Preeclampsia and eclampsia

PAMELA FLOOD
PROFESSOR OF ANESTHESIOLOGY,
PERIOPERATIVE AND PAIN MEDICINE
STANFORD UNIVERSITY
Preeclampsia / eclampsia
Expression of placental anemia of
mother

 Antenatal giat-
Influenced mother.
 Small for gestational
age, fetal effects
 Vegetables abruption is
an expression in the
cake is the effect on the
placenta rau.Abruption

Parker SE, Werler MM2. Epidemiology of ischemic placental disease: a focus

on preterm gestations. Semin Perinatol. 2014 Apr; 38 (3): 133-8.
Epidemiology:
A common problem
 Occurs in 2-8% of pregnant women.
 Increases in cosmetics but not gained as much in Europe
 2010 update: still rising due to increased severity due to increasing
rates of obesity, reducing smoking and maternal age

Parker SEfirst, Werler MM2.Epidemiology of ischemic placental disease:

a focus on preterm gestations. Semin Perinatol. 2014 Apr; 38 (3): 133-
8.
Serious problem

 Is the direct cause of death of 15% of women

in the United States, often due to stroke
 Causes increased mortality and morbidity in
the mother and child.
 Responsible for morbidity and maternal and
neonatal Considerable mortality
 eclampsia
 HELLP
 Bleed
 SGA / Neonatal weak
Diagnose

 Hypertension (SBP> 140 or DBP> 90 at least

twice)
 Proteinuria less used as diagnostic criteria (>
300 mg / 24 h)
 Dipsticksrather inaccurate because the protein rather
double blow all day.Dipstick
 Consistent rarely used
 Nonspecific

G Lambert, JF Brichant, Hartstein G, Bonhomme V, Dewandre PY.

Preeclampsia: an update. Anaesthesiol Acta Belg. 2014; 65 (4): 137-
49.
CHANGE LIST OF FRANCE
 No pre-eclampsia "mild"
 Changes due humanities (Philosophical REASONS)
 All preeclampsia are particularly dangerous
 Currently, Preeclampsia yes / no signs of heavy
 Reduced organ function
 Heart
 Liver
 Kidney
 Thrombocytopenia
 Blood coagulation
 Slow fetal growth in the uterus
Gestation onset

 Onset early - before 34 weeks of pregnancy

 Frequent fetal growth retardation (7 x risk of death
increased alcohol tolerance)
 Note pathological ischemic placenta
 Late-onset - after 34 weeks
 Slow fetal growth is less common
 Causes are usually less dangerous
Risk factor
 Anthropometric
 Ages 40 and older
 Nulliparous or personal history or family preeclampsia
 Birth spacing over 10 years
 new husband
 Metabolic syndrome - vascular diseases
 BMI 30kgm2 or more
 Hypertension earlier
 Pre-existing renal disease
 Diabetes before
 Antiphospholipid syndrome
Re-structure twisted arteries
placenta

endothelial

Uterus

• Human placental unit liberated the vascular growth factor

allows the twisted arteries entering the uterus. Fetal-
placental unit thường the
• Blood vessels increase in volume and pressure flow
In preeclampsia, FMS-like tyrosine kinase soluble 1 (SFlt-1) inhibits
the vascular growth factor
James M, Roberts MD. Pathophysiology of ischemic placental disease in 2015.
Seminars in perinatology; 38: 139 -145
Twisted arteries during
pregnancy and not
pregnant

 A - Not Pregnant
 B - Pregnancy, and not greater than the smooth muscle layer
 Maximum relaxation

James M, Roberts MD. Pathophysiology of ischemic placental

disease. Seminars in perinatology; 38: 139 -145
 etiology
 Phase 1: Restructuring abnormal artery twisted roll out
entering the uterus.
 RESERVED twisted thin and not penetrate deep

 Partial placenta anemia

 Inflammation of the placenta
 Endothelium dysfunction placenta.
 Stage 2: abnormalities in the placenta and the mother with
the expression dysfunction agencies

Duhig KE, Shennan AH. Recent Advances in the diagnosis and

management of pre-eclampsia.F1000Prime Rep. 2015 Feb 3; 7: 24.
Phase 2:
Showers of ischemic Particles
 Image awarded week Full people mom
 stress too submit oxygen goods
 inflammation - much weak factor cause inflammation
Factors
 Lost officials power internal tissue of the much
agencies offices
 can integrated blood relatively of the mom is not increase
up
 supply volume heart is not increase up
 SVR in mom is not reduction
 Guide next million proof often meet Best EXCUSE
 Crockery filter first trimester
Include:
Biomarkers: Percentage of pro / anti-angiogenic
 Pro-angiogenic
 VEGF: growth factor vascular endothelial
 PGIF: placenta growth factor
 Anti angiongenic
 sFLTp1: soluble fms-like tyrosine kinase-1
 Inhibition of VEGF receptors and PGIF
 Theimpedance measurement using ultrasound to
monitor
 Asensitivity at 95%
 10% of false positives

Poon LCfirst, Nicolaides KHfirst. Early prediction of preeclampsia. Obstet

Gynecol Int. 2014; 2014: 297,397
 Prevent

 Aspirin anthem filled starting week 17 of

pregnancy to alleviate the relative risk of late-
onset preeclampsia (RR 0.9)

Prof. Moorefirst, Allshouse AA2, Post ALfirst, Galan HLfirst, Heyborne Dealersfirst. Early
initiation of low-dose aspirin for reduction in preeclampsia risk in high-risk
women: a secondary analysis of the High-Risk MFMU Aspirin Study. J
Perinatol. 4 Dec 2014
statins - Prevent?
What?
 Drill! - not statins are classified into
categories according to the old classification
X by the FDA?
 True- canned fearing reduce cholesterol in
children.
 Several studies on the effects of cases
teratogenicity of the old station
 Not particularly used in pregnant women should not
be the public-private investments.
 Studies after being put on the market demonstrated
no increased risk in humans.
 Why Statins?

The same risk factors Preeclampsia and pathological TM

 diabetes
 EXCUSE
 Fat
 Dyslipidemia (dyslipidemia)
Similar pathology Pre-eclampsia and cardiovascular
disease
 Inflammatory processes
 Stress caused by oxidation
 Total trade endothelial
Marrs CCfirst 2017 Mar; 60 (1): 161-16
• 20 subjects were randomized to 10 mg or placebo pravastation
• 4 subjects in the placebo group with pre-eclampsia, no TSG in
the treatment group.
The safety and pharmacokinetics of pravastatin
preventing pre-eclampsia in pregnant women at
high risk: an exploratory study randomized
controlled
.
 21 high-risk women with
preeclampsia before 34
weeks each in a previous
pregnancy.
 No differences in unwanted
effects.
 4 women with preeclampsia,
all in the placebo group.

Obstet Gynecol J Am. 2016 Jun; 214 (6):

720.e1-720.e17.
Pravastatin improve treatment outcomes in
women with antiphospholipid syndrome does
not respond to anticoagulant therapy

Index bouncing circuit uterine artery

 20 patients
 10 placebo, 10
pravastatin
 The control group were
born premature, 6 life, 3
with severe deformities.
 Pravastatin group all
over 34 weeks, all living

Clin Invest. 2016 Aug 1; 126 (8): 2933-40.

Treatment

 The only treatment is giving birth

 The prolonged treatment after 37 weeks is
not beneficial
 And almost no benefits after 34 weeks in
severe cases.
 From 24-34 weeks gestation prolonged
treatment benefit for the fetus.
 Can safely monitored closely.
Treatment Before Birth
 Treatment of hypertension slowly to avoid
hypoperfusion placenta and fetus
inhibitors. Objective 160/90
 NMC analgesic can be useful during labor.
 Numberof Platelets should be tested in
women with preeclampsia.
 Remember that apart from reducing the
amount TSG TC also gshed the extra function
of platelets
 May provoke an epidural in higher positions.
Treatment Before Birth
 Room seizures
 MgSO4

 Phenobarbital when the seizures sudden or

acute kidney failure.
 Remember that MgSO4 renally eliminated,
so when there is renal impairment nagn
MgSO4 can cause poisoning.
 Slow reflexes
 Asleep

 Stop circulation
Treatment Before Birth
 eclampsia
 Emergency
 airways

 Respiratory

 Cut fastest seizures.

 benzodiazepines

 propofol
Treatment of Hypertension
 Labetalol is recommended to use first-hand.
 PK major changes in pregnant women.
 Sudden increase clearance.
 Thehalf-life of 1.7 hours compared to 6-8 ½ h in
women who are not pregnant.
 Distance dose should be shortened.
 Metoprolol time peak effect also reduced
 Atenolol oral absorption increases with increased
offset ups should renal dose constant.

Committee Opinion no. 514: Emergent therapy for acute-onset, preeclampsia or

eclampsia Severe hypertension with. Obstet Gynecol 2011; 118: 1465-8
Hypertension Preeclampsia
Early
 TSG soon increased hemodynamic
status coexist with vasoconstriction.
 Combination betablockers with
vasodilator may increase the effects
 hydralazine
 nifedipine
Preeclampsia late

 Increase vasoconstriction
 May be accompanied by heart failure
 Treatment can reduce afterload
 nifedipine
 hydralazine
Hypertension induction:
Regional anesthesia
 The old idea that affect cardiovascular risk is a
contraindication for regional anesthesia in patients with
preeclampsia.
 By vasodilation occurs when under the effect of
sympathetic blockades overcome the lack of circulation
volume and vasoconstriction
 However, it should follow the evidence suggests that
blood pressure less volatile in women with preeclampsia
compared with normal women lobby when the sensory
block.
 Perinatal, the short-term medication is used more often
due to the rapid changes in translation.
Pant MfirstFong R, Scavone B. Prevention of peri-induction in preeclamptic
hypertension Patients: a the focused review.Anesth Analg. 2014 Dec; 119 (6):
1350-6.
Regional anesthesia and
Preeclampsia
 Selected regional anesthesia more
 Reduce maternal mortality
 Reduce child mortality
 Maintain blood flow placenta uterus.
 Possible contraindications when coagulopathy.
 Low platelet
 HEELP

Ankichetty SP, Chin KJ, Chan VW, Sahajanandan R, Tan H, Grewal A, Perlas A.
Regional anesthesia in pregnancy induced hypertension Patients with. J Clin
Pharmacol Anaesthesiol. 2013; 29: 435-44
Hypertension induction
Anesthesia
 Beta blockers
 Esmolol - is preferred in surgery as a fast-acting and short.
 Labetolol - Can cause hypotension and bronchospasm.
 metoprolol
 nitroglycerine
 nitroprusside
 Cyanide poisoning if prolonged use
 hydralazine
 Onset time delay effects (5-10 minutes)
 Long-acting (1-4 h)

Pant MfirstFong R, Scavone B. Prevention of peri-induction in preeclamptic

hypertension Patients: a the focused review.Anesth Analg. 2014 Dec; 119 (6):
1350-6.
 Anesthesia for caesarean
section
 Request when coagulopathy.
 Airway edema may be caused by weakened
blood vessels.
 Need tight blood pressure control, often using HA
DMXL in severe cases.
 Depends on the airways, with remifentanil or
dexmedetomidine sedative may need to place the
tube when the patient is awake.
Palanisamy A, Klickovich RJ, Ramsay M, Ouyang DW, Tsen LC. Intravenous
dexmedetomidine as an adjunct for labor analgesia and anesthesia cesarean delivery
in a parturient with a J Obstet Anesth tethered spinal cord.Int. 2009 Jul; 18 (3): 258-61.
PP insensitive choice
Vaginal birth
 Priority regional anesthesia
 Platelets should sufficient number and function.
 Check clotting if liver failure or other serious illness characteristics.

 Ifthere is regional anesthesia is

contraindicated
 Consider using remifentanil for pain relief and blood pressure
control.
PRES:
Posterior reversible encephalopathy
syndrome brain syndrome- after
Reversible
 Comes with pre-eclampsia and eclampsia or severe hypertension.

 Headache
 drowsiness
 Vomit
 Changing perceptions
 Visual disturbances
 Convulsions

Poma S, Delmonte MP, Gigliuto C, IMBERTI R, M Delmonte, Arossa A, Iotti GA.

Management of posterior reversible syndrome in preeclamptic women. Obstet Gynecol
Case Rep .. Epub 2014 Nov 19.
 PRES:
Brain syndrome after Reversible

 White matter lesions in the occipital peak

later on MRI / CT
 May be due
 Endothelial injury
 edema
 Recovery with adjuvant treatment

Poma S, Delmonte MP, Gigliuto C, IMBERTI R, M Delmonte, Arossa A, Iotti GA.

Management of posterior reversible syndrome in preeclamptic women. Obstet Gynecol
Case Rep .. Epub 2014 Nov 19.
The end of pre-eclampsia
 145 patients with preeclampsia or pregnancy hypertension
 Hypertension
 Lasted 42 ± 24 days
 Early onset preeclampsia last longer
 Proteinuria
 Prolonged in 30 ± 40 days
 90% of all patients with hypertension and proteinuria after 77 days 60
days drunk.
 3 months is recommended to differentiate with new-onset
hypertension.

Mikami Y, Takagi K, Itaya Y, Ono Y, Matsumura H, Takai Y, Seki H.

Post-partum recovery in Patients with gestational hypertension course and pre-
eclampsia. J Obstet Gynaecol Res. 2014 Apr; 40 (4): 919-25.
Magpie Trial

 No difference in mortality and severe disease PU

women treated with MgSO4 in 26 (19-36) months
 3.5% MgSO4 group, 4.3% in the placebo group
died

 Magpie Trial Collaborative Group Follow-Up

Study. Magpie study: randomized study
comparing placebo MgSO4 in preeclampsia.
Track the results after 2 years .. BJOG. 2007 Mar;
114 (3): 300-9.
Long-term health risks

 Women with pre-eclampsia increased risk of chronic

hypertension 3 times compared with women with
normal blood pressure.
 Severe preeclampsia II diabetes increases the risk
2.7 times.
 Risk of death from cardiovascular disease increased
by 2 times
 9 times increased risk of causing birth if
preeclampsia before 34 weeks.
summary

 Changes in diagnostic criteria for

preeclampsia.
 Changes in nomenclature - wise with mild
preeclampsia.
 Major progress in research on mechanisms
 Little progress in the treatment and the room
 Tracking long-term cardiovascular