PIH and Anaesthesia

Issues for the Anaesthetist

Analgesia during labourChoice of anaesthesia for CSEffect of drugs for PIH on the anaestheticFluid managementCoagulopathy & regional anaesthesiaThe difficult airway & intubationObtunding the hypertensive response to intubationManagement of an Eclamptic fitPostoperative care & ICUThe multidisciplinary team & protocols

The end result should be……..

ANAESTHESIA for CS

An unstable pre-eclamptic should NOT beanaesthetised for a CS unless there is an

immediate threat to her life.Eg .massive haemorrhage

STABILISE the patient FIRST

HOW?

Control BP

Control fits

Fluid balance

WHICH DRUGS ARE USEFUL

TREATING BP! DOES IT HELP?Methyl-dopaHydralazineLabetalolNifedipineSodium NitroprussideGlycerol trinitrate

Preventing & treating fits

What drugs can you use ?Magnesium SulphateDiazepamPhenytoinChlorpromazinePhenobarbitoneThiopentone

POLYPHARMACY?

Choice of Anaesthetic for CS

General or Regional ?

Choice Determined By….

Maternal conditionFetal conditionThe indication for caesareanThe urgencyFacilities & equipment availableExperience of the anaesthetist

REGIONAL ANAESTHESIA

Often the safest choice for mother and baby

May be appropriate even in a ‘controlled’ eclamptic

Risk of Hypotension over-estimated and usually associated with hypovolaemia & antihypertensive agents

Difficult & Unwise in an obtunded, unconscious, agitated or convulsing patient

Spinal Haematoma

Incidence with normal coagulation:5 per million with spinal7 per million with epidural

Risk may be higher in pre-eclampsia because:

Coagulation in pre-eclampsia may be derangedPlatelet count may be reduced

Consequence may be permanent neurological damage

Balance tiny risk of peripheral neurological damage against the significant risk of hypoxic brain damage or death

GENERAL ANAESTHESIA

Stable operating conditions airway secure & convulsions attenuatedbut beware ……..

Difficult airway to maintain & intubateRisk of regurgitation & aspirationSevere hypertension on intubation may cause strokeHypotension due to drug interactionMuscle relaxant action may be prolonged

General or Regional ?

Regional generally considered safer than GA

Fetal emergency may suggest GA but maternal risk favours SPINAL

Need to balance the risk of mother & baby

GA usually reserved for cases where Regional is contraindicatedE.g. Uncontrolled Eclampsia

Who needs ICU /HDU?

Patients with:Airway obstruction Uncontrolled convulsionsPersistently lowered GCS (<8)Severe uncontrolled hypertensionCardio-respiratory problemsAdditional obstetric complications such as haemorrhage

WORK AS A TEAM TO PREVENT

PRE-ECLAMPSIA DEATHS