Академический Документы
Профессиональный Документы
Культура Документы
Task Force. HYPERTENSION IN PREGNANCY. The American College of Obstetrician and Gynecologists. 2013
TA ≥ 140/90
PREECLAMPSIA Embarazo > 20ss
Edema pulmonar
Task Force. HYPERTENSION IN PREGNANCY. The American College of Obstetrician and Gynecologists. 2013
PREECLAMPSIA SEVERA
Task Force. HYPERTENSION IN PREGNANCY. The American College of Obstetrician and Gynecologists. 2013
MORTALIDAD POR PREECLAMPSIA
Eclampsia 3 al 5% 14%
ACV 5% 40%
Edema 20% 1%
pulmonar
Ruptura 1% 75-90%
hepática
Sibai. Obstet Gynecol 2005; 105 (2): 402-410
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Factores Angiogenicos
• Diferenciación e
invasión del trofoblasto
• Desarrollo vascular
fetoplacentario
• Remodelación
vascular materna
FATORES ANTIANGIOGENICOS
sFlt-1
Trombospondina-1
Endoglina
Fragmentos truncados
de prolactina
sEng
PREDICCIÓN Biochemical markers
Poon 2009, Akolekar 2009, Poon 2010, Audibert 2010, Foidart 2010, Wortelboer 2010,
FACTORES DE RIESGO
Factor de Riesgo RR
Edad Materna > 40 años 1.96
Nulípara 3
IMC > 35 4
Gemelar 2,93
Sx Ac Anti-fosfolípidos 9.7
Antecedente personal 7.2
Antecedente familiar 2-4
Etnia 3.1
HTA Crónica 4–5
Diabetes 4
U T I L I D A D DE C O M B I N A C I O N D E P R U E B A S
Poon LC., Karagiannis G., Leal A., Romero XC. And Nicolaides KH, Hypertensive disorders in pregnancy: screening by
uterine artery Doppler imaging and blood pressure at 11-13 weeks. Ultrasound Obstetric and Gynecoly. 2009 Nov;
34(5):497-502.
PREVENCIÓN
CALCIO
1gr/día
Antioxidantes:
Ptes con déficit Vitamina C y E
en dieta
Reposo en
ASPIRINA cama
80-150mg <16ss
riesgo 60% Dite restrictiva
PES NNT 50 / PENS NNT en sal
500
Ronilk et al, Combined Multimarker Screening and Randomized Patient Treatment with Aspirin for Evidence-Based Preeclampsia
Prevention , The new england journal of medicine; 2017, vol. 377 no. 7
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C S
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CRISIS
HIPERTENSIVAS
El objetivo es disminuir
la presión arterial a un
nivel que se controle el
daño de órgano blanco y
evitar Hipotensión
Terminología Definición Metas de tratamiento
“Crisis hipertensivas”
Tensión arterial sistólica (TAS) ≥ 160 mmHg o
tensión arterial diastólica (TAD) ≥ 110 mmHg
TAS > 160 mm Hg: ppal factor asociado con ACV siendo el limite indiscutible de
inicio de antihipertensivos en preeclampsia/eclampsia
80% de gestantes con TAS mayor de 180 mmHg pueden hacer ACV
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
Marik, Varon. Chest 2007; 131:1949–1962
Mc Coy. Am J Health-Syst Pharm 2009; 66 (15): 337-349
Ghanem. Cardiovascular Therapeutics 2008; 26: 38–49
TRATAMIENTO
Nifedipino 10 mg x 5 dosis
Daño hepático
AST y ALT
Glutatión S Transferasa α-1
Trombocitopenia
Haram K., Svendsen E. And Abildgaard U., The HELLP syndrome: Clinical issues and management. A Review, BMC
Pregnancy and Childbirth: February 2009
DIAGNÓTICO
Haram K., Svendsen E. And Abildgaard U., The HELLP syndrome: Clinical issues and management. A Review, BMC
Pregnancy and Childbirth: February 2009
TRATAMIENTO
Finalizar el embarazo
Medidas de soporte
• Prevención de las convulsiones.
• Control de la tensión arterial.
• Control de los trastornos de la coagulación.
• Control y reposición de volúmenes.
• Evaluación del estado materno-fetal.
TRANSFUSIÓN DE HEMODERIVADOS
Disminuye el edema
ECC
Received
Received forforpublication
publication MM
arch 15, 2005;
arch revisedrevised
15, 2005; April 4, 2005;
A prilaccepted Julyaccepted
4, 2005; 5, 2005 July 5, 2005
ealth and School of M edicine, b Universidad del Valle; Department of Gynecology and Obst etrics,
a
Disminución de la mortalidad
Posparto 11 – 44%
>50% en las primeras 48 horas
Reportes hasta 23 días postparto
Sibai B., Diagnosis, Prevention, and Management of Eclampsia. The American College of Obstetricians and Gynecologists; 2005: VOL. 105, Nº 2
Mortalidad 1-15%
Países desarrollados 0 – 1.8%
Países subdesarrollados 15 %
Causas de Mortalidad
Hemorragia cerebral 43%
Falla renal 26%
CID 11%
Edema cerebral 4%
MORTALIDAD
CON TTO <1%
1.
Ghulmiyyah Labib and Sibai Baha, Maternal Mortality From Preeclampsia/Eclampsia. Semin Perinatol; 2012: 36:56-59
2.
Vigil-De Gracia Paulino, Maternal deaths due to eclampsia and HELLP syndrome . International Journal of Gynecology and
Obstetrics. 2008
M agnesium Sulfate for the Treatment of Eclampsia : A Brief Review
Anna G. Euser and Marilyn J. Cipolla
M S A Vasodilatación
Stroke. 2009;40:1169-1175; originally published online February 10, 2009;
doi: 10.1161/STROKEAHA.108.527788
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2009 American Heart Association, Inc. All rights reserved.
C O C Barrera Hemato-
I Encefalica
The online version of this article, along with updated information and services, is located on the
A World Wide Web at:
http://stroke.ahajournals.org/content/40/4/1169
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Anna G. Euser and Marilyn J. Cipolla. Magnesium Sulfate for the Treatment of Eclampsia : A
Brief Review. Storke Journal American Heart association
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Anna G. Euser and Marilyn J. Cipolla. Magnesium Sulfate for the Treatment of Eclampsia : A
Brief Review. Storke Journal American Heart association
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Anna G. Euser and Marilyn J. Cipolla. Magnesium Sulfate for the Treatment of Eclampsia : A
Brief Review. Storke Journal American Heart association
S
• 100% Renal
• Depuración total en 8 horas
• Alteración de la función renal
• Suspenderlo
• Disminuir su dosis a la
mitad si Cr >1.3
• En pte con falla renal las
manifestaciones tóxicas
aparecen a concentraciones
más bajas
DEPURACIÓN
Sulfato de Mg
EFECTOS ADVERSOS
• Flushing
• Nauseas
• Vomito
• Mareo
• Confusión
• Debilidad muscular
• Cefalea
TOXICIDAD
Arreflexia
8-10 mEq/L
Paro
Respiratorio
>13mEq/L
INTOXICACIÓN - MANEJO
GLUCONATO DE CALCIO
Aumenta la concentración de Ach
Presentación: Ampollas 10% 10cc 1gr
Dosis: 1 g IV en10 min
Realizar un EKG
Diuréticos
EFECTIVIDAD
RR
SULFTATO Mg PLACEBO
IC 95%
Eclampsia 40 (0.8%) 96 (1.6%) 0.42 (0.29 – 0.60)
# Convulsiones
1 27 63
2 10 24
3 2 7
>4 1 1
Desconocido 0 1
19Problemsatinjectionsite
DMorbilidad
A T A A NMaterna
D A N A L Y SES
1 9992 196Ri(3.9%)
skRatio (M-H,Fixed,95%CI) 183 (3.6%)1.78[1.52,2.08]
Depresión respiratoria 46 27
19.1 Intramuscul
Comparison 1.
Arresto arinjection 1 4553 Ris5kRatio (M-H,Fixed,95%CI) 2 1.49[1.25,1.79]
Magnesium sulphate versusnone/placebo (subgroupsby severity of pre-eclampsia)
respiratorio
Neumonía 14 6
19.2 Intravenousinjection 1
Outcome or subgroup title
Edema pulmonar
No. of
studies 5439 Ri32skRatio (M-H,Fixed,95%CI) 33 3.05[2.15,4.32]
No. of
participants Statistical method Effect size
1 Maternal death 2 10795 Risk Ratio (M -H , Fixed, 95% CI) 0.54 [0.26, 1.10]
20Placentalabrupti
Arresto cardiaco on
1.1 Severepre-eclampsia
1.2 Not severe pre-eclampsia
2 Eclampsia
2 2
1
6
8838 Ris4kRatio (M-H,Fixed,95%CI) 5 0.64[0.50,0.83]
3327
7468
11444
Risk
Risk
Risk
Ratio (M -H , Fixed, 95% CI)
Ratio (M -H , Fixed, 95% CI)
Difference (M -H , Fixed, 95% CI)
0.54 [0.19, 1.51]
0.54 [0.20, 1.45]
-0.01 [-0.02, -0.01]
Falla renal
2.1 Severepre-eclampsia 3 3555 49Risk 61
Difference (M -H , Fixed, 95% CI) -0.02 [-0.03, -0.01]
21Caesareansecti
Falla hepática on
2.2 Not severe pre-eclampsia
3 Serious maternal morbidity
3.1 Severepre-eclampsia
6 4
2
1
10096 Ri52skRatio (M-H,Fixed,95%CI) 67 1.05[1.01,1.10]
7889
10332
2642
Risk
Risk
Risk
Difference (M -H , Fixed, 95% CI)
Ratio (M -H , Fixed, 95% CI)
Ratio (M -H , Fixed, 95% CI)
-0.01 [-0.01, -0.00]
1.08 [0.89, 1.32]
1.23 [0.91, 1.66]
Coagulopatía
3.2 Not severe pre-eclampsia 2 7690
73Risk
86
Ratio (M -H , Fixed, 95% CI) 0.98 [0.75, 1.27]
22Inductionoflabour
4 Stroke
5 Pulmonary oedema
Accidente cerebrovascular
6 Pneumonia
1 1
3
1
8774 Ris3kRatio (M-H,Fixed,95%CI) 6 0.99[0.94,1.04]
10110
10560
10110
Risk
Risk
Risk
Ratio (M -H , Fixed, 95% CI)
Ratio (M -H , Fixed, 95% CI)
Ratio (M -H , Fixed, 95% CI)
0.5 [0.13, 2.00]
0.97 [0.60, 1.57]
2.33 [0.90, 6.07]
23Postpartumhaemorrhage
7 Renal failure
8 Renal dialysis
9 Liver failure
2 1
2
1
8909 RiskRatio (M-H,Fixed,95%CI)
10110
10338
10110
Risk
Risk
Risk
0.96[0.88,1.05]
Ratio (M -H , Fixed, 95% CI)
Ratio (M -H , Fixed, 95% CI)
Ratio (M -H , Fixed, 95% CI)
0.80 [0.55, 1.17]
0.70 [0.21, 2.32]
0.78 [0.54, 1.11]
10 Coagulopathy 1 10110 Risk Ratio (M -H , Fixed, 95% CI) 0.85 [0.62, 1.16]
MORBILIDAD
13 Any antihypertensive therapy
14 Rapid acting antihypertensives
2
2
- SOLO HUBO UNA PEQUEÑA DIFERENCIA EN
10795 Risk
Risk
Ratio (M -H , Fixed, 95% CI)
Ratio (M -H , Fixed, 95% CI)
0.97 [0.95, 0.99]
Subtotals only
NECESIDAD DE CESAREA (RR 1.05, 95% CI 1.01-
placenta
14.1 Intravenous or
SULFATO Mg Vs
intramuscular hydralazine
14.2 Oral nifedipine
2
2
10338
10276
Risk Ratio (M -H , Fixed, 95% CI)
Summary Introduction
Eclampsia, the occurrence of a seizure in association with Eclampsia is defined as the occurrence of one or more
pre-eclampsia, convulsions in association with the syndrome of pre-
Magnesium sulphateremains an important
versus diazepam of maternal
cause(Review)
for eclampsia
mortality. Although it is standard practice to use an eclampsia. Pre-eclampsia is a multisystem disorder that is
anticonvulsant for management of eclampsia, the choice of
Duley L, Henderson-Smart DJ, Walker GJA, Chou D
usually associated with raised blood pressure and
agent is controversial and there has been little properly proteinuria. In Europe and other developed countries
controlled evidence to support any of the options. 1687 eclampsia complicates about 1 in 2000 deliveries,’ while
women with eclampsia were recruited into an international
in developing countries estimates vary widely, from 1 in
100 to 1 in 1700.=-4
multicentre randomised trial comparing standard
Over half a million women die each year of pregnancy-
anticonvulsant regimens. Primary measures of outcome
related causes, and 99% of these deaths occur in the
were recurrence of convulsions and maternal death. Data
are available for 1680 (99·6%) women: 453 allocated
developing world. 5,6 Although rare, eclampsia probably
accounts for 50 000 maternal deaths a year worldwide.7 In
magnesium sulphate versus 452 allocated diazepam, and areas where maternal mortality is very high, infection and
388 allocated magnesium sulphate versus 387 allocated
haemorrhage are the main causes of death;8 but as deaths
phenytoin. Most women (99%) received the anticonvulsant from these causes become less common, those associated
that they had been allocated. with hypertension and eclampsia assume greater
Women allocated magnesium sulphate had a 52% lower
importance. In the UK, eclampsia is a factor in 10% of
risk of recurrent convulsions (95% Cl 64% to 37% direct maternal deaths.9 Successful prevention of all cases
reduction) than those allocated diazepam (60 [13·2%] vs of eclampsia is likely to be difficult,’ therefore it is
126 [27·9%]; ie, 14·7 [SD 2·6] fewer women with recurrent important to assess the relative merits of alternative
convulsions per 100 women; 2p<0·00001). Maternal treatments for eclampsia.
mortality was non-significantly lower among women Standard practice is to use anticonvulsants to control
Sulfato Mg Vs Diazepam
Sulfato Mg 70
Vs
60
Diazepam
50
Número de mujeres
40
SULFATO MG
30
DIAZEPAM
20
A 10
0
1 2 3 4 5 >5
M
Número de recurrencia de convulsiones
Sulfato Mg
Vs
Diazepam
Mortalidad materna RR 0,59; IC del 95%: 0,38 a 0,92
35
Fenitoina 30
Número de mujeres
25
20
SULFATO MG
15
FENITOINA
I
10
0
1 2 3 4 5 >5
N
Número de recurrencia de convulsiones
O
*Not known whether prior anticonvulsant was given to 11 women allocated MgS04 and to 7 allocated diazepam
tNot known whether prior anticonvulsant was given to 3 women allocated MgS04 and to 6 allocated phenytoin
Sulfato Mg
Vs
Fenitoina
No hay diferencias en mortalidad materna
MORBILIDAD MATERNA
Menor necesidad de ventilación mecánica
Menor Neumonía
Menor necesidad de ingreso a UCI
MORTALIDAD PERINATAL
No hay diferencias
MORBILIDAD PERINATAL
Mejor puntaje de APGAR
Menor necesidad de ventilación mecánica
Menor ingreso a UCI (RR 0.73, 95% CI 0.58–0.91)
CUANTO TIEMPO
Presión
perfusión Resistencia
Autorregulación cerebral
BAROTRAUMA
Presión persistentemente elevada debilita y destruye tejido
especialmente el endotelio
Daño endotelial
Daño de muscular
Medicamento ideal CPP Pero q mantenga el CFI
NIMODIPINO
Calcio antagonista
FC y el Índice cardiaco
RVS
FC y el consumo de oxigeno
• ECC
• 4000 ptes reciben Labetalol Vs 4000 ptes reciben sulfato
Magnesio
• Resultado primario: Incidencia de convulsiones
LAMPET
CONCLUSIONES
Prevención primaria