Naslov
Strategies to treat preeclampsia

Autori
Matijević, Ratko

Vrsta, podvrsta i kategorija rada
Sažeci sa skupova, neobjavljeni rad, stručni

Skup
Annual convention Fetus as a patient institute (14 ; 2005)

Mjesto i datum
Bacolod, Filipini, 17.10.2005. - 18.10.2005

Vrsta sudjelovanja
Plenarno

Vrsta recenzije
Nije recenziran

Ključne riječi
preeclampsia; treatment

Sažetak
Gestational hypertension with proteinuria or EPH gestosis is one of the most serious pregnancy complications responsible for a significant rate of maternal and perinatal morbidity and mortality. The pathogenesis, as well as prophylaxis and pathogenetically based treatment, have not been determined finally despite continuous attention to this problem all around the world. Absence of unique classification of this pathological condition makes it difficult to solve this problem. By one theory, it is a disease of endovascular damage. The endovascular damage leads to a loss of vascular autoregulation, significant vascular spasm, and vascular leakage. Disease severity varies not only from patient to patient but also from organ system to organ system within an individual. One woman may have oliguria but no change in liver functions, whereas another may have severe hypertension and minimal proteinuria, etc. Logically, as the disease progresses, organ systems become more susceptible to injury from vasospasm. Women with loss of cerebrovascular integrity may have seizures before the development of hypertension or proteinuria. According to ACOG ad RCOG, although there have been changing definitions and language ambiguity, mild and severe preeclampsia are now defined clearly, and these criteria should be used to make the best treatment decisions. Complications of severe uncontrolled hypertension are responsible for much of the morbidity and mortality associated with preeclampsia. To minimize the risk of such complications, international consensus statements recommend treatment of hypertension once blood pressure is persistently above 160/110 mm Hg or MAP above 125 mmHg. The three most commonly recommended and used first-line antihypertensive drugs for treatment of severe hypertension in pregnancy are hydralazine, labetalol, and nifedipine. Numerous randomized trials have compared one drug with another to evaluate the effectiveness and safety of each of these anti-hypertensive agents. Hydralazine use was challenged recently as it was associated with an increased risk of maternal hypotension (RR 5.5, 95% CI 1.2 to 25.8) and maternal side effects (RR 2.9, 95% CI 1.6 to 5.1). Comparing hydralazine with nifedipine the first one was associated with an increased risk of persistent hypertension (RR 2.5, 95% CI 1.4 to 4.3), adverse effects on fetal heart rate pattern (RR 6.4, 95% CI 1.7 to 24.7) and maternal tachycardia (RR 5.7, 95% CI 2.2 to 14.2), but reduced risk of facial flushing (RR 0.2, 95% CI 0.1 to 0.5). Although hydralazine appears to be associated with less favourable outcomes compared to labetalol and nifedipine, a number of factors may have influenced these results. Increased risk of persistent hypertension is based on five trials, all of them using different definitions of persistent hypertension. At least one definition is not appropriate, given the pharmacokinetic properties of hydralazine. Adverse effect on fetal heart rate is based mainly on one trial of poor methodological quality. Although maternal side effects such as tachycardia were increased with hydralazine, side effects were not severe enough to discontinue treatment, therefore, their clinical significance may not be substantial. Some have suggested that hydralazine should not be used as a first line anti-hypertensive despite a long history of safety and efficacy and familiarity with its use in acutely ill pregnant women. We believe that it is premature to preclude its use as a first line agent based on currently available evidence. However, as concerns have been raised, and there is a possibility that other agents may be safer and equally if not more efficacious, we suggest that a large randomised trial comparing hydralazine with the other first line antihypertensive drugs is the best way forward. Is magnesium sulfate the best medication for seizures with preeclampsia? Despite clear evidence from randomized controlled trials about its benefits, some investigators are beginning to question whether all patients with preeclampsia should receive seizure prophylaxis. Physicians will often look the other way in cases of mild preeclampsia, relabeling the disease to “ pregnancy-induced hypertension” to avoid the use of magnesium sulfate as it is potentially dangerous drug. It is associated with complications, and although most studies have shown that it does not increase the duration of labor, maternal blood loss, or cesarean delivery rate ; it does change intrapartum and postpartum care and does affect many maternal and fetal parameters. Some authors have suggested giving magnesium sulfate prophylaxis only to patients with severe preeclampsia. Unfortunately, most eclampsia occurs before patients reach the hospital and not primarily among women with severe preeclampsia. Randomized controlled trials and systematic reviews have demonstrated the efficacy of magnesium sulfate in preventing eclampsia in patients with preeclampsia or in patients with eclampsia.

Izvorni jezik
Engleski

Znanstvena područja
Kliničke medicinske znanosti

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