dr.

Yudianto Budi Saroyo, SpOG (K)

Staf Fetomaternal, Departemen Obstetri & Ginekologi FKUI/RSUPN

Cipto Manukusumo
Pelatih/ Anggota
Peserta
Fasilitator Advanved PokJa
International
Advanced Trainer HIV/AIDS &
Pelatih Course
Pelatih Basic Labour And Jaringan Pelatih
Resusitasi Sexual
Surgical Skill Risk Nasiona PMTCT
Neonatus Reproductive
POGI, tahun Management Pelatihan Kementerian
Perinasia, Health and
2004- (ALARM) Klinik- Kesehatan
tahun 2004- Right,
sekarang. POGI, tahun Kesehatan Republik
sekarang. Swedia,
2005- Reproduksi, Indonesia,
Pebruari
sekarang tahun 2005- tahun 2007-
2009
sekarang. sekarang.
Diagnosis and management of
pre-eclampsia in pregnancy
 Tujuan Pembicaraan
• Epidemiologi - Latar Belakang
• Definisi
• Fisiologi Implantasi Plasenta
• Beberapa teori tentang Pre-eklampsia
• Tatalaksana
• Pencegahan
• Kesimpulan
• Tera
 Tujuan Pembicaraan
• Epidemiologi - Latar Belakang
• Definisi
• Fisiologi Implantasi Plasenta
• Beberapa teori tentang Pre-eklampsia
• Tatalaksana
• Pencegahan
• Kesimpulan
• Tera
Millennium Development Goals
Goal 4: Menurunkan angka kematian balita
• Target 4a: Menurunkan 2/3 angka kematian balita.

Goal 5: Meningkatkan kesehatan maternal

• Target 5a: Menurunkan ¾ angka kematian maternal.
• Target 5b: Akses universal kesehatan reproduksi pada tahun 2015.

Goal 6: Memberantas penyakit HIV/AIDS, malaria dan

penyakit lainnya.
• Target 6a: Menghentikan dan mengurangi penyebaran HIV/AIDS
• Target 6b: Akses universal dan Pengobatan bagi seluruh penderita
HIV/AIDS
• Target 6c: Menghentikan dan mengurangi insidens malaria.
 Penyebab AKI

Lain-lain
12% Perdarahan
Kompl masa 29%
puerpureum
8%
Emboli obst
3%

P. lama/macet
5%

Abortus
5%
Infeksi
12%
Pre/Eklampsia
25%
 Prakiraan Waktu menuju Kematian untuk
Kasus Kegawatdaruratan Obstetri
Penyebab Waktu
Perdarahan Postpartum 2 jam
Perdarahan Antepartum 12 jam
Ruptur Uteri 1 hari
Eklampsia/PEB 2 hari
Persalinan Macet 3 hari
Infeksi 6 hari

Briley A, Bewley S. Management of obstetric hemorrhage: obstetric management. In: Briley A, Bewley S, editors. The Obstetric Hematology Manual.
Cambridge: Cambridge University Press; 2010. p. 151-58.
 PREEKLAMSIA

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

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

 Tujuan Pembicaraan
• Epidemiologi - Latar Belakang
• Definisi
• Fisiologi Implantasi Plasenta
• Beberapa teori tentang Pre-eklampsia
• Tatalaksana
• Pencegahan
• Kesimpulan
• Tera
 Definisi
• Hipertensi
– TD: 140/90 (135/85) mmHg

• Preeklampsia berat
– Absolut: TD: 160/110 mmHg + proteinuria (> 3 g/24 jam)
– Atau Hipertensi + Disfungsi Endotel : HELLP, Gagal Ginjal, Edema Paru, Buta
Kortikal, PJT, Nyeri kepala menetap

Pengukuran TD:
• Duduk, cuff setinggi atrium kanan, 60% lengan
• Istirahat 15 menit
• Korotkoff I & V
• Setara mmHg
AHA 2003
 PREEKLAMSIA

• Disease of theories
• Insiden: 16.3%, MM: 1.9%, MP: 9.9%
• Th/ Definitif: Lahirkan dengan segala risiko
• Pencegahan: upaya terbaik, hasil tidak bermakna???????

Buku Tahunan 1993-1994, BMJ 2007;335(7627):974,

Hypertension 2007;49(5):1056-62, J Clin Endocrinol Metab 2006;91(4):1233-8
 Hipertensi
bukan
penyakit tapi
merupakan
reaksi tubuh
PREEKLAMPSIA

Implantasi
yang tak
sempurna

Hipertensi terjadi
sebagai
mekanisme
kompensasi
penuhi kebutuhan
 Hipovolemia

Vasospame Preeklampsia Hipertensi

Peningkatan respon thd vasopresor

 Tujuan Pembicaraan
• Epidemiologi - Latar Belakang
• Definisi
• Fisiologi Implantasi Plasenta
• Beberapa teori tentang Pre-eklampsia
• Tatalaksana
• Pencegahan
• Kesimpulan
• Tera
 The diagram presents an overview of early
trophoblast development.

The first development of the trophoblast lineage at the blastocyst stage is followed by the
separation of cytotrophoblast and syncytiotrophoblast, which subsequently is followed by
the differentiation of the 2 pathways of trophoblast differentiation, villous and
extravillous. On the right, the time course of development after fertilization (p.c., post
coitum) is shown.
Huppertz B. Placental origins of preeclampsia: challenging the current hypothesis. Hypertension. 2008 Apr;51(4):970-5.
 Invasion defects in preeclampsia.
(A) In a normal placenta, extravillous
cytotrophoblast (ECTB) cells (green) move into
the decidua (endometrium) and myometrium via
interstitial invasion. Some ECTB cells enter
maternal spiral arteries and replace the
endothelial cells of the vessel walls, becoming
endovascular ECTB (eECTB) cells, increasing
vessel compliance and maximizing blood flow
into placental blood spaces. (B) In the placenta of
a preeclamptic patient, interstitial invasion is
shallow and limited, with many ECTB cells in the
basal plate remaining attached to anchoring villi
(AV). Endovascular invasion is nearly absent, and
spiral arterioles remain ‘stiff’. FV, floating villi.
Image courtesy of The Curators of the University
of Missouri (2011), a public corporation

Kathleen A. Pennington, Jessica M. Schlitt, Daniel L. Jackson, Laura C. Schulz, and Danny J. Schust. Preeclampsia: multiple
approaches for a multifactorial disease. Dis Model Mech. 2012 January; 5(1): 9–18.
 PO 2 placenta 17,9 (SD 6,9) mmHg

PO 2 plasenta 60,7 (sd 8,5)mmHg

Burst Oxidative

Prooxidant – antioxidant Balance

ROS dan RNS berperan penting pd PEE
– Scr langsung induksi disfungsi endothelial
– Induksi hipertensi dan proteinuria melalui:
• RAS
• inflammasi
• Insulin resistan
• Pro – anti angiogenic
• menurunkan NO dg meningkatkan
ADMA dan menurunkan HO-1
Poiseuille’s+Bernoulli’s • Kantung elastis
Failure SMC modification • Bertahanan rendah
Diameter : ↑4–6X • Arus tinggi
Aliran drh: tonik  O2-  hipertensi • Bebas regulasi neurovascular

Syncytial knot: aptototic sincytrophoblast FLOW 10.000

Exp.Physiol 1997; 82;377 - 87

Debris ke sirkulasi maternal sitokin  disfungsi endotel PENUHI KEBUTUHAN JANIN

 Possible pathophysiological processes in pre-eclampsia

AV=anchoring villus. COE=coelomic cavity. CY=cytotrophoblast. DB=decidua basalis. DC=decidua capsularis. DP=decidua parietalis.
EN=endothelium. ET=extravillous trophoblast. FB=fetal blood vessel. FV=fl oating villus. GL=gland. IS=intervillous space. JZ=junctional
zone myometrium. MB=maternal blood, leaving the intervillous space with various components such as antiangiogenic factors.
MV=maternal vein. SA=spiral artery. SM=smooth muscle. ST=stroma. SY=syncytiotrophoblast. TM=tunica media. UC=uterine cavity. sFlt-
1=soluble form of the vascular endothelial growth factor receptor. Centre panel of fi gure adapted from Karumanchi et al,18 with
permission from Elsevier.

Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44.
 Tujuan Pembicaraan
• Epidemiologi - Latar Belakang
• Definisi
• Fisiologi Implantasi Plasenta
• Beberapa teori tentang Pre-eklampsia
• Tatalaksana
• Pencegahan
• Kesimpulan
• Tera
 Pathogenesis of Preeclampsia

AT1-AA, immunological factors, oxidative stress and other factors (such as decreased
hemoxygenase expression) may cause placental dysfunction which in turn leads to the
release of anti-angiogenic factors (such as sFlt1 and sEng) and other inflammatory
mediators to induce preeclampsia
Powe CE, Levine RJ, Karumanchi SA. Preeclampsia, a disease of the maternal endothelium: the role of antiangiogenic factors
and implications for later cardiovascular disease. Circulation. 2011 Jun 21;123(24):2856-69.
 Perkembangan Pre-eklampsia

Skema sekuen kejadian sepanjang kehamilan sampai timbul gejala klinis pre-eklampsia. EC,
endothelial cell; HO-1, haem oxygenase 1; TGF-β, transforming growth factor β.
Ramma W, Ahmed A. Is inflammation the cause of pre-eclampsia? Biochem Soc Trans. 2011 Dec;39(6):1619-27.
 Genetik
Immunologik
Etiologic Factors Nutrisi
Infeksi

Perubahan pada angiogenesis

Fetoplacental

Pathophysiology
Lain2:
Kegagalan
Stress VEGF
Invasi
Oxidative TNF
Trophoblast
dll

Disfungsi Endothel

Clinical Manifestation Hypertensi & Proteinuria

PREEKLAMPSIA
 Overlapping role of hypertension, capillary leak, maternal
symptoms, and fibrinolysis/hemolysis in the spectrum of atypical
preeclampsia

Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet
Gynecol. 2009 May;200(5):481 e1-7.
PREECLAMPSIA
 Tujuan Pembicaraan
• Epidemiologi - Latar Belakang
• Definisi
• Fisiologi Implantasi Plasenta
• Beberapa teori tentang Pre-eklampsia
• Tatalaksana
• Pencegahan
• Kesimpulan
• Tera
 Antepartum management options for women with pre-
eclampsia by gestational age at diagnosis

NICU=neonatal intensive care unit. *As defi ned locally (usually between 23 weeks’ [+0 days] and 24 weeks’ [+6 days] gestation). †Unpublised
data from PIERS.86 ‡Chance of living to discharge from a NICU without major morbidity (≥grade 3 intraventricular haemorrhage, stage 3 or 4
retinopathy of prematurity, necrotising enterocolitis, and chronic lung disease).
Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44.
 Antepartum management options for women with pre-
eclampsia by gestational age at diagnosis

NICU=neonatal intensive care unit. *As defi ned locally (usually between 23 weeks’ [+0 days] and 24 weeks’ [+6 days] gestation). †Unpublised
data from PIERS.86 ‡Chance of living to discharge from a NICU without major morbidity (≥grade 3 intraventricular haemorrhage, stage 3 or 4
retinopathy of prematurity, necrotising enterocolitis, and chronic lung disease).
Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44.
 Suggested antepartum management options for women
with pre-eclampsia at any stage of diagnosis

Optional assessment and surveillance

• On admission, on day of delivery, and additional
testing as indicated by changes in clinical state.
Maternal
• Blood: haemoglobin, platelet count, creatinine,
uric acid, AST or ALT, further testing if indicated
Fetal
• CTG, ultrasound, AFI, umbilical artery Doppler

Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44.
 Suggested antepartum management options for women
with pre-eclampsia at any stage of diagnosis

MgSO4
• Regimen: MgSO4 4 g IV loading dose over 15–20 min,
followed by an infusion of 1 g/h; recurrent seizure(s) treated
with additional 2–4 g IV loading dose(s); clinical monitoring
by measurement of urinary output, respiratory rate, and
tendon refl exes.
Eclampsia prophylaxis
• Yes; for severe pre-eclampsia during initial stabilisation and
peripartum (delivery +24 h)
Eclampsia treatment
• Yes

Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44.
 Suggested antepartum management options for women
with pre-eclampsia at any stage of diagnosis

Antihypertensive therapy
Severe hypertension (systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg)
– Nifedipine capsule (5 mg orally for first dose, 10 mg orally subsequently) every 30
min;
– Nifedipine intermediate acting (10 mg orally) every 45 min;
– Labetalol (100 mg orally) every 45 min, maximum 1200 mg/day;
– Labetalol (20 mg IV first dose, repeat 20–80 mg IV every 30 min, or 1–2 mg/min,
maximum 300 mg);
– Hydralazine (5–10 mg IV) every 30 min, maximum 20 mg
• Nifedipine capsules are safe to use contemporaneously with MgSO4;
nifedipine capsules should not be used in women with known coronary
artery disease, aortic stenosis, or longstanding diabetes (eg, >15 years); after
two consecutive doses of acute therapy (ie, nifedipine, labetalol,
hydralazine), start or increase maintenance therapy with agents listed below

Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44.
 Suggested antepartum management options for women
with pre-eclampsia at any stage of diagnosis

Antihypertensive therapy
Non-severe hypertension (systolic BP <160 mm Hg and diastolic BP 90–
109 mm Hg)
– Labetalol (100–400 mg orally 2–4 times daily, maximum 1200 mg/day);
– Intermediate-acting nifedipine (10–20 mg orally 2–3 times daily, maximum 120
mg/day);
– Nifedipine sustained release preparation (20–60 mg orally daily, maximum 120
mg/day); methyldopa (250–500 mg orally 2–4 times daily, maximum 2 g/day);
– other β blockers (other than atenolol)
• In the absence of renal disease, pre-pregnancy diabetes, or other
indications for strict maintenance of strict normotension, whether BP
targets should be high normotension (eg, diastolic BP 85 mm Hg) or non-
severe hypertension (eg, diastolic BP 105 mm Hg) is unknown;
• ACE inhibitors, ARBs, atenolol, and prazosin should be avoided

Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44.
 Suggested antepartum management options for women
with pre-eclampsia at any stage of diagnosis

Plasma volume expansion

• No; because of risks of maternal mortality
associated with pulmonary oedema, in women
with severe pre-eclampsia infusion of sodium-
containing fluids might need to be restricted and
balanced against urine output over 4 h or more
and creatinine concentrations
Thromboprophylaxis
• Yes; if on bed rest for 4 days or more

Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010 Aug 21;376(9741):631-44.
 Warning signs preceding critical event

Hemodynamic changes included systolic blood pressure <90 or >200mmHg, pulse <50 or
>130 beats/min; respiratory included rate >30/min, oxygen saturation <85%; abnormal
laboratory results included pH <7.2, Na+ <125 or >150mmol/L, K+ >6mmol/L; abnormal
temperature <95°F or >104°F. GCS = Glasgow Coma Score
Buist MD, Jarmolowski E, Burton PR, et al. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to
intensive care. A pilot study in a tertiary-care hospital. Med J Aust. 1999;171:22–25. In: DeVita MA, Hillman K, Bellomo R, editors. Medical
Emergency Teams Implementation and Outcome Measurement. Pittsburgh: Springer Science+Business Media; 2006 p. 80-90.
 Position Task Completion
(Performance improvement of role-related tasks from the first through the third sessions of a
human-simulator crisis team-training program.)

DeVita MA, Hillman K, Bellomo R, editors. Medical Emergency Teams Implementation and Outcome Measurement. Pittsburgh: Springer
Science+Business Media; 2006 p. 80-90.
 Roles and goals of crisis team members

Roles Goals
Airway manager (#1) Manages ventilation and oxygenation,
intubates if necessary
Airway assistant (#2) Provides equipment to airway
manager, assists with bag-mask
ventilation
Bedside assistant (#3) Provides patient information including
AMPLE*, medications delivery
Equipment manager Draws up medications, supplies crash
(#4) cart contents to appropriate team
members
Data manager/ recorder Records vital signs, exam findings, test
(#8) results, chart
Circulation (#6) Evaluates pulses, performs chest
compressions
Procedure MD (#7) Performs procedures such as central
lines, chest tubes, pulse check
Treatment leader (#5) Analyzes data, diagnoses, and directs
patient treatment

DeVita MA, Hillman K, Bellomo R, editors. Medical Emergency Teams Implementation and Outcome Measurement. Pittsburgh: Springer
Science+Business Media; 2006 p. 80-90.
 Risk of Mortality: Independent
Predictors
Event Odds ratio and 95% CI
Decrease of 6,4 (2,6–15,7)
consciousness
Hypotension 2,5 (1,6–4,1)
Loss of consciousness 6,4 (2,9–13,6)
Bradypnea 14,4 (2,6–80,0)
SaO2 < 90% 2,4 (1,6–4,1)
Tachypnea 7,2 (3,9–13,2)

Buist M, Campbell D. The Challenge of Predicting In-Hospital Iatrogenic Deaths. In: DeVita MA, Hillman K, Bellomo R, editors. Medical Emergency
Teams Implementation and Outcome Measurement. Pittsburgh: Springer Science+Business Media; 2006 p. 32-48.
 Tujuan Pembicaraan
• Epidemiologi - Latar Belakang
• Definisi
• Fisiologi Implantasi Plasenta
• Beberapa teori tentang Pre-eklampsia
• Tatalaksana
• Pencegahan
• Kesimpulan
• Tera
 Faktor – faktor Risiko Preeclampsia
Faktor maternal Inheren • Umur < 20 atau 35–40
• 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
• Stress

Pregnancy specific • Kehamilan majemuk

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

Faktor Paternal Paparan dg sperma terbatas • Barrier contraception

• Pertama kali menjadi ayah
• Donor insemination

Suami dg riwayat preeklampsia dengan pasangan terdahulu

Lancet  2001;357:209–15
 Reviews and Randomized Clinical Trials for Preeclampsia
Recurrence Prevention
Odds Ratio
Agent Study Population N (95% CI)
Aspirin Coomarasamy33 High risk 12,416 0,86 (0,79-0,94)

Duley32 High risk 33,439 0,81 (0,75-0,88)

Calcium Hofmeyr34 Meta-analysis low risk 15,206 0,48 (0,33-0,69)

Meta-analysis high risk 587 0,22 (0,12-0,42)

Magnesium Spatling35 General low-risk 568 NS

Sibai36 Normotensive 374 NS
primigravidas
Fish oil Makrides37 All risk 1,683 0,86 (0,59-1,27)

Vitamins C + E Poston41 High risk 2,41 0,97 (0,80-1,17)

Rumbold42 Nulliparous women 1,877 1,20 (0,82-1,75)

Dildy GA, 3rd, Belfort MA, Smulian JC. Preeclampsia recurrence and prevention. Semin Perinatol. 2007 Jun;31(3):135-41.
 Summary of Studies that Present the Risk for Recurrence of
Preeclampsia
Author Study Population Rate of Recurrence
Campbell7 Preeclampsia (n = 279) Preeclampsia 7,5%
Sibai9 Second trimester severe preeclampsia (n Any preeclampsia 65%
= 169) <28 weeks 21%
28-36 weeks 21%
37-40 weeks 24%
van Rijn8 Preeclampsia with delivery <34 weeks Preeclampsia 25%
Sullivan 12 HELLP (n = 161) Preeclampsia 43%
HELLP 27%
Sibai11 HELLP (n = 192) Preeclampsia 19%
HELLP 3%
Chames13 HELLP with delivery <28 weeks (n = 62) Preeclampsia 55%
HELLP 6%
Adelusi14 Eclampsia (n = 64) Eclampsia 16%
Sibai16 Eclampsia (n = 366) Preeclampsia 22%
Eclampsia 2%
Trogstad17 Preeclampsia singleton (n = 19,960) Preeclampsia 14,1%
Preeclampsia twins (n = 325) Preeclampsia 6,8%
Dildy GA, 3rd, Belfort MA, Smulian JC. Preeclampsia recurrence and prevention. Semin Perinatol. 2007 Jun;31(3):135-41.
 Long-term health risks
Hypertensive disorder
Future Risk Gestational Severe pre-eclampsia,
Pre-eclampsia HELLP syndrome or
hypertension eclampsia
Gestational Risk ranges from about
hypertension in 1 in 6 (16%) to about 1 Risk ranges from about 1 in 8
(13%) to about 1 in 2 (53%).
future pregnancy in 2 (47%).
If birth was needed
Risk ranges from 1 in Risk up to about 1 in 6 (16%). before 34 weeks risk is
Pre-eclampsia in No additional risk if interval about 1 in 4 (25%).
50 (2%)
future pregnancy 14 (7%).to about 1 in before next pregnancy < 10 If birth was needed before
years. 28 weeks risk is about 1 in
2 (55%).
Cardiovascular
Increased risk of hypertension and its complications.
disease
If no proteinuria and no
End-stage hypertension at 6–8 week
postnatal review, relative risk
kidney disease
increased but absolute risk low.
No follow-up needed.
Thrombophilia Routine screening not needed.

NICE 2010 Quick Ref

 Methods to prevent pre-eclampsia

Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet. 2005;365:785-99

 Upaya pencegahan
• Pra konsepsi  optimalkan status nutrisi
– Multivitamin dan mineral, protein dan mix karbohidrat
– Bereskan infeksi: periodontitis, UTI, cervico vaginitis
– Upayakan berat badan ideal
– Olah raga teratur

• Saat hamil
– Pertahankan upaya pra konsepsi
 Kontrasepsi
Pil AKDR-
KOK KIK KOP KIP Implan Kondar AKDR LNG Tubektomi
Riwayat TD
tinggi selama
kehamilan 2 2 1 1 1 - 1 1 A
(sekarang TD
normal)
Sistolik 140–
159 atau 3 3 1 2 1 - 1 1 C
diastolik 90–99
Sistolik ≥ 160
or diastolik ≥ 4 4 2 3 2 - 1 2 S
100
KOK= Kontrasepsi oral kombinasi; KIK= Kontrasepsi injeksi kombinasi; KOP= Kontrasepsi
oral progestin; KIP= Kontrasepsi injeksi progestin; Kondar =kontrasepsi darurat; AKDR= alat
kontrasepsi dalam rahim; AKDR-LNG= alat kontrasepsi dalam rahim Levonorgestrel.
 Continuum of care for maternal, newborn, and child health: from
slogan to service delivery

Kate J Kerber, Joseph E de Graft-Johnson, Zulfi qar A Bhutta, Pius Okong, Ann Starrs, Joy E Lawn. Continuum of care for maternal, newborn, and
child health: from slogan to service delivery. Lancet 2007; 370: 1358–69
 Continuum of care for maternal, newborn, and
child health: from slogan to service delivery

Kate J Kerber, Joseph E de Graft-Johnson, Zulfi qar A Bhutta, Pius Okong, Ann Starrs, Joy E Lawn. Continuum of care for
maternal, newborn, and child health: from slogan to service delivery. Lancet 2007; 370: 1358–69
 Kesimpulan
• Preeklampsia masih merupakan salah satu
penyebab kematian maternal.
• Pengertian mendalam tentang patofisiologi
preeklampsia akan mengurangi dampak
preeklampsia.
• Penanganan terintegrasi dan pendekatan tim
akan menurunkan morbiditas dan mortalitas
maternal akibat PEB/Eklampsia
TERIMA KASIH