Gestational Hypertension

International

Gestational Hypertension

Gestational Hypertension
International

Ny. 25 th G1 mengeluh nyeri kepala dan

pandangan kabur selama bulan terakhir
kehamilannya.
Ia mencari saran medis dan pengobatan
dari seorang Dr.SpOG. Yang
meresepkan obat padanya.
Ia pulang kerumah tetapi keluhannya tidak
menghilang meskipun telah meminum
obat yang diberikan
Suaminya membawanya ke Rumah Sakit
Umum karena KEJANG.

Gestational Hypertension
International

Masalah/Diagnosis?
Eklampsia imminens Eklampsia

Gestational Hypertension

Objectives

International

Definisi
Diagnosis
Manajemen
- Penilaian Fetal / Maternal
- Terapi Anti-Hipertensi
- Terapi Anti-Kejang
- Transport

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Gestational Hypertension
International

Insidens
10% dari kehamilan mengalami komplikasi hipertensi
- 1/3 nya dengan proteinuria
Mayoritas preeklampsia terjadi pada nulipara
- Risiko kematian meningkat pada pada ibu hamil usia lanjut
- Risiko meningkat pada kehamilan pertama dengan pasangan baru
- Risiko meningkat pada hipertensi kronik, penyakit ginjal dan diabetes melitus
Preeklampsia merupakan penyebab terbanyak kematian maternal langsung (direct
maternal mortality) maupun Near Miss Maternal.

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Gestational Hypertension
International

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Gestational Hypertension
International

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Gestational Hypertension

Definisi

International

Hipertensi kronik
Hipertensi gestasional
- tanpa proteinuria
- dengan proteinuria
- dengan proteinuria dan penyulit
Hipertensi kronik superimposed hipertensi gestasional
dengan proteinuria

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Gestational Hypertension

International

Definisi

Hipertensi
Nilai mutlak 140/90 mmHg
peningkatan 30/15 mmHg
Tekanan darah diastolik 90 mmHg
Posisi duduk pada lengan setinggi jantung
Manset dengan ukuran yang tepat
Dengan sfigmomanometer air raksa
Bunyi Korotkoff I dan IV
Diulang 4 jam kecuali sangat tinggi.
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Gestational Hypertension
International

Definisi
Proteinuria
- Proteinurin 2+ dengan pemeriksaan dipstick
- proteinurin 300 mg/dL urin 24jam
proteinuria mengindikasikan disfungsi glomerular
Pemeriksaan urin 24 jam harus diperiksa bila
dengan pemeriksaan dipstich protein 1+

edema terjadi akibat vasospasme and penurunan

tekanan onkotik, tetapi bukan merupakan kriteria
diagnostik.
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Gestational Hypertension
International

Biochemical and biophysical markers defining fetal/placental and maternal

Gestational Hypertension
etiologies that determine the risk of developing pre-eclampsia
International
Fetal/
Placental
factors

Trophoblast invasion
-PLGF
- IGFBP-1, PAPP-A
- Doppler US
- HLA-G
Placental hypoxia
-sFlt-1
- VEGF
- PLGF
Reactive oxygen specieslipid peroxides
-activin/inhibin
- CRH/CRHBP
-PAI-2

Risk of
developing
preeclampsia

Maternal
Predisposition/
susceptibility
Metabolic syndrome
- BMI, leptin
- Insulin, SHBG
- Glucose
Endothelial function:
PAI-1
Fibronectin
VCAM/CAM
Pro-oxidants
8 epi-PGF2a
Antioxidant reserve
Vit C
Vit Eimmune function
Immune function
-AT1R autoantibodies

Gestational Hypertension
International

Perubahan fisiologik dan patologik plasentasi

Normal

Preeklampsia

Dikutip:
Redman and Ian L. Sargent
Science June 2005 Vol 308
1592

Gestational Hypertension
International

Produksi berlebihan radikal bebas menimbulkan

PreEklampsia

Dikutip:
Redman and Ian L. Sargent
Science June 2005 Vol 308
1592

Tanda-tanda semakin beratnya kondisi

Gestational Hypertension

International
Hipertensi
gestasional dengan penyulit
Tekanan darah diastolik > 110 mmHg
Hasil pemeriksaan laboratorium
trombosit, LFT's, uric acid
Ginjal - proteinuria > 3 g/d, oliguria
SSP - kejang, nyeri kepala, gangguan visus
Keterlibatan organ lain Paru-paru, hati, hematologik
Tanda-tanda gangguan pertumbuhan janin

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Manajemen

Gestational Hypertension

International

Pertama-tama mengurangi stres

Penilaian keadaan ibu dan janin
Terapi hipertensi bila dBP > 110 mmHg
Terapi terhadap keluhan mual dan muntah
Terapi nyeri uluhati
Terapi Antikejang
Terminasi kehamilan dengan cara dan waktu yang tepat

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Gestational Hypertension

Mengurangi Stres

International

Komponen tekanan darah adalah reseptor adrenergik

Ketidaknyamanan sedapat mungkin dikurangi
Beberapa komponen
quiet, dimly lit, isolated room
well planned management protocol
clear explanation of plan to patient/family
minimization of negative stimuli
consistent, confident team approach
nursing, obstetrics, anaesthesia, hematology, pediatrics

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Gestational Hypertension
Penilaian
Maternal - Klinis
International

Tekanan darah
- assess severity
- consistency in measuring
- relationship of high BP to CVA not seizure
Susunan Saraf Pusat
- presence and severity of headache
- vision disturbances - blurring, scotomata
- tremulousness, irritability, hyperreflexia, somnolence
- nausea and vomiting

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Gestational Hypertension

Assessment of Mother Clinical

International

Hematologic
- edema
- bleeding, petechiae
Hepatic
- RUQ and epigastric pain
- nausea and vomiting

Renal
- urine output and colour
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Gestational Hypertension
Assessment
of Mother
Laboratory

International

Hematologic
- hemoglobin, platelets, blood film
- PTT, INR, fibrinogen, FDP
- LDH, uric acid, bilirubin
Hepatic
- ALT, AST
- (glucose, ammonia to R/O AFLP)
Renal
- proteinuria
- creatinine, urea, uric acid
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Gestational Hypertension
International

Manfaat NACysteine (flumucil) sebagai antioksidan

untuk mencegah timbulnya Preeklampsia Berat
160
140
120

Dosis NAC: 2 x 600 mg

100
80

Kel. Kontrol

60
40

Kel. Studi

20
0
Sistolik

Diastolik

Sumber: Wibowo N, Angsar D, Wiknjosastro G., dkk (2005)

Gestational Hypertension

Assessment of Fetus

International

Fetal movement
Fetal heart rate assessment
Ultrasound for growth
Biophysical profile
Amniotic fluid volume
Doppler flow studies

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Gestational Hypertension

Treatment

International

Nausea and Vomiting

- antiemetic of choice
RUQ / Epigastric Pain
- morphine 2 - 4 mg IV
- antacid
- minimize palpation

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Gestational Hypertension
International

Anti-hypertensive Therapy - Goals

minimize risk of maternal CVA
maximize maternal condition for safe delivery
gain time for further assessment
- facilitate vaginal delivery if possible
- prolong gestation where appropriate/feasible

Gestational Hypertension
International

Anti-hypertensive Agents - Acute Therapy

Arteriolar Dilators
- hydralazine
-Blockers
- labetalol

Calcium Channel Blockers

- nifedipine

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Gestational Hypertension
International

Anti-hypertensive Agents - Maintenance

Therapy
Centrally Acting Sympatholytic Agents
methyl-dopa
-Blockers
atenolol
labetalol
Calcium Channel Blockers
nifedipine
ACE inhibitors are contraindicated in pregnancy
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Gestational Hypertension
International

Methyldopa

centrally acting a2-receptor agonist, oral agent

long history of safe use in pregnancy, well tolerated
some concern regarding ability to control BP
not for use in acute settings
Dosage - 500 - 3000 mg po in 2 - 4 divided doses
Cautions - drug of choice in essential hypertension
Benefits - minimal side-effects and safe
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Atenolol (Betablok, Tenormin)

Gestational Hypertension

International

1-receptor antagonist, oral agent

cardiac output, renin release, vasomotor inhibitor
onset of action in 1 hour peak levels in 2-4 hours
long half life once a day dosing
Dosage - 50 -100 mg po OD
Cautions - DM, asthma, baseline FH, variability present
risk of IUGR with chronic use
Benefits - often only agent needed

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Gestational Hypertension

Labetalol(Normodyne, Trandate)
International

combined 1 and -blocker with ISA

intravenous rapid onset useful for hypertensive crisis
can be used orally
Dosage - maximum 300 mg IV dose
- 20 mg IV followed by 20-80 mg IV titrated to BP
Cautions - concern re: fetal responses to hypoxia
Benefits - dependable, titratable, familiar

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Gestational Hypertension

Nifedipine
International

calcium channel blocker, oral agent

direct relaxation of vascular smooth muscle
rapid onset of action if regular capsule used
Dosage - Adalat-PA 10 mg bid 40 mg bid
Side Effects - magnesium toxicity, edema,
flushing,headache, palpitations, tocolytic

use of short acting form discouraged

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Hypertensive Crisis
Gestational Hypertension

International

Stabilisasi hipertensi berat

Nifedipine, -blocker,
tujuan maintain diastolic BP at 90 - 100 mmHg
monitor fetal status while treating BP
Pencegahan kejang
Monitor volume intravaskular
Foley catheter seldom experience ARF
do not fluid overload seldom require CVP line
Terminasi kehamilan

Gestational Hypertension

Pencegahan Kejang
International

Sulit diramalkan siap yang akan kejang

- Tidak berbanding lurus dengan beratnya hipertensi dan
proteinuria
high 'number needed to treat' to prevent seizure
agents not innocuous nor completely effective
MgSO4 is agent of choice when seizure prophylaxis is felt to
be indicated

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Gestational Hypertension

Magnesium Sulfate
International

obstetrical standard but not used in other settings

superior to phenytoin for prophylaxis
superior to phenytoin or diazepam in preventing recurrence
Dosage - 4 g IV followed by 1 - 4 g / hour IV or 4 g IM q4h
Side Effects - weakness, paralysis, cardiac toxicity
Monitor - reflexes, respiration, level of consciousness

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Gestational Hypertension
International

Magnesium sulphate
6 g (15 ml of MgSO4 40%)
In 500 ml Ringer Lactate/
Dextrose 5%

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Gestational Hypertension
International

Kadar Magnesium dalam serum pada penderita

Preeklampsi
Kadar Mg-serum pada
regimen infus 3 gram/jam
vs 1 gram/jam

Sumber : Hudono L. 1989

Gestational Hypertension
International

Kadar Mg serum pada regimen IV dan IM

Pemberian drip IV lebih
stabil dibandingkan
dengan pemberian IM

Gestational Hypertension

Magnesium Sulfate - Overdose

International

close observation for side effects

weakness, respiratory paralysis, somnolence
especially high risk in those with oliguria or
receiving Ca2+ channel blockers
ANTIDOTE
stop magnesium infusion
10% Calcium gluconate 10 mL IV over 3 minutes

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Gestational Hypertension
International

Transport
consider transport only if resources limited and
maternal/fetal condition permits
maternal BP and symptoms stable
fetal status reassuring
appropriate anti-hypertensive agents started
MgSO4 started if appropriate
discuss with accepting centre and patient/family
MgSO4 and anti-hypertensives potentially fatal in overdose

Gestational Hypertension

Terminasi kehamilan
International

37 weeks with gestational hypertension

34 weeks with severe gestational hypertension
< 34 weeks with any of:
- poorly controlled dBP
- lab evidence of worsening end-organ involvement
- suspected fetal compromise
- uncontrolled seizures
- symptoms unresponsive to appropriate therapy

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Gestational Hypertension

Delivery - The Cure

International

timely delivery minimizes maternal and neonatal morbidity

and mortality
optimize maternal status before interventions to deliver
delay delivery to gain fetal maturity and to allow transfer
only when maternal and fetal condition allow it
gestational hypertension is a progressive disease, expectant
management is potentially harmful in presence of severe
disease or suspected fetal compromise
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Gestational Hypertension
International

Peri- and Postpartum Management

do not drop BP too low risking fetal compromise
do not fluid overload
epidural analgesia is favoured in the absence of
low platelets or coagulopathy
multi-specialty approach
patient must be monitored post-partum

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Gestational Hypertension
International

Thank you
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Gestational Hypertension
International

of ActionStimulation of intracellular
cyclic-GMP results in vascular smooth
muscle relaxation of both arterial and
venous vasculature.
Increased venous pooling decreases left
ventricular pressure (preload) and arterial
dilatation decreases arterial resistance
(afterload).
Therefore, this reduces cardiac oxygen
demand by decreasing left ventricular
pressure and systemic vascular 3/14/2014
resistance
Mechanism