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Staf Fetomaternal,Departemen Obstetri &Ginekologi FKUI/RSUPN

Cipto Mangunkusumo
Anggota
Pelatih/Adva Peserta
Fasilitator PokJa
nvedTrainer International
Advanced HIV/AIDS&
Jaringan Pelatih Course
PelatihBasic LabourAnd Pelatih
Nasiona Resusitasi Sexual
SurgicalSkill Risk PMTCT
Pelatihan Neonatus Reproductive
POGI,tahun Management Kementerian
Klinik Perinasia, Healthand
2004 (ALARM) Kesehatan
Kesehatan tahun2004 Right,
sekarang. POGI,tahun Republik
Reproduksi, sekarang. Swedia,
2005 Indonesia,
tahun2005 Pebruari
sekarang tahun2007
sekarang. 2009
sekarang.
Lainlain
12% Perdarahan
Komplmasa 30%
puerpureum
8%
Emboliobst
3%
P.lama/macet
5%

Abortus
5%
Infeksi
12%
Pre/Eklampsia
25%
RS Rumah FasKes Perjalanan Tempatlain
Tempat Kematian Maternal di RS

Qomariyah SN, Bell JS, Pambudi ES, Anggondowati T, Latief K, Achadi EL, et al. A practical approach to identifying maternal
deaths missed from routine hospital reports: lessons from Indonesia: Global Health Action2009
PrakiraanWaktumenujuKematianuntuk
KasusKegawatdaruratanObstetri
Penyebab Waktu
PerdarahanPostpartum 2jam
Perdarahan Antepartum 12jam
RupturUteri 1hari
Eklampsia/PEB 2hari
PersalinanMacet 3hari
Infeksi 6hari

BrileyA,BewleyS.Managementofobstetrichemorrhage:obstetricmanagement.In:BrileyA,BewleyS,editors.TheObstetricHematologyManual.
Cambridge:CambridgeUniversityPress;2010.p.15158.
Laboratoryvaluesinpregnancy
comparedtonormal.
Pregnancyvalues Normalvalues
Hematocrit(%) 3242 3547
Whitebloodcellcount(M/L) 5,00032,000 4,50022,000
ESR(mm/hr) 78 <20
ArterialpH 7.407.45 7.357.44
Bicarbonate(mEq/L) 1722 2228
PCO(mmHg) 2530 3545
Fibrinogen(mg/dL) >400 200400
11.2 23.5
Prothrombintime(sec)
3 Nochangeor
Platelets(x10 L) 130400
decreased
MayaSSuresh.Cardiopulmonaryresuscitationandtheparturient.BestPractice&ResearchClinical
ObstetricsandGynaecology24(2010)383400
12/3/2016PK17.00 12/3/2016PK19.00 12/3/2016PK23.00
BidanTP RSKK RSKK

Pasienmengeluhmulas PasientibadiRS KK Pasienmengeluhperut


mulas.Riwayatdipijat semakinnyeri
olehdukun1hari Tekanandarah
SMRS. 140/100mmHg TD130/100mmHg,nadi
ANCbiasanyadidukun DJJtidakada 118x/m
beranakdanbidan Dikonfirmasidengan Produksiurinesedikit,
USGdjjtidak warnakemerahan(saat
PemeriksaandiBidan ditemukan kateterdipasangdiawal
Dikatakan TD Pasiendirencanakan bidanmengatakanurine
150/100 partuspervaginam jernih)
(tidakdilakukan PasiendipasangIVFD2
pemeriksaanprotein line.
urin) Pasiendirujukkarena
DJJ Sulit di temukan ICUpenuh

PasienDirujukkeRSKK
13/3/2016PK00.00 12/3/2016PK00.45
RSBA VKRS P

ICUpenuh PrimarySurvey
A:A:Clear
PasiendirujukkeRS P
B:24x/menit nasalkanul 3L/menit
C:120x/menit,TD:90/40 IVFD2
linecrystalloid1000cc,colloid500cc,
urinekemerahan 50cc,sedia PRC
1000cc,FFP500cc,backupICU
resusitasi 10menit TD140/100,
110x/menit

Rencana terminasi perabdominam


sampai denganHT
PemeriksaanFisik
StatusGeneralis
Genstatus:KU:sedang;KesadaranCM;BP90/40mmHg;N:
124x/menit;RR:24 x/menit; S:36.50C;TB160BB55kg
Pemeriksaanfisik:Konjungtivaanemis/,skleraikterik/,
cor:S1S2normal,M(),G(),pulmo:vesikuler+/+,rh/,
wh/,abd:lemas,bisingusus(+),extremitaedema/
Statusobstetri:
TFU29cm,kepala,punggungkanan,tetanikkontraksi,DJJ
negatif
I:vulva/uretraperdarahan
Io:Portiolicin,oueterbuka1cm,fluor(),fluksus(+)
Vt:portiolunak,axial,tebal1cm,pembukaan2cm,kepaladi
hodge1,selaputketuban()
Proposedalgorithmbasedontwoormorematernalearly
warningtriggerspersistingfor30minutesormore

Abbreviations:HR,heartrate;bpm,beatsperminute;MAP,meanarterialpressure;mmHg,millimetersmercury;AMS,
alteredmentalstate;AT,abnormaltemperature;RR,respiratoryrate;SpO2,oxygensaturation
HedrianaHL,etal,Baselineassessmentofahospitalspecificearlywarningtriggersystemforreducingmaternalmorbidity,IntJGynecol
Obstet(2015).
Syok
PerjalananSyokHipovolemiktanpapemberianterapi

Tekanan Darah Denyut Jantung


Tekanan darah (mm Hg)
Denyut Jantung (kali/menit)

150 Perdarahan

100

50

0 (Waktu)
Kompensasi Dekompensasi Irreversibel

Fase Syok
PrakiraanVolumedarahDewasa(70mL/kgBB)Hamil(100mL/kgBB)
Prakiraan Persentasi
Klasifikasi Tandadan GejalaKlinis Action
Perdarahan (ml) Perdarahan (%)

0(normal) <500 <10 Tidak ada


GarisWaspada

Perlupengawasanketatdan
1 5001000 <15 Minimal
Terapicairaninfus
Garis Bertindak
pulserate
2 12001500 2025 Nadihalus
Terapicairaninfusdan
diuresis
uterotonika
prernapasan
hipotensipostural
hipotensi
takikardia Manajemenaktifdan
3 18002100 3035
akraldingin agresif
takipnu
Manajemenaktikkritikal
4 >2400 >40 Syok (risiko50%mortalitasbila
tidakditatalaksanaaktif)

BenedettiT.Obstetrichaemorrhage.InGabbeSG,NiebylJR,SimpsonJL,eds.APocketCompaniontoObstetrics,4thedn.NewYork:ChurchillLivingstone,
2002:Ch17.In:BLynchC,KeithLG,LalondeAB,KaroshiM,editors.ATextbookOfPostpartumHemorrhageAcomprehensiveguidetoevaluation,
managementandsurgicalintervention.Dumfriesshire:SapiensPublishing;2007.p.3544.
GeneralGoalsforSupportofShock
Patients
HemodynamicSupport
MAP>6065mmHg
PCWP=1518mmHg
Cardiacindex>4.0L/minpersquaremeterofbodysurfacearea
forseptic,traumatic,orhemorrhagicshock
OptimizationofOxygenDelivery
Hblevel>10g/dL
Arterialoxygensaturation>92%
ReversalofOrganSystemDysfunction
Maintainurineoutput>0.5mL/kgperhour

PapadakosPJ.ApproachtoShock.In:ApostolakosMJ,PapadakosPJ,editors.TheIntensiveCareManual.NewYork:McGrawHill;2001.p.5570
PemeriksaanPenunjang
USG:janintunggalIUFD,plasentadikorpusanterior
tampakterlepasseluruhnya,hematomretrokorion(+)
DBP93,3mm/HC314.7mm/AC291mm/FL69.8mm/
TBJ2461gram
Lab11/3/2016
DPLHb6,5g/dL;Ht17%;L18.520;Tr71.000/mm3;
MCV84,1;MCH29,8;MCHC35,2
GDS92mg/dL
LDH427
OT/PT:33/31;Ur/Cr36/1,1;Alb:2,6mg/dL
Ya transfusi, jika
Ada tanda oxygen-want
tachycardia, tachypnea, mata berkunang, kepala-ringan
Ada cardiac ischemia, congestive heart disease
Ada asidosis metabolik, asidosis laktat

Hb 10 = optimal

Hb 7-8 = tolerable
OK
Hb < 5 = critical
Safari_HTA_Clinical use of
15
blood_06xx
Safari_HTA_Clinical use of
16
blood_06xx
MassiveTransfusionProtocolforSevere
Hemorrhage
Cycle 2 3 1
Redbloodcells 6units 6units
6units
Plasma 4unitsFFP 4unitsFFP
4unitsFFP
5units
Platelets 5unitspooled 5unitspooled
pooled
10units
Cryoprecipitate 10unitspooled
pooled
Administer60
RecombinantFVIIa Consider
90g/kg
Fibrinogen
2g 4g
concentrate*
*Canbeusedinsteadofcryoprecipitate. FFP=Freshfrozenplasma

ManagementofAcuteObstetricEmergencies FemalePelvicSurgeryVideoAtlasSeriesBahaM.Sibai4EvaluationandManagementofPostpartumHemorrhage,
41702011bySaunders
Distribusigolongandarah
Amerika Indonesia *)
O45%(38%Rh(+)dan7%Rh() 39%
A40%(34%Rh(+)dan6%Rh() 25%
B11%(9%Rh(+)dan2%Rh() 28%
AB4%(3%Rh(+)dan1%Rh() 7%
Rh()15% 0.02%

Padadasarnya,doktercumaperlu
golonganABOyangkompatibel
*) donor Jakarta 1990
Safari_HTA_Clinical use of
18
blood_06xx
DonorUniversalgolO
sangatbergunadalamkeadaandarurat,
jadiharusselalutersedia
Catatan:
JikasudahtransfusigolO4unit
makajangankembalikegolongan
aslinya sampai2minggusejak
transfusiterakhir.

Safari_HTA_Clinical use of
19
blood_06xx
ApakahpasienRh()bolehdiberi
donorRh(+)?
MencaridonorAB()dalamkeadaandarurathampir
mustahil,0.02%x7%=0.0014%
Rh()diIndonesia0.02%(orangkulitputih15%)
WanitaRh()0.01%
DarahABdiIndonesia7%
WanitaAB3.5%
WanitaAB()diIndonesia=0.01%x3.5%=0.00035%
Populasiumumyangperlutransfusi0.2%
KemungkinanadapasienwanitaAB()perlutransfusi
adalah0.2x0.00035=0.0000007%

Safari_HTA_Clinical use of
20
blood_06xx
DiIndonesia,rakyatpribumi:
DarahRh(+)boleh diberikanpasienRh()

Lakilaki
Wanitatidakdalamusiasubur
Bagaimanadenganwanitausiasubur?
tubuhpenerimaakanmembentukantiRhesus(+)
JikahamildarisuamiRh(+),janinyangdikandungRh(+)
ReaksiantiRhesus(+)ibuterhadapjanin mungkin
terjadiErythroblastosisfoetalis(tidak100%terjadi)
Penyulitinidapatdicegahdengansuntikanimmuno
globulinsebelumhamil(Rhogam)

Safari_HTA_Clinical use of
21
blood_06xx
DETEKSIDINIOBSTETRI
DiagramoftheoutcomesofadverseeventsinAustralian
hospitals

WilsonRM,RuncimanWB,GibberdRW,etal.TheQualityinAustralianHealthCareStudy.MedJAust.1995;163:458471.In:JonesD,BellomoR,
GoldsmithD.GeneralPrinciplesofMedicalEmergencyTeams.In:DeVitaMA,HillmanK,BellomoR,editors.MedicalEmergencyTeams
ImplementationandOutcomeMeasurement.Pittsburgh:SpringerScience+BusinessMedia;2006p.8090.
Warningsignsprecedingcriticalevent

Hemodynamicchangesincludedsystolicbloodpressure<90or>200mmHg,pulse<50or
>130beats/min;respiratoryincludedrate>30/min,oxygensaturation<85%;abnormal
laboratoryresultsincludedpH<7.2,Na+<125or>150mmol/L,K+>6mmol/L;abnormal
temperature<95For>104F.GCS=GlasgowComaScore
BuistMD,JarmolowskiE,BurtonPR,etal.Recognisingclinicalinstabilityinhospitalpatientsbeforecardiacarrestorunplannedadmissionto
intensivecare.Apilotstudyinatertiarycarehospital.MedJAust.1999;171:2225. In:DeVitaMA,HillmanK,BellomoR,editors.Medical
EmergencyTeamsImplementationandOutcomeMeasurement.Pittsburgh:SpringerScience+BusinessMedia;2006p.8090.
RiskofMortality:Independent
Predictors
Event Oddsratioand95%CI
Decreaseofconsciousness 6,4(2,615,7)
Hypotension 2,5(1,64,1)
Lossofconsciousness 6,4(2,913,6)
Bradypnea 14,4(2,680,0)
SaO2<90% 2,4(1,64,1)
Tachypnea 7,2(3,913,2)

BuistM,CampbellD.TheChallengeofPredictingInHospitalIatrogenicDeaths.In:DeVitaMA,HillmanK,BellomoR,editors.MedicalEmergency
TeamsImplementationandOutcomeMeasurement.Pittsburgh:SpringerScience+BusinessMedia;2006p.3248.
NationalEarlyWarningScore

KolicI,CraneS,McCartneyS,PerkinsZ,TaylorA.Factorsaffectingresponsetonationalearly
warningscore(NEWS).Resuscitation.2015May;908590
Amodifiedearlyobstetricwarningsystem
(MEOWS)UK,NICE
PhysiologicParameters YellowAlert RedAlert
Respirationrate 2130 <10or>30
Oxygensaturation <95
Temperature 3536 <35or>38
Systolicbloodpressure 150160or90100 <90or>160
Diastolicbloodpressure 90100 >100
Heartrate 100120or4050 >120or<40
Painscore 23
Neurologicresponse Voice Unresponsive,pain
Respirationrate(breathsperminute);Oxygensaturation(%);Temperature(degreesCelsius);Systolicblood
pressure(mmHg);Heartrate(beatsperminute).LevelofconsciousnessisbasedontheAlertVoicePain
Unresponsivescale,whichassesses4possibleoutcomestomeasureandrecordapatientslevelof
consciousness.Painscoresareasfollows:(05nopain,15slightpainonmovement,25intermittentpainat
rest/moderatepainonmovement).Asingleredscoreor2yellowscorestriggersanevaluation

The MEOWS alert parameters may lead to detection of the following unrecognized
conditions: hemorrhage (as demonstrated by hypotension and tachycardia),
sepsis (fever, hypotension, tachycardia, hypoxia), venous thromboembolism
(tachycardia, tachypnea, hypoxia), preeclampsia (hypertension, hypoxia), and
cardiovascular complications (tachycardia, bradycardia, hypoxia, hypotension).
SinghS,McGlennanA,EnglandA,etal.AvalidationstudyoftheCEMACHrecommendedmodifiedearlyobstetricwarningsystem(MEOWS).Anaesthesia
2012;67:128;In:FriedmanAM.Maternalearlywarningsystems.ObstetGynecolClinNorthAm.2015Jun;42(2)28998.
NationalEarlyWarningScore&Clinical
Risk
SkorNEWS RisikoKlinis
0
Rendah
Totalskor14
SkorMERAH(skor
parametertunggal 3) Sedang
Totalskor56
Total skor 7 Tinggi

KolicI,CraneS,McCartneyS,PerkinsZ,TaylorA.Factorsaffectingresponsetonationalearly
warningscore(NEWS).Resuscitation.2015May;908590
RingkasanAktivasi/PicuNEWS(Trigger)
SkorNEWS FrekuensiPemantauan Respon
0 Minimalsetiap 12jam LanjutkanpemantauanrutinNEWS
Total12 Minimal setiap46jam Peringatkanperawatuntuk melakukan
penilaianpadapasien
Perawatmemutuskanuntuk
meningkatkanfrekuensipemantauan
atauperluperawatankhusus
Total 5 Tingkatkanfrekuensi Perawatmemanggildokter yang
atauskor3 pemantauanmenjadi kompetendalamkasusakutuntuk
padasalah setiapjam menilaipasien.
satu Perawatankhususdenganpenambahan
parameter alatmonitor
Total 7 Pemantauan tandavital Perawat segeramemanggiltimyang
secarakontinyu kompetendalamkasuskritis(termasuk
kemampuanintubasi/manajemenjalan
napas)
PerawatanHCU/ICU
ModifiedEarlyObstetric
WarningScoringsystem
(MEOWS)chartfromthe
LiverpoolWomen's
Hospital.

Riskmanagementandmedicolegalissuesrelatedtopostpartumhaemorrhage.Upadhyay,Kalpana,MRCOG,BestPractice
&Research:ClinicalObstetrics&Gynaecology,Volume22,Issue6,11491169,2008
1.Aktivasi
Pemantauan
NEWSSPasienDewasa

3 2 1 0 1 2 3
Pernapasan/ <8 8 917 1820 2129 >30
menit
Nadi/menit <40 4050 51100 101110 111129 >130
Tekanandarah <70 7180 81100 101159 160199 200220 >220
Sistolik
Tingkat Coma Stupor Somnolen Compos Apatis Delirium
Kesadaran Mentis

SuhuTubuh <35oC 35.0536oC 36.05 38.05 >38.5oC


38.oC 38.5oC

Hijau Kuning Orange Merah


01 23 45 >6
PJ
Aktivasi Kaji Ulang
Merah CodeBlue
DPJP Ruangan
Kontinu
Perawat

Perbaikan PJ Kaji Ulang


Oranye Tatalaksana
DPJP
Ruangan tiap 1jam

PJ Kaji Ulang
Kuning Asesmenulang
Ruangan tiap 2Jam

Kaji ulang
Hijau Pasiendalamkeadaanstabil Setiap
Shift
Escalationduetoearlywarningsystem

AroraKS.Triggers,bundles,protocols,andchecklistswhateverymaternalcareproviderneedstoknow.AmJObstet
Gynecol.2016Apr;214(4)44451
Peran:TeamLeader
Jabatan:dr.TMRCUnit/
Perawat1
Tugas: Airway/Breathing

Skema Peran:Perawat2

Pertolongan Tugas:Compression

CodeBlue
(Sebelum TMRC Pusat Peran:Perawat3
/Wilayahdatang) Jabatan:IVline&drugs

TroliEmergensi

Peran:.Perawat4
Jabatan:Dokumentasi
Postpartumhaemorrhageclinicalchecklist
Call for assistance
Emergency bell activated
Airway Monitoring
Check airway Blood pressure
Heart rate
Circulation, tissue perfusion
Catheter and hourly urine
Consider CVP
Breathing Inspection
Check breathing Blood loss
Oxygen administered Uterine Tone
Placenta and membranes
Perineum
Circulation Treatment
Lie flat or head down IM Syntometrine
Insert two large gauge cannulae Syntocinon infusion
Take blood for FBC, Clotting, Cross match 6 units Misoprostol PR
Commence 2 litres crystalloid Carboprost/Hemabate IM
Consider O negative blood Uterine Massage
Bimanual compression
Decision for EUA
Documentation
Timings, drugs, persons present etc
PERDARAHANPOSTPARTUM
Syok
PerjalananSyokHipovolemiktanpapemberianterapi

Tekanan Darah Denyut Jantung


Tekanan darah (mm Hg)
Denyut Jantung (kali/menit)

150 Perdarahan

100

50

0 (Waktu)
Kompensasi Dekompensasi Irreversibel

Fase Syok
PrakiraanVolumedarahDewasa(70mL/kgBB)Hamil(100mL/kgBB)
Prakiraan Persentasi
Klasifikasi Tandadan GejalaKlinis Action
Perdarahan (ml) Perdarahan (%)

0(normal) <500 <10 Tidak ada


GarisWaspada

Perlupengawasanketatdan
1 5001000 <15 Minimal
Terapicairaninfus
Garis Bertindak
pulserate
2 12001500 2025 Nadihalus
Terapicairaninfusdan
diuresis
uterotonika
prernapasan
hipotensipostural
hipotensi
takikardia Manajemenaktifdan
3 18002100 3035
akraldingin agresif
takipnu
Manajemenaktikkritikal
4 >2400 >40 Syok (risiko50%mortalitasbila
tidakditatalaksanaaktif)

BenedettiT.Obstetrichaemorrhage.InGabbeSG,NiebylJR,SimpsonJL,eds.APocketCompaniontoObstetrics,4thedn.NewYork:ChurchillLivingstone,
2002:Ch17.In:BLynchC,KeithLG,LalondeAB,KaroshiM,editors.ATextbookOfPostpartumHemorrhageAcomprehensiveguidetoevaluation,
managementandsurgicalintervention.Dumfriesshire:SapiensPublishing;2007.p.3544.
SingkatanHAEMOSTASIS
Singkatan
Help.AskforHelp (Aktivasikodebiru,TimRespons
H
Cepat)
Aksesintravena,penilaianperdarahandanresusitasi Langkah
A
cairan awal
E Etiologicari(4T),sediadarah
M Masaseuterus
O OksitosinUterotonika Obat
SiapkeOK/Rujuk.Singkirkansisaplasentadantrauma.
S Konservatif
Kompresibimanual,kompresiaortaabdominalis. (video)
NonBedah
T Tampon uterus kondomkateter (video)
A AplikasikompresiuterusBLynchataupunmodifikasi
Systemicpelvicdevascularization:uterina,ovarika, Bedah
S
hipogastrika,tehnikLassoBudiman Konservatif
I Intervensiradiologiintervensi embolisasiarteriuterina
Langkah
S Subtotal/totalhisterektomi
Akhir

MishraN,ChandraharanE.Postpartumhaemorrhage(PPH).In:WarrenR,ArulkumaranS,editors.BestPracticeinLabourandDelivery.Cambridge:Cambridge
UniversityPress;2009.p.16070.
Prosedur No Kasus Luaran

SectioSesarea 1 Solusioplasenta,syokhipovolemik Anestesispinal


dilanjutkan
Histerektomi Ny.SR,31 th
Triawa Insisimediana
Saatperitoneumdibuka,tampakdarah+
Subtotal& MR223.85.01
bilateral 1000cc,bekuandarah+ 500cc
salpingektomi Diagnosispreop: dievakuasi
SyokhipovolemikgrIIecHAPecsolusioplasenta
ICD10 padaG1hamil3738minggu,janin presentasi Tampakuterusgravidus~couvulaire
Z35.0 kepalatunggalIUFD Korpusanteriordisayattajam,dilebarkan
O14.1 PEB tumpul
O36.4 Hematuriaecsusprupturuteri
O45 Hypoalbuminemia(2.6) Denganmenarikkaki,lahibayilakilaki,
O72.1 Trombocytopeniaeclosscoagulopathydd/HELLP 2600gram,48cm,matibermaserasigrI
Syndrome Plasentasudahterlepasseluruhnya
ICD9 CM
Uterusdikeluarkan,tampakcouvulaire
74.4 Diagnosispostop:
66.5 Solusio plasenta padaseluruhbagianuterus
68.3 Atoni Uteri
Hematuriaec inbibisi
PEB
Hypoalbuminemia(2.6)
Trombocytopeniaeclosscoagulopathydd/HELLP
Syndrome
PREEKLAMPSIA
TherevisedISSHPdefinitionpreeclampsia(2014)
Hypertension developing after 20 weeks gestation and
the coexistence of one or more of the following new onset
conditions:
1. Proteinuria
2. Othermaternalorgandysfunction:
Renalinsufficiency(creatinine >90umol/L)
Liver involvement (elevated transaminasesand/or severe right upper
quadrant or epigastric pain)
Neurological complications
Haematological complications
3. Uteroplacental dysfunction
Fetalgrowthrestriction

Theclassification,diagnosisandmanagementofthehypertensivedisordersofpregnancy:Arevisedstatementfromthe
ISSHP.PregnancyHypertension:AnInternationalJournalofWomensCardiovascularHealth4(2014)97104
Consideredseverelyelevated:>160
mmHgsystolicor>110mmHgdiastolic.
Nottorelyonasinglereading,
appropriatesizedcuff
InthecaseofseverelyelevatedBPnotto
waitfor6hapart,butin1530m
Suggestmercurysphygmomanometry or
sphygmomanometry usingaliquidcrystal
device.Ifanautomateddeviceistobe
usedthenitshouldhavebeenvalidated
foruseinpregnancy.

AndreaL.Tranquilli,MarkA.Brown,Gerda G.Zeeman,Gustaaf Dekker,Baha M.Sibai.Thedefinitionofsevereandearly


onsetpreeclampsia.StatementsfromtheInternationalSocietyfortheStudyofHypertensioninPregnancy(ISSHP)
Doesnotpredictclinicaloutcome
A spoturineprotein/creatinine ratio>30mg/mmol
Thereisnoclearconsensusontheamountofproteinuriato
beconsideredsevere(between>3and5g/l)
NOTCONSIDERPROTEINURIAFORDEFININGSEVERE
PREECLAMPSIA

AndreaL.Tranquilli,MarkA.Brown,Gerda G.Zeeman,Gustaaf Dekker,Baha M.Sibai.Thedefinitionofsevereandearly


onsetpreeclampsia.StatementsfromtheInternationalSocietyfortheStudyofHypertensioninPregnancy(ISSHP)
Hipertensi
bukan
penyakit tapi
merupakan
reaksi tubuh

Implantasi
yangtak
sempurna

Hipertensi terjadi
sebagai
mekanisme
kompensasi
penuhi kebutuhan
PerkembanganPreeklampsia

Skemasekuenkejadiansepanjangkehamilansampaitimbulgejalaklinispreeklampsia.EC,
endothelialcell;HO1,haemoxygenase1;TGF,transforminggrowthfactor.
RammaW,AhmedA.Isinflammationthecauseofpreeclampsia?BiochemSocTrans.2011Dec;39(6):161927.
Prooxidant antioxidant Balance
ROSdan RNSberperan penting pd PEE
Scr langsung induksi disfungsi endothelial
Induksi hipertensi dan proteinuria melalui:
RAS
inflammasi
Insulinresistan
Pro antiangiogenic
menurunkan NOdgmeningkatkan
ADMAdan menurunkan HO1
Poiseuilles+Bernoullis Kantung elastis
FailureSMCmodification
Bertahanan rendah
Diameter : 4 6 X Arus tinggi
Aliran drh:tonik O2 hipertensi
Bebas regulasi neurovascular
Syncytial knot:aptototic sincytrophoblast
Exp.Physiol 1997; 82;377 - 87

Debriske sirkulasi maternal sitokin disfungsi endotel


Twostagemodelofdevelopmentofpreeclampsia

CHRISTOPHERW.G.REDMAN,IANL.SARGENTANDROBERTN.TAYLOR.ImmunologyofNormalPregnancy
andPreeclampsia.Chesleys Hypertensive Disorder inPregnancy
Thepathophysiologicalprocesses
involvedinpreeclampsia

AT1AA,angiotensinIIreceptor1autoantibodies;HELLP,hemolysis,elevatedliverenzymes,and
lowplatelets;PlGF,placentalgrowthfactor;sFlt1,solubleFmsliketyrosinekinase1;VEGF,
vascularendothelialgrowthfactor.
UratoAC,NorwitzER.Aguidetowardsprepregnancymanagementofdefectiveimplantationandplacentation.BestPract
ResClinObstetGynaecol.2011Jun;25(3):36787.
Genetik
Immunologik
EtiologicFactors Nutrisi
Infeksi

Perubahan pada angiogenesis


Fetoplacental

Pathophysiology
Lain2:
Kegagalan
Stress VEGF
Invasi
Oxidative TNF
Trophoblast
dll

Disfungsi Endothel

ClinicalManifestation Hypertensi &Proteinuria

PREEKLAMPSIA
Overlappingroleofhypertension,capillaryleak,maternal
symptoms, andfibrinolysis/hemolysis inthespectrumof
atypicalpreeclampsia

SibaiBM,StellaCL.Diagnosisandmanagementofatypicalpreeclampsiaeclampsia.AmJObstet
Gynecol.2009May;200(5):481e17.
PREECLAMPSIA
FIRST,deliveryisalwaysappropriatetherapyforthemother
butnotbesoforthefetus
SECOND,thesignsandsymptomsofpreeclampsiaarenot
pathogenetically important(loweringbloodpressuredonot
alleviatetheimportantpathophysiologicchanges
THIRD,thepathogenicchangesorpreeclampsiaarepresent
longbeforeclinicalcriteriafordiagnosisareevident

F.GaryCunningham.Hypertensivedisorders.WilliamsObstetricsed 24th
Suggestedantepartummanagementoptionsforwomen
withpreeclampsiaatanystageofdiagnosis

Optionalassessmentandsurveillance
Onadmission,ondayofdelivery,andadditional
testingas indicatedbychangesinclinicalstate.
Maternal
Blood:haemoglobin,plateletcount,creatinine,
uricacid,AST orALT,furthertestingifindicated
Fetal
CTG,ultrasound,AFI,umbilicalarteryDoppler

SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.
SEIZUREPROPHYLAXISANDTREATMENT
IntheMagpiestudy,10,000preeclamptic womenwererandomized
toreceivemagnesiumsulfateorplacebo.
Magnesiumsulfateclearlyreducedtheriskofeclampsia inthistrial,
anditwasshowntobesuperiortootherprophylacticmedications,
includingphenytoin,anddiazepam.

RCTofMgSO4prophylaxiswithplacebooractivedruginwomenwithgestationalhypertension

JAMESM.ALEXANDERANDF.GARYCUNNINGHAM.ClinicalManagement.ChesleysHypertensive
Disorder inPregnancy
RandomizedcomparativetrialsofMagnesiumSulfate
withAnotherAnticonvulsanttoPreventRecurrent
Eclamptic Convulsions

JAMESM.ALEXANDERANDF.GARYCUNNINGHAM.ClinicalManagement.ChesleysHypertensive
Disorder inPregnancy
Inwomenwithnormalrenalfunction,thehalftimeforexcretionis
about4hours.
Becauseexcretiondependsondeliveryofafilteredloadof
magnesiumthatexceedstheTmax,thehalftimeofexcretionis
prolongedinwomenwithadecreasedGFR

Magnesium slows or blocks neuromuscular and cardiac conducting


system transmission, decreases smooth muscle contractility, and
depresses central nervous system irritability
Suggestedantepartummanagementoptionsforwomen
withpreeclampsiaatanystageofdiagnosis

MgSO4
Regimen:MgSO44gIVloadingdoseover1520min,
followedbyaninfusionof1g/h;recurrentseizure(s)
treated withadditional24gIVloadingdose(s);clinical
monitoring bymeasurementofurinaryoutput,
respiratoryrate,and tendonreflexes.
Eclampsiaprophylaxis
Yes;forseverepreeclampsiaduringinitialstabilisation
and peripartum(delivery+24h)
Eclampsiatreatment
Yes

SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.
Inhibitionofuterinecontractilityismagnesiumdose
dependent
Serumlevelsofatleast810mEq/Larenecessarytoinhibit
uterinecontractions(WattMorse,1995)

JAMESM.ALEXANDERANDF.GARYCUNNINGHAM.ClinicalManagement.ChesleysHypertensive
Disorder inPregnancy
CerebralBloodFlow

LossofAutoregulation
Riskof
hypertensive
encephalopathy
Normotensive

Poorlycontrolled
Riskof
ischemia hypertensive

50 100 150 200 250

MeanArterialPressure(MAP)

AdaptedwithpermissionfromVaronJ,MarikPE.Chest. 2000;118:214227.
JASONG.UMANS,EDGARDOJ.ABALOSANDF.GARYCUNNINGHAM.Antihypertensive treatment.Chesleys
Hypertensive Disorder inPregnancy
RandomizedPlaceboControlledTrialsofAntihypertensiveTherapyforEarly
MildHypertensionDuringPregnancy

JASONG.UMANS,EDGARDOJ.ABALOSANDF.GARYCUNNINGHAM.Antihypertensive treatment.Chesleys Hypertensive Disorder in


Pregnancy
DRUGSFORTREATMENTOFSEVEREHYPERTENSIONINPREGNANCY

Drug Dose Onset Duration AdverseEffects

Labetalol 2040mgIVq10min1 1020min 36h Scalptingling,vomiting,heartblock


mg/kgasneeded
Nifedipine 1020mgPOq2030min 1015min 45h Headache,tachycardia,synergistic
interactionwithmagnesiumsulfate
Nicardipine 515mg/hIV 510min 14h Tachycardia,headache,phlebitis
NocurrentagreementastowhatlevelBPshouldbe
maintainedwhenantihypertensives areinstitutedfornon
urgentindicationsinpregnancy
TheCanadianguidelinesrecommend130155/90105
mmHgintheabsenceofcomorbidconditions
TheNICEguidelinesrecommendkeepingBPbelow150mmHg
systolicandbetween80and100mmHg diastolic

Theclassification,diagnosisandmanagementofthehypertensivedisordersofpregnancy:Arevised
statementfromtheISSHP.PregnancyHypertension:AnInternationalJournalofWomensCardiovascular
Health4(2014)97104
Managementofmaternalfluidbalancebefore,duringand
afterdeliveryisachallengefortheclinician.

Thematernalplasmavolumeexpansionisattenuatedin
preeclampsia (deficitsof600800ml/m2)
Recommendation65125ml/hour
becauseofthepotentialriskofpulmonaryedema,cautionmustbe
takeninpreeclamptic oreclamptic womensimultaneouslyreceiving
magnesiumsulfateforseizureprophylaxis

T.Engelhardt,F.M.MacLennan.Fluid managementinpreeclampsia.InternationalJournalof
Obstetric Anesthesia.1999
GloriaT.Too,andJamesB.Hill.Hypertensivecrisisduringpregnancyandpostpartumperiod
FluidManagement
Rapidfluidinfusion asignificantincreaseinalveolar
arterialoxygendifference(AaDO,)andshuntfraction(Qs/Qt)

Vasodilator therapy alone appears to improve tissue


oxygenation without affecting Qs/Qt
F.GaryCunningham.Hypertensivedisorders.WilliamsObstetricsed 24th
Oliguria(<15mL/h)iscommoninpreeclampsia,particularly
postpartum.
Intheabsenceofpreexistingrenaldiseaseorarising
creatinine,oliguriashouldbetoleratedoverhours,toavoid
volumedependentpulmonaryoedema

LauraA.Magee,Anouk Pels,MichaelHelewa,Evelyne Rey,PetervonDadelszen,Onbehalfofthe


CanadianHypertensiveDisordersofPregnancy(HDP)WorkingGroup1.Diagnosis,evaluation,and
managementofthehypertensivedisordersofpregnancy
Suggestedantepartummanagementoptionsforwomen
withpreeclampsiaatanystageofdiagnosis

Plasmavolumeexpansion
No;becauseofrisksofmaternalmortality
associatedwith pulmonaryoedema,inwomen
withseverepreeclampsia infusionofsodium
containingfluidsmightneedtobe restricted
andbalancedagainsturineoutputover4hor
more andcreatinineconcentrations
Thromboprophylaxis
Yes;ifonbedrestfor4daysormore

SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.
ReviewsandRandomizedClinicalTrialsforPreeclampsia
RecurrencePrevention
OddsRatio
Agent Study Population N
(95%CI)
Aspirin Coomarasamy33 Highrisk 12,416 0,86(0,790,94)
Duley32 Highrisk 33,439 0,81(0,750,88)
Calcium Hofmeyr34 Metaanalysislowrisk 15,206 0,48(0,330,69)
Metaanalysishighrisk 587 0,22(0,120,42)
Magnesium Spatling35 Generallowrisk 568 NS
Sibai36 Normotensive 374 NS
primigravidas
Fishoil Makrides37 Allrisk 1,683 0,86(0,591,27)
VitaminsC+E Poston41 Highrisk 2,41 0,97(0,801,17)
Rumbold42 Nulliparouswomen 1,877 1,20(0,821,75)
Heparin Mello46 Angiotensin 80 0,26(0,080,86)
convertingenzyme
polymorphismin
nonthrombophilic
womenwithhistoryof
preeclampsia
DildyGA,3rd,BelfortMA,SmulianJC.Preeclampsiarecurrenceandprevention.SeminPerinatol.2007Jun;31(3):13541.
Longtermhealthrisks
Hypertensivedisorder
FutureRisk Severepreeclampsia,
Gestational
Preeclampsia HELLPsyndromeor
hypertension
eclampsia
Gestational Riskrangesfrom
Riskrangesfromabout1in8
hypertensionin about1in6(16%)to
(13%)toabout1in2(53%).
futurepregnancy about1in2(47%).
Ifbirthwasneeded
Riskuptoabout1in6(16%). before34weeksriskis
Riskrangesfrom1in
Preeclampsiain Noadditionalriskifinterval about1in4(25%).
50(2%)toabout1in
futurepregnancy beforenextpregnancy<10 Ifbirthwasneededbefore
14(7%).
years. 28weeksriskisabout1in
2(55%).
Cardiovascular
Increasedriskofhypertensionanditscomplications.
disease
Ifnoproteinuria andno
hypertensionat68week
Endstage
postnatalreview,relativerisk
kidneydisease
increasedbutabsoluterisklow.
Nofollowupneeded.
Thrombophilia Routinescreeningnotneeded.

NICE2010QuickRef
Kontrasepsi
Pil AKDR
KOK KIK KOP KIP Implan AKDR Tubektomi
Kondar LNG
RiwayatTD
tinggiselama
kehamilan 2 2 1 1 1 1 1 A
(sekarangTD
normal)
Sistolik 140
159atau 3 3 1 2 1 1 1 C
diastolik9099
Sistolik 160
ordiastolik 4 4 2 3 2 1 2 S
100
KOK=Kontrasepsioralkombinasi;KIK=Kontrasepsiinjeksikombinasi;KOP=Kontrasepsioral
progestin;KIP=Kontrasepsiinjeksiprogestin;Kondar=kontrasepsidarurat;AKDR=alat
kontrasepsidalamrahim;AKDRLNG=alatkontrasepsidalamrahimLevonorgestrel.
TrainingforObstetricEmergencies
RecommendationsforTraining EvidenceQuality
and
Recommendation
Methods
Simulationrehearsalsinadditiontolectures. Ib/A
Inhouseclinicaltraining. Ib/A
Teachingofstreamlinedclinicalprotocols. II/B
Practicalsolutionsthatmakeiteasytoimplementnationalguidelines. II/B
Multiprofessionalteams,interprofessionallearning. II/B
Lackofhierarchy,reducedauthoritygradient. II/B
Contextspecificfidelity:
Environmentalfidelity. II/B
Hightechmodelsforadvancedmanualskills. Ib/A
Hybridsimulationwithpatientactorsintegratedwithparttasktrainers Ib/A
forcommunicationtraining.
Humanfactors(teamwork)training:inhouse,integratedinclinical Ib/A
rehearsals.
Trainingindocumentationandtheuseofdocumentationproformas. II/B
HighRiskPregnancy,4thEditionDavidJames,79TrainingforObstetricEmergencies,13611368.e32011
TrainingforObstetricEmergencies
RecommendationsforTraining EvidenceQuality
and
Recommendation
Participation
Participationintrainingoftheentireworkforce. II/B
Threatfreeparticipation;lackofformalassessment;replacewith II/B
structuredselfassessmentanddebriefings.
Mandateandconfirmannualattendance. II/B
Followup
Prospectivesurveillanceofoutcomes. II/B
Disseminateresultsandoutcomes:sharedlearningofsuccessesand IV/C
challenges.
Modifyandapplylessonstoundergraduatetraining. Ib/A

HighRiskPregnancy,4thEditionDavidJames,79TrainingforObstetricEmergencies,13611368.e32011
SummaryofBestPracticesinTeamPerformance Measurement

Linkmeasurestoscenarioevents.
Focusonobservablebehaviors.
Incorporatemultiplemeasuresfromdifferentsources.
Captureperformanceprocessesinadditiontooutcomes:
Obtaininformationnotonlyabouttheendresult,but alsoabouthowtheteam
reachedthatperformance outcome.
Trainobserversandstructureobservationprotocols.
Facilitateposttrainingdebriefingandtraining remediation.

AdaptedfromRosenMA,SalasE,WilsonKA,etal.Measuring teamperformanceinsimulationbasedtraining:Adoptingbest
practicesforhealthcare.SimulationinHealthcare2008;3:3341.
PositionTaskCompletion
(Performanceimprovementofrolerelatedtasksfromthefirstthroughthethirdsessionsofahuman
simulatorcrisisteamtrainingprogram.)

DeVitaMA,HillmanK,BellomoR,editors.MedicalEmergencyTeamsImplementationandOutcomeMeasurement.Pittsburgh:SpringerScience+BusinessMedia;
2006p.8090.
KeystoSuccess
Properscenariodesign
Focusonlearningobjectives
Providemorethanoneopportunitytopractice
teambehaviors
Accuratemeasurement
Includeprocessandoutcomemeasures
Capturebehaviors
Debriefing
Learninghappensinthedebrief
Includefeedbackonhowtoimproveperformance
Upayapencegahan
Prakonsepsi optimalkanstatus
nutrisi
Multivitamindanmineral,proteindanmixkarbohidrat
Bereskaninfeksi:periodontitis,UTI,cervicovaginitis
Upayakanberatbadanideal
Olahragateratur
Saathamil
Pertahankanupayaprakonsepsi