5. Asintomatica
Predicción
Prevención
•Perfil de riesgo personal
•Perfil de riesgo cardiovascular
•Perfil de riesgo metabólico
•Perfil de riesgo trombotico
•Perfil de riesgo placentario
•Bashat. Ultrasound Obstet Gynecol 2015
6. Manejo de la fase
sintomatica
TOXEMIA
GRAVIDI
CA
Termino de la gestación
8. 20ss
140/90
proteinuria
Espinoza J, Uckele JE, Starr RA, Seubert DE, Espinoza AF, Berry SM. Angiogenic imbalances: the obstetric perspective. Am J Obstet Gynecol 2010
; Kim YN, Lee DS, Jeong DH, sung MS, Kim KT. The relationship of the level of circulating antiangiogenic factors to the clinical manifestations of preeclampsia.
Prenat Diagn. 2009 May;29(5):464-70
. Maynard S, Epstein FH, Karumanchi SA. Preeclampsia and angiogenic imbalance. Annu Rev Med 2008
sFlt-1 sEng-1
PLACENTA PLACENTA
SintomaticaAsintomatica
9. 20ss
140/90
proteinuria
*Koopmans CM. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a
multicentre, open-label randomised controlled trial. Lancet. 2009 Sep 19;374(9694):979-88
37ss
30% Resultados maternos adversos*
11. Fetal Materno
compensado sin gravedad
descompensado sin gravedad
con gravedadcompensado
Unidad Materno Fetal HNDAC marzo 2015,
37ss
max
34ss
terminar
HIPITATDIGITAT
Gratacos
MEXPRE
12. 20ss
140/90
proteinuria
Suzuki et al. Clinical trial of expectant management of severe preeclampsia that develops at532 weeks’ gestation at a Japaneseperinatal center. J Matern Fetal Neonatal
Med, 2014
Vigil-De Gracia et al. Expectant management of severe preeclampsia remote from term: the MEXPRE Latin Study, a randomized, multicenter clinical trial. NOVEMBER 2013
American Journal of Obstetrics & Gynecology
37ss34ss24ss
Preeclampsia severa
MEXPRE trial
Suzuki trial
: No mejoras en outcomes neonatal
: mayor riesgo de complicaciones maternas
15. Magnitud del daño endotelial en Preeclampsia
Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
16. Magnitud del daño endotelial en Preeclampsia
Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
Manejo multidisciplinario
Mantenimiento de las habilidades clinicas
Reconocimiento temprano de gravedad
17. Manejo de la presión arterial
Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
National Collaborating Centre for Women’s and Children’s Health. Hypertension in pregnancy. The management of hypertensive disorders during pregnancy. National
Institute for Health and Clinical Excellence Guideline 107. August 2010
Presion arterial leve: >140/60 < 160/110
No se recomienda el tratamiento de la
hipertensión arteria leve
18. Manejo de la presión arterial
Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
Am J Obstet Gynecol. 1999 Oct;181(4):858-61. A randomized, double-blind trial of oral nifedipine and intravenous labetalol in hypertensive emergencies of pregnancy.
Presion arterial severa: >160/110 Primera línea
Nifedipino labetalol23` 43`vs
•Mayor flujo urinario: 1hora
•Bloqueo neuromuscular no
demostrado
19. Manejo de la crisis hipertensiva
Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. ACOG february2015
Nifedipino
Primera línea
20. Manejo de la presión arterial
Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
Am J Obstet Gynecol. 1999 Oct;181(4):858-61. A randomized, double-blind trial of oral nifedipine and intravenous labetalol in hypertensive emergencies of pregnancy.
Presion arterial severa: >160/110 segunda línea
Nifedipino
labetalol •Manejo multidisciplinario,
medicina materno fetal,
anestesiologia, medicina
intensivaHidralacina
nitroprusiato
21. Profilaxis anticonvulsiva
Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
Duley L, Henderson-Smart DJ, Walker GJA, Chou D. Magnesium sulphate versus diazepam for eclampsia. Cochrane Database of Systematic Reviews 2010
Sulfato de Magnesio primera línea
•Disminuye el riesgo de morir
vs. Diacepam
1A
•Disminuye el riesgo convulsion
vs. Diacepam, CL y fenitoina
1A
•Disminuye el riesgo neumonia,
ingreso a UCI, VM vs. fenitoina 1A
RR:0.59
RR:0.06
RR:0.20
22. Terapia para las complicaciones hematológicas y hepáticas
Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
Woudstra DM, Chandra S, Hofmeyr GJ, Dowswell T. Corticosteroids for HELLP. Cochrane Database 2010
Corticoesteroides HELLP Evidencia insuficiente
•Dexametasona
SMD: 0.6 (0.2-1.1)
•Betametasona
RR: 0.95 (0.2-2.3)
•prednisolona
Incrementa el conteo plaquetario
No diferencias en MMM
23. Transfusion de plaquetas
Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
The Royal College of Obstetricians and Gynaecologists. Blood transfusion in obstetrics. Guideline Number 47
plaquetas <50000 Incrementa el riesgo de sangrado
Otros tratamientos
necesitan estudios
que avalen su uso
24. Fluidoterapia
Dennis | Management of pre-eclampsia. Anaesthesia 2012, 67, 1009–1020
Duley L, Williams J, Henderson-Smart DJ. Plasma volume expansion for treatment of pre-eclampsia. Cochrane Database 1999
Thornton CE, von Dadelszen P, Makris A, Tooher JM, Ogle RF, Hennessy A. Acute pulmonary oedema as a complication of hypertension during pregnancy. Hypertension in
Pregnancy 2011;
Edema agudo de pulmón Incrementa MMM
Administracion de fluidos No hay mejora significativa*
Administracion vs restriccion Riesgo incrementa >5500ml
PEPE trial 500cc asociado con RR: 0.6 (0.37-0.98)