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.