PREECLAMPSIA (2).pptx...................

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1. Hypertensive disorders in pregnancy, labour and postpartum period . Preeclampsia and eclampsia. Kazan State M edical U niversity Ganeeva Albina V. Teaching and research assistant of the department of obstetrics and gynecology

2. Classification of hypertensive disorders in pregnancy Pre-existing hypertension (AH) – AH diagnosed either before pregnancy, or during the first 20 weeks of gestation. It can be primary or secondary etiology. 2. Gestational arterial hypertension - arterial hypertension, established after 20th week of pregnancy, and that is not accompanied by significant proteinuria . 3. Preeclampsia (PE) - arterial hypertension, established after 20th week of pregnancy, that is accompanied by significant proteinuria . PE can be also developed at the background of Pre-existing hypertension. Significant proteinuria is defined as 0.3 g / L protein loss in daily urine.

3. Maternal mortality structure in the Russian Federation in 2016 Hypertensive disorders in pregnancy take the leading positions among the reasons of maternal and perinatal death.

4. 10% of pregnancies are complicated by Arterial Hypertension (АН) , 2-5% - by Preeclampsia (РЕ) , up to 12% in some countries in Africa.

5. Preeclampsia (PE) is a complication of the second half of pregnancy which is characterized by combination of symptoms: Proteinuria ( of >0,3 g/l in daily urine) + Arterial Hypertension + sometimes - edema. PE never occurs : O ut of pregnancy In animals Before the 20 weeks of gestational age DURING PREGNANCY PREECLAMPSIA ONLY PROGRESSES, IT CANNOT BE CURED! IT REGRESSES : After delivery (placental expulsion)

6. PE Pathogenesis is based on the incomplete trophoblast invasion to the spiral arteries of uterus. P hysiological pregnancy PATHOGENESIS OF PREECLAMPSIA The causes of PE development are multiple, varied and not clearly understood. Transformation of the muscular layer in spiral arteries T rophoblast cells migration to the spiral artery walls

7. Post-fertilization e vents

8. PREECLAMPSIA Spiral arteries retain the morphology of non-pregnant vessels S uppression of trophoblast migration PATHOGENESIS OF PREECLAMPSIA

9. • S uppression of trophoblast migration; • no transformation of the muscular layer in spiral arteries; they retain the morphology of non-pregnant vessels; • spiral artery spasm; • decrease in intervillous blood flow; • disturbance of placental microcirculation • hypoxia developing as a result (ischemia of placenta) PATHOGENESIS OF PREECLAMPSIA

10. In its turn, hypoxia of uteroplacental complex leads to overproduction of proinflamatory cytokines by placenta, that attack endothelium. • endothelial lesion and disorder of endothelial thromboresistant and vasoactive properties ; • generalized vascular spasm; • hypovolemia; • disorder of rheological and clotting properties of the blood ( hypercogulation );

11. • non-decrease in total peripheral vascular resistance; in physiological pregnancy it decreases; • reduced cardiac output; • decrease in blood flow and glomerular filtration in kidneys; • generalized compensatory arterial hypertension; • tissue hypoperfusion ; • multiple organ failure

12. Prediction: Factors that increase the risk of preeclampsia • Anamnestic factors : low-socioeconomic s tanding ( moderate risk) first pregnancy (moderate risk) mother's age 40 years or more (moderate risk) new partner ( husband) (moderate risk) PE in previous pregnanc ies ( h igh risk) f amily history of PE (moderate risk) IVF-induced pregnancy (moderate risk) some ethnic groups (like negroid race, for instance) (moderate risk)

13. Factors that increase the risk of preeclampsia Extragenital pathology : Obesity (moderate risk) C hronic renal disease (moderate risk) C hronic arterial hypertension (moderate risk) D iabetes mellitus (moderate risk) Thrombophilia (moderate risk) A utoimmune diseases (moderate risk)

14. Factors that increase the risk of preeclampsia The course of pregnancy : Systolic blood pressure of more than 130 mm Hg or diastolic blood pressure of more than 80 mm Hg (moderate risk) Excessive weight gain (moderate risk) Infections during pregnancy (moderate risk) Methamphetamine, cocaine use (moderate risk) Multiple pregnancy (moderate risk)

15. The screening for PE, conducted before the end of the 1st trimester (11-13 weeks 6 days), includes: * assessment of maternal risk factors; * measurement of average blood pressure ; * determination of Placental growth factor (PIGF) in serum; * measurement of the Pulsatory index of the Uterine arteries (the smallest value of the two is taken into account). International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: а pragmatic guide for first-trimester screening and prevention (2019)

16. A calculator of the individual risk of PE is freely available on the website https :// fetalmedicine.org/research/assess/preeclampsia International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: а pragmatic guide for first-trimester screening and prevention (2019)

17. Preeclampsia prophylaxis The risk of developing PE should be considered high if the result is ≥1 in 100 . Low-dose A spirine (150 mg a day) is used in the group of high risk starting from the 12 th week of gestational age, up to labour , 36 weeks of gestation or manifestation of PE. 2. Calcium supplementation(≥1000 mg a day) is used in patients with its deficit in diet.

18. CLINICAL FEATURES OF PREECLAMPSIA. Arterial hypertension - a condition characterized by high blood pressure . С riteria for hypertension during pregnancy : Systolic BP ≥140 mm Hg or / and diastolic BP≥90 mm Hg , defined as the average of at least two measurements о n the same hand .

19. Proteinuria is a sign developing in pregnancy; Ideally proteinuria should be determined by protein content in daily urine . Proteinuria is considered abnormal when it reaches or exceeds 0.3 g/day or 0.3 g/l in samples obtained at an interval of 6 hours. To assess the true level of proteinuria, it is necessary to exclude the infection of the urinary system.

20. Edema is a common symptom of preeclampsia but not its diagnostic criteria . Edema is general, excessive accumulation of fluid in tissues after 12-hour rest in bed. Edema develops secondary to disturbance of capillary permeability and escape of fluid from the blood stream to the interstitial space as a result of renal glomerular lesion with increased permeability of the basal membrane of their capillaries, and due to decreased oncotic pressure (with underlying hypoalbuminuria ). In physiological pregnancy moderate swelling is noted in 50 – 80% of women.

21. It is classified in the following way: • invisible edema (abnormal weight gain by 500 g and more within a week, positive ring symptom, nocturia , decrease in diuresis below 900–1000 ml while fluid intake is 1400–1500 ml); • visible edema divided into stages: – stage I: edema of upper and lower extremities; – stage II: edema of upper and lower extremities, abdominal wall; – stage III: edema of upper and lower extremities, abdominal wall and face; – stage IV: anasarca.

22. Classification . Moderate PE The criteria of moderate PE : Severe AH (Systolic BP ≥ 140 mm hg, up to 159 mm hg or / and Dyastolic BP ≥ 90 mm hg, up to 109 mm hg ) + Proteinuria >0,3 g / l in daily urine 2. Severe PE The criteria of severe PE : Severe AH (Systolic BP ≥160 mm hg or / and Dyastolic BP ≥ 110 mm hg) +(or) Proteinuria >5 g / l in daily urine or 3 g/l in each of 2 portions of urine ( interval - 6 hours) OR Hypertension + Evidence of other maternal organ dysfunction or Uteroplacental dysfunction

23. Additional criteria for severe PE indicating multiple organ failure : HELLP (ELLP) syndrome; persistent headaches, vomiting, or other cerebral or visual disturbances; impaired renal function (oliguria <500 ml / day, increased creatinine); acute lung damage / acute respiratory distress syndrome, pulmonary edema; swelling of the optic disc; impaired liver function (increased enzymes AlAT , AsAT , LDH); epigastric pain / right upper quadrant of the abdomen (overstretching of the liver capsule, intestinal ischemia due to circulatory disorders); thrombocytopenia and / or its progression; suddenly appearing, growing swelling on the hands, feet or face; confirmation of fetal suffering (RRP syndrome, oligohydramnios, negative non-stress test). In the presence of symptoms of a critical condition the presence of proteinuria is not necessary for the diagnosis of severe preeclampsia

24. Classification PE can be subclassified into: 1.Early‐onset PE (with delivery at <34+0 weeks of gestation); 2.Late‐onset PE (with delivery at ≥34+0 weeks of gestation ). Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer.

25. Early complications of preeclampsia Eclampsia; Edema, hemorrhage and retinal detachment; Acute fatty hepatosis ; HELLP syndrome (hematoma or rupture of the liver); Acute renal failure; Pulmonary edema; Stroke; Myocardial infarction Placental abruption; Antenatal fetal death.

26. Delayed complications of Preeclampsia (in mother) Increased body mass index ( BMI) C hronic hypertension Myocardial infarction Diabetes mellitus Renal failure Stroke

27. Eclampsia is a со nvulsion attack against the background of preeclampsia in the absence of other causes. Eclampsia can develop against the background of preeclampsia of any severity, and it is not a manifestation of the maximum severity of preeclampsia. In 30% of cases, eclampsia develops suddenly in the absence of the previous signs of preeclampsia . Headache, pain in the abdomen or disturbance of vision the main symptoms that predict the development of eclampsia. Eclampsia

28. Classification of Eclampsia Eclampsia during pregnancy and childbirth Eclampsia in the postpartum period:   early postpartum period (24 hours) late postpartum period(28 days) Up to 44% of cases of eclampsia occur in the postpartum period, especially after full-term pregnancy . Downtown Abbey

29. Attack of convulsion is the main manifestation of eclampsia, which leads to the loss of consciousness. Attack develops consequently, in 4 stages : I stage lasts for 20–30 s and is accompanied with fibrillar twitching of the mimic muscles, sometimes of the upper extremities, the look is fixed at one point; II stage lasts till 30 s and is characterized by the expressed tonic convulsions, which spread from the head on the trunk and extremities, head throw to the back, opistotonus can be observed. Respiration stops, pulse is not palpated, pupils are widened, occlusion of the tongue can occur; III stage lasts up to 2 min — clonic convulsions, which also spread from up downwards, cyanosis develops, saliva with admixture of blood discharges from the mouth (as the result of the tongue’s bite); IV stage — begins with deep interrupted inhalation, respiration gradually restores, however, the patient is in coma.

30. TREATMENT TACTICS IN PREECLAMPSIA AND ECLAMPSIA With moderate PE: careful monitoring of the condition of the pregnant woman and the fetus with symptomatic treatment. In the absence of negative dynamics, pregnancy can be prolonged. Delivery is indicated when the condition of the mother and fetus worsens. In severe PE – frequently* prolongation of pregnancy is impossible. Labour should be induced after stabilization of the mother’s condition and, if needed (25-34 weeks of gestation), after the prophylaxis of the fetal Respiratory distress syndrome. Vaginal delivery is preferable. * At the gestational age of 25-34 weeks, in the absence of negative dynamics we can make the attempt for prolongation of pregnancy even in severe PE.

31. Basic preeclampsia treatment Delivery (the most effective treatment for PE) Antihypertensive therapy Anticonvulsant therapy with magnesium sulfate ( in severe PE or eclampsia)

32. Criteria for initiating antihypertensive therapy in PE: Blood pressure > or = 140/90 mm Hg The target level of blood pressure (taking into account both the safety of the mother and the need of the fetus) is : Systolic blood pressure of 135 mm Hg Diastolic blood pressure 85 mm Hg

33. Antihypertensive therapy 1. Central α2-agonists of Methyldopa tab. 500 mg - 2000 mg per day, in 2-3 doses. The first-line drug, the most studied, possibly impaired liver function in the mother, depression, sedation, orthostatic hypotension are noted in 22% of women 2. Calcium antagonist - Nifedipine tab. prolonged action - 20 mg, the average daily dose of 40-90 mg in 1-2 doses, depending on the form of release, the maximum daily dose of 120 mg. 3. Labetalol - combined both alpha- and beta- adrenergic receptor blocker. If indicated, Metoprolol, Verapamil, A mlodipine also can be used.

34. MgSO4 dosage regimen Only intravenously, always using a device for continuous administration ( infusomat , pump). Loading dose – 4 g of dry matter for 10-15 minutes; Maintenance dose - 1-2 g of dry matter per hour. The introduction of Nagnesium sulfate should be carried out before and against the background of delivery, and should continue at least 24 hours after delivery or 24 hours after the last episode of seizures Magnesium sulfate is not actually a hypotensive drug. In severe PE, its introduction is necessary for the prevention of convulsive syndrome

35. Team approach with the participation of obstetrician-gynecologists, resuscitation anesthetists, therapists and neonatologists. Before delivery, it is necessary to stabilize the condition of the woman. With a gestational age of <32 weeks a cesarean section preferable After 34 weeks - vaginal delivery with cephalic presentation. Anticonvulsant, antihypertensive therapy should be carried out throughout the entire period of delivery. preeclampsia and its complicated forms represent the highest risk of massive bleeding in obstetrics. D elivery

36. Indications for urgent delivery (hours): persistent headache and visual manifestations persistent epigastric pain, nausea, or vomiting progressive deterioration in liver and / or kidney function eclampsia arterial hypertension not amenable to medical correction platelet count less than 5 0 * 10⁹ / l and its progressive decrease violation of the fetus, recorded according to CTG, ultrasound, Severe oligohydramnion

37. Indications for emergency delivery (minutes): Bleeding from the birth canal, suspected placental abruption A cute fetal hypoxia

38. Offer E nalapril to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium . Antihypertensive treatment during the postnatal period, including the period of breastfeeding For women with hypertension in the postnatal period, if blood pressure is not controlled with a single medicine, consider a combination of nifedipine (or amlodipine ) and enalapril . If this combination is not tolerated or is ineffective,consider either: • adding atenolol or labetalol to the combination treatment or • swapping 1 of the medicines already being used for atenolol or labetalol.

39. HELLP SYNDROME HELLP syndrome is a complex of symptoms including • h emolysis; • e levated l iver enzymes; • l ow p latelet count. the atypical PE form It is noted in 0.3% of all pregnancies. In case of severe PE and eclampsia it develops in 4–12% of cases; it is characterized by high maternal (up to 25%) and perinatal mortality.

40. Clinical features include a rapid, aggressive progression of signs. Initial manifestations are not specific: headache, weakness, vomiting, and abdominal pain localized mostly in the right subcostal area. Later there appear blood-tinged vomiting , hemorrhages at the sites of injections, progressive jaundice and hepatic failure , convulsions , marked coma . Rupture of liver with hemorrhage into the abdominal cavity is not a rare occasion. HELLP syndrome can be manifested as total placental abruption followed by massive coagulopathic hemorrhage and rapid development of hepatorenal failure.

41. Laboratory findings indicative of HELLP syndrome: •elevated aminotransferase activity (AST >200 IU/l, ALT >70 IU/l, Lactate dehydrogenase >600 IU/l; • thrombocytopenia (<100×109/l); • decrease in antithrombin III below 70%; • intravascular hemolysis and elevated bilirubin concentration; • increased prothrombin time and APTT; • decrease in fibrinogen concentration below the levels necessary in pregnancy; • increased nitrogenous waste content in the blood; • blood glucose fall to the extent of hypoglycemia.

42. For today there are no methods of conservative treatment of this complication. Similar to PE, the only treatment method is delivery .

43. Thank you