Preeclampsia 2010

Preeclampsia / Gestational Hypertension Diagnosis & Management 2010

For Patients at Risk for Developing Preeclampsia Obtain Baseline Labs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Chronic Hypertension Patients Increased Risk of Developing Superimposed Pre-Eclampsia ,[object Object],[object Object],[object Object],[object Object]

Baseline Labs for Patients at Risk ,[object Object],[object Object],[object Object],[object Object]

Consider ASA in High Risk Patients Prevention of Pre-Eclampsia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Consider Ca for All Patients Decrease Severity of Preeclampsia ,[object Object],[object Object],[object Object],[object Object]

Diagnosis Gestational Hypertension ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Diagnosis Preeclampsia ,[object Object],[object Object],[object Object],[object Object],[object Object],ObstetGynecol 2003:102:181

Diagnosis of Superimposed Pre-Eclampsia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

“Impending Preeclampsia” ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Edema and Rapid Weight Gain ,[object Object],[object Object],[object Object]

Assessment of Severity Laboratory Evaluation Sibai. Am J Obstet Gynecol 2009 ,[object Object],[object Object],[object Object],[object Object],LP ● Platelets  100k EL ● SGOT/SGPT  2x upper limit ( 70 ) H ● LDH  600 Iu and/or total bilirubin ≥1.2mg/dl

Diagnosis HELLP Syndrome ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Obstet Gynecol 2004:103:981 Sibai. Am J Obstet Gynecol 2009

“ Partial HELLP” ≈ 20% of Severe Disease Am J Obstet Gynecol 1996:175:460 Sao Paulo Med J 2002:120:180 Sibai. Am J Obstet Gynecol 2009 20 LP LP 24 or H 7 30 EL LP 6 12 H Combined % Isolated %

Lab Abnormalities Uric Acid ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Assessment of Severity Remember the Baby ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Epigastric pain Right upper quadrant pain Retrosternal chest pain Nausea and vomiting Shortness of breath/Congestive Heart Failure Headaches (not responsive to analgesics) Visual changes Altered mental status Bleeding from mucosal membranes Jaundice Signs and Symptoms Severe preeclampsia Sibai. Diagnosis and management of a typical preeclampsia-eclampsia. Am J Obstet Gynecol 2009

Prodromal Symptoms in Patients with Eclampsia BMJ 1994:309:1395 Am J Obstet Gynecol 2000:182:1389 Am J Obstet Gynecol 2002:186:1174 75% At least one of the above symptoms 10 – 20% Epigastric pain 20 – 30% Visual Change Blurred vision Photophobia 50 – 75% Headache

Criteria for Severe Preeclampsia* ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],SIBAI 2006 ACOG 33:2002

Criteria for Severe Gestational Hypertension* ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Complications of Preeclampsia Obstet Gynecol 2000:95:24 Am J Obster Gynecol 2004:190:1520 2 / 100 1 / 200 Eclampsia ≈No Mg < 2 1 < 2 Perinatal death 43 27 13 NICU 19 10 4 IUGR 19 2 3 Delivery < 34 4 < 1 < 1 Abruption 13 5 < 1 Kidney disease 20 3 < 1 Liver disease Severe (%) Mild (%) Control Complication

Complications Severe Gestational HTN & Severe Preeclampsia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Obstet Gynecol 2000:95:24

Complications HELLP Syndrome ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Obstet Gynecol 2004:103:981

ATYPICAL DISEASE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Sibai. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 2009;200:481.e1-481.e7.

ATYPICAL DISEASE Overlapping role of hypertension, capillary leak, maternal symptoms, and fibrinolysis/hemolysis in the spectrum of atypical preeclampsia Blood Pressure may be normal Fibrinolysis/Hemolysis 1 or none Low plts/DIC/ LFT’s elevated HELLP or Renal Failure Capillary Leak Symptoms Proteinuria, Facial edema, Pleural effusions, Pulmonary edema , Ascites Sibai. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 2009.

Atypical Disease ,[object Object],[object Object],[object Object],[object Object],[object Object],Am J Obstet Gynecol 2000:182:307 & Sibai 2009; 200:481.e1-481.e7. BMJ 1994:309:1395 Obstet Gynecol 2004:103:981

ATYPICAL DISEASE ,[object Object],[object Object],[object Object],Sibai. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 2009;200:481.e1-481.e7.

Initial Evaluation for Gestational Hypertension & Preeclampsia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Management Mild Preeclampsia & Gestational Hypertension ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Mild Preeclampsia Home Management Progression of Disease Consider Admission to Hospital ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Obstet Gynecol 2003:102:181

Indications for Delivery in Preeclampsia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Am J Obstet Gynecol 2000:183:S1 Obstet Gynecol 2003:102:181

Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation (HYPITAT): a multicentre, open-label randomised controlled trial Lancet 2009; 374: 979–88 Induction (n=377) Expectant (n=379) Vaginal Delivery 323 (85%) 307 (84%) NS Cesarean section 54 (14%) 72 (19%) NS Poor Maternal Outcome 117 (31%) 166 (44%) p<0·0001 Composite Adverse neonatal outcome 24 (6%) 32 (8%) NS

Indications for Delivery Preeclampsia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Expectant Management Severe Disease ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Postpartum Antihypertensive Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Multiple RCT Conclusively Demonstrate Clinical Obstet Gynecol 2005:48:478 ,[object Object],128 / 6330 (2.0%) 49 / 6343 (0.6%) Seizures No Mg So 4 Mg So 4

Magnesium Sulfate Mild Preeclampsia 2 Small Randomized Trials Am J Obstet Gynecol 1997:176:623 Obstet Gynecol 2003:101:217 Risk of eclampsia with no Mg So 4 1 / 200 13.8% 12.5% Progression to severe disease 0 / 181 0 / 176 Eclampsia Placebo Mg So 4

Mg SO 4 not Currently Recommended for Seizure Prophylaxis with Mild Preeclampsia ,[object Object],SIBAI Am J Obstet Gynecol 2004:190:1520 Obstet Gynecol 2005:105:402 Lancet 2002:359:1877 To prevent one – “imminent” – 4% PPV 1 / 36 To prevent one seizure – severe 1 / 71 To prevent one seizure – mild 1 / 400 Patients with mild PrE who seize 1 / 200

Continued Assessment of Maternal Status for patients who have initial Mild PreEclampsia is Necessary in Labor ,[object Object],[object Object],[object Object]

Preeclampsia Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lancet 2005:365:785 Obstet Gynecol 2003:102:181 Lancet 2009; 374: 979–88

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Preeclampsia 2010