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Preeclampsia
Darrell Fernando
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Introduction

Preeclampsia is much more than hypertension and

protein- uria complicating pregnancy it is a syndrome
affecting virtually every organ system.
Some organ systems are predominantly affected more than
others

Early preeclampsia (onset <34 weeks) is associated

with greater morbidity than late-onset preeclampsia.
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Risk Factors
for PE
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+ Risk Factors for PE
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Pathophysiology of PE
Cytotrophoblast
invasion of the uterus
is shallow, and
endovascular invasion
does not proceed
beyond the terminal
portions of the spiral
arterioles.
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Normal Trophoblastic Invasion
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Abnormal Trophoblastic Invasion in
PE
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Immunology of PE
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Immunology of Trophoblastic Cells
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Immunology of PE: Two Stage Model
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Role of
Seminal
Exposure
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Immunology of PE
Stage 1 of PE: Inadequate Trophoblastic Invasion

Endometrium in an immune tissue.

Uterine NK cells interact with HLA expressed by

trophoblastic tissue have capacity to secrete
cytokines and angiogenic factors promote infiltration
of spiral arteries by invasive trophoblast.
Inadequate activation of uterine NK cells may lead to
inadequate invasion.

Maternal T-cells may be activated as well to fetal HLA-

C, but its role is undefined.
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Immunology of PE
Stage 2 of PE: Maternal Syndrome

Associated with inflammatory response due to

syncytiotrophoblastic stress, hypoxia, or oxidative
stress.
PIGF, sVEGFR-1, soluble endoglin

Endothelial cells mediate systemic and local

inflammatory responses by upregulation of adhesion
molecules that anchor marginated leukocytes
(granulocytes, macrophages, NK lymphocytes).

Coagulation system, liver, and adipose tissue also

contribute factors to the inflammatory response.
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Updated: 4 stages of PE
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Cerebrovascular Impact
Gross intracerebral
hemorrhage was seen in
up to 60% of eclamptic
women, but it was fatal
in only half .

Most common in the

occipital lobes and least
common in the
temporal lobes

Cerebral edema may

occur, but is frequently
reversible.
Vasogenic more
common
Cytotoxic
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Cerebral Autoregulation

Autoregulation: process by which cerebral blood flow

(CBF) remains relatively constant in the face of
alterations in cerebral perfusion pressure
Physiological protective mechanism that prevents brain
ischemia during drops in pressure and prevents capillary
damage and edema from hyperperfusion during pressure
increases

In normotensive adults, CBF is maintained at

approximately 50mL per 100g of brain tissue per
minute (mL/100g/min), provided perfusion pressure is
in the range ~60160mm Hg. Above and below
these limits, autoregulation is lost and CBF
becomes dependent on mean arterial pressure in a
linear fashion
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Autoregulation
Sudden
elevations in BP
exceed the
normal CV
autoregulatory
capacity.
Disruption of
endothelial tight
junctions (BBB)
vasogenic
edema
Regions of
vasodilatation
and
vasoconstriction
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Mechanism of Seizure

Seizures consist of excessive release of excitatory

neurotransmitters (especially glutamate), massive
depolarization of network neurons, and bursts of action
potentials.

Fluctuations in neurosteroid levels (progesterone and

its metabolites) during pregnancy result in selective
changes in the expression and function of GABA
(inhibitory receptor) receptors that cause neuronal
hyperexcitability

Preeclampsia is a state of altered neuronal GABA

receptor function as well, further making the brain
hyperexcitable
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Platelet Changes & Activation

Increased platelet activation, due to:

Extrinsic factors: endothelial damage
Intrinsic factors: alterations in platelet-binding
sites
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Platelet Changes & Activation
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The Liver in PE

Macroscopic lesions:
Periportal hemorrhage
Ischemic parenchymal
lesions
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The Liver in PE
Clinical aspects:
Symptomatic involvement, typically manifest as
moderate to severe right upper, midepigastric or
substernal pain and tenderness
Asymptomatic levation of serum hepatic
transaminase levels AST and ALT.
Hepatic hemorrhage or infarction may extend to
form a hepatic subcapsular hematoma under the
Glisson capsule that may rupture into the
peritoneal cavity.
Acute fatty liver of pregnancy
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Role of
Steroid
s
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Antihypertensive Agents
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Antihypertensive Agents
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Antihypertensive Agents
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Antihypertensive Agents
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Pengukuran tekanan darah dilakukan pada posisi duduk nyaman,

cuff pada lengan atas sejajar dengan atrium kiri, pasien tenang dan tidak
berbicara selama pemeriksaan. Pengukuran dilakukan setelah 5 menit

Proteinuria is not absolutely required for the diagnosis of preeclampsia

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Preeklampsia ringan
vs berat
ACOG 2013 tidak
merekomendasikan
pembagian ini, karena
morbiditas dan
mortalitas tetap
meningkat signifikan
pada keduanya.
Disarankan:
preeclampsia without
severe features
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Perubahan pada Kriteria ACOG 2013

Proteinuria tidak secara absolut dibutuhkan untuk

diagnosis preeklamsia.

Proteinuria masif (> 5 g) dihapuskan dari kriteria beratnya

preeklampsia, karena hubungan antara jumlah protein urin dan
luaran kehamilan sangat minimal.

Pertumbuhan janin terhambat dihapuskan dari kriteria

beratnya preeklampsia, karena tatalaksananya sama saja
pada pasien dengan atau tanpa preeklamsia.
+ Temuan yang Membutuhkan
Pengawasan Lebih
Bila diagnosis preeklamsia belum ditegakkan tetapi
ditemukan gejala/tanda berikut, diperlukan pengawasan
lebih ketat:
New-onset headache or visual disturbances
Nyeri abdomen, terutama kuadran kanan atas atau epigastrium
PJT
New-onset proteinuria pada paruh kedua masa kehamilan
Peningkatan TD sistolik > 30 mmHg atau diastolik > 15 mmHg

Edema atau peningkatan berat badan yang cepat bukan

kriteria diagnostik dan tidak sensitif maupun spesifik
untuk preeklamsia.
+Upaya Pencegahan yang
Direkomendasikan

Aspirin dosis rendah (60-80 mg / hari)

Direkomendasikan pada perempuan dengan risiko tinggi
RR 0.90 (0.84-0.97), penurunan risiko hingga 17%.
Efek samping minimal.

Kalsium (1.5-2 g / hari)

Direkomendasikan pada perempuan hamil dengan baseline
calcium intake rendah (< 600 mg/hari)
RR 0.45 (0.31-0.65) pada semua perempuan hamil.
RR 0.36 (0.20-0.65) pada perempuan hamil dengan baseline
calcium intake rendah.
+Upaya Pencegahan yang
Tidak Direkomendasikan
Suplementasi antioksidan dengan Vit C dan Vit E
Bed rest
Pembatasan asupan garam
Penggunaan diuretik
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Prinsip Tatalaksana PE

1. Safety of the woman and her fetus

2. Delivery of a mature newborn that will not require

intensive or prolonged neonatal care.
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Maternal
CBC, liver enzyme, creatinine
at least once weekly

Fetal
Daily kick count
USG every 3 weeks
AFI once weekly
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TERIMA KASIH