HIPERTE
HIPERTE
NSI NSI
GESTASI
KRONIS
ONAL
HDK
SUPERIMP SINDRO Cunningham et.al, 2018. Williams
OSED MA
PREEKLA PREEKLA Obstetrics, 25 ed and ACOG, 2013
MSIA MSIA MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD
Preeclampsia Updated: Feb 16, 2018
8/3/22 2
HIPERTENSI
DALAM
KEHAMILAN (HDK)
(HYPERTENSIVE DISORDERS)
TERMINOLOGI DAN DIAGNOSIS .
(ISSHP, 2000; 2014)
HT HT
KLASIFIKASI DASAR HDK : White- KRONI
1. HIPERTENSI KRONIK, coats S
HT
2. HIPERTENSI KEHAMILA
N
GESTASIONAL,
3. DE NOVO - PREEKLAMSIA
atau SUPERIMPOSED
PREEKLAMSIA,
4. HIPERTENSI WHITE-COAT. PE
de novo/
HT
GESTASION
AL
superimpo
sed
3. HT + P (+/-) + UK ≥ 20
PROTEIN PROTEIN SINDROMA PREEKLAMSIA
URIA URIA
POSITIF NEGATIF 4. HT + P (-) P (+/-) UK ≥ 20
2 3 PREEKLAMSIA
SUPERIMPOSSED
Cunningham et.al, 2018. Williams MedScape, Kee-Hak Lim, MD; Ronald M Ramus,
Obstetrics, 25 ed and ACOG, 2013 MD Preeclampsia Updated: Feb 16, 2018
8/3/22 5
PREEKLAMSIA
H
HT (HIPERTENSI) : T
TEKANAN DARAH ≥
140/90.
TEKANAN SISTOLIK NAIK
P
E
30, DIATOLIK NAIK 15.
DELTA HIPERTENSI
KENAIKAN MAP PADA
TRIMESTER III
HIPERTENSI White Coats,
adalah DIPERIKSA (Dr/Per/
Bidan) ≥ 140/90, monitor 24 P
R
O
Abnormal ekskresi PROTEIN, adalah 300 mg/ 24 jam, atau rasio protein :
kreatinin urine ≥ 0,3, atau persisten 30 mg/dL (1+ dipstik).
Foley MR, et., 2018. Obstetric Intensive Care
Manual.
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PREEKLAMSIA BERAT
(Gabbe, et.al, 2017; Cunningham, et.al 2018; Lim KH, 2018)
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Superimposed preeclampsia
One or more of the following
criteria:
1. 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
2. A sudden increase in
hypertension previously well
controlled or escalation of antihypertensive
medication to control BP
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HELLP syndrome
Tennessee Classification (most commonly used)
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ATYPICAL PREECLAMPSIA
The criteria for atypical
preeclampsia include gestasional
proteinuria or FGR plus one or more of
the following symptoms of preeclampsia :
hemolysis, thrombocytopenia, elevated
liver enzymes, early signs and symptoms
of preeclampsia-eclampsia earlier than 20
weeks, and late postpartum preeclampsia-
eclampsia ( > 48 hours postpartum).
Gabbe et.al, 2017
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Risk factors- preeclampsia
Risk factors for preeclampsia and their odds
ratios are as follows [2] :
1. Nulliparity (3:1)
2. Age older than 40 years (3:1)
3. Black race (1.5:1)
4. Family history (5:1)
5. Chronic renal disease (20:1)
6. Chronic hypertension (10:1)
7. Antiphospholipid syndrome (10:1)
8. Diabetes mellitus (2:1)
9. Twin gestation (but unaffected by zygosity) (4:1) MedScape, Kee-Hak Lim, MD; Ronald M
10. High body mass index (3:1) Ramus, MD Preeclampsia Updated: Feb 16,
11. Homozygosity for angiotensinogen gene T235 (20:1) 2018
12. Heterozygosity for angiotensinogen gene T235 (4:1)
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Penanganan
Hanya persalinan obat Pasien dengan PEB
preeklamsia. induksi persalinan
Pasien dengan PE tidak berat seharusnya dilakukan
perlu induksi setelah umur setelah umur
kehamilan 37 mgg. kehamilan 34 mgg.
Sebelumnya pasien biasanya diawasi Dalam kasus ini, memberatnya
dengan ketat atau dirawat untuk penyakit dipertimbangkan
perkembangan, perburukan atau dengan risiko prematuritas
komplikasi PE, dan imaturitas janin
janin.
ditangani ekspektatif dengan
pemberian kortikosteroid guna Dalam kondisi darurat kontrol
memacu pematangan paru janin untuk TD dan kejang harus
persiapan persalinan prematur. diprioritaskan.
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MgSO4 MgSO4 ADALAH OBAT
PILIHAN UNTUK PENCEGAHAN
EKLAMSIA, MENURUNKAN 59%
DOSIS AWAL 4 gram iv RISIKO EKLAMSIA, 36%
BOLUS, DILANJUTKAN SOLUSIO PLASENTA, 46%
DENGAN DRIPS 8 gram (STATISTIK TIDAK SIGNIFIKAN)
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ALTERNATIF OBAT ANTIHIPERTENSI, ADALAH :
OBAT
ANTIHIPERTENSI 1. Labetalol 20 mg iv bolus,
dilanjutkan 40 mg, 80 mg, 80 mg jika
diperlukan, setiap 10 menit dengan
DIBERIKAN APABILA
dosis maksimal total 220 mg.
TEKANAN SISTOLIK
≥160 DAN ATAU TEKANAN 2.Nifedipin 10-20 mg po, diulang
DIASTOLIK ≥110 tiap 30 menit (bisa sampai 8 x per 24 jam)
(NHBPEP-WG,2000; RCOG,2006: dalam Cunningham 2014).
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Sample Order Set for Severe Intrapartum or Postpartum Hypertension
Initial First-line Management With Immediate-Release Oral Nifedipine*
Notify physician if systolic blood pressure (BP) is greater than or equal to 160 mm Hg or if diastolic
BP is greater than or equal to 110 mm Hg.
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TERAPI HIPERTENSI KRONIK
1. PERUBAHAN GAYA HIDUP BERUPA DIET KAYA PROTEIN, BUAH, SAYUR,
RENDAH LEMAK, MENGURANGI SATURASI DAN TOTAL LEMAK, (MENGURANGI
MASUKAN GARAM SAMPAI < 2,4 gram/ HARI TIDAK DIANJURKAN LAGI).
2. BEDREST DI RS DIHUBUNGKAN PENGURANGAN 42% HIPERTENSI BERAT, 47%
PERSALINAN PRETERM.
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MANAJEMEN CAIRAN pada
PEB
1. Hindari pemberian • TOTAL CAIRAN secara
diuretik. umum seharusnya dibatasi
2. Resusitasi volume TIDAK LEBIH dari
cairan yang agresif
penyebab utama 1. 80 mL/jam, atau
untuk EDEMA 2. 1 mL/kg/jam, atau
PULMONUM. 3. (60-125 ml/jam)
3. Sedapat mungkin pasien harus
RESTRIKSI CAIRAN, minimal (Cunningham, 2018)
sampai periode DIURESIS
POSTPARTUM.
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Postpartum management
Many patients will have a brief (up If a patient is discharged with BP
to 6 hours) period of oliguria medication, reassessment and a BP
check should be performed, at the
following delivery
latest, 1 week after discharge
Magnesium sulfate seizure
Unless a woman has undiagnosed
prophylaxis is continued for 24
chronic hypertension, in most cases
hours postpartum of preeclampsia, the BP returns to
Liver function tests and platelet baseline by 12 weeks’ postpartum
counts must document decreasing Patients should be carefully
values prior to hospital discharge monitored for recurrent
Elevated BP may be controlled with preeclampsia, which may develop up
nifedipine or labetalol to 4 weeks postpartum, and for
postpartum eclampsia that has occurred up to 6
weeks after delivery
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Offer women with pre-eclampsia who have
given birth transfer to community care if all of
the following criteria have been met:
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KOMPLIKASI PRE-EKLAMSIA
IBU, BERUPA HELLP SYNDROME (20%), DIC (10%), EDEMA
PULMONUM (2-5%), SOLUSIO PLASENTA (1-4%), GAGAL GINJAL (1-
2%), KEJANG EKLAMSIA (<1%), PERDARAHAN SEREBRAL (<1%),
PERDARAHAN HEPAR (<1%) DAN KEMATIAN (JARANG).
8/3/22 24
KOMPLIKASI EKLAMSIA
KEMATIAN MATERNAL 1-2% DI NEGARA
MAJU, LEBIH DARI 10% DI NEGARA BERKEMBANG.
KEMATIAN PERINATAL 6-12% DI NEGARA MAJU,
LEBIH DARI 25% DI NEGARA BERKEMBANG.
SOLUSIO PLASENTA 7-10%, DIC 7-11%, HELLP 10-15%,
EDEMA PULMONUM 3-5%, GAGAL GINJAL 5-9%,
PNEUMONIA ASPIRASI 2-3%, CARDIOPULMONARY ARREST
2-5%, PERSALINAN PRETERM 50%.
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MORBIDITAS DAN MORTALITAS
JANGKA PANJANG PENDERITA
PREEKLAMSIA, TERNYATA
MENINGKAT SECARA BERMAKNA
DIBANDINGKAN BUKAN
PENDERITA PREEKLAMSIA,
TERHADAP KEJADIAN
HIPERTENSI, IHD,
STROKE, DAN
PENYEBAB LAIN
KEMATIAN.
Long-term cardiovascular consequences of preeclampsia. All
differences p ≤.001 except p = 0.03 for all-cause mortality.
(Data from Bellamy and colleagues, 2007.)
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Acute Treatment of Severe Hypertension in
Pregnancy
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Prophylactic treatment with
magnesium sulfate
Prophylactic treatment with magnesium sulfate is indicated for
all patients with severe preeclampsia. However, no
consensus exists as to whether patients with mild preeclampsia
need magnesium seizure prophylaxis.
magnesium sulfate
Although ACOG recommends
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ABSTRACT: Patient care
emergencies may occur at any
Preparing for Clinical Emergencies
time in any setting, particularly in Obstetrics and Gynecology
the inpatient setting. It is
important that obstetrician–
gynecologists prepare themselves
Managing
Examples of Tools for
by assessing potential
emergencies, establishing
Clinical Emergencies
early warning systems, 1. Availability of appropriate emergency
designating specialized first supplies in a resuscitation cart (crash cart) or
responders, conducting kit
emergency drills, and 2. Development of a rapid response team
debriefing staff after actual 3. Development of protocols that include
events to identify strengths
and opportunities for clinical triggers
improvement. Having such 4. Use of standardized communication tools for
systems in place may reduce or huddles and briefs (eg, SBAR)
prevent the severity of medical
5. Implementation of emergency drills and
emergencies.
simulations
ACOG COMMITTEE OPINION Number
590, March 2014 (Replaces Committee Abbreviation: SBAR, Situation–Background–
Opinion Number 487, April 2011) Assessment–Recommendation.
(Reaffirmed 2018)
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Wassalamu’alaikum
warahmatullahi wabarakaatuh
Terima Kasih
Atas
perhatiannya
8/3/22 32