Pre Eclampsia with Severe Features

Nurul Wulandari

RSUD Banyumas

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KASUS

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 Identitas
Nama : Ny. R Nama pasangan : Tn. M
Usia : 36 tahun Usia : 37 tahun
Jenis kelamin : Perempuan Jenis kelamin : Laki-Laki
Alamat : Somagede Alamat : Danasri
Agama : Islam Agama : Islam
Pendidikan : SMP Pendidikan : SMP
Pekerjaan : Swasta Pekerjaan : Dagang
No. RM : 856XXX
Tanggal masuk RS : 22 Oktober 2018, pukul
12.50

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 Alasan ke RS
• Pasien merupakan rujukan puskesmas dengan
keterangan GH proinduksi
 Riwayat Kehamilan Sekarang
HPHT: 22/1/18
HPL : 29/10/18
UK : 39 mgg
Kontraksi uterus belum terasa
 Riwayat Obstetri
No Tanggal Tempat Umur Jenis Penolong Penyakit / Keadaan anak
persalinan persalinan kehamilan persalinan komplikasi
1. 2008 Rumah Aterm Spontan Bidan - Laki2, 2900 gram, sehat
2. 2010 RS 24 minggu Spontan, Bidan - 300 gram, meninggal
Gemelli 600 gram, meninggal
3. Hamil ini
 Riwayat Kesehatan Ibu
Riwayat penyakit yang pernah/sedang diderita
o Asma (-)
o Alergi (-)
o Jantung (-)
o Hipertensi (+) sejak UK 24 mg
o Diabetes Mellitus (-)
o Batuk lama >2 mgg (-)
o Riwayat mondok di rumah sakit (-)
• ANC di bidan 10x
 Riwayat Obstetri Sosial
• Kehamilan direncanakan: Ya
• Kehamilan diinginkan: Ya
• Jenis kelamin anak yang diharapkan : tidak ada
• Keluarga yang tinggal serumah: Suami, anak
• Status perkawinan : menikah pertama (13 tahun)
• Riwayat hubungan seksual : dengan suami
 Keadaan Umum
• Tampak baik, keadaan emosional stabil
• Kesadaran: CM
• Tanda Vital
 Tekanan darah : 150/100 mmHg
 Nadi : 80x /menit
 Respirasi : 16 x /menit
 Suhu : 36.5 C
• Status Gizi
 TB 166 cm, BB 75 kg, BB sebelum hamil 66 kg
 Kenaikan BB selama hamil 9 kg
 Pemeriksaan Fisik
• Kepala/Leher: • Cor:
– Conjunctiva Anemis -/-
– Sclera icteric -/- – S1 - S2 normal
– Refleks cahaya +/+ – Reguler
– JVP tidak meningkat
– Bising (-)
• Pulmo:
– Suara dasar vesikuler +/+, simetris di – Gallop (-)
kedua lapang paru
– Rhonkhi -/-
• Ekstremitas: edema (-/-)
– Wheezing -/-
 Pemeriksaan Fisik
• Pemeriksaan Abdomen
 Inspeksi : tidak ada bekas luka, tidak sesuai UK
 Palpasi : dinding perut: supel
 Leopold I : HIS +, TFU : 24 cm, bokong
 Leopold II : Punggung kiri
 Leopold III : Presentasi kepala
 Leopold IV : divergent
 DJJ : 142x/min, adekuat
 Pemeriksaan Anogenital Luar
• Perineum : elastis
• Vulva-vagina: licin, warna merah jambu, tidak ada luka
• Kelenjar bartholini : tidak ada pembengkakan ataupun
nyeri
• Anus : tidak ada hemorroid
 Pemeriksaan Dalam
• VU tenang, dinding vagina licin, portio tebal
posisi di posterior, pembukaan belum ada,
selaput ketuban utuh, kepala pada H 1, tali
pusat tak teraba, kesan panggul luas
 Follow up
22/10/18 14.00 (Bidan) 22/10/18 17.00 (Bidan)
S Kenceng2 (-), keluhan (-) S -
O KU: baik, sadar; O Hasil Lab :
TD: 150/90 mmHg; AL : 8.59
N: 82x/ menit; BUN : 7.0
DJJ 140 x/ menit Kreatinin : 0.54 (L)
PD: tidak dilakukan SGOT : 19
A G3P3A0 H39 mgg BDP GH SGPT : 21
Protein urin : +1
P Monitor KU DJJ HIS
Kolabs Medis A G3P3A0 H39 mgg BDP PE
R/Induksi Miso 25 mcg/vagina tunggu P Lapor residen, instruksi : Masuk MgSO4 4
hasil lab gram loading dose

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 Follow up
22/10/18 18.30 (Bidan) 22/10/18 20.00 (Bidan)
S - S Kencang-kencang masih jarang
O KU: baik, sadar; O KU : baik, sadar;
PD: Pembukaan belum ada TD : 150/90 mmHg
A G3P3A0 H39 mgg BDP PE HIS (+-) DJJ (+)160x/menit
P Masuk MgSO4 4 gram A G3P3A0 H39 mgg BDP PE
Miso 25 mcg/vagina (I) P Observasi
Evaluasi pukul 00.30

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 Follow up
23/10/18 00.30 (Bidan) 23/10/18 06.30 (Bidan)
S - S -
O KU: baik, sadar; O KU : baik, sadar;
PD: Pembukaan belum ada TD : 130/90 mmHg
HIS (-)
A G3P3A0 H39+1 mgg BDP PE PD : Pembukaan belum ada
P Misoprostol 25 mcg/vagina (II) A G3P3A0 H39+1 mgg BDP PE
P Misoprostol 25 mcg/vagina (III)

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 Follow up
23/10/18 08.00 (Bidan)
S Kencang-kencang masih jarang
O KU: baik, sadar;
TD:120/70 mmHg
HIS(+-)
DJJ (+)142x/menit
A G3P3A0 H39+1 mgg BDP PE
P Observasi KU, VS, HIS, DJJ
Evaluasi pukul 12.00
Kolab medis
23/10/18 12.30 (Bidan)
S -
O KU : baik, sadar;
PD : Pembukaan 4-5 cm
HIS (+)
DJJ (+) 134 x/menit
A G3P3A0 H39+1 mgg inpartu PE
P Misoprostol 25 mcg/vagina (IV)
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 Follow up
23/10/18 14.30 (Bidan) 23/10/18 15.55 (Bidan)
S Mulas (+) S Pasien gelisah
O KU: baik, sadar; O KU : baik, sadar;
TD: 130/90 mmHg PD : Pembukaan lengkap
N : 88 x/menit
HIS(+) A G3P3A0 H39+1 mgg inpartu PE
DJJ (+) 140x/menit
P Pimpin persalinan
A G3P3A0 H39+1 mgg inpartu PE
P Observasi KU, VS, HIS, DJJ
Evaluasi pukul 16.30
Kolab medis

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 Follow up
23/10/18 16.05 (Bidan)
S -
O Bayi lahir spontan A/S 7/9, JK laki-laki,
BB/PB 3031/48, LK/LD = 34/31, LP/LL =
28/9
BAB (-), BAK (-)
A PP spontan P4A0 PE
P Tab Amoxicilin 500 mg/8 jam/oral
Tab Asam mefenamat 500 mg/8 jam/oral
Tab SF 200 mg/24 jam/oral
23/10/18 16.05 (Obsgyn)
S -
O Bayi lahir spontan A/S 7/9, JK laki-laki,
BB/PB 3031/48, LK/LD = 34/31, LP/LL =
28/9
Plasenta lahir spontan, kesan lengkap,
perineum lecet, tidak hecting, masase
fundus uteri
A PP spontan P4A0 PE
P Tab Amoxicilin 500 mg/8 jam/oral
Tab Asam mefenamat 500 mg/8 jam/oral
Tab SF 200 mg/24 jam/oral
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 Follow up
23/10/18 17.30 (Bidan)
S -
O KU : baik, sadar;
TD : 160/93 mmHg
A PP spontan P4A0 PEB
P Usul MgSO4 1 gr 6 jam PP -> acc
23/10/18 20.00 (Perawat)
S -
O KU : baik, sadar;
TD : 160/100 mmHg
A PP spontan P4A0 PEB
P MgSO4 1 gr/jam mulai pk 22.05
Tab Amoxicilin 500 mg/8 jam
Tab asam mefenamat 500 mg/8jam
Tab SF 200 mg/24 jam
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 Follow up
24/10/18 06.00 (Obsgyn)
S Nyeri (+), ASI (+) sedikit
O KU baik, CM
Lochia (+) rubra
BAB (-), BAK (+) on DC
TFU setinggi umbilikus
Kontraksi baik
CA -/-
TD : 150/100 mmHg
A PP spontan P4A0 H1 PEB
P Tab Amoxicilin 500 mg/8 jam
Tab asam mefenamat 500 mg/8jam
Tab SF 200 mg/24 jam
Tab Nifedipine 3 x 10 mg
25/10/18 06.00 (Perawat)
S Pusing (-), nyeri (-), BAK (+)
O KU : baik, sadar;
TD : 130/93 mmHg
TFU : 2 jari di bawah umbilikus
A PP spontan P4A0 H2 PEB
P Tab Amoxicilin 500 mg/8 jam
Tab asam mefenamat 500 mg/8jam
Tab SF 200 mg/24 jam
Tab Nifedipine 3 x 10 mg
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 Follow up
25/10/18 06.00 (Obsgyn)
S Keluhan (-) , Nyeri (-), ASI (+), BAK (+)
O KU baik, CM
Lochia (+) rubra
TFU 2 jari di bawah umbilikus
Kontraksi baik
CA -/-
TD : 130/90 mmHg
A PP spontan P4A0 H2 PEB
P Tab Amoxicilin 500 mg/8 jam
Tab asam mefenamat 500 mg/8jam
Tab SF 200 mg/24 jam
Tab Nifedipine 3 x 10 mg
Usul BLPL

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Pemeriksaan penunjang
Hematologi Hasil Nilai rujukan Hasil Nilai rujukan
Hemoglobin 12.4 12-16 BUN 7.0 7-18
GDS 96 74-140
Hematokrit
Eritrosit
35.3 (L)
3.96 (L)
36-48
4.06-5.8 Albumin 3.1 (L) 3.4-5
Pemeriksaan
Leukosit 8.59 3.7- 10.10 SGOT (AST) 19 0-50 laboratorium
Trombosit 222 150-450 SGPT (ALT) 21 0-50
MCV 89.1 81 – 96 Kreatinin 0.54 (L) 0.60-1.30

MCH 31.3 (H) 27 – 31.2

Natrium
Kalium
139
3.4 (L)
135-155
3.5-5.5
22/10/18
MCHC 35.1 31.8 – 35.4
RDW 11.8 11.3 – 14.5
Klorida 101 94-111 pk 18.26
HBsAg Negatif
Neutrofil 74.35 (H) 39.3 – 73.7
Protein 1+ negatif
Limfosit 16.97 (L) 18-48.3 urin
Monosit 5.753 4.4-12.7
Eosinofil 2.213 0.6-7.3
Basofil 0.717 0-1.7
 CTG (22/10/18)
• FHR Baseline 150 kpm
• Akselerasi (+)
• Deselerasi (+)
• Variabilitas >5
• Gerak janin (+)
• Kesan Kategori I
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 USG
• Janin tunggal, memanjang, intrauterine,
preskep, DJJ (+), gerak janin (+), plasenta di
corpus, AK cukup
• TBJ : 2720 gram
• JK : Laki-laki

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HIPERTENSI DALAM KEHAMILAN - PREEKLAMPSIA

TEORI

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 Hypertension in Pregnancy
ACOG 2013
• Preeclampsia-eclampsia
• Chronic hypertension (of any cause)
• Chronic hypertension with superimposed preeclampsia
• Gestational hypertension
 Chronic hypertension
• Chronic hypertension (CHTN) is defined as
either a history of hypertension preceding the
pregnancy or a blood pressure (BP) ≥140/90
prior to 20 weeks gestation.
 Chronic hypertension with superimposed preeclampsia

• One or more of the following criteria:

• 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
• A sudden increase in hypertension previously well
controlled or escalation of antihypertensive medication to
control BP
 Gestational hypertension
• Sustained (on at least two occasions, six hours
apart) BP ≥140/90 after 20 weeks, without
proteinuria, other signs or symptoms of
preeclampsia, or a prior history of HTN.
 Preeclampsia-Eclampsia
• Preeklampsia: penyakit hipertensi yang spesifik pada kehamilan dengan keterlibatan
multiorgan
• HTN terjadi setelah kehamilan 20 minggu + proteinuria (≥ 300mg/24 jam atau ≥ 1+ atau
protein/creatinine ratio ≥ 3.0 )
– Proteinuria tidak mutlak dibutuhkan untuk diagnosis PE.
• Diagnosis preeclampsia tanpa proteinuria: HTN dengan satu atau lebih manifestasi berikut:
– Trombositopenia (plt <100.000/microliter)
– Impaired liver function (peningkatan transaminase serum 2x normal)
– New development of renal insufficiency (creatinine >1.1 mg/dl atau 2x serum creatinine tanpa adanya
penyakit renal lain)
– Edema pulmo
– New onset cerebral or visual disturbance
Perkembangan
klasifikasi
Preeclampsia
Preeclampsia with severe features
 Preeclampsia-Eclampsia
• Eclampsia is defined as new onset of grand
mal seizures in the presence of preeclampsia
and/or HELLP syndrome.
• Eclampsia can occur before, during, and after
labor.
 Impending Eclampsia
• Persistent occipital or frontal headaches
• Blurred vision
• Photophobia
• Epigastric or right upper quadrant pain or both
• Altered mental status

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Etiopathogenesis Preeklampsia
Symptoms of Preeclampsia

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 Preeclampsia Risk Factors
• Nulliparity
• Preeclampsia in a previous pregnancy
• Age >40 years or <18 years
• Family history of preeclampsia
• Chronic hypertension
• Chronic renal disease
• Autoimmune disease (eg, antiphospholipid
syndrome, systemic lupus erythematosus)
• Vascular disease
• Diabetes mellitus (pregestational and
gestational)
• Multifetal gestation
• Obesity
• Black race
• Hydrops fetalis
• Woman herself was small for gestational age
• Fetal growth restriction, abruptio placentae, or
fetal demise in a previous pregnancy
• Short interpregnancy interval (increases the risk
of recurrence, if the previous pregnancy was
preeclamptic)
• Partner-related factors (new partner, limited
sperm exposure [eg, previous use of barrier
contraception])
• In vitro fertilization
 Management
• Definitive treatment: delivery
• Timing of delivery is based upon a
combination of factors, including disease
severity, maternal and fetal condition, and
gestational age.
Management of
Preeclampsia
without
features of
severe disease
 Management of Preeclampsia without features of severe
disease
• Term pregnancies: Delivery
– Experts consistently recommend delivery of women with preeclampsia at 37 weeks
of gestation, even in the absence of features of severe disease
• Preterm pregnancies: Conservative management
– When mother and fetus are stable and without findings of serious end-organ
dysfunction
– Need close monitoring for evidence of progression to the severe end of the
disease spectrum
– At any gestational age, evidence of severe hypertension, serious maternal end-
organ dysfunction, or nonreassuring tests of fetal well-being are an indication for
prompt delivery
Immediate delivery is
associated with
increased rates of
admission to the NICU,
neonatal respiratory
complications, and a
slight increase in
neonatal death
compared with infants
born at or beyond 37
0/7 weeks of gestation.
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 Components of conservative management
• Inpatient versus outpatient care
– Close maternal monitoring upon diagnosis of preeclampsia is important
to establish disease severity and the rate of progression.
– After the initial diagnostic evaluation, outpatient care is a cost-effective
option for women with stable preeclampsia without severe features.
– Patients offered outpatient monitoring should be able to comply with
frequent maternal and fetal evaluations (every one to three days) and
should have ready access to medical care.
– If signs or symptoms of disease progression are noted, hospitalization for
more intensive monitoring and possible delivery is indicated.
 Components of conservative management
• Patient education
– All women with preeclampsia should be aware of the signs and symptoms
at the severe end of the disease spectrum and should monitor fetal
movements daily.
• Laboratory follow-up
– The minimum laboratory evaluation: platelet count, serum creatinine, and
liver enzymes.
– These tests should be repeated at least weekly in women with
preeclampsia without severe features to assess for disease progression,
and more often if clinical signs and symptoms suggest worsening disease
 Components of conservative management
• Treatment of hypertension
– Blood pressure should be measured at least twice weekly in outpatients.
– The use of antihypertensive drugs to control mild hypertension in the
setting of preeclampsia does not alter the course of the disease or
diminish perinatal morbidity or mortality, and should be avoided in most
patients
• Antenatal corticosteroids
– Antenatal corticosteroids to promote fetal lung maturity should be
administered to women <34 weeks of gestation since they are at
increased risk of progression to severe disease and preterm delivery.
 Components of conservative management
• Timing of delivery
– For patients managed conservatively, delivery is
indicated at 37 weeks of gestation, or
– as soon as they develop preeclampsia with severe
features or eclampsia
 Management of
Preeclampsia with
features of severe disease
 Route of Delivery
• Vaginal delivery is preferred with induction of labor if
necessary.
• Women with GHTN or preeclampsia without severe
features benefit most from induction if the cervix is
unfavorable.
• With severe preeclampsia, the chances of a successful
induction vary from 34% to more than 90% in different
studies
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 Route of Delivery
With labor induction, the likelihood of cesarean delivery increases
with decreasing gestational age

Gestasional Age Likelihood of Cesarean

Delivery
<28 weeks 93-97%
28-32 weeks 53-65%
32-34 weeks 31-38%

ACOG, 2013
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 Treatment of hypertension
• Commonest cause of death in women who
die of pre-eclampsia is cerebral bleeding
secondary to uncontrolled systolic blood
pressure.
• The aim of antihypertensive therapy  lower
the blood pressure and reduce the risk of
maternal cerebrovascular accident without
reducing uterine blood flow and
compromising the fetus.
• common threshold for initiating
antihypertensive therapy is sustained diastolic
pressures greater than 105 to 110 mmHg or
systolic blood pressures ≥160 mmHg
• Methyldopa
– centrally acting antihypertensive agent.
– Can only be given orally, it takes upwards of 24
hours to take effect, side-effects: sedation and
depression.
• Labetalol
– alpha-blocking and beta-blocking agent
– It is the first drug of choice in most national
guidelines
• Nifedipine
– a calcium-channel blocker with a rapid onset of
action.
– Can cause severe headache that may mimic
worsening disease.
 MgSO4
• Magnesium is the drug of choice for prevention of eclampsia; it is superior to phenytoin and
diazepam.
• Timing
– Magnesium sulfate for seizure prophylaxis is usually initiated at the onset of labor or induction, or prior to a
cesarean delivery.
– It is usually not administered to stable antepartum patients off the labor unit, but is sometimes given to
women with preeclampsia with severe features while they are being considered for conservative
management.
• Loading dose: 4-6 g of a 10 percent solution intravenously over 15 to 20 minutes
• Maintenance dose: 1-3 g/hour as a continuous infusion.
• The maintenance dose is only given when a patellar reflex is present (loss of reflexes is the first
manifestation of symptomatic hypermagnesemia), respirations exceed 12 breaths/minute, and
urine output exceeds 100 mL over four hours.
• Clinical assessment for magnesium toxicity should be performed every one to two hours.
 MgSO4
Cara Pemberian Dosis Awal
• Larutkan MgSO4 4gr (10ml larutan MgSO4 40%) dalam 10ml akuades. Larutan diberikan
secara IV selama 20 menit.
• Jika akses intravena sulit, berikan masing-masing MgSO4 5gr (12,5ml larutan MgSO4 40%)
secara IM pada bokong ka-ki.
Cara Pemberian Dosis Rumatan
• Larutkan MgSO4 6gr (15ml larutan MgSO4 40%) dalam 500ml RL. Berikan secara IV, 28
tpm, selama 6 jam. Ulangi hingga 24 jam setelah persalinan.
• Bila kejang berulang berikan MgSO4 2gr secara IV selama 15 menit
• Bila terdapat tanda intoksikasi MgSO4, berikan Ca Glukonas 1gr secara IV selama 10 menit
• Bila masih terdapat kejang, pertimbangkan pemberian diazepam 10mg secara IV selama 2
menit
 Postpartum care
• American College of Obstetricians and Gynecologists suggests frequently
monitoring blood pressure in the hospital or at home for the first 72 hours
postpartum and if it is in an acceptable range, then blood pressure is
measured at a follow-up visit 7 to 10 days postdelivery.
• Continued follow-up is needed until all of the signs and symptoms of
preeclampsia have resolved.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control should be
avoided in women with poorly controlled hypertension, oliguria, or renal
insufficiency, since NSAIDs can have an adverse effect on these conditions
 Postpartum hypertension and preeclampsia
• Postpartum hypertension and preeclampsia are either secondary to persistent
hypertension or exacerbation of hypertension in women with previous
gestational hypertension, preeclampsia, chronic hypertension or because of a
new-onset condition.
• Experts recommend antihypertension therapy in the postpartum period when
BP is persistently higher than 150 mmHg systolic or 100 mmHg diastolic (on at
least two occasions that are at least 4-6 hours apart)
• In addition, MgSO4 is recommended for women who present during the
postpartum period with hypertension or preeclampsia in association with
severe headaches, visual changes, altered mental status, epigastric pain, or
shortness of breath. MgSO4 is to be given for at least 24 hours from diagnosis.
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Management
of Woman
with Prior
Preeclampsia

68
Management
of Woman
with Prior
Preeclampsia

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 Pencegahan Sekunder
• Aspirin
1. Penggunaan aspirin dosis rendah (75mg/hari) direkomendasikan
untuk prevensi preeklampsia pada wanita dengan risiko tinggi
2. Efek preventif aspirin lebih nyata didapatkan pada kelompok risiko
tinggi
3. Belum ada data yang menunjukkan perbedaan pemberian aspirin
sebelum dan setelah 20 minggu
4. Pemberian aspirin dosis tinggi lebih baik untuk menurunkan risiko
preeklampsia, namun risiko yang diakibatkannya lebih tinggi.
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 Pencegahan Sekunder
• Suplementasi Kalsium
1. Suplementasi kalsium minimal 1 g/hari direkomendasikan
terutama pada wanita dengan asupan kalsium yang rendah
2. Penggunaan aspirin dosis rendah dan suplemen kalsium (minimal
1g/hari) direkomendasikan sebagai prevensi preeklampsia pada
wanita dengan risiko tinggi terjadinya preeklampsia
• Pemberian vitamin C dan E dosis tinggi tidak menurunkan risiko
hipertensi dalam kehamilan, preeklampsia dan eklampsia, serta berat
lahir bayi rendah, bayi kecil masa kehamilan atau kematian perinatal.

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Terima Kasih

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