3. Gestationa Pre- Eclampsia
l HTN Eclampsia
Superimposed
Preeclampsia
SBP≥140
Proteinuria Generalized
or
seizures
DBP ≥ 90
Severe
Preeclampsia
≥ 0.3 g/ 24hr
> GA 20th wk before , during
>30 mg/dL
< PP 12th wk or after labor
(1+ on dipstick)
HELLP
syndrome
4. Preeclampsia
2~7% of healthy nulliparous; 0.8~5% of
multiparous women
The third leading cause of maternal mortality
(17%)
A major cause of neonatal morbidity and
mortality (intrauterine growth restriction,
abruptio placentae and the need for preterm
delivery) Preeclampsia
Deadly
Triad
Hemorrhage Infection
5. Severe preeclampsia
BP 160/110 mm Hg
Proteinuria 2.0 g/24 hours or 2+ dipstick
Increase severity /certainty
Serum creatinine >1.2 mg/dL unless known to be previously elevated
Platelets < 100,000/L
Microangiopathic hemolysis—increased LDH
Elevated serum transaminase levels—ALT or AST
Persistent headache or other cerebral or visual disturbance
Persistent epigastric pain
6. Superimposed
Chronic
Preeclampsia
HTN
SBP≥140
or Proteinuria
DBP ≥ 90
< GA 20th wk > 20th GA wk
> PP 12th wk
HTN + PTuria b4 20wk
↑proteinuria or
↑BP or
PLT < 100,000/L
7. Risk factors
Nulliparity
Age >35 years (superimposed) or teenager
Obesity
Multifetal gestation
Medical illness: Chronic hypertension, lupus
erythematosus, IDDM, APS, PT C/S deficiency, renal
disease
Genetic: Hx / FH of previous preeclampsia or eclampsia
Hydatidiform moles
Smoking, placenta previa
11. Evaluation of a new-onset HTN
Clinical findings:
headache, visual disturbance, epigastric pain, rapid
weight gain…
Measure BW QD
Analysis for proteinuria on admission and QOD
BP measurement Q4H
CRE, AST/ALT, CBC (for PLT). UA? LDH?
Coagulation profile?
Sonography: fetal size, amnionic fluid
William’s Obstertrics, 23ed
12. Management of HTN disorder
Dietary
Lifestyle
Place of care
Antihypertensive therapy
Corticosteroids
Mode of delivery
13. Management of HTN disorder
Dietary
Salt restriction is not recommended
Insufficient evidence to make recommendation
Lifestyle
Avoid vigorous exercise
Bed rest?
Place of care
Severe hypertension or preeclampsia
(BP>160/110)should be hospitalized
Laura Magee et al, 2008, JOGC
14. Management of HTN disorder
Antihypertensive therapy
For severe hypertension (BP>160/110)
BP goal: <160/110
Initial antihypertensive: labetalol, nifedipine
hydralazine.
MgSO 4 is not recommended as antihypertensive
(only transient decrease in 30 mins)
Continuous FHR monitoring is advised until BP is
stable.
Laura Magee et al, 2008, JOGC
15. Management of HTN disorder
Antihypertensive therapy
Non-severe hypertension (BP:140-159/90-109
mmHg)
BP goal: w/o cormorbid - 130-155/80-105
w/ cormorbid – 130-139/80-89
Drug of choice: methyldopa, labetalol, other beta-
blockers, CCB (nifedipine). (I-A)
ACEi and ARBs should not beused. (II-2E)
Atenolol and prazosin are not recommended.
Laura Magee et al, 2008, JOGC
16. Management of HTN disorder
Mode of delivery
Induction of labour
Vaginal delivery, unless C/S is indicated
Oxytocin at 3rd stage of labor, esp.
thrombocytopenia or coagulopathy
Ergometrine should not be given
Laura Magee et al, 2008, JOGC
17. Management of HTN disorder
Corticosteroids
To accelerate fetal pulmonary maturity
Pre-eclampsia & GA < 34 wks
Gestational HTN & GA < 34 wks, about to deliver
within next 7 days
Laura Magee et al, 2008, JOGC
18. Management of Pre-eclampsia
Delivery is the only cure
Timing of delivery
MgSO4
Plasma volume expansion
Laura Magee et al, 2008, JOGC
19. Management of Pre-eclampsia
Timing of delivery
GA < 34 wks: expectant management
GA: 34-36 wks, non-severe pre-eclampsia:
debated
GA > 37 wks: immediate delivery
Laura Magee et al, 2008, JOGC
21. Management of Pre-eclampsia
MgSO4
First-line Tx for eclampsia
Prophylaxis against eclampsia in severe-
preeclampsia
Phenytoin and BZD should not be used for
eclampsia prophylaxis, unless MgSO4 is
contraindicated or ineffective
Plasma volume expansion
Not recommended
Laura Magee et al, 2008, JOGC
22. Management for HELLP
syndrome
PLT count > 50x109 /L
Prophylactic transfusion of platelets is not
recommended
Consider ordering blood when PLT drop rapidly
PLT count < 20 x 109 /L.
Platelet transfusion prior to vaginal delivery or C/S)
Corticosteriods may be considered for PLT count
< 50x109 /L
Plasma exchange or plasmapheresis?
Laura Magee et al, 2008, JOGC
23. Postpartum treatment
BP follow-up
Peak postpartum, D3, D6
Antihypertensive therapy may be restart, BP
goal <160/110 mmHg
Acceptable in breastfeeding: Nifedipine, labetalol,
methyldopa, captopril, enalapril
NSAID should be avoid if hypertension is
difficult to control, or oliguria, CRE ↑, PLT↓
Thromboporphylaxis may be considered
Laura Magee et al, 2008, JOGC
Hinweis der Redaktion
most common within 24 hrs
Impaired remodelling of spiral a. Imcomplete trophoblast invasion The deeper myometrial arterioles do not lose their endothelial lining and musculoelastic tissue, and their mean external diameter is only half that of vessels in normal placentas release of placental debris that incites a systemic inflammatory response