Preeclampsia with Fetal Growth RestrictionMulti/interdisciplinary approach

Dr. dr. AAN Jaya Kusuma, SpOG(K), MARS

PREECLAMPSIA AND FETAL MEDICINE AREA OF INTEREST

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

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

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

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

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

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

FETAL PROGRAMING

LONGTERM OF IUGR ON EFFECT MATERNAL CHILD/ADULT HEALTH

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.

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

Spiral artery diameter 500µm 700-800um

PreeclampsiaSpiral artery diameter remain 200-

300 um

Physiologic and pathologic changes of the uteroplacental circulation

in pregnancy

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.

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 ?

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

MANAGEMENT OF PREECLAMPSIA SCREENING

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

MANAGEMENT OF PREECLAMPSIA - IUGR

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

The management of PE is delivery, expectant management of PE pursued solely for neonatal benefit, close observation and monitoring must be undertaken !!!

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.

DIAGNOSTIC TOOLS IN IUGR

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

STAGING OF IUGR

MANAGEMENT OF IUGR(stagebased protocol)

MANAGEMENT OF IUGR

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

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

THANK YOU