1. thromboembolism

2. hemorrhage

3. hypertensive disease

Chronic HTN - prior to 20 wks gestation

Gestational HTN - after 20 wks gestation, no proteinuria

Preeclampsia - after 20 wks gestation, proteinuria present

When is chronic HTN present?

Chronic HTN may develop later in pregnancy & be confused with gestational HTN, however HTN persisting beyond ____ postpartum is considered chronic, not gestational

present prior to 20 wks

may develop later in pregnancy & be confused with gestational HTN, however HTN persisting beyond 12 wks postpartum is considered chronic, not gestational

What was gestational HTN formerly known as?

When does it develop?

Proteinuria present?

What % will progress to preeclampsia?

PIH

develops after 20 weeks gestation

no associated proteinuria

~25% will develop proteinuria, & as such be classified as preeclamptic

When does preeclampsia/eclampsia develop?

Proteinuria present?

Incidence?

develops after 20 weeks gestation

associated with proteinuria

incidence ~5-10% of pregnancies

Preeclampsia/eclampsia have a strong association with serum ____ levels?

85% of cases of preeclampsia are in ___ women?

The only difference between preeclampsia and eclampsia is whether or not a pt _______; it is not necessarily an indication of worse HTN.

20% of eclamptic pts will seize w/ ____ BP per lec.

 with elevated serum uric acid levels

nulliparous women

seizes

normal

*see mild versus severe preeclampsia tables on slide # 9-10

What conditions warrant immediate delivery? (6)

Severe, persistent HTN

Progressive thrombocytopenia (rapidly decreasing)

Liver dysfxn

Progressive renal dysfxn

Premonitory signs of eclampsia

Evidence of fetal jeopardy

Nulliparity (85% of cases)

Extremes of maternal age

no prenatal care

partner related factors

previous history of preeclampsia

family history of preeclampsia

chronic htn or renal disease

obesity

gestational or Type I diabetes

multiple pregnancies

Where is the problem in preeclampsia?

What is definitive treatment?

PLACENTA!

removal of placenta

exact mechanism is unclear

multifactoral

*immunologic

*genetic

*endothelial factors

platelet factors

calcium/angiotensin II

coagulation factors

hepatic fatty acid metabolism

Some preeclamptic pts ____ drop BP after placenta is out and others may take a ____?

* see slide 15 for mechanisms of preeclampsia

immediatly

few days

What is the classic (old) thinking of of CV changes with preeclampsia?

Reality?

Can you tell the difference in the 3 groups easily?

preeclamptic patients are hyperdynamic (increased CO), with contracted blood volume and markedly increased SVR

reality - there is a wide range of response with 3 distinct subgroups

No, wont appreciate the differences until insult pt (ie induction)

Preeclampsia - Group 1

 The ____ group

_________ CO

___________ SVR

___________ blood volume

normal CO

increased SVR

decreased blood volume

depressed LV function = ↓CO

markedly increased SVR

markedly decreased blood volume

7-10ml/kg fluid bolus per Ron

What is the colloid oncotic pressure for preeclampsia?

antepartum and postpartum

antepartum - 18mmHg

postpartum - 14mmHg

What is the colloid oncotic pressure for a normal pregnancy?

antepartum and postpartum

antepartum - 22mmHg

postpartum - 17mmHg

in combination with increased vascular permeability, leads to increased loss of intravascular fluid into the interstitial space

*Pulmonary Edema

*Airway Swelling

What are the 3 hematologic changes seen in preeclampsia?

Platelet activation leads to (3)?

1. hypercoagualability

2. decreased fibrinolytic activity

3. platelet activation

thrombocyotopenia

increased platelet aggregation

decreased sensitivity to prostacyclin

(PGI2 usually prevents platelet aggregation)

What are the renal changes seen in preeclampsia

Glomerular enlargement leading to _____.

What are the renal changes seen in preeclampsia

Glomerular enlargement leading to ischemia

GFR decreased ~25% from normal pregnancy levels (remember 50% incr. in pregnancy normally)

Decreased urate clearance leading to increased serum uric acid

Also see: (2)

oliguria

proteinuria

What is refractory oliguria?

T/F most pt will have this issue?

30ml/hr for 3 consecutive hours, unresponsive to a 300-500 ml bolus of crystalloid

False - most respond well to a fluid bolus and renal issues are usually transient

Basically these pts have less increase in vasodilators d/t dysfunctional endothelium and though have some decreased responsiveness to vasoconstrictors they are still more sensitive to them than normal pregnant pts.

↑Vasodilators

PGI2

Nitric oxide

↓responsiveness to Vasoconstrictors

Angiotensin II

TXA2

Serotonin

Endothelin

pharyngolaryngeal edema

pulmonary edema

What % of pulmonary edema is seen in severe preeclampsia?

30% ____ (usually in patients w/ pre-existing chronic HTN)

70% _____ (much of this likely iatrogenic)

It is important to rule out ____ cause of pulm edema if it is present.

~3% incidence in severe preeclampsia

(so its okay to give them fluid before epidural etc as long as they don't sound wet per Ron)

30% antepartum (usually in patients w/ pre-existing chronic htn)

70% postpartum (much of this likely iatrogenic)

It is important to rule out cardiac etiology - Echo?

What hepatic issues can be seen with preeclampsia? (2)

Epigastric or RUQ pain d/t

edema 

or

subscapular or parenchymal bleeding --life threatening event with massive hemorrhage

HELLP

Describe HELLP

Often treated with?

When are we most concerned with a low platelet count?

Hemolysis

Elevated Liver Enzymes

Low Platelets

Other concerns - DIC, pulmonary edema, renal failure

Often treated with Dexamethasone

 (helps fetal lung maturity so delivery can be expedited per book)

a rapidly developing thrombocytopenia is more ominous --is a sign of possible HELLP

2/3 of epidural hematomas occur with cath _____ so if have preeclamptic pt then you may have to leave the cath in for awhile.

With this in mind you should use ___ dressings with epidurals for these pts.

removal

sterile

What is placental abruption?

Is the incidence of this increased or decreased with preeclampsia?

partial or complete separation of the placenta before delivery of the fetus

INCREASED

1.3-1.6% of pregnancies

~2% in preeclampsia

hypertension

preeclampsia

cocaine use

alcohol use

smoking

previous hx of abruption

CHAPPS

delivery!!!!

restoration of blood volume

management of accompanying DIC

severe headache

(retro orbital is common)

visual distrubance

hyperreflexia

CNS excitability

The incidence of eclampsia varies greatly and is dependant mostly on what?

Mortality in US?

When is greatest risk for death with eclampsia?

quality of prenatal and antenatal care

incidence -- 1:110 to 1:3500

mortality - in US ~1%

greatest risk before 32 weeks gestation

Etiology of eclampsia is ______?

Will you always notice bleeding as a sign of placental abruption? What is most common sign?

unclear

NO 

fetal distress

What is the general management of eclampsia?

How do you choose your anesthetic technique?

establish a patent airway

oxygen

stop/prevent further seizure activity

antihypertensives if indicated

expedite delivery

? type of anesthetic?

-GA if neuro issues after seizure otherwise you can use the epidural per Ron?

How can you stop/prevent further seizure activity?

What is loading dose?

Infusion rate?

BZD's

Magnesium Sulfate

loading dose: 4-6g IV over 20 mins

infusion: 1-2g/hr

What is the anticonvulsant of choice?

What results were shown when it was compared to a placebo?

Mag Sulfate

58% reduction in progressing to eclampsia

55% lower risk of maternal death

What is Mag superior to as an anticonvulsant?

MoA?

superior to Phenytoin and Diazepam in preventing recurring seizures

MoA?

Does Mag alter the progression of the disease?

Does it effect labor?

does not alter progression of the disease, only used to prevent seizures

no increase in duration of labor, c/section rate, or need for oxytocin augmentation, but slight increase in dosage of oxytocin needed

N/V

pain

muscle weakness

hyporeflexia

calcium

sodium bicarb if acidotic

ventilatory support as needed

mixed resultsin the lab some prolongation of succs by hypermagnesemia has been shown

not observed clinically

Overall a non-issue per Ron

2 studies have shown a prolongation of the bleeding time in patients receiving mag sulfate

no change in thromboelastography in patients receiving mag sulfate

no increase in periop bleeding

What is the most common used antihypertensive in preeclampsia?

MoA?

Usual dose?

hydralazine

preferentially relaxes arterioles decreasing SVR

usual dose: 5mg q 20 min, up to 20 mg total

True

*may increase HR a bit

Labetalol

MoA

ratio of alpha:beta blockade?

combined alpha and beta-adrenergic blockade

alpha1/nonselective beta antagonist

ratio of alpha:beta blockade 1:5-10 IV

Labetalol________ SVR without ________ HR

Does it effect uterine blood flow?

Use cautiously in? (2)

decreases SVR without increasing HR

uterine blood flow well preserved at doses <1mg/kg

use catiously in: asthma and CHF

Nitroglycerin

MoA

Where is the greatest effect seen; venous or arterial --- preload or afterload?

Why is judicious dosing used with preeclampsia d/t likely ________ depletion?

What do some people use it for?

vascular smooth muscle relaxant

greatest effect on venous circulation, so greater reduction in preload than afterload

judicious dosing with preeclampsia due to likely volume depletion

some people use it to attenuate the hypertensive response to intubation

Sodium Nitroprusside

MoA

Greater effect on venous or arterial side---preload or afterload?

concern?

advantage?

vascular smooth muscle relaxant

greater effect on arterial side, so afterload reduced more than preload

concern over cyanide toxicity as it crosses the placenta

advantage: effect is brief, easy to titrate

*just stay away from this drug per Ron

Nifedipine

MoA

typical initial dose

issue?

calcium channel blockerpredominately arterial & arteriolar vasodilation

10mg po

may see exaggerated hypotension with Mag Sulfate

Esmolol

Duration?

Dose?

Why is this drug good with preeclamptic pts?

cardio selective Beta 1 antagonist

ultrashort acting

useful prior to intubation to attenuate hemodynamic response

typical dose: ~1mg/kg

b/c often when placenta is removed their BP "drops like a rock" and esmolol wont last very long per lec

superior analgesia

attenuates hypertensive response to pain

decreases circulating catecholamines

may improve intervillous blood flow in preeclamptic

preeclamptic patients are at increased risk of C/S preexisting means of providing surgical anesthesia is "peace of mind"

-avoids airway concerns in preeclamptic

RA for C/S

If an epidural is in place...

If there is no preexisting epidural...

if an epidural is in place, it can be incrementally dosed to provide an adequate level for surgery (T4-T6)

if there is no preexisting epidural, selection of spinal vs epidural vs GETA requires rapid patient assessment and risk/benefit analysis

If no epidural in place and pt needs a non-emergent C/S then what is anesthetic technique of choice?

If no epidural and pt needs an emergency C/S (speed is of the essence) what do you choose?

spinal

RSI and GETA

If the pt has a well defined coagulation issue then choose ____ for C/S anesthesia?

If have boarderline platelets..?

Airway concerns....?

Uncertain fluid status...?

Patient refusal of regional...?

What does sickle cell disease (homozygous SS or doubly heterozygous abnormal, ie SC) increase the incidence of?

maternal and fetal mortality?

preterm labor

placental abruption

placenta previa

gestational htn

maternal mortality up to 1%

fetal mortality up to 20%

Anesthetic management of sickle cell disease in a laboring pt (6)

The main goal in all of these efforts is to prevent stress to keep the pt from ________?

adequate pain control preferably with epidural

maintain intravascular volume

supplemental oxygen

maintain normothermia

avoid peripheral venous stasis

(left uterine displacement and infrequent BP measurements)

RBCs if needed for oxygen carrying capacity

sickling

What was autoimmune thrombocytopenic purpura formerly known as?

Managed by?

Is RA an anesthesia option?

idiopathic thrombocytopenic purpura (ITP)

managed by obstetricians with corticosteroids, and occasionally IV immunoglobulin

it is possible...

Are ASA or NSAIDs a contraindication to RA?

What about heparin or coumadin?

ASA, NSAIDs generally not considered a contraindication

safety of RA in patients receiving unfractioned heparin or coumadin may be determined by normalization of laboratory tests and absence of clinical bleeding

ASRA recommendations for LMWH

Needle placement at least 10-12 hours after last dose.

In patients receiving high dose LMWH, needle placement should be delayed until 24 hours after last dose.

LMWH dosing can be resumed 6-8 hours after surgery.

If an epidural catheter is left in place it should be removed at least 10-12 hrs after last dose and LMWH dosing can be resumed 2 hours after catheter removal

Does asthma get worse in pregnancy?

How does epidural analgesia help with asthma?

For C/S, regional avoids the potential for ________ at intubation and emergence.

What induction agents are appropriate?

symptoms often improve during pregnancy

epidural analgesia provides excellent pain relief & reduces stimulus to hyperventilation

For C/S, regional avoids the potential for bronchospasm at intubation and emergence

 Ketamine (if acutely compromised), Propofol, Pentathol (histamine??)

Are L-R heart shunts tolerated in pregnancy?

What is key to helping these pts do well?

Watch out for _______?

sm left-to-right shunts are usually well tolerated during pregnancy (typically sm ASD or VSD)

adequate pain control is important

meticulous attention to air embolization

significant R-L shunting carries a high mortality in pregnancy (30-50%)

-signifcant risk with single shot spinal anesthetic or rapidly dosed epidural with epinephrine

older mothers

obesity/diabetes

oral contraceptives

cocaine abuse

1. Increased HR

2. Increased myocaridal wall tension

3. Increased oxygen consumption

pregnant state

labor and pushing

remains elevated for some time postpartum

4. Autotransfusion of 300-500mL w/ contraction (from intervillous space = ↑BP & ↓HR unless pt in pain)

When is the onset of peripartum cardiomyopathy?

incidence?

etiology?

How many have complete recovery...if don't recover then...?

onset in final month of pregnancy or first 5 months postpartum

incidence 1:3000-4000

etiology unknown  - viral, autoimmune, toxic

~50% have complete recovery

the remainder progressively deteriorate to cardiac transplantation or early death

CPR during pregnancy...?

If the fetus is viable, & the mother does not immediately respond to resuscitative efforts, what must be done??

just like a non-pregnant patient but with uterine displacement to minimize aortocaval compression

If the fetus is viable, & the mother does not immediately respond to resuscitative efforts, immediate operative delivery (preferable within 4-5 min of arrest) may be life saving to mother & baby

Are arrythmias common in pregnancy?

What arrythmias are usually seen in pregnancy; are they a big deal?

Drugs?

more common during pregnancy

usually atrial, & rarely of hemodyanmic significance

digoxin, quinidine, beta-blockers, lidocaine, adenosine have all been used safely in pregnancy

BAD LQ

When does MS relapse increase in frequency in regards to pregnancy?

What is the controversial issue?

Is RA contraindicated?

increased frequency of relapse in postpartum period

controversial: does exposure of demyelinated areas of SC to LAs exacerbate the disease? Maybe its prudent to use dilute concs of LA

no data to contraindicate the use of RA in these patients -- just talk to your pt and let them decide what they want & document it.

An epidural or spinal is useful for the prevention of __________ in a pt w/ a spinal cord injury.

When may GETA be needed with these pts?

Avoid use of what med?

autonomic hyperreflexia

GETA may be needed in cases of severe respiratory insufficiency

avoid use of succs during the period of denervation injury

In myasthenia gravis + pregnancy, is RA desirable & if so what determines if RA can be utilized?

RA is preferred for pts without high/central disease involvement to avoid...?

RA preferred for C/S, unless there is signifcant respiratory or bulbar(brainstem ie cranial nerves IX X ect) involvement

to avoid respiratory depression of opioids

With Guillian-Barre syndrome & post-polio, is RA controversy?

 Can you use sucs with these pts? 

some controversy over whether epidural anesthesia might trigger a recurrence

Guillain-barre = NO

Post-poli = YES if no progression of disease for a long time

What is benign intracranial hypertension also known as?

What is it?

Do cases improve or get worse with pregnancy?

What is the treatment?

Is epidural placement contraindicated due to presence of a shunt?

also known as psuedotumor cerebri

globally increased CSF pressure with absence of focal intracranial lesions

~50% of cases worsen with pregnancy

treatment - remove CSF with serial lumbar punctures

NO

Meralgia Paresthesias can be caused by epidural T/F?

Remember this is only a _____ deficit.

False - the numbness of the lateral femoral cutaneous nerve occurs due to positioning or lumbar lordosis etc

only sensory deficit

Incidence of diabetes in pregnancy?

___% gestational/___% preexisting

~2%

increasing due to obesity & advanced maternal age

90% gestational/10% preexisting

Pregnancy results in progressive _________ _________ to insulin, likely involving an increase in ________ hormones.

Name 4

Pregnancy results in progressive peripheral resistance to insulin, likely involving an increase in counterregulatory hormones.

placental lactogen

placental growth hormone

cortisol

progesterone

Which diabetic pts have an ↑ risk for DKA?

Type I DM

Type I DM

Gestational DM - often need C/S d/t macrosomia (big baby)

and risk for shoulder dystocia and birth trauma

Gastroparesis

Autonomic dysfunction (more likely to need vasopressors & fluid)

Increased incidence of C/S (epidural is nice to have early)

Airway (ROM & edema)

Peripheral neuropathy (document)

PAIGA

PAIGE (w/A not E =-)

What are the euphoric effects of cocaine related to?

CV effects result from an accumulation of _____.

Pregnancy may result in ____ sensitivity to the CV effects of cocaine

Related to prolongation of dopaminergic activity in the limbic system and cortex (serotonin–norepinephrine–dopamine reuptake inhibitor)

CV effects result from an accumulation of catecholamines

Pregnancy may result in increased sensitivity to the CV effects of cocaine

HTN

Emotional lability

Acidosis

Tremors/Tachycardia

Convulsions

Dilated Pupils

Hyperreflexia

HEAT CD H

see details of cocaine abuse on slides 79 & 80

Is RA or GETA safer with cocaine abuse?

However?

RA is likely safer than GETA

However:

at risk for thrombocytopenia

increased risk of hypotension

patient with depleted catecholamines may be relatively unresponsive to ephedrine

often complain of pain despite adequate level of anesthetic, confusing situation

MAC may be decreased in chronic use (catecholamine stores may be used up)

MAC may be increased in acute use

avoid drugs that sensitize the myocardium to catecholamines -halothane

release catecholamines-ketamine

cause tachycardia-atropine

hydralazine

labetalol

NTG+labetalol

Hydralazine

good BP control

profound tachycardia

no improvement in uterine blood flow

Labetalol

 BP?

good BP control

lowered HR to baseline

no improvement in uterine blood flow

Cocaine user have a high concurrent use of _____?

Probably the most accurate predictor of cocaine is the absence of _________?

opioids and other drugs

prenatal care

cause profound CNS stimulation

catcholamine release from adrenergic nerve terminals and inhibition of reuptake

Symptoms of amphetamines

How do you manage patients that abuse ampthetamines?

similar to cocaine

anesthetic management is similar to management of cocaine abuse

Concurrent use of other drugs

Opioid withdrawl

Poor maternal nutrition

Infection

Direct opioid effects

COP ID

Withdrawal symptoms will show up within ____ hrs of last dose in an opioid abuser.

List 7 S&S of withdrawal:

12 hrs of last dose

Yawning

tearing 

fever

sweating

rhinorrhea

diarrhea

dehydration

Should neonates born from opioid abusing mothers be treated with Naloxone?

Pain is very difficult to control with pts who abuse opioids so RA is the best option. T/F?

neonates may require respiratory support, but should not be treated with Naloxone or may be put into withdrawal

TRUE

T/F asymptomatic HIV infections do NOT contraindicate RA?

If the mom is on opioids, what other type of infection is increased and would possibly contraindicate RA?

True - asymptomatic HIV infections do not contraindicate RA.

increasing incidence of spinal/epidural abscess and disc space infection (infections are present when pt comes to hospital and thus we often cant usually place an epidural etc.)

What % of pregnant women consume ethanol?

ETOH is a know _______?

15%

teratogen

List 2 ETOH related disorders that can effect the fetus?

Which anesthetic technique should you use with alcohol abusing pts?

1. Alcohol related neurodevelopment disorder

2. Fetal alcohol syndrome:

characteristic appearance

growth restriction

mental retardation

RA preferable in absence of coagulopathy or severe neuropathy

skin folds at the corner of the eye

low nasal bridge

short nose

indistinct philtrum (groove between nose and upper lip)

small head circumference

small eye opening

small midface

thin upper lip

Uterine contraction/intervillous space ↓

↓

 uterine venous outflow ↑

↓

autotransfusion to central circulation

↓

also aortic compresssion ↑ & loss of low pressure intervillous space during contraction

↓

↑ afterload

↓

end result:↑ BP + compensatory bradycardia