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Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Gestational hypertension, also referred to as pregnancy induced hypertension (PIH) is a condition characterized by high blood pressure during pregnancy. Gestational Hypertension– High blood pressure that develops after week 20 in pregnancy and goes away after delivery.
Preeclampsia – Both chronic hypertension and gestational hypertension can lead to this severe condition after week 20 of pregnancy. At each prenatal checkup, your healthcare provider will check your blood pressure and urine levels. If you have severe hypertension, your doctor may try to treat you with blood pressure medication until you are far enough along to deliver safely. If your hypertension is severe, it can lead to preeclmapsia, which can have much more serious affects on mom and baby. Increase the amount of protein you take in, and decrease the amount of fried foods and junk food you eat. Sign-Up For The APA NewsletterGet a roundup of all the best pregnancy news and tips from around the web with exclusive discounts and giveaways from our sponsors.
The Association is only able to accomplish our mission with the commitment of people like you. Pre-eclampsia remains the most frequent, most serious and least understood of these disorders. When grandmal convulsions occur in pre-eclampsatic patients, the syndrome is called eclampsia. Benzodiazepines are the first line of treatment to control convulsions in eclamptic patients. Phenytoin is gaining popularity in place of Diazepam due to lack of serious sedative side effects8.
Commonly used drugs are Hydralazine, beta-blockers (Propranolol, Atenolol), Ca-Channel blocker (Vempamil, Nifedipine) Nitrates (Nitroglycerin), Labetalol (alpha and mainly beta blocker with predominantly beta effects), Sodium Nitroprusside. Nifedipine is a calcium channel blocker and is effective as a safe antihypertensive agent in pregnancy particularly in Toxaemia of pregnancy16. Chronic use of cardio-selective beta-blockers, such as Atenolol, appears to be effective to treat moderate to severe hypertension during pregnancy. These drugs are to be used only in acute malignant hypertension (hypertensive emergencies). There is reduced circulating blood volume with haemo­concentration which will mask the presence of anaemia. Retention of sodium and waterand exaggerate effects of normal pregnancy hormones lead to the development of laryngeal oedema in pre-eclamptic patient. The neuromuscular weakness and potential hypoten­sive effects of magnesium sulphate might be slightly exagger­ated with sympathetic blockade, but the protective and beneficial effects on the uterine and umbilical blood flow due to epidural anaesthesia eliminates the increased fetal risk21, so combination is assumed to be safe. There is increased vascular reactivity which results man intensified response such as tachvcardia, severe hypertension, due to the release of catecholamines.
Before any procedure is undertaken, it is mandatory to optimize the condition of the patient. Central venous pressure monitoring is indicated in severe pre- eclamptic and eclamptic patients as a minimal invasive monitoring. Choice of analgesia will depend on obstetrical situation, the status of the patient and the condition of the fetus (if still in utero). In view of the vast favourable clinical experience and recent investigational work, the evidence supports the use of epidural analgesia for labor, vaginal delivery and Cesarean section in most mothers with severe pre-eclampsia or control­led eclarnpsia59. While planning for general anaesthesia, the hazards and possible pmblems which could be encountered in severe pre-cclamptic patients should be kept in mind. In case of severe fetal distress or compromise, intrave­nous induction with agents such as Thiopentone sodium or Propofol is likely to reduce placental perfusion with further detrimental effects to the fetus. Institution of LPPV can adversely affect the uterine blood flow by reducing cardiac output especially in dehy­drated or volume depleted patients. It is well known that Nitrous Oxide has low lipid solubility and it has relatively rapid transplacental passage which can cause some degree of neonatal depression during C-section. The cardiovascular changes due to extubation could be as severe as pressor responses to intubation.
The delivery of the fetus and placenta is the treatment but the full recovery may take 10 days to 2 weeks. 2) Prevention and control of convulsions by use ofMagncsium Sulphate, Diazepam and Phenytoin.
3) Optimal stabilization of cardiovascular system by careful fluid balance and use of vasodilators.
4) Proper pre-anaesthetic evaluation of various systems with specific attention towards cardiovascular, renal coagulation and hepatic system. A carefully administered epidural blockade is strongly advised, unless gross contraindications exists.
Subarachnoid block is not widely recommended due to the risk of sudden and severe hypotension. 8) The successful management of these patients depends upon the team work and communications of obstetrician, mid-wife and anaesthcsiologisL all of whom have iniportant roles to play.
This journal is a member of and subscribes to the principles of the Committee on Publication Ethics. Your doctor may also check your kidney and blood-clotting functions, order blood tests, perform an ultrasound scan to check your baby’s growth, and use a Doppler scan to measure the efficiency of blood flow to the placenta. If you are close to your due date and the baby is developed enough, your health care provider may want to deliver your baby as soon as possible.
Your tax deductible contribution provides valuable education and more importantly support to women when they need it most.
Pre-eclampsia or pregnancy induced hypertension (PIE) is defined as the triad of hypertension, proteinuria and generalized oedema, developing after the 20th week of gestation.
Chronic hypertension is the presence of sustained hypertension prior to pregnancy and continuing there into. Transient gestational hypertension, refers to develop­ment of hypertension without proteinuria or oederna in a previously normotensive gravida followed by return to nor­motension within 10 days postpartum.
The terminology used to define pre-eclampsia is confusing and atleast eight terntsare used in obstetric literature today1.
Whether the initiating factor of this disorder is immunological, genetic or simply a decrease in uterine blood flow, is unknown. Hydration: Adequate hydration and intravascular volume expansion with balanced salt solution is beneficial6. Anti convulsant therapy: Convulsions in these patients could produce deleterious effects on the mother and fetus.
Improved fetal outcome has been reported in various studiesJt does cross from maternal to umbilical plasnta but does not cause any ill effects on the fetal heart rate patterns orfetal peripheral resistance. Both systemic and pulmonary resistance fell but cardiac output was maintained without any significant side-ef­fects on mother and fetus21. The non-selective beta-blocker are feared to be associated with increased uterine activity, decreased uterine and placental blood flow, decreased fetal heart rate and decreased fetal tolerance to hypoxia, unacceptable levels of intrauterine growth retardation and fetal mortality.
They might be useful at time of induction and intubation for a rapid control of blood pressure.
The volume depletion may lead to an exaggeration of the response to aortocaval compression, therefore, left uterine displace­ment must be employed.


At admission it is necessary to obtain a complete blood picture with platelets count, followed by serial platelet counts when monitoring intra-partum coagulation indices.
Fibrin D-Dimer analysis has been proposed as a more sensitive and early indicator on intravascular coagulation and fibrinolysis than standard co­agu lation tests35.
While when platelets are between 50,000 to 1,00,000 per mm3 risk benefit balance should be assessed as possibility toepidural haematoma incidence is 1:10,000 cases. The reduction in the dosage and a continuous monitoring of neuromuscular func­tion with the help of peripheral nerve stimulator is advisable. Concerns have been expressed about placing epidurals in patients receiving aspirin as their antiplatelet actions might increase risk of epidural haematoma.
Antihypertcnsive drugs and anaesthetic drugs When anaesthetic drugs are administered to the patients who are on antihypertensive treatment cardiovascular depres­sion may be more pronounced and marked. This particular problem is apparent during with laryngoscopy, in light general anaes­thesia and at extubation.
We should try to control the blood pressure, restore blood volume, improve renal function, institute anticonvulsant therapy (if indicated) and initiate proper monitoring. Narcotics provide good analgesia but have no anticon­vulsant and antihypertensive properties. The major hazards are difficulties in airway maintenance, excessive and aggregated response to laiyngoscopy and endotracheal in­tubation. Ketamine is contraindicated while Etomidate has been condemned for undesirable effects on adrenocortical axis, but is a relatively cardio stable drug.
These patients should be kept normocapnic or somewhat hypcrcapnic to improved placental blood flow and decrease shunting. There is probably a slight but definite real risk that the already hypoxic infant may be adversely affected by this agent. At this moment, neither narcotics due to their respiratory depressant effects nor Magnesium Sulphate due to its neuromuscular blocking properties are likely to be ideal. The airway management may be more difficult in the postoperative period due to the worsened laryngeal oedema situation.
While (lie majority of patients require minimal interven­tion, severe pre-ectamptic patients need expert care with excess to invasive monitoring and therapy in the intensive care units. Lopcz-Liera, M Complicated eclampsia Fifteen years experience in a referral medical center. Pre-eclampsia is a disease unique to human pregnancy;predominantly affects the young multiparas. One proposed theory is immunological rejection of fetal tissues by the mother which causes placcental vasculitis and ischaemia. The main aim of management should be directed towards minimizing vasospasm, improving circulation to uterus, placenta and kidneys, improving the intravascular volume, correcting the acid base and electrolytes imbalance and above all decreasing reflex hyperactivity and central nervous system activity. Sodium intake should be adequate as salt restriction may result in increased production of renin, angiotensin and aldosterone.
Magnesium Sulphate affects the neuromuscular junction by inhibiting the presy naptic calcium-facilitated transmitter re­lease.
In severe pre-eclampsia for the seizure prophylaxis magnesium sul­phate appears to be a better choice when compared with a drug such as Phenytoin, as magnesium is an effective vasodilator even of cerebral vessels during cerebral vasospasm, while Phenytoin acts primarily by suppressing electrical activity13. It improves uterine blood flow and fetal oxygenation17, increases renal blood flow18 and urinary output. Intravenous fluid loading under the continuous monitoring of CVP or pulmonary capillary wedge pressure and urine output is necessary before the conduction of regional or general anaesthesia. Evaluation of PT, PTT and flbrinogcn to be added only if platelet count is less than 100.000 per mm331. Only if significant coagulation disorderexist with a platelet count falling under 100,000 mm3. There are yet no clear guidelines foracceptable safe limits but a level of platelets >100,000 mm3 or a bleeding time of37. A large multicentral40 randomized placebo control trial to evaluate the effects of low dose aspirin to prevent and treat pre-eclampsia failed to show any significant adverse effects on coagulation profile of these patients.
Such sudden rises in blood pressure may increase the risk of cerebral haemorrhage and oedema, myocardial infarction, pulmonary oedema or cardiac fail­ure39.
The minimal monitoring employed should be blood pressure by a non-invasive method, heart rate and urine output measurements.
Tranquilizers in combination with narcotics are in use and have variable success with significant side effects. All these effects cause an improvement in mother’s clinical status; moral attitude and fetal well being. There may be ajustification for the use ofbenzodiazepines for induction especially, when a specific benzodiazepine receptor antagonist (Flumazenil) is available. However, if an unacceptable risk of maternal awareness at operation is to be avoided due to low nitrous-oxide concentration or no nitrous oxide imposed by a high FIo2, additional vapor (inhalational) supplementation will be re­quired. Enflurane in low concentration is devoid of any adverse effects on neonates when used as a supplementary agent in subanaesthetic concentrations during labour50,69 Isoflurane has gained popularity due to properties of low blood solubility, apparent freedom from hepatic and renal toxicity and relative cardiovascular stability. The idea of extubating these patients in the deeper planes should be addressed very carefully due to high potential for airway management difficulties and aspiration. Respiratory embarrassment may be severe and airway maintenance may be impossible without anendotrachealtube. Perry, KG Ascites, a portent of cardiopulmonary complications in preeclamptic patient with the syndrome of haemolysis. Aspirin, Extradural anaesthesia and the MRC collaborative low dose aspirin study in pregnancy. Sympathoadrenal activity, maternal, fetal and neonatal responses after epidural anaesthesia in the preeclamptic patient. It appears that there are abnormali­ties in production and effects of circulating vasoconstricting (angiotensin and thromboxane) and vasodilating (PGE2; prostacyclin and EDRF) substances, perhaps due to wide­spread endothelial (immunoreactive) damage5.
Excessive sedation and airway management problems for the mother, while flaccidity, hypothermia, severe respiratory depression, low apgar score are the major disadvantages for the neonate. The patients receiving MgSO4 are sensitive to Peuromuscular drugs especially non-depolarizing blockers10.
Dose is 5 mg bolus increments till the desired effects are obtained or a maximum dose of 40 mg has been administered.
Nifedipine is a potent uterine muscle relaxant so is useful as tocolytic agent, but could calese post-partum haernorrhage. There is still controversy about the type of fluids (crystalloid versus colloid) for preloading and replacement. A rapid change in platelets count is a more significant event rather than an absolute value32. There is also no data to recommend routine bleeding tests on these patients as bleeding time does into indicate the risk of bleeding. Direct intra-arterial blood pressure monitoring is indicated in patients with severe pre-eclampsia or eclampsia. Apgar score in neonates born to mothers with Epidural was far better than non-epidural group.
Lidocaine does cause a slight decrease in fetal heart beat to beat variability, while Bupivac­inc use is not associated with decrease in fetal beat to beat variability63.
Despite various hazards, some authorities feel that risks of rneral anaesthesia are less than those of regional anaesthesia66 while others feel that general anaesthesia has markedly increased risks67. All antihypertensive and anticonvulsant drugs to be continued till patient is in the operating room.


The exaggerated pressor responses to laryngoscopy and intubation could be attenuated by various techniques using drugs such a Hydralazine, Labetalol or Sodium Nitroprusside. In general the available evidence suggest that Ha­lothane in a concentration of 1.0 MAC or less has little or no effect on placental perfusion or fetal well-being, while higher concentration result in deterioration68. At equipotent concentrations it’s effects on uterine contractility is similar to Halothane and Enflurane70, while maintaining normal maternal and neonatal conditions. There is sonic role for vasodilators or beta-blockers especially short acting such as Esmalol at this stage. The antihyperten­sive and anticonvulsant drugs should be continued in the postoperative period as long as indicated. Increased levels of EDI cellular fibronectin proceed the clinical signs of preeclampsia Am. Atrial natriuretric peptide contractions and haernodynamic effects of acute plasma volume expansion in normal pregnancy and preeclampsia. Attenuation of blood pressure response to laryngoscopy and tracheal intuhation with sodium Nitroprussude. I Maternally administered esmolol products fetal adrenergic blockade and hypoxemia in sheep.
Clinical indications for pulmonary artery catheterization in the patient with severe precclampsia Am. Evaluation of use of continuous lumbar epidural anesthesia for hypertensive pregnant women in labor.
Comparative maternal and neonatal effects of halothane and enflurane for caescrean section. The abnormal changes in these hormonal levels produce generalized arteno­lar vasoreactivity (spasm), retention of salt and water, and altered coagulation profile (Figure). The enhanced effects of Succiny lcholine is due to deficiency in plasma pseudocholinestase rather than MgSo411.
Volume loading should be done with caution as these patients have leaking capillaries, decreased oncotic pressures25 and reduced ventricular com­pliance. Platelet functions, rather than number is more important33, but tests (Thromboelastography) to check the function are time con­suming and expensive. Orlikowsk et al41 noted that chronic use of low dose of Aspirin does not seem to be associated with TEG (Thromboelastography) changes. The general recommen­dations are to use drugs such as short and rapidly acting anti hypertensives, xylocaine intravenously or high doses of narcotics, before induction and laryngoscopy. Concerns expressed by others are that epidural analgesia should not be used in severe pre-eclamptic patients53. Ideally, in patients with severe pre- eclampsia institution of epidural analgesia should be proceeded by placing a CVP or Pulmonary Artery Catheter64.
It is advisable to bring patient to the operating room in the lateral position and have oxygen via face mask during transportation. A ilie Parikland Memorial Hospital protocol for the treatment of eclampsia-evaluation of 245 cases Am. The effects of lumbar epidural analgesia on the fetal heart rate baseline variability Ancsth. Magnes­sium sulphate decreases peripheral resistance, increases cardiacoutput12 atemporaxy decrease in blood pressure which is offset by an increase in heart rate. Nisell et al26 examined the effects of acute plasma volume expansion on atrial nathuretic peplide concentration in 16 pre-eclamptic patients and compared with 16 healthy control patients. About 10 to 25% of pre-eclamptic patients with normal platelet counts have prolonged bleeding time33,34. Sudden hypotension which could be deleterious to already compromised fetus due to further decreases in uteroplacental blood flow54.
The usual doses of antiemetics (Meto­cloprarnide 10 rug IM) and antacids (Sodium Citrate 0.30 mmol, 30 ml) or a H2 histamine receptor antagonist (Ranitid­inc or Cimetidine or Famotidine) be given orally 1-2 hours prior or 40-60 minutes earlier intravenously.
As the onset of action is slow, so repeated dosage should not be given at less than 20 minutes intervals.
After oral administration peak effect is in 1-2 hours, witla plasma half life of 5 hours19.
Atrial natriuretic peptide (ANP) has diuretic smooth muscle relaxing and hypotensive properties and is known to reduce blood volume by increasing capillary permeability. Also anaesthetics used could decrease fetal beat-to-beat variability and impede the diagnosis of fetal hypoxia and distress55.
Animal and human studies, includ­ing studies in pre-eclamptic parturients showed that intervil­lous blood flow was maintained or improved with the use of epidural analgesia61,60. These patients should be closely and maximally nionitored (both invasively and non-invasively) in the Intensive Care Unit at least for the first 24 hours. Lumbar epidural analgesia to improve intervillour blood flow during labor in severe precclampsia Obstet. A combination of calcium chan blockers and MgSo4 should be used very cautiously, as hypotension respiratory difficulty and cardiac toxicity has been reported20.
Local infiltration of perineum or Pudendal nerve block provides satisfactory analgesia for most forceps deliveries. Due to cOagulopathy, in pre-cclamptic patients formation of epidural haematoma is a possibility during invasive regional techniques. Anecdotal reports of epidural or subarachnoid block inadvently administered to patients with platelets counts 3 have not described any epidural haernatorna as a consequence61. There is an enhanced response to ANP in pre­eclamptic patients, also there is an increased level in pre­eclamptic patients.
However, some workers do not think that pulmonary catheterization is strongly indicated and useful46. Epidural block administered before delivery in pre-eclamptic patients have not resulted in epidural haematoma even if the platelet numbers have decreased below 50,000 mm3 after delivery. Electronic monitoring of fetal heart rate and uterine contractions is essential, when labour is artificially induced or epidural analgesia is instituted. It is advisable to leave the catheter in place till the coagulation profile including platelets are within normal acceptable limits. The increased level of ANP may further exacerbate the capillary leak enhanced fluid loss and protein into extravascular space. Fetal blood analysis for PH may be indicated when significant fetal heart rate abnormalities occur.
Woods et al27 found a six-fold increase in incidence of CCF and four-fold increase of acute respiratory distress syndrome within 24 hours postoperatively in the pre-eclamp­tic patients as a result of over enthusiastic fluid loading. Rapid infusion of crystalloid fluid may significantly lower the colloid oncotic pressure for 24 hours28, which may not be tolerated by these patients and end up in pulmonary ocdema29. 500-1000 ml of 5% Albumin in severe pre- eclamptics increases cardiac output, decreases systemic vascular resis­tance with no or minimal effects on the mean arterial blood pressure30.
The colloidal solution (plasma protein fraction or Albumin 5%) seems to be a preferable choice in severe pre­eclamptic patients. A balanced crystalloid solution or 0.9% Nacl solution upto a volume load of 500 ml-l000 ml is well tolerated in these patients with epidural analgesia upto T10 level.



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