PREECLAMPSIA

DRA. MERLY MUOZ ESPINOSA

GINECO OBSTETRICIA
USCO 2008

PREECLAMPSIA
Hipertensin

y proteinuria posterior a las

20 semanas de gestacin
Presin arterial Sistlica

140 mmHg

Presin arterial Diastlica 90 mmHg

Y
Proteinuria de 0.3 gramos (300mg/dl) en
24 horas - En orina

Criterio diagnostico para preeclampsia

PREECLAMPSIA SEVERA

PREECLAMPSIA

New onset proteinuric hypertension and at least one of the following:

Symptoms of central nervous system
dysfunction

Blurred vision, scotomata, altered mental

status, severe headache

Symptoms of liver capsule distention

Right upper quadrant or epigastric pain

Nausea, vomiting

Hepatocellular injury

Serum transaminase concentration at least

twice normal

Severe blood pressure elevation

Systolic blood pressure 160 mm Hg or

diastolic 110 mm Hg (two at least six hours)

Thrombocytopenia

Less than 100,000 platelets per cubic millimeter

Proteinuria

5 or more grams in 24 hours

Oliguria

<500 mL in 24 hours

Severe fetal growth restriction

Pulmonary edema or cyanosis
Cerebrovascular accident

DIAGNOSTICO
METAS
Diagnostico

soportado

Excluyendo

Valoracin
Leve

otros desordenes

de severidad

Severa

PREECLAMPSIA

INCIDENCIA

PREECLAMPSIA

Desordenes

hipertensivos complican 10-20%

de embarazos
Preeclampsia ocurre en 3-14% de todos los
embarazos del mundo

5-8% en usa

Preeclampsia

leve 75% - usa

Preeclampsia severa 25% - usa
10% ocurren en <34 semanas
Sobre agregada 3%

Hall, DR, Odendaal, HJ, Steyn, DW, Grive, D. Urinary protein excretion and expectant management of early onset,
severe preeclampsia. Int J Gynaecol Obstet 2002; 77:1. Working group report on high blood pressure in pregnancy.

FACTORES DE RIESGO

PREECLAMPSIA
RELATIVE
RISK

FACTOR

Nulliparity
Preeclampsia in a previous pregnancy

25-75%

7.19

Age >40 years or <18 years

1.96

Family history of pregnancy-induced hypertension

2.90

Chronic hypertension
Chronic renal disease
Antiphospholipid antibody syndrome or inherited thrombophilia
Vascular or connective tissue disease
Diabetes mellitus (pregestational and gestational)

3.56

Multifetal gestation

2.93

High body mass index

Male partner whose previous partner had preeclampsia
Hydrops fetalis
Unexplained fetal growth restriction

PATOGENESIS

PREECLAMPSIA

SYSTEMIC ENDOTHELIAL
DYSFUNCTION

Fmslike tyrosine kinase-1

Vascular endothelial
growth factor
Antagonizes placental
growth factor
Hypothesis for the role of sFlt1 in preeclampsia

PATOGENESIS

PREECLAMPSIA

Stereographic representation of myometrial and endometrial

arteries in the macaque

PATOGENESIS

Abnormal placentation in preeclampsia

PREECLAMPSIA

Hypoperfusion
Exchange of oxygen, nutrients, and waste products between the fetus and the
mother depends on adequate placental perfusion by maternal vessels.

PATOGENESIS

PREECLAMPSIA

LABORATORIOS

PREECLAMPSIA

Hematocrito
Hemoconcentracin

Plaquetas
Trombocitopenia

Cuantificacin
300mg

de excrecin de protena

en 24 horas
1+ en 2 muestras de orina (4 horas)
3+ 5gr por da (Severidad)

LABORATORIOS
Depuracin

PREECLAMPSIA

de creatinina
Concentracin de creatinina srica
ALT AST Elevadas
LDH Elevada
Hemlisis

microangiopatica

Evaluacin

Bienestar fetal

PBF

Ecografa

MANEJO

PREECLAMPSIA

Parto
Edad

gestacional
Severidad de preeclampsia
Condiciones maternas y fetales
Disfuncin
rganos maternos

Monitoreo no reactivo

PARTO
Cualquier
edad gestacional

MANEJO

PREECLAMPSIA

PREECLAMPSIA LEVE
Embarazo a termino
Inducir

(Bishop 6)
Maduracin cervical (Cervix desfavorable)
0

Dilation, cm

Closed

1-2

3-4

5-6

Effacement, percent

0-30

40-50

60-70

80

Station*

-3

-2

-1, 0

+1, +2

Cervical consistency

Firm

Medium

Soft

Position of the cervix

Posterior

Midposition

Anterior

MANEJO

PREECLAMPSIA

PREECLAMPSIA LEVE
Embarazo pretermino
Manejo

expectante

Crecimiento

HOSPITALIZACIN

y maduracin fetal
VS

AMBULATORIO

Nicholson, JM. The impact of the interaction between increasing gestational age and obstetrical risk on birth outcomes
evidence of a varying optimal time of delivery. J Perinatol 2006; 26:392
Sibai, BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol 2003; 102:181

MANEJO

PREECLAMPSIA

PREECLAMPSIA LEVE
AMBULATORIO
Monitorizacin

c/ 3 da (Materno-fetal)
Consultar inmediatamente por sntomas
Cefalea

severa persistente, cambios visuales

Dolor en HCD epigastralgia, nauseas, vomito
Disnea disminucin de orina
Signos

de alarma

Barton, JR, Istwan, NB, Rhea, D, et al. Cost-savings analysis of an outpatient management
program for women with pregnancy-related hypertensive conditions. Dis Manag 2006; 9:236.

LABORATORIOS SEGUIMIENTO

PREECLAMPSIA

Laboratorios
Plaquetas,
2

creatinina y ALT-AST

veces por semana

Signos

mnimos

y sntomas de progresin de enf.

Otros laboratorios
Hematocrito
Hemoconcentracin

Hemlisis

LDH
Proteinuria

en 24 horas (5gr/24hrs)

Working group report on high blood pressure in pregnancy. National Institutes of Health, Washington, DC 2006

TRATAMIENTO HTA
Antihipertensivos
No

No

PREECLAMPSIA

en HT leve

disminuye morbi-mortalidad

es terapia de rutina

Restriccin

Actividad

de sodio y diurticos

fsica restringida

Disminuye

TA
Eficacia en resultado perinatal

Ganzevoort, W, Rep, A, Bonsel, GJ, et al. A randomised controlled trial comparing two temporising management strategies
one with and one without plasma volume expansion, for severe and early onset pre-eclampsia. BJOG 2005; 112:1358

MANEJO
Nuevas

PREECLAMPSIA

terapias Investigacin

L-arginina
Precursor

fisiolgico para xido ntrico

No mejoro resultado materno-fetal

Valoracin
Mejor

de bienestar fetal

mtodo para monitorizacin

Movimientos fetales Monitoreo NST PBF

Ganzevoort, W, Rep, A, Bonsel, GJ, et al. A randomised controlled trial comparing two temporising management strategies
one with and one without plasma volume expansion, for severe and early onset pre-eclampsia. BJOG 2005; 112:1358

MANEJO

PREECLAMPSIA

Valoracin

de crecimiento fetal

Restriccin

de crecimiento

PRIMERA MANIFESTACIN

Estimacin
RCIU

por ecografa

Oligoamnios

PREECLAMPSIA
SEVERA

MANEJO
DOPPLER

PREECLAMPSIA

MANEJO

PREECLAMPSIA

CORTICOESTEROIDES
Preeclampsia
Comn

acelera la maduracin fetal

Enf Membrana hialina

Corticoesteroides
34

antenatales

semanas

Dosificacin
Betametasona

12mg IM cada 24 horas 2 dosis

The association between hyaline membrane disease and preeclampsia.

Am J Obstet Gynecol 2007; 191:1414.

MANEJO
CORTICOESTEROIDES

PREECLAMPSIA

MANEJO

PREECLAMPSIA

PREECLAMPSIA SEVERA
Parto
Especialista en medicina materno fetal
Preeclampsia

en 32 34 semanas

No

hay indicacin de cesrea inmediata

Induccin maduracin cervical
Alexander, JM, Bloom, SL, McIntire, DD, Leveno, KJ. Severe preeclampsia and the very
low birth weight infant: is induction of labor harmful?. Obstet Gynecol 1999; 93:485
ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia
Number 33, January 2002. Obstet Gynecol 2002; 99:159

MANEJO

PREECLAMPSIA

PREECLAMPSIA SEVERA
Embarazo a termino - pretermino
Inducir

(Bishop 6)
Maduracin cervical (Cervix desfavorable)
0

Dilation, cm

Closed

1-2

3-4

5-6

Effacement, percent

0-30

40-50

60-70

80

Station*

-3

-2

-1, 0

+1, +2

Cervical consistency

Firm

Medium

Soft

Position of the cervix

Posterior

Midposition

Anterior

Coppage, KH, Polzin. Severe preeclampsia and delivery outcomes: Is immediate cesarean delivery beneficial?
Am J Obstet Gynecol 2006; 186:921

MANEJO

PREECLAMPSIA

PREECLAMPSIA SEVERA
Monitoreo intraparto
Empeoramiento

de hipertensin
Deterioro materno de la funcin heptica,
renal, cardiopulmonar hematolgica.
Insuficiencia placentaria
Abruptio placentae

Coppage, KH, Polzin. Severe preeclampsia and delivery outcomes: Is immediate cesarean delivery beneficial?
Am J Obstet Gynecol 2006; 186:921

MANEJO

PREECLAMPSIA

PREECLAMPSIA SEVERA
Monitoreo hemodinmica invasivo
Puede

ser usado en pacientes complicadas

Enfermedades cardiacas severas
Enf renales severas
Oliguria
No ser expuestas a los
riesgos asociados con
Hipertensin refractaria
cateterizacin arterial y
venosa
Edema pulmonar
ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia.
Number 33, January 2002. Obstet Gynecol 2002; 99:159.

COMPLICACIONES CVC

PREECLAMPSIA

IMMEDIATE
Bleeding
Arterial puncture
Arrhythmia
Air embolism
Thoracic duct injury (with left SC or left IJ approach)
Catheter malposition
Pneumothorax or hemothorax
DELAYED
Infection
Venous thrombosis, pulmonary emboli
Catheter migration
Catheter embolization
Myocardial perforation
Nerve injury

TERAPIA ANTICONVULSIVANTE

PREECLAMPSIA

Anteparto

en trabajo de parto
Terapia continuada por 24 horas
postparto (Rango de 12 a 48 horas)
SULFATO

DE MAGNESIO

Droga

de eleccin para prevenir la

eclampsia.
Mas efectiva que la fenitoina drogas
antihipertensivas como nimodipino
A comparison of magnesium sulfate with phenytoin for the prevention of eclamspia N Engl J Med 1995; 333:201
A comparison of magnesium sulfate and nimodipine for the prevention of eclampsia. N Engl J Med 2003; 348:304

SULFATO MAGNESIO
Mecanismo

PREECLAMPSIA

de accin como anticonvulsivante

Vasodilatacin de la vasculatura cerebral

Inhibicin de la agregacin plaquetaria
Proteccin de las clulas endoteliales desde el
dao de los radicales libres
Prevencin de la entrada del Ion calcio dentro de
las clulas isquemicas
Disminucin relacin acetilcolina
Antagonista competitivo del receptor

Duley, L, Henderson-Smart, D. Magnesium sulphate versus phenytoin for eclampsia.

Cochrane Database Syst Rev 2003; :CD000128.

SULFATO MAGNESIO

PREECLAMPSIA

PREECLAMPSIA SEVERA
Terapia anticonvulsivante
PREECLAMPSIA LEVE CONTROVERSIAL

Estudio

Magpie

>10.000

mujeres
Sulfato de magnesio a dosis

NNT
LEVE 75%
SEVERA 63
SEVERA 25%
LEVE 109

Carga

4g EV Mantenimiento 1g/hora
Carga 5g IM Seguido 5gr cada 4 horas IM
Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate?
The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002; 359:1877

MANEJO
WHO

PREECLAMPSIA

FIGO ISSHP

Terapia de sulfato de magnesio es recomendada

para prevencin de eclampsia en mujeres con
preeclampsia.
(No distingue entre leve o severa)

ACOG

Sulfato de magnesio en preeclampsia severa

Falta consenso en preeclampsia leve

DISCUSIN
No

PREECLAMPSIA

tratamiento fue asociado

Reduccin

de mortalidad neonatal y efectos

adversos maternos
Incremento en el riesgo de muerte materna
y compromiso neurolgico en el infante
ADMINISTRACIN INTRAPARTO DE SULFATO DE MAGNESIO
COMO PROFILAXIS EN PREECLAMPSIA LEVE
NO ADMON EN HIPERTENSIN GESTACIONAL NO PROTEINURICA
NO PREVIENE PROGRESIN DE ENFERMEDAD
10-15% P. LEVE PROGRESAN A P. SEVERA

SULFATO DE MAGNESIO

PREECLAMPSIA

Iniciado

al tiempo al inicio del trabajo de

parto la induccin, previo a cesrea
Dosis de carga es de 4 6 gramos EV
Dosis de mantenimiento 1-3gr por hora
RECOMENDADO:
DOSIS DE CARGA 6 GRS EV EN 15-20 MINUTOS
DOSIS MANTENIMIENTO 2 GRS/HR EN INFUSIN CONTINUA

Sibai, BM. Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Gynecol 2004
ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. Number 33, Obstet Gynecol 2002
Alexander, JM, McIntire, DD, Leveno, KJ, Cunningham, FG. Selective magnesium sulfate prophylaxis for the prevention
of eclampsia in women with gestational hypertension. Obstet Gynecol 2006

SULFATO DE MAGNESIO

PREECLAMPSIA

Excretado

por los riones

Insuficiencia

renal (Creatinina >1.0mg/dL)

Dosis

de carga estndar
Reducir dosis de mantenimiento 1g por hora
Si

creatinina >2.5mg/dL

Dosis

de carga sin dosis de mantenimiento

Monitoreo de niveles de magnesio serico

cada 6 horas

SULFATO MAGNESIO

PREECLAMPSIA

Contraindicado
Miastenia
Puede

Uso

gravis

precipitar a crisis miastenica severa

concomitante de sulfato con

bloqueadores de canales de calcio puede
resultar en hipotensin

SULFATO DE MAGNESIO

PREECLAMPSIA

MONITORIZACION
Fase

de mantenimiento

Reflejo

HIPERMAGNESEMIA

patelar presente
RESPIRACIN > 12 X MIN
GASTO URINARIO >100ML/ 4HR

RANGO TERAPEUTICO 4.8 8.4 MG/DL (2.0 A 3.5 mmol/L)

SULFATO MAGNESIO

PREECLAMPSIA

Continuado

por 24 horas postparto

Preeclampsia leve
12

horas

Preeclampsia
24

severa eclampsia

48 horas

SULFATO MAGNESIO

PREECLAMPSIA

COMPLICACIONES EFECTOS
Infusin rpida
Diaforesis,

sensacin de calor, flushing

Vasodilatacin perifrica, en TA
Nauseas, vomito, visin borrosa y
palpitaciones
Efecto

tocoltico

Atonia

uterina Hemorragia postparto

SULFATO MAGNESIO

PREECLAMPSIA

TOXICIDAD
Relacionada

con niveles sericos

Prdida

de reflejos tendinosos 9-12mg/dL (4-5)

Parlisis respiratoria 12-18mg/dL (5-7.5mmol/L)
Compromiso cardiaco 24-30mg/dL (10-12.5m/L)
Gluconato
1

de calcio

gramo endovenoso en 5-10 min

ANESTESIA
Tcnica

PREECLAMPSIA

neuroaxial

Epidural

espinal
En ausencia de trombocitopenia
Problemas
Edema

de la va area
Exacerbacin de la hipertensin
Observacin

por fibra ptica

TraqueoStoma

INTUBACION

Working group report on high blood pressure in pregnancy. National Institutes of Health, Washington, DC 2000
Randomized comparison of general and regional anesthesia for cesarean delivery in pregnancies complicated
by severe preeclampsia. Obstet Gynecol 1995; 86:193

MANEJO

PREECLAMPSIA

Labetalol
Beta Blocker With Alpha-Blocking Activity
Hipertensin
exacerbada durante la
induccin y/
intubacin
PREGNANCY
Crosses the placenta.
PHARMACOLOGIC

CATEGORY

IMPLICATIONS

Persistent bradycardia, hypotension

Safe during pregnancy
Cases of neonatal hypoglycemia during breast-feeding.

DOSING

I.V. bolus: 20 mg IVP over 2 minutes, may give 40-80 mg at 10minute intervals, up to 300 mg total dose.
I.V. infusion (acute loading): Initial: 2 mg/minute; titrate to
response up to 300 mg total dose. Administration requires the
use of an infusion pump.

DOSAGE FORMS

Injection, solution: 5 mg/mL (4 mL, 20 mL, 40 mL)

Trandate: 5 mg/mL (20 mL, 40 mL)
Tablet: 100 mg, 200 mg, 300 mg
Trandate: 100 mg, 200 mg, 300 mg

RESULTADOS ADVERSOS

PREECLAMPSIA

MATERNOS

Disfuncin en SNC,
heptico y renal

Hemorragia cerebral,
ruptura heptica, falla
renal

Sangrado relacionado
a trombocitopenia
Parto pretermino
RCIU
Abruptio placentae
Muerte perinatal

Factores que influyen

Edad gestacional
Severidad de enf
Condiciones medicas
coexistentes
Gestacin mltiple
Diabetes mellitus
Enfermedad renal
Trombofilia
Hipertensin
preexistente

RESULTADOS

PREECLAMPSIA

Normal blood
pressure,
(percent)

Mild preeclampsia
(percent)

Severe preeclampsia
(percent)

Liver dysfunction

0.2

3.2

20.2

Kidney dysfunction

0.3

5.1

12.8

Placental abruption

0.7

0.5

3.7

Induced labor

12.1

41.5

58.7

Cesarean delivery

13.3

30.9

34.9

Delivery <34 weeks

3.2

1.9

18.5

Growth restriction

4.2

10.2

18.5

Admission to NICU

12.9

27.3

42.6

Respiratory difficulty

3.8

3.2

15.7

Brain hemorrhage

0.2

0.5

Fetal death

0.9

0.5

0.9

Neonatal death

0.5

0.5

0.9

Outcome measure
Maternal

Fetal or neonatal

Adapted from data in Hauth, JC, Ewell, MG, Levine, RJ, et al. Obstet Gynecol 2000; 95:24

RESULTADOS

PREECLAMPSIA

Muerte materna por cada 100.000 NV

Tasa de caso-fatalidad 6.4 muerte/10000c
MORTALIDAD

PREECLAMPSIAECLAMPSIA

HEMORRAGIA

ENFERMEDAD
TROMBOEMBOLICA

POST-PARTO

PREECLAMPSIA

Resuelve

hipertensin y proteinuria
Medicamentos antihipertensivos
Suspender

al retorno de niveles normales

CLASIFICACION
SINDROME HELLP

Investigadores

de Mississippi

CLASE 1 Plaquetas 50.000cel/mL,

AST ALT 70 Iu/L, LDH 600IU/L

CLASE 2 Plaquetas 50.000 y 100000c/mL,

AST ALT 70 Iu/L, LDH 600IU/L

CLASE 3 Plaquetas 100000-150000c/mL AST

ALT 40 Iu/L, LDH 600IU/L

Martin, JN Jr, Rose, CH, Briery, CM. Understanding and managing HELLP syndrome: the integral role of aggressive
glucocorticoids for mother and child. Am J Obstet Gynecol 2006; 195:914