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Kepaniteraan klinik Fakultas Kedokteran Unika Atmajaya 2015
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PREECLAMPSIAFerdinand Ferry Wijaya 2013-061-110Laura Cynthia Bria 2013-061-113Stella Levina Kurniawan 2014-061-133Yohannes Kurniawan S 2014-061-149Maria Dominika Ankira F 2014-061-150
TOPIC LISTPembimbing : dr Sigit P Diptoadi, Sp.OG
PREECLAMPSIA
Hypertensive disorder specific to pregnancy affects nearly 6% of all pregnancies a major cause of maternal and neonatal
mortality and morbidity 24 % of maternal mortality in Indonesia
PREECLAMPSIA
Severity ranges from: a mild disorder (Gestational
Hypertension) to a life-threatening disorder with seizures
(eclampsia), HELLP syndrome, fetal hypoxia, and growth retardation (IUGR)
more severe disease: 0.56 per 1000 deliveries
PREECLAMPSIA
Risk Factor History of preeclampsia First pregnancy (Primigravida) Maternal age (>40 ) Chronic hypertension and CKD Obesity
PREECLAMPSIA
The etiology is unknown believed to be involved:
immune maladaptation placental ischemia oxidative stress genetic susceptibility
PREECLAMPSIA
Classification of hypertension in pregnancy Gestational hypertension Preeclampsia / eclampsia Chronic hypertension Preeclampsia superimposed on chronic
hypertension
PREECLAMPSIA Criteria
Hypertension a systolic blood pressure of 140 mmHg or
above, or a diastolic blood pressure of 90mmHg
or above, It measured on two occasions 4-6 hours
apart Abnormal Proteinuria
the excretion of 300 mg or more of protein in 24 hours urine sample
Generalized Edema
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
PREECLAMPSIA
Criteria for severe preeclampsia Severe Trombositopenia (< 100.000
cell/mm3) Pulmonary edema or cyanosis Oliguria (< 500 mL of urine in 24 hours) HELLP syndrome
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
Classifications
Prevention Know your blood pressure level before getting pregnant Get a regular prenatal checkups Avoid smoking, alcohol, and caffeine Dietary and lifestyle modifications
Low salt diet ineffective in preventing preeclampsia Calcium supplementation women with low dietary
calcium intake were at significantly increased risk for gestational hypertension. Besides, increasing calcium intake will lowered the risk for preeclampsia in high-risk women.
Maintain a healthy weight being overweight can make the women 2-6 times more likely to develop high blood pressure
Regular exercise found to be a risk reduction for hypertension in pregnancy
Reduce stress
Prevention
Antihypertensive drugs women given diuretics had a decreased incidence of edema and hypertension but not of preeclampsia.
Antioxidants imbalance between oxidant and antioxidant activity may play an important role in the pathogenesis of preeclampsia
Anti-cholesterol the use of statins may prevent hypertensive disorders of pregnancy.
Antithrombotic agents Low-dose aspirin the relative risk for development of
preeclampsia, superimposed preeclampsia, preterm delivery, decrease by 10%.
Low-dose aspirin plus heparin effective for women with thrombophilia and a history of early onset preeclampsia.
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
PREECLAMPSIA
Severe preeclampsia - expectant management gestational age: not recommended for <
24 weeks or > 34 weeks gestation hospitalization: tertiary care center antenatal testing: daily
Treatments
MgSO4 with an IV bolus of 4 g (15-20 minutes) to stop seizures, continuing maintenance infusion rate of 1 g/h
Aggressive prompt delivery is indicated for eclampsia at any gestational age after stabilization of the mother and the fetus. Attempt vaginal delivery with IV oxytocin infusion if mother and fetus are stable.
IV hydralazine, labetalol, and/or nifedipine to maintain systolic BP between 140 and 160 mmHg and diastolic BP between 90-110 mmHg.
Diuretics are used only in the setting of pulmonary edema Antenatal steroids may be administered in anticipation of
emergent delivery when gestational age is less than 32 weeks. Betamethasone (12mg IM/24hours x 2 doses) or dexamethasone (6 mg IM/12 hours x 4 doses) is recommended
Prevent aspiration and hypoxia
HELLP Syndrome
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
HELLP Syndrome
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
HELLP Syndrome
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
HELLP Syndrome
differential diagnosis of HELLP Syndrome acute fatty liver of pregnancy appendicitis diabetes insipidus gallbladder disease gastroenteritis glomerulonephritis hemolytic uremic syndrome hepatic encephalopathy
HELLP Syndrome
antepartum management of HELLP syndrome
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
HELLP Syndrome
• 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
HELLP Syndrome
management for cesarean birth with HELLP syndrome 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
HELLP Syndrome
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
ECLAMPSIA
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
ECLAMPSIA
Eclampsia precise cause unknown theories
vasospasm ischemia edema multisystem organ failure
ECLAMPSIA
Eclampsia - Symptoms seizures usually occur without aura hypertension not severe in 20% cases edema absent in 30% cases proteinuria absent in 20% cases hyperreflexia is not predictive of
seizures headache or visual changes - most
common prodromal event → impending eclampsia
ECLAMPSIA
Event of Eclampsia Most common in the last trisemester 80% of convulsions occur before or during
the delivery 2/3 of cases may be preventable by
adequate preeclampsia therapy atypical
less than 20 weeks gestation more than 48 hours postpartum (usually in
24 hours postpartum)
ECLAMPSIA
Eclampsia - risk factors low socioeconomic extremes childbearing age Afro-American no adequate prenatal care substance abuse Preexisting condition – diabetes, renal,
or cardiovascular disorder.
ECLAMPSIA
Eclampsia – Major Maternal Complication Placental Abruption 10% Neurological deficit 7% Aspiration Pneumonia 7% Pulmonary edema 5% Cardiopulmonary arrest 4% Acute renal failure 4% Dead 1%
ECLAMPSIA
Eclampsia - Management control of convulsions correction of hypoxia and acidosis anti hypertensive medication for blood
pressure control avoid diuretic if not indicated delivery after maternal stabilization to
achieve remission of preeclampsia
ECLAMPSIA
Eclampsia – convultions control magnesium sulfate
administer intravenously by continous infusion, or may be given intramuscularly by intermittent injection
mechanism of action - smooth muscle relaxation by displacement of calcium → avoid CNS depression of mother or fetus
ECLAMPSIA
Eclampsia - magnesium sulfate dosage intravenous
4-6 g intravenous loading dose in 100mL IV fluid in 15-20min
followed by 2 g/hr in 100mL maintenance infusion
Discontinue after 24 hours of delivery Monitor toxicity
Assess deep tendon reflex periodically Measure magnesium serum level every 4-6hr
or creatinine > 1.0 mg/dLand adjust infusion (keep at 4.8 – 8.4 mg/dL)
ECLAMPSIA
Eclampsia - magnesium sulfate dosage intramuscular
4 g intravenous as 20% solution at rate 1g/min 10 g of 50% solution → 5g injected deeply on
each upper outer quadrant of buttock (add 1mL lidocaine to minimize discomfort)
5g on alternate buttock/4hr after ensuring: Patellar reflex Respiration not depressed 4hr UO excedeed 100ml
Discontinued 24 hr after delivery
ECLAMPSIA
Eclampsia - magnesium sulfate side effects:
maternal hypotonia respiratory depression cardiac arrest neonatal depression
contraindicated in myasthenia gravis use with caution in renal insufficiency
ECLAMPSIA
Eclampsia - anticonvulsant therapy phenytoin
used mainly in Europe may be used in myasthenia gravis mechanism of action - increase gamma
aminobutyric acid-mediated chloride conduction in postsynaptic membranes
inhibit neurotransmitter inhibitory systems
ECLAMPSIA
Eclampsia - phenytoin dosage - 1 g loading dose over 1 hour cardiac monitoring during administration side effects
arrhythmias with rapid administration hepatitis Steven-Johnson syndrome
ECLAMPSIA
Eclampsia - anticonvulsant therapy diazepam
useful for status epilepticus mechanism of action - facilitate 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
ECLAMPSIA
• 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
ECLAMPSIA
• 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
ECLAMPSIA
• Eclampsia – fetus monitoring– Fetal heart rate and uterine contraction• Bradycardia ~ 5 minutes after the onset of
the seizure• may be associated with rebound
tachycardia• recovery phase may show late
decelerations
ECLAMPSIA
• Eclampsia - radiographic evaluation– abnormal CT findings - 50%• edema, hemorrhage, infarction
– cerebral angiography has limited use
ECLAMPSIA
• Eclampsia - radiographic evaluation– abnormal CT findings - 50%• edema, hemorrhage, infarction
– cerebral angiography has limited use
ECLAMPSIA
• Eclampsia - management• use bite block as needed to prevent
maternal injury• establish airway, breathing, and
circulation• Stabilized vital sign• administer magnesium sulfate as soon as
possible• obtain arterial blood gases• monitor urine output• control hypertension
ECLAMPSIA
• Eclampsia - management– DOC: magnesium sulfate loading dose : 4g IV for 15
minutes maintenance dose : 6g in RL/6 hr– do not intervene for fetal status while
mother is unstable
ECLAMPSIA
• Eclampsia ~ prognosis – With adequate medication eclampsia
resolve after delivery– 25% of women with eclampsia have
hypertension in subsequent pregnancies– 2% of women with eclampsia develop
eclampsia with future pregnancies
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.