In The Name Of God In The Name Of God
In The Name Of GodIn The Name Of God
TIME OF DELIVERY IN HYPERTENSIVE DISORERS OF
PREGNANCY
Laleh Eslamian MD. Prof. of Obstet & Gynecol
Perinatologist , Shariati hospital, TUMS
Preeclampsia:
Definitive Tx: delivery
To prevent maternal fetal complications from
disease progression
PE: WHEN To initiate Delivery?
Is based up on:
1) GA
2) Severity of the disease
3) Maternal condition
4) Fetal condition
PE 37w delivery
PE before term:
Preterm birthSerious Sequelae from
disease progression
Prompt delivery at any GA:
- Serious maternal end – organ dysfunction
- Nonreassuring tests of fetal well being.
Severe PE:
Is generally an indication for delivery:
1. Before fetal viability
2. GA 37w
3. Unstable maternal or fetal condition (regardless of GA)
Indications for delivery with Early onset severe preeclampsia:
Maternal
- Persistent severe headache or visual changes, eclampsia .
- Uncontrolled severe hypertension despite Tx.
- Oliguria <500cc/ 24h or creatinine 1.5mg/dl
- Persistent Pt <100.000/mm3, HELLP or partial HELLP
- Suspected abruption, progressive labor and / or ROM
Indications for delivery with Early onset
severe preeclampsia:
Fetal
- Severe FGR <5%
- Persistent severe oligo, AFI<5cm
- BPP 4 performed 6h apart
- REDF in Doppler study
- Fetal death
Severe PE:
Delivery minimizes the risk of:
Cerebral hemorrhage
Hepatic rupture
Renal failure
Pulmonary edema (other wise 4%)
Seizure
Bleeding due to thrombocytopenia
FGR
Placental abruption (other wise 20%)
Maternal death.
Route of delivery in severe PE
C/S is reasonable <30w:
1.Low Bishop score
2.High frequency of nonreassuring FHR
*<1/3 preterm inductions vaginal birth
PE without severe features:Delivery 37w versus expectant management:
- Significant reduction in composite adverse maternal
out come (RR: 0.71)
- But not significant at 36o – 366 weeks.
- No significant differences in neonatal outcome.
- Less costly
- Unfavorable cervix: not a reason to avoid induction.
PE without severe features:
EXPECTANT MANAGEMENT
* 34 – 36 0/7
- Stable maternal condition
- Stable fetal condition
* <34w
PE without severe features
<37w: 1- Check for new sign or symptoms.
2- Lab follow up.
3- Tx of hypertension.
4- Assessment of fetal wellbeing.
5- Assessment of fetal growth.
6- Antenatal corticosteroids.
PE without severe features:<37w: 1- Check for new sign & symptoms:Severe or persistent headache
Visual changes
Shortness of breath
RUQ or epigastric pain
FAD
Vaginal bleeding
Abdominal pain
ROM or uterine contractions.
PE without severe features:2- Lab follow – up:
* platelet count: weekly
* Serum creatinine: weekly
* Liver enzymes: weekly
- indirect Bili or LDH hemolysis, PBS
- no need to measure 24h protein > after
Pro > 300mg/24h
PE without severe features:3- Hypertension assessment.- BP assessment at least twice weekly- Anti hypertensive agents to control Sys BP<160
& Dia BP<110mmHg does not alter the course of the disease or diminish perinatal Mb or Mt
SHOULD BE AVOIDED IN MOST PATIENTS- Na restriction not recommended.- Plasma volume expansion = no improvement
PE without severe features:4- Assessment of fetal well being
No data from RCTs:
-Daily FAD
- NST & AF or BPP twice weekly
- (immediate repeat with an abrupt change in mat. condition)
- Doppler assessment of UA = 29% reduction in perinatal
death in PE and / or FGR
PE without severe features:
5- Assessment of fetal growth.
- Early FGR may be the 1st manifestation of PE
a sign of severe uteroplacental
insufficiency
- At the time of PE Dx: U/S estimation of EFW and AF,
when normal = repeat q3w
OPTIMUM TIME FOR DELIVERY IN
WOMEN WITH PREEXISTING
HYPERTENSION-No RCT- Expert consensus panel & ACOG:* 38 – 39 6/7th:Chronic hypertension not requiring medication.* 37 – 39 6/7th
Hypertension controlled with medication.* 36 – 37 6/7th
Severe hypertension difficult to control.* >37w at Dx for mild PE.* >34w at Dx for severe PE.
ACOG Task Force On Hypertension:
* Avoid delivery <380/7th in women with
uncomplicated chronic hypertension whom BP
remains controlled.
* Super imposed PE or other pregnancy
complications (FGR, previous stillbirth): case –
by case basis decision.
ACOG Task Force On Hypertension:
* Chronic hypertension with super imposed PE
without features of severe disease & with
reassuring fetal status:
expectant F/O until 37w.
* Severe PE or nonreassuring fetal status:
early delivery.