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Update on preeclampsia

A/Prof Alicia Dennis

MBBS PhD PGDipEcho FANZCAAssociate Professor, University of Melbourne

Staff Specialist Anaesthetist

Director of Anaesthesia Research

The Royal Women's Hospital

Parkville, Australia

OA SIG Sydney, Australia March 22nd 2014

alicia.dennis@thewomens.org.au

Disclosures

Nil

Patient consent and institutional ethics approval

yes

Outline

1. BackgroundHistorical context

Language

2. Global impact of the disease

3. Key aspectsDefinition

Classification

General principles of management

4. Specific scenariosHaemorrhage

Heart failure

5. Haemodynamics and transthoracic echocardiography

Introduction

World Health Organization 2000, reprint 2007 ISBN 92 4 154587 9

Historical records

~ 2500 years ago

“Heaviness and convulsions during pregnancy is considered bad”

(Hippocrates, 400 BCE)

1619 the word “eclampsia” first appeared in literature

1900’s onwards including today- Geographical influences regarding language/treatment/research/publications

The Language of Preeclampsia

There is no structured and conventional way to describe this condition.

Preeclampsia Pre eclampsiaPre-eclampsiaEclampsiaPreeclamptic toxaemia (PET)Toxaemia Proteinuric hypertensionPEPregnancy induced hypertensionGestational hypertension

Poorly acknowledged disease with a low profile

Poorly acknowledged disease with a low profile

But 131 million women give birth each year

6.5 million pregnant women will develop hypertension each

yearGoldkind, S. F., L. Sahin and B. Gallauresi (2010). "Enrolling pregnant women in research--lessons from the H1N1 influenza pandemic." N Engl J Med 362(24): 2241-2243.

Poorly acknowledged disease with a low profile

But 131 million women give birth each year

6.5 million pregnant women will develop hypertension each

yearGoldkind, S. F., L. Sahin and B. Gallauresi (2010). "Enrolling pregnant women in research--lessons from the H1N1 influenza pandemic." N Engl J Med 362(24): 2241-2243.

50,000 maternal deaths/year

300,000 neonatal deaths/year

Poorly acknowledged disease with a low profile

But 131 million women give birth each year

6.5 million pregnant women will develop hypertension each

yearGoldkind, S. F., L. Sahin and B. Gallauresi (2010). "Enrolling pregnant women in research--lessons from the H1N1 influenza pandemic." N Engl J Med 362(24): 2241-2243.

50,000 maternal deaths/year

300,000 neonatal deaths/year

COMMON DISEASE

Mortality

Mortality

Mortality

Dyer RA et al Curr Opin Anaesthesiol 2007;20:168-74.

Morbidity – short term and long term

Same as the long term

complications of hypertension

in the general population

• Ischaemic heart disease

• Cerebrovascular disease

• Heart failure

• Chronic kidney disease

• Peripheral vascular disease

Prevention

Unmet need for contraception remains high in many

settings, and is highest among the most vulnerable in

society: adolescents, the poor, those living in rural areas

and urban slums, people living with HIV, and internally

displaced people. The latest estimates are that

222 million women have an unmet need for modern

contraception, and the need is greatest where the risks

of maternal mortality are highest.

Ensuring human rights in the provision of contraceptive information and services: guidance and recommendations.1.Contraception. 2.Family Planning Services. 3.Human Rights. 4.Guideline. I.World Health Organization.ISBN 978 92 4 150674 8 (NLM classification: WP 630)© World Health Organization 2014

Prevention

Unmet need for contraception remains high in many

settings, and is highest among the most vulnerable in

society: adolescents, the poor, those living in rural areas

and urban slums, people living with HIV, and internally

displaced people. The latest estimates are that

222 million women have an unmet need for modern

contraception, and the need is greatest where the risks

of maternal mortality are highest.

Ensuring human rights in the provision of contraceptive information and services: guidance and recommendations.1.Contraception. 2.Family Planning Services. 3.Human Rights. 4.Guideline. I.World Health Organization.ISBN 978 92 4 150674 8 (NLM classification: WP 630)© World Health Organization 2014

Peripartum complications- Suboptimal care

Definition - Preeclampsia

Definition - Preeclampsia

1. New onset high blood pressure≥ 140/90 mmHg

2. Multiple organ complications due to vascular bed involvementcerebral, cardiac, respiratory, renal, gastrointestinal, placental, uterine

3. ≥ 20 weeks gestation

4. Resolves by 3 months post-birth

Classification - Mild versus severe preeclampsia

• Symptomatic disease is severe disease

• Abnormal biochemistry or haematology is usually severe disease

Dennis, A. Management of Pre-eclampsia:Issues for anaesthetists. Anaesthesia 2012 67(9): 1009-1020.

General principles - severe preeclampsia

1. Early senior and multidisciplinary involvement

Obstetrician, Midwife

Anaesthetist – optimise, ablate intubation/extubation response, no ergometrine

Haematologist, Intensive care team, Paediatrician, Perioperative staff

2. Standardised guidelines

3. Regular review and awareness of complications

4. Control of hypertension with antihypertensivesSBP > 180 mmHg constitutes a medical emergency and should trigger and emergency response

Do not use ergometrine

5. Prevention and treatment of seizures with MgSO4

6. Meticulous fluid balance

Specific complications

1. Haemorrhage and preeclampsia

2. Heart failure in preeclampsia

Haemorrhage and preeclampsia

Antepartum haemorrhage is a complication of severe preeclampsia

check the blood pressure prior to general anaesthesia

Manual methods to assist with uterine contraction – bimanual uterine compression

Pharmacological agents – oxytocin (high concentration/low volume infusions), prostaglandins

Do not give ergometrine

Surgical methods

Heart failure and preeclampsia

Healthy heart function

Heart failure with preserved ejection fraction

Heart failure with reduced ejection fraction

Hypertension and haemodynamics

pressure = flow resistance

Blood pressure Systemic vascular resistanceCardiac output

Stroke volume Heart rate

Systolic functionCardiac emptyingAmount of fluid and rate of emptying

Diastolic functionCardiac fillingAmount of fluid and the rate of filling

Transthoracic echocardiography

The ROSE Scan

Rapid Obstetric Screening Echocardiography Scan

Structural informationFunctional information

Real timeNon-invasive

At the bedside

Dennis AT: Transthoracic echocardiography in obstetric anaesthesia and obstetric critical illness. IJOA 2011; 20:160-168

Dennis AT, Stenson A. The use of transthoracic echocardiography in postpartum hypotension. Anesthesia and Analgesia 2012 115:1033-1037

Dennis AT, Castro C. Transthoracic echocardiography in women treated for severe pre-eclampsia. Anaesthesia 2014 doi:10.1111/anae.12623 in press

Dennis AT, Castro C. Transthoracic echocardiography in women treated for severe pre-eclampsia. Anaesthesia 2014 doi:10.1111/anae.12623 in press

Dennis AT, Dyer RA, Gibbs M, Nel L, Castro JM, Swanevelder JL. Haemodynamics using transthoracic echocardiography in women with untreated preeclampsia in South Africa. International Journal of Obstetric Anesthesia. 2014 in press (published abstract)

Heart failure and preeclampsia

?heart failure with preserved ejection fraction

?heart failure with reduced ejection fraction

Heart failure and preeclampsia

?heart failure with preserved ejection fraction

?heart failure with reduced ejection fraction

Hypertension & acute pulmonary oedema

(preserved or reduced ejection fraction heart failure)

1. Emergency response2. A,B,C (Maternal +Fetal +Positioning)3. Intravenous antihypertensive4. Diuretic5. +/- inotropic support

Heart failure and preeclampsia

?heart failure with preserved ejection fraction

?heart failure with reduced ejection fraction

Hypertension & acute pulmonary oedema

(preserved or reduced ejection fraction heart failure)

1. Emergency response2. A,B,C (Maternal +Fetal +Positioning)3. Intravenous antihypertensive4. Diuretic5. +/- inotropic support

Hypotension after severe preeclampsia(reduced ejection fraction heart failure, haemorrhage,

sepsis, right heart failure)

1. Emergency response2. A,B,C (Maternal + Fetal +Positioning)3. Fluids4. Inotropic support

The role of transthoracic echocardiography in women with severe preeclampsia

Can you answer these questions in the hypertensive woman you are about to anaesthetise?

1. Is the ejection fraction reduced?

2. Is the left ventricular end diastolic pressure elevated?

3. Is the heart dilated?

Transthoracic echocardiography

Transthoracic echocardiography

No diastolic dysfunction Diastolic dysfunction

Transthoracic echocardiography

Dennis, A. T., J. Castro, S. W. Simmons, M. Permezel and C. F. Royse (2012). "Haemodynamics in women with untreated pre-eclampsia." Anaesthesia 67(10): 1105-1118.

Transthoracic echocardiography

1. Central and key diagnostic tool in heart failure

2. Ejection fraction

3. Evidence of increased left ventricular end diastolic pressures

4. Dilated or non-dilated heart

Summary

1. History and language of preeclampsia

2. Significant short and long term global impact

3. Education and contraception for women

4. Definition, diagnosis and key management principles

5. Specific scenarios

6. Importance of transthoracic echocardiography in answering clinically relevant

questions and assisting with management decisions

Acknowledgements and thank you

Pregnant women who participate in our research

Staff at the Royal Women's Hospital, Parkville, Australia & Groote Schuur Hospital, Mowbray Maternity Hospital Cape Town South Africa