A 15 years-old nulliparous woman presents to the labor and delivery suite at the 35 th

week of pregnancy. Her chief complaint is headache. Her blood pressure is 145/95 mmHg,
and she appears edematous.

1. Classify the hypertensive disorders of pregnancy?

The hypertensive disorder of pregnancy are classified into four group by the America
College of Obstetricians and Gynecologist: chronic hypertension preeclampsia eclampsia,
chronic hypertension with superimposed preeclampsia, and gestational hypertension.

Hypertension is defined as :

Systolic blood pressure : > 140 mmHg or 30 mmHg above baseline

Diastolic blood pressure : > 90 mmHg or 15 mmHg above baseline
Mean arterial blood pressure : > 105 mmHg or 20 mmHg above baseline

Blood pressures should be measured at rest with left uterine displacement and should be
reproducible at least 6 hours later.

Chronic hypertension is diagnosed when the blood pressure elevated prior to the 20 th
week of pregnancy. Chronic hypertension is a disease state that predates pregnancy. Since
blood pressure normally decreases during pregnancy, any parturient with diastolic blood
pressure greater than 80 mmHg is suspected of having chronic hypertension.

Preeclampsia-eclampsia is a hypertensive disorder unique to pregnancy. The triad

hypertension, proteinuria, and edema characterizes preeclampsia. Except in association with
hydatidiform mole, preeclamptic hypertension does not manifest prior to the 20th week of
gestation. Proteinuria is defined as the exretion of greater than 0,3 grams of protein in a 24
hour urine collectinons or 1 + on dipstik analysis. Edema must be generalized an not
confined to dependent areas of the body. Preeclampsia is classified as either mild or severe
depending on the degree of hypertension, extent of proteinuria, or patient complaints.
Preeclampsia degenerates into eclampsia when generalized seizures occur.

Gestational hypertension is defined as hypertension occurring after the 20th week

of pregnancy in the absence of other signs of preeclampsia. Gestational hypertension is
frequently essential hypertension that is unmasked by pregnancy.
Sumber : CLINICAL CASES IN ANESTHESIA editor by Allan P. Reed, Francine S. Yudkowitz

2. Explains the etiologi of preeclampsia?

Although the etiologies of preeclampsia are unknow, uteroplacental ischemia appears to
be a common factor. Beer (1978) suggested that uteriplacental ischemia may result from
altered immunity such as graft-versus-host-reaction

Classification of Hypertension Disorders in Pregnancy

Chronic hypertension
Manifest before the 20th week of gestational
Preeclampsia-eclampsia
Manifest after the 20th week of gestational Associated with proteinuria and edema
Chronic hypertension with superimposed
Preeclampsia
Gestational hypertension
Manifest after the 20th week of gestational without associated symptoms

It is also possible that placental prostaglandin imbalance between thromboxane and

prostacyclin leads to preeclampsia. In the normal pregnancy, prostacyclin and thromboxane are
produced in equal amounts by the placenta. In the pregnancy complicated by preeclampsia, there
is a relative increase vasoconstriction, platelet aggregation, and uterine activity as well as a
simultaneous decrease in uteroplacental blood flow. These effects are observed in preeclampsia.
Uteroplacental ischemia leads to the production of substances similar to renin and
tromboplastin. Renin causes release of angiotensin and aldosterone, which result in hypertension
and edema. Thromboplastin can initiate coagulopathies such as disseminated intravascular
coagulation (DIC)

Sumber : CLINICAL CASES IN ANESTHESIA editor by Allan P. Reed, Francine S. Yudkowitz

3. Describe the pathophysiology of preeclampsia?

The hallmarkof preeclampsia is vasopasm that occurs secondary to increased circulating

levels of renin, aldosterone, angiostensin, and catecholamines. Aldosterone also causes sodium
and water retention, which leads to generalized edema. Since almost every organ system is
affected in the parturient with preeclampsia, it is best to take a systematic approach when
discussing the changes seen in preeclampsia.
 Central Nervous System Cerebral edema and cerebral vasopasm lead to the central
nervous system effects of preeclampsia. Intracranial pressure increases in some cases but
cerebral blood flow and oxygen consumption remain normal. Clinical findings related to the
above changes include headache, hyperrefrelxia, blurred vision, vertigo, blindness, seiures, and
coma. Cerebral hemorrhage is the leading cause of death in the preeclampsia patient.

Pulmonary Intubation may be exceedingly difficult secondary to laryngeal and upper

airway edema. Increased secretions and airway congestion predispose the mother to upper
airway infections. Pulmonary capillary leak into the interstitium accounts for intrapulmonary
shunting and a deteriorating alveolar to arterial (A-a) oxygen gradient.

Cardiovascular Generalized vasoconstriction produces hypertension, impaired tissue

perfusion, and cellular hypoxia. Translocated fluid from the vascular compartment to the
interstitium leads to generalized edema, hypovolemia, and hemoconcentration. An inverse
relationship exists between the intravascular volume and the degree of hypertension.
Hemoconcentration leads to increased blood viscosity, which further exacerbates tissue hypoxia.
Although the hematocrit is typically elevated, a relative anemia usually exists and blood loss is
poorly tolerated. Vasospasm leads to an increase in systemic vascular resistance (SVR). Which
increases cardiac work. The already hyperdynamic cardiovascular system becomes stressed
further and cardiac output rises. Over time, left ventricular hypertrophy occurs leading to left
ventricular dysfunction. Cotton and colleagues (1985) have shown that central venous pressure
does not necessarily correlate with pulmonary capillary wedge pressure and left ventricular
pulmonary artery cetheters may necessary in some preeclamptic patients.

Renal Renal blood flow is reduced leading to a decrease in the glomerular filtration rate and
creatinine clearance. Almost all renal function tests are impaired. An increasing uric acid level
correlates with the severity of disease. Damaged glomerulli allow for renal loss of proteins.

Hepatic vasopasm leads to hepatic periportal hemorrhages and hepatocellular damage.

Swelling of the liver capsule from subcapsular hematomas may produce abdominal pain. Hepatic
rupture has been reported in severe cases. Elevated liver enzymes occur with deteriorating
hepatic function.
 Hematologic coagulation abnormalities also occur. The most common findings is
thrombocyttopenia that can occur with or without other coagulopathies. A syndrome of
hemolysis, elevated liver function and low platelet count (acronym HELLP) has been described.
There is also frequently a qualitative platelet abnormality even without a quantitative problem.
The prothrombin time, thrombin time and partial thromboplastin time can also be elevated.
Fibrinogen levels can decrease and frank DIC can occut.

Uteroplacental Intervillous blood flow decrease 2- to 3- fold and is a major contributing

factor of fetal morbidity and mortality. The incidence of premature labor is high due to placental
hypoperfusion. Because of decreased uteroplacental blood flow, the placenta is often small and
shows signs of premature aging. The uterus is also hyperactive and markedly sensitive to
oxytocin. The parturient with preeclampsia is at an increased risk for placenta abruption.

Sumber : CLINICAL CASES IN ANESTHESIA editor by Allan P. Reed, Francine S. Yudkowitz.

A 32 years old woman present to the emergency room complaining of abdominal pain,
nausea, and vomiting. After physical examination, a presumptive diagnosis of appendicitis
is made and an emergency appendectomy is scheduled. The patient is also 17 week
pregnant.

4. What are the anesthetic concerns when anesthetizing a pregnant patient?

Anesthetizing the pregnant patient is one of the only times an anesthesiologist must
consider two patient simustaneously. Maternal consideration result from the physiologic
changes of pregnancy that affect almost every organ system (Table 62.1). in order to provide
safe anesthesia to the pregnant patient, one must not only understand the physiologic changes
but also when they occur during the gestational period and how they impact on the
administration of anesthesia. Fetal concerns include the possible teratogenic effects of
anesthetic agents, avoidance of intrauterine fetal asphyxia, and prevention of premature labor.

Sumber : CLINICAL CASES IN ANESTHESIA editor by Allan P. Reed, Francine S. Yudkowitz

5. What are the physiologic changes during pregnancy and how do they impact on
anesthesia?
Respiratory system
Due to increased progesterone levels during the first trimester, minute ventilation is
increased by alost 50% and remains at this level for the remainder of the pregnancy. The
increase in minute ventilation leads to adecrease in arterial carbon dioxide tension (PaCO2) to
approximately 30 mmHg. Arterial ph remains unchanged because of a compensatory increase
in renal excretion of bicarbonate ions. At term, alveolar ventilation is increased by 70%
because anatomic dead space does not change significantly during pregnancy. After the fifht
month of pregnancy, the functional residual capacitu, expiratory reserve volume, and residual
volume are all decreased by about 20% because of the gravid uterus pushing on the
diaphragm. Vital capacity is not appreciably change from prepregnancy levels.
Anesthetic implications : increased alveolar ventiolation and decreased functional residual
capacity lead to a more rapid uptake aand excretion of inhaled anesthetics. The decrease in
functional residual capacity in conjunction with increases in cardiac output, melabolic rate,
and consumption make the pregnant patient more susceptible to arterial hypoxemia during
periods of apnea or airway obstruction.
Edema weight gain, and increase in breast size may make intubation of the trachea
technically difficuh. An array of laryngoscope blades and handles and other emergency airway
management equipment should be available. Capillary engorgement of the mucosal lining of
the upper airway accompanies pregnancy. This mandates extreme care during manipulation of
the airway and the use of a smaller-than-normal tracheal tube. The use of a nasal airway and
nasotracheal intubation should be avoided.

Cardiovascular System

Cardiac output is increased by 30-40% during the fast trimester. This is primarily related
to an increase in stroke volume (30%) and secondarily related to an increase in heart rate
(15%). Cardiac output increases slightly further during the second trimester and lasts
throughout the pregnancy.

Blood pressure normally decreases during pregnancy because of a 15% decrease in

systemic vascular resistance. Near term, 10-15% of patient have a dramatic reduction in blood
pressure in the supine Position, often assosiated with diaphoresis, nausea, vomiting, Pallor,
and changes in cerebration. This is the supine hypotensive Syndrome and it caused by
compression of the inferior vena cava and aorta by gravid uterus. Other manifestations of the
syndrome are decreases in renal and uteroplacental blood flow from compression of the aorta.
Displacing the uterus by tilting the patient on her left side cari alleviate the symptom of this
syndrome.

Intravascular volume is increased by 35% during pregnancy. Because plasma volume

increases by a greater percentage than red bkod cell volume (45% and 20% respectively) there
is a relative anemia during pregnancy. Nevertheless, a hemoglobin concentration of less than
11g/dL is considered abnormal.

Anesthetic Implications Increases in cardiac output will hasten the speed of intravenous
inductions.

Gastrointestinal System

Due to increased progesterone levels, gastrointestinal tract motility is decreased by the

end of the first trimester. The stomach, displaced upward by the enlarging uterus, eventually
assumes a horizontal position further slowing stomach emptying. This also results n a change
in position and function of the gastroesophageal sphincter. Anxiety, pain, and administration
of opioids and anticholinergics will further slow gastric emptying. Gastrin production is
increased during pregnancy (because the placenta produces gastrin) leading to an increase in
acid production.

Anesthetic Implications

The above changes in the gastro intestinal system by the end of the first trimester, place
the pregnant patient at increased risk for aspiration of gastric contents. A nonparticulate
antacid, H2 receptor blocker, and metoclopramide should be used to decrease the acidity and
volume of the gastric contents. After the first trimester, all general anesthetics should be
conductedwith a rapid sequence induction, cricoid pressure, and tracheal intubation.

Hepatic System
 Tests of liver function (Serum glutamic-oxaloacetic transaminase lactic acid
dehydrogenase alkalin phos phatase, and cholesterol) are commonly increased during
pregnancy These increases do not necessarily indicate abnormal liver function.
Pseudocholinesterase activity declines by as much as 20% duing the first trimester and
remains fairly table during the remainder of the pregnancy.

Anesthetic implications.

Prolonged apnea is rarely a problem following a standard dose of succinil choline.

Similarly, prolonged activity of easter-linked local anesthesia has not been a problem.

Hematologic system and Blood Constituents

Pregnancy does not significantly alter the lymphocyte count, but lymphocyte function is
decreased, which can decrease maternal resistance to infection. The risk of upper respiratory
infenctions is increased, which may complicate airway management.

The platelet count decrease by about 20% during pregnancy but is usually of no clinical
significance. Circulating level of coagulation factors incrase significantly during pregnancy
leading to the hypercoagulable state of pregnancy.

Anesthetic Implications

The increased risk of upper airway connection may complicate airway management
during general anesthesia. Increased coagulability may predispose the pregnant patient to
thromboembolic events including pulmonary-embolism.

Renal system

Renal blood flow and gromerular filtration rate are increased during the first trimester,
leading to a rise in creatinine clearanceand a fall in serum cratinine. During the third trimester,
RBF and GFR decreased toward prepregnant level because of compresion of the aorta by the
enlarging uterus. Due to progesterone, renal calyces and pelves dilate during the third month
of pregnancy. During the third semester, they dilate further because of ureteral compression.
This dilatation may lead to stasis and urinary tract infections.
 Anesthetic implication

Care should be taken not to overhydrate the patient because urinary retention is common
during spinal or epidural anestheesia, whic may necessitate bladder catheterization and further
predispose the patient to urinary tracts infections.

Central Nervous System

The minimum alveolar concentration (MAC) for inhaled anesthetics is decreased by up to

40% during pregnancy. This is related to a progesterone and endorphin effect. Compression of
the inferior vena cava by the gravid uterus leads to dilatation of the azygos system and the
epidural veins. Epidural venous engorgement decreases thesize of the epidural and intrathecal
spaces.

Anesthetic implication

The decrease in MAC along with an increase in alveolar ventilation place the pregnant
patient at risk for anesthetic overdose. The decreased size of the of the epiduraI and
intrathecaI spaces as a result of epidural venous engorgement explains why the doses of drugs
used during a major conduction block must be decreased. An alternative explanation is that
progesterone may increase the sensitivity of nerve cells to local anesthetics since neuroaxial
drug requirements decrease prior to uterine enlargement.

Sumber : CLINICAL CASES IN ANESTHESIA editor by Allan P. Reed, Francine S. Yudkowitz.

6. What is terratogen and which anesthetic agents are known teratogens?

A teratogen is a substance that produces an increase in the incidence of a particular
defect that cannot attributed to chance. In order to produce a defect, the tcratogen must be
administered in a sufficient dose at a critical point in development. In human, this critical
point is during organogenesis, which extends from 15 days to approximately 60 days
gestational age. However, the central nervous system does not fully develop until after birth;
therefore the critical time for this system may extend beyond gestation.
 Three approaches have been utilized to study the effects of anesthetic agents or anesthesia
in the pregnant patient: (1) animal studies, (2) studies of operating room personnel chronically
exposed to trace concentrations of inhaled anesthetics, and (3) studies of women who
underwent surgery while pregnant.
The results of animal studies are of limited value because of (1) species variation, (2) the
fact that the doses of anesthetic agents used in animal studies were usually far greater than
those used clinically, and (3) other factors such as hypercarbb, hypothermia. and hypoxemia
(known reratogcns) were either not measured or not controlled. Siecies variation is
particularly important. Thalidomide has no known teratogenic effects on rats and was
approved By United States Food and Drug Administration (FDA) for use in humans. It is
known that talidomide is the teratogenic in humans. The FDA has established a risk
Classification system physicians in weighing the risk and choosing therapeutic agents for the
pregnant woman.
The use of two commonly used agents, benzodiazepine and nitrous oxide, are
controversial. Sorne investigators, in retrospective studies, noted an association broil
diazepam taken in the first 6 weeks of pregnancy and cleft palate. Although this finding has
been questioned results of a prospective study. diazepam and other benzodiazepines are
classified by the FDA as Category D drugs(i.e, positive evidence of risk) and, therefore should
be avoided.
Nitrous oxide is a known teratogen in mammals. The presumption was that the
teratogenicity of nitrous oxide in animals is related to its oxidation of vitamin B 12 which then
cannot function as a cofactor for the enzyme methionine synthetase. Methionine synthetase is
needed for the formation of thymidine. a subunit of DNA. However. pretreatment of rats
exposed to nitrous oxide with foIinic acid, which bypasses the methionine synthetase step in
DNA synthesis, does not prevent congenital abnormalities. In addition, suppression of
methionine synthetase occurs at low concentrations of nitrous oxide concentrations found
safe in animal studies. Despite these theoretical concerns, nitrous oxide has not been found to
be associated with congenital abnormalities in humans. Interestingly, the FDI has not given
nitrous oxide a category classification because it is a medical gas and not directly regulated by
the FDA.

Sumber : CLINICAL CASES IN ANESTHESIA editor by Allan P. Reed, Francine S. Yudkowitz.

A 22-year-old woman presents to the labor and delivery suite at 40 weeks gestation with
mild uterine contractions. The obstetricians decided to augment labor with oxytocin and
request an epidural anesthetic for labor analgesia. Past medical history is significant for
having a miscarriage during a previous pregnancy. Until 2 weeks ago, she has been on
lovenox injections 30mg twice a day. Her laboratory data are within normal limits except
for a platelet count of 76.000mm-3 .

7. What are the concern when placing an epidural catheter if the platelet count is
low?

The concern when placing an epidural catheter in the face of a low platelet count
is that either the needle or the catheter will puncture a blood vessel and the blood will not
clot, leading to an epidural hematoma.

Sumber : CLINICAL CASES IN ANESTHESIA editor by Allan P. Reed, Francine S.

Yudkowitz.

8. Who is at risk for developing an epidural hematoma?

Anyone who receives a spinal or epidural anesthetic is at risk for developing an

epidural hematoma. Epidural hematoma is extremely rare and is generally associated with
patients who have disorders of hemostatis. A patient with a clinically active coagulopathy
or with a history of easy bruising or bleeding is considered to have an absolute
contraindication to regional anesthesia. However, many gray areas exist and this is
especially true in patient with thrombocytopenia.

Sumber : CLINICAL CASES IN ANESTHESIA editor by Allan P. Reed, Francine S.

Yudkowitz.
9. What is considered a low platelet count from the perspective of epidural catheter
placement and why is there controversy regarding choosing a lowest safe
platelet count?

An epidural hematoma is a catastrophic complication, which can lead to permanent

paralysis. It is, therefore, prudent to practice in a conservative manner and not place an
epidural anesthetic if the patient is at any risk of developing this complication. Cousins and
bromage recommended in 1988 that one should not perform an epidural anesthetic if the
platelet count is less than 100,000 mm-3. Recently, how-ever, this recommendation has been
widely disputed.

Thrombocytopenia is the most common hematologic disorder during pregnancy.

Choosing an absolute platelet count below which it is considered too dangerous to place a
neuraxial anesthetic may dictate the use of general anestehsia, a riskier technique in the
parturient. Hawkins et al. (1997) reviewed pregnancy-related deaths in the United States
between 1985 and 1990 and found that the fatality rate for a parturient administered general
anesthesia for cesarean section was 32 deaths per million and for neuraxial anestehsia was
only 2 death per million.

Refaining from administering a neuraxial anesthetic during the labor and delivery process
based on a laow platelet count commits the patient, at least, to a painful labor. It is possible
that later in the course of labor the woman may require a cesarean delivery, perhaps
emergently. The anestehsiologist in that situation may than be forced to administer an
anesthetic under less than optimal conditions.

10. What are the causes of thrombocytopenia during pregnancy?

Most cases (99%) of thrombocytopenia during pregnancy are related to one of

three causes: hypertensive disorders such as preeclampsia, gestational thrombocytopenia,
or idiopathic thrombocytopenia purpura (ITP). When evaluating the parturient with
thrombocytopenia there are two specific issues to consider. The first concern is whether
the disorder is static or dynamic. If the disorder is static, as occurs during gestational
thrombocytopenia or ITP, the platelet count is usually stable. If the disorder is dynamic,
as occurs during preeclampsia, the platelet count may change rapidly and it is important
to obtain serial platelet counts. The second issue is whether platelet function is normal or
abnormal. Platelet function is typically normal in gestational thrombocytopenia and ITP
and usually abnormal preeclampsia.

Sumber : CLINICAL CASES IN ANESTHESIA editor by Allan P. Reed, Francine S.

Yudkowitz.