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Manejo de la preeclampsia marzo 2015

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Complemento de la exposicion de fisiopatologia de la preeclampsia.

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Manejo de la preeclampsia marzo 2015

  1. 1. preeclampsia manej o D R . J O R G E AVA L O S G O M E Z Medico Gineco-Obstetra HNDAC Marzo - 2015
  2. 2. Objetivos •Mostrar opciones terapéuticas frente a la etapa asintomática de esta enfermedad •Manejo de la etapa sintomática basada en evidencia
  3. 3. Disbalance antiangiogenico Disfunción endotelial HTA Proteinuria Alteración hepática Edema pulmonar Daño neurológico Placentacion anormal Hipoxia placentaria Insuficiencia Placentaria relativa Adenosina fetal Estadio feto - placentario Estado Pro-inflamatorio Obesidad materna Asintomatica Sintomatica
  4. 4. Asintomatica Sintomatica Predicción Prevención Manejo de cuadro agudo multidisciplinario
  5. 5. Asintomatica Predicción Prevención •Perfil de riesgo personal •Perfil de riesgo cardiovascular •Perfil de riesgo metabólico •Perfil de riesgo trombotico •Perfil de riesgo placentario •Bashat. Ultrasound Obstet Gynecol 2015
  6. 6. Manejo de la fase sintomatica TOXEMIA GRAVIDI CA Termino de la gestación
  7. 7. 140/90 proteinuria Task force on Hypertension in Pregnancy 2013 20ss
  8. 8. 20ss 140/90 proteinuria Espinoza J, Uckele JE, Starr RA, Seubert DE, Espinoza AF, Berry SM. Angiogenic imbalances: the obstetric perspective. Am J Obstet Gynecol 2010 ; Kim YN, Lee DS, Jeong DH, sung MS, Kim KT. The relationship of the level of circulating antiangiogenic factors to the clinical manifestations of preeclampsia. Prenat Diagn. 2009 May;29(5):464-70 . Maynard S, Epstein FH, Karumanchi SA. Preeclampsia and angiogenic imbalance. Annu Rev Med 2008 sFlt-1 sEng-1 PLACENTA PLACENTA SintomaticaAsintomatica
  9. 9. 20ss 140/90 proteinuria *Koopmans CM. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet. 2009 Sep 19;374(9694):979-88 37ss 30% Resultados maternos adversos*
  10. 10. Fetal Materno *Gratacos. Fetal Diagn Ther 2014, 140/90 proteinuria Daño endotelial severo Urea? PDW? PIERS
  11. 11. Fetal Materno compensado sin gravedad descompensado sin gravedad con gravedadcompensado Unidad Materno Fetal HNDAC marzo 2015, 37ss max 34ss terminar HIPITATDIGITAT Gratacos MEXPRE
  12. 12. 20ss 140/90 proteinuria Suzuki et al. Clinical trial of expectant management of severe preeclampsia that develops at532 weeks’ gestation at a Japaneseperinatal center. J Matern Fetal Neonatal Med, 2014 Vigil-De Gracia et al. Expectant management of severe preeclampsia remote from term: the MEXPRE Latin Study, a randomized, multicenter clinical trial. NOVEMBER 2013 American Journal of Obstetrics & Gynecology 37ss34ss24ss Preeclampsia severa MEXPRE trial Suzuki trial : No mejoras en outcomes neonatal : mayor riesgo de complicaciones maternas
  13. 13. PR EECLAMPSI AManejo del daño endotelialsistémico materno
  14. 14. 20ss 140/90 proteinuria sFlt-1 sEng-1 PLACENTA PLACENTA Daño funcional Daño estructural Unidad Materno Fetal HNDAC marzo 2015,
  15. 15. Magnitud del daño endotelial en Preeclampsia Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
  16. 16. Magnitud del daño endotelial en Preeclampsia Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020 Manejo multidisciplinario Mantenimiento de las habilidades clinicas Reconocimiento temprano de gravedad
  17. 17. Manejo de la presión arterial Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020 National Collaborating Centre for Women’s and Children’s Health. Hypertension in pregnancy. The management of hypertensive disorders during pregnancy. National Institute for Health and Clinical Excellence Guideline 107. August 2010 Presion arterial leve: >140/60 < 160/110 No se recomienda el tratamiento de la hipertensión arteria leve
  18. 18. Manejo de la presión arterial Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020 Am J Obstet Gynecol. 1999 Oct;181(4):858-61. A randomized, double-blind trial of oral nifedipine and intravenous labetalol in hypertensive emergencies of pregnancy. Presion arterial severa: >160/110 Primera línea Nifedipino labetalol23` 43`vs •Mayor flujo urinario: 1hora •Bloqueo neuromuscular no demostrado
  19. 19. Manejo de la crisis hipertensiva Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. ACOG february2015 Nifedipino Primera línea
  20. 20. Manejo de la presión arterial Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020 Am J Obstet Gynecol. 1999 Oct;181(4):858-61. A randomized, double-blind trial of oral nifedipine and intravenous labetalol in hypertensive emergencies of pregnancy. Presion arterial severa: >160/110 segunda línea Nifedipino labetalol •Manejo multidisciplinario, medicina materno fetal, anestesiologia, medicina intensivaHidralacina nitroprusiato
  21. 21. Profilaxis anticonvulsiva Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020 Duley L, Henderson-Smart DJ, Walker GJA, Chou D. Magnesium sulphate versus diazepam for eclampsia. Cochrane Database of Systematic Reviews 2010 Sulfato de Magnesio primera línea •Disminuye el riesgo de morir vs. Diacepam 1A •Disminuye el riesgo convulsion vs. Diacepam, CL y fenitoina 1A •Disminuye el riesgo neumonia, ingreso a UCI, VM vs. fenitoina 1A RR:0.59 RR:0.06 RR:0.20
  22. 22. Terapia para las complicaciones hematológicas y hepáticas Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020 Woudstra DM, Chandra S, Hofmeyr GJ, Dowswell T. Corticosteroids for HELLP. Cochrane Database 2010 Corticoesteroides HELLP Evidencia insuficiente •Dexametasona SMD: 0.6 (0.2-1.1) •Betametasona RR: 0.95 (0.2-2.3) •prednisolona Incrementa el conteo plaquetario No diferencias en MMM
  23. 23. Transfusion de plaquetas Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020 The Royal College of Obstetricians and Gynaecologists. Blood transfusion in obstetrics. Guideline Number 47 plaquetas <50000 Incrementa el riesgo de sangrado Otros tratamientos necesitan estudios que avalen su uso
  24. 24. Fluidoterapia Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020 Duley L, Williams J, Henderson-Smart DJ. Plasma volume expansion for treatment of pre-eclampsia. Cochrane Database 1999 Thornton CE, von Dadelszen P, Makris A, Tooher JM, Ogle RF, Hennessy A. Acute pulmonary oedema as a complication of hypertension during pregnancy. Hypertension in Pregnancy 2011; Edema agudo de pulmón Incrementa MMM Administracion de fluidos No hay mejora significativa* Administracion vs restriccion Riesgo incrementa >5500ml PEPE trial 500cc asociado con RR: 0.6 (0.37-0.98)
  25. 25. PR EECLAMPSI A Nuevos tratamientos
  26. 26. Disbalance antiangiogenico Disfunción endotelial HTA Proteinuria Alteración hepática Edema pulmonar Daño neurológico Placentacion anormal Hipoxia placentaria Insuficiencia Placentaria relativa Adenosina fetal Estadio feto - placentario Sindrome antiangiogen materno Estado Pro-inflamatorio Obesidad materna Asintomatica Sintomatica
  27. 27. George EM, Granger JP. Mechanisms and Potential Therapies for Preeclampsia.Current hypertension reports. 2011
  28. 28. Bien tolerado, no efectos adversos en feto / no beneficio
  29. 29. Incremento de AC OR: 12.9 IC(1.3-126)
  30. 30. Inicio 2015 – termino 2017
  31. 31. Disminuye la expresion de factores antiangiogenicos
  32. 32. Gracias

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