Pregnancy Induced Hypertension

Jack Lin, M.D.

Albert Woo, M.D.

Advisor: Marissa Lazor, M.D.

Boston University Medical Center
Dept. of Anesthesiology
Hypertension
Most common medical problem encountered
during pregnancy
8% of pregnancies

4 categories:
Chronic Hypertension
Pregnancy Induced hypertension
Preeclampsia-eclampsia
Preeclampsia superimposed on chronic HTN

*Hypertensive disorder in pregnancy may cause an increase in
maternal and fetal morbidity and remains a leading source of
maternal mortality*
Hypertension
Third leading cause of maternal mortality, after
thromboembolism and non-obstetric injuries

Maternal DBP > 110 is associated with risk of placental
abruption and fetal growth restriction

Superimposed preeclampsia cause most of the morbidity
Pregnancy Induced Hypertension
HTN
Usually mild and later in pregnancy
No renal or other systemic involvement
Resolves 12 wks postpartum
May become preeclampsia

Preeclampsia
New onset HTN
After 20 weeks of gestation, or
Early post-partum, previously normotensive
Resolves within 48 hrs postpartum

With the following (Renal or other systemic)

Proteinuria > 300 mg/24hr
Oliguria or Serum-plasma creatinine ratio > 0.09 mmol/L
Headaches with hyperreflexia, eclampsia, clonus or visual disturbances
LFTs, glutathione-S-Transferase alpha 1-1, alanine aminotransferase or right
abdominal pain
Thrombocytopenia, LDH, hemolysis, DIC

10% in primigravid
20-25% with history of chronic HTN



Maternal Risk Factors
First pregnancy
Age younger than 18 or older than 35
Prior h/o preeclampsia
Black race
Medical risk factors for preeclampsia - chronic HTN,
renal disease, diabetes, anti-phospholipid syndrome
Twins
Family history
Mild vs. Severe Preeclampsia
Mild Severe
Systolic arterial pressure 140 mm Hg 160 mm Hg 160 mm Hg
Diastolic arterial pressure 90 mm Hg 110 mm Hg 110 mm Hg
Urinary protein <5 g/24 hr
Dipstick +or 2 +
5 g/24 hr
Dipstick 3+or 4+
Urine output >500 mL/24 hr 500 mL/24 hr
Headache No Yes
Visual disturbances No Yes
Epigastric pain No Yes
Etiology
Exact mechanism not known

Immunologic
Genetic
Placental ischemia


Endothelial cell dysfunction
Vasospasm
Hyper-responsive response to vasoactive hormones (e.g.
angiotensin II & epinephrine)
Symptoms of preeclampsia
Visual disturbances
Headache
Epigastric pain
Rapidly increasing or nondependent edema - may be a
signal of developing preeclampsia
Rapid weight gain - result of edema due to capillary leak
as well as renal Na and fluid retention
Pathophysiology
Pathophysiology

Airway edema
Cardiac
Renal
Hepatic
Uterine

Upper airway edema
Upper airway edema
Laryngeal edema
Airway obstruction

Potential for airway compromise or difficulty in intubation




Cardiac/Pulmonary
Increased CO & SVR
CVP normal or slightly increased
Plasma volume reduced

Pulmonary edema
Decrease oncotic/collid pressure
Capillary/endothelial damage leak
Vasoconstriction
increase PWP and CVP
Occurs 3 % of preeclamptic patients

Hepatic

Usually mild
Severe PIH or preeclampsia complicated by HELLP
periportal hemorrhages
ischemic lesion
generalized swelling
hepatic swelling epigastric pain

Renal
Adversely affected proteinuria
GFR and CrCl decrease
BUN increase, may correlate w/ severity
RBF compromised
ARF w/ oliguria PIH, esp. w/ abruption, DIC, HELLP

*Oliguria + renal failure may occur in the absence of hypovolemia. Be
careful w/ hydration pulmonary edema*

Uterine
Activity increased
Hyperactive/hypersensitive to oxytocin
Preterm labor frequent
Uterine/placental blood flow decreased by 50-70%
Abruption incidence increased
Morbidity / Mortality
Maternal complications:

Leading cause of maternal death in PIH is intracranial hemorrhage
Seizures
Pulmonary edema
ARF
Proteinuria
Hepatic swelling with or without liver dysfunction
DIC (usually associated with placental abruption and is uncommon
as a primary manifestation of preeclampsia)

Morbidity / Mortality

Fetal complications:

Abruptio placentae
IUGR
Premature delivery
Intrauterine fetal death

HELLP Syndrome
Hemolysis
Elevated Liver enzymes
Low Platelets

< 36 wks
Malaise (90%), epigastric pain (90%), N/V (50%)
Self-limiting
Multi-system failure
HELLP Syndrome
Hemostasis is not problematic unless PLT <
40,000
Rate of fall in PLT count is important
Regional anesthesia - contraindicated fall is sudden
PLT count normal within 72 hrs of delivery
Thrombocytopenia may persist for longer periods.
Definitive cure is delivery


Treatment

Management of maternal hemodynamics & prevention of
eclampsia are key to a favorable outcome

MgSO
4
- Rx of choice for preeclampsia.

Does not significantly reduce systemic BP at the serum
concentration that are efficacious in treating
preeclampsia

Goals
Control BP
Prevent seizures
Deliver the fetus
Controlling the HTN
Hydralazine
Labetalol
Nitroglycerin
Nifedipine
Esmolol
Na Nitroprusside risk of cyanide toxicity in the fetus
Preventing Seizures
MgSO
4
- Drug of choice. Narrow therapeutic index

Reduce > 50% w/o any serious maternal morbidity
4g IV Bolus over 10 minutes, then infusion @ 1g/hr
Renal failure - rate of infusion by serum Mg levels
Plasma Level should be between 4-6 mmol/L
Monitor clinical signs for toxicity

Toxic: 10 ml of 10% Ca Gluconate IV slowly

MgSO
4
Toxicity
5-10 mEq/L Prolonged PR, widened QRS
11-14 mEq/L Depressed tendon reflexes
15-24 mEq/L SA, AV node block, respiratory paralysis
>25 mEq/L - Cardiac arrest

Anesthetic Considerations
Detailed preanesthetic assessment
Focuses on airway, fluid status, and BP control
Lab: CBC, BUN/Cr, LFTs
Routine coagulation is NOT recommended unless there
is clinical suspicion
PLT count - if neuraxial techniques are considered

Regional Anesthesia
Labor epidural - advantage of a gradual onset of
sympathetic blockade provides cardiovascular
stability & avoids neonatal depression.
Epidurals may reduce vasospasm and HTN may
improve uteroplacental blood flow
Reduce risk of airway complications and avoid
hemodynamic alterations associated with intubation
Regional (part 2)
Neuraxial anesthesia in preeclamptic pt - still
controversial
Many studies this is the best option
National High blood Pressure Education Program
Working Group
Neuraxial, epidural, spinal and combined spinal-epidural (CSE),
techniques offer many advantages for labor analgesia and can
be safely administered to the parturient with preeclampsia. Dilute
epidural infusions of local anesthetic plus opioid produce
adequate sensory block without motor block or clinically
significant sympathectomy.
Regional (part 3)
Possibility of extensive sympatholysis with profound
hypotension
decrease CO & uteroplacental perfusion

Single shot spinal technique controversial
Recent analysis suggest that it can be used safety in pt with
severe preeclampsia undergoing C-section. BP decline similar
to epidural. Hypotension can be avoided by meticulous attention
to anesthetic technique and careful volume expansion

General Anesthetic Techniques
Laryngeal response blunted by pre-treatment with
hydralazine, nitroglycerin or labetalol
Airway edema increased risk of difficult airway
situation
Neuraxial techniques preferred method,
contraindicated in the presence of coaguloapthy
In pt receiving MgSO
4
, SUX activity potentiated
Enhanced sensitivity to non-depolarizing muscle
relaxants
MgSO
4
blunts response to vasconstrictors and inhibits
catecholamine release after sympathetic stimulation
Thank You!