You admitted a previously healthy nullipara at 36 weeks gestation who presented with new-onset periorbital edema and is found to have blood pressure

Transcription

1 Preeclampsia

2 Case report You admitted a previously healthy nullipara at 36 weeks gestation who presented with new-onset periorbital edema and is found to have blood pressure readings of 150/100 to 155/105 mmhg, 4+ protein on urinary dipstick, modest (ie, less than 2- fold) elevations in her hepatic transaminases, a platelet count of 105,000/µL and a mildly (8th percentile) growth-restricted fetus.

3 Question? Does she have severe preeclampsia? Should you start parenteral magnesium sulfate? Should you give antihypertensive therapy? Is delivery indicated?

4 Criteria for the diagnosis of preeclampsia Systolic blood pressure 140 mmhg or diastolic blood pressure 90 mmhg on two occasions at least four hours apart after 20 weeks of gestation in a previously normotensive patient. If systolic blood pressure is 160 mmhg or diastolic blood pressure is 110 mmhg, confirmation within minutes is sufficient. Proteinuria 0.3 grams in a 24-hour urine specimen or protein (mg/dl)/creatinine i (mg/dl) ratio 0.3. Dipstick 1+ if a quantitative measurement is unavailable.

5 Criteria for the diagnosis of preeclampsia without proteinuria, the new onset of any of the following is diagnostic of preeclampsia: Platelet l t count <100,000/microliter. 000/ Serum creatinine >1.1 mg/dl. doubling of serum creatinine in the absence of other renal disease. Liver transaminases at least twice the normal concentrations. Pulmonary edema. Cerebral or visual symptoms.

6 Severe preeclampsia Symptoms of central nervous system dysfunction: Photopsia, scotomata, cortical blindness, retinal vasospasm Severe headache ( incapacitating) or headache that persists and progresses despite analgesic therapy Altered mental status Hepatic abnormality: Severe persistent right upper quadrant or epigastric pain unresponsive to medication or serum transaminase concentration twice normal

7 Severe preeclampsia Systolic blood pressure 160 mmhg or diastolic blood pressure 110 mmhg on two occasions at least four hours apart while the patient is on bedrest (unless the patient t is on antihypertensive t i therapy) Thrombocytopenia: <100, platelets/microl l t Renal abnormality:serum creatinine >1.1 mg/dl or doubling of serum creatinine i concentration ti in the absence of other renal disease Pulmonary edema

8 Severe Preeclampsia indication for delivery in the following settings: Before fetal viability At 34 0/7ths weeks of gestation When the maternal or fetal condition is unstable, regardless of gestational age

9 Severe Preeclampsia between 24 and 34 weeks gestation antenatal corticosteroids transfer to a tertiary care facility antihypertensive therapy if blood pressures reach or exceed 160/110 mm Hg.

10 indication delivery preterm premature rupture of the membranes labor persistently abnormal ( 2-fold increase) transaminase elevations platelet count <100,000/µL fetal growth restriction <5th percentile severe oligohydramnios ( AFI <5 cm) absent end-diastolic umbilical artery Doppler flow studies new-onset renal dysfunction

11 Nonsevere Preeclampsia Inpatient versus outpatient care Laboratory follow-up : platelet count, serum creatinine, and liver enzymes(at least weekly), and signs and symptoms suggest worsening disease. Blood pressure :at least twice weekly. antihypertensive drugs : not alter the course of the disease or diminish perinatal morbidity or mortality.

12 Nonsevere Preeclampsia Assessment of fetal well-being: daily fetal movement counts. twice weekly fetal nonstress testing with assessment of amniotic fluid volume. twice weekly biophysical profiles. Testing is repeated immediately if there is an abrupt change in maternal condition Evaluation of umbilical artery Doppler indices

13 Nonsevere Preeclampsia sonographic estimation of fetal weight to evaluate for growth restriction ti and oligohydramnios. Timing delivery : 37 weeks

14 INTRAPARTUM MANAGEMENT Continuous maternal-fetal monitoring Maintenance fluids of 80 ml/hour Severe hypertension in labor should be treated with intravenous labetalol l l or hydralazine or oral nifedipine to prevent stroke. Antihypertensive medications do not prevent eclampsia.

15 Invasive hemodynamic monitoring severe cardiac disease severe renal disease severe oliguria refractory hypertension pulmonary edema

16 magnesium sulfate 2013 American College of Obstetricians and Gynecologists recommendations: for women with preeclampsia with systolic blood pressure of less than 160 mmhg and a diastolic blood pressure less than 110 mmhg and no maternal symptoms, it is suggested that magnesium sulfate not be administered universally for the prevention of eclampsia

17 magnesium sulfate We do not administer seizure prophylaxis to women with only ygestational hypertension as the seizure risk in the latter is less than 0.1 percent.

18 magnesium sulfate other anticonvulsants regimen and monitoring Dosing Duration of therapy Recovery sign :diuresis of 100 ml/hour for two consecutive hours, absence of symptoms [headache, visual changes, epigastric pain], and absence of severe hypertension. Diuresis (greater than 4 L/day) - the most accurate clinical indicator of resolution of preeclampsia/eclampsia, but is not a guarantee against the development of seizures.

19 POSTPARTUM MANAGEMENT Nonsteroidal antiinflammatory drugs be avoided in women with poorly controlled hypertension, oliguria, renal insufficiency, or thrombocytopenia. monitor vital signs every two hours while the patient remains on magnesium sulfate and repeat laboratory tests until two consecutive sets of data are normal.

20 POSTPARTUM MANAGEMENT monitoring blood pressure in hospital for the first 72 hours postpartum and again 7 to 10 days postdelivery. Antihypertensive therapy (ACOG) : systolic blood pressure 150 mmhg or diastolic blood pressure 100 mmhg on two occasions four to six hours apart. within one hour if systolic blood pressure is 160 mmhg or diastolic blood pressure is 110 mmhg.

21 LONG TERM MANAGEMENT recommendations that women with a history of preeclampsia lose weight, exercise, not smoke and have their blood pressure, fasting glucose, and lipid levels followed yearly to mitigate their risks of subsequent cardiovascular mortality.

22 Case report You admitted a previously healthy nullipara at 36 weeks gestation who presented with new-onset periorbital edema and is found to have blood pressure readings of 150/100 to 155/105 mmhg, 4+ protein on urinary dipstick, modest (ie, less than 2- fold) elevations in her hepatic transaminases, a platelet count of 105,000/µL and a mildly (8th percentile) growth-restricted fetus.

23 Recommendation Screening to predict preeclampsia beyond taking an appropriate medical history to evaluate for risk factors is not recommended. Vitamin C or vitamin E to prevent preeclampsia is not recommended. Daily low-dose aspirin to help prevent preeclampsia is suggested in very high-risk women with a history of preeclampsia and preterm delivery. Antihypertensive medication is recommended for severe hypertension during pregnancy. A decision to deliver should not be based on the amount of proteinuria or change in the amount of proteinuria. The use of magnesium sulfate is recommended for severe preeclampsia, eclampsia,or HELLP syndrome.

24 low-dose aspirin prophylaxis prior preterm preeclampsia (early onset) prior late onset preeclampsia more than twice chronic hypertensive patients

25 Treatment therapy with labetalol, l l nifedipine, i or methyldopa is recommended for systolic blood pressures 160 mm Hg or diastolic pressures 110 mm Hg or with lower levels l of hypertension if there is evidence of end-organ damage. Target blood pressure: / mmhg Reducing mean arterial pressure no more than 25 % over 2 hour.