A cura di Herbert Valensise. La gravidanza è un periodo molto bello della vita di una donna, ma non sempre le cose procedono senza problemi. Alcuni di questi sono particolarmente importanti e possono mettere a rischio la salute della mamma e del bambino. La Preeclampsia, che si manifesta con un aumento della pressione arteriosa e con la perdita di proteine nelle urine, ha un decorso rapidamente ingravescente, talora fulminante, e può danneggiare molti organi materni tra cui cervello, fegato, rene, cuore e sistema circolatorio. Spesso si accompagna a una grave alterazione del sistema della coagulazione, con seri rischi sia emorragici che trombotici. In più compromette quasi inevitabilmente la funzione della placenta e quindi la crescita ed il benessere del feto. Soprattutto nei casi ad esordio in epoche precoci della gravidanza, i danni feto-neonatali comportano disabilità permanenti a causa della prematurità. È importante pertanto la diagnosi precoce unitamente alla sorveglianza clinica mirata a cogliere precocemente i segni di eventuali complicazioni, al fine di programmare il parto nel momento più opportuno sia per la madre che per il bambino. Su queste basi questo corso, a più voci di Specialisti scelti in base al loro specifico expertise, si pone l'obiettivo di un aggiornamento del trattamento dell'Ipertensione in gravidanza sulle più recenti linee guida della International Society for the Study of Hypertension in Pregnancy ISSHP per il miglioramento dei sistemi di valutazione e di misurazione dell'efficienza e appropriatezza delle prestazioni nei livelli di assistenza.

1. PROF HERBERT VALENSISE
Department of Obstetrics and Gynecology
University of Rome Tor Vergata
Director of the Division of Obstetrics and Gynecology
Policlinico Casilino Hospital
Emodinamica materna e terapia
Una finestra verso il futuro

2. endothelium damage
hematological changes
humoral factors
IUGR
preterm delivery
abruptio placentaeproteinuria
decreased GFR
Glomerulo capillary endotheliosis
renal failure
decreased plasma volume
increased SVR
increased PA
decreased CVP
hypertensive encephalopathy
ischemia and vasospasm
hemorrhage
edema
eclampsia
leaky capillaries
pulmonary edema
ARDS
alterated liver function test
subcapsular hemorrhage
fibrin deposition
HELLP
multisystem changes in pre-eclampsia

3. TAKE HOME A MESSAGE
Blood Pressure alone
is not sufficient to choose a
medical treatment in
Hypertensive Disorders of
Pregnancy

4. BP: 150/95
NO COMPLICATIONS
PE
FGR
With the same blood pressure
we can have an uneventful
or complicated pregnancy

5. Comparison of less tight control (DBP 100-104) with
tight control (DBP 81-85) in Hypertension during
pregnancy(CH=74.6%; GH=25.4%
What’s the difference?
Magee et al.
IF WE LOOK ONLY AT THE RADIATOR………..

9. ➤ 50% of the patients were obese (hemodynamics
in an obese pt might be different vs lean pt
given the same BP)
➤ 75% were CH (apple and peers)
➤ non significant reduction of severe
complications (i.e HELLP Syndrome) might be
due to low numbers
➤ The starting point to choose a treatment cannot
be the BP level

10. Is maternal cardiac
function
different in hypertensive
pregnant patients that
will and will not develop
clinical complications?

11. 111
144 145
62
83 85
0
20
40
60
80
100
120
140
160
SBP DBP
Controls Uncomplicated EMGH Complicated EMGH
949
1138
1754
0
200
400
600
800
1000
1200
1400
1600
1800
TVR
Blood Pressure levels and TVR in
uncomplicated and complicated early mild
gestational hypertension
*P<0.05 vs controls; °P<0.05 vs. uncomplicated EMGH
* *
*
° *
* *
Valensise et al, BJOG 2006

12. 00:38
00:41
00:46
00:00
00:07
00:14
00:21
00:28
00:36
00:43
00:50
RWT
Controls Uncomplicated EMGH Complicated EMGH
Relative wall thickness of the left ventricle
(geometric pattern)
*P<0.05 vs controls; °P<0.05 vs. uncomplicated EMGH
*
° *
RWT>0.45
Concentric
geometry of the
left ventricle
Valensise et al, BJOG 2006

13. 0%
20%
40%
60%
80%
100%
0% 50% 100%
1-Specificity
Sensitivity
SBP
DBP
MBP
ROC CURVE for Blood Pressure Values

14. ROC CURVE Relative Wall Thickness Cut off 0.45
Valensise et al, BJOG 2006

15. ROC CURVE Total Vascular Resistance
Cut off 1340 dyn.s.cm-5
Valensise et al, BJOG 2006

16. Proposal for a clinical
classification of Gestational
Hypertension
➤High risk Gestational
Hypertension
➤TVR>1340 dyne•sec•cm-5
➤ Concentric left ventricular geometry
➤Low risk Gestational
Hypertension
➤TVR<1340 dyne•sec•cm-5
➤ Non concentric left ventricular geometry
Valensise et al.
BJOG 2006

17. PUMP Radiator

18. take into account
maternal
hemodynamic
HOW DO WE OVERCOME
THESE PROBLEMS?

19. WE LOOKED AT THE RADIATOR
AND AT THE PUMP

20. 400 MGH pts (20-27 weeks)
Maternal Echocardiography
(TVR>1350 dyn)
100 nifedipine
(A)
100
nifedipine+NO (B)
100 Nifedipine+fluid
therapy*+NO (D)
Patient Selection:
100 nifedipine+fluid
therapy* (C)
Case Control
study
* 2.5-3 L per os

22. Cardiac Output
Stroke Volume
Blood Pressure
Preload Inotropy Afterload
Hb SpO2
Oxygen Delivery – DO2
Heart Rate
SVR

23. Cardiac Output
Stroke Volume
Blood Pressure
Preload Inotropy Afterload
Hb SpO2
Oxygen Delivery – DO2
Heart Rate
SVR

24. 1° STEP:
-SVV (stroke volume
variation):
-11% (vn >12%)
- FTc (Flow time corrected):
- 390 (vn 350-425)
- SV (Stroke Volume):
-78 (vn 75-90)
- CO (Cardiac Output):
-4,1 (vn >5.8)
LOW PRELOAD
LOW STROKE
VOLUME
LOW CARDIAC
OUTPUT

25. Cardiac Output
Stroke Volume
Blood Pressure
Inotropy Afterload
Hb SpO2
Oxygen Delivery – DO2
Heart Rate
SVR
Preload

27. 2° STEP:
-INO (Inotropia):
-1,6 (vn 1.6-2.2)
- VpK (Velocity
Peak)
-: 1,1 (vn 0.9-1.4)
REDUCED
CONTRACTILITY

28. Cardiac Output
Stroke Volume
Blood Pressure
Inotropy Afterload
Hb SpO2
Oxygen Delivery – DO2
Heart Rate
SVR
CASO CLINICO PREECLAMPSIA
Preload

30. 3° STEP:
-TVR (Total vascular
resistance):
2033 (vn <1200)
- MD (Minute distance):
17 (vn 14-25)
INCREASED
AFTERLOAD

31. Cardiac Output
Stroke Volume
Blood Pressure
Inotropy
Hb SpO2
Oxygen Delivery – DO2
Heart Rate
SVR
Preload
Afterload

32. An experienced plummer is needed!!

34. TREATMENT OF HYPERTENSION AND
PREECLAMPSIA
➤ TAKE CARE OF THE HEART RATE
(CALCIUM ANTAGONIST MIGHT
INCREASE THE HEART RATE
LOWERING THE CARDIAC OUTPUT)
➤ (LABETALOL MIGHT REDUCE THE
HEART RATE REDUCING
PLACENTAL PERFUSION)

35. TREATMENT OF HYPERTENSION AND
PREECLAMPSIA
➤ TAKE CARE OF THE CARDIAC
OUTPUT (IF YOU DECREASE THE
TVR YOU MUST INCREASE THE
PLASMA VOLUME)
➤ TAKE CARE OF THE INOTROPIC
INDEX (YOU MIGHT BE ALREADY
BEYOND THE HEART CAPACITY TO
CONTRACT)

37. SMII = 1.1 W/m2 What is the LVEDV?
Stroke
Volume
Left ventricular end diastolic volume
LVEDV
SV

38. CConclusions and Perspective
Look at the treatment from a different point of view.
Up to now the questions where:
1.How is blood pressure?
2.How much do I have to lower it (no matter what drug I use)?
NOW the questions are?
-How is heart rate?
-How is stroke volume?
-How is blood pressure?
-How can I modify these three paramters armonically?
THE DRUG MATTERS!