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 Medica
 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 profilaksis ≥ 34 minggu

< 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) tanpa
 IUFD menunda terminasi
 Janin tidak viabel (tergantung kasus)

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

Tidak:

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 inpartu
  Perburukan
PENATALAKSANAAN
Pemberian anti HT jika TD ≥ 160/110
 Pematangan paru 2x24 jam maternal - fetal

PREEKLAMPSIA
Evaluasi maternal-fetal secara berkala
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
histopatologi
• pH dari arteri dan vena tali
pusat
Ditawarkan pada wanita • Review dari histologi placenta
dengan IUGR < 3
percentile dan
• Screening trombophilia
melahirkan di usia < 34 • Modifikasi dari faktor risiko
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