Preeclampsia Scenario with HELLP & Eclampsia C omplications

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

2. Case presentation • 38 yroldnulliparous at 331weeks’ gestation • 67 kg & 161 cm • SymptomsHeadache, epigastricpain, blurredvision, nausea-vomiting & dizziness • Vitalsigns • BP:190/110 mmHgHR:102 beat/minRR:22 breath/minTemperature: 37.1°C • Physicalexam • Bilateral + pittingedemain lowerextremities

3. Initialmedicaltreatment IV bolus of 5 mg hydralazineover 2 min IV 5 mg hydralazinerepeatedafter 20 min Blood pressure (BP) decreasedto 170/110 mmHg IV bolus20 mg labetalolover 2 min BP:160/90mmHg, 96 beat/min& 16 breath/min Betamethasone6 mg IM (twice) Continuouscardiotacographymonitoringprovided

4. Whileplanning her expectantmanagement she had a grandmalseizure

5. StandardMonitorization • ECG: NSR • HR: 96 beat/min • BP: 160/90 mmHg • Sp02: 98% • RR: 16 breath/min IV bolus MgSO4 4 g in 20 minfollowedby1 g/h IV infusion • 12 h fasting • ASA III-E • Airwayexam: Class II Mallampati • RL infusion 200 mL/h Preoperative Evaluation bg

6. Management General Anesthesia First leftlateraltilt • After cord clamping IV oxytocin infusionstarted • NewbornwithApgarscores 8 and 9, at 1 & 5 min • Operation lasted 35 min • Residual neuromuscular block antagonized by neostigmine & atropine • Induction • After preoxygenation • IV propofoland rocuronium with RSI • For blunting response to laryngoscopy • IV bolus 5mg labetalol • IV 1.5 mg/kg lidocaine • Maintenance • Sevoflurane 0.75 MAC in 50% NO2/O2 mixture

7. Followup • Patientwastoldtoreportanysigns/symptomsafterdischargeat home as well • BP monitored 72 hours at thehospital • Discharged on postoperative4 day • Postopretaivemultimodalanalgesia • IV MgSO4continuedfor 24 hours Postoperative Care bg

8. Plateletcount52,000/µL • AST 331 U/L • ALT 116 U/L • LDH 1524 U/L • Eclampsia • Seizure (+) Diagnosisconfirmed bg

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

10. 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

11. 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

12. Drugsbluntinghemodynamicresponsetolaryngoscopy &intubation bg

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. Airway Management bg

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

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

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

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

26. Thank you TakSkal du have bg