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Review Article
Abstract
Pregnancy induced hypertension is a hypertensive disorder, which occurs in 5% to 7% of all pregnancies. These parturients
present to the labour and delivery unit ranging from gestational hypertension to HELLP syndrome. It is essential to understand
the various clinical conditions that may mimic preeclampsia and the urgency of cesarean delivery, which may improve perinatal
outcome. The administration of general anesthesia(GA) increases morbidity and mortality in both mother and baby. The provision
of regional anesthesia when possible maintains uteroplacental blood flow, avoids the complications with GA, improves maternal
and neonatal outcome. The use of ultrasound may increase the success rate. This review emphasizes on the regional anesthetic
considerations when such parturients present to the labor and delivery unit.
Key words: Anesthesia, hypertension, pregnancy, regional
Introduction
Preeclampsia is a hypertensive disorder of gestation,
complicating 5% to 7% of all pregnancies. It is characterized
by new onset of hypertension (140/90 mmHg) and
proteinuria that develops after 20 weeks of gestation and
usually resolves within 48h of fetal delivery. It can progress
to a severe form in 25% of parturients when it is undiagnosed
or untreated.[1] It increases both maternal and fetal morbidity
with the occurrence of eclampsia in 0.040.05% of the affected
parturients[2,3] with an estimated annual mortality rate of
50,000 parturients with preeclampsia worldwide.[4]
Parturients with pregnancy induced hypertension may present
to the labor and delivery unit with or without a prior diagnosis
Address for correspondence: Dr.Saravanan P Ankichetty,
Fellow in Regional Anesthesia and Pain Management, Toronto
Western Hospital, University of Toronto, Canada.
Email:sarandoc2000@gmail.com
Website:
www.joacp.org
DOI:
10.4103/0970-9185.119108
Classification of Hypertension in
Pregnancy
Parturients with high blood pressure fall into four categories,
which include:
Gestational hypertension
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Ankichetty etal.: Regional anesthesia in preeclampsia
Preeclampsiaeclampsia
Chronic hypertension or prepregnant hypertension
Preeclampsia superimposed on chronic hypertension.[10]
Mild
Severe
140160
90110
Absent
Absent
Absent
160
110
Present
Present
Present
>500ml/24 h
<5g/24 h
1+/2+
500ml/24 h
5g/24 h
3+/4+
Pathophysiology of Preeclampsia/
Eclampsia
In normal pregnancy, the uterine blood flow is about
10% (500600 ml/min) of cardiac output, with 80% of
uterine blood flow normally supplying the placenta and the
remaining 20% supplying the myometrium. In preeclampsia,
there is an abnormal trophoblastic invasion of the maternal
spiral arteries with impaired uteroplacental perfusion. There
is a release of vasoactive factors into the maternal circulation,
resulting in endothelial dysfunction, vasoconstriction and
hypertension. [15] These parturients have an elevated
thromboxane/prostacyclin ratio, factor VIII antigen and
fibronectin prior to the onset of clinical manifestation.[16]
Similarly, there is an exaggerated inflammatory response
that affects every single organ in the body compared with
normal pregnancy.[17] However, there is limited evidence
to the role of nitric oxide in the pathophysiology and
management of preeclampsia. The assessment of uterine
arteries by Doppler studies has shown higher uterine artery
Preeclampsia
Present
Present
Absent
Absent
Absent
Absent
Absent
HELLP syndrome
85
9095
Present
Absent
Present
Present
Present
AFLP
50
3050
Present
Present
Absent
Present
Present
TTP
2075
Hematuria
Rare
Present
Absent
Present
Present
HUS
8090
8090
Rare
Present
Absent
Present
Less common
SLE exacerbation
80+nephritis
100 nephritis
Absent
During flare
Absent
Present
Present
Absent
Mild elevation
>100000
Absent
Absent
Present
Gross elevation
>20,000
Present
Absent
Less common
Gross elevation
>50,000
Less common
Absent
Present
Mild elevation
<20,000
Present
Present
Present
Mild elevation
>20,000
Present
Rare
Less common
Mild elevation
>20,000
Less common
Rare
Absent
RA
Absent
GA
Absent
GA
Increased
GA
Increased
GA
Increased
GA
AFLP=Acute fatty liver of pregnancy, TTP=Thrombotic thrombocytopenic purpura, HUS=Hemolytic uremic syndrome, SLE=Systemic lupus erythematous, VWF=Von
Willebrand factor, RA=Regional anesthesia, GA=General anesthesia, TAP=Transversus abdominis plane block, ADAMTS=A disintegrin and metalloprotease, with
thrombospondin1like domains, HELLP=Hemolytic anemia, elevated liver enzymes and low platelet
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Ankichetty etal.: Regional anesthesia in preeclampsia
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Ankichetty etal.: Regional anesthesia in preeclampsia
Spinal anesthesia
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Figure1: Perioperative care of parturient with preeclampsia
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Ankichetty etal.: Regional anesthesia in preeclampsia
Epidural anesthesia
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Ankichetty etal.: Regional anesthesia in preeclampsia
General anesthesia
Lucas classification[48]
Immediate threat to life of
woman or fetus
No immediate threat to
life of woman or fetus
Clinical features
Maternal or fetal
compromise
No maternal or
fetal compromise
Kinsella classification[49]
Cord prolapse, significant placental abruption
Maternal cardiorespiratory distress
Late fetal heart rate decelerations
CS prebooked to avoid vaginal delivery but woman
presents in advanced labor
Bleeding placenta praevia without hypovolemic
Failed instrumental delivery with no fetal compromise
Deteriorating but compensated maternal medical
condition
Operation at short notice but no clinical urgency
Anesthetic technique
GA
RA/GA
RA
RA
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Ankichetty etal.: Regional anesthesia in preeclampsia
Conclusions
Parturients with mild preeclampsia may safely undergo regional
anesthetic procedures for labor analgesia and CS delivery.
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Ankichetty etal.: Regional anesthesia in preeclampsia
Acknowledgment
The authors acknowledge Dr.Koshkin Arkady, Research fellow,
Toronto Western Hospital, Toronto for his editorial assistance.
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Ankichetty etal.: Regional anesthesia in preeclampsia
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How to cite this article: Ankichetty SP, Chin KJ, Chan VW, Sahajanandan R,
Tan H, Grewal A, et al. Regional anesthesia in patients with pregnancy induced
hypertension. J Anaesthesiol Clin Pharmacol 2013;29:435-44.
Source of Support: Department of Anesthesia, Toronto Western Hospital,
University Health Network, University of Toronto, Toronto, Canada.
Conflict of Interest: None declared.
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