PENANGANAN

TERKINI PREEKLAMSIA

dr. Wahyudi Wirawan, M.Biomed, SpOG

Bagian Obstetri dan Ginekologi
RS HERMINA KEMAYORAN - Jakarta
Di USA 9, 4  12,6 per 1000 kelahiran meningkat dalam 8
tahun (1998-2006).
Sumber : Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG.
Low-Dose Aspirin for the Prevention of Morbidity and Mortality From Preeclampsia: A
Systematic Evidence Review; 2014.

WHO memperkirakan kasus preeklampsia tujuh kali lebih

tinggi di negara berkembang daripada di negara maju.
Prevalensi preeklampsia di negara maju adalah 1,3% - 6%,
sedangkan di negara berkembang adalah 1,8% - 18%. Insiden
preeklampsia di Indonesia sendiri adalah 128.273/tahun atau
sekitar 5,3%.
Sumber: PNPK Diagnosis dan tata laksana Preeklampsia, POGI-HKFM, 2016.
K L AS IF IK A S I H IP E R T E N S I D A L A M
KEHAMILAN ACOG, 2013
Hypertension in Pregnancy
(Report of the ACOG Task Force on Hypertension in Pregnancy)
Obstetrics & Gynecology, Vol. 122, No. 5, November 2013

• Preeklampsia - eklampsia
• Hipertensi gestational : Hipertensi yang terjadi
sesudah UK 20 minggu tanpa disertai tanda-tanda
preeklamsia
• Hipertensi kronis : Hipertensi yang terjadi sebelum
kehamilan atau sebelum UK 20 minggu
• Superimposed preeklampsia : Hipertensi yang memberat
setelah kehamilan 20 minggu disertai tanda tanda
preeklampsia
Townsend et al. Integrated Blood Pressure Control 2016:9 79–94
 Faktor – faktor Risiko Preeclampsia
Faktor maternal Individu • Umur < 20 atau 35–40 tahun
• Nulliparitas
• Diri/kel. Dg. riw. PE atau peny. Kardiovaskular
• Wanita yg terlahir PJT

Kondisi medis • Obesitas

• Hipertensi Kronik
• Peny Ginjal kronis
• DM (IR, type 1, dan GDM)
• APS
• Peny Jaringan Ikat (SLE dsb)
• Thrombophilia

Pregnancy specific • Kehamilan majemuk

• Oocyte donation
• UTI
• Janin dg kelainan
• Mola Hydatidosa
• Hydrops fetalis
• Anomali Structural

Faktor Paternal Paparan dg semen & sperma • Barrier contraception

terbatas • Pertama kali menjadi ayah
• Donor insemination

Suami dg riwayat preeklampsia dengan pasangan terdahulu

Lancet  2001;357:209–15
Townsend et al. Integrated Blood Pressure Control 2016:9 79–94
KLASIFIKASI PREEKLAMSIA YANG
BARU

JANGAN mengangap
preeklamsia : R I N G A N

• Preeklamsia dan preeklamsia berat

• Diagnosis preeklamsia tidak tergantung pada
proteinuria
 Onset of Preeclampsia

Early – onset of Preeclapmsia (< 34 minggu)

Late – onset of Preeclampsia (> 34 minggu)

Screening Trimester 1 (11-13+6 hari) :

1. MAP
2. Arteri Uterina – PI
3. PGF
4. PAPP-A
5. Maternal serum α-Fetoprotein

(Sonek J, et al. Am J Obstet Gynecol, 2018)

Hipertensi Gestational : tekanan darah > 140/90
mmHg dan ada minimal 1 dari gejala berikut :
• Protenuria : dipstick > +1 atau > 300 mg/24 jam
• Serum kreatinin > 1,1 mg/dL
• Edema paru
• Peningkatan fungsi hati > 2 kali
• Trombosit >100.0000
• Nyeri kepala, nyeri epigastrium dan pandangan
kabur
Preklampsia : tekanan darah >160/110 mmHg dan
ada minimal 1 dari gejala berikut :
• Protenuria : dipstick > +1 atau > 300 mg/24 jam
• Serum kreatinin > 1,1 mg/dL
• Edema paru
• Peningkatan fungsi hati > 2 kali
• Trombosit > 100.0000
• Nyeri kepala, nyeri epigastrium dan pandangan kabur
Hypertension in Pregnancy
(Report of the ACOG Task Force on Hypertension in Pregnancy)
Obstetrics & Gynecology, Vol. 122, No. 5, November 2013
Sumber: Hypertension in Pregnancy
(Report of the ACOG Task Force on Hypertension in Pregnancy)
Obstetrics & Gynecology, Vol. 122, No. 5, November 2013
Sumber: Hypertension in Pregnancy
(Report of the ACOG Task Force on Hypertension in Pregnancy)
Obstetrics & Gynecology, Vol. 122, No. 5, November 2013
Sumber: PNPK Preeklampsia POGI, hal 6, 2016
 KOMPLIKASI

• Wanita dengan riwayat preeklamsia memiliki risiko penyakit

kardiovaskuler, termasuk 4x peningkatan risiko hipertensi, dan 2x
risiko penyakit jantung iskemik, stroke, dan DVT di masa depan
• Risiko kematian pada wanita dengan riwayat preeklamsia lebih
tinggi , termasuk disebabkan oleh penyakit serebrovaskuler
 PREEKLAMPSIA

DAMPAK
Anak:
Jangka Pendek: Jangka Panjang: Cerebral Palsy
HELLP, Gagal Ginjal Kronik, DM tipe 2
CVD Peny. Kardio Penyakit Kardio Vaskular
Edema pulmonum, Vaskular, Obesitas
Eklampsia DM tipe 2 PCO
Teratozoospermia

Preeclampsia: No longer solely a pregnancy disease

Hypertension 2007;49(5):1056-62, J Clin Endocrinol Metab 2006;91(4):1233-8

REVIEW
Preeclampsia: No longer solely a pregnancy disease
Andrea L. Tranquillia, Beatrice Landia, Stefano R. Giannubiloa,*, Baha M. Sibaib

Risk of developing disease after preeclampsia

Relative risk
Chronic hypertension 2.5 [23]-3.7 [2]
Cardiovascular disease, if preeclampsia associated with IUGR 3.9 [6]
Ischemic heart disease (overall) 2.16 [2]
Ischemic heart disease mild preeclampsia 2.0 [24]
Ischemia heart disease severe preeclampsia 5.36 [24]
Mortality from ischemic heart disease 1.38 [26]
Death from circulatory diasease 1.30 [26]
Death from cardiovascular disease ; preeclampsia > 34 wks HR 2.08 [25]
Death from cardiovascular disease ; preeclampsia < 34 wks HR 9.54 [25]
Premature death (within 25 yrs) 2.71 [20]
Non-fatal stroke 1.76 [2]
Fatal stroke 2.98 [2]
Stroke preeclampsia > 37 wks 0.98 [2]
Stroke preeclampsia < 37 wks 5.98 [2]
Venous thromboembolism 1.19 [2]
End-stage renal disease 4.7 [41]
Type 2 diabetes mellitus 1.40 [8]-3.8 [3]
Hypothyroidism 1.7 [49]
Cancer HR 0.92 [15]-0.86 [26]

In brackets: reference cited in the text.

HR: Hazard ratio

Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 2 (2012) 350-357

UPAYA
PENCEGAHAN PE
 Primary Prevention of PE
Intervention No of RCTs No of women RR (95% CI)
Ambulatory BP 0 0
Bed rest for high BP 1 228 0.98 (0.80, 1.20)
Exercise 2 45 0.31 (0.01, 7.09)
Rest alone for normal BP 1 32 0.05 (0.00, 0.83)
Altered dietary salt 2 631 1.11 (0.46, 2.66)
Antioxidants 7 6082 0.61 (0.50, 0.75)
Calcium 12 15206 0.48 (0.33, 0.69)
Nutritional advice 1 136 0.98 (0.42, 1.88)
Balanced protein/energy intake 3 512 1.20 (0.77, 1.89)
Isocaloric balanced protein supplementation1 782 1.00 (0.57, 1.75)
Energy/protein restriction 2 284 1.13 (0.59, 2.18)
Garlic 1 100 0.78 (0.31, 1.93)
Magnesium 2 474 0.87 (0.57, 1.32)
Marine oils 4 1683 0.86 (0.59, 1.27)
Antihypertensives v none 19 2402 0.99 (0.84, 1.18)
Antiplatelets 43 33439 0.81 (0.75, 0.88)
Diuretics 4 1391 0.68 (0.45, 1.03)
Nitric oxide donors and precursors 4 170 0.83 (0.49, 1.41)
Progesterone 1 128 0.21 (0.03, 1.77)

0.01 0.1 0.2 0.5 1 2 5 10

Relative Risk (95% Confidence Interval)
 Daily Calcium Intake

1500

Minimum daily calcium intake, Pregnant Women (1300−1500 mg/day)

Minimum daily calcium intake, Adult WRA (1000−1200 mg/day)

1000
860

472 499 498

500
346 363 352

0
World Developed Developing Africa Latin America Near East Far East
Countries countries

Source: Calcium and Prevention of Pre-Eclampsia: Summary of Current Evidence, Monitoring, Evaluation and Research Task Force of the PE/E working
group 2010
 Pencegahan-Kalsium

Pemberian kalsium (1,5 – 2 g kalsium elemental/hari) berhubungan

dengan penurunan hipertensi dalam kehamilan dan preeklampsia
terutama pada wanita dengan asupan rendah kalsium dan risiko
tinggi preeklampsia.
 
Rekomendasi:
Pemberian kalsium dapat diberikan pada wanita yang memiliki risiko
tinggi preeklampsia dan rendah asupan kalsium untuk mencegah
terjadinya preeklampsia.
Level of evidence I a, Rekomendasi A
WHO. Guidelines : Calcium supplemantation in pregnant women, Geneve, World Health
Organization , 2013
WHO. Guidelines : Calcium supplementation in pregnant women, Geneva, World Health
Organization , 2013
WHO. Guidelines : Calcium supplementation in pregnant women, Geneva, World Health
Organization , 2013
Antioxidant supplementation

Tidak berdampak terhadap risiko PE atau luaran klinis

Level 2 evidence; Cochrane Library 2008 Issue 1: CD004227
 Pencegahan

Pembatasan garam untuk mencegah preeklampsia dan

komplikasinya tidak direkomendasikan.
Level evidence I a, Rekomendasi A
 Aspirin

Rekomendasi

Aspirin dosis 75 mg atau kurang, cukup aman diberikan pada

kelompok risiko tinggi untuk menurunkan risiko preeklampsia.

Level evidence Ia, Rekomendasi A

 Prevention of Preeclampsia

Antioxidants: vitamins C and E are not effective.

Calcium: may be useful in populations with low
calcium intake (not in the USA).
Low-dose aspirin (60 to 80 mg): beginning in the
late first trimester may have slight effect to
reduce preeclampsia and adverse perinatal
outcomes.
Bed rest or salt restriction: no evidence of benefit
 TASK FORCE RECOMMENDATIONS
MONITORING
Close monitoring of women with gestational hypertension
or preeclampsia without severe features, with serial
assessment of maternal symptoms and fetal movement
(daily by the woman), serial measurements of BP (twice
weekly), and assessment of platelet counts and liver
enzymes (weekly) is suggested.

For women with gestational hypertension, monitoring BP at

least once weekly with proteinuria assessment in the office
and with an additional weekly measurement of BP at home
or in the office is suggested.
 TASK FORCE RECOMMENDATIONS

For women with severe preeclampsia at less

than 34 0/7 weeks of gestation with stable
maternal and fetal conditions, it is
recommended that continued pregnancy be
undertaken only at facilities with adequate
maternal and neonatal intensive care
resources.
 TASK FORCE RECOMMENDATIONS

For women with preeclampsia, it is suggested that a delivery

decision should not be based on the amount of proteinuria or
change in the amount of proteinuria.
It is suggested that corticosteroids be administered and
delivery deferred for 48 hours if maternal and fetal
conditions remain stable for women with severe
preeclampsia and a viable fetus at 33 6/7 weeks or less .
For women with severe preeclampsia and before fetal
viability, delivery after maternal stabilization is
recommended. Expectant management is not recommended.
 TASK FORCE RECOMMENDATIONS
MODE OF DELIVERY

For women with preeclampsia, it is suggested

that the mode of delivery need not be cesarean
delivery.

The mode of delivery should be determined by

fetal gestational age, fetal presentation, cervical
status, and maternal and fetal conditions.
 TASK FORCE RECOMMENDATIONS

For women with HELLP syndrome and before the gestational

age of fetal viability, it is recommended that delivery be
undertaken shortly after initial maternal stabilization.
For women with HELLP syndrome at 34 0/7 weeks or more of
gestation, it is recommended that delivery be undertaken
soon after initial maternal stabilization.
For women with HELLP syndrome from the gestational age of
fetal viability to 33 6/7 weeks of gestation, it is suggested
that delivery be delayed for 24-48 hours if maternal and fetal
conditions remain stable to complete a course of
corticosteroids for fetal benefit.
AC O G
 Chronic Hypertension

For women with chronic hypertension and NO

additional maternal or fetal complications, delivery
before 38 0/7 weeks of gestation is not
recommended.
A PENATALAKSANAAN PREEKLAMPSIA
Preeklampsia

L
O Usia
Kehamilan <
Usia
Kehamilan ≥

G
37 mgg 37 mgg

O Perawatan poliklinik
- Kontrol 2 kali perminggu

R
- Evaluasi gejala pemberatan preeklmapsia (tekanan darah, Terminasi
tanda impending, edemia paru Kehamilan
- Cek laboratorium (trombosit, serum kreatinin, albumin,

I (AST/ALT) setiap minggu

- Evaluasi kondisi janin (hitung fetal kick count/hari ),
kesejahteraan janin (NST dan USG) 2 kali/minggu, evaluasi

T pertumbuhan janin setiap 2 minggu.

M Perburukan kondisi maternal dan

janin/Preeklampsia Berat Usia

A Protokol Preeklampsia Berat

Kehamilan ≥ 37
mgg
 Pasien memenuhi persyaratan
perawatan konservatif
MANAJEMEN Preeklampsia dengan gejala
berat

KONSERVATIF
 Injeksi MgSO4sesuai prosedur (Alternatif 1 / Alternatif 2 )
PEB dilanjutkan hingga 24 jam
 Berikan pematangan paru (Dexamathason 2 x 6mg i.m
selama 2 hari atau bethametason 1 x 12 mg i.m selama
2 hari)

Pindah ruangan, l akukan evaluasi ketat

Evaluasi Klinis Evaluasi Evaluasi Janin

 Kontrol tekanan darah
 Evaluasi tanda impending
eklampsia (nyeri
epigastrium, nyeri kepala,
mata kabur)
Laboratorium  NST setiap minggu
 Trombosit, fungsi liver,  USG untuk evaluasi
fungsi ginjal, albumin kesejahteraan janin 2 kali
setiap minggu seminggu
 Evaluasi pertumbuhan janin /
2 minggu

Semua parameter Salah satu parameter

baik memburuk

Umur kehamilan ≥ 34 Terminasi kehamilan

minggu
Terminasi kehamilan
 PENATALAKSANAAN PREEKLAMPSIA BERAT

A Preeklampsia dengan gejala berat

 MRS, Evaluasi gejala, DJJ, dan
cek
laboratorium
≥ 34

L
minggu
 Stabilisasi, pemberian MgSO4
profilaksis

< 34

O
minggu

Jikadidapatkan
Eklampsa:

G
 Edema paru
 DIC
Terminasi kehamilan
 HT berat, tidak terkontrol
 Gawat janin setelah stabilisasi

O
Iy
 Solusio plasenta a
 IUFD
 Janin tidak viabel (tergantung

R
kasus)
Tida
k
Jika didapatkan : Jika usia kehamilan >

I
 Gejala persisten 24 minggu :
 Sindrom HELLP Pematangan paru (inj
 Pertumbuhan janin terhambat dexamethason IM
2x6 mg atau

T
 Severe olygohydramnion Iya
 Reversed end diastolic flow betamethason IM
 Gangguan renal berat 1x12 mg) 2x24 jam,
MgSO4 40%

M
Tidak

Perawatan konservatif
:  Evaluasi di kamar bersalin selama 24-48  Usia kehamilan ≥ 34 minggu

A
jam
K PD atau inpartu
 Rawat inap 4hingga
Stop MgSO terminasi
, profilaksis (1x24 jam)
 Perburukan maternal - fetal
 Pemberian anti HT jika TD ≥ 160/110
 Pematangan paru 2x24 jam
 Evaluasi maternal-fetal secara
PENGOBATAN PE
 Hypertension in Pregnancy
ANTI HIPERTENSI (Report of the ACOG Task Force on Hypertension in Pregnancy)
Obstetrics & Gynecology, Vol. 122, No. 5, November 2013

• Indikasi utama pemberian anti hipertensi ada kehamilan adalah

untuk keselamatan ibu dan mencegah penyakit
serebrovaskuler
• Obat anti hipertensi diberikan bila tekanan darah >160/110
mmHg (II/A)  MAP ≥ 125 mmHg UNTUK Hipertensi
Gestational dan Preeklampsia
• Untuk Hipertensi Kronik > 140/90 mmHg dapat di terapi.
• Pemberian anti hipertensi pilihan pertama adalah Nifedipin oral ,
hydralazine, dan labetalol parenteral (I/A)
• Alternatif anti hipertensi yang lain adalah : Metildopa (Dopamet),
nitrogliserin,, labetalol (I/B)
MEAN ARTERIAL PRESSURE (MAP): Sistolik + (2 x Diastolik)
3
American Journal of Obstetrics & Gynecology Vol. 227 Issue
2B24–B27 Published online: April 19, 2022
S E M INARSIN P E R I N ATOLOGY 3 7(2013)280 – 2 8 7
Aronow WS. Treatment of hypertensive emergencies. Ann Transl Med 2017;5(Suppl 1):S5
 MAGNESIUM SULFAT – MgSO4

• Direkomendasikan sebagai terapi lini

pertama
preeklampsia / eklampsia
• Direkomendasikan sebagai profilaksis terhadap
eklampsia pada pasien preeklampsia (I/A)
• Merupakan pilihan utama pada pasien preeklampsia
dibandingkan diazepam atau fenitoin untuk mencegah
terjadinya kejang atau kejang berulang (1a/A)
 DOSIS D AN CARA
PEMBERIAN
MgSO4
• Loading dose : 4 g MgSO4 40% dalam 100 cc NaCL :
habis
dalam 30 menit (73 tts/ menit)
• Maintenance dose : 6 gr MgSO4 40% dalam 500 cc Ringer
Laktat/ D5 selama 6 jam (28 tts/menit)
• Awasi : volume urine, frekuensi nafas, dan reflex patella setiap
jam
• Pastikan tidak ada tanda-tanda intoksikasi magnesium
pada setiap pemberian MgSO4 ulangan
• Bila ada kejang ulangan : berikan 2 g MgSO4 40% IV bolus
 MgSO4 40% 1 gr = 2,5
cc
MgSO4 20% 1 gr – 5 cc

ANTIDOTUM CALCIUM GLUCONAS 1 GRAM (10cc)