Severe Pre-eclampsia and Anesthesia

Chief Complaint: elevated blood pressures, now with elevated liver enzymes

SUMMARY OF RECOMMENDATIONS
1. Nifedipine 60mg ER BID, next dose at 0900.
2. Continue q4hr blood pressure monitoring; increase to q15mins should she have systolic blood pressure >160 or diastolic blood pressure >110. Please call Perinatologist should that occur.
3. NPO for now.
4. Follow-up serum preeclampsia labs at 1200, along with type & cross x2 units.
5. If AST/ALT continue to rise, would recommend primary cesarean section at that time.
6. Continue magnesium sulfate for now, and for 24 hours postpartum.
7. NICU aware.

PROBLEM LIST
1. INTRAUTERINE PREGNANCY AT 25w6d
2. SUPERIMPOSED PREECLAMPSIA WITH SEVERE FEATURES
3. TRANSAMINITIS, NOT YET 2x THE UPPER LIMITS OF NORMAL

HPI/HOSPITAL COURSE: 37 y.o. G1P0 at 25w6d, hospitalized for exacerbation of chronic hypertension, found to have preeclampsia with proteinuria. Patient received betamethasone and magnesium sulfate course. Since <deleted date> with change of her regimen from labetalol to nifedipine 30mg XR BID, patient had had normal to mild range blood pressures.

Patient had acute exacerbations in her blood pressures to the severe range. Please see my note from <date> in regards to her antihypertensive course. After her 10mg IV hydralazine yesterday evening, starting magnesium sulfate, and increasing her nifedipine to 60mg XR BID, she has now had normal to mild range blood pressures overnight. However, her 0000 and 0600 AM labs show an acute rise in her LFTs above her baseline, with AST now 74 and ALT 81. Platelets remain normal range, as is serum creatinine (0.5). Magnesium level this morning at 6.4, infusion rate decreased to 1gm/hr.

Review of systems: denies headache, visual changes, RUQ or epigastric pain. No contractions, leakage of fluid, or vaginal bleeding. She is feeling fetal movement this morning.

Allergies:
• Amoxicillin Rash
CONV. REACTION:Rash
• Penicillins

Exam:
Vitals:
BP: (!) 140/97
Pulse: 89
Resp: 18
Temp: 36.7 °C (98 °F) 36.7 °C (98 °F)
TempSrc: Oral Oral
SpO2: 98% 98% 98%
Weight:
Height:
General: no acute distress
Cardiovascular: regular rate, normal rhythm. Intact S1/S2
Pulmonary: clear to auscultation bilaterally
Abdomen: gravid, non-tender to palpation
Extremities: non-tender; trace lower extremity edema, symmetric. 2+ brisk patellar reflexes

Ultrasound (12/5): Cephalic presentation. estimated fetal weight 28th percentile, 776g. Normal umbilical artery dopplers.

Labs:
Lab Results
Component Value Date
WBC 14.4 (H)
RBC 4.51
HGB 13.7
HCT 41.3
MCV 91
MCH 30
MCHC 33
RDW 11.8
PLT 313
PRENEUTROABS 9.56 (H)
DIFFTYPE Auto
NEUTOPHILPCT 66.4
LYMPHOPCT 24.0 (L)
MONOPCT 7.9
EOSPCT 0.7
BASOPCT 0.9
NEUTROABS 9.56 (H)
LYMPHSABS 3.46
MONOSABS 1.14 (H)
EOSABS 0.11

Lab Results
Component Value Date
NA 133 (L)
K 4.0
CL 102
CO2 22
GLUCOSE 84
BUN 11
CREATININE 0.5
OSMOLALITY 275 (L)
ALBUMIN 4.0
LABPROT 7.4
CALCIUM 7.0 (CL)
ALKPHOS 91
AST 74 (H)
BILITOT 0.2
ANIONGAP 9
ALT 81 (H)
GFRCNAFA >60
GFRCAFA >60

NST: appropriate for gestational age and magnesium sulfate administration. Baseline 135, mild to moderate variability, occasional 10×10 accelerations. Rare variable decelerations.
Toco: irritability

Assessment/Plan:
37 y.o. G1P0 at 25w6d, admitted for superimposed preeclampsia with severe features.

With preeclampsia with severe features, we do try to wait until 34 weeks for delivery; however, delivery is recommended once in the steroid window for the following: persistent symptoms of preeclampsia (i.e., headache, vision changes, upper abdominal pain), worsening or uncontrolled blood pressure despite medication therapy, development of pulmonary edema, placental abruption, eclampsia, HELLP syndrome (i.e., platelets < 100,000 or LFTs > 2x normal), evidence of acute kidney injury (i.e., creatinine >/= 1.1 mg/dl), eclampsia or non-reassuring fetal testing.

I discussed my concern that her liver enzymes, which had mildly been elevated on admission, are now acutely rising, which would be an indication for delivery at this time. However, at 25+6 weeks, I recommend rechecking her preeclampsia labs again at 1200. If there is a further acute rise, I do recommend delivery via cesarean section at that point.

We discussed the risks/benefits/alternatives of primary cesarean section, as well as the possibility for a classical hysterotomy, in which she would not be allowed to labor in the future. Risks of cesarean section discussed included:

Risks of cesarean section:
1. Bleeding, with the possibility or requiring a transfusion. Risk of transfusion include allergic reaction (1/50,000), transmission of HIV/Hepatitis B or C 1/1.5-1.7 million. The patient is accepting of blood transfusion if needed, and a type and cross x2 units will be ordered at noon.
2. Infection, requiring intravenous antibiotics and potentially prolonged hospital stay
3. Damage to surrounding organs, not limited to baby (<1%), bowel, bladder, nerves, vessels, ureters.
4. Possible need for hysterectomy in the event of irreversible catastrophic bleeding
5. Wound complications not limited to separation and/or infection
6. Medical complications not limited to deep venous thrombosis, pulmonary embolism, cardiovascular accident, myocardial infarction, death.

I would not advise induction of labor at 26 weeks, as the chance of a successful vaginal delivery prior to 28-30 weeks in a primip is low.

Patient will remain NPO and on magnesium sulfate (for maternal seizure prophylaxis and fetal neuroprotection) at this time, as we await her 1200 labs. Will continue q4hr blood pressure monitoring, and she will be given her 60mg XR nifedipine at 0900.

Scientists-discover-critical-molecular-biomarkers-of-preeclampsia
From Debuglies.com

Spinal Anesthesia in Severe Preeclampsia. Anesthesia & Analgesia: September 2013 – Volume 117 – Issue 3 – p 686–693.

PDF version of article above

Subarachnoid block for caesarean section in severe preeclampsia. J Anaesthesiol Clin Pharmacol. 2011 Apr-Jun; 27(2): 169–173.

Comparing the Hemodynamic Effects of Spinal Anesthesia in Preeclamptic and Healthy Parturients During Cesarean Section. Anesth Pain Med. 2016 Jun; 6(3): e11519.

Recent advances in pre-eclampsia management: an anesthesiologist’s perspective! Anaesthesia, Pain & Intensive Care ISSN 1607-8322, ISSN (Online) 2220-5799.

Hemodynamic Changes Associated with Spinal Anesthesia for Cesarean Delivery in Severe Preeclampsia. Anesthesiology 5 2008, Vol.108, 802-811.

Birth plan: Vaginal delivery vs. Elective C-section

Today, I’m the OB anesthesiologist on call.  Hours in the L&D OR have provided me with a “real” understanding of what is involved in a C-section (C/S).  I’ve seen countless spontaneous vaginal deliveries (SVD) including natural birth (without pain medications), deliveries with epidurals, vacuum-assisted deliveries, shoulder dystocias, postpartum hemorrhages, etc.  A lot can happen to both the mom and the baby — and it can be scary.  Someday, I’d like to have my own family, and it got me thinking about what I would like to choose for my “birth plan”.  As much emphasis is placed on this…it’s really out of your control. The idea seems nice in that you feel like you have control, but nature has a very interesting way of doing what it will do irrespective of your plans.

My Reddit comment

One of our OBs had her two children via elective C/S. Given that a C/S is major surgery, I often wondered why one would electively choose to go that route vs. vaginal delivery.  I opted to take a poll on the OB floor (nurses, docs, midwives, staff, etc.)….

The results:

  • CS decreases urinary incontinence/vaginal prolapse
  • CS offers a time/schedule/control
  • SVD seems to offer shorter hospital stay and improved breathing in the neonate
  • Personal preference

But a little research….

ACOG Committee Opinion: Cesarean Delivery by Maternal Request

I loved my elective C-section

Pros and Cons of elective c-section

Vaginal Birth vs. C-section

A gal’s account of her elective c-section

CMAJ: Planned elective c-section — a reasonable choice for some women?

Clinical Perinatology: CS vs Vaginal Delivery: Long term infant outcomes

The Guardian: Vaginal birth vs. C-Section

A Canadian gal’s account of her elective c-section

My other OB blog posts: