Preeclampsia with Fetal Growth Restriction Multi ...
Transcript of Preeclampsia with Fetal Growth Restriction Multi ...
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Preeclampsia with Fetal Growth RestrictionMulti/interdisciplinary approach
Dr. dr. AAN Jaya Kusuma, SpOG(K), MARS
PREECLAMPSIA AND FETAL MEDICINE AREA OF INTEREST
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Recent issue
Envrionmrnt and GeneticConcensus IUGR ?Diagnosis IUGR 1st trimester and 2nd trimsterMagnesium sulfatParameter USG the best ?Diffrentiating IUGR and SGA ?Doppler UA placental side or non placental sidePREDICTOR STILLBIRTH
FETAL ORIGIN OF ADULT DISEASE WHAT WE SHOLUD DO TO PREVENT IUGRERA REVOLUSI INDUSTRI 4,0 : LIETERASI DATA, LITERASI SDM, LITERASI TEKNOLOGI
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Patient Safety
Hospital
Providers
Patients
Payers/Regulation
SYSTEMS/REGULATIONS, MEDICAL/MEDICAL
RESOURCES (SEPARATED BUILDING, LACK OF
MEDICAL EQUIPMENT)
COMPETENCEPROFESSIONALISM
RESPONSIBILITYSLIPPERY SLOPE
HEALTH STATUS, EDUCATION, INVOLVEMENT
(POOR, BAD BEHAVIOUR)
LIMITATION SCOPE OF
SERVICES, FUNDING
PUSKESMAS/PRIMARY CARE
SECUNDARY HOSPITAL
TERTIARY HOSPITAL
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Definitions for multidisciplinary approach
A multidisciplinary approach involves drawing appropriately from multiple disciplines to
redefine problems outside of normal boundaries and reach solutions based on a new
understanding of complex situations.
.
One of the major barriers to the multidisciplinary approach is the long established
tradition of highly focused professional practitioners cultivating a protective boundary
around their area of expertise. This tradition has sometimes been found not to work to the
benefit of the wider public interest, and the multidisciplinary approach has recently
become of interest to government agencies and some enlightened professional bodies who
recognise the advantages of systems thinking for complex problem solving.
The use of the term 'multidisciplinary' has in recent years been overtaken by the
term 'interdisciplinary' for what is essentially holistic working by another name.
The former term tends to relate to practitioner led working while the latter
term tends to carry a more academic overtone.
Complexs High Risk Pregnancy, 2108
29yearsold, primipara,SLE on treatment 2years ago, 32 weeks,BP 160/110mmHg,dysneu RR 28x/mt,PR 110 x/m,SC 1,8, EFW 1200 gr
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The 3 Musketeers of Perinatology
Obstetrics(fetomaternal)
Pediatrics(Noenatologist)
Anestesia ( Obstetrics Anestesia
)
Maternalfetal problems, critical care and near miss
Neonatal intensive care
Maternal and fetal effects of anestetics subastanceIntensive care obstetrics
3 MODEL OF INTERDISICIPLINARY APPROACH
Other Disciplines
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MILESTONE IUGR
Yippo,1911..based on Neonatal Weight (
<1000, <1500,1500-2500,>2500,4000
Lubchenco, 1960an
Persentil
VSGA<3rd, SGA<10th,AGA 10-90th,LGA >90th
Poderal Index :
INTRAUTERINE :
HADLOCK CHART PERSENTIL SEMUA
PARAMETER
TIDAK UNIVERSAL
WHO Ffetalgrowth chart
2017
EKSTRAUTERINEINTRAUTERINE
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Preeclampsia is the main factor of MMR- 5-8%
Triad pathophysiology : placenta inadequate, placental insufficiency and vascular reactivity
Failure of uterine artery remodeling : hypoxia-reperfusion injury-stress oxidative–endothelial dysfunction
Angio-antiangiogenic imbalance
Preeclampsia and UGR have similar causes and pathophysiological mechanism (abnormal placentation) IUGR may precede preeclampsia or as a consequence of PE
INTRODUCTION
Preeclampsia and IUGR
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FETAL PROGRAMING
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LONGTERM OF IUGR ON EFFECT MATERNAL CHILD/ADULT HEALTH
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Pathophysiology• Early (before 34 weeks) and late (after 34 weeks) onset preeclampsia
have different etiologies and therefore a different clinical expression
The late onset type of preeclampsia (80% of all
preeclampsia) asssociated with:
● A normally grown baby with no signs of any
growth restriction;
● A normal or only slightly altered behavior of the
uterine spiral arteries (no changes in the Doppler
waveforms or slight increase of the pulsatility
index [PI])
● No changes in the blood flow of the umbilical
arteries;
● An increased risk for pregnant women displaying
an enlarged placental mass or surface (diabetes,
multiple pregnancies, anemia, high altitude).
PATOPHYSIOLOGY
The early onset type of preeclampsia (5% to 20%,
but comprises the most severe cases of
respective clinical relevance.
An inadequate and incomplete trophoblast invasion of maternal spiral arteries;
● Changes of the blood flow within the placental bed spiral arteries and thus in the uterine arteries (notches and other changes [increased PI] of the Doppler waveforms);
● An increased peripheral resistance of the placental vessels may be one cause of an abnormal blood flow of the umbilical arteries (increased systolis/diastolic (S/D) ratio in still preserved flow or absent and even reversed end diastolic blood flow velocity in these arteries);
● Clear signs of a fetal growth restriction.
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STAGE 1 : SHORT INTERVAL BETWEEN FISRT COITUS ANDCONCEPTION
STAGE 2 : IMPLANTATION OF EMBRYO
STAGE 3 : DEFECTIVE PLACENTATION (8-10 WEEKS)
STAGE 4 : EXCESSIVE/DIMINISHED PLACENTA DERIVED FACTORS
STAGE 5 : CLINICAL SIGNS OF PREECLAMPSIA
STAGE 6 : PLACENTAL ATHEROSIS
Cwg Redman,2014
2nd Trimester
1st Trimester
THE SIX STAGES OF PREECLAMPSIA
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Spiral artery diameter 500µm 700-800um
PreeclampsiaSpiral artery diameter remain 200-
300 um
Physiologic and pathologic changes of the uteroplacental circulation
in pregnancy
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CLASSIFICATION AND DIAGNOSIS : REVISED ISSHP 2014
Why is there a need for update classification ? 1. Use of mercury sphygmomanometry—automated BP devices2. Protenuria– sine qua non and severity of PE ? Inadequacy of measurement3. Research
The revised classification for hypertensive disorders inpregnancy is as follows :
1. Chronic hypertension.2. Gestational hypertension.
3. Pre-eclampsia – de novo or superimposed on chronichypertension.
4. White coat hypertension.
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Hypertension : ≥ 140 mmHg/90 mmHg , mercury sphygmomanometer as a standard, oe automated omron sphygmomanometer, minimum two BP measurement after overnight rest in hospital, or in a day assesement unit
Chronic Hypertension : hypertension predating the pregnancy, before 20 weeks of pregnancy
Gestaional and Preeclampsia :
If hypertension presents after 20 weeks Gestational or Preeclampsia ?
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PREECLAMPSIAGESTATIONAL HYPERTENSION
And Superimposed Preeclamsia
DIAGNOSTIC CRITERIA PREECLAMPSIA AND SUPERIMPOSED PREECLAMPSIA
PROTEINURIA ?The Gold standar abnormal proteinuria : 24-h urinary protein ≥ 300 mg/day spot urine protein/creatinine ratio ≥ 30 mg/mmol
PREECLAMPSIA WITH AND WITHOUT SEVERE FEATURES
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MANAGEMENT OF PREECLAMPSIA SCREENING
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KEY POINTS
ISSHP RECOMMENDED MANAGEMENT 2018 :
1. All cases of PE should be admitted to hospital, outpatients with ANC focused
2. Clinical assement included pulse oximetry
3. Maternal blood test ( twice weekly) Hb,platelet count,liver enzymes,creatinine
4. Antihypertensive ≥BP 160 mmHg/110 mmG lowering in few hours ( urgent)
hydralasone,labetalol,nifedipine, methyldopa target : 130-155 mmhg/ 90-105 mmHg
5. Adminstration og MgSO4
6. Closer attention to : ongoing or reccrent severe headache,visual
scotomata,nausea,epigastric pain,oliguria,severe hypertension,risng creatinine, or liver
transminases, and falling platelet count,IUGR and abnormal doppler findings
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MANAGEMENT OF PREECLAMPSIA - IUGR
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MATERNAL –PLACENTAL FETAL
OXYGEN PATHWAY
Lungs
Heart
Vaculature
Uterus
Umbilical Cord
Placenta
FETUS( Fetal Circulation)
Hypoxemia
Hypoxia
Metabolic Acidosis
Metabolic Acidemia
HYPOTENSION
DEATH
Fetal oxygenation involves the tansfer of oxygen
from the environment to the fetus along the
“oxygen pathway
Fetal oxygenation also involves the fetal
physiologic response to interruption of the
“oxygen pathway”
Clinical Signs/Symptomps- Organ dysfunction- Organ Failured
Courtesy by Jaya Kusuma,2015
Etiologies IUGR
3 POSSIBLE SCENARIOS :
1. Anormal placental function
2. Inadequate maternal supply of
oxygen
3. Decreased ability of the fetus to
use the supply
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The management of PE is delivery, expectant management of PE pursued solely for neonatal benefit, close observation and monitoring must be undertaken !!!
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DIAGNOSTIC TOOLS IN IUGR
What's new? WHO publishes new multinational fetal growth charts
New research shows variation in fetal growth between countries.
24 January 2017: A new study, published today by PLOS Medicine, shows that there is
significant variation in fetal growth between countries. The study also found that fetal
growth was to some extent influenced by maternal age, height, weight, parity and by
fetal sex. A significant variation in birth weight was also observed between countries.
The article which is open access also provides new WHO charts for estimating fetalgrowth and should be particularly useful for countries who may not have resources todevelop their own charts.
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DIAGNOSTIC TOOLS IN IUGR
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INTEGRATED DIAGNOSTIC APPROACH OF SUSPECT IUGR
SEFW < 10TH PERC IN COMBINATION WITH DOPPLER
ANATOMIC SURVEY AND AFV
UMBILICAL ARTERY AND MCA
CPR RATIO
REPEAT EXAMINATION2 WEEKS
NORMAL
NORMAL ANATOMY,NORMAL AFI/OLIGO
IF BOTH NORMAL
FETAL ANOMALY/POLY
ANEUPLOIDY/VIRAL
ELEVATED INDEX,A/ERDV,BRAIN SPARING
PLACENTAL INSUFF or IUGR
IF NORMAL CONSTITUIONALLY SMALL
DALY, et all, 2013. Optimizing the definition of IUGR, Am, J, Obst Gynec
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STAGING OF IUGR
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MANAGEMENT OF IUGR(stagebased protocol)
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MANAGEMENT OF IUGR
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CONCLUSION :PREECLAMPSIA – IUGR MANAGEMENT
PREECLAMPSIA with IUGR
≥ 34 Weeks
Immediate Delivery
Neonatologist
≤ 34 weeks
Hospitalized-Corticosteroid-Stage based management
protocolMFM- neonatologist
IDENTIFY RISK FACTOR
PREECLAMPSIA IUGR-DIFFRENCE PATHOPHYSIOLOGY
DIAGNOSE
STAGEBASED PROTOCOL
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TAKE HOME MESSAGES( keep in your mind yaa…)
Preeclampsia leading cause of Maternal Mortality, unpredictable sequences
Preeclampsia and IUGR similar pathogenesis and risk factors
Detection,early recognition and prompt treatment reduce complicationMULTIMODAL STRATEGY : PRIMER-SEKUNDER-TERTIARY
IUGR make sure you can measure birth weight on your USG Machine, use growth chart, establishing dating pregnancy, use doppler, use stage base protocol
Avoid deliver preterm baby, and or IUGR Quality of human life
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THANK YOU
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