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In The Name Of GodIn The Name Of God
TIME OF DELIVERY IN HYPERTENSIVE DISORERS OF
PREGNANCY
Laleh Eslamian MD. Prof. of Obstet & Gynecol
Perinatologist , Shariati hospital, TUMS
Preeclampsia:
Definitive Tx: delivery
To prevent maternal fetal complications from
disease progression
PE: WHEN To initiate Delivery?
Is based up on:
1) GA
2) Severity of the disease
3) Maternal condition
4) Fetal condition
PE 37w delivery
PE before term:
Preterm birthSerious Sequelae from
disease progression
Prompt delivery at any GA:
- Serious maternal end – organ dysfunction
- Nonreassuring tests of fetal well being.
Severe PE:
Is generally an indication for delivery:
1. Before fetal viability
2. GA 37w
3. Unstable maternal or fetal condition (regardless of GA)
Indications for delivery with Early onset severe preeclampsia:
Maternal
- Persistent severe headache or visual changes, eclampsia .
- Uncontrolled severe hypertension despite Tx.
- Oliguria <500cc/ 24h or creatinine 1.5mg/dl
- Persistent Pt <100.000/mm3, HELLP or partial HELLP
- Suspected abruption, progressive labor and / or ROM
Indications for delivery with Early onset
severe preeclampsia:
Fetal
- Severe FGR <5%
- Persistent severe oligo, AFI<5cm
- BPP 4 performed 6h apart
- REDF in Doppler study
- Fetal death
Severe PE:
Delivery minimizes the risk of:
Cerebral hemorrhage
Hepatic rupture
Renal failure
Pulmonary edema (other wise 4%)
Seizure
Bleeding due to thrombocytopenia
FGR
Placental abruption (other wise 20%)
Maternal death.
Route of delivery in severe PE
C/S is reasonable <30w:
1.Low Bishop score
2.High frequency of nonreassuring FHR
*<1/3 preterm inductions vaginal birth
PE without severe features:Delivery 37w versus expectant management:
- Significant reduction in composite adverse maternal
out come (RR: 0.71)
- But not significant at 36o – 366 weeks.
- No significant differences in neonatal outcome.
- Less costly
- Unfavorable cervix: not a reason to avoid induction.
PE without severe features:
EXPECTANT MANAGEMENT
* 34 – 36 0/7
- Stable maternal condition
- Stable fetal condition
* <34w
PE without severe features
<37w: 1- Check for new sign or symptoms.
2- Lab follow up.
3- Tx of hypertension.
4- Assessment of fetal wellbeing.
5- Assessment of fetal growth.
6- Antenatal corticosteroids.
PE without severe features:<37w: 1- Check for new sign & symptoms:Severe or persistent headache
Visual changes
Shortness of breath
RUQ or epigastric pain
FAD
Vaginal bleeding
Abdominal pain
ROM or uterine contractions.
PE without severe features:2- Lab follow – up:
* platelet count: weekly
* Serum creatinine: weekly
* Liver enzymes: weekly
- indirect Bili or LDH hemolysis, PBS
- no need to measure 24h protein > after
Pro > 300mg/24h
PE without severe features:3- Hypertension assessment.- BP assessment at least twice weekly- Anti hypertensive agents to control Sys BP<160
& Dia BP<110mmHg does not alter the course of the disease or diminish perinatal Mb or Mt
SHOULD BE AVOIDED IN MOST PATIENTS- Na restriction not recommended.- Plasma volume expansion = no improvement
PE without severe features:4- Assessment of fetal well being
No data from RCTs:
-Daily FAD
- NST & AF or BPP twice weekly
- (immediate repeat with an abrupt change in mat. condition)
- Doppler assessment of UA = 29% reduction in perinatal
death in PE and / or FGR
PE without severe features:
5- Assessment of fetal growth.
- Early FGR may be the 1st manifestation of PE
a sign of severe uteroplacental
insufficiency
- At the time of PE Dx: U/S estimation of EFW and AF,
when normal = repeat q3w
OPTIMUM TIME FOR DELIVERY IN
WOMEN WITH PREEXISTING
HYPERTENSION-No RCT- Expert consensus panel & ACOG:* 38 – 39 6/7th:Chronic hypertension not requiring medication.* 37 – 39 6/7th
Hypertension controlled with medication.* 36 – 37 6/7th
Severe hypertension difficult to control.* >37w at Dx for mild PE.* >34w at Dx for severe PE.
ACOG Task Force On Hypertension:
* Avoid delivery <380/7th in women with
uncomplicated chronic hypertension whom BP
remains controlled.
* Super imposed PE or other pregnancy
complications (FGR, previous stillbirth): case –
by case basis decision.
ACOG Task Force On Hypertension:
* Chronic hypertension with super imposed PE
without features of severe disease & with
reassuring fetal status:
expectant F/O until 37w.
* Severe PE or nonreassuring fetal status:
early delivery.
Recommended