PRESENTASI RM

HIPERTENSI DALAM KEHAMILAN

Derian Irawan – 406172061

Pembimbing – dr. Andriana Kumala Dewi, Sp.OG
Kepaniteraan Obstetri dan Ginekologi
RS Sumber Waras- FK UNTAR
Identitas Pasien

 Nama : Ny. R A
 Usia : 38 thn
 Status Pernikahan : Menikah
 Pekerjaan : Ibu Rumah Tangga
 Agama : Islam
 Alamat : JL. Angke Jaya 1 RT 7001/006 No. 21
Anamesa
 Dilakukan pada tanggal 11 Mei 2018 pk 10.37 secara autoanamesa
 Keluhan utama :
 Kontrol Hamil, dirujuk dari puskesmas Angke untuk USG
 Riwayat Penyakit Sekarang
 G1P0A0 H.35-36 minggu dirujuk dari puskesmas untuk periksa USG
 HPHT pasien 6 September 2017, Hari Perkiraan Lahir 13 Juni 2018
 TP-USG pada usia kehamilan 4 bulan dikatakan pasien adalah 12 Juni 2018
 Gerak janin sekarang dikatakan aktif
 Pasien mengatakan ada bengkak pada kedua tangan dan kaki sejak sekitar 3 hari
yang lalu
 Sakit kepala, pusing, gangguan penglihatan, nyeri pada abdomen kanan atas
disangkal
 Pasien menikah 1x, sudah 14 tahun dengan suami sekarang
 Rutin melakukan pemeriksaan tiap bulannya di puskesmas
 Tidak ada perdarahan, ataupun mual dan muntah yang berlebihan.
 Nafsu makan dikatakan baik, tidak ada demam, batuk, ataupun pilek.
 Riwayat Penyakit Dahulu
 Riwayat Hipertensi sebelumnya disangkal oleh pasien
 Riwayat DM, TBC, Asma, Penyakit Jantung, Alergi (-)
 Riwayat Penyakit Keluarga
 Riwayat hipertensi, DM (+)
 Riwayat keluhan serupa disangkal oleh pasien
 Riwayat alergi, TBC, asma, penyakit jantung (-)
 Riwayat Obstetri dan Ginekologi
 Haid dikatakan teratur, setiap 28 hari
 G1 P1 A0  Riwayat KB suntik dan pil
 Pasien menikah 1 kali, dengan suami selama total 5 tahun
sekarang sudah 14 tahun
 HPHT 6 September 2017
 HPL 13 Juni 2018
No. Tahu Tempat Umur Jenis Penolong Penyuli Anak
n Kehamilan t
JK BB Keadaan sekarang

1 Hamil ini
Riwayat Kebiasaan & Asupan Nutrisi

 Makan cukup dan bervariasi (sayur, buah-buahan, daging ayam dan

ikan)
 Minum cukup (kurang lebih 3L per hari)
 Mendapat tablet penambah darah, asam folat, vitamin B6 dari
puskesmas
 Kebiasaan minum alkohol, kopi, merokok, obat-obatan (-)
Pemeriksaan fisik
Pemeriksaan Umum
 Keadaan umum : Baik
 Kesadaran : Compos mentis GCS 15 (E4V5M6)
 Suhu : 36,5 ◦C
 Tekanan darah : 146/81 mmHg -> ½ jam kemudian -> 155/89
 Nadi : 90x/menit; reguler, isi cukup
 Pernapasan :18x/menit, teratur, tipe pernapasan thoracoabdominal
 Berat badan terakhir : 91 kg
 Tinggi badan : lupa
Pemeriksaan Fisik
 Kepala :
 konjungtiva anemis (-/-), kloasma gravidarum (+), sklera ikterik (-/-),
edema wajah (-), epulis (-), pandangan kabur (-)
 Leher : Bendungan vena jugularis (-)
 Thorax :
 (A) Suara nafas vesikuler +/+, ronkhi basah -/-, wheezing -/-
 Abdomen
 Inspeksi
 Tampak perut membesar ke depan, kesan menggantung, pusat tampak datar
dengan perut, linea nigra (+), linea alba (+) , bekas luka SC (-)
 Palpasi
 Supel, Nyeri tekan (-) pada RUQ, TFU 3 jari di bawah processus xiphoideus
 Leopold I : lunak, bulat, tidak melenting -> bokong
 Leopold II : bagian besar di sebelah kiri -> punggung di kiri
 Leopold III : keras, bulat, melenting -> kepala
 Leopold IV : konvergen -> belum masuk pintu atas panggul (Perlimaan : 5/5)
 Auskultasi
 DJJ (+) dengan USG trans abdominal
 Anus
 Inspeksi : tampak tenang, perineum tidak menonjol, fisura (-), benjolan
(-)
 Vulva/Vagina
 Inspeksi
 Vulva vagina tampak tenang, vulva hiperemis (-), pembesaran kelenjar (-),
tumor (-), vulva tampak membuka
 Vaginal touché
 Tidak dilakukan
 Kulit
 Turgor kulit baik, akral hangat, kloasma gravidarum (+), linea alba (+),
linea nigra (+)
 Kelenjar Getah Bening
 Tidak terlihat adanya pembesaran kelenjar getah bening
 Pemeriksaan Neurologis
 Tidak dilakukan
 Ekstremitas
 Inspeksi : Edema (+) kedua tungkai bawah dan atas
 Palpasi : Pitting edema
PEMERIKSAAN PENUNJANG
 Lab- Darah Lengkap + Skrining HIV + Skrining Hep B + Urinalisa
(7/5/2018)
 USG (11/5/2018) :
 Janin Tunggal Hidup
 Presentasi Kepala
 Plasenta implantasi di corpus uteri, tidak menutupi jalan lahir
 Air ketuban cukup
 Biometri usia kehamilan = 35 minggu 4 hari
 EFW = 2362 gram
 Pemeriksaan Lab Darah
Pemeriksaan(7/5/18) Hasil Satuan Nilai Normal

Hb 11.7 g/dL 12-16

Eritrosit 4.10 Juta/uL 4.0-5,2

Hematokrit 44.4 % 36-47

Leukosit 13.67 Ribu/µL 4-11

Trombosit 391 Ribu/µL 150-440

HIV NR

HbsAg -
 Urinalisa

Pemeriksaan(5/4/18) Hasil Satuan Nilai Normal

Protein Negative Negative
 Resume
 G1P1A0 H.35-36 minggu dirujuk dari puskesmas untuk periksa USG
 HPHT pasien 6 September 2017, Hari Perkiraan Lahir 13 Juni 2018
 TP-USG pada usia kehamilan 4 bulan dikatakan pasien adalah 12 Juni 2018
 Pasien mengatakan ada bengkak pada kedua tangan dan kaki sejak sekitar 3 hari yang
lalu
 Sakit kepala, pusing, gangguan penglihatan, nyeri pada abdomen kanan atas disangkal
 Pasien menikah 1x, sudah 14 tahun dengan suami sekarang
 Bengkak kedua tungkai bawah sejak 2 minggu yang lalu
 Nyeri seperti tertusuk di RUQ abdomen (-)
 Riwayat hipertensi sebelumnya disangkal oleh pasien
 Riwayat hipertensi dalam keluarga, DM (+)
 Riwayat keluhan serupa dalam keluarga disangkal
Resume
Pemeriksaan Fisik :

 TD = 146/81 mmHg -> ½ jam kemudian -> 155/89 mmHg

 Nyeri pada palpasi abdomen (-)
 Pada inspeksi didapatkan edema (+) kedua tungkai atas dan bawah ->
pitting edema pada palpasi
Resume
Pemeriksaan Penunjang :

 USG (11/5/2018) : JTH Preskep, air ketuban cukup, plasenta di

corpus, TBJ 2362 gram
 Hasil pemeriksaan lab pada tanggal 7/5/2018
 Eritrosit : 4,10juta/µL
 Hb : 11,7 g/dL
 Hematokrit : 34,4%
 Leukosit : 13,67 Ribu/µL
 Trombosit: 391 Ribu/ µL
 Urinalisa Protein = -
Diagnosa Kerja
Ibu :
G1 P0 A0 H. 35-36 minggu + Gestational Hypertension

Janin :
Janin Tunggal Hidup Presentasi Kepala dengan TBJ 2362
gram
 Rencana Diagnostic
 Lab darah rutin + BT + CT + Golongan Darah
 USG
 Urinalisa (cek kuantitatif produksi protein urin per 24 jam atau cek
protein urin)
 Lab Kimia Darah (SGPT/SGOT)
 Cek Serum Kreatinin
Rencana terapi farmakologis
 -
Terapi Non Farmakologis Rencana Evaluasi
 -  Evaluasi tekanan darah di
puskesmas (Jaga tekanan darah
<160/110 mmHg)
 Datang kembali minggu depan
untuk kontrol kehamilan
Edukasi
 Menjelaskan kepada pasien tentang apa itu hipertensi dalam
kehamilan
 Menjelaskan kepada pasien apa saja tanda-tanda dari preeklamsia
 Menjelaskan kepada pasien dampak dan bahaya dari Hipertensi dalam
kehamilan kepada ibu dan bayinya
 Menjelaskan kepada pasien untuk kontrol tekanan darahnya di
puskesmas dan datang kembali minggu depan untuk evaluasi ulang
kondisi serta kontrol kehamilan
 Prognosis
 Ad vitam – dubia ad Bonam
 Ad sanationam – Bonam
 Ad functionam – Bonam
Hypertension in pregnancy
Hypertension in pregnancy
 Is among the most significant and intriguing unsolved problems in
obstetrics
 Complicate 5-10% of all preganancies
 PE either alone or superimposed on chronic HTN -> most dangerous
 PE is identified in 3.9% of all pregnancies
 16% maternal death were reported to be due to HTN disorders
 hemorrhage—13%, abortion—8%, and sepsis—2% = HTN is higher
Classification
 4 types :
 Gestational hypertension—evidence for the preeclampsia syndrome does
not develop and hypertension resolves by 12 weeks postpartum
 Preeclampsia and eclampsia syndrome
 Chronic hypertension of any etiology
 Preeclampsia superimposed on chronic hypertension
Diagnosis of Hypertensive Disorders
 Hypertension is diagnosed empirically when appropriately taken
blood pressure exceeds 140 mm Hg systolic or 90 mm Hg diastolic.
 women who have a rise in pressure of 30 mm Hg systolic or 15 mm
Hg diastolic should be observed more closely because eclamptic
seizures develop in some of these women whose blood pressures have
stayed < 140/90 mm Hg (Alexander, 2006)
Gestational Hypertension
 women whose blood pressures >= 140/90 mm Hg for the first time
after midpregnancy, but in whom proteinuria is not identified
 Almost ½ -> develop Preeclampsia syndrome (findings = headaches
or epigastric pain, proteinuria, and thrombocytopenia)
 reclassified by some as transient hypertension if evidence for
preeclampsia does not develop and the blood pressure returns to
normal by 12 weeks postpartum
Preeclampsia syndrome
 Best described as = a pregnancy-specific syndrome that can affect virtually every organ
system
 appearance of proteinuria remains an important diagnostic criterion
-> ? -> proteinuria = an objective marker and reflects the system-wide endothelial leak,
which characterizes the preeclampsia syndrome
 Abnormal protein excretion = defined by 24-hour urinary excretion exceeding 300 mg; a
urine protein:creatinine>= 0.3; or persistent 30 mg/dL (1+ dipstick) protein in random
urine samples (Lindheimer, 2008a).
 urine concentrations vary widely during the day, as do dipstick readings
 assessment may show a dipstick value of 1+ to 2+ from concentrated urine specimens
from women who excrete <300 mg/day
 overt proteinuria may not be a feature in some women with the preeclampsia syndrome
(Sibai, 2009)
 Headaches or visual disturbances such as scotomata can be premonitory
symptoms of eclampsia
 Epigastric or right upper quadrant pain frequently accompanies hepatocellular
necrosis, ischemia, and edema that ostensibly stretches Glisson capsule ->
frequently accompanied by elevated serum hepatic transaminase levels
 thrombocytopenia is also characteristic of worsening preeclampsia as it
signifies platelet activation and aggregation as well as microangiopathic
hemolysis
 renal or cardiac involvement and obvious fetal-growth restriction, which also
attests to its duration
Eclampsia
 Preeclampsia + convulsion that can not be attributed to another cause
-> eclampsia
 Convulsions are generalized, may appear before, during, or after labor
 10% (Sibai, 2005), or 25% (Chames, 2002) -> x develop seizure until
after 48 hrs postpartum
Preeclampsia Superimposed on Chronic Hypertension

 any chronic hypertensive disorder -> predisposes a woman to develop superimposed

preeclampsia syndrome
 Chronic underlying hypertension is diagnosed in women with documented blood
pressures >=140/90 mm Hg before pregnancy or before 20 weeks’ gestation, or both
 Women not seen until after midpregnancy -> difficult to diagnosed -> ? -> blood
pressure normally <<< during the 2nd and early 3rd trimesters in both normotensive
and chronically hypertensive women
 woman with previously undiagnosed chronic vascular disease who is seen before 20
weeks frequently has blood pressures within the normal range
 third trimester -> blood pressures return to their originally hypertensive levels -> may
be difficult to determine whether hypertension is chronic or induced by pregnancy
 many of these women have mild disease and no evidence of ventricular
hypertrophy, retinal vascular changes, or renal dysfunction.
 In some women with chronic hypertension, their blood pressure increases to
obviously abnormal levels, and this is typically after 24 weeks.
 New-onset or worsening baseline hypertension is accompanied by new-
onset proteinuria or Severe features of PE -> superimposed preeclampsia is
diagnosed
 Superimposed preeclampsia commonly develops earlier in pregnancy
 tends to be more severe and often is accompanied by fetal-growth
restriction
Risk Factors
Young and nulliparous women are particularly vulnerable
to developing preeclampsia, whereas older women are at
greater risk for chronic hypertension with superimposed
preeclampsia
obesity,
multifetal gestation,
maternal age,
hyperhomocysteinemia,
and metabolic syndrome
Smoking – ironically associated with reduced risk
for hypertension during pregnancy
Prior history of preeclampsia
Management
 Pregnancy complicated by gestational hypertension is managed based on
severity, gestational age, and presence of preeclampsia.
 Task Force of the American College of Obstetricians and Gynecologists
(2013b) recommends more frequent prenatal visits if preeclampsia is
“suspected
 for women with new-onset diastolic blood pressures >80 mm Hg but <90
mm Hg or with sudden abnormal weight gain of more than 2 pounds per
week includes, at minimum, return visits at 7-day intervals
 Outpatient surveillance is continued unless overt hypertension, proteinuria,
headache, visual disturbances, or epigastric discomfort supervene
Evaluation

Hospitalisation
for women
with new
onset HT
Elective Cesarean Delivery
 labor induction and vaginal delivery have traditionally been
considered ideal
 Several concerns, including an unfavorable cervix, a perceived sense
of urgency because of preeclampsia severity, and a need to coordinate
neonatal intensive care, have led some to advocate cesarean delivery
 Whenever it appears induction almost certainly will not succeed or
attempts have failed, then cesarean delivery is indicated
Hospitalization vs Outpatient Management
 mild to moderate stable hypertension— whether or not preeclampsia
has been confirmed—surveillance is continued in the hospital, at
home for some reliable patients, or in a day-care unit
 Bed rest was associated with a significantly reduced relative risk—
RR 0.27—of developing preeclampsia
 complete bed rest is not recommended by the 2013 Task Force
AntiHypertrensive Therapy
Future Pregnancies
 Hypertensive disorders may serve as markers for subsequent preterm labor
and fetal-growth restriction
 even in subsequent nonhypertensive pregnancies, women who had
preterm preeclampsia are at increased risk for preterm birth
 Sibai and colleagues (1986, 1991) found that nulliparas diagnosed with
preeclampsia before 30 weeks have a recurrence risk as high as 40 percent
during a subsequent pregnancy
 In a prospective study of 500 women previously delivered for
preeclampsia at 37 weeks, the recurrence rate in a subsequent gestation
was 23 percent (Bramham, 2011).
Future Pregnancies
 Women whose first pregnancy was complicated by preeclampsia
between 32 and 36 weeks had a significant twofold increased
incidence of preeclampsia in their second pregnancy’
 preterm delivery and fetal-growth restriction in the first pregnancy
significantly increased the risk for preeclampsia in the second
pregnancy
 Long Term Consequences

 Women with hypertension identified

during pregnancy should be evaluated
during the first several months
postpartum and counseled regarding
long-term risks
 hypertension attributable to pregnancy
should resolve within 12 weeks of
delivery (National High Blood
Pressure Education
 Program, 2000). -> if >>> -> chronic
Hypertension
Daftar Pustaka
 Williams Obstetrics Ed. 24
 The Task Force of the American College of Obstetricians and
Gynecologist 2013 – Hypertension in Pregnancy
Bishop Score - Williams page 526
 definition currently
recommended by the
American College of
Obstetricians and
Gynecologists and the
American Academy of
Pediatrics (2012) is two or
more accelerations that peak
at 15 bpm or more above
baseline, each lasting 15
seconds or more, and all
occurring within 20 minutes
of beginning the test