Preeclampsia Scenario with HELLP & Eclampsia C omplications

1. PreeclampsiaScenariowithHELLP & EclampsiaComplications D. Berrin Gunaydin, MD, PhD Ankara, Turkey www.berringunaydin.com No disclosure

2. Olgu • 38 yaşında nullipar 331 hafta • 67 kg, 161 cm • Semptomlar • Başağrısı, epigastrik ağrı, bulanık görme, bulantı-kusma ve başdönmesi • Vitalbulgular • 190/110 mmHg, 102 atım/dk, 22 soluk/dk, 37.1°C • Fizik muayene • Bilateral(+) ödem bacaklarda

3. İlk medikal tedavisi İV bolus5 mg hidralazin 2 dk içinde İV 5 mg hidralazin (20 dk sonra) Kan basıncı 170/110 mmHg İV bolus20 mg labetalol2 dk içinde 160/90mmHg, 96 atım/dk ve 16 soluk/dk Betametazon 6 mg IM (2 kez) Sürekli kardiotakograf ile monitörizasyon

4. Bekleme tedaviisi planlanırken grand mal nöbet geçirir

5. StandardMonitörizazyon • EKG: NSR • 96 atım/dk • 160/90 mmHg • Sp02: %98 • 16 soluk/dk İV bolus MgSO44 g/20 dk 1 g/st İV infüzyonla idame • 12 saattir aç • ASA III-E • Havayolu: Sınıf II Mallampati • RL 200 mL/st Preoperatif Değerlendirme bg

6. Yönetim Genel Anestezi • Umbilikal kord klemplendikten sonra İV oksitosin infüzyonu • Apgar 8 ve 9 (1. ve 5. dk) • Operasyon 35 dk • Rezidüel nöromüsküler blok neostigmin-atropinleantagonize Önce sola tilt • İndüksiyon • Preoksijenasyon • İV propofol/rokuronyumlahızlı-seri indüksiyon • For blunting response to laryngoscopy • İV bolus 5mg labetalol • İV 1.5 mg/kg lidokain • İdame • Sevofluran 0.75 MAK ile 50% NO2/O2

7. Hastaya evde herhangi bir semptom olursa rapor etmesi • Hastanede 72 saat kan basıncı takibi • Postoperatif 4.gün taburcu • Postoperatif multimodal analjezi • İV MgSO4infüzyonuna 24 st devam Postoperatif Takip bg

8. Trombosit 52,000/µL • AST 331 U/L • ALT 116 U/L • LDH 1524 U/L • Eklampsi • Nöbet (+) Tanı doğrulanır bg

9. bg

10. Pathophysiology and Prevalance Overallincidence of HELLP is 2-12% of allpregnancies 20% of preeclampticwomenwith severe features developHELLP

11. After 20 weeksgestationBP treshold on 2 occasionswith≥ 4 h apart • if BP ≥ 140/90 mmHgformildpreeclampsia • İf BP ≥ 160/110 mmHgfor severe preeclampsia New terminology Hypertension • ≥ 300 mg/24 h in urineorUrineP/C ratio >0.3 Proteinuria Edema ObstetGynecolClin N Am 2017:44:219-30

12. Cesarean • Platelettransfusionif<50,000/µLbefore CS • Spinal is an appropriate choice • General anesthesia • Continue MgSO4infusion • Smaller ETT tube • Blunt hemodynamic response to intubation Labor • Neuraxial techniques are appropriate as long as platelet function/count are adequate • Early catheter placement • Checking platelet count before catheter removal • Platelettransfusionif< 20,000/µLbefore or after delivery Anesthetic Management: General Principles bg

13. Drugsbluntinghemodynamicresponsetolaryngoscopy &intubation bg

14. RevBrasilAnestesiol 2016 AnesthesiaEssaysRes 2017 • CSE(n=50) Spinal(n=12) General(n=37) • Platelet (mean) 112,600/µL 95,700/µL 76,800/µL • ClinExpObstetGynecol 2009 (Retrospectivestudy in 102 preterm HELLP) J AnaesthesiolClinPharmacol 2011 AnesthAnalg2013

15. Delivery at 37 weeks • 34-37 weeks optimum time topreventmaternal/neonatalmorbidity is unknown • <34 wks’ electivedelivery is NOT considered bg

16. Methyldopa Diazoxide Labetalol Hydralazine Nifedipine Peripartum AVOIDED SAFE Atenolol ACE inhibitors AT type-2 receptorantagonists (FDA Category C) CritCare 2016 ObstetGynecol N Am 2017 Antihypertensivedrugs bg

17. Invasivecontinuousintraarterial BP monitoring is indicated • in caseswithpoorlycontrolled HT • rapidneedforloweringBP • forfrequentuse of bloodgases • Central venouspressuremonitoring is advisable • forassessment of oliguriaanditsresponsetofluidadministration Non-invasive modalitiesof haemodynamic measurement such as; lungultrasound,transthoracic echocardiography or pulse waveform monitors Monitoring FHR/Uterinecontractions

18. MgSO4 is 1st linedrugfor preventionof seizuresinpreeclampsia & ongoingseizures in eclampsia IV bolusloadingdose 4-6 g/100 mLsalineover 20 min IV maintenancedose 1-2 g/h infusion Adverseeffects Hypotension, arrhythmias, respiratorydepression, flushingnausea-vomiting, drowsiness, slurredspeech, doublevision... Prevention-treatment of seizures

19. Phenylephrine (1) Ephedrine (1,2 andweak ) Noradrenaline (1, ) • 50 µg/mL IV bolus • 5-10 mg/mL IV bolus • 5 µg/mL IV bolus • Optimum initialdose • Target BP • Automatedcomputercontrolledsystems • (bolusand/orinfusion) Vasopressors

20. SAFE AVOIDED • Oxytocin (bolusand/orinfusion) • ED90=0.35 IU or 2.99 IU • ‘’Rule of threes’’ forinfusion • t1/2 elim ≅ 4-10 min Methergin Ann FrAnesthReanim 2010 • Carbetocin • IV bolus 100 µg • t1/2elim ≅ 20-30 min Uterotonics

21. MOST recentstudies in severe preeclampsia Airway management Fluidmanagement Use of vasopressors Use of colloidpreload + vasopressors

22. Airway Management bg

23. Fluid Management • Colloidvolume had noeffect on HR and CI • Fluidmanagementshould be tailoredtotheindividualpatientwiththeaid of non-invasivehemodynamicmonitoringifavailable bg

24. Use of vasopressors Fetalacidbasestatus is independent of whetherephedrineorphenylephrineusedtotreatspinalanesthesia inducedhypotensionin severelypreeclampticpatientswithnon-reassuring FHR tracings bg

25. Use of colloidpreload+vasopressors Phenylephrineeffectivelyreversesspinalanesthesiainducedhemodynamicchanges in severe earlyonsetpreeclampsia, ifleftventricularsystolicfunction is preserved bg

26. SUMMARY Control of highbloodpressure Prevention & treatment of seizures Monitoring (invasiveornoninvasive) Fluidmanagement Use of uterotonics & vasopressors Anesthesiaoptionsaccordingtocoagulationstatus Longtermramifications!!!!!!!!!!!!

27. Thank you TakSkal du have bg