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PREECLAMPSIA

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.

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PREECLAMPSIA

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  1. PREECLAMPSIA Reinaldo Figueroa, MD Winthrop-University Hospital

  2. 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

  3. 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

  4. PREECLAMPSIA • Predisposes women to other serious complications: • placental abruption • acute renal failure • cerebral hemorrhage • disseminated intravascular coagulation • circulatory collapse

  5. PREECLAMPSIA • The etiology is unknown • believed to be involved: • immune maladaptation • placental ischemia • oxidative stress • genetic susceptibility

  6. PREECLAMPSIA • Classification of hypertension in pregnancy • Gestational hypertension • Preeclampsia / eclampsia • Chronic hypertension • Preeclampsia superimposed on chronic hypertension

  7. PREECLAMPSIA • 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

  8. 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

  9. PREECLAMPSIA • Criteria for severe preeclampsia • Pulmonary edema or cyanosis • Oliguria (< 500 mL of urine in 24 hours) • Eclampsia (grand mal seizures) • HELLP syndrome

  10. 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

  11. 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

  12. 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

  13. PREECLAMPSIA • Severe preeclampsia - expectant management • gestational age: not recommended for < 24 weeks or > 34 weeks gestation • hospitalization: tertiary care center • antenatal testing: daily

  14. PREECLAMPSIA • 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

  15. 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

  16. 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

  17. PREECLAMPSIA • 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

  18. PREECLAMPSIA • 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

  19. PREECLAMPSIA • 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

  20. 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

  21. PREECLAMPSIA • HELLP syndrome - differential diagnosis • acute fatty liver of pregnancy • appendicitis • diabetes insipidus • gallbladder disease • gastroenteritis • glomerulonephritis • hemolytic uremic syndrome • hepatic encephalopathy

  22. PREECLAMPSIA • HELLP syndrome - differential diagnosis • idiopathic thrombocytopenia • kidney stones • pancreatitis • pyelonephritis • systemic lupus erythematosus • thrombotic thrombocytopenia purpura • viral hepatitis

  23. 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

  24. PREECLAMPSIA • 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

  25. 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

  26. 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

  27. PREECLAMPSIA • 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

  28. PREECLAMPSIA • 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

  29. PREECLAMPSIA • Eclampsia • precise cause unknown • theories • vasospasm • ischemia • edema • multisystem organ failure

  30. PREECLAMPSIA • Eclampsia • 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

  31. PREECLAMPSIA • 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

  32. PREECLAMPSIA • Eclampsia - risk factors • low socioeconomic status • extremes in childbearing age • African-American • no prenatal care • substance abuse

  33. PREECLAMPSIA • Eclampsia - management • control convulsions • correction of hypoxia and acidosis • blood pressure control • delivery after maternal stabilization

  34. 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

  35. PREECLAMPSIA • Eclampsia - magnesium sulfate • side effects: • maternal hypotonia • respiratory depression • cardiac arrest • neonatal depression • contraindicated in myasthenia gravis • use with caution in renal insufficiency

  36. 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

  37. PREECLAMPSIA • Eclampsia - phenytoin • dosage - 1 g loading dose over 1 hour • cardiac monitoring during administration • side effects • arrhythmias with rapid administration • hepatitis • Steven-Johnson syndrome

  38. 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

  39. PREECLAMPSIA • 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

  40. 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

  41. 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

  42. PREECLAMPSIA • Eclampsia • delivery is indicated regardless of gestational age • immediate cesarean delivery is not necessary

  43. PREECLAMPSIA • 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

  44. PREECLAMPSIA • Eclampsia - management • 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

  45. PREECLAMPSIA • 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.

  46. PREECLAMPSIA • 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%

  47. 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.

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