Internal Society for the

Study of Hypertension in Pregnancy

Manajemen Preklampsia
dengan Intrauterine
Growth Restriction (IUGR)

WORKSHOP PREECLAMPSIA UPDATE, 13 OCTOBER 2019

GRAND CAKRA HOTEL MALANG
Preeklampsia
Tekanan darah ≥140/90 mmHg yang baru terjadi pada kehamilan / diatas usia kehamilan 20 minggu dan Protein
urin melebihi 300 mg dalam 24 jam atau tes urin dipstik ≥ positif 1, rasio protein : kreatinin ≥ 30 mg/mmol

Preeklampsia Berat
Tekanan darah ≥160/110 mmHg yang baru terjadi pada kehamilan / diatas usia kehamilan 20 minggu dan
Proteinuria ≥ 5g/24 jam atau tes urin dipstik ≥ positif 2

Ada keterlibatan organ lain :

• Trombositopenia : trombosit < 100.000 / mikroliter
• Gangguan ginjal : kreatinin serum >1,1 mg/dL atau didapatkan peningkatan kadar kreatinin serum pada kondisi
dimana tidak ada kelainan ginjal lainnya
• Gangguan liver : peningkatan konsentrasi transaminase 2 kali normal dan atau adanya nyeri di daerah epigastrik /
regio kanan atas abdomen
• Edema Paru
• Didapatkan gejala neurologis : stroke, nyeri kepala, gangguan visus
• Gangguan pertumbuhan janin yang menjadi tanda gangguan sirkulasi uteroplasenta : Oligohidramnion, Fetal Growth
Restriction (FGR) atau didapatkan adanya absent or reversed end diastolic velocity (ARDV)

(The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: Int J Gynecol Obstet 2019)
 PEB DAN IUGR
PEB terjadi gangguan implantasi plasenta dan hipoksia persisten

Pelepasan sitokin profinflamasi, faktor anti angiogenik, stress terhadap

RE  mengurangi aliran darah ke fetus

Nutrisi tidak adekuat untuk pertumbuhan fetus

IUGR

Cunningham, F. G., et al. (2014). Hypertensive Disorders. Williams Obstetrics 24th Edition. F. G. Cunningham, K. J.Leveno, S. L. Bloom et al., McGraw Hill Medical:
 Intrauterine Growth Restriction
Definisi: TBJ < 10th percentil berdasarkan
ultrasonografi untuk usia kehamilan

FAKTOR RISIKO

Bachin, I. and D. Peebles (2012). Fetal Growth, Intrauterine Growth Restriction and Small-Gestasional-for-Age Babies. Rennie and Roberton's Textbook of Neonatology.
Cunningham, F. G., et al. (2014). Fetal-Growth Disorders. Williams Obstetrics 24th Edition. F. G. Cunningham, K. J.Leveno, S. L. Bloom et al., McGraw Hill Medical
Asimetris vs Simetris IUGR

(Sharma, D et al., Intrauterine growth restriction.J Matern Fetal Neonatal Med, 2016)
 Diagnosis

Anamnesa dan Pemeriksaan Fisik

Penentuan awal usia kehamilan yang
akurat berupa riwayat menstruasi
Pengawasan terhadap kenaikan berat
badan ibu
Identifikasi faktor risiko untuk IUGR
Pengukuran yang cermat ukuran
tinggi fundus uteri selama kehamilan

Resnik, R. and R. K. Creasy (2013). Intrauterine Growth Restriction. Creasy and Resnik's Maternal-Fetal Medicine Priciples and Practice Seventh Edition. R. K. Creasy, R. Resnik, J.D. Iams et al., Elsevier
Saunders: 743 - 755.
Cunningham, F. G., et al. (2014). Fetal-Growth Disorders. Williams Obstetrics 24th Edition. F. G. Cunningham, K. J.Leveno, S. L. Bloom et al., McGraw Hill Medical: 872-920
 Ultrasound

Mengidentifikasi kelainan genetik

atau bawaan
USG Serial penting dalam
mendokumentasikan pertumbuhan dan
menyingkirkan anomali
Mengukur TBJ dengan
mengkombinasikan dimensi kepala
(HC dan BD), perut (AC) dan
tulang femur (FL)
Menilai AFI, Placenta, Doppler
Velocimetry
Resnik, R. and R. K. Creasy (2013). Intrauterine Growth Restriction. Creasy and Resnik's Maternal-Fetal Medicine Priciples and Practice Seventh Edition. R. K. Creasy, R. Resnik, J.D. Iams et al., Elsevier
Saunders: 743 - 755.
Cunningham, F. G., et al. (2014). Fetal-Growth Disorders. Williams Obstetrics 24th Edition. F. G. Cunningham, K. J.Leveno, S. L. Bloom et al., McGraw Hill Medical: 872-920
Prenatal Diagnosis:

1. Maternal history: e.g. pregnancy-

induced-hypertension.

2. Maternal examination - measurement of

fundal height is an excellent screening tool
for IUGR. 95% sensitivity.
- If fundal height is 4 cm less than expected -
?SGA. Fundal height in cms should equal
gestation at 20 to 25 weeks.
3. Fetal ultrasound: BPD and AC measured.

- BPD) 43-100% accurate but inaccuracy due to

head-sparing in symmetric IUGR.

- AC (Abdominal circumference better sensitivity

than that of cephalometry for IUGR detection.

- HC/AC (Head circumference/abdominal

circumference ratio) is an important
measurement for detection of asymmetric
IUGR infants.
Between 20 and 36 weeks of gestation, the HC/AC ratio
normally drops almost linearly from 1.2 to 1.0.  The ratio is
normal in the fetus with symmetric growth restriction and
elevated in the infant with asymmetric growth restriction.

Ratio of femoral length to abdominal circumference (FL/AC)

can being as a prediction of IUGR, however it does not have
any relationship with fetal well being.
4. Amniotic fluid volume: oligohydramnios due to
decreased renal blood flow and urine output.

5. Blood flow measurements: by Doppler flow studies,

fetal and uterine blood flow can be measured and
therefore uteroplacental circulation dysfunctions
can be assessed.

6. Biophysical profile scoring

 The Doppler velocimetry data of umbilical
artery (UA), middle cerebral artery (MCA),
and ductus venosus (DV) are considered as
highly indicative of placental-fetal
insufficiency resulting in the etiology of IUGR.
Absent of end diastolic flow

Reversed of end diastolic flow

Umbilical vein pulsation on IUGR
 Ductus venousus
• Lies within the two layers of lesser omentum (hepato-gastric ligament) in a groove
between the left and caudate lobes of the liver and closes, within 2 weeks, after
birth.
• Originates from the Umbilical Vein
• Courses posterior in a cephalad direction with increasing steepness. Enters the IVC
just below the diaphragm.
• The velocity increases dramatically as the blood leaves the umbilical vein through
the inlet of the ductus, and represents the highest blood velocity in the fetal
venous system. It is usually about 50 cm/s in early pregnancy (10-15 wks), and may
exceed 65 cm/s near term (1). Aliasing at the isthmus of the ductus venosus during
color doppler interrogation is thought represent high laminar velocity and “possibly
vortices rather than turbulent flow” (1).
• Diameter < 1/3 of umbilical vein and this accelerates blood flow
velocity (maximum inner width of narrowest portion = 2 mm).

• Functionally, the ductus venosus is linked to the foramen ovale due to

“preferential streaming of umbilical blood” to the left atrium.

• A second important source for streaming umbilical blood is that

portion that flows through the left portion of the liver where oxygen
extraction is modest (10-15%).

• Once it reaches the IVC, the blood flows in a near vertical direction,
and laminar flow prevents extensive mixing of oxygenated and
deoxygenated blood.

• Two separate pathways therefore exist:

Ductus - LA Pathway.
IVC - RA Pathway.
Absent of end diastolic flow

Reversed of end diastolic flow

Increase of peak systolic velocities of MCA at IUGR
7. Biochemical data:

a. Estriol: low 24 hours urinary estriol

excretion is associated with 21% of
IUGR infants.
b. Human placental lactogen (HPL).
 FOLLOW UP IUGR

NON STRESS TEST INDEKS CAIRAN USG BIOMETRIK USG DOPPLER

AMNION

• Evaluasi kondisi janin (hitung fetal kick count/hari

• Kesejahteraan janin (NST dan USG) 2 kali/minggu
• Evaluasi pertumbuhan janin setiap 2 minggu

(POGI, Pedoman Nasional Pelayanan Kedokteran. Pengelollan Kehamilan dengan Pertumbuhan Janin Terhambat, 2016)
 FOLLOW UP PREKLAMPSIA

EVALUASI LABORATORIUM
EVALUASI KLINIS

EVALUASI JANIN
NON STRESS
KONTROL TEST
TEKANAN TIAP 1 MINGGU
DARAH
TIAP 2X/MINGGU

• TROMBOSIT
TANDA • FUNGSI LIVER
IMPENDING • FUNGSI GINJAL
TIAP HARI • ALBUMIN USG
TIAP 2X/ MINGGU
(POGI, Pedoman Nasional Pelayanan Kedokteran. Diagnosis & TIAP 1 MINGGU
Tatalaksana Pre-Eklamsia. 2016)
 FOLLOW UP PREKLAMPSIA

• Following first-trimester screening for preterm PE, women

identified at high risk should receive Aspirin prophylaxis
commencing at 11–14+6 weeks of gestation at a dose of ~150
mg to be taken every night until 36 weeks of gestation

• In women with low calcium intake (<800mg/day), either

calcium replacement (≤ 1 gr elemental calcium /day) or
calcium supplementation (1,5-2mg calcium/day) may reduce
the burden of both early-late onset PE

(The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: Int J Gynecol Obstet 2019)
 Preeklampsia dengan gejala berat
 MRS, Evaluasi gejala, DJJ, dan cek
laboratorium
 Stabilisasi, pemberian MgSO4 ≥ 34 minggu
profilaksis

< 34 minggu

Jika didapatkan :
 Eklampsia Jika usia kehamilan
 Edema paru ≥ 24 minggu, janin
 DIC hidup : Berikan Terminasi kehamilan
 HT berat, tidak terkontrol pematangan paru setelah stabilisasi
 Gawat janin Iya (dosis tidak harus
 Solusio plasenta selalu lengkap)
 IUFD tanpa menunda
 Janin tidak viabel (tergantung terminasi
kasus)

Tidak
Jika usia
Jika didapatkan kehamilan > 24
 Gejala persisten minggu :
 Sindrom HELLP Pematangan paru
 Pertumbuhan janin terhambat (inj.
 Severe olygohydramnion Iya dexamethason
 Reversed end diastolic flow IM 2x6 mg atau
 Gangguan renal berat betamethason IM
1x12 mg) 2x24
Tidak: jam

Perawatan Konservatif
 Evaluasi di kamar bersalin selama 24-48 jam Usia kehamilan ≥ PNPK Preeklamsia POGI, 2016
 Rawat inap hingga terminasi 34 minggu
 Stop MgSO4, profilaksis (1x24 jam)  KPP atau

PENATALAKSANAAN
 Pemberian anti HT jika TD ≥ 160/110 inpartu
 Pematangan paru 2x24 jam  Perburukan
maternal -
PREEKLAMPSIA
 Evaluasi maternal-fetal secara berkala
fetal
EFW : Estimated fetal weight, UA : umbilical artery, EDF : end of dyastolic flow, AEDF : Absent end diastolic flow, REDF Reversed Absent end diastolic flow, AFI Amniotic fluid
index, AREDF : Absent Reversed Absent end diastolic flow, CTG : cardiotocografi, MCA : midle cerebral artery CLINICAL PRACTICE GUIDELINE FETAL GROWTH RESTRICTION -
RECOGNITION, DIAGNOSIS & MANAGEMENT, 2017
Pada semua kasus indikasi dari terminasi kehamilan juga berdasarkan CTG yang abnormal
pada usia kehamilan bila janin viable ( usia kehamilan > 24 mgg dan EFW > 500mg

• Placenta dikirim untuk Ditawarkan pada • Review dari histologi placenta

histopatologi wanita dengan • Screening trombophilia
• pH dari arteri dan vena
IUGR < 3 percentile • Modifikasi dari faktor risiko
dan melahirkan di
tali pusat usia < 34 minggu
• Mencegah dengan Aspirin/
LMWH

CLINICAL PRACTICE GUIDELINE FETAL GROWTH RESTRICTION - RECOGNITION, DIAGNOSIS & MANAGEMENT, 2017
 What can be done to prevent FGR in a
subsequent pregnancy?

• Risiko kekambuhan FGR pada kehamilan berikutnya

adalah sekitar 25%
• Dianjurkan untuk meninjau penyebab yang mendasari
(histologi plasenta, komorbiditas ibu) dan faktor risiko
yang dapat dimodifikasi (saran tentang penghentian
merokok)
• Pertimbangan harus diberikan Aspirin 75mg setiap hari
sebelum 16 minggu atau heparin dengan berat
molekul rendah (dalam kasus tertentu saja dan setelah
diskusi dengan dokter kandungan yang
berpengalaman)

CLINICAL PRACTICE GUIDELINE FETAL GROWTH RESTRICTION - RECOGNITION, DIAGNOSIS & MANAGEMENT, 2017
TERIMA KASIH

Departemen Obsetri & Ginekologi

Fakultas Kedokteran Universitas Brawijaya