Hellp syndrome and anesthesia

diagnostic criteria and pathophysiology of hellp syndrome. Its anesthetic management both pre-operatively and post operatively. complication and differential diagnosis of hellp

1. HELLP SYNDROME & ANESTHESIA DR. PRATEEK GUPTA SAVEETHA MEDICAL COLLEGE

2. HELLP SYNDROME The acronym HELLP was coined by Weinstein in 1982 to describe a syndrome consisting of Hemolysis, Elevated Liver enzymes, and Low Platelet count. HELLP syndrome is a life-threatening obstetric complication usually considered to be a variant of pre-eclampsia. Both conditions usually occur during the later stages of pregnancy or sometimes after childbirth.

3. It may be a variant of severe preeclampsia, but this is controversial because a substantial fraction of HELLP syndrome patients do not have hypertension or proteinuria Additionally , 70% of HELLP syndrome patients deliver preterm; -prematurity-related neonatal complications increase the risk for perinatal morbidity and mortality.

4. INCIDENCE 2–12 % of all pregnancies, and in 10–20 % of cases of pre-eclampsia It occurs during 70% of antepartum periods and during 30% of postpartum periods, and emerges mostly in the first 48 hRS

5. CLASSIFICATION PARTIAL -one or two abnormalities COMPLETE -three abnormalities CLASS 1 - < 50 x 10 9 /l; CLASS II -50–100 x 10 9 /l; and CLASS III , -100 – 150 x 10 9 / l

6. PATHOPHYSIOLOGY It is a syndrome that is characterized by hepatic endothelial disruption followed by platelet activation, aggregation and consumption, ultimately resulting in ischemia and hepatocyte death The elevated liver enzymes are thought to be secondary to obstruction of hepatic blood flow by fibrin deposition in the sinusoids. This obstruction leads to peri -portal necrosis and in severe cases intra-hepatic haemorrhage , subcapsular haematoma formation or hepatic rupture.

7. CONTD.. Haemolysis is due to microangiopathic haemolytic anaemia . Red cells become fragmented as they pass through small vessels with endothelial damage and fibrin deposits, -results in increase in bilirubin levels and LDH. - peripheral blood smear demonstrates schistocytes , burr cells, and echinocytes Decreased platelet count is due to their increased consumption. Platelets are activated, and adhere to damaged vascular endothelial cells, resulting in increased platelet turnover with shorter lifespan

8. Clinical features right upper quadrant or epigastric pain, nausea and vomiting , headache , hypertension , and proteinuria .

9. Rupture of a subcapsular hematoma of the liver Life threatening complication Abdominal pain nausea and vomiting, H eadaches ; P ain localized to the epigastric area or right upper quadrant. Hypotension and shock typically develop, and the liver is enlarged and tender

10. DIAGNOSIS ultrasonography, computed tomography (CT), MRI of the liver

11. MANAGEMENT intravascular volume resuscitation and blood and plasma transfusions. S elective arterial embolization LIVER TRANSPLANT in fulminant hepatic failure Conservative management is recommended for sub- capsular hematoma or intraparenchymal hemorrhage without capsular rupture in stable women - avoid all potential trauma to the liver

12. FETAL COMPLICATIONS placental abruption, cerebral hemorrhaging, perinatal death, preterm delivery, neonatal thrombocytopenia, respiratory distress syndrome, and intrauterine growth restriction

13. MANAGEMENT T he first priority is to stabilize the maternal condition, with particular attention given to hypertension and coagulation abnormalities. Next , the fetal condition should be assessed with FHR monitoring, Doppler ultrasonography of fetal vessels, a biophysical profile, or several of these options. Some of the drugs used in this syndrome are: corticoids, antihypertensive drugs and magnesium sulfate

14. PLAN I mmediate delivery at 34 weeks or later ; Delivery in 48 h after evaluating or stabilizing the maternal clinical conditions and treating with corticoids. The most advisable option appears to be between 27 and 34 weeks ; wait-and-see attitude in pregnancy earlier than 27 weeks , and treatment with corticoids

15. CORTICOIDS For fetal lung maturation (standard regime treatment), and for maternity benefits (high doses of corticoids) for extremely low levels of platelets, extremely high liver enzymes, or diminished urine output .

16. ANTI-HYPERTENSIVE Lowering SBP to 140–150 mmHg and DBP to 90–100 mmHg using labetalol as the drug of choice Other drugs -hydralazine, -methyldopa , - nifedipine or - isradipine , -some β -adrenoceptor blockers (metoprolol, pindolol , propranolol), and -low-dose diazoxide

17. ANTI-CONVULSANTS Magnesium sulfate (MgSO4 ) is the drug of choice for prophylaxis, treatment, and recurrences of seizures (eclampsia ). 4–5 g of MgSO 4 administered in 5 min, and -subsequently 1 g/h for 24 h. If a recurring seizure appears, 2 g of MgSO4 should be administered

18. MONITORING -urine output, -breathing rate, -oxygen saturation , -patellar reflexes. The normal plasma concentration lies between 1.58 and 2.55 mg/dl . The recommended therapeutic concentrations lie between 4 and 7 mg/dl.35 ANTIDOTE -10 % calcium gluconate, 1 g administered in 10 min.

19. Platelet transfusions are indicated in the presence of significant bleeding and in all parturients with a platelet count less than 20,000/mm3. For women with a platelet count less than 40,000/mm3 who are scheduled for cesarean delivery, the pre-incision administration of 6 to 10 units of pooled random-donor platelets (or 1 to 2 units of apheresis platelets ) at least 2 red blood cell units should be type and crossmatched and large-bore intravenous access obtained. If DIC occurs, it can be treated with fresh frozen plasma to replace clotting proteins

20. PLASMAPHERESIS In patients who are refractory to conventional treatment Removes plasma factors and replaces new elements by encouraging plasma from patients For bilirubin or creatinine has progressively increased for more than 72 h after delivery

21. FLUID THERAPY Restrictive therapy -exacerbate intravascular vasoconstrictors -Lead to kidney failure Non- Restrictive therapy -positive fluid balance entails a possible risk of producing a pulmonary edema . Use of IVF to increase plasma volume or to treat oliguria in women with normal renal function and stable creatinine levels is not advisable, nor is treating oliguria with furosemide and low doses of dopamine recommended in women with normal renal function

22. ANESTHESIA MANAGEMENT

23. PRE-OP ECG and a complete blood count with a platelet count, LFT RFT FDP, and PT & APTT

24. BLOOD PRODUCTS Blood components, including cross-matched red cells, platelet concentrates, and plasma, should be available In thrombocytopenia , platelet transfusion should be considered at the time of surgery, and not before - platelets can be rapidly consumed Urinary catheterization

25. TYPE OF ANESTHESIA RA or GA

26. CVP??? - oliguria resistance to fluid therapy; -pulmonary edema, or -some form of heart disease. -refractory hypertension Transthoracic echocardiography (TTE) can be used in place of invasive monitoring to quantify cardiac function and volume status

27. Neuraxial Analgesia for labour R ecommended for several reasons: -Avoid GA and the possibility of airway catastrophe and marked hypertension with laryngoscopy in the event of emergency cesarean delivery, -Optimize the timing of epidural catheter placement in the setting of a declining platelet count, and -Obtain the beneficial effects of neuraxial analgesia on uteroplacental perfusion.

28. Lumbar Epidural Analgesia Advantages include - provision of high quality analgesia, which attenuates the hypertensive response to pain -a reduction in levels of circulating catecholamines and stress-related hormones -possible improvement in intervillous blood flow; and -provision of a means for administration of local LA for emergency cesarean delivery, thus obviating the need for GA

29. However, four special considerations exist in pre- eclamptic women: ( 1) assessment of coagulation status, ( 2) intravenous hydration before the epidural administration of a local anesthetic, ( 3) treatment of hypotension, and ( 4) use of epinephrine-containing local anesthetic solutions.

30. assessment of coagulation status, >1 lakh vs 50k-1 lakh vs <50k PFA vs TEG

31. PRECAUTIONS The most skilled anesthesia provider A spinal technique may be preferable to an epidural technique Use of a flexible wire-embedded epidural cath - eter The patient should be carefully monitored after delivery for neurologic sign The platelet count should be checked for evi - dence of a return toward normal measurements (at least 75,000 to 80,000/mm3) before removal of the epidural catheter Imaging studies and neurologic or neurosurgi - cal consultation should be obtained immedi - ately if there is any question of an epidural hematoma

32. REMOVAL OF CATHETER if there are no signs of intraspinal bleeding, the catheter must be removed as soon as possible given the risk of intravascular catheter migration and bleeding could begin ; if bleeding is observed around the insertion point, it could also occur in the intraspinal or the epidural space, so the catheter must be left without moving it

33. GENERAL ANESTHESIA Involves a higher materno -fetal anesthetic risk INDICATION - severe ongoing maternal hemorrhage, -sustained fetal bradycardia with a reassuring maternal airway examination , and -severe thrombocytopenia or other coagulopathy, -pulmonary edema; and -if the level of consciousness has altered

34. CHALLENGES (1) the potential difficulty of securing the airway, ( 2) the hypertensive response to direct laryngoscopy and tracheal intubation, and ( 3) the effects of magnesium sulfate on neuromuscular transmission and uterine tone.

35. Airway Considerations. IBP should be initiated before the induction of GA in patients Endotracheal tubes in various sizes and difficult airway equipment should be immediately available. Patient in the supine position with a left uterine displacement, and de- nitrogenation , to help ensure optimal maternal oxygenation. RSI and intubation Avoid repeated attempts -proceed with insertion of a SGA before the airway is irretrievably lost - obstetrician should be encouraged to complete the procedure as quickly as possible.

36. Hemodynamic Monitoring. ( 1) poorly controlled maternal blood pressure; ( 2) need for frequent arterial blood gas measurements , especially in the context of pulmonary edema; ( 3) planned use of a rapid-acting vasodilator (e.g., sodium nitroprusside, nitroglycerin, nicardipine infusion); (4 ) use of calculated systolic pressure variation ( SPV) to estimate intravascular volume status; and ( 5) need for continuous blood pressure monitoring during the induction of and emergence from general anesthesia in hypertensive women with severe preeclampsia.

37. HYPERTENSIVE RESPONSE RISK OF CEREBRAL HEMORRHAGE OR PULM. EDEMA DRUGS -labetalol , - esmolol , -nitroglycerin , -sodium nitroprusside, - remifentanil/ fentanyl/ alfentanil - lidocaine GOAL – 140/90 (PRE INDUCTION) MAINTAIN SBP - 140 to 160 mm Hg DBP - 90 to 100 mm HG

38. Effects of Magnesium Sulfate. infusion should continue throughout surgery to minimize the risk of eclampsia CONSIDERATION - interaction with nondepolarizing muscle relaxants , - effects on uterine tone, and - interaction with calcium entry blocking agents. NDMR administered in very small doses and the response should be monitored carefully with a PNS DMR - single intubating dose is not prolonged when administered concurrently with a magnesium sulfate infusion

39. UTERINE CONTRACTION OXYTOCIN VS ERGOMETRINE VS MISOPROSTOL

40. POST-OP ANALGESIA S ame as for healthy pregnancies If postpartum HTN persists longer than one day, the ACOG has suggested that nonsteroidal anti-inflammatory medications be replaced by alternative analgesics In case of a continuing severe refractory hypertension, continuous epidural analgesia for its blood pressure–modulating properties.

41. POST-PARTUM MANAGEMENT In most patients, blood pressure, platelet count, and levels of liver enzymes normalize within 48–96 h postpartum , BUT -Pulmonary edema is also highest in the postpartum period -Sustained hypertension, -Stroke , -Venous thrombo - embolism, -Airway obstruction, and -Seizures E clampsia can present for the first time in the postpartum period, with delayed presentation as late as 4 weeks after delivery

42. ACOG recommends antihypertensive therapy in the postpartum period when systolic blood pressure persistently exceeds 150 mm Hg or diastolic blood pressure exceeds 100 mm Hg . Who develop new-onset hypertension associated with headaches or other neurologic symptoms -a 24-hour course of magnesium sulfate administration may help prevent eclampsia or a cerebrovascular accident.

43. CONCLUSION D ecisions to administer GA or RA must involve consideration of the evolving nature of coagulopathy or the existence of thrombocytopenia. Whenever RA is not contraindicated and ensures the mother’s hemodynamic stability, it should be considered Early detection and the interdisciplinary treatment of these patients by obstetricians, pediatricians, and anesthesiologists of severe complications associated are important to lower maternal-fetal morbidity and mortality.

44. THANK YOU