Seminar Evidence Based Obstetric & Gynecology POGI Cabang Surabaya 17 Juli 2016 - Pullman Hotel Surabaya

1. Evidence Based Management
Preeclampsia/ eclampsia
Dr. Ernawati, dr., SpOG (K)
Dept./ SMF Obstetri Ginekologi RSU Dr. Soetomo
Fakultas Kedokteran Universitas Airlangga Surabaya
2016

2. Preeclampsia
–
clinical
defini0on
• a multisystem disorder
• usually first detected by hypertension
• proteinuria common but not essential for a
clinical diagnosis of pre-eclampsia in the
presence of other organ involvement,
(including feto-placental unit)

3. Preeclampsia: Diagnosis
de novo hypertension after 20 weeks
and new onset of one or more of :
proteinuria or end organ disfunction
• renal insufficiency
• liver disease
• neurological problems
• haematological changes
• pulmonary oedema
• IUGR ACOG, 2013; ISSHP, 2014

4. Criteria Diagnosis

5. Classification
• Severe
Preeclampsia
–
lack
of
consensus
• BP
criteria:
blood
pressure
>
160/110
mmHg
• No
consensus
on
degree
of
proteinuria
• Sign/
symptom
end
organ
injury
• HELLP
=
severe
preeclampsia
• Early-­‐Onset
Preeclampsia
=
<
34
weeks

6. Other
maternal
organ
dysfunc4on:
•
renal
insufficiency
(crea4nine
>
1,1
mg/dL
)
•
liver
involvement
(elevated
transaminases
±
right
upper
quadrant
or
epigastric
abdominal
pain)
•
neurological
complica4ons
(examples
include
eclampsia,
altered
mental
status,
blindness,
stroke,
or
more
commonly
hyperreflexia
when
accompanied
by
clonus,
severe
headaches
when
accompanied
by
hyperreflexia,
persistent
visual
scotomata)
•
haematological
complica4ons
(thrombocytopenia,
DIC,
hemolysis)
Uteroplacental
dysfunc4on
-­‐
fetal
growth
restric4on

7. • The definitive treatment is
delivery
• Timing of delivery is based
upon gestational age, the
severity of preeclampsia, and
maternal and fetal condition
• PE < 34 W, maternal/
fetal stable, prolonged
antepartum management
in a tertiary care setting or
in consultation with a MFM
Specialist is an option
Delivery minimize serious
maternal & fetal complication
eg pulmonary edema, seizure,
cerebral hemorraghe,
Severe PE does not mandate
immediate Cesarean birth
Cervical rippening agent can be
used if Cx unfavorable, but avoid
prolonged induction
Cesarean delivery reasonable for
PE/E under 32 W with
unfavorable Cx (given high freq
intermediate FHR tracing & Cx
failure to dilate
PE with feature of severe disease

8. • Recommend delivery at ≥ 37 W, even in absent of feature of severe
disease
• Cervical rippening should be used in unfavorable cx
• HYPITAT trial : 756 women with Mild PE / gestational HT :
ü Routine induction reduce maternal adverse outcome (Red risk:
12,76%), lower rate of CS. No differences on neonatal outcome)
ü Less costly overal than expectant management
PE without feature of severe disease

14. • Women with preterm < 37 W, manage expectantly without anti-
hypertensive theraphy.
• Inpatient versus outpatient care
• A systematic review of 3 trials with a total of 504 women with various
complications of pregnancy observed no major differences in clinical
outcomes for mothers or babies between antenatal day units or
hospital admission
• Outpatient care can be provided in the patient’s home or, where
available, at an antenatal day care unit
Expectant management of PE without feature of
severe disease

15. Outpatient monitoring
• Frequent maternal & fetal evaluation ( every 1-3 days)
• Restricted activity
• Rest in left lateral decubitus potition
• Monitor Fetal movement every day
• Laboratory follow up : platelet count, creatinin serum, liver enzyme,
repeated weekly
Expectant management of PE without feature of
severe disease

16. Treatment of Hypertension
• BP should be assessed 2x/ weeks
• No antihypertensif agent
Assessment of fetal weelbeing
• Twice weekly NST
Assessement fetal wellbeing : USG every 3 weeks
Antenatal corticosteroids to promote fetal lung maturity should be administered
to women <34 W since they are at increased risk of progression to severe
disease and preterm delivery (grade 1A)
Expectant management of PE without feature of
severe disease

17. Intrapartum management:
• Fluids à should monitored closely, avoid excssive administration
• Hypertension à severe HT : oral nifedipin or Labetalol IV or
hidralazin
• Trombocytopenia : platelets transf in case excessive bleeding
• Glucocorticoid therapy does not appear to be effective for
significantly raising the platelet count in women with PE
Management of PE

18. • Intrapartum and postpartum seizure prophylaxis for severe PE
(Grade 1A )
• MgSo4 as a first-line agent for seizure prophylaxis in preeclampsia
(Grade 1A ).
• Intrapartum and postpartum MgSo4 prophylaxis for women without
severe HT or PE (Grade 2B )
• RCT including 10,000 women (MAGPIE) [magnesium sulfate for
prevention of eclampsia trial]), about 100 px mild PE & about 60 px
severe PE would need to be treated to prevent one seizure (Altman
D, 2002)
Seizure Prophylaxis

20. 1687 women with eclampsia recruited into an international multicentre randomised trial
comparing standard anticonvulsant regimens; 1680 (99.6%) women: 453 allocated
magnesium sulphate versus 452 allocated diazepam, and 388 allocated magnesium
sulphate versus 387 allocated phenytoin.
Magnesium sulphate - 52% lower risk of recurrent convulsions (95% CI 64% to 37%
reduction) than those allocated diazepam . Maternal mortality was non-significantly lower
among women allocated magnesium sulphate.
Women allocated magnesium sulphate had a 67% lower risk of recurrent convulsions
(95% CI 79% to 47% reduction) than those allocated phenytoin
There is now compelling evidence in favour of magnesium sulphate, rather than
diazepam or phenytoin, for the treatment of eclampsia.

23. Seizure Prophylaxis :
• Magnesium regimen and monitoring — There is no consensus on
the optimal magnesium regimen, when it should be started and
terminated, or route of administration
• Usually initiated at the onset of labor or induction, or prior to a
cesarean delivery
• Dosing —Vary widely (loading dose of 4 to 6 grams IV (15-20 mnt) &
(maintenance dose of 1 to 3 grams per hour, should be adjusted in
women with renal insufficiency)
• Duration of therapy —Usually continued for 24 hours postpartum
Management of PE

24. STABILISATION OF ECLAMPSIA
• airway free / intubation, MET team
• magnesium sulfate
• antihypertensive medication
• no emercency C section
Prevention
• magnesium sulfate

25. Postpartum Management
• There are no evidence-based standards for the optimal approach to
postpartum monitoring and follow-up
• Repeat laboratory tests until two consecutive sets of data are normal
• Severe hypertension should be treated; some patients will have to
be discharged on antihypertensive which are discontinued when
blood pressure returns to normal
• ACOG suggests monitoring BP in hospital or at home for the first 72
hours postpartum and again 7 to 10 days post-delivery
Management of PE

26. • MgSo4 should be administered to those at increased risk of
developing seizures : (Women with new onset hypertension and
headache or blurred vision, or Women with severe hypertension)
• Antihypertensive therapy should be initiated if BP ≥ 160/110 mmHg
Postpartum Onset of PE

28. Conclusions Magee et al 2009 review
• Expectant
care
of
severe
preeclampsia
<34
wk
associated
with
pregnancy
prolonga4on
of
7-­‐14
d
and
few
serious
maternal
complica4ons
(<5%),
similar
to
interven4onist
care
• Complica4on
rates
higher
with
HELLP
<34wk
and
severe
preeclampsia
<28wk,
BUT
similar
to
interven4onist
care

33. Maternal Outcomes PL (n=22) MP (n=22) P
Admission delivery interval
(days) 13.86 ± 7,7 13,76 ± 7,9 0,848
Gestational age at delivery
(days) 238.77 ± 8.9 237.54 ± 12.97 0,485
Vaginal birth 4 5
Cesarean delivery overall (n)
- For fetal reason 6 2
- For maternal reason 12 14
- Systolic BP at birth 164.4 166.95 0,714
- Diastolic BP at birth 102.35 103.409 0,945
Antihypertensive drugs (n)
- Oral Nifedipine 11 5
- Oral Nifedipine + Methyl
Dopa 11 17
Nicardipine IV 1 2
Albumin transfusion (n) 6 9
Complications during study (n) 4 5
- HELLP 2 2
- Eclampsia 0 0
- Placental abruption 0 0
- DIC 0 0
- Sepsis 0 0
- Lung edema 1 0
- Acute kidney injury 0 0
- Multiple complications 1 3
Maternal death 0 0
Post-partum stay (days) 3,96 ± 2,1 6,38 ± 6,03 0,083
!
Overall
maternal
outcomes

34. Overall
Neonatal
Outcomes
Table 5.23 Neonatal outcomes :
Neonatal Outcomes PL (n=22) MP (n=22)
GA at delivery (days) 238.77 ± 8.9 237.54 ± 12.97 0,509
1 min Apgar score < 7 9 10
5 min Apgar score < 7 5 8
Birth weight (g) 1954,17 ± 617,84 1924,09 ± 558,45 0,592
IUGR (n) 4 4 0,819
Perinatal death / infant death (n) 3/0 5/0
RDS gr I-II (n) 3 3
RDS gr III-IV (n) 3 2
IVH gr I-II (n) 0 0
IVH gr III-IV (n) 0 0
Sepsis (n) 0 1
Mechanical ventilation (n) 4 4
Duration of NICU admission
(days) 6.53 6.71
Congenital anomaly (n) 1 0
Long term neonatal follow up at
6
th
month
HC -2 SD (n) 3 3
Abnormal DDST (n) 2 0
!

40. Gestational based approach to
Preeclampsia with severe features
< 24 weeks
• Termination of pregnancy
to reduce maternal risk of
life- treathening morbidity
• Birth of infant with severe
permanent disability
25-34 weeks
• Offer expectant
management to
appropriately selected
woman
• 25-28 weeks : ( decision
making process are
complex & individualized
management)
• ≥ 28 weeks : better
maternal & fetal
outcomes
> 34 weeks
• Deliver all woman with
preeclampsia severe
fetures

43. SIBAI, 2011

44. SIBAI, 2011

45. Thankyou