PREEKLAMSIA

DALIMAN
 TERMINOLOGI
HIPERTENSI DALAM KEHAMILAN (HDK)

HIPERTENSI
GESTASIONAL

HIPERTENSI SINDROMA
KRONIS HDK PREEKLAMSIA

Cunningham et.al, 2018. Williams

SUPERIMPOSED Obstetrics, 25 ed and ACOG, 2013
PREEKLAMSIA MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD
Preeclampsia Updated: Feb 16, 2018
Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 2
 HIPERTENSI
DALAM
KEHAMILAN (HDK) HT
(HYPERTENSIVE DISORDERS) KRONIS
TERMINOLOGI DAN DIAGNOSIS .
(ISSHP, 2000; 2014)

KLASIFIKASI DASAR HDK :

1. HIPERTENSI KRONIK,
HT HT HT
KEHAMILAN GESTASIONAL
2. HIPERTENSI GESTASIONAL, White-coats
3. DE NOVO - PREEKLAMSIA
atau SUPERIMPOSED
PREEKLAMSIA,
4. HIPERTENSI WHITE-COAT. PE de novo/
superimposed
James D, et.al., 2017. High-Risk Pregnancy, management option, 5th ed.
Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 3
 KLASIFIKASI HDK
I. GESTASIONAL HIPERTENSI,
II. GESTASIONAL PROTEINURIA,
III. PE (HT ± PROTEINURIA),
IV. KRONIK HIPERTENSI,
V. SUPERIMPOSED PE,
VI. SUPERIMPOSED PEB.
Foley MR, et., 2018. Obstetric
Intensive Care Manual.
DIAGNOSIS HDK
1. HT + P(-) + UK ≥ 20 
HIPERTENSI HIPERTENSI GESTASIONAL
≥ 140/90 2. HT + P(-) + UK < 20 
HIPERTENSI KRONIK
1
3. HT + P (+/-) + UK ≥ 20 
PROTEIN PROTEIN SINDROMA PREEKLAMSIA
URIA URIA
POSITIF 4. HT + P (-)  P (+/-) UK ≥ 20
NEGATIF  PREEKLAMSIA
2 3 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
Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 5
 PREEKLAMSIA
HT (HIPERTENSI) :
 TEKANAN DARAH ≥
HT

PE
140/90.
 TEKANAN SISTOLIK NAIK
30, DIATOLIK NAIK 15.
 DELTA HIPERTENSI 
KENAIKAN MAP PADA PROT
TRIMESTER III
+/-
 HIPERTENSI White Coats,
adalah DIPERIKSA (Dr/Per/
Bidan) ≥ 140/90, monitor 24 James D, et.al., 2017. High-Risk
jam < 140/90 Pregnancy, management option, 5th ed.
Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 6
 Sindroma PREEKLAMSIA
 Diskripsi yang paling baik, adalah sindroma spesifik
kehamilan yang pada hakekatnya dapat mempengaruhi setiap
sistem organ.

 Dasar diagnosis- paling sederhana- adalah TEKANAN DARAH

≥ 140/90 mmHg ( 2 X pemeriksaan, ≥ 4 jam- 1 mgg) + POSITIF
PROTEINURIA ( gambaran kerusakan endothelial-
karakteristik sindroma Preeklamsia)

 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.
Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 7
 PREEKLAMSIA BERAT
(Gabbe, et.al, 2017; Cunningham, et.al 2018; Lim KH, 2018)

HIPERTENSI (baru) tanpa

Ditandai (salah satu):
 Tek sistolik >/= 160 mmHg, atau
tekanan diastolik >/= 110 mmHg.
 Kegagalan fungsi hati,
 Insufisiensi ginjal progresif,
 Gangguan serebral atau
pandangan (baru muncul),
 Edema pulmonum,
 trombositopenia
proteinuria, didiagnosis PE, jika
didapatkan salah satu :
 Trombositopenia,
 Serum kreatinin > 1,1 mg/dl, atau
2 kali lipat Normal,
 SGOT dan SGPT 2 kali Normal,
 Edema pulmonum,
 Gangguan serebral dan
pandangan.

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 8

 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

Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, 3rd ed

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 9
 Superimposed preeclampsia with severe
features
Superimposed preeclampsia and one or more of the following
criteria:
1. Severe range of BP (≥160/110 mmHg) despite escalation of
antihypertensive medication
2. Platelet count <100,000/mm3
3. Increased hepatic transaminases (AST and/or ALT) two times the upper
limit of normal concentration at a particular laboratory
4. New onset or worsening renal insufficiency (creatinine ≥1.1
mg/dL or a doubling of the serum creatinine)
5. Pulmonary edema
6. Persistent neurological symptoms (e.g., headache, visual changes)
Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, 3rd ed
Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 10
Eclampsia
Seizures (grand mal) in the presence of
preeclampsia and/or HELLP
syndrome.
Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, 3rd ed

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 11

HELLP syndrome
Tennessee Classification (most commonly used)

• Hemolysis as evidenced by an abnormal peripheral smear in

addition to either serum LDH >600 IU/L or total bilirubin ≥1.2
mg/dL (≥20.52 μmol/L)
• Elevated liver enzymes as evidenced by an AST or ALT two
times the upper limit of normal concentration at a particular
laboratory
• Platelets <100,000 cells/mm3.
• If all the criteria are met, the syndrome is defined “complete”; if only
one or two criteria are present, the term “partial HELLP” is preferred.

Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, 3rd ed

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 12
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- Gabbe et.al, 2017
eclampsia ( > 48 hours postpartum).

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 13

 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,
2018
11. Homozygosity for angiotensinogen gene T235 (20:1)
12. Heterozygosity for angiotensinogen gene T235 (4:1)

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 14

 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.

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 15

 MgSO4
 DOSIS AWAL 4- 6 gram
iv BOLUS, DILANJUTKAN
DENGAN DRIPS 1-2
gram/ JAM.
 PEMBERIAN ULANG iv 2 gr
(BB≤ 70 kg), ATAU 4 gr (BB>
70 kg), MINIMAL 3-5/ 5-10
MENIT KEMUDIAN
(JARANG),
 JIKA PERLU DAPAT DIBERIKAN
Na-AMOBARBITAL 250 mg IV
MINIMAL 3-5 MENIT
Monday, September 9, 2019 Preeklamsia, Daliman.DM 18
MgSO4 ADALAH OBAT
PILIHAN UNTUK PENCEGAHAN
EKLAMSIA, MENURUNKAN 59%
RISIKO EKLAMSIA, 36%
SOLUSIO PLASENTA, 46%
(STATISTIK TIDAK SIGNIFIKAN)
KEMATIAN MATERNAL.
 SYARAT PEMBERIAN MgSO4 ADALAH
REFLEKS PATELLA +, URINE OUTPUT >30
CC/JAM, DAN REPIRASI > 16 KALI/MENIT,
SERTA TERSEDIA ANTIDOTUMNYA YAITU
Ca Gluconas.
 TOKSISITAS MgSO4 BERUPA
HILANGNYA REFLEKS PATELLA,
DEPRESI RESPIRASI, PERUBAHAN
KONDISI JANTUNG, CARDIAC
ARREST.
16
 REKOMENDASI PNPK-Preeklamsia
1. Pemberian MgSO4 pada PEB berguna
untuk mencegah terjadinya kejang
eklamsia atau kejang berulang.
2. Rute administrasi MgSO4 yang
dianjurkan adalah IV untuk mengurangi
nyeri pada lokasi sutikan.
3. MgSO4 merupakan pilihan utama pada
pasien PEB dibandingkan diazepam atau
fenitoin, untuk mencegah terjadinya
kejang/ eklamsia atau kejang berulang.
Level evidence Ia, Rekomendasi A

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 17

 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).

3. Hydralazine 5-10 mg iv/ im, tiap 20

menit, dosis maksimal 30 mg.
4. Sodium nitroprusside dimulai 0,25
ug/kg/min sampai dosis maksimal 5
ug/kg/min (second line).(Cunningham,2018)

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 18

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.

 Institute fetal surveillance if undelivered and fetus is viable.

1. If severe BP elevations persist for 15 minutes or more, administer nifedipine (10 mg
orally).
2. Repeat BP measurement in 20 minutes and record results. If either BP threshold is still
exceeded, administer nifedipine capsules (20 mg orally).
3. If BP is below thresh-old, continue to monitor BP closely. Repeat BP measurement in 20
minutes and record results. If either BP threshold is still exceeded, administer nifedipine
capsule (20 mg orally).
4. If BP is below thresh-old, continue to monitor BP closely. Repeat BP measurement in 20
minutes and record results. If either BP threshold is still exceeded, administer labetalol
(40 mg intravenously over 2 minutes) and obtain Give additional antihypertensive
medication per specific order.
 Once the aforementioned BP thresholds are achieved, repeat BP measurement every 10 minutes for 1 hour,
then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every hour for 4 hours.
Institute additional BP timing per specific order.
ACOG, 2017. COMMITTEE OPINION

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 19

 TERAPI HIPERTENSI KRONIK
1. PERUBAHAN GAYA HIDUP BERUPA DIET KAYA BUAH, SAYUR, RENDAH
LEMAK, MENGURANGI SATURASI DAN TOTAL LEMAK, (MENGURANGI
MASUKAN GARAM SAMPAI < 2,4 gram/ HARI  TIDAK DIANJURLKAN LAGI).
2. BEDREST DI RS DIHUBUNGKAN PENGURANGAN 42% HIPERTENSI BERAT, 47%
PERSALINAN PRETERM.

3. OBAT ANTIHIPERTENSI – METHYLDOPA, LABETALOL,

BETABLOKER, NIFEDIPIN, DIURETIK.
4. ACE-INHIBITOR KONTRAINDIKASI DIBERIKAN PADA TRIMESTER PERTAMA,
DIHUBUNGKAN DENGAN PENINGKATAN 2 KALI TERJADINYA MALFORMASI, DAN
JANGKA PANJANG IUGR, OLIGOHIDRAMNION, GAGAL GINJAL DAN KEMATIAN
NEONATUS.

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 20

 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. Sedapat mungkin pasien harus
3. (60-125 ml/jam)
RESTRIKSI CAIRAN, minimal (Cunningham, 2018)
sampai periode DIURESIS
POSTPARTUM.

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 21

 Postpartum management
 Many patients will have a brief (up
to 6 hours) period of oliguria
following delivery
 Magnesium sulfate seizure
prophylaxis is continued for 24
hours postpartum
 Liver function tests and platelet
counts must document decreasing
values prior to hospital discharge
 Elevated BP may be controlled with
nifedipine or labetalol
postpartum
Monday, September 9, 2019 Preeklamsia, Daliman.DM 18
 If a patient is discharged with BP
medication, reassessment and a BP
check should be performed, at the
latest, 1 week after discharge
 Unless a woman has undiagnosed
chronic hypertension, in most cases
of preeclampsia, the BP returns to
baseline by 12 weeks’ postpartum
 Patients should be carefully
monitored for recurrent
preeclampsia, which may develop up
to 4 weeks postpartum, and for
eclampsia that has occurred up to 6
weeks after delivery
22
 Offer women with pre-eclampsia who have
given birth transfer to community care if all of
the following criteria have been met:

 there are no symptoms of pre-eclampsia

 blood pressure, with or without
treatment, is 149/99 mmHg or lower
 blood test results are stable or improving.

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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).

 BAYI, BERUPA PERSALINAN PRETERM (15-60%), IUGR

(10-25%), KEMATIAN PERINATAL (1-2%), TRAUMA
HIPOKSEMIA-NEROLOGIK (<1%), MORBIDITAS
KARDIOVASKULER JANGKA PANJANG (TIDAK
DIKETAHUI)

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 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%.

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 25

 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.)

Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 26

 Acute Treatment of Severe Hypertension in
Pregnancy

In the setting of The goal of hypertension

severe hypertension treatment is to lower BP
to prevent
(SBP >160 mm Hg; cerebrovascular and
DBP >110 mm Hg), cardiac complications
antihypertensive while maintaining
treatment is uteroplacental blood flow
recommended. (ie, maintain BP around
140/90 mm Hg).

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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

in severe preeclampsia, it has not recommended

this therapy in all cases of mild preeclampsia.
Monday, September 9, 2019 Preeklamsia, Daliman.DM 18 28
Some Indications for Delivery
with Early-Onset Severe Preeclampsia (Cunningham, 2018):

Maternal ONE OR MORE ≤ 72 JAM

1. Persistent severe headache or visual changes; eclampsia
2. Shortness of breath; chest tightness with rales and/or SaO2 < 94
percent breathing room air; pulmonary edema
3. Uncontrolled severe hypertension despite treatment
4. Oliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dL
5. Persistent platelet counts < 100,000/L,
6. AST or ALT > 2 x upper limit of normal with RUQ or epigastric pain,
7. Suspected abruption, progressive labor, and/or ruptured
membranes,
Foley MR, et., 2018. Obstetric AFI = amnionic fluid index; EGA = estimated gestational age;
Intensive Care Manual. SaO2 = oxygen saturation.
From Sibai and Barton (2007).
Seminar dan Workshop Kegawatdaruratan
Monday, September 9, 2019 29
Maternal-ESWS, DALIMAN.DM18
Fetal ONE OR MORE
≤ 72 JAM
1. Severe growth restriction—< 5th percentile for
EGA
2. Persistent severe oligohydramnios—AFI < 5 cm/
DVP < 2 cm.
3. Biophysical profile 4 done 4-6 hr apart
4. Reversed end-diastolic umbilical artery flow
5. Repetitive late or severe variable heart rate
deceleration,
6. Fetal death Foley MR, et., 2018. Obstetric Intensive
Care Manual.
Seminar dan Workshop Kegawatdaruratan
Monday, September 9, 2019 30
Maternal-ESWS, DALIMAN.DM18
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
emergencies.
5. Implementation of emergency drills and
ACOG COMMITTEE OPINION Number
simulations
590, March 2014 (Replaces Committee Abbreviation: SBAR, Situation–Background–
Opinion Number 487, April 2011)
Assessment–Recommendation.
(Reaffirmed 2018)
Seminar dan Workshop Kegawatdaruratan
Monday, September 9, 2019 31
Maternal-ESWS, DALIMAN.DM18
 Wassalamu’alaikum
warahmatullahi wabarakaatuh

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