PREECLAMPSIAFerdinand Ferry Wijaya 2013-061-110Laura Cynthia Bria 2013-061-113Stella Levina Kurniawan 2014-061-133Yohannes Kurniawan S 2014-061-149Maria Dominika Ankira F 2014-061-150

TOPIC LISTPembimbing : dr Sigit P Diptoadi, Sp.OG

PREECLAMPSIA

Hypertensive disorder specific to pregnancy affects nearly 6% of all pregnancies a major cause of maternal and neonatal

mortality and morbidity 24 % of maternal mortality in Indonesia

PREECLAMPSIA

Severity ranges from: a mild disorder (Gestational

Hypertension) to a life-threatening disorder with seizures

(eclampsia), HELLP syndrome, fetal hypoxia, and growth retardation (IUGR)

more severe disease: 0.56 per 1000 deliveries

PREECLAMPSIA

Risk Factor History of preeclampsia First pregnancy (Primigravida) Maternal age (>40 ) Chronic hypertension and CKD Obesity

PREECLAMPSIA

The etiology is unknown believed to be involved:

immune maladaptation placental ischemia oxidative stress genetic susceptibility

PREECLAMPSIA

Classification of hypertension in pregnancy Gestational hypertension Preeclampsia / eclampsia Chronic hypertension Preeclampsia superimposed on chronic

hypertension

PREECLAMPSIA Criteria

Hypertension a systolic blood pressure of 140 mmHg or

above, or a diastolic blood pressure of 90mmHg

or above, It measured on two occasions 4-6 hours

apart Abnormal Proteinuria

the excretion of 300 mg or more of protein in 24 hours urine sample

Generalized Edema

PREECLAMPSIA

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

PREECLAMPSIA

Criteria for severe preeclampsia Severe Trombositopenia (< 100.000

cell/mm3) Pulmonary edema or cyanosis Oliguria (< 500 mL of urine in 24 hours) HELLP syndrome

PREECLAMPSIA

Screening tests for gestational hypertension

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

Classifications

Prevention Know your blood pressure level before getting pregnant Get a regular prenatal checkups Avoid smoking, alcohol, and caffeine Dietary and lifestyle modifications

Low salt diet ineffective in preventing preeclampsia Calcium supplementation women with low dietary

calcium intake were at significantly increased risk for gestational hypertension. Besides, increasing calcium intake will lowered the risk for preeclampsia in high-risk women.

Maintain a healthy weight being overweight can make the women 2-6 times more likely to develop high blood pressure

Regular exercise found to be a risk reduction for hypertension in pregnancy

Reduce stress

Prevention

Antihypertensive drugs women given diuretics had a decreased incidence of edema and hypertension but not of preeclampsia.

Antioxidants imbalance between oxidant and antioxidant activity may play an important role in the pathogenesis of preeclampsia

Anti-cholesterol the use of statins may prevent hypertensive disorders of pregnancy.

Antithrombotic agents Low-dose aspirin the relative risk for development of

preeclampsia, superimposed preeclampsia, preterm delivery, decrease by 10%.

Low-dose aspirin plus heparin effective for women with thrombophilia and a history of early onset preeclampsia.

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

PREECLAMPSIA

Severe preeclampsia - expectant management gestational age: not recommended for <

24 weeks or > 34 weeks gestation hospitalization: tertiary care center antenatal testing: daily

Treatments

MgSO4 with an IV bolus of 4 g (15-20 minutes) to stop seizures, continuing maintenance infusion rate of 1 g/h

Aggressive prompt delivery is indicated for eclampsia at any gestational age after stabilization of the mother and the fetus. Attempt vaginal delivery with IV oxytocin infusion if mother and fetus are stable.

IV hydralazine, labetalol, and/or nifedipine to maintain systolic BP between 140 and 160 mmHg and diastolic BP between 90-110 mmHg.

Diuretics are used only in the setting of pulmonary edema Antenatal steroids may be administered in anticipation of

emergent delivery when gestational age is less than 32 weeks. Betamethasone (12mg IM/24hours x 2 doses) or dexamethasone (6 mg IM/12 hours x 4 doses) is recommended

Prevent aspiration and hypoxia

HELLP Syndrome

HELLP syndrome - diagnosis 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

HELLP Syndrome

HELLP syndrome parameters used to diagnose

preeclampsia are not reflective of disease severity

target organ systems liver brain kidneys coagulation system

increased maternal and perinatal risk

HELLP Syndrome

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

HELLP Syndrome

differential diagnosis of HELLP Syndrome acute fatty liver of pregnancy appendicitis diabetes insipidus gallbladder disease gastroenteritis glomerulonephritis hemolytic uremic syndrome hepatic encephalopathy

HELLP Syndrome

antepartum management of HELLP syndrome

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

HELLP Syndrome

• 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

HELLP Syndrome

management for cesarean birth with HELLP syndrome 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

HELLP Syndrome

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

ECLAMPSIA

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

ECLAMPSIA

Eclampsia precise cause unknown theories

vasospasm ischemia edema multisystem organ failure

ECLAMPSIA

Eclampsia - Symptoms seizures usually occur without aura hypertension not severe in 20% cases edema absent in 30% cases proteinuria absent in 20% cases hyperreflexia is not predictive of

seizures headache or visual changes - most

common prodromal event → impending eclampsia

ECLAMPSIA

Event of Eclampsia Most common in the last trisemester 80% of convulsions occur before or during

the delivery 2/3 of cases may be preventable by

adequate preeclampsia therapy atypical

less than 20 weeks gestation more than 48 hours postpartum (usually in

24 hours postpartum)

ECLAMPSIA

Eclampsia - risk factors low socioeconomic extremes childbearing age Afro-American no adequate prenatal care substance abuse Preexisting condition – diabetes, renal,

or cardiovascular disorder.

ECLAMPSIA

Eclampsia – Major Maternal Complication Placental Abruption 10% Neurological deficit 7% Aspiration Pneumonia 7% Pulmonary edema 5% Cardiopulmonary arrest 4% Acute renal failure 4% Dead 1%

ECLAMPSIA

Eclampsia - Management control of convulsions correction of hypoxia and acidosis anti hypertensive medication for blood

pressure control avoid diuretic if not indicated delivery after maternal stabilization to

achieve remission of preeclampsia

ECLAMPSIA

Eclampsia – convultions control magnesium sulfate

administer intravenously by continous infusion, or may be given intramuscularly by intermittent injection

mechanism of action - smooth muscle relaxation by displacement of calcium → avoid CNS depression of mother or fetus

ECLAMPSIA

Eclampsia - magnesium sulfate dosage intravenous

4-6 g intravenous loading dose in 100mL IV fluid in 15-20min

followed by 2 g/hr in 100mL maintenance infusion

Discontinue after 24 hours of delivery Monitor toxicity

Assess deep tendon reflex periodically Measure magnesium serum level every 4-6hr

or creatinine > 1.0 mg/dLand adjust infusion (keep at 4.8 – 8.4 mg/dL)

ECLAMPSIA

Eclampsia - magnesium sulfate dosage intramuscular

4 g intravenous as 20% solution at rate 1g/min 10 g of 50% solution → 5g injected deeply on

each upper outer quadrant of buttock (add 1mL lidocaine to minimize discomfort)

5g on alternate buttock/4hr after ensuring: Patellar reflex Respiration not depressed 4hr UO excedeed 100ml

Discontinued 24 hr after delivery

ECLAMPSIA

Eclampsia - magnesium sulfate side effects:

maternal hypotonia respiratory depression cardiac arrest neonatal depression

contraindicated in myasthenia gravis use with caution in renal insufficiency

ECLAMPSIA

Eclampsia - anticonvulsant therapy phenytoin

used mainly in Europe may be used in myasthenia gravis mechanism of action - increase gamma

aminobutyric acid-mediated chloride conduction in postsynaptic membranes

inhibit neurotransmitter inhibitory systems

ECLAMPSIA

Eclampsia - phenytoin dosage - 1 g loading dose over 1 hour cardiac monitoring during administration side effects

arrhythmias with rapid administration hepatitis Steven-Johnson syndrome

ECLAMPSIA

Eclampsia - anticonvulsant therapy diazepam

useful for status epilepticus mechanism of action - facilitate 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

ECLAMPSIA

• 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

ECLAMPSIA

• 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

ECLAMPSIA

• Eclampsia – fetus monitoring– Fetal heart rate and uterine contraction• Bradycardia ~ 5 minutes after the onset of

the seizure• may be associated with rebound

tachycardia• recovery phase may show late

decelerations

ECLAMPSIA

• Eclampsia - radiographic evaluation– abnormal CT findings - 50%• edema, hemorrhage, infarction

– cerebral angiography has limited use

ECLAMPSIA

• Eclampsia - radiographic evaluation– abnormal CT findings - 50%• edema, hemorrhage, infarction

– cerebral angiography has limited use

ECLAMPSIA

• Eclampsia - management• use bite block as needed to prevent

maternal injury• establish airway, breathing, and

circulation• Stabilized vital sign• administer magnesium sulfate as soon as

possible• obtain arterial blood gases• monitor urine output• control hypertension

ECLAMPSIA

• Eclampsia - management– DOC: magnesium sulfate loading dose : 4g IV for 15

minutes maintenance dose : 6g in RL/6 hr– do not intervene for fetal status while

mother is unstable

ECLAMPSIA

• Eclampsia ~ prognosis – With adequate medication eclampsia

resolve after delivery– 25% of women with eclampsia have

hypertension in subsequent pregnancies– 2% of women with eclampsia develop

eclampsia with future pregnancies

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.