hypertensive disorders of pregnancy HELLP syndrome preeclampsia eclampsia mississipi tennesse classification

1. ANAESTHETIC
IMPLICATIONS AND
MANAGEMENT IN
PREECLAMPSIA &
ECLAMPSIA
Dr Arundev P Nair
Dept of Anaesthesiology
Government medical
college, Kottayam

2. INTRODUCTION
• Hypertensive disorders complicate nearly 6-10% of all
pregnancies
• Deadly triad with infection and haemorrhage
• In developed countries, 16% of maternal deaths due to
hypertensive disorders
• Preeclampsia – a multifactorial, multi-system hypertensive
disorder of pregnancy
• etiology remains unknown
• Management evidence-based

3. • Classification of hypertensive disorders of pregnancy
• Diagnosis AND Risk factors of preeclampsia
• Obstetric and Anaesthetic management
• Complications of preeclampsia
• Diagnosis and risk factors of Eclampsia
• Obstetric and Anaesthetic management in Eclampsia
• Complications of Eclampsia
References
Chestnut’s,
Miller

4. • 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

5. HISTORY
Year Milestones
1903 Chesley -Preeclampsia word included in books
1961 Chesley -Preeclampsia-eclampsia restricted to obstetric
definition.
1966 Eastman and
Hellmann
-Toxemia of pregnancy
-Diagnostic criteria of preeclampsia: hypertension,
proteinuria, edema after 24 weeks
1976 Pritchard and Mc
Donald
-Hypertensive disorders of pregnancy
-Diagnostic criteria of preeclampsia: hypertension,
proteinuria, edema after 20 weeks
1988 Hibbard -Under classification Hypertensive disorders of
pregnancy, preeclampsia grouped into Pregnancy
induced Hypertension
-Classified into mild-moderate and severe preeclampsia

6. CLASSIFICATION

7. 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
• Almost half of these develop preeclampsia syndrome

8. CHRONIC HYPERTENSION
• Blood Pressure ≥ 140/90 before 20 weeks of
gestation
Or
• Persistence of hypertension beyond 12 weeks
after delivery.

9. 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 before 20 weeks’ gestation
• More adverse outcome than preeclampsia alone

10. PREECLAMPSIA
• New onset of hypertension & proteinuria in a
previously normotensive woman
• after 20 weeks of gestation
• Returning to normal within 12 weeks
postpartum.
• Edema not a part of diagnosis now.
• A retrospective diagnosis

11. 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

12. • 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

13. PREECLAMPSIA

14. EPIDEMIOLOGY
• Preeclampsia complicates nearly 6% - 10% of all
pregnancies.
• maternal ICU admission
• Leading cause of preterm delivery-NICU
• Birth of LBW babies- economic, social and medical
burden
• Leading cause of maternal and fetal morbidity and
mortality.

15. • A 37 year old obese lady G3P2L1(IUD1) who is a known
case of SLE admitted for safe confinement
• She had History of Preeclampsia in 1st pregnancy when she
was 19 years of age. 1st
baby had IUGR
• Had IUD at 28weeks because of abruption in 2nd
pregnancy
• Later got divorced and got remarried to another person.
• Her current Partner had fathered a preeclamptic pregnancy
in another woman

16. • She also has history of DM,HTN, & CKD (due to SLE)
• Her elder sister also had history of preeclampsia
• She is now at 34 weeks of gestation
• She c/o headache, photophobia, epigastric pain
• Her Bp was 160/110
• Foetal BPP showed IUGR
• 24 hour Urine protein was 6gm & serum creatinine was 1.4

17. CLASSIFICATION OF PREECLAMPSIA
PE PE with Severe features
Blood pressure >140/90 >160/110
Proteinuria
On 2 occasions, >4hrs
apart
>0.3gm/ 24 hrs
Dip stic > 1+
>5gm/24 hrs
Dipstic > 3+
S. creatinine normal elevated
Pulmonary edema _ +
oliguria _ +
IUGR _ +
headache _ +
Visual disturbance _ +
Epigastric pain _ +
HELLP syndrome _ +

18. RISK FACTORS

19. RISK FACTORS CONTD..
Maternal conditions
 Hypertension
 Diabetes
 Chronic renal disease
 Thrombotic vascular diseases-APLA,SLE
 Obesity, BMI>35 doubles the risk
Behavioural factor
 Smoking : - preventive
Obstetric conditions
 Multiple gestation
 Molar pregnancy

20. RISK FACTORS CONTD..
Demographic Factors
 Hispanic
 Black race
 Advanced age>35

21. ETIOPATHOGENESIS
• Exact mechanism unknown, disease of theories.
1.ABNORMAL PLACENTATION
• Stage1:failure of trophoblastic invasion into myometrium
Penetrates only decidua
superficial placentation  placental perfusion↓
• stage2 : endothelial damage
systemic manifestations of Preeclampsia
(Asymptomatic)
(symptomatic)

22. 1.ABNORMAL PLACENTATION

23. 2. INFLAMMATORY MEDIATORS
↓PGI2
↑TXA2
Vasoconstriction
Platelet aggregation
↑Vasopressor
response
↑uterine activity

25. 3. GENETIC
Early onset Late onset
onset < 34 wks POG > 34 wks POG
frequency 20% 80%
Association with IUGR High negligible
Familial component yes no
Placental morphology abnormal normal
etiology Primarily placental Primarily maternal
Risk factors Family history DM, HTN, Maternal age,
BMI, CVS disorder↑
Risk of adverse outcome high negligible
Family history of pre eclampsia: genetic origin
Mutations in Complement Regulatory Protein gene
Genes assoc.: MTHFR, F5 leiden, AGT, HLA, NOS3, F2(prothrombin), ACE

26. 4. IMMUNOLOGIC
• Exposure to sperms of different partner
• long term exposure to paternal antigen in sperms of same
partner- protective
• activated auto antibodies to angiotensin receptor-1 AA-
AT1activate AT1 receptorsincreased sensitivity to
angiotensins  hypertension

28. 5.ANTIANGIOGENIC PROTEINS

29. PATHOPHYSIOLOGY
Superficial placentation + diffuse endothelial dysfunction
It affects primarily only the peripheral circulation & not your
central circulation

30. RESPIRATORY
• Airway is edematous;
• ↓ internal diameter of trachea
• Pharyngolaryngeal edema
• ↑ risk of pulmonary edema; 3% women with
preeclampsia.

31. CNS
• CNS manifestations include:
headache,
visual disturbances,
hyperexcitability, hyperreflexia,
coma,seizures
Cause: cerebral edema and hypoperfusion

32. CVS
• Vasospasm and exaggerated responses to catecholamines
• Increased vascular permeability
• ↓ Colloid Oncotic Pressure
 hypertension
 endorgan ischemia
 Intravascular volume deficit

33. HAEMATOLOGY
• Hemoconcentration (pts with anemia may appear to have
normal hematocrit)
• Thombocytopenia  most common
• Platelet count correlates with disease severity and incidence of
abruptio placentae
• DIC due to activation of coagulation
cascadeoverconsumption of coagulants and platelets
spontaneous haemorrhage.

34. HEPATIC

35. RENAL
Decreased GFR
- oliguria
- renal failure
- uric acid, creatinine is elevated
- proteinuria

36. UTEROPLACENTAL CIRCULATION
• Uteroplacental insufficiency
• Fetal complications:
- hypoxia
-IUGR
-Prematurity
-IUD
-Placental abruptio

37. PREDICTION OF PREECLAMPSIA
No screening test is really helpful
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.

38. PREVENTION
• Regular Antenatal checkup:
rapid gain in weight
rising blood pressure
edema
proteinuria/deranged liver or renal profile
• Low dose Aspirin in High risk group: PGs and TXA2↑ ↓
• Calcium supplementation: no effects unless women are calcium
deficient
• Antioxidants-Vitamin C and E
• Nutritional supplementation: zinc, magnesium, fish oil, low salt diet

39. OBSTETRIC
MANAGEMENT

40. OBSTETRICS MANAGEMENT
1. Maternal evaluation :
Hemoglobin and hematocrit
platelet count : decreased, if < 1 lakh
coagulation profile
LFTs : indicated in all patients
RFT : raised (S.urea creatinine is
decreased in Normal pregnancy)
Urine Routine : proteinuria

41. OBSTETRICS MANAGEMENT CONTD..

42. OBS. MANAGEMENT CONTD..
3.Treatment of Acute Hypertension:
• Goal: to prevent adverse maternal sequalae
• Aim: to keep DBP below 100 mm Hg and to lower MAP
not >15-25%

43. ANTI HYPERTENSIVE DRUGS
DRUGS 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
sedation
Fetal-intestinal ileus
Hepatic disorders,
psychic pts., CCF
Labetalol
Oral-100mg tds till
800mg/d
Iv- 20 mg till desired
effect (max. 220mg)
Alpha + beta blocker Maternal-tachycardia,
hypotension
Fetal-bradycardia,
hypotension
Hepatic disorders
Hydralazine
Oral-100mg/d in 4 divided
doses
Peripheral vasodilation Maternal-hypotension,
tachycardia, arrythmia,
palpitations, lupus like
syndrome
Fetal- safe
Neonate-
thrombocytopenia
Causes sodium retention
so use diuretic

44. ANTI HYPERTENSIVES CONTD..
DRUGS MOA SIDE EFFECTS C/I &
PREVENTION
Nifedipine
Oral: 5-10mg tds
Arteriolar
vasodilation
Flushing,
hypotension,
tachycardia,
inhibition of labor
With MgSO4 and
NMBs
Nitroprusside
0.25-8
mcg/kg/min
Direct vasodilator Maternal- nausea,
vomiting, severe
hypotension
Fetal- cyanide
toxicity
Bed rest
Avoid Diuretics, ACE inhibitors, ARBs
Avoid uterotonics

45. OBS MANAG CONTD..
4. Seizure Prophylaxis
Routinely used in severe PE
Magnesium sulphate: most commonly used
Initiated with onset of labor till 24h postpartum
For caesarean, started 2hrs before the section till 12hrs
postpartum
abrupt, sustained blood pressure elevation overwhelms myogenic vasoconstriction &
causes forced dilation of the cerebral vessels
Leading to hyperperfusion,& cerebral edema.

46. DOC FOR PROPHYLAXIS OF
ECLAMPTIC CONVULSIONS
M.O.A: blocks Ca2+
ion influx into neurons
leading to cerebral vasodilatation
Other actions: -lowers endothelin-1 levels
- production of PG I↑ 2
- tocolytic action
- attenuates the release of Ach and sensitivity
to Ach at myoneuronal junction
MgSO4

47. RECOMMENDED REGIME FOR
MGSO4
• Zuspan or sibai regime: 4-6 gm i.v over
15 min f/b infusion of 1-2 gm/hr
• 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

48. SIDE EFFECTS OF MGSO4
• Maternal : flushing, chest pain & tightedness, palpitations,
nausea, blurred vision, perspiration, transient hypotension,
muscle weakness, pulmonary edema
• Neonatal: lethargy, hypotonia, respiratory depression

49. MAGNESIUM LEVELS
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

50. MANAGEMENT OF MGSO4
TOXICITY
• Stop infusion
• Inj Calcium gluconate iv 10 ml 10% over 10
minutes
• Endotracheal intubation in respiratory depression

51. ANAESTHETIC IMPLICATIONS DURING
MGSO4 THERAPY
o MgSO4 potentiate and prolong the action of both depolarizing non-depolarizing
muscle relaxants
o MgSO4 interactions with calcium channel blockers, uterotonics and uterine relaxants
o At higher doses Mg2+
rapidly crosses the placental barrier, has been found to
significantly FHR variability↓
o Should be given cautiously with Ca2+
as may antagonize the anticonvulsant effect of
MgSO4
o Also be cautious in patients with renal impairment
o May the possibility of hypotension during regional block↑

52. LYTIC COCKTAIL REGIMEN
Menon in India has started this regimen-
1961
25 mg Chlorpromazine & 100 mg Pethidine in 20 ml of 5%D IV
+50 mg Chlorpromazine & 25 mg Promethazine IM
50 mg Chlorpromazin & 25mg Promethazine IM alternatively 4 hrly X 24 hr
IV drip 10%D with 100 mg Pethidine at rate of 20-30 drop/min X 24 hr following
last episode of seizure.
52

53. OBS. MANAG. CONTD..
5. Delivery
• The only definitive treatment
• Preeclamptic patients divided into 3 categories
A- Preeclampsia features fully subside
B- partial control, but BP maintains a steady high level
C- persistently increasing BP to severe level or addition of
other features

54. Management:
Gp A: can wait till spontaneous onset of labor
don’t exceed Expected Date of Delivery
Gp B: >37wk terminate w/o delay
<37wk, expectant management at least
till 34wks
Gp C: terminate irrespective of POG,
start seizure prophylaxis and
steroids if<34wks

56. ANAESTHETIC
MANAGEMENT

57. PRE ANAESTHETIC EVALUATION
1.Airway
2. Haemodynamic monitoring :
blood pressure, ECG, Pulse oxymetry
3. Fluid status: volume depleted patients
higher risk of hypotension with induction of anaesthesia
4. BP control
5. Coagulation status

58. INVASIVE HAEMODYNAMIC
MONITORING
• Invasive central blood pressure monitoring not routinely indicated
• Does not improve patient outcome
• Indications:
-oliguria patients
-pulmonary edema
-poorly controlled maternal blood pressure
- massive hemorrhage
-frequent arterial blood gas measurements
• Poor correlation between central venous and pulmonary capillary wedge
pressure

59. ANESTHETIC GOALS OF LABOR
ANALGESIA IN PREECLAMPSIA
• To establish & maintain hemodynamic stability (control
hypertension & avoid hypotension)
• To provide excellent labor analgesia
• To prevent complications of preeclampsia
• Pulmonary edema
• Eclampsia
• Intracerebral haemorrhage
• Renal failure
• To be able to rapidly provide anesthesia for Caesarean
Section

60. ANALGESIA FOR LABOR & DELIVERY
• Neuraxial analgesia:
Lumbar Epidural-
gradual onset of sympathetic blockade
cardiovascular stability
↓ stress response
maintains uteroplacental circulation
avoids neonatal depression
extended analgesia if cesarean required
excellent post op analgesia

61. NEURAXIAL ANALGESIA CONTD..
Combined Spinal Epidural Analgesia-
advantages of both
Spinal - rapidity
requires only small dose of LA
↑vasopressor response-better
control of hypotension
disadvantage:
immediate verification of catheter function
not possible

62. ANAESTHESIA FOR CAESAREAN
• Epidural anaesthesia
• Spinal anaesthesia:
advantage: rapidity
requires only small dose of LA
↑vasopressor response-better control of
hypotension
• Combined Spinal Epidural Anaesthesia
• Indications:
• Patient preference
• Contraindications to general anaesthesia
• Hemodynamically stable patient

63. ANAESTHESIA FOR CAESAREAN
CONTD..
General anaesthesia:
Indications
- coagulopathy
-sustained fetal bradycardia with reassuring maternal
airway
- severe ongoing maternal hemorrhage
- contraindications to neuraxial technique

64. CONCERNS WITH NEURAXIAL
ANAESTHESIA
• Adequate hydration:
- risk of pulmonary edema
-Lower concentration of local anesthetics:
hypotension less common
• Treatment of hypotension if any:
- small doses of vasopressors
• Epinephrine containing test dose should be avoided
• Coagulation status
-mild preeclampsia-: hypercoagulable
-severe preeclampsia-: hypocoagulable
-bleeding time poor indicator of platelet function

65. PLATELETS AND NEURAXIAL
ANAESTHESIA
• platelets >1lakh/mm3
, coagulation profile not
indicated
• Platelets <1 lakh/mm3
-clinical evidence of bleeding
-platelet trend-Every 6hourly if stable, every
1-3hrly if declining
-coagulation profile: PTINR,APTT,TEG
-quality of platelets:PFA100
-risk vs benefit
• Platelets <50,000: contraindication

66. PLATELETS CONTD..
- remove epidural catheter only when platelet count
returns normal (at least 75000-80000/mm3
)
- emergency imaging studies and neurologic evaluation if
epidural hematoma suspected
- In various studies, it has been found that low dose aspirin
doesn’t significantly affect bleeding time, neuraxial analgesia
can be given safely without any complication

67. HAZARDS OF GENERAL ANAESTHESIA
1.Difficult intubation-
-smaller size tube
-difficult airway cart ready
2. Exaggerated and prolonged hypertensive response to laryngoscopy
and intubation: -risk of intracranial hemorrhage,pul oedema
-labetalol(5-10 mg),
local anesthetics,
esmolol( 2mg/kg ),
nitroglycerine(200mcg/ml),
nitroprusside 0.5mcg/kg/min,
remifentanyl (1mcg/kg) used before intubation and extubation

68. HAZARDS CONTD..
3.MgSO4 with neuromuscular blockers, calcium
channel blockers, uterotonics and uterine
relaxants
4. Uterotonics avoided: risk of acute hypertension
and eclampsia

69. GENERAL ANAESTHESIA
ADMINISTRATION IN SEVERE
PREECLAMPSIA
 Place a radial canula for continuous BP monitoring
 i.v line secured
 Arrange smaller size endotracheal tubes
 Antacids and perinorm given 30 minutes before
 100% oxygen for 3 min.
 Labetalol 10 mg iv bolus and titrate to effect before
induction, while monitoring fetal heart rate
 Rapid Sequence Induction
 Labetalol 5-10 mg before extubation
 Give opioids or BZDS after delivery

72. POST OP CONCERNS
• Post op analgesia:
intravenous opioids, neuraxial opioids
concern : monitor for respiratory
depression
• Post partum management:
risk of pulmonary edema, sustained
hypertension, stroke,
Venous thromboembolism,
seizures, HELLP, postpartum hemorrhage.

73. COMPLICATIONS
• CVA: main leading cause of death in pts with PE
absolute risk is low
reversible cerebral edema is m/c
• Pulmonary edema, pleural effusion,ARDS:
head end elevation
oxygen therapy
restrict fluids
diuretics
mechanical ventilation
• laryngeal edema
• Placental abruptio

74. COMPLICATIONS CONTD..
• Renal failure: oliguria most common
haemodynamic monitoring
diuretics
• Liver:
Subcapsular liver hematoma: avoid trauma to liver,
HELLP Syndrome,
hepatic rupture with shock : surgical emergency
• DIC: treat the cause
platelets/Fresh Frozen Plasma/cryoprecipitate
• Eclampsia
• Maternal death

76. HELLP SYNDROME

77. PRECLAMPTIC DISORDERS IN
PREGNANCY
Preeclampsia
occurs in around
10% of the
pregnancies
HELLP occurs almost
always
in setting of preeclmapsia
; in 12% cases.
Preeclampsia is
an associated
diagnosis in 21-61
% cases of AFLP:
Preeclampsia
HELLP
AFLP

78. HELLP SYNDROME
Diagnosis:
1. Hemolysis:
• Peripheral smear
• ↑bilirubin >1.2mg/dL,
• LDH>600 IU/L
1. Elevated liver enzymes:
• SGOT> 70 IU/L
• LDH>600 IU/L
1.Low platelets: <1 lakh /mm3
HELLP syndrome was
named by Dr. Louis
Weinstein in 1982

79. • Tennessee Classification
1. Microangiopathic hemolytic anemia with abnormal
blood smear, low serum haptoglobin, and elevated
serum LDH levels
2. Serum LDH level >600 IU/L or twice the laboratory upper
limit of normal and serum AST level >70 IU/L or twice
the laboratory upper limit of normal, or serum bilirubin
level more than >1.2 mg/dL
3. Platelet count <100,000/μL
4. Incomplete HELLP syndrome is defined as the presence of
only 1 or 2 of these abnormalities and may be less
severe)

80. • Mississippi Triple-Class Classification
– Class I: platelet count nadir ≤50,000/mm3
– Class II: platelet count nadir >50,000/mm3 and
≤100,000/mm3
– Class III: platelet count nadir >100,000/mm3 and
≤150,000/mm3

81. MANAGEMENT OF HELLP SYNDROME
• Immediate hospitalisation
• Stabilise mother
• antihypertensives
• anti seizure prophylaxis
• correct coagulation abnormalities
• Assess fetal condition- FHR, doppler ultrasound, biophysical
profile

83. HELLP CONTD..
• Ultimate goal:
• >34 wks gestation deliver
• <34wks expectant management if stable maternal
and fetal conditions
• Platelet transfusion if:
• <40,000/mm3
before cesarean
• <20,000/mm3
before delivery

85. ECLAMPSIA

86. • 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

87. ECLAMPSIA
• Is the new onset of seizures or unexplained coma
during pregnancy or postpartum period in
patients with pre-existing PE and without pre-
existing neurological disorder.

88. EPIDEMIOLOGY
• 0.1- 5.5 per 10,000 pregnancies
• Decreasing incidence with time
• Antepartum(50%): mostly in third trimester
• Intrapartum(30%):
• Postpartum(20%): usually within 48hours,
• beyond 7days generally rules out eclampsia

89. RISK FACTORS
Maternal age less than 20 years
Multigravida
Molar pregnancy
Triploidy
Pre-existing hypertension or renal disease
Previous severe Preeclampsia or Eclampsia
Nonimmune hydrops fetalis
Systemic Lupus Erythematosus

90. CLINICAL FEATURES
• Eclamptic convulsions are epileptiform and consist of four
stages
Premonitory stage: twitching of muscles of face, tongue,
limbs and eye. Eyeballs rolled or turned to one side, 30s
Tonic stage: opisthotonus, limbs flexed, hands clenched, 30s
Clonic stage: 1-4 min, frothing, tongue bite, stertorous
breathing
Stage of coma: variable period.

91. PHYSICAL EXAMINATION
• Sustained rise in blood pressure
• Tachycardia,Tachyponea
• Rales
• Mental status changes
• Hypereflexia
• Clonus
• Papilloedema
• Oliguria or anuria
• Right upper quadrant or epigastric abdominal
tenderness
• Generalized edema
• Small fundal height for the estimated gestational
age

92. PATHOGENESIS
• Loss of normal cerebral auto regulatory
mechanisms
cerebral hyperperfusion
Edema & cerebral blood flow↓
abrupt, sustained blood pressure elevation overwhelms myogenic vasoconstriction &
causes forced dilation of the cerebral vessels
Leading to hyperperfusion,& cerebral edema.

93. DIFFERENTIAL DIAGNOSIS
• meningitis
• encephalitis
• space occupying lesion
• electrolyte disturbance
• vasculitis
• amniotic fluid embolism
• medications
• organ failure
• stroke

94. PREDICTION AND PREVENTION
• Early detection and judicious treatment with
termination of pregnancy in Preeclamptic patients
• Adequate sedation,Anti hypertensives and
prophylactic Anticonvulsant in peripartum period
• Observe for 24-48 hrs postpartum

95. MANAGEMENT OF ECLAMPSIA
1. Prevention of seizures
2. Control of seizures

96. PREVENTION OF CONVULSIONS
•MgSO4 therapy:
DOC for prophylaxis of eclamptic convulsions

97. CONTROL OF SEIZURES
-turn patient head to one side,
-apply jaw thrust if airway compromised
- nasopharyngeal airway
- Adequate oxygenation
- ensure adequate breathing ,
bag and mask ventilation can be done
- secure an i.v line
- Drugs- Antiepileptics
Antihypertensives
- Delivery

98. ANTICONVULSANTS
Drugs Mechanism of action Contraindications Side effects
MgSO4
Zuspan or sibai regime:
4-6g iv over 15 min f/b
infusion of 1-2g/h
Pitchard regime: 4g i.v
over 3-5min f/b 5g in
each buttock with
maintenance of 5g i,.m in
alternate buttock 4hrly
Competitive inhibition of
calcium ions at motor
end plate or cell
membrane, Ach↓
release & sensitivity
Patients with MG and
impaired renal function,
heart block, digitalis
Maternal : flushing
Perspiration, headache,
muscle weakness,
pulmonary edema
Neonatal: lethargy,
hypotonia, respiratory
depression
Diazepam
10-20 mg I.V f/b 40 mg
diazepam in 500ml
normal saline at 30 drops
per minute
Cerebral muscle relaxant
and anticonvulsants
Maternal : hypotension
Fetal : respiratory
depression, may last even
3 weeks after delivery
Phenytoin
10 mg/kg IV at not more
than 50 mg/min f/b 2 hrs
later by 5 mg/kg for 12
hrs, thereafter 200mg
orally till 48hours
Centrally acting
anticonvulsants
Maternal: hypotension,
cardiac arrythmias,
phlebitis, hyperglycemia,
respiratory arrest,
cardiac arrest,
bradycardia
Fetal: Fetal hydantoin
syndrome

99. REFRACTORY SEIZURES
• Thiopentone sodium 0.5 g in 20 ml of 5%
Dextrose intravenously slowly
• Propofol infusion
• Midazolam infusion
• if fails then General Anaesthesia
• Seizures still not controlled then termination of
pregnancy

100. DELIVERY IN ECLAMPSIA
Unless contraindicated: Eclamptic women should undergo
normal vaginal delivery
Indications for cesarean section -
Fetal distress
Placental abruption
Extreme prematurity
Unfavorable cervix
Failed induction of labor

101. ANAESTHETIC MANAGEMENT
1. Assess seizure control and neurologic function
2. Fluids : 75-100 ml/hr
avoid cerebral edema,
CVP guided fluid therapy
3. BP control : appropriate anti hypertensives
4. Monitoring :Pulse oxymeter , ECG, Fetal Heart Rate, Urine output, NM monitoring,
5. Lab inv: CBC, Bld sugar, Bld urea, S.creatinine, S.uric acid level with S.E, LFTs,
Coagulation profile, 24 hrs specimen for protein
6. Choice of anaesthesia: GA preferred with thiopentone or propofol (both decreases
ICP)
7. Avoid hypo or hyperglycaemia, hypoxia, hyperthermia
8. Peripartum : manage for shock, sepsis, psychosis,thrombocytopenia, DIC,
coagulopathy

102. CHOICE OF ANAESTHESIA IN ECLAMPSIA
• Neuraxial: -
indications - seizures controlled
- no coagulopathy
- patient cooperative
• GA: -
Indications -seizures not controlled
-coagulopathy
-reassuring airway
-uncooperative patients

103. GENERAL ANESTHESIA IN ECLAMPTIC PT.
o Careful preanesthetic evaluation to be done
o Aspiration prophylaxis to be given
o Secure an i.v line
o Small endotracheal tubes ( 6 and 6.5mm) should be ready
o Difficult airway cart should be ready
o All monitors to be attached
o Start preoxygenation with100% oxygen via well fitting mask for 3-5 minutes
o Exaggerated CVS response should be pretreated with either lignocaine or beta
blockers
o Induces anesthesia with : inj.Thiopentone 4-5mg/kg
inj Sch 1-1.5mg/kg (RSI)
#If pt. is on MgSo4 therapy, the usual fasciculation following Sch may not occur and it
may take 60 sec.

104. GENERAL ANESTHESIA IN ECLAMPTIC PT.
o Maintain anesthesia with 100% O2 +0.5% isoflurane until
delivery of neonate,
o #Neuromuscular monitoring to be done and dosage of NDMR
to be titrated accordingly
o Extubation: Should be done after 24-48 hrs later in view of
Postpartum seizure, Cerebral edema,
Aspiration pneumonia,
Hypertensive crisis, Pulmonary edema,ARDS
DIC, HELLP syndrome

105. The tracheas of patients who have
not recovered neurologically should remain intubated,
and these patients should be monitored in an intensive
care unit
Avoidance of hypoxia, hyperthermia, and hyperglycemia
is also important in avoiding an exacerbation of
neurologic injury.

106. • 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

107. SUMMARY
• Preeclampsia is a multisystem disorder.
• Management is supportive, delivery is the only definitive.
• Preeclampsia patients: High risk for difficult intubation.
• Hypertensive response to laryngoscopy intracranial
hemorrhage.
• Spinal Anaesthesia not contraindicated in severe Preeclampsia
• Eclampsia can be prevented by prophylactic MgSO4 therapy
• Eclamptic patients should be monitored for at least 24 hrs post
partum.

108. THANKYOU