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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
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