Professional Documents
Culture Documents
Pregnancy
Selly Septina, SpOG
Classification
by the working group of the
NHBPEP (2000)
1. Gestational hypertension
2. Chronic hypertension
3. Preeclampsia
4. Eclampsia
5. Preeclampsia superimposed on chronic
hypertension (superimposed preeclampsia)
I. Gestational hypertension
BP
Underlying causes of
Chronic Hypertension
III. Preeclampsia
Preeclampsia
Mild preeclampsia
BP >= 140/90 mmHg after 20 wk gestation
Proteinuria >= 300 mg/24hr or >=1+ dipstick
Severe preeclampsia
Anyone who meets at least two of the
following signs:
IV. Eclampsia
Seizures
Seizures
are generalized
May appear before , during or after labor
10% develop after 48 hr postpartum
V. Superimposed preeclampsia
New
Diagnosis
Gestational HT
Also
called transient HT
Final Dx : after delivery , by exclusion
BP : resting BP , Korotkoff phase V is
used to defined diastolic pressure
GHT may later develop preeclampsia
10% of eclamptic seizures develop before
overt proteinuria is identified
BP rise , increase both mother and fetus
risks
Preeclampsia
Advanced
maternal age
Race and ethnicity (genetic predisposition
& envoronmental factor)
Multifetal gestation
Obesity
BMI > 35 kg/m2
Superimposed preeclampsia
1. Hypertension (>=140/90) is documented
antecedent to pregnancy
2. Hypertension is detected before 20 wk ,
unless there is GTD
3. Hypertension persists long after delivery
Etiology?
Etiology
1. Abnormal trophoblastic invasion of uterine
vessels
2. Immunological intolerance between
maternal and fetoplacental tissues
3. Maternal maladaptation to cardiovascular
or inflammatory changes of normal
pregnancy (vasculopathy)
4. Dietary deficiencies
5. Genetic influences
Complications
Cardiovascular system
Increase
after load
Preload diminish
Endothelial activation with extravasation
Decreased cardiac output
Hemoconcentration from generalized
vasoconstriction and endothelial
dysfynction
Decreased blood volume
Kidney
RPF
Liver
Periportal
Elevated
transaminase
HELLP syndrome
Bleeding cause hepatic rupture(mortality
30%) , subcapsular hematoma
Conservative treatment
Recombinant factor VIIa
HELLP syndrome
No
strict definition
Incidence 20% of severe preeclampsia or
eclampsia
Factors contributing to death : include
stroke , coagulopathy , ARDS , ARF ,
sepsis
Insufficient evidence : adjunctive steroid
Brain
Headache
Prediction
Biological
markers
To identify markers of
faulty placentation
reduced placental perfusion ,
endothelial cell activation & dysfunction ,
activation of coagulation
HOW?
Uric acid
Decreased
Fibronectin
Endothelial
cell activation
Low sensitivity 69%
Positive predictive vaules 12%
Higher levels by 12 wks (PPV 29% NPV
98%)
Coagulation activation
Thrombocytopenia
and platelet
dysfunction
Increased destruction cause platelet
volumes increase (younger platelet)
Preeclampsia : PAI-1 increase increased
relative to PAI-2 because of endothelial
cell dysfunction
Cytokines
Released
Fetal DNA
Fetal
Prevention
Salt
restriction : ineffective
Inappropriate diuretic therapy
Low dietary calcium increased risk GHT
Fish oil capsules : modify abnormal PG
balance : ineffective
Low dose aspirin (60mg) : ineffective
Antioxidants : vitamin C & E : reduced
endothelial cell activation , reduction in
preeclampsia
Antioxidant
39%
0.61)
Reduced risk of SGA infant (RR 0.64)
More preterm birth (RR 1.38)
No difference in develop preeclampsia
among low & high risk (RR 0.66 & 0.44)
GA : no diff (<20wk VS before & after
20wk)
Dietary salt
Reduce
in risk of preeclampsia in
supplemented groups ( 200 ug & 5 mg/d)
In low serum folate pregnancy & women
with Hx preeclampsia
Odd ratios of preeclampsia no diff
between receive folic 200 ug VS 5 mg/d
(0.46 VS 0.59)
Management
Management
Early
prenatal detection
Antepartum hospital management
Termination of pregnancy
Antihypertensive drug therapy
2. Antepartum management
Admit
Antepartum management
Evaluate
fetal size , AF
Reduced physical activity
Sedative not prescribed
Ample, not excess, protein & calories diet
Sodium & fluid intake not limit or forced
Further Mg depend on : severity ,
Gestational Age , condition of cervix
Preeclampsia-Initial Evaluation
Serial
Severe PreeclampsiaManagement
Seizure
prophylaxis
Blood pressure control
Delivery
Preeclampsia-Term Pregnancy
Delivery
is a short-term goal
Induction of labor is appropriate after
maternal-fetal observation/stabilization
Cesarean reserved for standard obstetric
indications
Cesarean may be recommended in cases
of severe preeclampsia where delivery is
remote
Preeclampsia-Preterm
Pregnancy
Mild
preeclampsia - expectant
management is acceptable under certain
conditions
Close maternal-fetal surveillance
Ability to intervene either if conditions
worsen or if acceptable gestational age
reached
In-hospital vs. home care?
Preeclampsia-Preterm
Pregnancy
Severe
preeclampsia - controversial
Delivery for poor maternal condition is
likely to be necessary over the short term
Sibai has advocated expectant
management for selected patients to
attempt to reduce perinatal morbidity and
mortality due to prematurity
Preeclampsia-Preterm
Pregnancy
Expectant
management of severe
preeclampsia at preterm gestational age:
Hospitalization
Magnesium sulfate for seizure prophylaxis, at
least during initial observation period
Blood pressure control to range of 140155/90-105 (labetalol or nifedipine)
Daily assessment of maternal-fetal condition
Preeclampsia-Preterm
Pregnancy
weeks corticosteroids for fetal
lung maturation
24-34
Deliver
3. Termination of pregnancy
Delivery
Termination of pregnancy
Preterm
vaginal delivery
c-section if indicated
Induction
4. Antihypertensive drug
To
Antihypertensive drug
Glucocorticoids
Not
worsen maternal HT
Decrease RDS , improve fetal survival
No evidence : benefit to ameliorate
severity of HELLP syndrome
Transient improve hematological lab :
platelet counts
2 Maternal death , 18 stillbirth
Eclampsia-Management
Preeclampsia
complicated by generalized
tonic-clonic convulsions OR
Fatal coma without convulsions also
Major complications included placental
abruption (10%) , neuro deficit (7%) ,
aspiration pneumonia (7%) , pulm edema
(5%) , arrest (4%) , ARF (4%) , death (1%)
Eclampsia
Duration
of coma variable
Hypercarbia , lactic acidemia , fetal brady
cardia
High fever
Proteinuria
Diminished urine output , hemoglobinuria
Pronounced edema
Proteinuria & edema disappear within 1 wk
BP return within a few days to 2 wk PP
Eclampsia
Differential
diagnosis : epilepsy ,
encephalitis , meningitis , cerebral tumor ,
cysticercosis , ruptured cerebral aneurysm
Prognosis always serious
6% of Maternal death relate to eclampsia
Among PIH patient , maternal death 16%
Treatment
1. control of convulsions using IV MgSO4
2. Intermittent IV or oral of antihypertensive
drug to lower Diastolic BP <100
3. Avoidance of diuretics , limit IV fluid
adminstration , avoid hyperosmotic agents
4. Delivery
Continuous IV regimen
4-6 gm MgSO4 dilute in 100 ml fluid , admin
over 15-20 min
Begin 2 g/hr in 100 ml IV maintenance
Measure Mg level at 4-6 hr , adjust level
between 4-7 mEq/L
MgSO4 discontinued 24 hr after delivery
Intermittent intramuscular
Give
MgSO4
Effective
MgSO4
Almost
MgSO4
Fetal effects
Promptly cross placenta
Neonatal depression occurs only if severe
hypermagnesemia at delivery
Decrease in beat-to-beat variability
Possible protective effect against cerebral palsy
in VLBW infants
Substantial gross motor dysfunction reduced
No serious harmful effects
Antihypertensive
Hydralazine
suggested if persistent
systolic > 160 , or diastolic > 105 mmHg
(NHBPEP2000)
5-10 mg doses at 15-20 min inervals
Satisfactory response ante or intrapartum :
diastolic 90-100
Seldom another antihypertensive needed
FHR deceleration when BP fell to 110/80
Antihypertensives
: IV 1& nonselective -blocker
Lower BP more rapidly , associated
tachycardia
NHBPEP(2000) : recommends 20 mg IV
bolus , if not effective within 10 min ,
followed by 40 mg , then 80 mg q 10 min
but not exceed 220 mg total dose per
episode treated
Labetolol
Antihypertensives
Nifedipine
Persistent postpartum HT
Hydralazine
10-25 mg IM q 4-6 hr
If HT persists or recur : oral labetolol or
thiazide diuretic are given
Two mechanisms :
Fluid therapy
Lactate
Pulmonary edema
Invasive monitoring
Use
Delivery
After