Pre-eclampsia

 

Disease:

Definition

1. Hypertension:

·     >140/90 after 20 weeks

2. End-organ dysfunction

·     Placenta: IUGR

·     Kidney: proteinuria >30mg/mmol, ↑creat

·     Liver: ↑transaminases, RUQ pain

·     Haem: ↓plt, haemolysis, DIC

·     Neuro: hyperreflexia, confusion, seizure, stroke

Risk factors

Obvious:

·     PHx

·     FHx

Obstetric:

·     Nulliparous, or grand multiparous

·     Donor egg, or donor embryos

Comorbidities:

·     Older

·     Metabolic (obesity, HTN, T2DM, CKD)

·     Autoimmune (APLS, other)

Pathophysiology

·     Abnormal placentation

·     Endothelial dysfunction

·     Organ dysfunction

 

Complications: mother

Airway

·     Airway oedema

Breathing

·     Pulmonary oedema

Circulation

·     ↑SVR

·     ↓Volume

·     ↓LV function

Disability/neuro

·     Stroke

·     Eclampsia

·     PRES

Kidney

·     Failure

Liver

·     Failure

·     Capsule rupture

Blood

·     DIC / PPH

·     HELLP

 

Complications: baby

Placental insufficiency

·     IUGR

Premature delivery

·     Toxicity: neuro, oxygen

·     Immaturity: respiratory, cardiovascular, metabolic, thermoreg.

 

Goals: mother

Stop the disease

·     Indications for delivery

o   Disease is severe

o   Baby is ready (>37/40)

Prevent maternal complications

Blood pressure control:

·     Aim <160/100

·     Oral: methyldopa, labetalol, nifedipine, hydralazine

·     IV: labetalol 5-10mg q2min, hydralazine 5-10mg q15min

·     Beware intubation and extubation

Magnesium:

·     MgSO4 4g 15min + 1g/h for 24h

·     Aim 2-3mM

Prevent neonatal complications

·     Magnesium

·     Glucocorticoid if <35/40

 

GA Caesarean recipe for pre-eclampsia:

Goals

·     No stroke

·     No aspiration

·     No bleeding

·     No drowning

Pre-op

·     Treatment: Mg2+, BP control

·     Investigations: blood tests, ultrasound

·     Phone calls: theatre NIC, anaes NIC, paeds, obs
Anaes nurse: prepare for spinal, GA, MTP

Intra-op

·     Anaes: relaxant GA with mRSI

o  Induction: propofol 3mg/kg, sux 1.5mg/kg, alf 20mcg/kg

o  Maintenance: sevo/nitrous

o  Emergence: remifentanil TCI

·     Airway: ETT + video laryngoscope + positioning + pre-ox + cricoid

·     Access: large IVC, A-line pre-induction

·     Probes: standard + A-line, temp (with warming), BIS

·     Pain: morphine 20mg after delivery, beware NSAID and tramadol

·     People: O&G scrubbed, paeds present

·     Oxytocics: oxytocin bolus + concentrated infusion, beware ergot

Post-op

·     HDU

·     More anti-hypertensive

 

Magnesium effects:

2.5mM

·     ECG changes

5mM

·     Areflexia, weakness

7.5mM

·     Conduction delay

·     Respiratory paralysis

10mM

·     Cardiac arrest

 

 

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