Hypertensive Disorder Hypertensive Disorder in Pregnancyin Pregnancy

Oleh. Hj. Siti Isye NasripahOleh. Hj. Siti Isye Nasripah

Penyakit Hipertensi pada Penyakit Hipertensi pada KehamilanKehamilan

1.1. Gestational hypertension ( Hipertensi Gestational hypertension ( Hipertensi dalam Kehamilan )dalam Kehamilan )

2.2. PreeclampsiaPreeclampsia3.3. EclampsiaEclampsia4.4. Superimposed Preeclampsia Superimposed Preeclampsia 5.5. Chronic HypertensionChronic Hypertension

EpidemiologiEpidemiologi

One of the deadly triad (hemorrhage, One of the deadly triad (hemorrhage, infection)infection)

3,7 % of all pregnancy 3,7 % of all pregnancy

Gestasional hypertensionGestasional hypertensionBP BP >> 140/90 mmHg, setelah usia 140/90 mmHg, setelah usia

kehamilan > 20 minggu tanpa adanya kehamilan > 20 minggu tanpa adanya riwayat HTriwayat HT

No proteinuriaNo proteinuriaBP return to normal < 12 weeks (3 bulan) BP return to normal < 12 weeks (3 bulan)

post partumpost partum

PreeclampsiaPreeclampsiaMild :Mild :- BP BP >> 140/90 mmHg after 20 weeks 140/90 mmHg after 20 weeks

gestationgestation- Proteinuria Proteinuria >> 300 mg/24 hours or 300 mg/24 hours or >> 1+ 1+

dipstickdipstick- Edema generalisataEdema generalisata

PreeclampsiaPreeclampsiaSevereSevere

- BP BP >> 160/110 mm Hg 160/110 mm Hg- Proteinuria 2 g/24 hours or Proteinuria 2 g/24 hours or >> 2+ dipstick 2+ dipstick- Serum Creatinin > 1,2 mg/dLSerum Creatinin > 1,2 mg/dL- Platelets < 100.000/mm3Platelets < 100.000/mm3- Increase LDHIncrease LDH- Elevated AST/ALTElevated AST/ALT- Persistent headache or other cerebral or Persistent headache or other cerebral or

visual disturbancevisual disturbance- Persistent epigastric painPersistent epigastric pain

EclampsiaEclampsia

Seizures that cannot be attributed to other Seizures that cannot be attributed to other causes in women with preeclampsiacauses in women with preeclampsia

ComaComa

Superimposed preeclampsiaSuperimposed preeclampsia

New onset proteinuria New onset proteinuria >> 300mg/24 hours 300mg/24 hours in in hypertensive womenhypertensive women but no proteinuria but no proteinuria before 20 weeks gestasionbefore 20 weeks gestasion

Sign and symptoms severe preeclampsiaSign and symptoms severe preeclampsia

Chronic HypertensionChronic HypertensionBP BP >> 140 mmHg before pregnancy or 140 mmHg before pregnancy or

diagnosed before 20 weeks gestationdiagnosed before 20 weeks gestation

Risk Factor PreeclampsiaRisk Factor PreeclampsiaNulliparous (85%)Nulliparous (85%)Multiple pregnancyMultiple pregnancyHistory of chronic hypertensionHistory of chronic hypertensionMaternal age over 35 yearsMaternal age over 35 yearsObesitasObesitasSosial ekonomiSosial ekonomiGenetikGenetik

Patophyisiology PreeclampsiaPatophyisiology Preeclampsia Maternal vascular deseaseMaternal vascular desease Faulty placentation (cacat)Faulty placentation (cacat) Excessive trophoblast (terlalu banyak)Excessive trophoblast (terlalu banyak)

Reduced uteroplacental perfusionReduced uteroplacental perfusion

Endothelial activationEndothelial activation

Endothelial activation

Vasospasme Capillary Activation of coagulation

-Hypertension-Seizure-Oliguria-Abruption-Liver ischemia

EdemaProteinuriaHemoconcentration

Thrombocytopenia

Mild PreeclampsiaMild Preeclampsia> 37 weeks gestasion : induction of labour> 37 weeks gestasion : induction of labour<< 37 weeks gestasion : 37 weeks gestasion :

- No medicationNo medication- No diuretikNo diuretik- Limitation activityLimitation activity- ANC 2x/weeks : Blood Pressure, proteinuria, ANC 2x/weeks : Blood Pressure, proteinuria,

refleks, fetal surveillancerefleks, fetal surveillance

Management severeManagement severe1.1. Delivery is the cure for preeclampsiaDelivery is the cure for preeclampsia >> 35 weeks gestation : induction of labor 35 weeks gestation : induction of labor < 35 weeks gestation, no complication: < 35 weeks gestation, no complication: expectant expectant ( (

the hope that few more weeks in utero will reduce the hope that few more weeks in utero will reduce the risk of neonatal mortality and morbidity ) the risk of neonatal mortality and morbidity )

- Anti hypertensionAnti hypertension- Lung maturation : dexametason 12 mg/day Lung maturation : dexametason 12 mg/day - (sediaan: 6 mg), 2 days(sediaan: 6 mg), 2 days- Observation : Blood pressure, symptom impanding Observation : Blood pressure, symptom impanding

eclampsia, lab., fetal surveillance eclampsia, lab., fetal surveillance any disturbance any disturbance termination termination

ManagementManagement2. Anti hypertensive Drug2. Anti hypertensive Drug- ββ-blocking agent : labetolol-blocking agent : labetolol- Calcium channel blocker : nifedipineCalcium channel blocker : nifedipine- ACE inhibitor ACE inhibitor

(Angiotensin-converting-enzyme): should be (Angiotensin-converting-enzyme): should be avoided : avoided : oligohidramnios, IUGR, pulmonary oligohidramnios, IUGR, pulmonary hypoplasia, etchypoplasia, etc

- Methyldopa : delayed onset (long-acting)Methyldopa : delayed onset (long-acting)

ManagementManagement

33. . Preventive and control convulsionPreventive and control convulsion- MgSOMgSO44 : control convulsion without central : control convulsion without central

nervous system depressionnervous system depression- i.v : 4-6 g loading dose diluted in 100 ml of iv i.v : 4-6 g loading dose diluted in 100 ml of iv

fluid 15-20 min, maintenance 1-2 g/ hour in fluid 15-20 min, maintenance 1-2 g/ hour in 100 ml100 ml

- i.m : 4 g in both buttock, maintenance i.m : 4 g in both buttock, maintenance (stabilisasi 3 jam) 4g in one buttock,and then (stabilisasi 3 jam) 4g in one buttock,and then after 6h, 4g in other buttock.after 6h, 4g in other buttock.

ManagementManagement

Before giving MgSOBefore giving MgSO44 : :1.1. The patellar refleks is presentThe patellar refleks is present2.2. Respiration are not depressed ( RR>16/min)Respiration are not depressed ( RR>16/min)3.3. Urin output > 100ml/4 hourUrin output > 100ml/4 hour

MgSoMgSo44 is discontinued 24 h after delivery is discontinued 24 h after delivery MgSOMgSO44 toxicity : respiratory depression, toxicity : respiratory depression,

paralysis, and arrestparalysis, and arrest Antidotum MgSOAntidotum MgSO44 : calcium gluconate : calcium gluconate

ComplicationComplication

1.1. EclampsiaEclampsia

- Generalized tonic-clonic seizuresGeneralized tonic-clonic seizures- Coma without convulsionComa without convulsion- Cerebral edemaCerebral edema- ICUICU

ComplicationComplication2. HELLP Syndrome2. HELLP Syndrome

- Hemolysis : fragmented erythrocyte, bilirubun > Hemolysis : fragmented erythrocyte, bilirubun > 1,2 ml/dL1,2 ml/dL

- Elevated Lever enzymes : SGOT > 72 IU/L, LDH Elevated Lever enzymes : SGOT > 72 IU/L, LDH > 600IU/L> 600IU/L

- Low Platelet count : < 100.000/mm3Low Platelet count : < 100.000/mm3- DICDIC- Tx : dexamethason 2 x 10 mg, then 2 x 5 mgTx : dexamethason 2 x 10 mg, then 2 x 5 mg

ComplicationComplication

33. . Pulmonary edemaPulmonary edema

- Tachypneu/dyspneaTachypneu/dyspnea- Respiratory distressRespiratory distress- Severe hypoxemiaSevere hypoxemia- Diffuse rales in both lungDiffuse rales in both lung- ICU, ventilatorICU, ventilator- FurosemidFurosemid

ComplicationComplication

4. Acut Renal Failure4. Acut Renal Failure5. Hepatic rupture5. Hepatic rupture6. Abruptio placentae6. Abruptio placentae7. Cerebral hemorrhage7. Cerebral hemorrhage8. Visual disturbances8. Visual disturbances

TERIMAKASIHTERIMAKASIH