Materi Dr. Daliman

PENATALAKSANAAN
PREEKLAMSIA
MASA KEHAMILAN,
PERSALINAN DAN NIFAS
DALIMAN
RS MARGONO SOEKARJO/
FK UNSOED
PURWOKERTO
PENATALAKSANAAN PREEKLAMSIA,
Jumat, 08 Maret 2019 SEMINAR POLTEKES, 09 MARET 2019, 1
DALIMAN.DM19
INSIDENSI
 DI NEGARA MAJU 10–16 %
 KELAINAN KEMATIAN IBU DISEBABKAN OLEH
HIPERTENSI DALAM KELAINAN HIPERTENSI.
KEHAMILAN (HDK)  PROPORSI 3 PENYEBAB

MERUPAKAN KEMATIAN LAIN PERDARAHAN
13% , ABORSI 8 %, DAN SEPSIS
KOMPLIKASI 5 – 10% 2%.
DARI SELURUH
YANG PENTING, BAHWA LEBIH
KEHAMILAN.
DARI SETENGAH
 PREEKLAMSIA HIPERTENSI YANG
TERIDENTIFIKASI 3,9% DIHUBUNGKAN DENGAN
DARI SELURUH PENYEBAB KEMATIAN DAPAT
KEHAMILAN. DICEGAH
DALIMAN.DM19
HIPERTENSI DALAM KEHAMILAN (HDK)
(Pregnancy-Related Hypertension, Preclampsia and Hypertensive disorder,
Hypertension in Pregnancy, Hypertensive Disorders, Hipertensive Emergencies)
Klasifikasi (ACOG Tak Force for Klasifikasi :

Hypertension, 2013; NIH Working group
on Hypertension in Pregnancy):
I. Gestasional Hypertension,
II. Gestasional Proteinuria,
1. Preeclampsia (PE) and III. Preeclampsia and
eclampsia (E) syndrome,
Preeclampsia with severe
2. Chronic hypertension (CHTN) of any
etiology,
features.
3. Preeclampsia superimposed on IV. Chronic Hypertension,
chronic hypertension (SIPE), V. Superimposed Preeclampsia,
4. Gestational hypertension (GHTN).
Gabe, SG,. Et.al, 2017. Obstetrics; Normal and problem Pregnancies, 7ed.
VI. Superimposed Preeclampsia
Mularz A, et.al.,2017. OB/GYN, secrets, 4th ed.
with severe featrures
Creasy & Resnik’s, 2019. Maternal-Fetal Medicine: Principles and Practice, 8th ed.
Cunningham et.al., 2018. Williams Obstetrics, 25th ed) Foley MR, et.al., 2018. Obstetrics, Intensive Care Manual, 5th ed.
DALIMAN.DM19
ATYPICAL PREECLAMPSIA
The criteria for atypical
preeclampsia include
gestasional proteinuria or FGR
plus one or more of the following
symptoms of preeclampsia :
hemolysis, thrombocytopenia,
elevated liver enzymes, early signs
and symptoms of preeclampsia-
eclampsia earlier than 20 weeks,
and late postpartum preeclampsia- Gabbe et.al, 2017
eclampsia ( > 48 hours postpartum).
DALIMAN.DM19
HIPERTENSI DALAM KEHAMILAN
Definisi dan kriteria Klasifikasi (ISSHP, 2000;
diagnostik : 2014):
1. Chronic hypertension, 1. Chronic hypertension,
2. Gestasional hypertension,
3. Preeclampsia without severe
2. Gestasional hypertension,
features (“mild preeclampsia”), 3. Preeclampsia – de novo or
4. Superimposed Preeclampsia, Superimposed on chronic
5. Superimposed Preeclampsia with hypertension,
severe features,
6. Preeclampsia with sevevre 4. White-coat hypertension
features (“severe preeclampsia”).
7. HELLP syndrome,
James D, et.al., 2017. High-Risk Pregnancy, managemant options, 5th ed.
8. Eclampsia.
Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, 3th ed.
DALIMAN.DM19
Hipertensi Dalam Kehamilan (HDK)
HTN
1. Hipertensi (HTN) +, +
2. Hipertensi (HTN) -, G&T HTN
3. Proteinuria (PU) +, PEB -
4. Proteinuria (PU) -, HAMIL
5. Hasil laboratorium LAB
PU +
(Lab) PEB, PEB
6. Gejala atau tanda PU-
(G&T) PEB.
DALIMAN.DM19
DEFINISI
KEHAMILAN: HIPERTENSI :
• TEKANAN DARAH ≥ 140/90 mmHg,
• SEBELUM HAMIL, • White-coat Hypertension 
diperiksa TD ≥ 140/90 mmHg,
• HAMIL ≤ 20 MGG, monitor 24 jam TD < 130/80 mmHg,
• HAMIL > 20 MGG, • Delta Hypertension  kenaikan
• PERSALINAN, MAP setelah UK 28 mgg.
• Kenaikan Tek Sistolik > 30 mmHg,
• NIFAS. Tek Diastolik > 15 mmHg.
DALIMAN.DM19
PENEGAKAN DIAGNOSIS HIPERTENSI
Tensimeter air raksa American Society of Hypertension
 Menggunakan  Sebelum dilakukan pengukuran TD,

ibu duduk tenang selam 15 menit,
tensimeter air
 Pengukuran pada posisi DUDUK
raksa, atau atau TERLENTANG, posisi lateral
kiri, kepala ditinggikan 30º, posisi
 Tensimeter jarum atau manset setingkat dengan jantung,
otomatis yang sudah dan tekanan DIASTOLIK diukur
dengan mendengar bunyi
divalidasi. Pengukuran
Korotkoff V (hilang bunyi). Pada
tekanan darah (TD) wanita dengan hipertensi kronik
menggunakan alat otomatis pengukuran dilakukan pada kedua
sering memberikan hasil yang lengan, dengan menggunakan hasil
lebih rendah. pemeriksaan yang tertinggi.
DALIMAN.DM19
DELTA HIPERTENSI
Cunningham et.al, 2018.

Williams Obstetrics, 25 ed
DALIMAN.DM19
DEFINISI
Proteinuria + (posistif): Lab Preklamsia Berat
 ≥ 300 mg/ 24 jam (PEB):
urine tampung, • Trombositopenia ( <
100.000/ µL),
 Rasio creatinin/
• Konsentrasi Creatinin serum
protein urine, 1 x > 1,1 mg/ dL (2 x nilai
pemeriksaan, > 0,3 NORMAL, tanpa penyakit
mg/ dL, ginjal lain),
 Kualitatif dipstik 1+ (30 • SGOT/ PT > 2 x NILAI ATAS
mg/ dL) NORMAL.
DALIMAN.DM19
DEFINISI
Gejala dan tanda PEB:
1. Muncul gangguan baru
cerebral atau visual,
2. Edema paru atau SIANOSIS
3. Nyeri menetap epigastrik
atau kuadran kanan atas
yang tidak respon terapi
dan tidak ada alternatif
diagnosis.
Creasy & Resnik’s, 2019. Maternal-Fetal Medicine: Principles and Practice, 8th ed.
DALIMAN.DM19
DIAGNOSIS HDK
1. HTN + PU (-)(LAB PEB -, G&T PEB -) +
UK ≥ 20  HIPERTENSI GESTASIONAL
HIPERTENSI
2. HTN + PU (-) (LAB PEB -, G&T PEB -) +
≥ 140/90
UK < 20  HIPERTENSI KRONIK
1
3. HTN + PU (+)/(-) (LAB PEB +, G&T PEB
LAB & PROTEIN +) + UK ≥ 20  SINDROMA
GEJALA URIA
-TANDA POSITIF PREEKLAMSIA (PE)
PEB 2
4. HTN + PU (-)  PU (+)/ (-) (Kenaikan
PROTEINURIA HTN) pada UK ≥ 20  PREEKLAMSIA
NEGATIF SUPERIMPOSSED (SIPE).
2 Creasy & Resnik’s, 2019. Maternal-Fetal Medicine: Principles and Practice, 8th ed.
Cunningham et.al, 2018. Williams MedScape, Kee-Hak Lim, MD; Ronald M Ramus,
Obstetrics, 25 ed and ACOG, 2013 MD Preeclampsia Updated: Feb 16, 2018
DALIMAN.DM19
PREEKLAMSIA
HT (HIPERTENSI) :
 TEKANAN DARAH ≥
HT
PE
140/90.
 HIPERTENSI White Coats,
adalah DIPERIKSA (Dr/Per/
Bidan) ≥ 140/90, monitor 24
jam < 130/80, ≥ UK 20 mgg PROT
 DELTA HIPERTENSI 
KENAIKAN MAP PADA
+/-
TRIMESTER III
 TEKANAN SISTOLIK NAIK
30, DIATOLIK NAIK 15.
DALIMAN.DM19
Sindroma PREEKLAMSIA
 Diskripsi yang paling baik, adalah sindroma spesifik
kehamilan yang pada hakekatnya dapat mempengaruhi setiap
sistem organ.
 Dasar diagnosis- paling sederhana- adalah TEKANAN DARAH

≥ 140/90 mmHg + POSITIF PROTEINURIA ( gambaran
kerusakan endothelial-karakteristik sindroma Preeklamsia)
 Abnormal ekskresi PROTEIN, adalah 300 mg/ 24 jam, atau

rasio protein : kreatinin urine ≥ 0,3, atau persisten 30
mg/dL (1+ dipstik).
DALIMAN.DM19
Sindroma Preeklamsia
 Menurut Sibai (2009) dan ACOG
(2013b): diagnosis sindroma
Preeklamsia dapat ditegakkan TIDAK
HARUS PROTEINURIA POSITIF.
 HIPERTENSI + DISFUNGSI
MULTIORGAN, seperti trombositopenia
(< 100.000), disfungsi renal (kreatinin >
1,1 mg/dL), nekrosis hepatoseluler
(disfungsi liver)( AST dan ALT > 2 X
NORMAL), pertubasi sistema syaraf
pusat/ SSP (nyeri kepala, gangguan
penglihatan, dan KEJANG), EDEMA
PULMONUM
DALIMAN.DM19
PREEKLAMSIA BERAT
(Gabbe, et.al, 2017; Cunningham, et.al 2018; Lim KH, 2018)
Ditandai (salah satu): HIPERTENSI (baru) tanpa

proteinuria, didiagnosis PE, jika
 Tek sistolik >/= 160 mmHg, didapatkan salah satu :
atau tekanan diastolik >/= 110
mmHg.  Trombositopenia,
 Kegagalan fungsi hati,  Serum kreatinin > 1,1 mg/dl, atau
 Insufisiensi ginjal progresif, 2 kali lipat Normal,
 Gangguan serebral atau  SGOT dan SGPT 2 kali Normal,
pandangan (baru muncul),  Edema pulmonum,
 Edema pulmonum,  Gangguan serebral dan
 trombositopenia pandangan.
DALIMAN.DM19
Preeclampsia with severe features
(“severe preeclampsia”)
Preeclampsia with any one of the following criteria:
1. BP ≥160/110 mmHg (two occasions, >4 hours apart)
2. Thrombocytopenia (platelets <100,000/mm3) and/or evidence of
microangiopathic hemolytic anemia
3. Increased hepatic transaminases (AST and/or ALT) two times of the
upper limit of normal concentration for the particular laboratory
4. Progressive renal insufficiency (creatinine ≥1.1 mg/dL or a doubling
of the serum creatinine) or oliguria (<500 mL urine in 24 hours)) in
absence of other renal disease
5. Persistent headache or other cerebral or visual disturbances
(including grand mal seizures)
6. Persistent epigastric (or right upper quadrant) pain
7. Pulmonary edema or cyanosis
Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, 3rd ed
DALIMAN.DM19
Superimposed preeclampsia
One or more of the following
criteria:
1. New onset of proteinuria (≥300 mg in 24
hours without prior proteinuria) after 20
weeks in a woman with chronic HTN or
sudden increase in proteinuria in a
woman with known proteinuria before or
early in pregnancy
2. A sudden increase in
hypertension previously well
controlled or escalation of antihypertensive
medication to control BP
Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, rd

PENATALAKSANAAN PREEKLAMSIA,3 ed
DALIMAN.DM19
Superimposed preeclampsia with severe
features
Superimposed preeclampsia and one or more of the following
criteria:
1. Severe range of BP (≥160/110 mmHg) despite escalation of
antihypertensive medication
2. Platelet count < 100,000/mm3.
3. Increased hepatic transaminases (AST and/or ALT) two times the upper
limit of normal concentration at a particular laboratory
4. New onset or worsening renal insufficiency (creatinine ≥1.1
mg/dL or a doubling of the serum creatinine)
5. Pulmonary edema
6. Persistent neurological symptoms (e.g., headache, visual changes)
DALIMAN.DM19
Eclampsia
Seizures (grand mal) in the presence of
preeclampsia and/or HELLP
syndrome.
DALIMAN.DM19
Eklamsia 15% ?
SEKITAR 15% KASUS,
TANPA HIPERTENSI
DAN PROTEINURIA
85%
SEBELUM EKLAMSIA, ?
LEBIH DARI 50%
KASUS TERJADI PADA
KASUS YANG TIDAK
DIDIAGNOSIS PRE-
HT PE PEB Ekl
EKLAMSIA, TETAPI
HANYA PENYAKIT
RINGAN, PRETERM, ?
DAN TANPA DAPAT
DICEGAH. 15% (-) HT dan (-) PU
DALIMAN.DM19
EKLAMSIA ≠ 57%-58%
1. Hanya 42%-43% 42%-43%
Eklamsia didahului
dengan PE  57%-
58% tidak didahului
PE
2. 30%-50% Eklamsia
PE PEB EKL
tidak didahului
dengan PEB  25%
50%-70% didahului 50%-70%
PEB. Creasy and Resnik’s, et.al., 2019. Maternal-
th
Fetal Medicine, Principle and Practice, 8 ed. ≠30%-50%
MedScape, Kee-Hak Lim, MD; Ronald M
Jumat, 08 Maret 2019 SEMINAR POLTEKES, 09 MARET 2019,Ramus, MD Preeclampsia Updated: Nov 29, 2018 22
DALIMAN.DM19
HELLP syndrome
Tennessee Classification (most commonly used)
• Hemolysis as evidenced by an abnormal peripheral smear in

addition to either serum LDH >600 IU/L or total bilirubin ≥1.2
mg/dL (≥20.52 μmol/L)
• Elevated liver enzymes as evidenced by an AST or ALT two
times the upper limit of normal concentration at a particular
laboratory
• Platelets <100,000 cells/mm3.
• If all the criteria are met, the syndrome is defined “complete”; if only
one or two criteria are present, the term “partial HELLP” is preferred.

DALIMAN.DM19
PENATALAKSANAAN
PREEKLAMSIA
The basic management objectives
for any pregnancy complicated by
Preeclampsia are (Cunningham, 2018):
1. Termination of pregnancy with the least possible trauma
to mother and fetus
2. Birth of an infant who subsequently thrives
3. Complete restoration of health to the mother.
PEMBELAJARAN TERFOKUS AMP, 150517,

03/08/2019 24
DALIMAN.DM17
PENCEGAHAN PE
Terminologi umum  PRIMER, artinya menghindari
PENCEGAHAN, terjadinya PENYAKIT,
dibagi 3:  SEKUNDER, artinya
memutus proses terjadinya
PENYAKIT yang sedang
1. Pencegahan berlangsung sebelum timbul
PRIMER, GEJALA atau KEDARURATAN
KLINIS,
2. Pencegahan
 TERSIER, berarti
SEKUNDER, pencegahan dari KOMPLIKASI
yang disesbabkan oleh proses
3. Pencegahan PENYAKIT TATALAKSANA
TERSIER.
PNPK PREEKLMASIA, HKFM POGI
DALIMAN.DM19
PENCEGAHAN PRIMER
o Pencegahan
1. Umur > 40 th,
yang terbaik,
2. Nulipara,
namun hanya 3. Multipara dengan riwayat PE,
dapat dilakukan 4. Multipara dengan kehamilan oleh pasangan BARU
apabila (primipaternitas),
5. Multipara yang jarak kehamilan sebelumnya ≥ 7-10 th,
penyebab PE
6. Riwayat PE sebelumnya,
telah diketahui
7. Riwayat keluarga PE (IBU atau saudara perempuan),
dengan jelas. 8. Kehamilan multipel,
9. IDDM,
o Dilakukan 10. Penyakit GINJAL,
11. Penyakit GIGI,
dengan prediksi 12. APS,
dan mengontrol 13. Kehamilan dengan inseminasi dodor sperma, oosit atau embryo,
FAKTOR RISIKO 14. OBESITAS sebelum hamil,
PE 17 15. BMI ≥ 35,
16. Takanan darah DIASTOLIK ≥ 80 mmHg
17. Proteinuria (dipstick ≥+1 pada 2 kali pemeriksaan berjarak 6 jam atau
secara kuantitatif 300 mg/ 24 jam)
PNPK HKFM POGI. PREEKLAMSIA

DALIMAN.DM19
Risk factors- Preeclampsia
Risk factors for preeclampsia and their odds
ratios are as follows [2] :
1. Nulliparity (3:1)
2. Age older than 40 years (3:1)  >35 th (1,2 :1 / 1,1-1,3)
3. Black race (1.5:1)
4. Family history (5:1)
5. Chronic renal disease (20:1) Cunningham, 2018.
6. Chronic hypertension (10:1) Williams Obstetrics,
7. Antiphospholipid syndrome (10:1) 25th ed.)
8. Diabetes mellitus (2:1)
9. Twin gestation (but unaffected by zygosity) (4:1)
10. High body mass index (BMI > 30) (3:1)
11. Homozygosity for angiotensinogen gene T235 (20:1)
12. Heterozygosity for angiotensinogen gene T235 (4:1)
13. TEK SIS > 130, TEK DIASTOLIK > 80 mmHg UK < 20.
14. Interval KEHAMILAN > 7 TH, Creasy and Resnik’s, et.al., 2019. Maternal-
15. RIWAYAT PE kehamilan sebelumnya (8,4:1 / 7,1-9,9), Fetal Medicine, Principle and Practice, 8th ed.
16. Kehamilan dengan ASISSTED REPRODUCTIONS TECHNOLOGY (1,8:1).
James D., et.al., 2017. High-Risk
17. Riwayat SOLUSIO PLASENTA (2,0:1/ 1,4-2,7), LAHIR MATI (2,4:1) th
Pregnancy, Management Options. 5 ed
MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD Preeclampsia Updated: Nov 29, 2018
Gabbe et.al., 2017. Obstetrics, Normal adnd Problem Pregnancies,
PENATALAKSANAAN 7th ed.
PREEKLAMSIA,
DALIMAN.DM19
PENCEGAHAN SEKUNDER
KESIMPULAN (ASPIRIN DOSIS RENDAH)
1. Penggunaan Aspirin dosis rendah untuk
1. Istirahat, PENCEGAHAN PRIMER berhubungan dengan
penurunan risiko PE, persalinan PRETERM,
kematian janin atau neonatus dan BAYI KMK,
2. Restriksi sedangkan untuk PENCEGAHAN SEKUNDER
berhubungan dengan penurunan risiko PE,
garam, persalinan PRETEM < 37 mgg, dan BBL < 2500
gram.
3. ASPIRIN dosis 2. Efek Asprin lebih nyata didapatkan pada
KELOMPOK RISIKO TINGGI,
rendah, 3. Pemberian Aspirin dosis > 75 mg lebih baik untuk
menurunkan risiko PE, namun risiko yang
4. Suplemenatsi diakibatnya lebih tinggi.
KALSIUM, REKOMENDASI
Aspirin dosis 75 mg atau kurang cukup aman
5. Suplementasi diberikan pada KELOMPOK RISIKO TINGGI
untuk menurunkan risiko PE baik sebagai
ANTIOKSIDAN. pencegahan PRIMER atau SEKUNDER.
Level evidence Ia, Rekomendasi A
03/08/2019 28
DALIMAN.DM17
PENCEGAHAN SEKUNDER
KESIMPULAN (KALSIUM)
1. Pemberian KALSIUM (1,5-2 gram)
1. Istirahat, berhubungan dengan penurunan HDK
dan PE pada wanita dengan ASUPAN
2. Restriksi RENDAH KALSIUM dan risiko tinggi PE,
garam, 2. Pemberian Kalsium juga berhubungan
dengan penurunan risiko MORBIDITAS
3. ASPIRIN dosis BERAT dan MORTALITAS MATERNAL,
persalinan PRETERM, dan tekanan
rendah, darah diastolik > persentil 95 pada
masa kanak.
4. Suplemenatsi
KALSIUM, REKOMENDASI
Pemberian KALSIUM dapat dilakukan pada
5. Suplementasi WANITA yang MEMILIKI RISKO TINGGI
PE dan RENDAH ASUPAN KALSIUM
ANTIOKSIDAN. untuk mencegah terjadinya PE.
DALIMAN.DM19
TOG release: Low dose aspirin and calcium
supplementation for prevention of pre-eclampsia
• Low dose aspirin started before 16 weeks
gestation and calcium supplementation after 20
weeks gestation in low-intake populations can
prevent the onset of pre-eclampsia in pregnancies at
risk of the condition, states a new review published
today in The Obstetrician & Gynaecologist (TOG). It
is also possible to assess a woman’s risk of
developing pre-eclampsia from as early as 11 weeks
of pregnancy, say the authors.
18 July 2014
03/08/2019 30
DALIMAN.DM17
PENCEGAHAN SEKUNDER
Rekomendasi : Rekomendasi :
• Istirahat di rumah ( 4jm/ hr atau
• Pembatasan garam
2 x 15 menit + suplemen) untuk mencegah PE dan
direkomendasikan untuk komplikasinya selama
pencegahan primer PE,
kehamilan TIDAK
• Tirah baring TIDAK direkomendasikan.
direkomendasikan untuk
memperbaiki luaran pada wanita
dengan hipertensi (dengan atau Level evidence Ia, Rekomendasi A
tanpa proteinuria)

DALIMAN.DM19
Clinical Risk Assessment for
Preeclampsia
Risk Level Risk Factors Recommendation
History of preeclampsia, especially when Recommend low-dose

High accompanied by an adverse outcome, Multifetal
aspirin if the patient
gestation, Chronic hypertension, Type 1 or 2 has ≥1 of these

diabetes, Renal disease, Autoimmune disease high-risk factors
(systemic lupus erythematous, antiphospholipid

syndrome)
Moderate Nulliparity, Obesity (body mass index >30 kg/m2), Family history of Consider low-dose
preeclampsia (mother or sister), Sociodemographic characteristics aspirin if the patient
(African American race, low socioeconomic status), Age ≥35 years has several of
Personal history factors (e.g., low birthweight or small for these moderate-risk
gestational age, previous adverse pregnancy outcome, >10-year factors.
pregnancy interval)
Do not recommend
Low Previous uncomplicated full-term delivery low-dose aspirin
Timing Use of low-dose aspirin was initiated between 12 and 28 weeks of gestation. Evidence did not suggest additional benefit when
use of aspirin was started earlier (12 to 16 weeks) rather than later (≥16 weeks) in pregnancy in women at increased risk for
preeclampsia 1.
DALIMAN.DM19
Penanganan MedScape, Kee-Hak Lim, MD; Ronald
M Ramus, MD Preeclampsia Updated:
Nov 29, 2018
 Hanya persalinan obat  Pasien dengan PEB

preeklamsia. induksi persalinan
 Pasien dengan PE tidak berat seharusnya dilakukan
perlu induksi setelah umur setelah umur
kehamilan 37 mgg. kehamilan 34 mgg.
 Sebelumnya pasien biasanya diawasi  Dalam kasus ini, memberatnya
dengan ketat atau dirawat untuk penyakit dipertimbangkan
perkembangan, perburukan atau dengan risiko prematuritas
komplikasi PE, dan imaturitas janin janin.
ditangani ekspektatif dengan
pemberian kortikosteroid guna  Dalam kondisi darurat kontrol
memacu pematangan paru janin untuk TD dan kejang harus
persiapan persalinan prematur. diprioritaskan.
DALIMAN.DM19
MgSO4 MgSO4 ADALAH OBAT
PILIHAN UNTUK PENCEGAHAN
EKLAMSIA, MENURUNKAN 59%
RISIKO EKLAMSIA, 36%
 DOSIS AWAL 4- 6 gram
iv BOLUS, DILANJUTKAN SOLUSIO PLASENTA, 46%
(STATISTIK TIDAK SIGNIFIKAN)
DENGAN DRIPS 1-2 KEMATIAN MATERNAL.
gram/ JAM.
 SYARAT PEMBERIAN MgSO4 ADALAH
REFLEKS PATELLA +, URINE OUTPUT >30
 PEMBERIAN ULANG iv 2 CC/JAM, DAN REPIRASI > 16 KALI/MENIT,
gr (BB≤ 70 kg), ATAU 4 SERTA TERSEDIA ANTIDOTUMNYA YAITU
Ca Gluconas.
gr (BB> 70 kg), MINIMAL
3-5/ 5-10 MENIT  TOKSISITAS MgSO4 BERUPA
KEMUDIAN (JARANG), HILANGNYA REFLEKS PATELLA,
DEPRESI RESPIRASI, PERUBAHAN
 JIKA PERLU DAPAT DIBERIKAN KONDISI JANTUNG, CARDIAC
Na-AMOBARBITAL 250 mg IV ARREST.
MINIMAL 3-5 MENIT
DALIMAN.DM19
REKOMENDASI PNPK-Preeklamsia
1. Pemberian MgSO4 pada PEB
berguna untuk mencegah terjadinya
kejang eklamsia atau kejang berulang.
2. Rute administrasi MgSO4 yang
dianjurkan adalah IV untuk
mengurangi nyeri pada lokasi sutikan.
3. MgSO4 merupakan pilihan utama
pada pasien PEB dibandingkan
diazepam atau fenitoin, untuk
mencegah terjadinya kejang/ eklamsia
atau kejang berulang.
DALIMAN.DM19
ALTERNATIF OBAT ANTIHIPERTENSI, ADALAH :
OBAT
ANTIHIPERTENSI 1. Labetalol 20 mg iv bolus, dilanjutkan
40 mg, 80 mg, 80 mg jika diperlukan,
setiap 10 menit dengan dosis
DIBERIKAN APABILA
maksimal total 220 mg.
TEKANAN SISTOLIK
≥160 DAN ATAU TEKANAN 2.Nifedipin 10-20 mg po, diulang
DIASTOLIK ≥110 tiap 30 menit (bisa sampai 8 x per 24 jam)
(NHBPEP-WG,2000; RCOG,2006: dalam Cunningham 2014).
3. Hydralazine 5-10 mg iv/ im, tiap 20

menit, dosis maksimal 30 mg.
4. Sodium nitroprusside dimulai 0,25
ug/kg/min sampai dosis maksimal 5
ug/kg/min (second line).
Cunningham,PREEKLAMSIA,
PENATALAKSANAAN 2018. Williams Obstetrics, 25th ed.)
DALIMAN.DM19
Sample Order Set for Severe Intrapartum or Postpartum Hypertension
Initial First-line Management With Immediate-Release Oral Nifedipine*
Notify physician if systolic blood pressure (BP) is greater than or equal to 160 mm Hg or if
diastolic BP is greater than or equal to 110 mm Hg.
 Institute fetal surveillance if undelivered and fetus is viable.

1. If severe BP elevations persist for 15 minutes or more, administer nifedipine (10 mg
orally).
2. Repeat BP measurement in 20 minutes and record results. If either BP threshold is still
exceeded, administer nifedipine capsules (20 mg orally).
3. If BP is below thresh-old, continue to monitor BP closely. Repeat BP measurement in 20
minutes and record results. If either BP threshold is still exceeded, administer nifedipine
capsule (20 mg orally).
4. If BP is below thresh-old, continue to monitor BP closely. Repeat BP measurement in 20
minutes and record results. If either BP threshold is still exceeded, administer labetalol
(40 mg intravenously over 2 minutes) and obtain Give additional antihypertensive
medication per specific order.
 Once the aforementioned BP thresholds are achieved, repeat BP measurement every 10 minutes for 1 hour,
then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every hour for 4 hours.
Institute additional BP timing per specific order.
ACOG, 2017. COMMITTEE OPINION
DALIMAN.DM19
TERAPI HIPERTENSI KRONIK
1. PERUBAHAN GAYA HIDUP BERUPA DIET KAYA BUAH,
SAYUR, RENDAH LEMAK, MENGURANGI SATURASI DAN
TOTAL LEMAK, (MENGURANGI MASUKAN GARAM SAMPAI < 2,4 gram/
HARI  TIDAK DIANJURLKAN LAGI).
2. BEDREST DI RS DIHUBUNGKAN PENGURANGAN 42%
HIPERTENSI BERAT, 47% PERSALINAN PRETERM.
3. OBAT ANTIHIPERTENSI – METHYLDOPA, LABETALOL,
BETABLOKER, NIFEDIPIN, DIURETIK.
4. ACE-INHIBITOR KONTRAINDIKASI DIBERIKAN PADA TRIMESTER PERTAMA,
DIHUBUNGKAN DENGAN PENINGKATAN 2 KALI TERJADINYA MALFORMASI, DAN
JANGKA PANJANG IUGR, OLIGOHIDRAMNION, GAGAL GINJAL DAN KEMATIAN
NEONATUS.
DALIMAN.DM19
MANAJEMEN CAIRAN pada
PEB
• Hindari pemberian TOTAL CAIRAN secara
diuretik. umum seharusnya dibatasi
• Resusitasi volume cairan TIDAK LEBIH dari
yang agresif penyebab
utama untuk EDEMA
PULMONUM. 1. 80 mL/jam, atau
• Sedapat mungkin pasien harus
RESTRIKSI CAIRAN, minimal
2. 1 mL/kg/jam, atau
sampai periode DIURESIS
POSTPARTUM.
3. (60-125 ml/jam)
Cunningham,
PENATALAKSANAAN PREEKLAMSIA,2018. Williams Obstetrics, 25th ed.)
DALIMAN.DM19
Postpartum management
 Many patients will have a brief (up  If a patient is discharged with BP
medication, reassessment and a BP
to 6 hours) period of check should be performed, at the
oliguria following delivery latest, 1 week after discharge
 Unless a woman has undiagnosed
Magnesium sulfate seizure chronic hypertension, in most cases
prophylaxis is continued for 24 of preeclampsia, the BP returns to
hours postpartum baseline by 12 weeks’ postpartum
 Liver function tests and platelet counts  Patients should be carefully monitored
must document decreasing values for recurrent preeclampsia,
prior to hospital discharge
which may develop up to 4 weeks
 Elevated BP may be controlled
postpartum, and for eclampsia
with nifedipine or labetalol that has occurred up to 6 weeks
postpartum after delivery
DALIMAN.DM19
Offer women with pre-eclampsia who have
given birth transfer to community care if
all of the following criteria have been met:
 there are no symptoms of pre-eclampsia

 blood pressure, with or without
treatment, is 149/99 mmHg or lower
 blood test results are stable or improving.
DALIMAN.DM19
KOMPLIKASI PRE-EKLAMSIA
 IBU, BERUPA HELLP SYNDROME (20%), DIC (10%), EDEMA
PULMONUM (2-5%)( ok. Permeabilitas kapiler,
cardiogenic atau kombinasi keduanya, disamping
penurunan tekanan ONKOTIK ok. hipoALBUMIN),
SOLUSIO PLASENTA (1-4%), GAGAL GINJAL (1-2%), KEJANG
EKLAMSIA (<1%), PERDARAHAN SEREBRAL (<1%), PERDARAHAN
HEPAR (<1%) DAN KEMATIAN (JARANG).
 BAYI, BERUPA PERSALINAN PRETERM (15-60%), IUGR (10-25%),

KEMATIAN PERINATAL (1-2%), TRAUMA HIPOKSEMIA-
NEROLOGIK (<1%), MORBIDITAS KARDIOVASKULER JANGKA
PANJANG (TIDAK DIKETAHUI)
Cunningham, 2018. Williams Obstetrics, 25th ed.) Berghella V., 2017. Maternal-Fetal Eviddence Based Guidelines, 3 th ed.
DALIMAN.DM19
KOMPLIKASI EKLAMSIA
 KEMATIAN MATERNAL (1-2%) DI NEGARA
MAJU, LEBIH DARI (10%) DI NEGARA BERKEMBANG.
 KEMATIAN PERINATAL (6-12%) DI NEGARA

MAJU, LEBIH DARI (25%) DI NEGARA BERKEMBANG.
 SOLUSIO PLASENTA (7-10%), DIC (7-11%), HELLP

(10-15%), EDEMA PULMONUM (3-5%), GAGAL GINJAL
(5-9%), PNEUMONIA ASPIRASI (2-3%),
CARDIOPULMONARY ARREST (2-5%), PERSALINAN
PRETERM (50%).
DALIMAN.DM19
MORBIDITAS DAN MORTALITAS
JANGKA PANJANG PENDERITA
PREEKLAMSIA, TERNYATA
MENINGKAT SECARA
BERMAKNA DIBANDINGKAN
BUKAN PENDERITA
PREEKLAMSIA, TERHADAP
KEJADIAN HIPERTENSI,
IHD, STROKE, DAN
PENYEBAB LAIN
KEMATIAN.
Long-term cardiovascular consequences of
preeclampsia. All differences p ≤.001 except p =
0.03 for all-cause mortality. (Data from Bellamy and
colleagues, 2007.)
DALIMAN.DM19
Acute Treatment of Severe Hypertension in
Pregnancy
In the setting of severe The goal of hypertension
hypertension (SBP >160 treatment is to lower BP
mm Hg  93% STROKE H; to prevent
DBP >110 mm Hg  20% cerebrovascular and
STROKE H), cardiac complications
antihypertensive while maintaining
treatment is uteroplacental blood
recommended. flow (ie, maintain BP
around 140/90 mm
Cunningham, 2018. Williams Hg).
Obstetrics, 25th ed.)
DALIMAN.DM19
ANTIHYPERTENSIVE and PE
Antihypertensive treatment decreases the
incidence of cerebrovascular problems, is dose
not alter the progression of PREECLAMPSIA.
CONTROL of MILDLY increasing BP does not appear to

improve PERINATAL MORBIDITY or MORTALITY, and it
may, in fact, REDUCE BIRTH WEIGHT.
MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD Preeclampsia

Updated: Nov 29, 2018
DALIMAN.DM19
Prophylactic treatment with
magnesium sulfate
 Prophylactic treatment with magnesium sulfate is indicated for
all patients with severe preeclampsia. However,
no consensus exists as to whether patients with mild
preeclampsia need magnesium seizure prophylaxis.
 Although ACOG recommends magnesium sulfate in

severe preeclampsia, it has not recommended this
therapy in all cases of mild preeclampsia.
DALIMAN.DM19
Some Indications for Delivery
with Early-Onset Severe Preeclampsia (Cunningham, 2018):
Maternal ONE OR MORE ≤ 72 JAM

1. Persistent severe headache or visual changes; eclampsia
2. Shortness of breath; chest tightness with rales and/or SaO2 < 94
percent breathing room air; pulmonary edema
3. Uncontrolled severe hypertension despite treatment
4. Oliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dL
5. Persistent platelet counts < 100,000/L,
6. AST or ALT > 2 x upper limit of normal with RUQ or epigastric pain,
7. Suspected abruption, progressive labor, and/or ruptured
membranes,
Foley MR, et., 2018. Obstetric AFI = amnionic fluid index; EGA = estimated gestational age;
Intensive Care Manual. 5th ed. SaO2 = oxygen saturation.
From Sibai and Barton (2007).
DALIMAN.DM19
Fetal ONE OR MORE
≤ 72 JAM
1. Severe growth restriction—< 5th percentile for
EGA
2. Persistent severe oligohydramnios —AFI < 5 cm/
DVP < 2 cm.
3. Biophysical profile 4 done 4-6 hr apart
4. Reversed end-diastolic umbilical artery flow
5. Repetitive late or severe variable heart rate
deceleration,
MedScape, Kee-Hak Lim, MD; Ronald M Ramus,
6. Fetal death MD Preeclampsia 2018
Updated: Nov 29,
Foley MR, et., 2018. Obstetric Intensive Care Manual. 5th ed

DALIMAN.DM19
Penyebab EDEMA PULMONUM
1.CARDIAC (HIGH PRESSURES)  Cardiac dysfunction,
Pulmonary venous dysfunction, Pulmonary Embolism, Airway
Obstruction, Preeclampsia, Miscelaneous,  (decreased Left
Ventricular contractility, Mitral stenosis, Mitral regurgitation, INTRAVASCULAR
VOLUME OVERLOAD, dysrithmias), (Venous occlusive disease, Neurogenic
pulmonary vasoconstriction), (Amniotic fluid, thrombus, fat, air), (edema, astma,
foreign body), (Pulmonary hypertension), (Pneumothorax, tumor, one lung
anesthesia (down lung syndrome)).
2.NONCARDIOGENIC (PERMEABILITY)  Adult
Respiratory Disterss Syndrome (ARDS), Aspiration Syndrome,
Pulmonary Embolism, Abruptio Placentae, Dead Fetus
Syndrome, Sepsis.
Foley MR, et., 2018. Obstetric Intensive Care Manual. 5th ed
DALIMAN.DM19
EDEMA PULMONUM
DIAGNOSIS, FAKTOR PREDISPOSISI, MANAJEMEN,
TERAPI FARMAKOLOGI, MONITOR.
DIAGNOSIS  PROGRESIF nafas pendek, desaturasi, takhipnea,
kadang HIPERTENSI, bilateral RBBH, S3 Gallops (tidak selalu).
FAKTOR PREDISPOSIS  KELEBIHAN CAIRAN (fluid overload), PE, terapi
TOKOLITIK, HT tak terkontrol.
MANAJEMEN  posisi semi-Fowler, kepala dan dada ditinggikan, O2 10 L/m
sungkup (facemask) atau CPAP, puls oxymetri kontinyu dan monitor
cardiac, PEMBATASAN CAIRAN (30-50 ml/jam), kontrol faktor predisposisi.
Terapi farmakologi  MORFIN sulfat : 3-5 mg IV, FUROSEMID : 20-40 mg iv
dapat diulang – maksimal dosis 120 mg/jam-pelan untuk menghindari
INTOKSIKASI, NITROGLYCERIN 2 in of paste to chest atau 1 pill (1/150) IV,
HYDRALAZINE : 5-10 mg IV  HT BERAT.
Foley MR, et., 2018.
PENATALAKSANAAN Obstetric Intensive Care Manual. 5TH ed.
PREEKLAMSIA,
DALIMAN.DM19
ABSTRACT: Patient care
emergencies may occur at any
Preparing for Clinical Emergencies
time in any setting, particularly in Obstetrics and Gynecology
the inpatient setting. It is
important that obstetrician– Examples of Tools for Managing Clinical
gynecologists prepare themselves
by assessing potential Emergencies
emergencies, establishing 1. Availability of appropriate emergency
early warning systems, supplies in a resuscitation cart (crash cart) or
designating specialized first
kit
responders, conducting
emergency drills, and 2. Development of a rapid response team
debriefing staff after actual 3. Development of protocols that include
events to identify strengths clinical triggers
and opportunities for
4. Use of standardized communication tools for
improvement. Having such
systems in place may reduce or huddles and briefs (eg, SBAR)
prevent the severity of medical 5. Implementation of emergency drills and
emergencies. simulations
ACOG COMMITTEE OPINION Number 590, Abbreviation: SBAR, Situation–Background–Assessment–
March 2014 (Replaces Committee Opinion
Number 487, April 2011) (Reaffirmed 2018) Recommendation.
DALIMAN.DM19
Wassalamu’alaikum
warahmatullahi wabarakaatuh
DALIMAN.DM19
CURICULUM VITAE (CV)
• Nama : DALIMAN, dr.Sp.OG(K)FM.
• T/ TL : Klaten, 3 Februari 1956.
• Alamat : Jl. Dr. Angka, 28. PURWOKERTO.
• Email : dalridaliman@yahoo.com
• Pendidikan :
 SD – SMA ,tamat 1974, Wonosobo.
 Dokter, FK UGM Angkatan 1975, tamat 1981.
 Spesialis Obgin, Sp.OG, FK UGM 1989, tamat 1993.
 Konsultan Fetomaternal, (K)FM, FK UGM 2009, tamat 2011.
• Pekerjaan :
 Kepala Puskesmas Nanga Sepauk, Sintang, Kalbar (1982-1987)
 Direktur RSUD Sintang, Kalbar (1987-1989).
 Tenaga Medis Fungsional, Sp.OG, RSUD Sintang, Kalbar (1994-1998).
 Wakil Direktur RSUD Margono Soekarjo (2000-2008).
 Wakil Dekan FK Unsoed (2001-2004)
 Dokter Pendidik Klinis RSUD Margogono Soekarjo/ FKIK Unsoed (2009-
SEKARAG).
DALIMAN.DM19

Materi Dr. Daliman

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PENATALAKSANAAN

KEHAMILAN (HDK)  PROPORSI 3 PENYEBAB

Klasifikasi (ACOG Tak Force for Klasifikasi :

Tensimeter air raksa American Society of Hypertension

 Menggunakan  Sebelum dilakukan pengukuran TD,

Cunningham et.al, 2018.

 Dasar diagnosis- paling sederhana- adalah TEKANAN DARAH

 Abnormal ekskresi PROTEIN, adalah 300 mg/ 24 jam, atau

Ditandai (salah satu): HIPERTENSI (baru) tanpa

Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, rd

• Hemolysis as evidenced by an abnormal peripheral smear in

Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, 3rd ed

PEMBELAJARAN TERFOKUS AMP, 150517,

PNPK HKFM POGI. PREEKLAMSIA

Level evidence Ia, Rekomendasi A

History of preeclampsia, especially when Recommend low-dose

gestation, Chronic hypertension, Type 1 or 2 has ≥1 of these

(systemic lupus erythematous, antiphospholipid

 Hanya persalinan obat  Pasien dengan PEB

3. Hydralazine 5-10 mg iv/ im, tiap 20

 Institute fetal surveillance if undelivered and fetus is viable.

 there are no symptoms of pre-eclampsia

 BAYI, BERUPA PERSALINAN PRETERM (15-60%), IUGR (10-25%),

 KEMATIAN PERINATAL (6-12%) DI NEGARA

 SOLUSIO PLASENTA (7-10%), DIC (7-11%), HELLP

CONTROL of MILDLY increasing BP does not appear to

MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD Preeclampsia

 Although ACOG recommends magnesium sulfate in

Maternal ONE OR MORE ≤ 72 JAM

Foley MR, et., 2018. Obstetric Intensive Care Manual. 5th ed

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