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The National High Blood Pressure Education Program (NHBPEP) Working
Group defines HYPERTENSION in PREGNANT WOMAN:
systoli...
Multifactorial
3% of all pregnancies
Primiparity Immunologic factors Previous pregnancy complicated by
Preeclampsia/Eclampsia/HELLP
Family history of Preeclamp...
Primipaternity Sexual co-habituation Maternal infection
Gestational age at delivery of 1st
Pregnancy Socioeconomic status ...
Stage 0
3-8 weeks
Stage 1
8-18 weeks
Stage 2
20 weeks to
birth
Poor Immunoregulation
Inadequate tolerance to feto-paternal...
invasive cytotrophoblasts
of fetal origin invade the
maternal spiral arteries
transforms them from
small-caliber resistanc...
cytotrophoblasts fail to adopt an invasive
endothelial phenotype
invasion of the spiral arteries is shallow and they
remai...
Soluble Flt-1 (sFlt-1) causes endothelial
dysfunction by antagonizing vascular
endothelial growth factor (VEGF) and
placen...
Faulty placentation
Excessive trophoblastsMaternal vascular disease
Reduced Uteroplacental Perfusion
Genetic/Immunologic/I...
Activation of CoagulationCapillary LeakVasospasm
Abruption
Seizures
Hypertension
Liver Ischemia
Oliguria
Proteinuria
Edema...
Gestational HPN
• Previously normal BP
• Elevated BP without proteinuria
• Develops after 20 weeks of gestation and BP nor...
Chronic HPN
• Previously elevated BP
• Use of antihypertensive medications before pregnancy
• Develops before 20 weeks of ...
Ideal: mercury manometer
• Alternative: aneroid, digital, or other automated devices
• Cuff should cover: 2/3 of arm or at...
Systolic BP: 1st clear tapping sound (Korotkoff phase I)
• Diastolic BP: disappearance of tapping sounds (Korotkoff phaseV...
Screening maneuvers
• Mean Arterial Pressure
• Roll over test
• MAP-2 with Roll over test
• 48 hour BP monitoring
• 24 hou...
Calcium Supplementation
Dose: 1.5 to 2 g per day before 32 weeks AOG until delivery
Antiplatelet agents
ASA or dipyridamol...
PREECLAMPSIA
MILD No manifestations of any of severe preeclampsia
SEVERE
BP SBP ≥ 160 or
DBP ≥ 110
Laboratories
Elevated s...
Criteria for home health care
Ability to comply with recommendation
Diastolic BP <100 mm Hg
Systolic BP <140 mm Hg
Protein...
TimingofDelivery Gestational Age
≥ 40 weeks
• Bishop score > 5
• Fetal weight < 10th percentile
• Non-reactive non-stress ...
Maternal and fetal well-being at least once weekly
• BP each visit
• Platelet count and liver enzymes at regular intervals...
5-6% of all pregnancies worldwide
5-10% - severe
Local incidence: 2-5%
2nd most common cause of maternal death
High perina...
CNSDysfunction
• Blurred
vision
• Scotomata
• Altered
mental
status
• Severe
headache
Livercapsuledistentionor
rupture
• P...
Pulmonaryedemaorcyanosis
• Excessive
fluid
accumu-
lation in
the lungs
Cerebrovascularaccident(CVA)
• Acute loss
of brain
...
Proteinuria
• >5 g per 24h
or ≥3+ on 2
random
urine
samples
collected at
least 4 hours
apart
Oliguriaand/orRenalFailure
• ...
Activation of CoagulationCapillary LeakVasospasm
Hypertension
Seizures
Proteinuria
Edema
Hemoconcentration
Endothelial Act...
Objectivesofmanagement Reduce severity or prevent progression of disease process
Prevent convulsions
Control severe hypert...
•Safety of mother
and fetus
Main objective
• Stabilization of mother’s
condition
• Confirmation of gestational age
• Asses...
Maternal
DELIVER
Fetal
Drug of choice for prevention of seizures
Drug is considered when women is at risk for eclampsia: moderate to severe
preec...
Continuous intravenous infusion
• Loading dose: 4-6 g dose of MgSO4 diluted in 100 ml of IVF administered over 15-20 min
•...
SBP: 140-155 mm Hg
DBP: 90-105 mm Hg
 Labetolol
 Hydralazine
 Nifedipine
 IV Nicardipine
 Methyldopa
 Second line ag...
Labetalol (C)
> 10 to 20 mg IV, then 20 to 80 mg every
20 to 30 minutes
> maximum of 300 mg;
> for infusion: 1 to 2 mg/min...
Methyldopa (B)
Secondlineagents
Preferred agent:
0.5 to 3.0 g in 2 divided dosage
Labetolol (C)
Nefidipine (C)
Hydralazine...
Hydrochlothiazide (C)
Contraindicated
Second line agents:
12.5 to 25.0 mg/d
ACE-I
ARB
Drug Dose Concerns
 Can cause volum...
Controlof
seizures
MgSO4 For prevention and reduction of recurrence
Diazepam Loading dose: 10
mg IV over 2 min
Followed by...
> 34 weeks
Deliver
Mode: vaginal
delivery
< 34 weeks
Defer delivery
Give corticosteroids
(24-34 weeks)
<32 weeks: CS
Eclam...
DEFINITION: Amniotic fluid index < 5cm
Fetal Growth restriction
ChromosomalAbnormalities
Demise
Congenital anomalies
Postt...
Most widely used for assessment of fetal well
being
Hypothesis: HR of non-acidotic fetus temporarily
increase in response ...
5 biophysical
variables
Highest
score: 10
NST
2
≥2 accelerations of ≥15 bpm
lasting for ≥15 sec within 20
min
0 0 or 1 acceleration in 20-
40 min
Fetal
Breathing
2 ...
Modified BPP
NSTUTZ assessment of AF
Requires less time
Excellent method of fetal surveillance
Biophysical
Score
Interpretation Recommended management
10 Normal, nonasphyxiated
No fetal indication for intervention
Rep...
Non-invasive way to assess blood flow characterizing downstream impedance
Umbilical artery systolic/diastolic ratio is com...
ABSENCE OF END-DIASTOLIC
FLOW
NORMAL DIASTOLIC FLOW
REVERSED END-DIASTOLIC
FLOW
ABNORMALITY BPS FREQUENCY DECISION TO DELIVER (FETAL)
Elevated Indices
Only
Weekly
Abnormal BPS orTerm or >36
weeks with n...
Preeclampsia
Preeclampsia
Preeclampsia
Preeclampsia
Preeclampsia
Preeclampsia
Preeclampsia
Preeclampsia
Preeclampsia
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A discussion on preeclampsia its management and treatment.

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Preeclampsia

  1. 1. The National High Blood Pressure Education Program (NHBPEP) Working Group defines HYPERTENSION in PREGNANT WOMAN: systolic blood pressure (BP) of 140 mmHg or higher diastolic BP of 90 mmHg or higher on more than 1 occasion
  2. 2. Multifactorial 3% of all pregnancies
  3. 3. Primiparity Immunologic factors Previous pregnancy complicated by Preeclampsia/Eclampsia/HELLP Family history of Preeclampsia BMI Pregnancy related conditions
  4. 4. Primipaternity Sexual co-habituation Maternal infection Gestational age at delivery of 1st Pregnancy Socioeconomic status Smoking
  5. 5. Stage 0 3-8 weeks Stage 1 8-18 weeks Stage 2 20 weeks to birth Poor Immunoregulation Inadequate tolerance to feto-paternal antigens during conception and implantation Poor Placentation Deficient trophoblast invasion and spiral artery remodelling Clinical manifestation Over activation of maternal endothelium and systemic inflammatory network Oxidative Stress Endoplasmic reticulum Stress Inflammatory Stress
  6. 6. invasive cytotrophoblasts of fetal origin invade the maternal spiral arteries transforms them from small-caliber resistance vessels to high-caliber capacitance vessels capable of providing placental perfusion adequate to sustain the growing fetus Normal Pregnancy
  7. 7. cytotrophoblasts fail to adopt an invasive endothelial phenotype invasion of the spiral arteries is shallow and they remain small caliber, resistance vessels placental ischemia Preeclampsia
  8. 8. Soluble Flt-1 (sFlt-1) causes endothelial dysfunction by antagonizing vascular endothelial growth factor (VEGF) and placental growth factor (PlGF) In normal pregnancy, the placenta produces modest concentrations ofVEGF, PlGF, and soluble Flt-1 In preeclampsia, excess placental soluble Flt-1 binds circulatingVEGF and PlGF and prevents their interaction with endothelial cell-surface receptors decreased prostacyclin nitric oxide production release of procoagulant proteins ENDOTHELIAL DYSFUNCTION
  9. 9. Faulty placentation Excessive trophoblastsMaternal vascular disease Reduced Uteroplacental Perfusion Genetic/Immunologic/Inflammatory factors Activation of CoagulationCapillary Leak Endothelial Activation Vasospasm Vasoactive Agents:  Prostaglandin  Nitric oxide  Endothelins Noxious Agents:  Cytokines  Lipid Peroxidases  Multiple gestation  Hydrops fetalis
  10. 10. Activation of CoagulationCapillary LeakVasospasm Abruption Seizures Hypertension Liver Ischemia Oliguria Proteinuria Edema Hemoconcentration Endothelial Activation Thrombocytopenia
  11. 11. Gestational HPN • Previously normal BP • Elevated BP without proteinuria • Develops after 20 weeks of gestation and BP normalizes 12 weeks postpartum Preeclampsia • Previously normal BP • Elevated BP with proteinuria • Develops after 20 weeks of gestation and BP normalizes 12 weeks postpartum Eclampsia • Hypertension in pregnancy with proteinuria along with convulsions • Preeclampsia with occurrence of grand mal seizures
  12. 12. Chronic HPN • Previously elevated BP • Use of antihypertensive medications before pregnancy • Develops before 20 weeks of gestation and • BP elevation persists longer than 12 weeks postpartum Chronic HPN with Superimposed Preeclampsia • Previously elevated BP or persists postpartum with associated signs and symptoms of preeclampsia • Develops before 20 weeks of gestation with new-onset proteinuria • Development of HELLP syndrome
  13. 13. Ideal: mercury manometer • Alternative: aneroid, digital, or other automated devices • Cuff should cover: 2/3 of arm or at least 80% of pt’s arm circ Position: seated, supine, or left lateral recumbent position • Should be rested at least 5-10 minutes • Not smoked or ingested caffeine 30 min. before measurement Bladder is inflated 30 mmHg above point of radial pulse extinction • Deflation: 2 mmHg per beat
  14. 14. Systolic BP: 1st clear tapping sound (Korotkoff phase I) • Diastolic BP: disappearance of tapping sounds (Korotkoff phaseV) OR • Present near 0: softening of sounds (Korotkoff phase IV) If BP taken for the 1st time: take BP of both arm, subsequent determination is done on the arm with higher BP • Arm with the higher values will be used for all BP measurements For white coat HPN: ambulatory BP monitoring • Instruct proper BP monitoring if BP monitoring is done at home
  15. 15. Screening maneuvers • Mean Arterial Pressure • Roll over test • MAP-2 with Roll over test • 48 hour BP monitoring • 24 hours ambulatory BP with heart rate • Hyperbaric Index Laboratory Test • Doppler Velocimetry • Fibronectin • Hematocrit • Proteinuria • Serum uric acid LaboratoryTest • Hemoglobinuria • Masternal Serum AFP • Hypocalciuria • Glucose intolerance • Inhibin A Others: biochemical markers
  16. 16. Calcium Supplementation Dose: 1.5 to 2 g per day before 32 weeks AOG until delivery Antiplatelet agents ASA or dipyridamole: reduce risk of preeclampsia by 17% Insufficient evidence on others Antioxidants, nitric oxide, rest, exercise, diuretics, ↓ed salt intake, marine oil, prostaglandin
  17. 17. PREECLAMPSIA MILD No manifestations of any of severe preeclampsia SEVERE BP SBP ≥ 160 or DBP ≥ 110 Laboratories Elevated serum creatinine Thrombocytopenia Hepatocellular dysfunction (↑ed AST and ALT)Pulmonary edema Microangiopathic hemolysis Urine ≥5 g/24h or ≥ 3 in 2 random urine sample (q4h) Oliguria <500ml/24h IUGR or Oligohydramnios Symptoms of End-organ involvement Headache Visual disturbances Epigastric pain or RUQ pain
  18. 18. Criteria for home health care Ability to comply with recommendation Diastolic BP <100 mm Hg Systolic BP <140 mm Hg Proteinuria < 1,000 mg/24 hr OR < 2+ on dipstick Platelet count > 120,000/mm Normal fetal growth and testing No indications for delivery
  19. 19. TimingofDelivery Gestational Age ≥ 40 weeks • Bishop score > 5 • Fetal weight < 10th percentile • Non-reactive non-stress test (NST) Gestational Age ≥ 37 weeks with: • Labor • Rupture of membranes • Vaginal bleeding • Abnormal biophysical profile • Criteria for severe preeclampsia Gestational Age ≥ 34 weeks with: DELIVER Expectant management: remote from term with mild preeclampsia
  20. 20. Maternal and fetal well-being at least once weekly • BP each visit • Platelet count and liver enzymes at regular intervals • NST at regular interval • Fetal growth every 2 to 3 weeks MEDICATIONS Anti-HPN meds will be given only if there is an increase in BP reading. Not recommended: • Magnesium sulfate and other anti-convulsants • Low-dose aspirin and high dose calcium for prevention of progression to severe preeclampsia
  21. 21. 5-6% of all pregnancies worldwide 5-10% - severe Local incidence: 2-5% 2nd most common cause of maternal death High perinatal mortality and morbidity rate: Iatrogenic prematurity Definitive treatment: Delivery of fetus and placenta
  22. 22. CNSDysfunction • Blurred vision • Scotomata • Altered mental status • Severe headache Livercapsuledistentionor rupture • Persistence right quadrant pain • Epigastric pain Bloodpressurecriteria • Sitting SBP ≥160 mm Hg • DBP ≥110 mm Hg • * On 2 separate occasions at rest or at least 6 hours apart Eclampsia • Generalized seizure • Unexplained coma in setting of preeclampsia in absence of neurologic d/o
  23. 23. Pulmonaryedemaorcyanosis • Excessive fluid accumu- lation in the lungs Cerebrovascularaccident(CVA) • Acute loss of brain function • Altered mental status • coma CorticalBlindness • Partial or total loss of vision in normal appearing eye IUGR • EFW < 5 percentile for gestational age • EFW <10 percentile for gestational age with evidence of fetal compromise CoagulopathyandThrombocytopenia • Prolonged prothrombin time: >1.4s • Low fibrinogen: <300 mg/dl • Low platelet: <100,000 mm3 Due to disturbance of vasculature that supplies the brain Damage to the visual region of occipital cortex
  24. 24. Proteinuria • >5 g per 24h or ≥3+ on 2 random urine samples collected at least 4 hours apart Oliguriaand/orRenalFailure • Urine output <500 ml per 24h • Serum creatinine: >1.2 mg/dl HELLPSyndrome • Hemolysis: • Abnormal peripheral smear • total bilirubin >1.2 mg/dl • LDH >600 U/L • Elevated liver enzyme: • ALT > 70 U/L • LDH > 600 U/L • Low platelet: • Platelet <100,000 mm3 Hepatocellularinjury • Serum transaminase ≥ 2x the normal
  25. 25. Activation of CoagulationCapillary LeakVasospasm Hypertension Seizures Proteinuria Edema Hemoconcentration Endothelial Activation Thrombocytopenia Multiple factors Oliguria↓ed kidney perfusion Liver Ischemia ↓ed liver perfusion Severe headache Cortical blindness Altered mental status Scotomata Blurred vision Occipital cortex damage CNS Dysfunction Hepatocellular damage ↓ed brain perfusion RUQ pain/abd’l pain ↑ed AST Pulmonary edema HELLP SYNDROME ARF Uteroplacental insuffieciency IUGR Eclampsia ComplicationsSigns and symptomsProcess Abruption Oligohydramnios
  26. 26. Objectivesofmanagement Reduce severity or prevent progression of disease process Prevent convulsions Control severe hypertension Deliver the fetus at the optimum time and with the least trauma Detect and appropriately treat end-organ damage Completely restore the health of the mother
  27. 27. •Safety of mother and fetus Main objective • Stabilization of mother’s condition • Confirmation of gestational age • Assessment of fetal well-being Initial
  28. 28. Maternal DELIVER Fetal
  29. 29. Drug of choice for prevention of seizures Drug is considered when women is at risk for eclampsia: moderate to severe preeclampsia (at least BP 150-160/100-110 mm Hg) Can be given in 2 ways: (2) intermittent intramuscular injections (1) continuous intravenous infusions When given, regularly assess: Maternal reflexes Urine output Oxygen saturation Respiratory rate
  30. 30. Continuous intravenous infusion • Loading dose: 4-6 g dose of MgSO4 diluted in 100 ml of IVF administered over 15-20 min • Begin 2 g/h in 50 ml of IV maintenance infusion • Measure serum Mg level at 4-6 h and adjust infusion to maintain levels between 4 and 7 mEq/L • MgSO4 is discontinued 24 h after delivery Intermittent intramuscular injections • Give 4 g MgSO4 as 20% solution of intravenous at a rate not to exceed 1 g/min • Follow with 10 g of 50% MgSO4 solution: • 5 g (one-half) injected deep in the upper outer quadrant of both buttocks through a 3-inch-long, 20 gauge needle. • If convulsion persists after 15 min, give up to 2 g more IV as 20% solution at a rate not to exceed 1 g/min. (if the woman is large up to 4 g may be given slowly) • Every 4 h thereafter: 5 g of 50% solution of MgSO4 deep IM upper outer quadrant of alternate buttocks, assuring that: • Patellar reflex is present • Respirations are not depressed • Urine output during the previous 4 h exceeded 100 ml • MgSO4 is discontinued 24 h after delivery
  31. 31. SBP: 140-155 mm Hg DBP: 90-105 mm Hg  Labetolol  Hydralazine  Nifedipine  IV Nicardipine  Methyldopa  Second line agent: • Labetolol • Nifedipine • Hydralazine • Beta-receptor blocker • Hydrochlothiazide  ACE-I  ARB  Diuretics Given if BP >150/100 mm Hg PP:  Drugs used during antepartum  Diuretics  Avoid NSAIDs PP
  32. 32. Labetalol (C) > 10 to 20 mg IV, then 20 to 80 mg every 20 to 30 minutes > maximum of 300 mg; > for infusion: 1 to 2 mg/min > Lower incidence of maternal hypotension and other adverse effects, displaces hydralazine; > Avoid in women with asthma or congestive failure. > Not available locally Hydralazine (C) > 5 mg IV or IM, then 5 to 10 mg every 20 to 40 minutes; once BP controlled repeat every 3 hours; > for infusion: 0.5 to 10.0 mg/hr; if no success with 20 mg IV or 30 mg IM, consider another drug A drug of choice according to NHBEP; long experience of safety and efficacy Nifedipine (C) >Tablets recommended only: 10 to 30 mg PO, repeat in 45 minutes if needed Should be used with caution if concomitantly used with MgSO4 IV Nicardipine > D5W 90 mL + Nicardipine 10 mg in soluset Concentration = 0.1 mg/mL > Start drip at 10 ugtts/min (equivalent to 1 mg/hr). > Maximum dose 10mg/hr *Note:The IV infusion site must be changed every 12 horus Should be used with caution if concomitantly used MgSO4 DRUG Dose and Route Precautions andAdverse Effects
  33. 33. Methyldopa (B) Secondlineagents Preferred agent: 0.5 to 3.0 g in 2 divided dosage Labetolol (C) Nefidipine (C) Hydralazine (C) Beta Blockers (C) Drug Dose Concerns Drug of choice (NHBEP) Safety after 1st trimester 200 to 1200 mg/d in 2-3 divided dose 30 to 120 mg/d slow release prep May be assoc. with fetal growth restriction May inhibit labor and synergistic action with MgSO4 in lowering BP Useful in combination with sympatholytic agents May cause neonatal thrombocytopenia May ↓ uteroplacental blood flow May impair fetal response to hypoxia Risk of IUGR when start 1st or 2nd Tri (Atenolol) Associcated with neonatal hypoglycemia 50 to 300 mg/d in 2-4 divided doses Depends on specific agent
  34. 34. Hydrochlothiazide (C) Contraindicated Second line agents: 12.5 to 25.0 mg/d ACE-I ARB Drug Dose Concerns  Can cause volume contraction and electrolyte d/o  Useful in combination with Methyldopa and vasodilator to mitigate fluid retention Leads to fetal loss in animals Human use is associated with: 1. Cardiac defects 2. oligohydramnios 3. Fetopathy 4. Growth restriction 5. Renal agenesis 6. Neonatal anuric renal failure
  35. 35. Controlof seizures MgSO4 For prevention and reduction of recurrence Diazepam Loading dose: 10 mg IV over 2 min Followed by: IV infusion 40 mg in 500 ml Normal saline for 24 h After 24 h: 20 mg in 500 ml NS, slowly reduced Phenytoin Only for seizure prevention Dose: initial - 1 g slow IV d by 100 mg every 6 hours for the next 24 hours Anti-HPN Therapy Hydralazine Drug of choice IV boluses of 5 to 10 mg at 20-30 min interval until desired BP attained Clonidine Next recommended drug IM: 75-150 mcg Nifedipine 5-10 mg orally NOT sublingual Labetalol Initial dose: 20 mg IV bolus If desired BP not attained w/in 10 min, give 40 mg then 80 mg every 10 minutes
  36. 36. > 34 weeks Deliver Mode: vaginal delivery < 34 weeks Defer delivery Give corticosteroids (24-34 weeks) <32 weeks: CS Eclampsia Deliver after seizure is controlled CS is done if: Anticonvulsant therapy continued atleast 24 hours after deliver Betamethasone: 12 mg IM every 24 h for 2 doses Dexamethasone: 6 mg IM every 12 h for 4 dosesGiven between 23-34 weeks for fetal lung maturity Corticosteroids  Vaginal delivery is not easy and imminent  Failure of progress after induction  Fetal compromise
  37. 37. DEFINITION: Amniotic fluid index < 5cm Fetal Growth restriction ChromosomalAbnormalities Demise Congenital anomalies Postterm pregnancy Ruptured membranes Placental Abruption Twin-twin transfusion Maternal Preeclampsia Uteroplacental insufficiency Diabetes Hypertension Drugs Prostaglandin synthase inhibitors ACE Inhibitors Idiopathic
  38. 38. Most widely used for assessment of fetal well being Hypothesis: HR of non-acidotic fetus temporarily increase in response to movement Normal or reactive: ≥2 accelerations of ≥15 bpm lasting for ≥15 sec within 20 min Nonreactive: Does not contain at least 2 accelerations Uteroplacental insufficiency: Absent acceleration during 80-min period with variability or late deceleration following spontaneous uterine contractions
  39. 39. 5 biophysical variables Highest score: 10
  40. 40. NST 2 ≥2 accelerations of ≥15 bpm lasting for ≥15 sec within 20 min 0 0 or 1 acceleration in 20- 40 min Fetal Breathing 2 ≥1 ep rhythmic breathing lasting ≥30 sec w/in 30 min 0 <30 sec of breathing in 30 min Fetal mov’t 2 ≥3 discrete or body limb movement w/in 30 min 0 <3 discrete movements Fetal tone 2 ≥1 ep of ext and flex of extremity OR opening/closing of hand w/in 30 min 0 No movement or no extension/felxion AF volume 2 Single vertical pocket >2cm 0 Largest single vertical pocket <2cm
  41. 41. Modified BPP NSTUTZ assessment of AF Requires less time Excellent method of fetal surveillance
  42. 42. Biophysical Score Interpretation Recommended management 10 Normal, nonasphyxiated No fetal indication for intervention Repeat test weekly Repeat 2x weekly for postterm and diabetic 8 Normal fluid Normal, nonasphyxiated fetus No fetal indication for intervention Repeat test per protocol 8 oligohydramnios Chronic fetal asphyxia suspected Deliver if ≥37 weeks, otherwise repeat test 6 Possible fetal asphyxia IF: AF is abnormal: deliver Norma AF >36 weeks w/ favourable cervix: deliver Repeat test <6: deliver Repeat test >6: observe and repeat per protocol 4 Probable fetal asphyxia Repeat test on same day: if ≤6 - deliver 0-2 Almost certain fetal asphyxia Deliver
  43. 43. Non-invasive way to assess blood flow characterizing downstream impedance Umbilical artery systolic/diastolic ratio is commonly used Doppler index Ratio compares max systolic flow with end-diastolic flow: evaluate downstream impedance to flow Consider abnormal if elevated above 95th percentile OR if diastolic flow is absent or reversed Doppler of the uterine and uteroplacental arteries at 24 weeks is an effective test to predict Preeclampsia
  44. 44. ABSENCE OF END-DIASTOLIC FLOW NORMAL DIASTOLIC FLOW REVERSED END-DIASTOLIC FLOW
  45. 45. ABNORMALITY BPS FREQUENCY DECISION TO DELIVER (FETAL) Elevated Indices Only Weekly Abnormal BPS orTerm or >36 weeks with no fetal growth AEDV Twice weekly Abnormal BPS or >34 weeks proven maturity or conversion to REDV REDV Daily Any BPS < 10/10 or >32 weeks dexamethasone given REDV-UVP Three times daily Any BPS < 10/10 or >28 weeks dexamethasone given
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A discussion on preeclampsia its management and treatment.

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