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Section C Madulara Magno Magsino Malig Mallari Mamba Manguba Mangubat Mansukhani Manzana

Severe Pre- Eclampsia. Section C Madulara Magno Magsino Malig Mallari Mamba Manguba Mangubat Mansukhani Manzana. Pre-eclampsia. the presence of hypertension and proteinuria occurring after 20 th week of gestation. Indications of Severe Pre-eclampsia.

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Section C Madulara Magno Magsino Malig Mallari Mamba Manguba Mangubat Mansukhani Manzana

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  1. Severe Pre-Eclampsia Section C Madulara Magno Magsino Malig Mallari Mamba Manguba Mangubat Mansukhani Manzana

  2. Pre-eclampsia • the presence of hypertension and proteinuria occurring after 20th week of gestation

  3. Indications of Severe Pre-eclampsia

  4. Incidence – Philippine Setting • According to Dept. of Health, Maternal Mortality Rate (MMR) • 162 out of 10,000 live births (Family Planning Survey 2006) • Maternal deaths account for 14% of deaths among women • For the past 5 years, all of the causes of maternal deaths exhibited an upward trend. • Pre-Eclampsia showed an increasing trend of 6.89%, 20%, 40%, and 100% • 10 women die everyday in the Philippines due to pregnancy and childbirth-related causes, such as pre-eclampsia

  5. Severe Pre-eclampsia • BP 160/110 mmHg • Proteinuria: • at least 4 g/day or persistent > +2 on dipstick • Oliguria: • <400 cc/day • Signifying decreased renal blood flow and diminished glomerular filtration rate • Severe headache and visual disturbance • Pulmonary edema or cyanosis • Due to hemodynamic changes (inc. afterload)

  6. Severe Pre-eclampsia • Abdominal pain (epigastric or RUQ location) • distention of glisson’s capsule of the liver due to heptocellular edema and/or necrosis • Hemolysis • inc. serum LDH, hemoglobinuria, hyperbilirubinemi, presence of schistocytes • Elevated liver enzymes • Due to hepatocellular necorsis • Thrombocytopenia • Due to microangiopathic hemolysis induced by spasm

  7. Signs to identify include: • Cardiovascular system: hypertension, vasoconstriction leading to cool peripheries, peripheral oedema • Respiratory system: pulmonary edema, facial and laryngeal edema, acute respiratory distress syndrome (ARDS) • Renal system:proteinuria, oliguria, acute renal failure • Central nervous system: hyperreflexia, clonus, cerebral haemorrhage, convulsions (eclampsia), papilloedema, coma • Others: HELLP (Haemolysis, Elevated Liver Enzymes and Low Platelets), thrombocytopenia, DIC (disseminated intravascular coagulopathy) • Fetal signs include: CardioTocoGraphy (CTG) abnormalities, pre-term labour, and intrauterine growth retardation.

  8. Risk factors associated with pregnant women: • First pregnancy • Age under 20 or above 35 • High BP before pregnancy • Previous pre-eclamptic pregnancy • Short interpregnancy intervals • Family history • Obesity • DM, kidney disease, rheumatioud arthritis, lupus, or scleroderma • Low socio-economic status • Poor protein or low calcium in the diet

  9. Risk factors associated with the pregnant women’s husband: Risk factors associated with the fetus: Multifetal pregnancy Hydrops/triploidy Hydatidiform mole • First time father • Previously fathered a pre-eclamptic pregnancy

  10. Risk factors and their odds ratio for pre-eclampsia

  11. PE Findings • BP > 160/110 mmHg • Proteinuria 2.0g/24 hrs or > 2+ dipstick • Serum creatinine > 1.2 mg/dL unless previously elevated • Platelets < 100,000 mm3 • Microangiopathichemolysis: Elevated LDH

  12. PE Findings • Persistent headache, visual disturbance, epigastric pain • Increase serum transaminase • Obvious growth restriction • Pulmonary edema: increase permeability in maternal circulation

  13. Laboratory Tests • Hematocrit • Increased hematocrit levels in pre-eclampsia • Proteinuria • More than 300 mg/24h or dipstick values of 1+ denotes poor prognosis • Serum uric acid • Correlate with the development and severity of pre-eclampsia, and increased perinatal mortality

  14. Ultrasound • Doppler velocimetry • Diastolic notch • Increased systolic/diastolic index (Stuart index) • Pulsatility index • Absence or reversed end diastolic blood flow

  15. TREATMENT

  16. TREATMENT • 3 cardinal principles: A. control of convulsions B. Control of hypertension C. Delivery at optimum time and mode

  17. CONTROL OF CONVULSION • D.O.C : MAGNESIUM SULFATE • Versus Diazepam: reduced recurrence of convulsions; reduced maternal mortality; fewer APGAR scores <7 at 5 mins. • Versus Phenytoin: reduced recurrence of convulsions; fewer admissions to NICU and fewer babies who died • Versus Lytic cocktail: reduced recurrence of convulsions; less respiratory depression; less maternal deaths

  18. CONTROL OF CONVULSION • Thus, Magnesium Sulfate: - reduces risk of eclampsia - Reduces risk of maternal death • SIDE EFFECTS: - neutropenia - nosocomial infections in infants - Lower fetal biophysical profile by decreasing breathing - Increased incidence of nonreactive NST - Decreased variability of FHR - Disturbed fetal and maternal calcium homeostasis and bone density

  19. CONTROL OF CONVULSION • DOSE: • Loading dose – 4 gm IV slowly over 5 mins Maintenance dose -1-2 Gms per hour IV drip • Loading dose – 4 Gm IV slowly over 5 mins and 10 gm IV (5gm on each buttock) Maintenance – 5 Gms IM every 6 hours

  20. CONTROL OF CONVULSION • Monitoring: • Presence of DTRs • RR of >12 per minute • Urine output at least 100cc every 4 hours • Serum magnesium

  21. CONTROL OF HYPERTENSION • Use of anti-hypertensives for BP at least 160/110 mmHg – to prevent maternal CVA-Hemorrhage • D.O.C: HYDRALAZINE • Initial dose: 5 mg IV bolus followed by 5 mg incremental increases half-hourly if diastolic BP does not improve up to a total dose of 20mg • Beta blockers (labetalol) • Lowers systolic and diastolic BP • Prevent more severe forms of PIH • Prevent ventricular arrythmia, tachycardia and pulmonary edema • ADVERSE EFFECTS on fetal growth and fetal hemodynamics

  22. CONTROL OF HYPERTENSION • Calcium-channel blocker • Nifedipine • Reduce maternal BP, proteinuria and improve renal function • Given sublingually: prevent erythrocyte aggregation • Nicardipine: • More selective on peripheral vasculature • Less inotropic effect: tachycardia, flushing and hot flushes • Lower rate of placental transport with limited exposure of fetal tissues

  23. CONTROL OF HYPERTENSION • Sodium nitroprusside • For signs of severe hypertensive encephalopathy • ACE inhibitors • Not recommended due to fetal side effects (defective skull ossification, oligohydramnios, neonatal anuria) • Diuretics • Not used unless with evidence of pulmonary edema or congestion

  24. OPTIMUM TIME AND MODE OF DELIVERY • 5 Factors: • Age of gestation • Severity of disease • Fetal status • Maternal condition • Nursery capabilities

  25. OPTIMUM TIME AND MODE OF DELIVERY • General guidelines: • Hospitalize all patients once signs or symptoms of pre-eclampsia are evident • Immediate delivery done for: • All cases of eclampsia regardless of age of gestation • Severe pre-eclamptics at least 34 wks in presence of mature fetal lung and adequate nursery facilities; - Complications may mandate delivery <34 wks AOG thus, steroids are advised

  26. OPTIMUM TIME AND MODE OF DELIVERY c. Severe maternal disease - uncontrollable hypertension of 160/110 - oliguria <400 hours - thrombocytopenia <100,000/cu SGPT - pulmonary edema - impending eclampsia d. Fetal compromise - abnormal fetal movement counting - CTGs - BPS - ARED patterns on Doppler velocimetry

  27. OPTIMUM TIME AND MODE OF DELIVERY 3. Presence of clinical disease at <34 wks AOG - conservative management: - evaluation of maternal and fetal status - therapy with anticonvulsant, antihypertensive, low dose aspirin and high dose calcium 4. Labor and Delivery options: - cervical ripening with oxytocin or prostaglandins - amniotomy - vaginal or cesarean delivery

  28. OPTIMUM TIME AND MODE OF DELIVERY • Similar treatment protocol with Parkland hospital but we are more liberal on use of CS especially if: • Intact fetus is growth restricted • Bishop’s score <5 • Fetal BPS score <6/10 • CTG tracing shows persistent late or severe variable decelerations

  29. PREVENTION

  30. BMI and Diet • BMI > 30 increases the risk of pre-eclampsia • Obesity  augmented placental production of leptin, adinopectin or triglycerides and inflammation •  Drinking water • avoid salty foods, junk foods and foods that are fried • Avoid alcohol and caffeinated beverages • exercise

  31. Low dose aspirin • Doses are kept at 60-80 mg/day • Selective thromboxane (TXL-A2) suppression with resultant dominance of endothelial prostacyclin (PGI) • Monitoring of platelet counts, coagulation profiles, fetal ductusarteriosus, urine production/amniotic fluid. • Indications: • High-risk • Started during the 2nd trimester to prevent fetal malformations • Contraindications: • Aspirin allergy or hypersensitivity (acid peptic disease or coagulopathy

  32. High Dose Calcium • oral intake of calcium (2g/day) • Reduction in IUGR and BP levels • Exerts a negative feedback effect on parathyroid hormone decrease calciumsmooth muscle relaxation and diminished responsiveness to pressor stimuli

  33. Associated with higher levels of calcium excretion which is coupled with an ion exchange with magnesium sulfate • Increased levels of magnesium sulfate  smooth muscle relaxation in blood vessels  control of hypertension

  34. Thank You!

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