R.

HARYONO ROESHADI,

KLASIFIKASI :
Report on the National High Blood Pressure Education
Program Working Group on High Blood Pressure in
Pregnancy (AJOG Vol 183:S1, July 2000)

HIPERTENSI GESTASIONAL :
DIDAPATKAN DESAKAN DARAH 140/90 mmHg PERTAMA

KALINYA PD KEHAMILAN, TDK DISERTA DGN PROTEINURIA

DAN DESAKAN DARAH KEMBALI NORMAL < 12 MGG PASCA
PERSALINAN

PREECLAMSIA :
KRITERIA MINIMUM
DESKAN DARAH 140/90 mmHg UMUR KEHAMILAN 20 MGG,
DISERTAI PROTEINURIA 300 mg/24 JAM ATAU DIPSTICK 1 +

ECLAMSIA
KEJANG2 PADA PREECLAMPSIA DISERTAI KOMA

HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA

PROTEINURIA 300 MG/24 JAM PD HAMIL YG SUDAH

MENGALAMI HIPERTENSI SEBELUMNYA. PROTEINURIA

TIMBUL

SETELAH KEHAMILAN 20 MGG

HIPERTENSI KRONIK
DITEMUKANNYA DESAKAN DARAH 140/90 mmHg, SEBELUM
KEHAMILAN ATAU SEBELUM KEHAMILAN 20 MGG DAN TDK

MENGHILANG SETELAH 12 MGG PASCA PERSALINAN

INTRODUCTION :

INDUCED BY PREGNANCY

DISEASE OF THEORIES

CLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUT

ORGAN DYSFUNCTION / FAILURE

THIRD LEADING CAUSE OF MATERNAL MORTALITY

MORTALITY RATE

: 150.000 WOMEN A YEAR WORLD

WIDE

INCIDENCE
PE/E : 2% - 9% OF ALL PREGNANT WOMEN
IN SEVERAL HOSPITAL IN INDONESIA
YEAR

HOSPITAL

PERCENTAGE

1993 1997

RSPM

1996 1997

12 HOSPITALS

1995 1998

RS. H.S.

13,0

MEIZIA

2000 2002

RSHAM RSPM

7,0

GIRSANG. E

2002

RSCM

9,17

PRIYATINI

5,75
0,8 - 14

AUTHOR
SIMANJUNTAK J.
TRIBAWONO A.

ETIOLOGY : NOT FULLY KNOWN

RISK FACTORS :
NULLI PARITY / TEENAGE PREGNANCY
HISTORY OF PREVIOUS PREGNANCY
FAMILY HISTORY OF PE/E
MULTIPLE GESTATION
PREEXISTING HYPERTENSION / RENAL DISEASE
D.M, ANTI PHOSPOLIPID ANTIBODY
HYDROPS FETALIS
HYDATIDIFORM MOLES
URYNARY TRACT INFECTION

PATHOGENESE :

CONTROVERSION : THE DISEASE OF THEORIES

IMMUNITY, GENETIC
VASC. DISEASE
TROPHOBLAST

INADEQUATE TROPHOB. INVASION TO

SPIRAL ARTERY OF PLACENTA

INSUFF, PLACENTA
HYPOXIA

IUGR

CIRCULATING FACTOR(S)
CYTOKINES
LIPID
(IL-6, TNF-)
PEROXIDES

OXYDATIVE STRESS

NEUTROPHIL
ACTIVATION

ENDOTHELIAL DYSFUNCTION

PLATELET
ACTIVATION

ENDOTHELIAL DYSFUNCTION

BLOOD
THROMBOCYTOPENIA
COAGULAPATHY

ALTERED VASCULAR
PERMEABILITY
PERIPHERAL OEDEMA
PULMONARY OEDEMA

LIVER
ABNORMAL FUNCTION
TESTS
HAEMORRHAGE

SYSTEMIC
VASOCONSTRICTION
HYPERTENSION

KIDNEYS
HYPERURICAEMIA
PROTEINURIA
RENAL FAILURE

CNS / EYES
SEIZURES
CORTICAL BLINDNESS
RETINAL DETACHMENT
& HAEMORRHAGE

CLINICAL CLASSIFICATION:
PREECLAMPSIA

- MILD
- SEVERE

IMPENDING ECLAMPSIA
ECLAMPSIA
HELLP SYNDROME

MILD PREECLAMPSIA :
BP 140/90 mmHg AFTER 20 WEEKS GESTATION
PROTEINURIA 300 mg/ 24 H OR 1+ DIPSTICK
WITH OR WITHOUT OTHER SYMPTOMS AND SIGN

SEVERE PREECLAMPSIA

BP 160/110 mmHG

PROTEINURIA 2.0 gr / 24 H OR 2 + DIPSTICK

HEADACHE, VISUAL OR CEREBRAL DISTURBANCE

EPIGASTRIC PAIN

OLIGURIA : < 400 500 CC/ 24 HOURS

HYPER REFLEX, MOTORIC EXCITATION, IMPAIRED

CONSIOUSNESS, SUDDEN DETERIORATION

PLATELETS COUNT < 1000.000 / mm3

BILIRUBIN 1,2 mg / DL

LDH > 600 IU/L

SGOT > 70 mg/DL

IMPENDING ECLAMPSIA

SEVERE PREECLAMPSIA WITH :

HEADACHE

NAUSEA AND VOMITING

BLURRED VISION, SCOTOMA, IMPAIRED CONSIOUSNESS,

SUDDEN DETERIORATION

EPIGASTRIC PAIN

ECLAMPSIA
SEVERE PREECLAMPSIA + CONVULSION
IS THE LEADING CAUSE OF 50.000 MATERNAL MORTALITY
A YEAR WOLRD WIDE
75% OCCURRED ANTEPARTUM AND 25% POST PARTUM
40% OF SEIZURES OCCUR BEFORE HOSPITALIZATION
CEREBRAL HAEMORRHAGE, PULMONARY EDEMA ARE THE
MOST COMMON COMPLICATION

HELLP SYNDROME

COMPLICATION OF SEVERE PREECLAMPSIA

10-15% DIRECTLY FROM PREGNANCY

MANAGEMENT OF PREECLAMPSIA
ADEQUAT AND PROPER PRENATAL CARE
IDENTIFICATION OF WOMEN AT HIGH RISK
EARLY DETECTION BY THE RECOGNATION OF CLINICAL
SIGNS AND SYMPTOMS
THE PROGRESSION OF CONDITION TO SEVERE STATE

 MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD

PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY
FAVOURABLE
MATERNAL AND PERINATAL OUTCOMES DEPEND ON :
GESTATIONAL AGE AT TIME OF DISEASE ONSET
SEVERITY OF DISEASE
QUAITY OF MANAGEMENT
PRESENCE OR ABSENCE OF PRE-EXISTING MEDICAL
DISORDERS

MILD PREECLAMPSIA
AMBULATORY CARE
BED REST : NOT NECESSARILY
REGULAR DIET, NO SALT RESTRICTION
PRENATAL VITAMIN
NO OTHER MEDICATION : ANTI HYPERTENSIVE,
SEDATIVE, DIURETICS
ANTENAL VISIT : EVERY WEEK

HOSPITAL CARE
PERSISTENT HYPERTENSION MORE THAN 2 WEEKS
PERSISTENT PROTENURIA MORE THAN 2 WEEKS
ABNORMAL LABORATORY TEST
ABNORMAL FETAL GROWTH
ONE OR MORE SIGN AND SYMPTOM SEVERE PE

 OBSTETRIC MANAGEMENT

GESTATIONAL AGE < 37 WEEKS

~ SIGN AND SYMPTOM ARE NOT WORSENED
MAINTAIN UNTIL TERM

GESTATIONAL AGE > 37 WEEKS

~ WAIT UNTIL THE ONSET OF LABOR
~ CERVIX IS FAVORABLE, INDUCTION OF LABOR

SEVERE PREECLAMPSIA
MEDICAL TREATMENT
OBSTETRIC MANAGEMENT :

CONSERVATIVE : -

PREGNANCY 37 WEEKS

ACTIVE

PREGNANCY 37 WEEKS

: -

FETAL INDICATION

MATERNAL INDICATION

MEDICAL TREATMENT :

HOSPITALIZE
TOTAL BED REST
FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.
Mg SO4 IV

ANTI HYPERTENSION :
HYDRALAZIN
LABETALOL
NIFEDIPINE : 10 20 mg / ORALLY EVERY - 1 H,
MAX : 120 mg / 24 Hours
DIURETIC
: NOT RECOMMENDED
ANTI OXYDANT : N-ACETYL CYSTEIN
CORTICOSTEROID + LUNG MATURITY 34 WEEKS

OBSTETRIC MANAGEMENT
CONSERVATIVE MANAGEMENT:
GOAL

: TO IMPROVE INFANT OUTCOME,

WITHOUT COMPROMISING THE MOTHER

PREGNANCY 37 WEEKS, IMPENDING ECLAMPSIA (-)

ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY
INDICATION
FETAL

: - PREGNANCY 37 WEEKS
- IUGR AND ABNORMAL
BIOPHYSICAL PROFILE

MATERNAL : - PERSISTENT HYPERTENTION

- IMPENDING ECLAMPSIA
- COMPLICATION : HELLP SYNDROME,
ABRUPTIO PLAC., OLIGURIA
ROUTE OF DELIVERY :

VAGINAL DELIVERY IS PREFERABLE THAN CS.

ECLAMPSIA : PE + CONVULSION
BASIC MANAGEMENT :
CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)
STABILIZE THE MOTHER
CONTROL CONVULSION
CORRECT MATERNAL HYPOXEMIA / ACIDEMIA
PREVENT COMPLICATION : HYPERTENSION CRISIS
TERMINATE PREGNANCY

MEDICAL TREATMENT :
SAME AS SEVERE PREECLAMPSIA

COMPLICATION : P.E AND ECLAMPSIA

MOTHER

BABY

HELLP SYNDROME

IUGR

LIVER RUPTURED

PREMATURE LABOR

PULMONARY EDEMA

INTRA CRANIAL HAEMORRHAGE

RENAL FAILURE

CEREBRAL PALSY

ABRUPTIO PLACENTAE

PNEUMO THORAX

DIC

IUFD

CEREBROL VASCULER ACCIDENT

MATERNAL DEATH

HIPERTENSI KRONIK DALAM KEHAMILAN

DEFINISI KLINIK:
HIPERTENSI YG DIDAPAT SEBELUM KEHAMILAN ATAU
SEBELUM UMUR KEHAMILAN 20 MGG DAN HIPERTENSI TDK
MENGHILANG SETELAH 12 MGG PASCA PERSALINAN

ETIOLOGI HIPERTENSI KRONIK DALAM KEHAMILAN

PRIMER (IDIOPATIK) : 90 %
SEKUNDER : 10 %, YG BERHUBUNGAN DGN PENY.
GINJAL, PENY. ENDOKRIN (dm), PENY. HIPERTENSI DAN
VASKULER

DIAGNOSIS
BERDASARKAN RISIKO :
- RISIKO RENDAH : HIPERTENSI RINGAN TANPA DISERTAI
KERUSAKAN ORGAN
- RISIKO TINGGI : HIPERTENSI BERAT / HIPERTENSI
RINGAN DISERTAI PERUBAHAN
PATOLOGIS, KLINIS MAUPUN BIOLOGI
KERUSAKAN ORGAN
KRITERIA RISIKO TINGGI PD HIPERTENSI KRONIK DLM
KEHAMILAN
- HIPERTENSI BERAT :
DESAKAN SISTOLIK 160 mmHg DAN
DESAKAN DIASTOLIK 110 mmHg, SEBELUM 20 MGG
KEHAMILAN

HIPERTENSI RINGAN < 20 MGG KEHAMILAN DGN :

PERNAH PREECLAMPSIA
UMUR IBU > 40 THN
HIPERTENSI 4 THN
ADANYA KELAINAN GINJAL
ADANYA DIABETES MELLITUS (KLAS B KLAS F)
KARDIOMIOPATI
MEMINUMI OBAT ANTI HIPERTENSI SEBELUM HAMIL

KLASIFIKASI HIPERTENSI KRONIK

KLASIFIKASI

SISTOLIK (mmHg)

DIASTOLIK (mmHg)

NORMAL
PREEHIPERTENSI
HIPERTENSI STADIUM I
HIPERTENSI STADIUM II

< 120
120 139
140 159
160

< 80
80 89
90 99
110

(the 7th Report of the Joint National Committee (JNC 7)

MIMs Cardiovascular Guide th. 2003 2004)

 PENGELOLAAN HIPERTENSI KRONIK DLM KEHAMILAN:

TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM
-

MENEKAN RISIKO PD IBU KENAIKAN DESAKAN DARAH

MENGHINDARI PEMBERIAN OBAT2 YG MEMBAHAYAKAN

JANIN

KEHAMILAN

PEMERIKSAAN LABORATORIUM
PEMERIKSAAN (TEST) KLINIK SPESIALISTIK :
-

ECG

ECHOCARDIOGRAPHY

OPHTALMOLOGY

USG GINJAL

 PEMERIKSAAN (TEST) LABORATORIUM

-

FUNGSI GINJAL : CREATININE SERUM BUN SERUM, ASAM

URAT, PROTEINURIA 24 JAM
PEMERIKSAAN PROTEINURIA SECARA
PERIODIK

FUNGSI HEPAR

HEMATOLOGIK : Hb, HEMATOKRIT, TROMBOSIT

 PEMERIKSAAN KESEJAHTERAAN JANIN

ULTRASONOGRAPHY :
-

USG UTK DATA DASAR DIAMBIL 18-20 MGG KEHAMILAN

DIULANG PD UMUR KEHAMILAN 28-32 MGG DAN DIIKUTI

SETIAP BLN

BILA DICURIGAI IUGR DI MONITOR DGN NST DAN PROFIL

BIOFISIK

HIPERETENSI KRONIK DLM KEHAMILAN DGN PENYULIT

KARDIOVASKULER ATAU PENY. GINJAL PERLU MENDAPAT

PERHATIAN KHUSUS

PENGOBATAN MEDIKAMENTOSA
INDIKASI PEMBERIAN ANTIHIPERTENSI:
RISIKO RENDAH HIPERTENSI:
-

IBU SEHAT DGN DESAKAN DIASTOLIK MENETAP 100

mmHg

DGN DISFUNGSI ORGAN DAN DESAKAN DIASTOLIK 90

mmHg

OBAT ANTIHIPERTENSI
-

PILIHAN PERTAMA : METHYLDOPA : 0.5-3.0 g/hr, DIBAGI DLM

2-3 DOSIS.

: NEFEDIPINE : 30-120 g/hr, DLM SLOWRELEASE TABLET

PENGELOLAAN TERHADAP KEHAMILAN

SIKAP TERHDP KEHAMILANNYA PD HIPERTENSI KRONIK

RINGAN : KONSERVATIF DILAHIRKAN SEDAPAT MUNGKIN

PERVAGINAM PD KEHAMILAN ATERM.

SIKAP TERHDP KEHAMILAN PD HIPERTENSI KRONIK BERAT :

AKTIV SEGERA KEHAMILAN DIAKHIRI (DITERMINASI)

ANESTESI : REGIONAL ANESTESI

HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA

PENGELOLAAN HIPERTENSI KRONIK DGN SUPERIMPOSED

PREECLAMPSIA SAMA DGN PENGELOLAAN PREECLAMPSIA

BERAT.

HELLP SYNDROME

PREGNANCY

10-14% CASE

HYPERTENSION AND
PROTEINURIA

PREECLAMPSIA

HELLP SYNDROME

HELLP SYNDROME
FIRST DISCRIBED BY WEINSTEIN 1982:
ACRONYM OF : H

INCIDENCE :

HEMOLYSIS

EL

ELEVATED LIVER ENZYM

LP

LOW PLATETLED COUNT

2%-12% AMONG PATIENTS WITH

PREECLAMPSIA.
30% OCCURS IN POSTPARTUM

CRITERIA DIAGNOSTIC
LABORATORY FINDING:

HEMOLYSIS
ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND
BURR CELLS
TOTAL BILIRUBIN LEVEL > 1,2 mg/Dl
LACTATE DEHYDROGENASE LEVEL > 600 /L

ELEVATED LIVER FUCTION

SGOT LEVEL 70 / L (LDH)
LACTATE DEHYDROGENASE LEVEL > 600 /L

LOW PLATELET COUNT

PLATELET COUNT < 100.000/m3
THE LABORATORY DIAGNOSTIC CRITERIA USED AT THE UNIVERSITY OF TENNESSEE
DIVISION OF MATERNAL FETAL MEDECINE, MEMPHIS TN. WITLIN AND SIBAI (1999)

CLASSIFICATION BASED ON PLATELET COUNT

(MISSISIPPI):
CLASS I : PLATELET 50.000/m3
WITH : LDH 600 U/L
SGOT 40 U/L
CLASS II : PLATELET 50.000/m3 - < 100.000/m3
WITH : LDH 600 U/L
SGOT 40 U/L
CLASS II : PLATELET 50.000/m3 - < 150.000/m3
WITH : LDH 600 U/L
SGOT 40 U/L

MANAGEMENT OF HELLP SYNDROME

MATERNAL STABILISATION IS THE MAYOR PRIORITY

BEGIN WITH A STANDART MANAGEMENT OF SEVERE

PREECLAMPSIA

HELLP SYNDROME IS NOT AN INDICATION FOR CS

MEDICAL MANAGEMENT

SAME AS SEVERE PREECLAMPSIA

WHEN THROMBOCYTE COUNT IS < 50.000 mm3, 10 UNITS

OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE
GIVEN

WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO

THE ICU

WHEN THROMBOCYTE COUNTS IS < 50.000/mm3

FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL
THROMBOPLASTIN TIME, D-DIMMER MUST BE CHECKED
TO FIND DIC

OBSTETRIC MANAGEMENT
WHEN MOTHERS IS STABLE TERMINATE THE
PREGNANCY OR CONSERVATIVE MANAGEMENT.
CONSERVATIVE MANAGEMENT CAN BE DONE
WHEN :
THE BLOOD PRESSURE < 160/110 m g
THE OLIGURIA RESPONSE TO FLUID
REPLACEMENT
THERE IS NO EPIGASTRIC PAIN
THE GESTATIONAL AGE IS < 34 WEEKS

COMPLICATION
THE COMPLICATIONS THAT CAN OCCUR IN
HELLP SYNDROME ARE : NEUROLOGIC
DISORDER, PULMONARY EDEMA, ABRUPTIO
PLACENTA, DIC AND UGR

CONCLUSIONS :

1. HYPERTENSION, PROTEINURIA AND OTHERS SYMPTOMS-SIGN OF

PREECLAMPSIA ARE INDUCED BY PREGNANCY
2. BESIDE HYPERTENSION AND PROTEINURIA, OTHER SYNDROMA OF
PREECLAMPSIA ARE EPIGASTRIC PAIN, HEADCHE, VISUAL DISTURBANCE,
OLIGURIA, CONVULSION, AND RENAL FAILURE.
3. THERE ARE STILL CONTROVERSION IN CLASSIFICASION, DIAGNOSTIC
AND MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION.
4. IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN
MANAGEMENT IS NEEDED.
5. IGNORANCE, POVERTY, LATE ADMITTANCE TO HOSPITAL WILL INCREASE
FERINATAL - MATERNAL, MORBIDITY AND MORTALITY

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