Evidence Based Management Preeclampsia/ eclampsia

Dr. Ernawati, dr., SpOG (K)

Dept./ SMF Obstetri Ginekologi RSU Dr. Soetomo Fakultas Kedokteran Universitas Airlangga Surabaya

2016

Preeclampsia  –  clinical  defini0on  

•  a multisystem disorder

•  usually first detected by hypertension •  proteinuria common but not essential for a

clinical diagnosis of pre-eclampsia in the presence of other organ involvement, (including feto-placental unit)

Preeclampsia: Diagnosis de novo hypertension after 20 weeks and new onset of one or more of : proteinuria or end organ disfunction

•  renal insufficiency •  liver disease •  neurological problems •  haematological changes •  pulmonary oedema •  IUGR ACOG, 2013; ISSHP, 2014

Criteria Diagnosis

Classification

•  Severe  Preeclampsia  –  lack  of  consensus  •  BP  criteria:  blood  pressure  >  160/110  mmHg  •  No  consensus  on  degree  of  proteinuria  •  Sign/  symptom  end  organ  injury  •  HELLP    =  severe  preeclampsia    •  Early-­‐Onset  Preeclampsia  =  <  34  weeks    

Other  maternal  organ  dysfunc4on:  •     renal  insufficiency  (crea4nine  >  1,1  mg/dL  )  •   liver  involvement  (elevated  transaminases  ±  right        upper  quadrant  or  epigastric  abdominal  pain)  •   neurological  complica4ons  (examples  include      eclampsia,  altered  mental  status,  blindness,      stroke,  or  more  commonly  hyperreflexia  when      accompanied  by  clonus,  severe  headaches  when      accompanied  by  hyperreflexia,  persistent  visual      scotomata)  •   haematological  complica4ons  (thrombocytopenia,      DIC,  hemolysis)  

Uteroplacental  dysfunc4on  -­‐  fetal  growth  restric4on  

•  The definitive treatment is delivery

•  Timing of delivery is based upon gestational age, the severity of preeclampsia, and maternal and fetal condition

•  PE < 34 W, maternal/ fetal stable, prolonged antepartum management in a tertiary care setting or in consultation with a MFM Specialist is an option

Delivery minimize serious

maternal & fetal complication

eg pulmonary edema, seizure,

cerebral hemorraghe,

Severe PE does not mandate

immediate Cesarean birth

Cervical rippening agent can be

used if Cx unfavorable, but avoid

prolonged induction

Cesarean delivery reasonable for

PE/E under 32 W with

unfavorable Cx (given high freq

intermediate FHR tracing & Cx

failure to dilate

PE with feature of severe disease

•  Recommend delivery at ≥ 37 W, even in absent of feature of severe

disease

•  Cervical rippening should be used in unfavorable cx

•  HYPITAT trial : 756 women with Mild PE / gestational HT :

ü  Routine induction reduce maternal adverse outcome (Red risk:

12,76%), lower rate of CS. No differences on neonatal outcome)

ü  Less costly overal than expectant management

PE without feature of severe disease

•  Women with preterm < 37 W, manage expectantly without anti-

hypertensive theraphy.

•  Inpatient versus outpatient care •  A systematic review of 3 trials with a total of 504 women with various

complications of pregnancy observed no major differences in clinical outcomes for mothers or babies between antenatal day units or hospital admission

•  Outpatient care can be provided in the patient’s home or, where available, at an antenatal day care unit

Expectant management of PE without feature of severe disease

Outpatient monitoring

•  Frequent maternal & fetal evaluation ( every 1-3 days)

•  Restricted activity

•  Rest in left lateral decubitus potition

•  Monitor Fetal movement every day

•  Laboratory follow up : platelet count, creatinin serum, liver enzyme,

repeated weekly

Expectant management of PE without feature of severe disease

Treatment of Hypertension

•  BP should be assessed 2x/ weeks

•  No antihypertensif agent

Assessment of fetal weelbeing

•  Twice weekly NST

Assessement fetal wellbeing : USG every 3 weeks Antenatal corticosteroids to promote fetal lung maturity should be administered to women <34 W since they are at increased risk of progression to severe disease and preterm delivery (grade 1A)

Expectant management of PE without feature of severe disease

Intrapartum management:

•  Fluids à should monitored closely, avoid excssive administration

•  Hypertension à severe HT : oral nifedipin or Labetalol IV or

hidralazin

•  Trombocytopenia : platelets transf in case excessive bleeding

•  Glucocorticoid therapy does not appear to be effective for

significantly raising the platelet count in women with PE

Management of PE

•  Intrapartum and postpartum seizure prophylaxis for severe PE (Grade 1A )

•  MgSo4 as a first-line agent for seizure prophylaxis in preeclampsia (Grade 1A ).

•  Intrapartum and postpartum MgSo4 prophylaxis for women without severe HT or PE (Grade 2B )

•  RCT including 10,000 women (MAGPIE) [magnesium sulfate for prevention of eclampsia trial]), about 100 px mild PE & about 60 px severe PE would need to be treated to prevent one seizure (Altman D, 2002)

Seizure Prophylaxis

1687 women with eclampsia recruited into an international multicentre randomised trial comparing standard anticonvulsant regimens; 1680 (99.6%) women: 453 allocated magnesium sulphate versus 452 allocated diazepam, and 388 allocated magnesium sulphate versus 387 allocated phenytoin. Magnesium sulphate - 52% lower risk of recurrent convulsions (95% CI 64% to 37% reduction) than those allocated diazepam . Maternal mortality was non-significantly lower among women allocated magnesium sulphate. Women allocated magnesium sulphate had a 67% lower risk of recurrent convulsions (95% CI 79% to 47% reduction) than those allocated phenytoin There is now compelling evidence in favour of magnesium sulphate, rather than diazepam or phenytoin, for the treatment of eclampsia.

Seizure Prophylaxis : •  Magnesium regimen and monitoring — There is no consensus on

the optimal magnesium regimen, when it should be started and terminated, or route of administration

•  Usually initiated at the onset of labor or induction, or prior to a cesarean delivery

•  Dosing —Vary widely (loading dose of 4 to 6 grams IV (15-20 mnt) & (maintenance dose of 1 to 3 grams per hour, should be adjusted in women with renal insufficiency)

•  Duration of therapy —Usually continued for 24 hours postpartum

Management of PE

STABILISATION OF ECLAMPSIA

•  airway free / intubation, MET team •  magnesium sulfate •  antihypertensive medication

•  no emercency C section Prevention •  magnesium sulfate

Postpartum Management •  There are no evidence-based standards for the optimal approach to

postpartum monitoring and follow-up

•  Repeat laboratory tests until two consecutive sets of data are normal

•  Severe hypertension should be treated; some patients will have to be discharged on antihypertensive which are discontinued when blood pressure returns to normal

•  ACOG suggests monitoring BP in hospital or at home for the first 72 hours postpartum and again 7 to 10 days post-delivery

Management of PE

•  MgSo4 should be administered to those at increased risk of

developing seizures : (Women with new onset hypertension and

headache or blurred vision, or Women with severe hypertension)

•  Antihypertensive therapy should be initiated if BP ≥ 160/110 mmHg

Postpartum Onset of PE

Conclusions Magee et al 2009 review

•  Expectant  care  of  severe  preeclampsia  <34  wk  associated  with  pregnancy  prolonga4on  of  7-­‐14  d  and  few  serious  maternal  complica4ons  (<5%),  similar  to  interven4onist  care    

 •  Complica4on  rates  higher  with  HELLP  <34wk  and  severe  preeclampsia  <28wk,  BUT  similar  to  interven4onist  care  

Maternal Outcomes PL (n=22) MP (n=22) P

Admission delivery interval

(days) 13.86 ± 7,7

13,76 ± 7,9

0,848

Gestational age at delivery

(days) 238.77 ± 8.9

237.54 ± 12.97

0,485

Vaginal birth 4 5

Cesarean delivery overall (n)

- For fetal reason 6 2

- For maternal reason 12 14

- Systolic BP at birth 164.4 166.95 0,714

- Diastolic BP at birth 102.35 103.409 0,945

Antihypertensive drugs (n)

- Oral Nifedipine 11 5

- Oral Nifedipine + Methyl

Dopa 11 17

Nicardipine IV 1 2

Albumin transfusion (n) 6 9

Complications during study (n) 4 5

- HELLP 2 2

- Eclampsia 0 0

- Placental abruption 0 0

- DIC 0 0

- Sepsis 0 0

- Lung edema 1 0

- Acute kidney injury 0 0

- Multiple complications 1 3

Maternal death 0 0

Post-partum stay (days) 3,96 ± 2,1

6,38 ± 6,03

0,083

!

Overall  maternal  outcomes  

Overall  Neonatal  Outcomes  

Table 5.23 Neonatal outcomes :

Neonatal Outcomes PL (n=22) MP (n=22)

GA at delivery (days) 238.77 ± 8.9

237.54 ± 12.97

0,509

1 min Apgar score < 7 9 10

5 min Apgar score < 7 5 8

Birth weight (g) 1954,17 ± 617,84 1924,09 ± 558,45 0,592

IUGR (n) 4 4 0,819

Perinatal death / infant death (n) 3/0 5/0

RDS gr I-II (n) 3 3

RDS gr III-IV (n) 3 2

IVH gr I-II (n) 0 0

IVH gr III-IV (n) 0 0

Sepsis (n) 0 1

Mechanical ventilation (n) 4 4

Duration of NICU admission

(days) 6.53 6.71

Congenital anomaly (n) 1 0

Long term neonatal follow up at

6th month

HC -2 SD (n) 3 3

Abnormal DDST (n) 2 0

!

Gestational based approach to Preeclampsia with severe features

< 24 weeks

• Termination of pregnancy to reduce maternal risk of life- treathening morbidity

• Birth of infant with severe permanent disability

25-34 weeks

• Offer expectant management to appropriately selected woman

• 25-28 weeks : ( decision making process are complex & individualized management)

• ≥ 28 weeks : better maternal & fetal outcomes

> 34 weeks

• Deliver all woman with preeclampsia severe fetures

SIBAI, 2011

SIBAI, 2011

Thankyou