9 Gestasional Hypertension

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    Gestational HypertensionInternational

    Gestational Hypertension

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    Ny. 25 th G1 mengeluh nyeri kepala dan

    pandangan kabur selama bulan terakhir

    kehamilannya.

    Ia mencari saran medis dan pengobatan

    dari seorang Dr.SpOG. Yang

    meresepkan obat padanya.

    Ia pulang kerumah tetapi keluhannya tidak

    menghilang meskipun telah meminum

    obat yang diberikan

    Suaminya membawanya ke Rumah Sakit

    Umum karena KEJANG.

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    Masalah/Diagnosis?

    Eklampsia imminens Eklampsia

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    Objectives

    Definisi Diagnosis

    Manajemen

    - Penilaian Fetal / Maternal

    - Terapi Anti-Hipertensi- Terapi Anti-Kejang

    - Transport

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    Insidens

    10% dari kehamilan mengalami komplikasi hipertensi

    - 1/3 nya dengan proteinuria

    Mayoritas preeklampsia terjadi pada nulipara

    - Risiko kematian meningkat pada pada ibu hamil usia lanjut

    - Risiko meningkat pada kehamilan pertama dengan pasangan baru

    - Risiko meningkat pada hipertensi kronik, penyakit ginjal dan diabetes melitus

    Preeklampsia merupakan penyebab terbanyak kematian maternal langsung (direc

    maternal mortality) maupun Near Miss Maternal.

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    Definisi

    Hipertensi kronik

    Hipertensi gestasional

    - tanpa proteinuria

    - dengan proteinuria

    - dengan proteinuria dan penyulit Hipertensi kronik superimposed hipertensi gestasional

    dengan proteinuria

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    Definisi

    HipertensiNilai mutlak 140/90 mmHg

    peningkatan 30/15 mmHg

    Tekanan darah diastolik 90 mmHg

    Posisi duduk pada lengan setinggi jantung Manset dengan ukuran yang tepat

    Dengan sfigmomanometer air raksa

    Bunyi Korotkoff I dan IV

    Diulang 4 jam kecuali sangat tinggi.

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    Definisi

    Proteinuria

    - Proteinurin 2+ dengan pemeriksaan dipstick

    - proteinurin 300 mg/dL urin 24jam

    proteinuria mengindikasikan disfungsi glomerular

    Pemeriksaan urin 24 jam harus diperiksa bila

    dengan pemeriksaan dipstich protein 1+

    edema terjadi akibat vasospasme and penurunantekanan onkotik, tetapi bukan merupakan kriteria

    diagnostik.8/25/2014

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    Biochemical and biophysical markers defining fetal/placental and maternal

    etiologies that determine the risk of developing pre-eclampsia

    Risk of

    developingpre-

    eclampsia

    Fetal/

    Placental

    factors

    Maternal

    Predisposition/

    susceptibility

    Trophoblast invasion

    -PLGF

    - IGFBP-1, PAPP-A

    - Doppler US

    - HLA-G

    Placental hypoxia

    -sFlt-1

    - VEGF

    - PLGF

    Reactive oxygen species-

    lipid peroxides

    -activin/inhibin

    - CRH/CRHBP

    -PAI-2

    Metabolic syndrome

    - BMI, leptin

    - Insulin, SHBG

    - Glucose

    Endothelial function:

    - PAI-1

    - Fibronectin

    - VCAM/CAM

    Pro-oxidants

    8 epi-PGF2a

    Antioxidant reserve- Vit C

    - Vit Eimmune function

    Immune function

    -AT1R autoantibodies

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    Perubahan fisiologik dan patologik plasentasi

    Dikutip:

    Redman and Ian L. Sargent

    Science June 2005 Vol 308

    1592

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    Tanda-tanda semakin beratnya kondisi

    Hipertensi gestasional dengan penyulit

    Tekanan darah diastolik > 110 mmHg

    Hasil pemeriksaan laboratorium

    trombosit, LFT's, uric acid

    Ginjal - proteinuria > 3 g/d, oliguria

    SSP - kejang, nyeri kepala, gangguan visus

    Keterlibatan organ lainParu-paru, hati, hematologik

    Tanda-tanda gangguan pertumbuhan janin

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    Gestational HypertensionInternationalanajemen

    Pertama-tama mengurangi stres Penilaian keadaan ibu dan janin

    Terapi hipertensi bila dBP > 110 mmHg

    Terapi terhadap keluhan mual dan muntah

    Terapi nyeri uluhati

    Terapi Antikejang

    Terminasi kehamilan dengan cara dan waktu yang tepat

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    Gestational HypertensionInternationalengurangi Stres

    Komponen tekanan darah adalah reseptor adrenergik

    Ketidaknyamanan sedapat mungkin dikurangi Beberapa komponen

    quiet, dimly lit, isolated room

    well planned management protocol

    clear explanation of plan to patient/family

    minimization of negative stimuli consistent, confident team approach

    nursing, obstetrics, anaesthesia, hematology, pediatrics

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    Gestational HypertensionInternationalPenilaian Maternal - Klinis

    Tekanan darah

    - assess severity- consistency in measuring

    - relationship of high BP to CVA not seizure

    Susunan Saraf Pusat

    - presence and severity of headache

    - vision disturbances - blurring, scotomata

    - tremulousness, irritability, hyperreflexia, somnolenc

    - nausea and vomiting

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    Gestational HypertensionInternationalAssessment of Mother -

    Clinical

    Hematologic- edema- bleeding, petechiae

    Hepatic- RUQ and epigastric pain- nausea and vomiting

    Renal- urine output and colour

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    Assessment of Mother

    Laboratory

    Hematologic

    - hemoglobin, platelets, blood film

    - PTT, INR, fibrinogen, FDP

    - LDH, uric acid, bilirubin

    Hepatic

    - ALT, AST

    - (glucose, ammonia to R/O AFLP)

    Renal

    - proteinuria

    - creatinine, urea, uric acid8/25/2014

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    Manfaat NACysteine (flumucil) sebagai antioksidan

    untuk mencegah timbulnya Preeklampsia Berat

    0

    20

    40

    60

    80

    100

    120

    140

    160

    Sistolik Diastolik

    Dosis NAC: 2 x 600 m

    Kel. Kontrol

    Kel. Studi

    Sumber: Wibowo N, Angsar D, Wiknjosastro G., dkk (2005

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    Assessment of Fetus

    Fetal movement

    Fetal heart rate assessment

    Ultrasound for growth

    Biophysical profile

    Amniotic fluid volume

    Doppler flow studies

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    Treatment

    Nausea and Vomiting

    - antiemetic of choice

    RUQ / Epigastric Pain

    - morphine 2 - 4 mg IV

    - antacid- minimize palpation

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    Anti-hypertensive Therapy - Goals

    minimize risk of maternal CVA

    maximize maternal condition for safe delivery

    gain time for further assessment

    - facilitate vaginal delivery if possible- prolong gestation where appropriate/feasible

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    Anti-hypertensive Agents - Acute Therapy

    Arteriolar Dilators- hydralazine

    -Blockers

    - labetalol

    Calcium Channel Blockers

    - nifedipine

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    Anti-hypertensive Agents - Maintenance

    Therapy

    Centrally Acting Sympatholytic Agents methyl-dopa

    -Blockers atenolol labetalol

    Calcium Channel Blockers nifedipine

    ACE inhibitors are contraindicated in pregnancy

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    Methyldopa

    centrally acting a2-receptor agonist, oral agent

    long history of safe use in pregnancy, well tolerated

    some concern regarding ability to control BP

    not for use in acute settings

    Dosage - 500 - 3000 mg po in 2 - 4 divided doses

    Cautions - drug of choice in essential hypertension

    Benefits - minimal side-effects and safe

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    Gestational HypertensionInternationaltenolol Betablok, Tenormin)

    1-receptor antagonist, oral agent

    cardiac output,

    renin release, vasomotor inhibitor onset of action in 1 hour peak levels in 2-4 hours

    long half life once a day dosing

    Dosage - 50 -100 mg po OD Cautions - DM, asthma, baseline FH, variability present

    risk of IUGR with chronic use

    Benefits - often only agent needed

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    Gestational HypertensionInternationalLabetalolNormodyne, Trandate)

    combined 1 and -blocker with ISA

    intravenous rapid onset useful for hypertensive crisis

    can be used orally

    Dosage - maximum 300 mg IV dose

    - 20 mg IV followed by 20-80 mg IV titrated to BP Cautions - concern re: fetal responses to hypoxia

    Benefits - dependable, titratable, familiar

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    Nifedipine

    calcium channel blocker, oral agent

    direct relaxation of vascular smooth muscle

    rapid onset of action if regular capsule used

    Dosage - Adalat-PA 10 mg bid 40 mg bid

    Side Effects - magnesium toxicity, edema,

    flushing,headache, palpitations, tocolytic

    use of short acting form discouraged

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    Gestational HypertensionInternationalypertensive risis

    Stabilisasi hipertensi berat

    Nifedipine, -blocker, tujuan maintain diastolic BP at 90 - 100 mmHg monitor fetal status while treating BP

    Pencegahan kejang Monitor volume intravaskular

    Foley catheter seldom experience ARF do not fluid overload seldom require CVP line

    Terminasi kehamilan

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    Gestational HypertensionInternationalPencegahan Kejang

    Sulit diramalkan siap yang akan kejang

    - Tidak berbanding lurus dengan beratnya hipertensi daproteinuria

    high 'number needed to treat' to prevent seizure

    agents not innocuous nor completely effective

    MgSO4 is agent of choice when seizure prophylaxis is felt t

    be indicated

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    Kadar Mg serum pada regimen IV dan IM

    Pemberian drip IV lebih

    stabil dibandingkan

    dengan pemberian IM

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    Gestational HypertensionInternationalMagnesium Sulfate - Overdose

    close observation for side effects weakness, respiratory paralysis, somnolence

    especially high risk in those with oliguria orreceiving Ca2+ channel blockers

    ANTIDOTE

    stop magnesium infusion 10% Calcium gluconate 10 mL IV over 3 minutes

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    Transport

    consider transport only if resources limited and

    maternal/fetal condition permits

    maternal BP and symptoms stable

    fetal status reassuring appropriate anti-hypertensive agents started

    MgSO4 started if appropriate

    discuss with accepting centre and patient/family

    MgSO4 and anti-hypertensives potentially fatal in overdose

    G t ti l H t i

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    Terminasi kehamilan

    37 weeks with gestational hypertension

    34 weeks with severe gestational hypertension

    < 34 weeks with any of:

    - poorly controlled dBP

    - lab evidence of worsening end-organ involvement

    - suspected fetal compromise

    - uncontrolled seizures

    - symptoms unresponsive to appropriate therapy

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    G t ti l H t i

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    Delivery - The Cure

    timely delivery minimizes maternal and neonatal morbidit

    and mortality

    optimize maternal status before interventions to deliver

    delay delivery to gain fetal maturity and to allow transfe

    only when maternal and fetal condition allow it

    gestational hypertension is a progressive disease, expectan

    management is potentially harmful in presence of sever

    disease or suspected fetal compromise

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    G t ti l H t i

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    Peri- and Postpartum Management

    do not drop BP too low risking fetal compromise

    do not fluid overload

    epidural analgesia is favoured in the absence of

    low platelets or coagulopathy

    multi-specialty approach

    patient must be monitored post-partum

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    Gestational Hypertension

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    Gestational Hypertension

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    Mechanism of ActionStimulation of intracellular

    cyclic-GMP results in vascular smooth

    muscle relaxation of both arterial and

    venous vasculature.

    Increased venous pooling decreases left

    ventricular pressure preload) and arterial

    dilatation decreases arterial resistance

    afterload).

    Therefore, this reduces cardiac oxygen

    demand by decreasing left ventricular

    pressure and systemic vascular resistance

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