tipus preeklampsia

8/10/2019 tipus preeklampsia

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PREECLAMPSIA & ECLAMPSIA


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Hypertension

Sustained BP elevation of 140/90 or greater


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PIH

Mild

HELLP

Synd

Impendingeclampsia

Preeclampsia

Gestasional

Effect

Chronic

Severe

Eclampsia


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20

Proteinuria (+)

Hipertensi kronik

Preeklampsia

Proteinuria (-)

Hipertensi Gestasional

Proteinuria (+) Super imposed


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Hypertensive isease Associated !ith

Pregnancy

Chronic Hypertension

Gestational Hypertension

Preeclampsia

clampsia

H!!P Syndrome


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Pregnancy


"iagnosed #efore the $0th%ee& or present #efore thepregnancy

'ild hypertension( 140)1*0 mmHg systolic

( 90)100 mmHg diastolic


Preeclampsia

clampsia

H!!P Syndrome


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Pregnancy



Criteria

"evelops after $0 %ee&s of gestation Proteinuria is a#sent

Blood pressures return to normal postpartum

'or#idity is directly related to the degree of hypertension

Preeclampsia

clampsia

H!!P Syndrome


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"verlap#isease Progression

25%

E l e v a t e d B P a b o v ef i r s t t r i m e s t e r

l e v e l s5 5 - 7 5 %

G e s t a t i o n a l h y p e r t e n s i o nN o p r o t e i n u r i a

5 - 1 0 % o f s i n g l e t o n s 0 % o f m u l t i p l e s

P r e e ! l a m p s i a" y p e r t e n s i o n

P r o t e i n u r i a5 - # % o f p r o g n a n ! i e s

P a t i e n t $ i t h " y p e r t e n s i o n


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Pregnancy



Preeclampsia

Criteria

"evelops after $0 %ee&s

Blood pressure elevated on t%o occasions at least + hours apart

,ssociated %ith proteinuria and edema

'ay occur less than $0 %ee&s %ith gestational tropho#lastic

neoplasia

clampsia

H!!P Syndrome


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Preeclampsia vs$ Severe Preeclampsia

Criteria forPreeclampsia

Previously normotensive

%oman( 140 mmHg systolic

( 90 mmHg diastolic

Proteinuria ( -00 mg in$4 hour collection

.ondependent edema


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Criteria for Severe Preclampsia

%P '() systolic or '') diastolic

* gr of protein in +, ho-r -rine or ./ on + dipstic0 -rines greater than ,

ho-rs apart

"lig-ria 1 *)) mL in +, ho-rs

Cere2ral or vis-al distr-2ances 3headache4 scotomata5

P-lmonary edema or cyanosis

Epigastric or R67 pain

Evidence of hepatic dysf-nction

8hrom2ocytopenia

Intra-terine gro!th restriciton 3I6GR5


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Ris0 9actors for Preeclampsia

.ulliparity

'ultifetal gestations

'aternal age over -

Preeclampsia in aprevious pregnancy

Chronic hypertension

Pregestational dia#etes

ascular and connectivetissue disorders

.ephropathy,ntiphospholipid

syndrome

#esity,frican),merican race


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Pregnancy



Preeclampsia

clampsia

"iagnosis of preeclampsia

Presence of convulsions not e2plained #y a neurologicdisorder

Grand mal sei3ure activity

ccurs in 0 to 45 or patients %ith preeclampsia

H!!P Syndrome


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Pregnancy



Preeclampsia

Eclampsia

HELLP Syndrome

A distinct clinical entity !ith:

Hemolysis4 Elevated Liver en;ymes4 Lo! Platelets

"cc-rs in , to '+ < of patients !ith severe preeclampsia

Microangiopathic hemolysis

8hrom2ocytopenia

Hepatocell-lar dysf-nction


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Mor2idity and Mortality from

Hypertensive isease

Hypertension a6ects 1$ to $$5 of pregnantpatients

Hypertensive disease is directly responsi#le for

appro2imately $05 of maternal mortality in the7nited State


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Mississippi Classification:

Class ' : Platelet co-nt : 50.000 100.000


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Pathophysiology

asospasm

7terine vessels

Hemostasis

Prostanoid #alance

ndothelium)derived factors

!ipid pero2ide8 free radicals and antio2idants


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Pathophysiology

>asospasm

Predominant finding in gestational hypertension and

preeclampsia

6terine vessels

Hemostasis

Prostanoid 2alance

Endotheli-m?derived factors

Lipid pero@ide4 free radicals and antio@idants


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Pathophysiology

>asospasm

6terine vessels

Inade-ate maternal vasc-lar response to tropho2lastic

mediated vasc-lar changes Endothelial damage

Hemostasis

Prostanoid 2alance




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Pathophysiology

asospasm

7terine vessels

Hemostasis

ncrease platelet activation resulting in consumption ncreased endothelial :#ronectin levels

"ecreased antithrom#in and ;$)antiplasmin levels

,llo%s for microthrom#i development %ith resultantincrease in endothelial damage

Prostanoid #alance

ndothelium)derived factors

!ipid pero2ide8 free radicals and antio2idants


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Pathophysiology

>asospasm

6terine vessels

Hemostasis

Prostanoid 2alance

Prostacyclin 3PGI+5:8hrom2o@ane 38BA+5 2alance shifted to favor

8BA+

8BA+ promotes:

>asoconstriction

Platelet aggregation




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Pathophysiology

>asospasm

6terine vessels

Hemostasis

Prostanoid 2alance


itric o@ide is decreased in patients !ith preeclampsia

As this is a vasodilator4 this may res-lt in vasoconstriction



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Pathophysiology

>asospasm

6terine vessels

Hemostasis

Prostanoid 2alance


Lipid pero@ide4 free radicals and antio@idants Increased in preeclampsia

Have 2een implicated in vasc-lar inD-ry


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Pathophysiologic Changes

Cardiovascular e6ects

Hematologic e6ects

.eurologic e6ects

Pulmonary e6ects


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Cardiovasc-lar effects

Hypertension

Increased cardiac o-tp-t

Increased systemic vasc-lar resistance

Hematologic effects

e-rologic effects

P-lmonary effects

Renal effects

9etal effects


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Hematologic effects

>ol-me contraction#Hypovolemia

Elevated hematocrit

8hrom2ocytopeni; Microangiopathic hemolytic anemia

8hird spacing of fl-id

Lo! oncotic press-re

e-rologic effects

P-lmonary effects

Renal effects

9etal effects


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Hematologic effects

e-rologic effects

Hyperrefle@ia

Headache

Cere2ral edema

Sei;-res

P-lmonary effects

Renal effects

9etal effects


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Hematologic effects

e-rologic effects

P-lmonary effects

Capillary lea0

Red-ced colloid osmotic press-re

P-lmonary edema

Renal effects

9etal effects


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Hematologic effects

e-rologic effects

P-lmonary effects

Renal effects

ecreased glomer-lar filtration rate

Glomer-lar endotheliosis

Protein-ria "lig-ria

Ac-te t-2-lar necrosis

9etal effects


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Renal Effects

"ecreased glomerular :ltration rate

Glomerular endotheliosis

Proteinuria

liguria

,cute tu#ular necrosis


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Hematologic effects

e-rologic effects

P-lmonary effects

Renal effects

9etal effects

Placental a2r-ption

9etal gro!th restriction

"ligohydramnios

9etal distress

Increased perinatal mor2idity and mortality


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Management

>he ultimate cure is delivery

,ssess gestational age

,ssess cervi2

=etal %ell)#eing

!a#oratory assessment


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Gestational H8 at 8erm

"elivery is al%ays a reasona#le option if term

f cervi2 is unfavora#le and maternal disease ismild8 e2pectant management %ith close

o#servation is possi#le


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Mild Gestational H8 not at 8erm

%ice %ee&ly visits

,ntenatal fetal surveillance

utpatient versus inpatient


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Indications for elivery

@orsening BP

.onreassuring fetal condition

"evelopment of severe PH

=etal lung maturity

=avora#le cervi2


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6nfavora2le Cervi@

.o contraindication to prostaglandin agents

f A -$ %ee&s8 consider cesarean

@hen favora#le8 o2ytocin


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Hypertensive Emergencies

=etal monitoring

access

hydration

>he reason to treat is maternal8 not fetal

'ay reuire C7


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Criteria for 8reatment

"iastolic BP ( 10)110

Systolic BP ( $00

,void rapid reduction in BP

"o not attempt to normali3e BP

Goal is "BP A 10 not A 90

'ay precipitate fetal distress


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Characteristics of Severe H8

Crises are associated %ith hypovolemia

Clinical assessment of hydration is inaccurate

7nprotected vascular #eds are at ris&8 eg8 uterine


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ey Steps 6sing >asodilators

$0)00 cc of uid8

,void multiple doses in rapid succession

,llo% time for drug to %or&

'aintain !!" position

,void over treatment


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Ac-te Medical 8herapy

Hydrala3ine

!a#etalol

.ifedipine

.itroprusside

"ia3o2ide

Clonidine


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Hydrala;ine

"oseD )10 mg every $0 minutes

nsetD 10)$0 minutes

"urationD -)* hours

Side e6ectsD headache8 ushing8 tachycardia8lupus li&e symptoms

'echanismD peripheral vasodilator


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La2etalol

"oseD $0mg8 then 408 then *0 every $0 minutes8for a total of $$0mg

nsetD 1)$ minutes

"urationD +)1+ hours

Side e6ectsD hypotension

'echanismD ,lpha and Beta #loc&


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ifedipine

"oseD 10 mg po8 not su#lingual

nsetD )10 minutes

"urationD 4)* hours

Side e6ectsD chest pain8 headache8 tachycardia

'echanismD C, channel #loc&


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Clonidine

"oseD 1 mg po

nsetD 10)$0 minutes

"urationD 4)+ hours

Side e6ectsD unpredicta#le8 avoid rapid %ithdra%al

'echanismD ,lpha agonist8 %or&s centrally


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itropr-sside

"oseD 0$ E 0* mg/min

nsetD 1)$ minutes

"urationD -) minutes

Side e6ectsD cyanide accumulation8 hypotension

'echanismD direct vasodilator


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Sei;-re Prophyla@is

'agnesium sulfate

4)+ g #olus

1)$ g/hour

'onitor urine output and ">


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Magnesi-m S-lfate

s not a hypotensive agent

@or&s as a centrally acting anticonvulsant

,lso #loc&s neuromuscular conduction

Serum levelsD +)* mg/d!


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8o@icity


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8reatment of Eclampsia

=e% people die of sei3ures

Protect patient

,void insertion of air%ays and padded tongue#lades

access

'GS4 4)+ #olus8 if not e6ective8 give another $ g


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8HE 9IRS8 8HIG 8" " A8 A SEIF6RE IS 8" 8AE

"6R " P6LSE


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Alternate Anticonv-lsants

Have not #een sho%n to #e as ecacious asmagnesium sulfate and may result in sedationthat ma&es evaluation of the patient more dicult

"ia3epam )10 mg

Sodium ,mytal 100 mg

Pento#ar#ital 1$ mg

"ilantin 00)1000 mg infusion


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After the Sei;-re

,ssess maternal la#s

=etal %ell)#eing

6ect delivery

>ransport %hen indicated

.o need for immediate cesarean delivery


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"ther Complications

Pulmonary edema

liguria

Persistent hypertension

"C


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P-lmonary Edema

=luid overload


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8reatment of P-lmonary Edema

,void over)hydration


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"lig-ria

$)-0 cc per hour is accepta#le

f less8 small uid #oluses of $0)00 cc as needed

!asi2 is not necessary

Postpartum diuresis is common

Persistent oliguria almost never reuires a P, cath


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Persistent Hypertension

BP may remain elevated for several days

"iastolic BP less than 100 do not reuiretreatment

By de:nition8 preeclampsia resolves #y + %ee&s


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isseminated Intravasc-lar Coag-lopathy


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Anesthesia Iss-es

Continuous lum#ar epidural is preferred ifplatelets normal

.eed adeuate pre)hydration of 1000 cc

!evel should al%ays #e advanced slo%ly to avoidlo% BP

,void spinal %ith severe disease


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HELLP Syndrome

He)hemolysis

!)elevated liver en3ymes

!P)lo% platelets


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HELLP Syndrome

s a variant of severe preeclampsia

Platelets A 1008000

!=>Fs ) $ 2 normal

'ay occur against a #ac&ground of %hat appearsto #e mild disease


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Conservative Management

Controversial

Steroids


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Prevention

!o% dose ,S, ine6ective in patients atlo% ris&

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tipus preeklampsia