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33 Cards in this Set

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What are the hypertensive disorders of pregnancy?
Gestational HTN-b/p >140/90, with no proteinuria (after 20 weeks)
Preeclampsia
Eclampsia
Superimposed preeclampsia
Chronic HTN
What is preeclampsia?
Syndrome of pregnancy induced HTN, proteinuria, generalized edema, sustained SBP>140, 300mg or protein in 24 hr collection, S/S appear after 20weeks gestation, resolves 48 hours after delivery
What causes preeclampsia?
Occurs only in the prescence of placental tissue, endothelial cell dysfunction central to pathogenesis-pt. produces deficient levels of vasodilator prostacyclin & excessive levels of vasoconstrictor thromboxane, vasospasm central to physiology of preeclampsia; trophoblass (outermost layer of placenta) fail to implant into spiral arteries=hypoperfusion=endothial damage/vascular hyperreactivity=maternal HTN & decreased placental perfusion
How does preeclampsia impact the patient'S CV & RESP SYSTEMS?
CV: HTN d/t generalized vasoconstriction, increased SVR, hemoconcentration, hypoalbuminemia; Pulmonary: low colloid oncotic pressure d/t hypoproteinemia and increased vascular permeability, increasaed risk of pulmonary edema and difficult airway;
How does preeclampsia impact the patient's CNS, Renal, Hepatic, Hematologic systems?
CNS: vasospasm +/- cerebral edema can cause visual disturbance, H/A, hyperreflexia; Renal: decreased GFR, RBF, proteinuria; Hepatic: risk of hepatic hematoma, rupture; Hematologic: hemoconcentration, thrombocytopenia, increased fibrinolysis
What causes the maternal HTN in preeclampsia?
Placental ischemia leads to the release into maternal circulation of vasoactive substances (thromboxane, renin, angiotensin, aldosterone, catecholamines, and thromboplastin) which increase maternal B/P
What is eclampsia?
Seizures associated with pregnancy induced HTN; treat with magnesium sulfate
What is HELLP syndrome?
Hemolysis, Elevated Liver enzymes, Low Platelet count
When does HELLP syndrome occur?
Before the 36th week of gestation, dx is indication for delivery
What are the signs of severe preeclampsia?
Hypertension >160/110, oliguria <500ml/d, pulmonary edema, hepatic tenderness, proteniuria, systemic edema, CNS dysfunction, HELLP syndrome
The most serious complications of pre-eclampsia are?
Pulmonary edema, renal failure, airway obstruction, cerebral hemorrhage, DIC, cerebral edema
What are the two leading causes of maternal death in preeclampia?
Cerebral hemorrhage, pulmonary edema, (then renal failure, DIC, airway obstruction)
How does preeclampsia effect circulation?
Protein content is decreased, intravascular space is contracted, usually not under filled, associated vasoconstriction d/t increased renin, angiotensin, & aldosterone
What is the impact of pre-eclampsia on the uteroplacental circulation/
uterine vascular resistance increases d/t vasculitis=decreased uterine blood flow
In the preeclamptic patient what is the best test to evaluate bleeding?
PT/PTT, platelets, fibrinogen, & FSP
Which drugs are used to control B/P in the preeclamptic patient?
Hydralazine, SNP, Trimethaphan, NTG, Labetolol, Nifedipine, Methyldopa, diazoxide
What are the concerns when giving SNP or NTG to preeclamptic patients?
SNP can cause cyandie toxicity,
NTG can be unpredictable,
In patients with HTN & low PAOP, SNP or NTG can precipitate profound decrease in B/P
Why is hydralazine used so commonly in preeclamptic patients?
Hydralazine can reduce maternal B/P and increase uterine blood flow simultaneously
Which anti-hypertensive techniques should be avoided in the preeclamptic patient?
Esmolol should NOT be used, adverse fetal effects;
General or regional anesthetics should NOT be used to reduce the B/P in this population
What is the drug of choice to control preeclampsia?
Magnesium Sulfate
What are the normal serum levels for Magnesium Sulfate?
Norm: 1.4-2.0mEq/L
Therapeutic range for preeclampsia/eclampsia is 4-7mEq/L; (divide by 0.8 to convert mEq/L to mg/dl); Loading dose 4-6gm over 20min; gtt 2-3gm/hour
In order of prgression, what are the signs of hypermangnesemia?
Least-to-worst: decreased deep tendon reflex (DTR), ECG changes, somnolence, loss of DTR, heart block, respiratory arrest, cadiac arrest
If the patellar reflex is absent in patients on Magnesium Sulfate what can happen to the patient?
Heart block
Ventilatory failure
Cardiac arrest
How does MgSO4 work as an anticonvulsant?
increases the seizure threshold by decreasing the presynaptic releaseof acetylcholine and reducing the sensitivity of post synaptic receptors to Ach; can also act as NMDA receptor antagonist
The patient shows signs of MgSO4 toxicity, should you give Ca+?
IV Ca+ gluconate should be given only if supportive therapies are ineffective; it reverses magnesium toxicity but increases risk of seizures; supportive measures first (intubation)
Does magnesium toxicity impact the neonate?
Yes, it can cross the placenta, neonate can be somnolent, atonic, and need ventilation assistance
What is the definitive treatment for preeclampsia?
Delivery of fetus and placenta
Considering pt. hx (preeclampsia)-which anesthetic technique is most appropriate?
CLE, SAB, or GA can be used, CLE best choice
When is GA appropriate for delivery of a preeclamptic?
coagulopathy present, fetal distress,
What issues complicate fluid management in preeclamptics?
plasma volume may be decreased in preeclampsia-filling pressures maintained by increased capacitance, colloid oncotic pressure is reduced, capillary permeability is increased
What induction agent should be AVOIDED in PIH patients?
Ketamine
How does Magnesium Sulfate interact with muscle relaxants?
It increases sensitivity to both depolarizing & non-depolarizing
How long should you continue MgSO4 after delivery?
24-48hrs d/t risk of seizures remains