Preeclampsia

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Overview of Pre-eclampsia

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  • Progesterone vasodilation  decreased systemic vascular resistance  decreased BP
  • HTN in pregnancy: BP>=140/90 2x 6/24 apart > 20/52PIH: develops due to pregnancy, regresses postpartumPaggrevatedH: underlying HTN worsened by pregnncy
  • Proteinura: >300mg protein in urine
  • Mucosal alloimmunizationCellular cascade & molecular events resemble classical inflammatory responseNo immune tolerance  no placentation
  • Biochem: LDH raised  heamolysisLFT: AST >75 iu/l  liver damageUS: Abdominal Circ (Asymmetrical IUGR)Uri c Acid: increases mortality
  • RCOG: 1g/h MgSO4; recurrent increase to 2Goal of severe preeclampsia: prevent eclampsia, control bp, dliverLabetalol: iv/po. B and a blockade. Hydralizine: VasodilatorPlacental antigens increase in labor and delivery  increased risk postpartum seizuresAspirin: 25% recurrent. Prevents it. 70% if CHTN. Prior and during new pregnancy
  • Preeclampsia

    1. 1. Androu Waheeb
    2. 2. Blood Pressure in normalpregnancy 6/52: 5-10 (sbp) /10-15 (dbp) mmHg 26/52: nadir after 26/52:  Less than pre-pregnancy
    3. 3. Hypertension in Pregnancy Hypertension in Pregnancy >140 or 90 mmHg 2 consecutive times 6 hours apart Pregnant patient Pregnancy Induced Chronic Hypertension Hypertension >20/52 <20/52 Gestational Preeclampsia Eclampsia Hypertension -ve protrinuria + proteinuria (≥300mg/24 or 1+) + unexplained grand mal seizures +/- nondependant edema (face & hands)
    4. 4. Preeclampsia - Definition Presence of Hypertension • SBP ≥ 140 or DBP ≥ 90 • 2 readings 6 hours apart • > 20/52 gestation Proteinuria • ≥ 1+ Urine dipstick (not sensitive) • ≥ 300 mg / 24 Nondependent Edema • Hand • Face • Not sensitive or specific
    5. 5. Preeclampsia – Incidence3025 2000 (per 1000 F)20 1994 (per 1000 F)15 1987 to 2004 (PE:MM per10 100,000 births) 5 2008 (MMR per 100,000 births)0 UK US South Saudi Bahrain World (EURO (AMRO Africa Arabia A) A) (AFRO E)
    6. 6. Preeclampsia – Cause of Death(2006)
    7. 7. Preeclampsia - Pathophysiology Systemic Inflammatory Response  Endothelial Activation  Maternal symptoms  Generalized transudative edema   intravascular depletion   symptoms of ischemia, necrosis, hemorrhage  Vascular damage   imbalance of prostacyclin (VD) & thromboxane (VC)  Generalized arteriolar Constriction (Vasospasm)
    8. 8. Preeclampsia – Pathology (1) Vascular Theory  Poorly perfused placenta  Abnormal placentation  Maternal microvascular disease  ‘Relative’: due to hyperplacentosis   placental ischemia   release of factors by placenta   cascade   damage maternal vascular endothelium
    9. 9. Preeclampsia – Pathology (2) Alloimmune Theory  Sperm exposure   mucous alloimmunization   cascade (≈ classical inflammatory response)   inhibition of placentation
    10. 10. Preeclampsia – Risk Factors • Nulliparous • Chronic HTN • African American • Previous preeclampsia • Chronic Renal Disease • Obesity • Multiple Gestation • Collagen Vascular • 35 < Age < 20 • Abnormal Disease • New paternity Placentation • Pregestational DM • Cohabiliation < 1 year Immunogenic Disease Maternal Related Related Related • Relatives • Mother-in-Law Family History
    11. 11. Preeclampsia - Complications Maternal Fetal CNS • Seizures Preterm Delivery • Cerebral Edema • Cerebral Hemorrhage • Strokes (thrombosis) Hepatic Stillbirth (IUFD) • Hepatic Failure Intrapartum Fetal Distress • Hepatic Rupture • Subcapsular Hemorrhage Heamatological • DIC Placental Abruption • HELLP Renal Uteroplacental Insufficency • Renal Failure • Hypoxic Neurological Injury • Oliguria • Proteinuria >> Hypoproteinemia (Glomerular Injury) • IUGR • Oligohydraminos Lungs • Pulmonary Edema
    12. 12. Preeclampsia - ClassificationMild Severe Maternal Criteria Fetal Criteria Oligohyd Abnormal Clincal Criteria Labs IUGR -raminos Doppler RUQ Oligo- Protein- Pulmonary HTN NS Edema Pain uria uria HELLP (≤500ml) (≥5mg) Hyperreflexia Headache Disturbances Visual SBP ≥ 160 DBP ≥110
    13. 13. Preeclampsia - Diagnosis Upon antenatal visits  First visit  Identify risk (Hx, PEx)  BP + Urine protein test  Following visits  28/52 : Monthly BP + Urine protein test  After 28/52 : More frequent BP + Urine protein tests  2nd trimester : Uterine Artery Doppler (not sensitive)
    14. 14. Preeclampsia - Management • Fetal: 2qw • Close monitoring • CTG • USAdmission required Severity • US Doppler: Umbilical + Cerebral Assessment • Liquor Assessment • Bloods IV Line • Infusions Stabilize Patient • Monitoring urine • Fluid Restriction (80ml/h) output and ease of • Decision based on severity + Urinary gestational age Catheter 24h urine collection Therapy • Mother is concern • Maternal • PEx • BP :15m, 30, 4qh • 24/24 Urinary Collection • Decision on date required Severity • 2qw: FBC, Coag. DeliveryAssessment Profile, LFT, serum(Cr), Uric Acid
    15. 15. Preeclampsia – Treatment Curative Therapy: Delivery  Balance maternal and fetal status Severe Follow-UpMild Preeclampsia Seizure Preeclampsia (44% PP  1/12)•Expectant • Admission • A,B,C • Reassess.•Admission • MgSO4 • Ox Stat Discharge when•Betamethasone • Intrapartum • Oxygen stable  6/52•MgSo4 4g.2g/h • Postpartum • MgSO4 4g.2g/h • MgSO4 1d•RCOG: 1g/h 24h postpartum/post • 2g bolus last seizure • IV Labetalol / IV • Left Lateral Hydralizine / • PO Labetalol / Position Nifedipine PO Methyldopa / • Prepare for Nifedipine: • Decide on delivery CHTN delivery • Low dose Aspirin / LMWH • Monitor HELLP (LP: corticosteroids)
    16. 16. Preeclampsia – Therapy (2) MgSO4  Antihypertensive  Monitor  Monitor  Ox Stat  BP  Respiratory Rate  ≥ 130/80  Replace Ca Gluconate 1g  Only improves morbidity infusion  Deep tendon reflexes  Urine Output  Aspirin  Halt if less than 20 ml/h  Inhibits thromboxane A2  Recurrent Seizures synthesis  MgSO4: 2g bolus (RCOG:   re-altering increase infusion to 2g/h) TXA2/Prostacyclin balance
    17. 17. Preeclampsia – Delivery Indications Mild Preeclampsia  Severe Preeclampsia  Expectant (Betamethasone +  Expectant MgSO4)  Stable  GA 24-32/52  Deliver  Preterm  GA > 32/52  Deliver  Patient presenting with  Uncontrollable BP  Term  Symptoms  Unstable preterm  Headache, RUQ, Visual  Hyperreflexia  Fetal compromise  Complications  GR/OH/abnormal  HELLP or LP  Renal Failure Umbilical Doppler  Hepatic InjuryInduced delivery  Pulmonary Edema(PG, Oxytocin, Amniotomy) unless  DICobstetric indication
    18. 18. Androu Waheeb

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