2. TIME OF DELIVERY IN HYPERTENSIVE DISORERS OF PREGNANCY Laleh Eslamian MD. Prof. of Obstet & Gynecol Perinatologist, Shariati hospital, TUMS

3. Preeclampsia: Definitive Tx: delivery To prevent maternal fetal complications from disease progression

4. PE: WHEN To initiate Delivery? Is based up on: 1)GA 2)Severity of the disease 3)Maternal condition 4)Fetal condition

5. PE  37 w delivery PE before term: Preterm birth Serious Sequelae from disease progression

6. Prompt delivery at any GA: -Serious maternal end – organ dysfunction -Nonreassuring tests of fetal well being.

7. Severe PE: Is generally an indication for delivery: 1.Before fetal viability 2.GA  37 w 3.Unstable maternal or fetal condition (regardless of GA)

8. Indications for delivery with Early onset severe preeclampsia: Maternal -Persistent severe headache or visual changes, eclampsia. -Uncontrolled severe hypertension despite Tx. -Oliguria <500cc/ 24h or creatinine  1.5mg/dl -Persistent Pt <100.000/mm 3, HELLP or partial HELLP -Suspected abruption, progressive labor and / or ROM

9. Indications for delivery with Early onset severe preeclampsia: Fetal -Severe FGR <5% -Persistent severe oligo, AFI<5cm -BPP  4 performed 6h apart -REDF in Doppler study -Fetal death

10. Severe PE: Delivery minimizes the risk of: Cerebral hemorrhage Hepatic rupture Renal failure Pulmonary edema (other wise 4%) Seizure Bleeding due to thrombocytopenia FGR Placental abruption (other wise 20%) Maternal death.

11. Route of delivery in severe PE C/S is reasonable <30 w : 1.Low Bishop score 2.High frequency of nonreassuring FHR * <1/3 preterm inductions  vaginal birth

12. PE without severe features: Delivery  37 w versus expectant management: - Significant reduction in composite adverse maternal out come (RR: 0.71) - But not significant at 36 o – 36 6 weeks. - No significant differences in neonatal outcome. - Less costly - Unfavorable cervix: not a reason to avoid induction.

13. PE without severe features: EXPECTANT MANAGEMENT * 34 – 36 0/7 - Stable maternal condition - Stable fetal condition * <34 w

14. PE without severe features <37 w : 1- Check for new sign or symptoms. 2- Lab follow up. 3- Tx of hypertension. 4- Assessment of fetal wellbeing. 5- Assessment of fetal growth. 6- Antenatal corticosteroids.

15. PE without severe features: <37 w : 1- Check for new sign & symptoms: Severe or persistent headache Visual changes Shortness of breath RUQ or epigastric pain  FAD Vaginal bleeding Abdominal pain ROM or uterine contractions.

16. PE without severe features: 2- Lab follow – up: * platelet count: weekly * Serum creatinine: weekly * Liver enzymes: weekly - indirect Bili or LDH  hemolysis, PBS - no need to measure 24h protein > after Pro > 300mg/24h

17. PE without severe features: 3- Hypertension assessment. - BP assessment at least twice weekly - Anti hypertensive agents to control Sys BP<160 & Dia BP<110mmHg  does not alter the course of the disease or diminish perinatal Mb or Mt SHOULD BE AVOIDED IN MOST PATIENTS - Na restriction not recommended. - Plasma volume expansion = no improvement

18. PE without severe features: 4- Assessment of fetal well being No data from RCTs: -Daily FAD - NST & AF or BPP  twice weekly - (immediate repeat with an abrupt change in mat. condition) - Doppler assessment of UA =  29% reduction in perinatal death in PE and / or FGR

19. PE without severe features: 5- Assessment of fetal growth. - Early FGR  may be the 1 st manifestation of PE a sign of severe uteroplacental insufficiency - At the time of PE Dx: U/S estimation of EFW and AF, when normal = repeat q3 w

20. OPTIMUM TIME FOR DELIVERY IN WOMEN WITH PREEXISTING HYPERTENSION -No RCT - Expert consensus panel & ACOG: * 38 – 39 6/7th : Chronic hypertension not requiring medication. * 37 – 39 6/7th Hypertension controlled with medication. * 36 – 37 6/7th Severe hypertension difficult to control. * >37 w at Dx for mild PE. * >34 w at Dx for severe PE.

21. ACOG Task Force On Hypertension: * Avoid delivery <38 0/7th in women with uncomplicated chronic hypertension whom BP remains controlled. * Super imposed PE or other pregnancy complications (FGR, previous stillbirth): case – by case basis decision.

22. ACOG Task Force On Hypertension: * Chronic hypertension with super imposed PE without features of severe disease & with reassuring fetal status: expectant F/O until 37 w. * Severe PE or nonreassuring fetal status: early delivery.