mild or severe
- 16. ECLAMPSIA • severe form of preeclampsia • occurrence of seizures not attributable to other causes.
- 18. ETIOLOGY • abnormal trophoblast invasion of uterine vessels • Immunologic intolerance between fetoplacental and maternal tissues • Maladaptation to cardiovascular changes • inflammatory changes of pregnancy • abnormal angiogenesis and genetic abnormalities
- 19. ETIOLOGY • Placental ischemia • generalized vasospasm • abnormal hemostasis with activation of the coagulation system • vascular endothelial dysfunction • abnormal nitric oxide and lipid metabolism • leukocyte activation changes in various cytokines and growth factors
- 24. Preoperative evaluation and monitoring
- 25. ANESTHETIC MANAGEMENT • Preanesthesia Evaluation: • Patients are at increased risk for life threatening events, including placenta abruption, cerebral hemorrhage, pulmonary edema, acute kidney injury, hepatic failure or rupture, disseminated intravascular coagulation. • Goal Blood Pressure • Blood pressure should be close to baseline blood pressure rather than normal, to preserve uteroplacental perfusion, but always less than systolic 160 mmHg and diastolic 110 mmHg. Avoid severe hypertension to reduce risk of stroke and intracranial hemorrhage. •
- 26. ANESTHETIC MANAGEMENT • Intravenous Fluid Management • Fluid administration should be monitored closely. Patients with severe preeclampsia are at risk for pulmonary edema. The etiology of pulmonary edema may be multifactorial, including myocardial dysfunction, low colloid oncotic pressure with capillary leak, and iatrogenic fluid administration •
- 27. ANESTHETIC MANAGEMENT • Anesthetic plan should be flexible to include strategies to manage all of the aforementioned complications. • ensure that hypertension is well controlled, seizure prophylaxis is initiated, and volume status is optimized. • proper airway evaluation is important and equipment to manage a difficult airway should be immediately available. • Use of low dose aspirin should not affect the decision to use neuroaxial technique. POGS recommend low dose aspirin low dose for PREVENTION of preeclampsia for high risk patient
- 28. LABORATORY INVESTIGATIONS • complete blood count, hemoglobin levels, platelet count • liver function tests • serum BUN and creatinine, and urine analysis. • PT, PTT, fibrinogen levels, and INR
- 29. ANESTHESIA FOR CESAREAN DELIVERY • Regional anesthesia is the method of choice for cesarean delivery • Major advantage is the avoidance of general anesthesia and the risks of difficult airway management. • conventional epidural anesthetic-highly desirable in patients with severe preeclampsia • spinal anesthesia in patients with severe preeclampsia anticipated profound hypotension from sympathetic blockade of pre-existing intravascular volume depletion • Combined spinal–epidural anesthetic (CSE)- remarkable hemodynamic stability, intense motor and sensory block and the ability to maintain the level of the block
- 30. ANESTHESIA FOR CESAREAN DELIVERY • General anesthesia indications • Patient refusal of regional anesthesia • emergency cesarean delivery for fetal bradycardia, coagulopathy, hypovolemia from severe hemorrhage • inability to site the epidural due to anatomic problems- scoliosis, or back surgeries in the lumbar area
- 31. ANESTHESIA FOR CESAREAN DELIVERY • Induction of anesthesia: • Minimize or eliminate the hypertensive response to laryngoscopy and intubation. • Propofol 2 mg/kg • Esmolol 2mg/kg IV during induction, or 1 mg/kg IV with lidocaine • Nicardipine 15 to 30 mcg/kg IV or 100-200 mcg bolus during induction • Fentanyl 1-3 mcg/kg IV • Labetalol titrated with 10 mg bolus IV boluses up to 1mg/kg prior to induction • Opioids are generally avoided during induction due to concern of neonatal respiratory depression. •
- 32. ANESTHESIA FOR CESAREAN DELIVERY Neuroaxial Anesthesia • Fluid administration: IV co-loading should be avoided or minimized. Intraoperative fluid administration should be conservative in patient with severe preeclampsia to 80- 100 ml/hour IV, including oxytocin and magnesium administration. • Vasopressors: initially administered in low, incremental doses, titrated to effect and aiming for bp close to baseline.
- 33. ANESTHESIA FOR CESAREAN DELIVERY Uterotonic medications: • Methylergonovine should not be administered. Postpartum hemorrhage unresponsive to oxytocin administration, prostaglandin should be administered. • Carboprost should be avoided for patients with asthma.
- 34. ANESTHESIA FOR CESAREAN DELIVERY • Intraoperative Magnesium: • Magnesium causes muscle relaxation, potentiates the effects of NMBA and can prolong the duration of action of rocuronium, cisatracurium, and vecuronium. • Magnesium does not potentiate the effects of succinylcholine and the usual RSI dose should be administered (1-1.5mg/kg) •
- 35. SUDDEN CARDIAC ARREST IN PREGNANCY
- 36. RESUSCITATION PROCEDURES • Airway management is the initial consideration • Chest compressions- high quality chest compressions (at least 100 compressions per minute but not more than 120, compressing the chest at least 5 cm (2 inches) but no more than 6 cm (2.5 inches with each downstroke • Intravenous access- Intravenous access should be established above the diaphragm • Avoiding aortocaval compression- manual uterine displacement to avoid aortocaval compression and to preserve supine positioning • Defibrillation-management of ventricular arrythmias
- 37. RESUSCITATION PROCEDURES • Determining gestational age- determining the gestational age is critical as the likelihood of neonatal viability is a factor in decision making • Fetal heart rate monitoring • Delivery as part of the resuscitation process
- 38. PERIMORTEM CESAREAN OR OPERATIVE VAGINAL DELIVERY • rapid delivery of the fetus in the setting of maternal cardiac arrest unresponsive to CPR • immediate relief of vena caval obstruction with improved venous return and cardiac output, decreased oxygen demand, and improved pulmonary mechanics.
- 40. THANK YOU!
Editor's Notes
- Patient is a G2P1 (1001) PU 41 6/7 weeks AOG by LMP, NIL Prompted consult at RHU-Limasawa due to the following symptoms. Methyldopa 250mg/tab, 1 tab PO Nefidipine 30mg/tab, 1 tab SL Persistence of the above symptoms prompted at SOYMPH
- Still with aforementioned symptoms Persistence of elevated BP and no OB specialist available prompted referral at our institution, hence admitted
- Gestational hypertension is the elevation of blood pressure during the second half of pregnancy or in the first 24 hours postpartum, without proteinuria and without symptoms.
- Another severe form of preeclampsia is eclampsia, which is the occurrence of seizures not attributable to other causes.
- The etiology of preeclampsia remains an obstetric enigma. Several theories have been proposed but most have not withstood the test of time. Some of the suggested causes include abnormal trophoblast invasion of uterine vessels, immunologic intolerance between fetoplacental and maternal tissues, maladaptation to cardiovascular changes, inflammatory changes of pregnancy, abnormal angiogenesis, and genetic abnormalities
- Some reported abnormalities of preeclampsia include placental ischemia, generalized vasospasm, abnormal hemostasis with activation of the coagulation system, vascular endothelial dysfunction, abnormal nitric oxide and lipid metabolism, leukocyte activation, and changes in various cytokines and growth factors
- Hypothesis on the role of sFlt1 in preeclampsia. A: During normal pregnancy, the uterine spiral arteries are infiltrated and remodeled by endovascular invasive trophoblasts, thereby increasing blood flow significantly in order to meet the oxygen and nutrient demands of the fetus. B: In the placenta of preeclamptic women, trophoblast invasion does not occur and blood flow is reduced, resulting in placental hypoxia. In addition, increased amounts of soluble Flt1 (sFlt1) are produced by the placenta and scavenge VEGF and PlGF, thereby lowering circulating levels of unbound VEGF and PlGF. This altered balance causes generalized endothelial dysfunction, resulting in multiorgan disease. It remains unknown whether hypoxia is the trigger for stimulating sFlt1 secretion in the placenta of preeclamptic mothers and whether the higher sFlt1 levels interfere with trophoblast invasion and spiral artery remodeling.
- Anesthetic management of patients with preeclampsia poses a challenge because in addition to the pathophysiologic changes of the disease itself, the presence of concurrent obstetric and medical problems such as prematurity, diabetes, morbid obesity, extremes of age, chronic hypertension, etc. can add to the complexity of the problem. Besides, the condition can suddenly deteriorate into hypertensive crisis, pulmonary edema, placental abruption, and eclampsia or HELLP syndrome. Therefore, the anesthetic plan should be flexible to include strategies to manage all of the aforementioned complications. It is important to ensure that hypertension is well controlled, seizure prophylaxis is initiated, and volume status is optimized. A complete physical examination including proper airway evaluation is important and equipment to manage a difficult airway should be immediately available. 2. Hemodynamic status Coagulation: Preec severe and/or HELLP syndrome may develop thrombocytopenia, increase risk of spinal and epidural hematoma with neuroaxial technique. The absolute platelet count and trend in count overtime are important considerations. In absence of other coagulation abnormalities, platelet count >70,000/microL. <50,000/microL, neuroaxial anesthesia is avoided. Use of low dose aspirin should not affect the decision to use neuroaxial technique. POGS recommend low dose aspirin low dose for PREVENTION of preeclampsia for high risk patients. Other coagulopathies may develop, including DIC as well as liver function abnormalities and may also preclude the use of neuroaxial technique. Transfusion of platelet to solely allow neuoaxial anesthesia is not recommended.
- complete blood count, hemoglobin levels, platelet count, liver function tests, serum BUN and creatinine, and urine analysis. Estimation of PT, PTT, fibrinogen levels, and INR are needed only in the presence of admission platelet counts <100,000 mm3, abnormal liver enzyme levels, placental abruption, and HELLP Syndrome. platelet count of 100,000 mm3 is considered adequate for the safe administration of the block. In a patient with severe preeclampsia and thrombocytopenia, a major concern regarding the administration of a neuraxial block is the potential for epidural bleeding and hematoma formation. This is a rare but devastating complication.
- Regional anesthesia is the method of choice for cesarean delivery on account of the overwhelming evidence of maternal and fetal safety and efficacy. Needless to say, the major advantage is the avoidance of general anesthesia and the risks of difficult airway management. There are other advantages for using epidural anesthesia. For example, while the stressrelated hormones such as ACTH, cortisol and catecholamine levels remain stable or decrease in those receiving epidural block, they increase significantly during cesarean deliveries in patients receiving general anesthesia (119). Anesthetic options include conventional epidurals, single shot spinal and combined spinal–epidural anesthesia. With a conventional epidural anesthetic, the advantages are the superior hemodynamic stability, highly desirable in patients with severe preeclampsia. The disadvantages are the slow onset and less intense block compared to spinal One of the concerns with the use of spinal anesthesia in patients with severe preeclampsia used to be the anticipated profound hypotension from sympathetic blockade in the presence of pre-existing intravascular volume depletion. Another option is the use of sequential low dose combined spinal–epidural anesthetic (CSE). This technique provides remarkable hemodynamic stability, intense motor and sensory block and the ability to maintain the level of the block with epidural top-up doses.
- The indications for general anesthesia are: Patient refusal of regional anesthesia, emergency cesarean delivery for fetal bradycardia, coagulopathy, hypovolemia from severe hemorrhage, and inability to site the epidural due to anatomic problems such as scoliosis, or back surgeries in the lumbar area. There are two major risks associated with the induction of general anesthesia and rapid sequence tracheal intubation, namely, reflex tachycardia and severe hypertension as well as the possibility of a very difficult tracheal intubation. Generalized edema of preeclampsia also involves the structures in the upper airway causing severe upper airway swelling. A difficult airway should be anticipated in all patients with severe preeclampsia (128,129). Preparations should include immediate access to a difficult airway cart with equipment to manage the airway such as different laryngoscope blades and tracheal tubes of various sizes, laryngeal mask airways, bronchoscope, etc.
- Prevention of recurrent seizure: MgSO4 is the drug of choice. LD 4 to 6 g intravenously and administered over 15-20 minutes, followed by 2g/h as continuous infusion. For recurrent seizure for those already receiving magnesium, an additional 2g over 5-10 minutes should be administered. If necessary, benzodiazepine, MC midazolam 1 to 2 mg iv, repeated every 5 minutes until seizure stop
- Sudden cardiac arrest in pregnancy affects 2 patients: the mother and the fetus. Depending on availability, management of these patients demans a rapis multidisciplinary approach, including anesthesiology, cardiology, obstetrics, neonatology and sometimes cardiothoracic surgery. Basic and advanced cardiac life support algorithms should be implemented; however, the physiologic and anatomic changes of pregnancy require some modifications to these protocols.
- Immediate Basic Life Support (BLS) and Calls for Help
- Current guidelines and case reviews support rapid delivery of the fetus in the setting of maternal cardiac arrest unresponsive to CPR,1,14,46–50 yet one-third of these patients remain undelivered at the time of death.51 When vaginal delivery is not immediately possible, perimortem cesarean delivery (PMCD) is required in order to improve the chance of ROSC and maternal and fetal survival.1,14,46–50 Delivery should be performed as soon as possible if ROSC has not occurred within minutes of the start of the cardiac arrest. Teams should continue CPR throughout and strive to make incision at 4 minutes in order to effect fetal delivery at 5 minutes after the start of cardiac arrest. The team should be actively preparing for expedited delivery as soon as the arrest is confirmed.1,14 The decision to do an operative vaginal delivery instead of PMCD should be at the discretion of the obstetrician.