Martina Cog
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Transcript of Martina Cog
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ACOGS NEW BEST PRACTICEGUIDELINES FOR PREECLAMPSIA:
USING THEM TO MINIMIZEMORBIDITY & MORTALITY
The University of Iowa & The Preeclampsia
Foundation
October 18, 2013James N. Martin Jr., MD, [email protected]
62nd President ACOG 2010-2013
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Preeclampsia
Summarize the current
state of knowledge
Develop practiceguidelines and checklists
for Best Practices
Identify the mostcompelling areas for
research
ACOG Presidential Initiative 2011-2012
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In the United States.. PRE either alone or superimposed on preexisting
hypertension presents the major risk
Maternal-fetal serious morbidity and mortality still
occur, sometimes avoidable vs lessened
Optimal managementclose observation for signsand early findingsdiagnosisbest time for
delivery
A continuing challenge: differentiate worseningchronic hypertension vs developing preeclampsia
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Some Problem Areas Identified.
Failure of care providers to appreciate the
multisystemic nature of PRE, sometimes the fault
of rigid criteria for diagnosis
PRE is a dynamic and a progressive process
Continuing reevaluation of thepatient required
PRE can first present or worsen
during the puerperium
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ACOG Hypertension in Pregnancy
Working Group 2011-2012
Jim Roberts (Chair)
Phyll is August (Internist)
George Bakris (Internist)
RR Gaiser (Anesthesia)
SA Karumanchi (Renal)
M Lindheimer (Renal)
Joey P Granger (Physiol)
Eleni Z Tsigas (Patient)
Jim Martin (Ex Officio)
John R Barton (MFM)
Ira M Bernstein (MFM)
Maury L Druzin (MFM)
A Jeyabalan (MFM)
Donna D Johnson (MFM)
Michelle Y Owens (MFM)
George R Saade (MFM)
Baha M Sibai (MFM)
Cathy Y Spong (MFM)
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The ACOG HIP APPROACH. Working Group of experts: Obstetrics,
Hypertension, Anesthesia, Consumer Advocate
Review the data
develop evidence-basedrecommendations (Level I desired)
Assessment of evidence/implications/confidence in
estimates of effect (very low, low, moderate or high)make a recommendation strategy developed by
the GRADE group
[http://www.gradeworkinggroup.org/]
Develop the most appropriate course of action:
Strong (all patients) Qualified (most patients)
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The GRADE approach
Grading of Recommendations Assessment, Development
and Evaluation (GRADE)
An approach used by many groups
Evaluate and score evidence
Very low, low, moderate, or high quality of evidence
Make and rate recommendation
Strong recommendation
Qualified recommendation
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Recommendations
Strong: Astrongrecommendationisonethatissowellsupported
that
it
would
be
the
approach
appropriate
for
virtually
all
patients.
It
could
be
the
basis
for
health
care
policy.
Qualified:Aqualifiedrecommendationisalsoonethatwouldbe
judged
as
appropriate
for
most
patients,
but
it
might
not
be
the
optimalrecommendationforsomepatients(whosevaluesand
preference
differ,
or
who
have
a
different
attitude
toward
uncertaintyinestimatesofeffect).WhentheTaskForcehasmadea
qualified
recommendation,
the
health
care
provider
and
patient
are
encouragedtoworktogethertoarriveatadecisionbasedonthe
values
and
judgment
and
underlying
health
condition
of
a
particular
patient
in
a
particular
situation.
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MAKING THE DIAGNOSIS Maintain the classification scheme advanced by
National Blood Pressure Education Program and
ACOG in 1998: GH
PRE
CHTN with Superimposed PRE
In recognition of the syndromic nature of PRE, we
have eliminated the dependence of the diagnosisupon proteinuria..and made it proteinuria OR any
evidence of maternal compromise to be listed soon
Blood pressure criteria
are same as prior
recommendations
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GESTATIONAL HYPERTENSIONESTATIONAL HYPERTENSION
Development of hypertension after 20 wks Previously normotensive
SBP > 140 mmHg
OR (not and/or)
DBP > 90 mmHg
Persistent for 4 hrs
BP returns to normal by 6 wks postpartum
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Mild PREECLAMPSIA
Its never mild
Increased morbidity
Increased mortality
Rapid progression is possible
Early onset
Co-morbidities
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MILD PREECLAMPSIA:
THE PROBLEM.Preeclampsia is progressive
Mild preeclampsia seems to result in a false senseof security
As an attempt to avoid this the Task Forcerecommends:
Preeclampsia without severe features
(Preeclampsia)Preeclampsia with severe features (Severe
Preeclampsia)
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PROTEINURIA
Preeclampsia is not just hypertension but a
multisystemic syndrome.
Proteinuria has been the traditional way to test thissyndromic nature.
Not all eclamptics or sick preeclamptics have
proteinuria.
Amount of protein does not correlate with maternal
or fetal outcome.Conclusion: Use other signs of syndromic nature
(other systemic findings) for diagnosis.
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PREECLAMPSIA
REECLAMPSIA
Proteinuria
> 300 mg/day or
Protein/Cr > 0.30
Thrombocytopenia
Impaired liver function
Renal insufficiency
Pulmonary edema
Cerebral disturbances Visual impairment
Gestational
hypertension
+new onset of
any of the
following:
(dipstick 1+) (IUGR out)
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Induction versus Expectant Management in
Mild GHTNPreeclampsia after 36 wk
(HYPITAT randomized trial)*
Induction
(n=377)
Expectant
(n=379)
GA (wk) 38.4 (36-41) 38.6 (36-41)
GHTN 65% 66%
Preeclampsia 33% 32%
Proteinuria 450 (300 -
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HYPITAT Randomized Trial
Maternal Outcome
Induction
n=377
Expectant
n=379
RR
(95% C.I.)Composite adverse outcome 31% 44% 0.71 (0.59-0.86)
HELLP 1% 3%
Pulmonary edema 0 1%
Abruptio 0 0
Eclampsia 0 0
Maternal ICU 2% 4%
Severe systolic HTN
Cesarean delivery
15%
14%
23%
19%
0.63 (0.46-0.86)
0.75 (0.55-1.04)
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HYPITAT Randomized Trial
Neonatal Outcome
Induction (%) Expectant
(%)
Composite adverse outcome 6 8
Perinatal deaths 0 0
Apgar < 7 at 5 min 2 2
Cord PH < 7.05 3 6
NICU admission 3 2
RDS 0.25 0.25
Koopmans et al, Lancet 2009
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GHTN PRE Without Severe Features
Maternal & Fetal Evaluation
37 weeks gestation
34 weeks gestation Labor, PPROM, FGR
Suspected Abruptio
Abnormal M/F testing
Delivery
Inpatient / outpatient
Maternal / fetal testing
Worsening M/F condition
Labor / PPROM
37 weeks gestation
Yes
No
HYPITATD&D
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MANAGEMENT OF
ANAGEMENT OF
PREECLAMPSIA WITH
REECLAMPSIA WITH
SEVERE
EVERE
FEATURES
EATURES
Term
Delivery Remote from term
Individualize
Deliver
>34Weeks
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ACUTE CONTROL OF SEVERE HYPERTENSION
Persistent (>15 min) SBP > 160 mmHg or
Persistent DBP > 105 mmHg
IV labetalol
bolus doses 20-40 mg (max 300/hr) continuous IV infusion (1-2 mg/min)
IV bolus doses ofhydralazine
5, 10, 10 mg q 20 min (max 25 mg)
Oral nifedipine
10-20 mg q 20 min (max 60 mg) ACOG CO 514
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PREVENTION OF SEIZURES
Magnesium sulfate
Intravenous regimen
Loading dose: 4 or 6 g IV over 20 mins
Maintenance: 2 g IV per hr
If convulsions recur
2 g dose of magnesium sulfate
Treat: Eclampsia, Preeclampsia (sev), HELLP
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MATERNAL-PERINATAL Outcome
According to GA at Start of Expectant
Management
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FETAL DELIVERY GUIDELINES-
preeclampsia w/severe features
Expedited delivery (within 72 hrs)
Fetal distress by FHR tracing or BPP 4
Amniotic fluid index < 5 cm
Ultrasound EFW < 5th percentile
Reverse umbilical artery diastolic flow
Labor / ROM > 34 weeks gestation
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PROTEINURIA PREECLAMPSIA
Does the amount matter
No differences in outcomes (< 5 vs
5 g)
Renal function
Latency
Similar outcomes (< 5, 5-9.99,
10 g/24h)
Delivery decision should not be based on: Amount of proteinuria
Change in amount of proteinuria
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PRE < 34 wks WITH SEVERE FEATURES
Admit to L&D: ? Expectant Management ?
Corticosteroids, MgSO4 prophylaxis, antihypertensives
Ultrasound, FHR monitoring, symptoms, laboratory tests
Contraindications to continued expectant
management after initial 24-48hrs?
Eclampsia
< 230/7 wks (may individualize)
Pulmonary edema
Abnormal fetal testing ARF/AKI, DIC
Abruptio placentae
Delivery
*******
No
Yes
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PRE < 34 wks with SEVERE FEATURES
Offer continued expectant management after first 24-48hrs
Inpatient only, D/C MgSO4
Daily maternal / fetal testing, sxs, BP, labs (?biomarkers?)
No Contraindication
Additional complications present?
Persistent symptoms
HELLP / partial HELLP syndrome
FGR (
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MAGNESIUM SULFATE DURING
CESAREAN DELIVERY
Half-life of 5 hours
Discontinuing magnesium
will not change drug
interactions DCing increases risk for
seizure outside the
operative suite
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MANAGEMENT OF HELLP SYNDROME
Refer to tertiary care facil ity (< 35 wks)Admit to labor & delivery area
IV magnesium sulfate
Antihypertensives if SBP 160; or DBP 105mmHg
< 23 wks or 34 wks
Fetal distress
Maternal distress
EclampsiaAbruptio placentae / DIC
Renal failure
Respiratory distress
Suspect liver hematoma
23-34 wks Complete steroid course
24-48 hours latency
DeliveryYes
No
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ManagementofHELLPSyndrome:MISSISSIPPIPROTOCOL
Class1or
2HELLP
Syndrome?
(PLT600
AST/ALT>70,+Schistocytes,
Ind.Bili>1.2)
YES
NO Eclampsia?
NO
YES
Class3or
Partial
HELLPSyndrome?
NO
YES
Severe
EpigastricPain?YES
NOEndOrganInjury(renal,
hepatic,
CVS,
CNS)
and/or
abruptionDIC?
NO
YES
ContinueCurrent
Managementwithout
IVDexamethasone
INITIATEIV
DEXAMETHASONE10mgIVq12HOURS
CONSIDERIV
DEXAMETHASONE
10mgIVq12HOURS
SevereHypertension
DifficulttoControl,
orCNSSymptoms?
YESNO
Hypertension in Pregnancy January 2012
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HELLP SYNDROME: Best Practice Martin JN Jr. Milestones in the quest for best
management of patients with HELLPsyndrome. Int J Gynaecol Obstet 2013
March22 [PMID: 23528799]
Martin JN Jr, Owens MY, Keiser SD, ParrishMF, Tam Tam KB, Brewer JM, Cushman JL,
May WL. Hypertens Pregnancy [Level 2]
2012;31(1):79-90. [PMID: 21219123]
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Rate of Persistent Diastolic Hypertension
Proteinuria in POSTPARTUM Period
%
Hypertension Proteinuria Hypertension Proteinuria
3 Days 7 Days H Stepan et al.,J Hum Hypert 2006
POSTPARTUM PREECLAMPSIA
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POSTPARTUM PREECLAMPSIA:Points to Consider
In reviewing morbidity and mortality figures several
mistakes leading to mortality were evident.
Care providers whose care resulted in bad
outcomes:
did not appreciate the progressive nature ofpreeclampsia (mild preeclampsia).
Did not act in the absence of proteinuria despite other
systemic signs (did not understand syndromic) Postpartum preeclampsia & severe hypertension were
frequently seen in these cases
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BP monitored a minimum 72 hours postpartum
Repeat BP assessment 7-10 days postpartumOffice / clinic
Home health
Specific written discharge instructions
Headache
RUQ or chest painVision impairment
Office and L&D telephone numbers
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LONG TERM MATERNAL
OUTCOME
Recurrent preeclampsia+
CHTN (4-fold*)
Ischemic heart disease (2-fold*)
Stroke (2-fold*
) Venous thromboembolism(2-fold*)
All-cause mortality (1.5-fold*)
Preeclampsia is a screening test for future health
+
Barton, Sibai 2008*Craici et al 2008
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Primary
Prevention
of
Preeclampsia
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Preeclampsia Pharmacopoeia
What works?
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PREVENTION OF RECURRENT
PREECLAMPSIA
Pre-pregnancy
Weight loss to ideal BMI
Control of glucose in diabetes
Control of BP in CHTN (diet, exercise)Low dose aspirin in select patients (from 12 wks)
Not recommended
Vitamins C & E
Dietary salt restriction
Anti-HTN therapy to prevent preeclampsia
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PREDICTION OF PREECLAMPSIA?
Encouraging but not yet ready for routine clinical
use, alone or in combination:
Identification of demographic factors Biochemical analytes
Biophysical findings
NO RECOMMENDATIONS