tipus preeklampsia
TRANSCRIPT
-
8/10/2019 tipus preeklampsia
1/65
PREECLAMPSIA & ECLAMPSIA
-
8/10/2019 tipus preeklampsia
2/65
Hypertension
Sustained BP elevation of 140/90 or greater
-
8/10/2019 tipus preeklampsia
3/65
PIH
Mild
HELLP
Synd
Impendingeclampsia
Preeclampsia
Gestasional
Effect
Chronic
Severe
Eclampsia
-
8/10/2019 tipus preeklampsia
4/65
20
Proteinuria (+)
Hipertensi kronik
Preeklampsia
Proteinuria (-)
Hipertensi Gestasional
Proteinuria (+) Super imposed
-
8/10/2019 tipus preeklampsia
5/65
Hypertensive isease Associated !ith
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
clampsia
H!!P Syndrome
-
8/10/2019 tipus preeklampsia
6/65
Hypertensive isease Associated !ith
Pregnancy
Chronic Hypertension
"iagnosed #efore the $0th%ee& or present #efore thepregnancy
'ild hypertension( 140)1*0 mmHg systolic
( 90)100 mmHg diastolic
Gestational Hypertension
Preeclampsia
clampsia
H!!P Syndrome
-
8/10/2019 tipus preeklampsia
7/65
Hypertensive isease Associated !ith
Pregnancy
Chronic Hypertension
Gestational Hypertension
Criteria
"evelops after $0 %ee&s of gestation Proteinuria is a#sent
Blood pressures return to normal postpartum
'or#idity is directly related to the degree of hypertension
Preeclampsia
clampsia
H!!P Syndrome
-
8/10/2019 tipus preeklampsia
8/65
"verlap#isease Progression
25%
E l e v a t e d B P a b o v ef i r s t t r i m e s t e r
l e v e l s5 5 - 7 5 %
G e s t a t i o n a l h y p e r t e n s i o nN o p r o t e i n u r i a
5 - 1 0 % o f s i n g l e t o n s 0 % o f m u l t i p l e s
P r e e ! l a m p s i a" y p e r t e n s i o n
P r o t e i n u r i a5 - # % o f p r o g n a n ! i e s
P a t i e n t $ i t h " y p e r t e n s i o n
-
8/10/2019 tipus preeklampsia
9/65
Hypertensive isease Associated !ith
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Criteria
"evelops after $0 %ee&s
Blood pressure elevated on t%o occasions at least + hours apart
,ssociated %ith proteinuria and edema
'ay occur less than $0 %ee&s %ith gestational tropho#lastic
neoplasia
clampsia
H!!P Syndrome
-
8/10/2019 tipus preeklampsia
10/65
Preeclampsia vs$ Severe Preeclampsia
Criteria forPreeclampsia
Previously normotensive
%oman( 140 mmHg systolic
( 90 mmHg diastolic
Proteinuria ( -00 mg in$4 hour collection
.ondependent edema
-
8/10/2019 tipus preeklampsia
11/65
Criteria for Severe Preclampsia
%P '() systolic or '') diastolic
* gr of protein in +, ho-r -rine or ./ on + dipstic0 -rines greater than ,
ho-rs apart
"lig-ria 1 *)) mL in +, ho-rs
Cere2ral or vis-al distr-2ances 3headache4 scotomata5
P-lmonary edema or cyanosis
Epigastric or R67 pain
Evidence of hepatic dysf-nction
8hrom2ocytopenia
Intra-terine gro!th restriciton 3I6GR5
-
8/10/2019 tipus preeklampsia
12/65
Ris0 9actors for Preeclampsia
.ulliparity
'ultifetal gestations
'aternal age over -
Preeclampsia in aprevious pregnancy
Chronic hypertension
Pregestational dia#etes
ascular and connectivetissue disorders
.ephropathy,ntiphospholipid
syndrome
#esity,frican),merican race
-
8/10/2019 tipus preeklampsia
13/65
Hypertensive isease Associated !ith
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
clampsia
"iagnosis of preeclampsia
Presence of convulsions not e2plained #y a neurologicdisorder
Grand mal sei3ure activity
ccurs in 0 to 45 or patients %ith preeclampsia
H!!P Syndrome
-
8/10/2019 tipus preeklampsia
14/65
Hypertensive isease Associated !ith
Pregnancy
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Eclampsia
HELLP Syndrome
A distinct clinical entity !ith:
Hemolysis4 Elevated Liver en;ymes4 Lo! Platelets
"cc-rs in , to '+ < of patients !ith severe preeclampsia
Microangiopathic hemolysis
8hrom2ocytopenia
Hepatocell-lar dysf-nction
-
8/10/2019 tipus preeklampsia
15/65
Mor2idity and Mortality from
Hypertensive isease
Hypertension a6ects 1$ to $$5 of pregnantpatients
Hypertensive disease is directly responsi#le for
appro2imately $05 of maternal mortality in the7nited State
-
8/10/2019 tipus preeklampsia
16/65
Mississippi Classification:
Class ' : Platelet co-nt : 50.000 100.000
-
8/10/2019 tipus preeklampsia
17/65
Pathophysiology
asospasm
7terine vessels
Hemostasis
Prostanoid #alance
ndothelium)derived factors
!ipid pero2ide8 free radicals and antio2idants
-
8/10/2019 tipus preeklampsia
18/65
-
8/10/2019 tipus preeklampsia
19/65
Pathophysiology
>asospasm
Predominant finding in gestational hypertension and
preeclampsia
6terine vessels
Hemostasis
Prostanoid 2alance
Endotheli-m?derived factors
Lipid pero@ide4 free radicals and antio@idants
-
8/10/2019 tipus preeklampsia
20/65
Pathophysiology
>asospasm
6terine vessels
Inade-ate maternal vasc-lar response to tropho2lastic
mediated vasc-lar changes Endothelial damage
Hemostasis
Prostanoid 2alance
Endotheli-m?derived factors
Lipid pero@ide4 free radicals and antio@idants
-
8/10/2019 tipus preeklampsia
21/65
Pathophysiology
asospasm
7terine vessels
Hemostasis
ncrease platelet activation resulting in consumption ncreased endothelial :#ronectin levels
"ecreased antithrom#in and ;$)antiplasmin levels
,llo%s for microthrom#i development %ith resultantincrease in endothelial damage
Prostanoid #alance
ndothelium)derived factors
!ipid pero2ide8 free radicals and antio2idants
-
8/10/2019 tipus preeklampsia
22/65
Pathophysiology
>asospasm
6terine vessels
Hemostasis
Prostanoid 2alance
Prostacyclin 3PGI+5:8hrom2o@ane 38BA+5 2alance shifted to favor
8BA+
8BA+ promotes:
>asoconstriction
Platelet aggregation
Endotheli-m?derived factors
Lipid pero@ide4 free radicals and antio@idants
-
8/10/2019 tipus preeklampsia
23/65
Pathophysiology
>asospasm
6terine vessels
Hemostasis
Prostanoid 2alance
Endotheli-m?derived factors
itric o@ide is decreased in patients !ith preeclampsia
As this is a vasodilator4 this may res-lt in vasoconstriction
Lipid pero@ide4 free radicals and antio@idants
-
8/10/2019 tipus preeklampsia
24/65
Pathophysiology
>asospasm
6terine vessels
Hemostasis
Prostanoid 2alance
Endotheli-m?derived factors
Lipid pero@ide4 free radicals and antio@idants Increased in preeclampsia
Have 2een implicated in vasc-lar inD-ry
-
8/10/2019 tipus preeklampsia
25/65
Pathophysiologic Changes
Cardiovascular e6ects
Hematologic e6ects
.eurologic e6ects
Pulmonary e6ects
-
8/10/2019 tipus preeklampsia
26/65
Pathophysiologic Changes
Cardiovasc-lar effects
Hypertension
Increased cardiac o-tp-t
Increased systemic vasc-lar resistance
Hematologic effects
e-rologic effects
P-lmonary effects
Renal effects
9etal effects
-
8/10/2019 tipus preeklampsia
27/65
Pathophysiologic Changes
Cardiovasc-lar effects
Hematologic effects
>ol-me contraction#Hypovolemia
Elevated hematocrit
8hrom2ocytopeni; Microangiopathic hemolytic anemia
8hird spacing of fl-id
Lo! oncotic press-re
e-rologic effects
P-lmonary effects
Renal effects
9etal effects
-
8/10/2019 tipus preeklampsia
28/65
Pathophysiologic Changes
Cardiovasc-lar effects
Hematologic effects
e-rologic effects
Hyperrefle@ia
Headache
Cere2ral edema
Sei;-res
P-lmonary effects
Renal effects
9etal effects
-
8/10/2019 tipus preeklampsia
29/65
Pathophysiologic Changes
Cardiovasc-lar effects
Hematologic effects
e-rologic effects
P-lmonary effects
Capillary lea0
Red-ced colloid osmotic press-re
P-lmonary edema
Renal effects
9etal effects
-
8/10/2019 tipus preeklampsia
30/65
Pathophysiologic Changes
Cardiovasc-lar effects
Hematologic effects
e-rologic effects
P-lmonary effects
Renal effects
ecreased glomer-lar filtration rate
Glomer-lar endotheliosis
Protein-ria "lig-ria
Ac-te t-2-lar necrosis
9etal effects
-
8/10/2019 tipus preeklampsia
31/65
Renal Effects
"ecreased glomerular :ltration rate
Glomerular endotheliosis
Proteinuria
liguria
,cute tu#ular necrosis
-
8/10/2019 tipus preeklampsia
32/65
Pathophysiologic Changes
Cardiovasc-lar effects
Hematologic effects
e-rologic effects
P-lmonary effects
Renal effects
9etal effects
Placental a2r-ption
9etal gro!th restriction
"ligohydramnios
9etal distress
Increased perinatal mor2idity and mortality
-
8/10/2019 tipus preeklampsia
33/65
Management
>he ultimate cure is delivery
,ssess gestational age
,ssess cervi2
=etal %ell)#eing
!a#oratory assessment
-
8/10/2019 tipus preeklampsia
34/65
Gestational H8 at 8erm
"elivery is al%ays a reasona#le option if term
f cervi2 is unfavora#le and maternal disease ismild8 e2pectant management %ith close
o#servation is possi#le
-
8/10/2019 tipus preeklampsia
35/65
Mild Gestational H8 not at 8erm
%ice %ee&ly visits
,ntenatal fetal surveillance
utpatient versus inpatient
-
8/10/2019 tipus preeklampsia
36/65
Indications for elivery
@orsening BP
.onreassuring fetal condition
"evelopment of severe PH
=etal lung maturity
=avora#le cervi2
-
8/10/2019 tipus preeklampsia
37/65
6nfavora2le Cervi@
.o contraindication to prostaglandin agents
f A -$ %ee&s8 consider cesarean
@hen favora#le8 o2ytocin
-
8/10/2019 tipus preeklampsia
38/65
Hypertensive Emergencies
=etal monitoring
access
hydration
>he reason to treat is maternal8 not fetal
'ay reuire C7
-
8/10/2019 tipus preeklampsia
39/65
Criteria for 8reatment
"iastolic BP ( 10)110
Systolic BP ( $00
,void rapid reduction in BP
"o not attempt to normali3e BP
Goal is "BP A 10 not A 90
'ay precipitate fetal distress
-
8/10/2019 tipus preeklampsia
40/65
Characteristics of Severe H8
Crises are associated %ith hypovolemia
Clinical assessment of hydration is inaccurate
7nprotected vascular #eds are at ris&8 eg8 uterine
-
8/10/2019 tipus preeklampsia
41/65
ey Steps 6sing >asodilators
$0)00 cc of uid8
,void multiple doses in rapid succession
,llo% time for drug to %or&
'aintain !!" position
,void over treatment
-
8/10/2019 tipus preeklampsia
42/65
Ac-te Medical 8herapy
Hydrala3ine
!a#etalol
.ifedipine
.itroprusside
"ia3o2ide
Clonidine
-
8/10/2019 tipus preeklampsia
43/65
Hydrala;ine
"oseD )10 mg every $0 minutes
nsetD 10)$0 minutes
"urationD -)* hours
Side e6ectsD headache8 ushing8 tachycardia8lupus li&e symptoms
'echanismD peripheral vasodilator
-
8/10/2019 tipus preeklampsia
44/65
La2etalol
"oseD $0mg8 then 408 then *0 every $0 minutes8for a total of $$0mg
nsetD 1)$ minutes
"urationD +)1+ hours
Side e6ectsD hypotension
'echanismD ,lpha and Beta #loc&
-
8/10/2019 tipus preeklampsia
45/65
ifedipine
"oseD 10 mg po8 not su#lingual
nsetD )10 minutes
"urationD 4)* hours
Side e6ectsD chest pain8 headache8 tachycardia
'echanismD C, channel #loc&
-
8/10/2019 tipus preeklampsia
46/65
Clonidine
"oseD 1 mg po
nsetD 10)$0 minutes
"urationD 4)+ hours
Side e6ectsD unpredicta#le8 avoid rapid %ithdra%al
'echanismD ,lpha agonist8 %or&s centrally
-
8/10/2019 tipus preeklampsia
47/65
itropr-sside
"oseD 0$ E 0* mg/min
nsetD 1)$ minutes
"urationD -) minutes
Side e6ectsD cyanide accumulation8 hypotension
'echanismD direct vasodilator
-
8/10/2019 tipus preeklampsia
48/65
Sei;-re Prophyla@is
'agnesium sulfate
4)+ g #olus
1)$ g/hour
'onitor urine output and ">
-
8/10/2019 tipus preeklampsia
49/65
Magnesi-m S-lfate
s not a hypotensive agent
@or&s as a centrally acting anticonvulsant
,lso #loc&s neuromuscular conduction
Serum levelsD +)* mg/d!
-
8/10/2019 tipus preeklampsia
50/65
8o@icity
-
8/10/2019 tipus preeklampsia
51/65
8reatment of Eclampsia
=e% people die of sei3ures
Protect patient
,void insertion of air%ays and padded tongue#lades
access
'GS4 4)+ #olus8 if not e6ective8 give another $ g
-
8/10/2019 tipus preeklampsia
52/65
8HE 9IRS8 8HIG 8" " A8 A SEIF6RE IS 8" 8AE
"6R " P6LSE
-
8/10/2019 tipus preeklampsia
53/65
Alternate Anticonv-lsants
Have not #een sho%n to #e as ecacious asmagnesium sulfate and may result in sedationthat ma&es evaluation of the patient more dicult
"ia3epam )10 mg
Sodium ,mytal 100 mg
Pento#ar#ital 1$ mg
"ilantin 00)1000 mg infusion
-
8/10/2019 tipus preeklampsia
54/65
After the Sei;-re
,ssess maternal la#s
=etal %ell)#eing
6ect delivery
>ransport %hen indicated
.o need for immediate cesarean delivery
-
8/10/2019 tipus preeklampsia
55/65
"ther Complications
Pulmonary edema
liguria
Persistent hypertension
"C
-
8/10/2019 tipus preeklampsia
56/65
P-lmonary Edema
=luid overload
-
8/10/2019 tipus preeklampsia
57/65
8reatment of P-lmonary Edema
,void over)hydration
-
8/10/2019 tipus preeklampsia
58/65
"lig-ria
$)-0 cc per hour is accepta#le
f less8 small uid #oluses of $0)00 cc as needed
!asi2 is not necessary
Postpartum diuresis is common
Persistent oliguria almost never reuires a P, cath
-
8/10/2019 tipus preeklampsia
59/65
Persistent Hypertension
BP may remain elevated for several days
"iastolic BP less than 100 do not reuiretreatment
By de:nition8 preeclampsia resolves #y + %ee&s
-
8/10/2019 tipus preeklampsia
60/65
isseminated Intravasc-lar Coag-lopathy
-
8/10/2019 tipus preeklampsia
61/65
Anesthesia Iss-es
Continuous lum#ar epidural is preferred ifplatelets normal
.eed adeuate pre)hydration of 1000 cc
!evel should al%ays #e advanced slo%ly to avoidlo% BP
,void spinal %ith severe disease
-
8/10/2019 tipus preeklampsia
62/65
HELLP Syndrome
He)hemolysis
!)elevated liver en3ymes
!P)lo% platelets
-
8/10/2019 tipus preeklampsia
63/65
HELLP Syndrome
s a variant of severe preeclampsia
Platelets A 1008000
!=>Fs ) $ 2 normal
'ay occur against a #ac&ground of %hat appearsto #e mild disease
-
8/10/2019 tipus preeklampsia
64/65
Conservative Management
Controversial
Steroids
-
8/10/2019 tipus preeklampsia
65/65
Prevention
!o% dose ,S, ine6ective in patients atlo% ris&