Preeclampsia,Transtornos hipertensivos del embarazo, manejo de la preeclampsia

SINDROME HIPERTENSIVO ASOCIADO AL EMBARAZO Samuel Gelvez Tellez Ginecologia y Obstetricia Facultad de Medicina Universidad de Antioquia

MANEJO DEL SINDROME HIPERTENSIVO ASOCIADO AL EMBARAZO

SINDROME HIPERTENSIVO ASOCIADO AL EMBARAZO ,[object Object],[object Object],[object Object],[object Object],Endocrinol Metab Clin N Am 35 (2006) 157-171

[object Object],[object Object],[object Object],[object Object],Sibai BM,Caritis S, Hatuh J, Hypertensive Disorders in Twin vs Singletons gestations.National Institute of Child Health And Human Development Network of maternal- fetal Medicine Units. Am J Obstet Gynecol; 2002;182: 938-42

[object Object],[object Object],[object Object],Sibai BM, villar MA, Mabie BC, Acute Renal Failure In hypertensives Disorders of pregnancy. Am J Obstet Gynecol 2001; 98: 861-6

[object Object],[object Object],[object Object],[object Object],E.E.U.U Critical Care Clin 20 (2004) 697 – 712

[object Object],[object Object],Critical Care Clin 20 (2004) 697 – 712

HUSVP ,[object Object],[object Object],Sistema informativo perinatal local. CLAP/OPS, Departamento de Ginecologia y Obstetricia del HUSVP. Año 2001

MORTALIDAD MATERNA EN COLOMBIA Fuente: Instituto Nacional de Salud, Vol 6, No 23, dic 2001

Mortalidad materna en Antioquia Distribución según causa básica de muerte 2004 CLAP/OPS-OMS/UdeA

A C O G ,[object Object],[object Object],[object Object],[object Object],ACOG Committee on practice Bulletins-Obstetrics Diagnosis and Management of preeclampsia and eclampsia. Obstet Gynecol 2001; 98 159-67

[object Object],[object Object],[object Object],ACOG Committee on practice Bulletins-Obstetrics Diagnosis and Management of preeclampsia and eclampsia. Obstet Gynecol 2001; 98 159-67

Preeclampsia moderada ,[object Object],[object Object],Adverse Perinatal Outcomes are significantly higher in severe gestational that in mild preeclampsia. Am J Obstet Gynecol 2002; 186:66-71

Disminuir Morbi-mortalidad materna y perinatal.

Preeclampsia moderada ,[object Object],[object Object],BartonJR. Within AG, Sibai BM. Management of mild preeclampsia. Clin Obstet Gynecol 1999; 42: 465 -9

Preeclampsia moderada ,[object Object],[object Object],[object Object],[object Object],Greer IA, Thrombosis in Pregnancy, Materna and Fetal Issues, Lancet 1999, 353:1258-65

Preeclampsia moderada ,[object Object],[object Object],American College of Obstetricians and Gynecologists 2002

Preeclampsia moderada ,[object Object]

Pruebas controladas sulfato de magnesio vs Placebo en preeclampsia moderada Eclampsia Progresion a severa 0.90(0.52-1.54) 25/181(13) 22/176 (12.5) 0/181 0/176 TOTAL 0.76(0.42.4) 19/113(16.8) 14/109(12.8) 0/113 0/109 Livingston et al 1.35(0.5-3.7) 6/68(9.1%) 8/67(12%) 0/68 0/67 Witling et al RR(95%CI) Placebo Sulfato de magnesio placebo Sulfato de magnesio Authors

Livingston JC, Livingston LW, Ramsey R, Mabie BC, Sibai BM, Magnesium Sulfate in Women with mild preeclampsia A Randomized, doubleblind,placebo-controlled trial. Obstet Gynecol 2003; 101, 217-220 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Livingston JC, Livingston LW, Ramsey R, Mabie BC, Sibai BM, Magnesium Sulfate in Women with mild preeclampsia A Randomized, doubleblind,placebo-controlled trial. Obstet Gynecol 2003; 101, 217-220

[object Object],[object Object],[object Object],Livingston JC, Livingston LW, Ramsey R, Mabie BC, Sibai BM, Magnesium Sulfate in Women with mild preeclampsia A Randomized, doubleblind,placebo-controlled trial. Obstet Gynecol 2003; 101, 217-220

[object Object],[object Object],[object Object],Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Ginecol 2004; 190 1520-6

Tratamiento ambulatorio ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CONDICIONES ,[object Object],[object Object],[object Object],ACOG Committee on practice Bulletins-Obstetrics Diagnosis and Management of preeclampsia and eclampsia. Obstet Gynecol 2001; 98 159-67

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],ACOG Committee on practice Bulletins-Obstetrics Diagnosis and Management of preeclampsia and eclampsia. Obstet Gynecol 2001; 98 159-67

Vigilancia Fetal ,[object Object],[object Object],[object Object],[object Object],[object Object],ACOG Committee on practice Bulletins-Obstetrics Diagnosis and Management of preeclampsia and eclampsia. Obstet Gynecol 2001; 98 159-67

Vigilancia Materna ,[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],Critical Care Clin 20 (2004) 697 – 712

Preeclampsia moderada ,[object Object],[object Object],[object Object],[object Object],[object Object]

Preeclampsia moderada Evaluacion materna y fetal 1.>= 37 s de gestacion 2. >= 37 s, Bishop > 6 3. >34 s. T de P, RPMO, RCIU, test anormales PARTO SI <37 > 37 Tratamiento hospitalario o ambulatorio Evaluación materna y fetal NO prostaglandinas 1.empeoramiento materno-fetal 2.37 s de gestación. 3. Bishop >= 6 a las > 37S. 4.T de P Diagnosis and management of gestational Hypertension and preeclampsia. Sibai BM. Obstetrics ang Ginecology; Vo l 102 N1, 2003

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],Am J ObstetGynecol.1994;171:818-22

SOBREVIDA NEONATOS HUSVP POR EDAD GESTACIONAL 2004-2005 Unidad neonatal HUSVP.Estadisticas sobrevida 2004-2005

SOBREVIDA NEONATOS HUSVP POR PESO AL NACER 2004-2005 Unidad neonatal HUSVP.Estadisticas sobrevida 2004-2005

Manejo Expectante PE severa ,[object Object],[object Object],[object Object]

TRATAMIENTO EXPECTANTE EN PREECLAMPSIA SEVERA ,[object Object],[object Object],[object Object],[object Object],Am J ObstetGynecol.1994;171:818-22

CRITERIOS PARA MANEJO EXPECTANTE ,[object Object],[object Object],American Journal of Obstetrics and Gynecology (2004)190,1590-7

CRITERIOS PARA MANEJO EXPECTANTE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Hasta Cuando? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],American Journal of Obstetrics and Gynecology (2004)190,1590-7

Preeclampsia severa EG < 24 s ,[object Object],[object Object],[object Object],Am J ObstetGynecol.1994;171:818-22

Preeclampsia severa EG 24-32 s ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Preeclampsia severa > 35 s, Eclampsia y cualquier EG ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 1999 Lippincott Williams & Wilkins, Inc. Volume 42(3), September 1999, p 470 Expectant Management of Severe Preeclampsia Remote from Term

PREECLAMPSIA SEVERA 1.HOSPITALIZAR. 2.EVALUACION MATERNA Y FETAL POR 24 H. 3.SULFATO DE MAGNESIO. 4.ANTIHIPERTENSIVOS SI TAS> 160 O TAD > 105 -DETERIORO MATERNO. -ESTADO FETAL NO SATISFACTORIO. -T de P o RPMO -> 34 s Sulfato de Mg PARTO RCIU severo ESTEROIDES < 23 S 23-32 33-34 ESTEROIDES ANTIHIPERTENSIVOS A NECESIDAD EVALUACION DIARIA MATERNO-FETAL PARTO A LAS 34 S PARTO SI SI NO NO

Sulfato de Magnesio ,[object Object],[object Object],[object Object],[object Object]

Pruebas controladas aleatorizadas de sulfato de magnesio en PE severa A Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Ginecol 2004; 190 1520-6 0.39(0.28-0.55) 128/6330(2) 49/6343(0.6) TOTAL 0.33(0.14-0.77) 21/819(2.6) 7/831(0.8) Belfort et al 0.42(0.26-0.60) 96/5055(1.9) 40/5055(0.8) Magpie trial 0.09 (0.01-0.69) 11/340 (3.2) 1/345 (0.3) Coetzee et al N/A 0/116 1/112 (0.9) Moodley and Moodley RR (95%CI Control N.( %) Convulsiones(%) Authors

Efectos del sulfato de magnesio en la proporcion de depresion respiratoria en mujeres con PE severa Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Ginecol 2004; 190 1520-6 2.06(1.33-3.18) 29/6268(0.46) 63/6287(1) Total 1.96(1.22-3.14) 26/4993(0.5) 51/4999(1) Magpie trial N/A 0/340 1/345(0.3) Coetzee et al N/A 0/116 0/112 Moodley and Moodley RR (95%CI) Control N. % Sulfato de Magnesio N. % Authors

Efectos del sulfato de magnesio sobre la tasa de muerte perinatal en PE severa Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Ginecol 2004; 190 1520-6 1.03(0.87-1.22) 601/4958(13) 634/5003(13) Total 1.02(0.92-1.14) 558/4486(12) 576/4538(13) Magpie trial 1.38(0.87-2.20) 38/354(8) 38/348 (11) Coetzee et al 0.81(0.47-1.37) 25/118 (21) 20/117 (17)) Moodley and Moodley RR (95%CI) Control N. % Sulfato de Magnesio N. % Authors

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[object Object],[object Object],[object Object],[object Object],[object Object]

Tiempo, duración, dosis, via ,[object Object]

[object Object],[object Object],[object Object],[object Object],Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Ginecol 2004; 190 1520-6

[object Object],[object Object],[object Object],[object Object]

Control de la Hipertensión severa ,[object Object],[object Object],[object Object],[object Object],[object Object],Critical Care Clin 20 (2004) 697 – 712

Cuando utilizar antihipertensivos? ,[object Object],[object Object],[object Object],[object Object],[object Object],Critical Care Clin 20 (2004) 697 – 712

Control de la hipertensión severa ,[object Object],[object Object],[object Object],[object Object],[object Object]

Control de la hipertensión severa ,[object Object],[object Object],[object Object],Infusión en DAD al 5% desde 0,25 micro/kg/minuto

Vía del parto ,[object Object],[object Object]

Via del parto ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],Diagnosis and management of gestational Hypertension and preeclampsia.Baha M Sibai. Obstet Gynecol; 102: 181-92

[object Object],[object Object]

Comparación de morbilidades maternas (N=93) Severe preeclampsia and delivery outcomes. Is immediate Cesarea delivery beneficial? Am J Obstet And Ginecol.2002; 186:921-3 NS 2 1 Renal NS 16 10 Neurologico <.05 14 3 Pulmonar NS 15 7 Hepático NS 29 21 Hipertension NS 2 4 Hemorragia NS 3 0 Endometritis NS 2 0 CID NS 1 0 cardiaco Valor de P cesárea vaginal Resultado materno

Morbilidad Neonatal n=93 Valor de P cesárea vaginal Resultado Neonatal NS 15 3 ventilador <.05 11 1 Surfactante <.05 28 7 SDR NS 8 2 Sepsis NS 2 2 HIV NS 24 13 RCIU 0 0 Convulsión 0 0 Hipercalcemia NS 20 12 Hiperbilirruninemia NS 2 0 Mortalidad

Manejo Intraparto ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Critical Care Clin 20 (2004) 697 – 712

A que pacientes se les hace monitoreo invasivo? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Mortalidad materna en Antioquia Momento de la muerte

Seguimiento posparto ? ,[object Object],[object Object],[object Object],[object Object],Critical Care Clin 20 (2004) 697 – 712 ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],Barton JR, Hiett AK, Conover WB, The use Of nifedipine during of pospartum period in patiens with Severe preeclasmpsia. Am J obstect Gynecol 1990; 162:788-92

Cuando dar de alta y como? ,[object Object],[object Object],[object Object],[object Object],Critical Care Clin 20 (2004) 697 – 712

CONCLUSIONES. ,[object Object],[object Object],[object Object]

Preeclampsia,Transtornos hipertensivos del embarazo, manejo de la preeclampsia

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Preeclampsia,Transtornos hipertensivos del embarazo, manejo de la preeclampsia