Figeroa pih

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Figeroa pih

  1. 1. PREECLAMPSIA Reinaldo Figueroa, MD Winthrop-University Hospital
  2. 2. PREECLAMPSIA <ul><li>Hypertensive disorder specific to pregnancy </li></ul><ul><ul><li>affects nearly 6% of all pregnancies </li></ul></ul><ul><ul><li>a major cause of maternal and neonatal mortality and morbidity </li></ul></ul><ul><ul><li>15 to 20 % of maternal mortality in developed countries </li></ul></ul>
  3. 3. PREECLAMPSIA <ul><li>Severity ranges from: </li></ul><ul><ul><li>a mild disorder (transient hypertension in the later part of the pregnancy) to </li></ul></ul><ul><ul><li>a life-threatening disorder with seizures, HELLP syndrome, fetal hypoxia, and growth retardation </li></ul></ul><ul><li>more severe disease: 0.56 per 1000 deliveries </li></ul>
  4. 4. PREECLAMPSIA <ul><li>Predisposes women to other serious complications: </li></ul><ul><ul><li>placental abruption </li></ul></ul><ul><ul><li>acute renal failure </li></ul></ul><ul><ul><li>cerebral hemorrhage </li></ul></ul><ul><ul><li>disseminated intravascular coagulation </li></ul></ul><ul><ul><li>circulatory collapse </li></ul></ul>
  5. 5. PREECLAMPSIA <ul><li>The etiology is unknown </li></ul><ul><li>believed to be involved: </li></ul><ul><ul><li>immune maladaptation </li></ul></ul><ul><ul><li>placental ischemia </li></ul></ul><ul><ul><li>oxidative stress </li></ul></ul><ul><ul><li>genetic susceptibility </li></ul></ul>
  6. 6. PREECLAMPSIA <ul><li>Classification of hypertension in pregnancy </li></ul><ul><ul><li>Gestational hypertension </li></ul></ul><ul><ul><li>Preeclampsia / eclampsia </li></ul></ul><ul><ul><li>Chronic hypertension </li></ul></ul><ul><ul><li>Preeclampsia superimposed on chronic hypertension </li></ul></ul>
  7. 7. PREECLAMPSIA <ul><li>Definition of hypertension </li></ul><ul><ul><li>a systolic blood pressure of 140 mmHg or above, </li></ul></ul><ul><ul><li>or a diastolic blood pressure of 90mmHg or above, </li></ul></ul><ul><ul><li>on two occasions 6 hours apart </li></ul></ul><ul><li>Abnormal proteinuria </li></ul><ul><ul><li>the excretion of 300 mg or more of protein in 24 hours </li></ul></ul>
  8. 8. PREECLAMPSIA <ul><li>Criteria for severe preeclampsia </li></ul><ul><ul><li>Blood pressure: > 160 mmHg systolic or > 110 mm Hg diastolic </li></ul></ul><ul><ul><li>Proteinuria: > 5 g in 24 hours </li></ul></ul><ul><ul><li>Persistent and severe cerebral or visual disturbances (headache, scotoma, blurred vision) </li></ul></ul><ul><ul><li>Persistent and severe epigastric pain or right upper quadrant pain </li></ul></ul>
  9. 9. PREECLAMPSIA <ul><li>Criteria for severe preeclampsia </li></ul><ul><ul><li>Pulmonary edema or cyanosis </li></ul></ul><ul><ul><li>Oliguria (< 500 mL of urine in 24 hours) </li></ul></ul><ul><ul><li>Eclampsia (grand mal seizures) </li></ul></ul><ul><ul><li>HELLP syndrome </li></ul></ul>
  10. 10. PREECLAMPSIA <ul><li>Screening tests for gestational hypertension </li></ul><ul><ul><ul><li>routine components of antepartum care trimester </li></ul></ul></ul><ul><ul><ul><li>early detection of vasoconstriction </li></ul></ul></ul><ul><ul><ul><li>early detection of altered renal function </li></ul></ul></ul><ul><ul><ul><li>early detection of altered hemodynamics </li></ul></ul></ul><ul><ul><ul><li>detection of placental hypoperfusion / ischemia </li></ul></ul></ul><ul><ul><ul><li>detection of endothelial activation or injury </li></ul></ul></ul><ul><ul><ul><li>detection of an activated coagulation / fibrinolytic system </li></ul></ul></ul>
  11. 11. PREECLAMPSIA <ul><li>Prevention of preeclampsia </li></ul><ul><ul><ul><li>women at risk: multifetal gestation, vascular or renal disease, previous severe preeclampsia-eclampsia, abnormal uterine artery Doppler velocimetry </li></ul></ul></ul><ul><ul><ul><li>antihypertensive drugs </li></ul></ul></ul><ul><ul><ul><li>magnesium </li></ul></ul></ul><ul><ul><ul><li>zinc </li></ul></ul></ul><ul><ul><ul><li>fish oil </li></ul></ul></ul><ul><ul><ul><li>calcium </li></ul></ul></ul><ul><ul><ul><li>low-dose aspirin </li></ul></ul></ul>
  12. 12. PREECLAMPSIA <ul><li>Mild preeclampsia - management </li></ul><ul><ul><li>< 37 weeks gestation </li></ul></ul><ul><ul><ul><li>inpatient or outpatient management </li></ul></ul></ul><ul><ul><ul><li>worsening disease: delivery, magnesium sulfate </li></ul></ul></ul><ul><ul><li>> 40 weeks gestation </li></ul></ul><ul><ul><ul><li>delivery, magnesium sulfate </li></ul></ul></ul><ul><ul><li>37 - 39 weeks gestation </li></ul></ul><ul><ul><ul><li>inducible cervix: delivery, magnesium sulfate </li></ul></ul></ul><ul><ul><ul><li>cervix not inducible: inpatient or outpatient management </li></ul></ul></ul>
  13. 13. PREECLAMPSIA <ul><li>Severe preeclampsia - expectant management </li></ul><ul><ul><li>gestational age: not recommended for < 24 weeks or > 34 weeks gestation </li></ul></ul><ul><ul><li>hospitalization: tertiary care center </li></ul></ul><ul><ul><li>antenatal testing: daily </li></ul></ul>
  14. 14. PREECLAMPSIA <ul><li>Severe preeclampsia - guidelines for expedient delivery </li></ul><ul><ul><li>maternal indications </li></ul></ul><ul><ul><ul><li>eclampsia, thrombocytopenia, pulmonary edema, acute renal failure </li></ul></ul></ul><ul><ul><ul><li>persistent severe headache or visual changes </li></ul></ul></ul><ul><ul><ul><li>elevated liver enzymes with persistent severe epigastric pain or right upper quadrant tenderness </li></ul></ul></ul><ul><ul><ul><li>labor or rupture of membranes </li></ul></ul></ul><ul><ul><ul><li>vaginal bleeding, abruptio placenta </li></ul></ul></ul>
  15. 15. PREECLAMPSIA <ul><li>Severe preeclampsia - guidelines for expedient delivery </li></ul><ul><ul><li>fetal indications </li></ul></ul><ul><ul><ul><li>repetitive severe variables or late decelerations </li></ul></ul></ul><ul><ul><ul><li>biophysical profile < 4 on two occasions 4 hours apart </li></ul></ul></ul><ul><ul><ul><li>amniotic fluid index < 2 cm </li></ul></ul></ul><ul><ul><ul><li>intrauterine growth restriction </li></ul></ul></ul><ul><ul><ul><li>fetal death </li></ul></ul></ul><ul><ul><ul><li>> 34 weeks gestation </li></ul></ul></ul>
  16. 16. PREECLAMPSIA <ul><li>Severe preeclampsia - management protocol </li></ul><ul><ul><li>admission to labor and delivery for 24 hours </li></ul></ul><ul><ul><li>magnesium sulfate IV for 24 hours </li></ul></ul><ul><ul><li>antihypertensives if diastolic blood pressure > 110 mmHg </li></ul></ul><ul><ul><li>meet guidelines for expedited delivery? </li></ul></ul><ul><ul><ul><li>yes? delivery </li></ul></ul></ul>
  17. 17. PREECLAMPSIA <ul><li>Severe preeclampsia - management protocol </li></ul><ul><ul><li>Expedited delivery? no? </li></ul></ul><ul><ul><ul><li>< 23 weeks: counseling for termination of pregnancy </li></ul></ul></ul><ul><ul><ul><li>23-32 weeks: steroids, antihypertensive medications, daily maternal and fetal evaluation, delivery at 34 weeks </li></ul></ul></ul><ul><ul><ul><li>32-33 weeks: amniocentesis </li></ul></ul></ul><ul><ul><ul><ul><li>immature fluid - steroids, delivery in 48 hours </li></ul></ul></ul></ul>
  18. 18. PREECLAMPSIA <ul><li>HELLP syndrome - diagnosis </li></ul><ul><ul><li>10% before 27 weeks </li></ul></ul><ul><ul><li>20% after 37 weeks </li></ul></ul><ul><ul><li>70% between 27 and 37 weeks </li></ul></ul><ul><ul><li>slow initial phase with accelerated final phase versus secondary expression of sepsis, ARDS, renal failure </li></ul></ul>
  19. 19. PREECLAMPSIA <ul><li>HELLP syndrome </li></ul><ul><ul><li>parameters used to diagnose preeclampsia are not reflective of disease severity </li></ul></ul><ul><ul><li>target organ systems </li></ul></ul><ul><ul><ul><li>liver </li></ul></ul></ul><ul><ul><ul><li>brain </li></ul></ul></ul><ul><ul><ul><li>kidneys </li></ul></ul></ul><ul><ul><ul><li>coagulation system </li></ul></ul></ul><ul><ul><li>increased maternal and perinatal risk </li></ul></ul>
  20. 20. PREECLAMPSIA <ul><li>HELLP syndrome - diagnostic criteria </li></ul><ul><ul><li>hemolysis </li></ul></ul><ul><ul><ul><li>abnormal peripheral smear </li></ul></ul></ul><ul><ul><ul><li>lactate dehydrogenase > 600 U/L </li></ul></ul></ul><ul><ul><li>elevated liver enzymes </li></ul></ul><ul><ul><ul><li>serum aspartate aminotransferase > 70 U/L </li></ul></ul></ul><ul><ul><ul><li>lactate dehydrogenase > 600 U/L </li></ul></ul></ul><ul><ul><li>low platelets </li></ul></ul><ul><ul><ul><li>platelet count < 100,000/mm 3 </li></ul></ul></ul>
  21. 21. PREECLAMPSIA <ul><li>HELLP syndrome - differential diagnosis </li></ul><ul><ul><li>acute fatty liver of pregnancy </li></ul></ul><ul><ul><li>appendicitis </li></ul></ul><ul><ul><li>diabetes insipidus </li></ul></ul><ul><ul><li>gallbladder disease </li></ul></ul><ul><ul><li>gastroenteritis </li></ul></ul><ul><ul><li>glomerulonephritis </li></ul></ul><ul><ul><li>hemolytic uremic syndrome </li></ul></ul><ul><ul><li>hepatic encephalopathy </li></ul></ul>
  22. 22. PREECLAMPSIA <ul><li>HELLP syndrome - differential diagnosis </li></ul><ul><ul><li>idiopathic thrombocytopenia </li></ul></ul><ul><ul><li>kidney stones </li></ul></ul><ul><ul><li>pancreatitis </li></ul></ul><ul><ul><li>pyelonephritis </li></ul></ul><ul><ul><li>systemic lupus erythematosus </li></ul></ul><ul><ul><li>thrombotic thrombocytopenia purpura </li></ul></ul><ul><ul><li>viral hepatitis </li></ul></ul>
  23. 23. PREECLAMPSIA <ul><li>HELLP syndrome - antepartum management </li></ul><ul><ul><ul><li>assess and stabilize the maternal condition </li></ul></ul></ul><ul><ul><ul><li>correct coagulopathy if DIC is present </li></ul></ul></ul><ul><ul><ul><li>give intravenous magnesium sulfate to prevent seizures </li></ul></ul></ul><ul><ul><ul><li>provide treatment for severe hypertension to prevent stroke </li></ul></ul></ul><ul><ul><ul><li>transfer to tertiary center if appropriate </li></ul></ul></ul><ul><ul><ul><li>if subcapsular hematoma of liver, computed tomography or ultrasound of the abdomen </li></ul></ul></ul>
  24. 24. PREECLAMPSIA <ul><li>HELLP syndrome - antepartum management </li></ul><ul><ul><li>evaluate fetal well-being </li></ul></ul><ul><ul><ul><li>non stress test </li></ul></ul></ul><ul><ul><ul><li>biophysical profile </li></ul></ul></ul><ul><ul><li>timing of delivery </li></ul></ul><ul><ul><ul><li>if > 34 weeks gestation, deliver </li></ul></ul></ul><ul><ul><ul><li>if < 34 weeks gestation, administer corticosteroids, then deliver in 48 hours </li></ul></ul></ul>
  25. 25. PREECLAMPSIA <ul><li>HELLP syndrome - management for cesarean birth </li></ul><ul><ul><li>use general anesthesia if platelet count is < 75,000 / mm 3 </li></ul></ul><ul><ul><li>transfuse 5 to 10 units of platelets before surgery if platelet count is < 50,000 / mm 3 </li></ul></ul><ul><ul><li>leave vesicouterine peritoneum open </li></ul></ul><ul><ul><li>install subfascial drain </li></ul></ul>
  26. 26. PREECLAMPSIA <ul><li>HELLP syndrome - management for cesarean birth </li></ul><ul><ul><li>schedule secondary closure of skin incision or subcutaneous drain </li></ul></ul><ul><ul><li>administer postoperative transfusions as needed </li></ul></ul><ul><ul><li>perform intensive monitoring for at least 48 hours postpartum </li></ul></ul><ul><ul><li>consider dexamethasone (10 mg IV every 12 hours) until postpartum resolution of disease occurs </li></ul></ul>
  27. 27. PREECLAMPSIA <ul><li>HELLP syndrome - management of women with a subcapsular liver hematoma </li></ul><ul><ul><li>general considerations - blood bank aware for potential need of many units of blood </li></ul></ul><ul><ul><li>general or vascular surgeon consultation </li></ul></ul><ul><ul><li>avoid direct and indirect manipulation of liver </li></ul></ul><ul><ul><li>closely monitor hemodynamic status </li></ul></ul><ul><ul><li>management of hematoma depends on whether it is ruptured or not </li></ul></ul>
  28. 28. PREECLAMPSIA <ul><li>Eclampsia </li></ul><ul><ul><li>occurrence of convulsions or coma unrelated to other associated conditions </li></ul></ul><ul><ul><li>all new onset seizures during pregnancy - eclampsia until proven otherwise </li></ul></ul><ul><ul><li>incidence: 1 in 500 pregnancies </li></ul></ul><ul><ul><ul><li>3% in multiple gestations </li></ul></ul></ul>
  29. 29. PREECLAMPSIA <ul><li>Eclampsia </li></ul><ul><ul><li>precise cause unknown </li></ul></ul><ul><ul><li>theories </li></ul></ul><ul><ul><ul><li>vasospasm </li></ul></ul></ul><ul><ul><ul><li>ischemia </li></ul></ul></ul><ul><ul><ul><li>edema </li></ul></ul></ul><ul><ul><ul><li>multisystem organ failure </li></ul></ul></ul>
  30. 30. PREECLAMPSIA <ul><li>Eclampsia </li></ul><ul><ul><li>seizures usually occur without aura </li></ul></ul><ul><ul><li>hypertension not severe in 20% </li></ul></ul><ul><ul><li>edema absent in 30% </li></ul></ul><ul><ul><li>proteinuria absent in 20% </li></ul></ul><ul><ul><li>hyperreflexia is not predictive of seizure </li></ul></ul><ul><ul><li>headache or visual changes - most common precipitating event </li></ul></ul>
  31. 31. PREECLAMPSIA <ul><li>Eclampsia </li></ul><ul><ul><li>80% of convulsions occur before or during the delivery </li></ul></ul><ul><ul><li>1/3 of cases may be not preventable </li></ul></ul><ul><ul><li>atypical </li></ul></ul><ul><ul><ul><li>less than 20 weeks gestation </li></ul></ul></ul><ul><ul><ul><li>more than 48 hours postpartum </li></ul></ul></ul>
  32. 32. PREECLAMPSIA <ul><li>Eclampsia - risk factors </li></ul><ul><ul><li>low socioeconomic status </li></ul></ul><ul><ul><li>extremes in childbearing age </li></ul></ul><ul><ul><li>African-American </li></ul></ul><ul><ul><li>no prenatal care </li></ul></ul><ul><ul><li>substance abuse </li></ul></ul>
  33. 33. PREECLAMPSIA <ul><li>Eclampsia - management </li></ul><ul><ul><li>control convulsions </li></ul></ul><ul><ul><li>correction of hypoxia and acidosis </li></ul></ul><ul><ul><li>blood pressure control </li></ul></ul><ul><ul><li>delivery after maternal stabilization </li></ul></ul>
  34. 34. PREECLAMPSIA <ul><li>Eclampsia - anticonvulsant therapy </li></ul><ul><ul><li>magnesium sulfate </li></ul></ul><ul><ul><ul><li>mechanism of action - smooth muscle relaxation by displacement of calcium </li></ul></ul></ul><ul><ul><ul><li>dosage - 4-6 g intravenous loading dose, followed by 2 g per hour </li></ul></ul></ul><ul><ul><ul><li>may be given intramuscularly </li></ul></ul></ul>
  35. 35. PREECLAMPSIA <ul><li>Eclampsia - magnesium sulfate </li></ul><ul><ul><li>side effects: </li></ul></ul><ul><ul><ul><li>maternal hypotonia </li></ul></ul></ul><ul><ul><ul><li>respiratory depression </li></ul></ul></ul><ul><ul><ul><li>cardiac arrest </li></ul></ul></ul><ul><ul><ul><li>neonatal depression </li></ul></ul></ul><ul><ul><li>contraindicated in myasthenia gravis </li></ul></ul><ul><ul><li>use with caution in renal insufficiency </li></ul></ul>
  36. 36. PREECLAMPSIA <ul><li>Eclampsia - anticonvulsant therapy </li></ul><ul><ul><li>phenytoin </li></ul></ul><ul><ul><ul><li>used extensively in Europe </li></ul></ul></ul><ul><ul><ul><li>may be used in myasthenia gravis </li></ul></ul></ul><ul><ul><ul><li>mechanism of action - may increase gamma aminobutyric acid-mediated chloride conduction in postsynaptic membranes </li></ul></ul></ul><ul><ul><ul><li>may inhibit neurotransmitter inhibitory systems </li></ul></ul></ul>
  37. 37. PREECLAMPSIA <ul><li>Eclampsia - phenytoin </li></ul><ul><ul><li>dosage - 1 g loading dose over 1 hour </li></ul></ul><ul><ul><li>cardiac monitoring during administration </li></ul></ul><ul><ul><li>side effects </li></ul></ul><ul><ul><ul><li>arrhythmias with rapid administration </li></ul></ul></ul><ul><ul><ul><li>hepatitis </li></ul></ul></ul><ul><ul><ul><li>Steven-Johnson syndrome </li></ul></ul></ul>
  38. 38. PREECLAMPSIA <ul><li>Eclampsia - anticonvulsant therapy </li></ul><ul><ul><li>diazepam </li></ul></ul><ul><ul><ul><li>useful for status seizures </li></ul></ul></ul><ul><ul><ul><li>mechanism of action - facilitate the binding of GABA to its receptor </li></ul></ul></ul><ul><ul><ul><ul><li>benzodiazepine receptors </li></ul></ul></ul></ul><ul><ul><ul><li>dosage - 10 mg at a rate of 5 mg per min </li></ul></ul></ul><ul><ul><ul><li>may be repeated at 10 to 15 minute intervals </li></ul></ul></ul>
  39. 39. PREECLAMPSIA <ul><li>Eclampsia - diazepam </li></ul><ul><ul><li>side effects - loss of consciousness, hypotension, respiratory depression </li></ul></ul><ul><ul><li>caution - may increase risk of aspiration </li></ul></ul><ul><ul><li>causes prolonged depression of the neonate </li></ul></ul><ul><li>sodium thiopentotal </li></ul><ul><ul><li>long acting barbiturate </li></ul></ul><ul><ul><li>used when sedation, paralysis and intubation needed </li></ul></ul>
  40. 40. PREECLAMPSIA <ul><li>Eclampsia - which anticonvulsant to use? </li></ul><ul><ul><li>magnesium is associated with decreased recurrence risks of seizures when compared with diazepam or phenytoin </li></ul></ul><ul><ul><li>diazepam is associated with increased need for mechanical ventilation </li></ul></ul>
  41. 41. PREECLAMPSIA <ul><li>Eclampsia - management of fetus </li></ul><ul><ul><li>fetal bradycardia during seizure </li></ul></ul><ul><ul><ul><li>~ 5 minutes after the onset of the seizure </li></ul></ul></ul><ul><ul><ul><li>may be associated with rebound tachycardia </li></ul></ul></ul><ul><ul><ul><li>recovery phase may show late decelerations </li></ul></ul></ul><ul><ul><li>monitor for uterine hypertonicity </li></ul></ul><ul><ul><ul><li>allow for fetal recovery </li></ul></ul></ul><ul><ul><ul><li>monitor for signs of abruption </li></ul></ul></ul>
  42. 42. PREECLAMPSIA <ul><li>Eclampsia </li></ul><ul><ul><li>delivery is indicated regardless of gestational age </li></ul></ul><ul><ul><li>immediate cesarean delivery is not necessary </li></ul></ul>
  43. 43. PREECLAMPSIA <ul><li>Eclampsia - radiographic evaluation </li></ul><ul><ul><li>should be reserved for women with neurological deficit, recurrent seizures, or atypical presentation </li></ul></ul><ul><ul><li>abnormal CT findings - 50% </li></ul></ul><ul><ul><ul><li>edema, hemorrhage, infarction </li></ul></ul></ul><ul><ul><li>cerebral angiography has limited use </li></ul></ul><ul><ul><li>90% of EEG evaluations may be abnormal </li></ul></ul>
  44. 44. PREECLAMPSIA <ul><li>Eclampsia - management </li></ul><ul><ul><ul><li>allow patient to have seizure </li></ul></ul></ul><ul><ul><ul><li>use bite block as needed to prevent maternal injury </li></ul></ul></ul><ul><ul><ul><li>establish airway </li></ul></ul></ul><ul><ul><ul><li>administer magnesium sulfate as soon as possible </li></ul></ul></ul><ul><ul><ul><li>obtain arterial blood gases </li></ul></ul></ul><ul><ul><ul><li>monitor urine output </li></ul></ul></ul><ul><ul><ul><li>control hypertension </li></ul></ul></ul>
  45. 45. PREECLAMPSIA <ul><li>Eclampsia - management </li></ul><ul><ul><li>rebolus with magnesium sulfate if repeat seizure occurs </li></ul></ul><ul><ul><li>do not intervene for fetal status while mother is unstable </li></ul></ul><ul><ul><li>if seizure continues, paralyze and intubate. </li></ul></ul>
  46. 46. PREECLAMPSIA <ul><li>Counseling regarding future pregnancies - HELLP syndrome </li></ul><ul><ul><li>information available varies </li></ul></ul><ul><ul><li>recurrent risk of preeclampsia: 43% (19%) </li></ul></ul><ul><ul><li>recurrent risk of HELLP syndrome: 19-27% (3%) </li></ul></ul><ul><ul><li>If HELLP syndrome < 32 weeks </li></ul></ul><ul><ul><ul><li>recurrent risk of preeclampsia / eclampsia is 61% </li></ul></ul></ul>
  47. 47. THANK YOU <ul><li>Sibai BM. Hypertensive disorders in women. 2001. </li></ul><ul><li>Witlin AG, Sibai BM. Magnesium sulfate therapy in preeclampsia and eclampsia. Obstet Gynecol 1998;92:883-9. </li></ul><ul><li>Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol 2003;102:181-92. </li></ul><ul><li>Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol 2005;105:402-10. </li></ul>

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