Tatalaksana DM &

Hipertensi dalam
Kehamilan
Isharyah Sunarno
01
DM dalam
Kehamilan
Standar Pendidikan Profesi
Dokter Indonesia 2019
 diabetes

intoleransi karbohidrat è
pertama kali ditemukan segera setelah
kehamilannya
pada kehamilan

5-10% DMG
Penyakit Endokrin

Perubahan metabolisme
Hiperglikemia kronis v Karbohidrat
v Lemak
v Protein
 Klasifikasi

Proposed Classification System for Diabetes in Pregnancy

(American Diabetes Association, 2012)
Gestational diabetes: diabetes diagnosed during pregnancy that is not clearly
overt (type1 or type 2) diabetes
Type 1 Diabetes Type 2 Diabetes
Diabetes resulting from β-cell Diabetes from inadequate insulin
destruction, usually leading to absolute secretion in the face of increased
insulin deficiency insulin resistance
a.Without vascular complications a.Without vascular complications
b.With vascular complications (specify b.With vascular complications (specify
which) which)
Other types of diabetes: genetic in origin, associated with pancreatic disease,
drug-induced, or chemically induced
 Diabetes Mellitus Gestasional

Dalam kehamilan Risiko

Perubahan endokrin – metabolik Dipicu kehamilan è hormon
dibutuhkan untuk jamin asupan energi
& nutrisi ke janin

Fisiologis Outcome
Perubahan metabolisme glukosa Intoleransi glukosa
 Hormon diabetogenik
Hormon
pertumbuhan

Corticotropin
releasing hormone
Placental
lactogen
DM
Gestasional Progesteron
fungsi p
ankreas
tidak ad
ekuat
Resistensi
insulin
 Promosi Kesehatan & Pencegahan

Komplikasi ibu Komplikasi Janin Komplikasi Neonatal

§ Preeklampsia § Abortus spontan § Respiratory distres
§ Nefropati diabetes § Persalinan preterm syndrome (RDS)
§ Retinopti diabetes § Kelainan bawaan § Hipoglikemia
§ Neuropati diabetes lahir § Hipokalsemia
§ Diabetes § Makrosomia § Polisitemia
ketoasidosis § Trauma persalinan § Hiperbilirubinemia
§ Infeksi § Kematian janin § Kardiomiopati
§ Seksio sesarea § Hidramnion § Gangguan kognitif jangka
§ DM tipe 2 di panjang
kemudian hari § DM
 Usia
Penapisan (skrining)
24 minggu
kehamilan

28 minggu

Intoleransi
glukosa pada
kehamilan
dini tidak
diketahui
Penyakit Endokrin

single-step approach two-step approach

puasa 12 puasa 12
jam jam

50 gram
75 gram glukosa
glukosa
100 gram
glukosa
 Diagnosis

Nilai ambang Diabetes Gestasional (International

Association of Diabetes and Pregnancy Study Group
Consensus Panel, 2010) Pelayanan Kesehatan Ibu di Fasilitas
Kesehatan Dasar dan Rujukan (2013)
Nilai ambang konsentrasi glukosa
Glukosa plasma Kadar gula darah puasa > 92 mg/dL, ATAU
mmol/L mg/dL
Kadar gula darah setelah 1 jam > 180 mg/dL,
Puasa 5,1 92 ATAU
1 jam TTGO 10,0 180
Kadar gula darah setelah 2 jam > 153 mg/dL
2 jam TTGO 8,5 153
 Tatalaksana
Tatalaksana terpadu :
spesialis penyakit dalam,
spesialis obstetri dan
ginekologi, ahli gizi,
spesialis anak.

Rujuk ibu ke
rumah sakit

Jelaskan : tatalaksana
DMG adekuat è
komplikasi ↓
 Pema
ntauan
ICU janin

NICU

Rujukan
Tindaklanjut Sesudah Kembali dari
Rujukan

ga
i

ber ntrol
ens

hra
an
bad at
ur
48%

Ko

Ola
rek

Perubahan pola hidup

 Take Home Messages

Skrining &
Pencegahan

Diagnosis
02
Hipertensi
dalam
Kehamilan
Standar Pendidikan Profesi
Dokter Indonesia 2019
ISSHP Classification of the Hypertensive
Disorders of Pregnancy

Hypertension. 2018;72:24-43
Hipertensi UK < 20 mgg
Chronic White-coat Masked
hypertension hypertension hypertension
• Tightly controlling • Elevated • BP normal at office
maternal blood office/clinic visit
pressure (BP, 110– (≥140/90 mmHg) BP • Elevated at other
140/85 mmHg) • Normal BP times: 24-hour
• Monitoring fetal measured at home ambulatory BP
growth or work (<135/85 monitoring (ABPM)
• Repeatedly mmHg) / automated home
assessing for • Not an entirely BP monitoring.
development of benign condition
preeclampsia & • Increased risk for
maternal preeclampsia.
complications
• Outpatient setting
Hipertensi UK ≥ 20 mgg
Transient • Arises in 2nd / 3rd trimester.
• Usually detected in the clinic but then settles with repeated BP readings
gestational • Associated with 40% risk of developing true gestational hypertension or
preeclampsia

hypertension • Resolves without treatment during the pregnancy

• Absence of proteinuria
Gestational • Without biochemical or hematological abnormalities.
• Usually not accompanied by fetal growth restriction.
hypertension • Outcomes normally good
• Present at <34 weeks è preeclampsia

Preeclampsia • Can deteriorate rapidly & without warning

• We do not recommend classifying it as mild or severe.
Pengukuran Tekanan Darah

● PNPK, 2016
Diagnosis Hypertensi dalam
Kehamilan
Kriteria Diagnosis
Preeklampsia

● PNPK, 2016
 Kriteria Diagnosis
Preeklampsia Berat

● PNPK, 2016
 Penentuan Proteinuria
● Proteinuria
○ Not mandatory for diagnosis of preeclampsia
○ Diagnosed: de novo hypertension > 20 weeks’ gestation + proteinuria and/or
evidence of acute kidney injury, liver dysfunction, neurological features,
hemolysis or thrombocytopenia, or fetal growth restriction.
● Proteinuria è
Automated dipstick urinalysis è positive è urine protein/creatinine ratio
≥30 mg/mmol (0.3 mg/mg) è abnormal
 Penentuan Proteinuria

PNPK, 2016
 Pencegahan Preeklampsia
ISSHP, 2018 PNPK, 2016
Pencegahan Sekunder Preeklampsia
Tidak direkomendasikan:
1. Istirahat di rumah
2. Tirah baring
3. Pembatasan garam Rekomendasi:
4. Vitamin C dan E 1. Aspirin dosis rendah (75 mg/hari)
2. Aspirin dosis rendah mulai sebelum usia kehamilan 20 minggu
3. Suplementasi kalsium minnimal 1 g/hari
4. Aspirin dosis rendah + Kalsium è risiko tinggi
Pemantauan Tekanan
Darah secara Mandiri
ISSHP, 2018
Manajemen Ekspektatif
Preeklampsia tanpa
Gejala Berat
PNPK, 2016
Manajemen Ekspektatif
Preeklampsia Berat
PNPK, 2016
 Tatalaksana
Preeklampsia Berat
ISSHP, 2018
Penggunaan MgSO4
ISSHP, 2018
Penggunaan MgSO4 ● PNPK, 2016
Antihipertensi pada
Preeklampsia Berat

● PNPK, 2016
 IA
PS
A M
K L
E
9
11
12
 25

Impending of eclampsia

•Hypertension
•‘Severe sign” (lab, iugr, adverse sign)
•sign of impending of eclampsia
•Visual and cerebral disturbances, Epigastric or
right upper quadrant pain
 Skrining

Penanda
Biofisik
Riwayat Penanda
medis Biokimia
Sel Bebas
DNA
• PlGF
• PAPP-A
• Placental Protein 13 (PP13) MAHAL
• Cystatin C
• sVEFG-1
 HIPERTENSI DALAM KEHAMILAN

HIPERTENSI PREEKLAMPSIA EKLAMPSIA

BIDAN inf RL
PREEKLAMPSIA PREEKLAMPSIA 1.
Dirujuk ke
puskesmas BERAT 2. MgSO4
untuk 3. Oksigen
konsultasi
1. Istirahat 1. inf RL/RD5% 4. Dirujuk
baring ke RS
2. MgSO4
2. Dirujuk ke
puskesmas 3. Dirujuk ke
RS
PUSKESMAS

1. Evaluasi
2. Berobat jalan
/ dirujuk ke RS

Rawat Rawat
RS

konserv./ aktif konserv./aktif Rawat aktif

 Monitoring
Maternal Janin

Tanda vital / jam Denyut jantung janin

Refleks tendon dalam kontinyu menggunakan
Urine output
kardiotokografi

• Laju pernafasan < 12x/menit

Hentikan • TD sistolik turun >15 mmHg dari
nilai normal
MgSO4 jika :
• Refleks tendon tidak ada
• Urine Output <100 ml / 4 jam
MANAJEMEN EMERGENSI
EKLAMPSIA

illustrated by : Andina
Rialdi

41
Penatalaksanaan Emergensi Eklampsia - Preeklampsia

• Airway (sembari miringkan ibu 15-30°)

• Breathing => pasang O2
• Circulation: ukur tekanan darah, infus
• Control
– Kejang (MGSO4)
– Tekanan darah (antihipertensi)
• Continuous Monitoring: Balans Cairan, pasang
kateter, pemeriksaan penunjang.
• Deliver: LAHIRKAN BAYI
• CEGAH KEJANG BERULANG DAN KOMPLIKASINYA

Multisitem
v Hemolysis (H)
v Elevated liver enzym (EL)
v Low platelet count (LP)
LP
Decrease of platelet count
< 100.000/mm3
HELLP Syndrome
Hemolisis EL
v Peripheral blood smear Aminotransferase serum ≥ 70
v Indirect bilirubin increase IU/L
≥1,2 mg/dl
v lactate dehydrogenase ≥
600 UL
Number of abnormality Platelet count
v Partial: 1 or 2 abnormality v Class I < 50.000 /mm3
v Full / complete: 3 (all v Class II 50.000/mm3 –
laboratory criterias) 100.000/mm3
v Class III 100.000/mm3 –
150.000/mm3
Dosis dan cara pemberian MgSO4
• Loading dose : 4 g MgSO4 40% dalam 100 cc NaCL :
habis dalam 30 menit (73 tts / menit)
• Maintenance dose : 6 gr MgSO4 40% dalam 500 cc
Ringer Laktat selama 6 jam : (28 tts/menit)
• Awasi : volume urine, frekuensi nafas, dan reflex
patella setiap jam
• Pastikan tidak ada tanda-tanda intoksikasi
magnesium pada setiap pemberian MgSO4
ulangan
• Bila ada kejang ulangan : berikan 2g MgSO4 40%, IV
 Take Home Messages

Diagnosis

Skrining & Pencegahan

Tatalaksana Awal
Terima
Kasih
CREDITS: This presentation template was
created by Slidesgo, and includes icons by
Flaticon and infographics & images by Freepik

Please keep this slide for attribution