Clinical features. Abnormal vasculogenesis and angiogenesis and releasing of antiangiogenic

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1 Clinical features Abnormal vasculogenesis and angiogenesis and releasing of antiangiogenic factors results in Vasospasm Endothelial dysfunction Etiology of various clinical signs and symptoms

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3 So, Preeclampsia usually develops Abnormal placentation Endothelial dysfunction

4 Clinical diagnosis of Preeclampsi a ACOG Task Force on Hypertension in Pregnancy

5 Classification of Preeclampsia 1. Preeclampsia-eclampsia 2. Chronic hypertension 3. Chronic hypertension with superimposed preeclampsia 4. Gestational hypertension

6 Preeclampsia-eclampsia 2013 PROTEINURIA Not always necessary HYPERTENSION OR SEVERE FEATURES **edema, IUGR, oligohydramnios, 24 hour proteinuria > 5 gms/day

7 Systolic BP 140 Diastolic BP 90 (4 hours apart) HYPERTENSION

8 24 hours 300 mg Urine dipstick 1+ PROTEINURIA

9 SEVERE FEATURES Severe hypertension ( 160/110 mmhg) Low platelet count (< 100,000/cu.mm.) Abnormal liver function (Increase AST/ALT 2 folds or RUQ pain) Abnormal renal function (Cr > 1.1 mg/dl or 2 folds of baseline level) Pulmonary edema Symptoms of nervous system and vision CBC with platelet, AST, ALT, LDH, Creatinine, Bilirubin, Uric acid

10 Mild preeclampsia Preeclampsia without severe features Severe preeclampsia Preeclampsia with severe features

11 ECLAMPSIA

12 during pregnan cy 38-55%

13 during labor 18-36%

14 11-44% POSTPARTUM MOSTLY WITHIN 48 HOURS

15 Can Preeclampsia-eclampsia be prevented?

16 ASPIRIN Low dose aspirin (60-80 mg) for high risk group beginning in the late first trimester

17 ASPIRIN High risk group Previous preeclampsia, diabetes, hypertension, renal disease, autoimmune disease, multiple pregnancy

18 Preeclampsia-eclampsia Principle of management

19 Preeclampsia-eclampsia 1. Controlling or prevention of eclampsia 2. Lowering blood pressure 3. Adequate hydration 4. Termination of pregnancy

20 1 MgSO 4 Preeclampsia with severe features Eclampsia

21 1 MgSO 4 Dosage : 20% MgSO4 2-6 gram IV loading dose in min, then 50% MgSO4 40 gram + 5%DW 920 ml IV drip 2 gram (50 ml)/hr Therapeutic level : mg/dl Monitor : urine output, reflex, respiratory rate, blood pressure Antidote : 10% Calcium gluconate 10 ml (1gram) IV

22 Antihypertensive 2 BP 160/110 mmhg Labetalol Hydralazine Nifedipine

23 Antihypertensive 2 BP 160/110 mmhg and viable fetus Labetalol 20 mg IV over 2 minutes Labetalol 40 mg IV over 2 minutes Labetalol 80 mg IV over 2 minutes 10 minutes 10 minutes 10 minutes Hydralazine 10 mg IV over 2 minutes Consult or Surveillance ACOG Committee opinion; FEB 2015

24 2 Antihypertensive BP 160/110 mmhg and viable fetus Hydralazine 5-10 mg IV over 2 minutes Hydralazine 10 mg IV over 2 minutes Labetelol 20 mg IV over 2 minutes 20 minutes 20 minutes 10 minutes Labetelol 40 mg IV over 2 minutes Consult or Surveillance ACOG Committee opinion; FEB 2015

25 2 Antihypertensive BP 160/110 mmhg and viable fetus Nifedipine 10 mg PO Nifedipine 20 mg PO Nifedipine 20 mg PO 20 minutes 20 minutes 20 minutes Labetelol 40 mg IV over 2 minutes Consult or Surveillance ACOG Committee opinion; FEB 2015

26 2 Special precaution Do not prescribe diazepam (valium ) in case of preeclampsia-eclampsia Unless status epilepticus was observed

27 3 Limited IV access

28 4 Termination as soon as possible Preeclampsia without severe features 37 weeks gestation Preeclampsia with severe features at least 34 weeks gestation

29 4 Termination as soon as possible Expectant management should be considered If GA >24 to < 34 weeks gestation and available NICU Corticosteroids are recommended if GA < 34 weeks gestation

30 4 Termination as soon as possible Delivery after completion of 4 doses of corticosteroids - PPROM - Labour - Platelet < 100,000 - Abnormal LFT - Renal dysfunction - Fetal growth restriction - Severe oligohydramnios - Abnormal doppler study - reversed end diastolic flow (umbilical a)

31 4 Termination as soon as possible Prompt delivery after maternal stabilization regardless of GA if - uncontrolled BP - eclampsia - pulmonary edema - abruptio placentae - disseminated intravascular coagulation - evidence of nonreassuring fetal status - intrapartum fetal demise

32 Postpartum surveillance - Treatment if BP 150/100 mmhg (4-6 hrs apart) - Prompt treatment if BP 160/110 mmhg

33 Postpartum surveillance - BP monitoring for 72 hrs - BP follow up 7-10 days postpartum