Transcript PREECLAMPSIA - Saint Francis Care

PREECLAMPSIA
Reinaldo Figueroa, MD
Winthrop-University Hospital
PREECLAMPSIA
• Hypertensive disorder specific to
pregnancy
– affects nearly 6% of all pregnancies
– a major cause of maternal and neonatal
mortality and morbidity
– 15 to 20 % of maternal mortality in developed
countries
PREECLAMPSIA
• Severity ranges from:
– a mild disorder (transient hypertension in the
later part of the pregnancy) to
– a life-threatening disorder with seizures,
HELLP syndrome, fetal hypoxia, and growth
retardation
• more severe disease: 0.56 per 1000
deliveries
PREECLAMPSIA
• Predisposes women to other serious
complications:
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placental abruption
acute renal failure
cerebral hemorrhage
disseminated intravascular coagulation
circulatory collapse
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• The etiology is unknown
• believed to be involved:
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immune maladaptation
placental ischemia
oxidative stress
genetic susceptibility
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• Classification of hypertension in
pregnancy
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Gestational hypertension
Preeclampsia / eclampsia
Chronic hypertension
Preeclampsia superimposed on chronic
hypertension
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• Definition of hypertension
– a systolic blood pressure of 140 mmHg or
above,
– or a diastolic blood pressure of 90mmHg or
above,
– on two occasions 6 hours apart
• Abnormal proteinuria
– the excretion of 300 mg or more of protein in
24 hours
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• Criteria for severe preeclampsia
– Blood pressure: > 160 mmHg systolic or
> 110 mm Hg diastolic
– Proteinuria: > 5 g in 24 hours
– Persistent and severe cerebral or visual
disturbances (headache, scotoma, blurred
vision)
– Persistent and severe epigastric pain or right
upper quadrant pain
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• Criteria for severe preeclampsia
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Pulmonary edema or cyanosis
Oliguria (< 500 mL of urine in 24 hours)
Eclampsia (grand mal seizures)
HELLP syndrome
PREECLAMPSIA
• Screening tests for gestational
hypertension
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routine components of antepartum care trimester
early detection of vasoconstriction
early detection of altered renal function
early detection of altered hemodynamics
detection of placental hypoperfusion / ischemia
detection of endothelial activation or injury
detection of an activated coagulation / fibrinolytic
system
PREECLAMPSIA
• Prevention of preeclampsia
• women at risk: multifetal gestation, vascular or renal
disease, previous severe preeclampsia-eclampsia,
abnormal uterine artery Doppler velocimetry
• antihypertensive drugs
• magnesium
• zinc
• fish oil
• calcium
• low-dose aspirin
PREECLAMPSIA
• Mild preeclampsia - management
– < 37 weeks gestation
• inpatient or outpatient management
• worsening disease: delivery, magnesium sulfate
– > 40 weeks gestation
• delivery, magnesium sulfate
– 37 - 39 weeks gestation
• inducible cervix: delivery, magnesium sulfate
• cervix not inducible: inpatient or outpatient
management
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• Severe preeclampsia - expectant
management
– gestational age: not recommended for < 24
weeks or > 34 weeks gestation
– hospitalization: tertiary care center
– antenatal testing: daily
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• Severe preeclampsia - guidelines for
expedient delivery
– maternal indications
• eclampsia, thrombocytopenia, pulmonary edema,
acute renal failure
• persistent severe headache or visual changes
• elevated liver enzymes with persistent severe
epigastric pain or right upper quadrant tenderness
• labor or rupture of membranes
• vaginal bleeding, abruptio placenta
PREECLAMPSIA
• Severe preeclampsia - guidelines for
expedient delivery
– fetal indications
• repetitive severe variables or late decelerations
• biophysical profile < 4 on two occasions 4 hours
apart
• amniotic fluid index < 2 cm
• intrauterine growth restriction
• fetal death
• > 34 weeks gestation
PREECLAMPSIA
• Severe preeclampsia - management
protocol
– admission to labor and delivery for 24 hours
– magnesium sulfate IV for 24 hours
– antihypertensives if diastolic blood pressure
> 110 mmHg
– meet guidelines for expedited delivery?
• yes? delivery
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• Severe preeclampsia - management
protocol
– Expedited delivery? no?
• < 23 weeks: counseling for termination of
pregnancy
• 23-32 weeks: steroids, antihypertensive medications,
daily maternal and fetal evaluation, delivery at 34
weeks
• 32-33 weeks: amniocentesis
– immature fluid - steroids, delivery in 48 hours
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• HELLP syndrome - diagnosis
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10% before 27 weeks
20% after 37 weeks
70% between 27 and 37 weeks
slow initial phase with accelerated final phase
versus secondary expression of sepsis, ARDS,
renal failure
PREECLAMPSIA
• HELLP syndrome
– parameters used to diagnose preeclampsia are
not reflective of disease severity
– target organ systems
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liver
brain
kidneys
coagulation system
– increased maternal and perinatal risk
PREECLAMPSIA
• HELLP syndrome - diagnostic criteria
– hemolysis
• abnormal peripheral smear
• lactate dehydrogenase > 600 U/L
– elevated liver enzymes
• serum aspartate aminotransferase > 70 U/L
• lactate dehydrogenase > 600 U/L
– low platelets
• platelet count < 100,000/mm3
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• HELLP syndrome - differential diagnosis
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acute fatty liver of pregnancy
appendicitis
diabetes insipidus
gallbladder disease
gastroenteritis
glomerulonephritis
hemolytic uremic syndrome
hepatic encephalopathy
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• HELLP syndrome - differential diagnosis
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idiopathic thrombocytopenia
kidney stones
pancreatitis
pyelonephritis
systemic lupus erythematosus
thrombotic thrombocytopenia purpura
viral hepatitis
PREECLAMPSIA
• HELLP syndrome - antepartum
management
• assess and stabilize the maternal condition
• correct coagulopathy if DIC is present
• give intravenous magnesium sulfate to prevent
seizures
• provide treatment for severe hypertension to prevent
stroke
• transfer to tertiary center if appropriate
• if subcapsular hematoma of liver, computed
tomography or ultrasound of the abdomen
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• HELLP syndrome - antepartum
management
– evaluate fetal well-being
• non stress test
• biophysical profile
– timing of delivery
• if > 34 weeks gestation, deliver
• if < 34 weeks gestation, administer corticosteroids,
then deliver in 48 hours
PREECLAMPSIA
• HELLP syndrome - management for
cesarean birth
– use general anesthesia if platelet count is
< 75,000 / mm3
– transfuse 5 to 10 units of platelets before
surgery if platelet count is < 50,000 / mm3
– leave vesicouterine peritoneum open
– install subfascial drain
PREECLAMPSIA
• HELLP syndrome - management for
cesarean birth
– schedule secondary closure of skin incision or
subcutaneous drain
– administer postoperative transfusions as needed
– perform intensive monitoring for at least 48
hours postpartum
– consider dexamethasone (10 mg IV every 12
hours) until postpartum resolution of disease
occurs
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• HELLP syndrome - management of
women with a subcapsular liver hematoma
– general considerations - blood bank aware for
potential need of many units of blood
– general or vascular surgeon consultation
– avoid direct and indirect manipulation of liver
– closely monitor hemodynamic status
– management of hematoma depends on whether
it is ruptured or not
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• Eclampsia
– occurrence of convulsions or coma unrelated to
other associated conditions
– all new onset seizures during pregnancy eclampsia until proven otherwise
– incidence: 1 in 500 pregnancies
• 3% in multiple gestations
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• Eclampsia
– precise cause unknown
– theories
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vasospasm
ischemia
edema
multisystem organ failure
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• Eclampsia
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seizures usually occur without aura
hypertension not severe in 20%
edema absent in 30%
proteinuria absent in 20%
hyperreflexia is not predictive of seizure
headache or visual changes - most common
precipitating event
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• Eclampsia
– 80% of convulsions occur before or during the
delivery
– 1/3 of cases may be not preventable
– atypical
• less than 20 weeks gestation
• more than 48 hours postpartum
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• Eclampsia - risk factors
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low socioeconomic status
extremes in childbearing age
African-American
no prenatal care
substance abuse
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• Eclampsia - management
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control convulsions
correction of hypoxia and acidosis
blood pressure control
delivery after maternal stabilization
PREECLAMPSIA
• Eclampsia - anticonvulsant therapy
– magnesium sulfate
• mechanism of action - smooth muscle relaxation by
displacement of calcium
• dosage - 4-6 g intravenous loading dose, followed
by 2 g per hour
• may be given intramuscularly
PREECLAMPSIA
• Eclampsia - magnesium sulfate
– side effects:
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maternal hypotonia
respiratory depression
cardiac arrest
neonatal depression
– contraindicated in myasthenia gravis
– use with caution in renal insufficiency
PREECLAMPSIA
• Eclampsia - anticonvulsant therapy
– phenytoin
• used extensively in Europe
• may be used in myasthenia gravis
• mechanism of action - may increase gamma
aminobutyric acid-mediated chloride conduction in
postsynaptic membranes
• may inhibit neurotransmitter inhibitory systems
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• Eclampsia - phenytoin
– dosage - 1 g loading dose over 1 hour
– cardiac monitoring during administration
– side effects
• arrhythmias with rapid administration
• hepatitis
• Steven-Johnson syndrome
PREECLAMPSIA
• Eclampsia - anticonvulsant therapy
– diazepam
• useful for status seizures
• mechanism of action - facilitate the binding of
GABA to its receptor
– benzodiazepine receptors
• dosage - 10 mg at a rate of 5 mg per min
• may be repeated at 10 to 15 minute intervals
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• Eclampsia - diazepam
– side effects - loss of consciousness,
hypotension, respiratory depression
– caution - may increase risk of aspiration
– causes prolonged depression of the neonate
• sodium thiopentotal
– long acting barbiturate
– used when sedation, paralysis and intubation
needed
PREECLAMPSIA
• Eclampsia - which anticonvulsant to use?
– magnesium is associated with decreased
recurrence risks of seizures when compared
with diazepam or phenytoin
– diazepam is associated with increased need for
mechanical ventilation
PREECLAMPSIA
• Eclampsia - management of fetus
– fetal bradycardia during seizure
• ~ 5 minutes after the onset of the seizure
• may be associated with rebound tachycardia
• recovery phase may show late decelerations
– monitor for uterine hypertonicity
• allow for fetal recovery
• monitor for signs of abruption
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• Eclampsia
– delivery is indicated regardless of gestational
age
– immediate cesarean delivery is not necessary
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• Eclampsia - radiographic evaluation
– should be reserved for women with
neurological deficit, recurrent seizures, or
atypical presentation
– abnormal CT findings - 50%
• edema, hemorrhage, infarction
– cerebral angiography has limited use
– 90% of EEG evaluations may be abnormal
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• Eclampsia - management
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allow patient to have seizure
use bite block as needed to prevent maternal injury
establish airway
administer magnesium sulfate as soon as possible
obtain arterial blood gases
monitor urine output
control hypertension
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• Eclampsia - management
– rebolus with magnesium sulfate if repeat
seizure occurs
– do not intervene for fetal status while mother is
unstable
– if seizure continues, paralyze and intubate.
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• Counseling regarding future pregnancies HELLP syndrome
– information available varies
– recurrent risk of preeclampsia: 43% (19%)
– recurrent risk of HELLP syndrome: 19-27%
(3%)
– If HELLP syndrome < 32 weeks
• recurrent risk of preeclampsia / eclampsia is 61%
THANK YOU
• Sibai BM. Hypertensive disorders in women.
2001.
• Witlin AG, Sibai BM. Magnesium sulfate therapy
in preeclampsia and eclampsia. Obstet Gynecol
1998;92:883-9.
• Sibai BM. Diagnosis and management of
gestational hypertension and preeclampsia. Obstet
Gynecol 2003;102:181-92.
• Sibai BM. Diagnosis, prevention, and
management of eclampsia. Obstet Gynecol
2005;105:402-10.