PREEKLAMPSIA/EKLAMPSIA

5/19/09

Didi DANUKUSUMO, Dr.Sp.OG(K) Division of Maternal Fetal Medicine

Department of Obstetrics and Gynecology Fatmawati General Hospital/

Faculty of Medicine University of Indonesia, Jakarta

 Ny.25thG1mengeluhnyerikepaladanpandangankaburselamabulanterakhirkehamilannya.

 IamencarisaranmedisdanpengobatandariseorangDr.SpOG.Yangmeresepkanobatpadanya.

 Iapulangkerumahtetapikeluhannyatidakmenghilangmeskipuntelahmeminumobatyangdiberikan

 SuaminyamembawanyakeRumahSakitUmumkarenaKEJANG.

 Masalah/Diagnosis? EklampsiaimminensEklampsia

Objectives Definisi

 Diagnosis

 Manajemen  PenilaianFetal/Maternal  TerapiAnti‐Hipertensi  TerapiAnti‐Kejang  Transport

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Insidens  10%darikehamilanmengalamikomplikasihipertensi

  1/3nyadenganproteinuria

 Mayoritaspreeklampsiaterjadipadanulipara  Risikokematianmeningkatpadapadaibuhamilusia“lanjut”  Risikomeningkatpadakehamilanpertamadenganpasanganbaru  Risikomeningkatpadahipertensikronik,penyakitginjaldandiabetesmelitus

 Preeklampsiamerupakanpenyebabterbanyakkematianmaternallangsung(directmaternalmortality)maupunNearMissMaternal.

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Definisi

 Hipertensikronik Hipertensigestasional

  tanpaproteinuria  denganproteinuria  denganproteinuriadanpenyulit

 Hipertensikroniksuperimposedhipertensigestasionaldenganproteinuria

 Unclassifiableantenatally

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Definisi Proteinuria

  Proteinurin≥2+denganpemeriksaandipstick  proteinurin≥300mg/dLurin24jam

 proteinuriamengindikasikandisfungsiglomerular Pemeriksaanurin24jamharusdiperiksabiladenganpemeriksaandipstichprotein≥1+

 edematerjadiakibatvasospasmeandpenurunantekananonkotik,tetapibukanmerupakankriteriadiagnostik.

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5/19/09 - Dahulu disebut Preeklampsia berat

Manajemen Pertama‐tamamengurangistres

 Penilaiankeadaanibudanjanin

 TerapihipertensibiladBP>110mmHg

 Terapiterhadapkeluhanmualdanmuntah

 Terapinyeriuluhati

 TerapiAntikejang

 Terminasikehamilandengancaradanwaktuyangtepat

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PenilaianMaternal‐Klinis Tekanandarah

  assessseverity  consistencyinmeasuring  relationshipofhighBPtoCVAnotseizure

 SusunanSarafPusat  presenceandseverityofheadache  visiondisturbances‐blurring,scotomata  tremulousness,irritability,hyperreflexia,somnolence  nauseaandvomiting

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AssessmentofMother‐Clinical Hematologic

  edema  bleeding,petechiae

 Hepatic  RUQandepigastricpain  nauseaandvomiting

 Renal  urineoutputandcolour

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AssessmentofMother‐Laboratory Hematologic

  hemoglobin,platelets,bloodfilm  PTT,INR,fibrinogen,FDP  LDH,uricacid,bilirubin

 Hepatic  ALT,AST  (glucose,ammoniatoR/OAFLP)

 Renal  proteinuria  creatinine,urea,uricacid

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AssessmentofFetus Fetalmovement

 Fetalheartrateassessment

 Ultrasoundforgrowth

 Biophysicalprofile

 Amnioticfluidvolume

 Dopplerflowstudies

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Treatment NauseaandVomiting

  antiemeticofchoice

 RUQ/EpigastricPain  morphine2‐4mgIV  antacid  minimizepalpation

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Anti‐hypertensiveTherapy‐Goals minimizeriskofmaternalCVA

 maximizematernalconditionforsafedelivery

 gaintimeforfurtherassessment  facilitatevaginaldeliveryifpossible  prolonggestationwhereappropriate/feasible

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Anti‐hypertensiveAgents‐AcuteTherapy ArteriolarDilators

  hydralazine

 ß‐Blockers  labetalol

 CalciumChannelBlockers  nifedipine

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Methyldopa centrallyactinga2‐receptoragonist,oralagent

  longhistoryofsafeuseinpregnancy,welltolerated

 someconcernregardingabilitytocontrolBP

 notforuseinacutesettings

 Dosage‐500‐3000mgpoin2‐4divideddoses

 Cautions‐drugofchoiceinessentialhypertension

 Benefits‐minimalside‐effectsandsafe

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Labetalol(Normodyne,Trandate)

 combinedα1andß‐blockerwithISA

  intravenousrapidonsetusefulforhypertensivecrisis

 canbeusedorally

 Dosage‐maximum300mgIVdose  20mgIVfollowedby20‐80mgIVtitratedtoBP

 Cautions‐concernre:fetalresponsestohypoxia

 Benefits‐dependable,titratable,familiar

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PencegahanKejang Sulitdiramalkansiapyangakankejang

 Tidak berbanding lurus dengan beratnya hipertensidanproteinuria

 high'numberneededtotreat'topreventseizure

 agentsnotinnocuousnorcompletelyeffective

 MgSO4isagentofchoicewhenseizureprophylaxisisfelttobeindicated

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MagnesiumSulfate obstetricalstandardbutnotusedinothersettings

 superiortophenytoinforprophylaxis

 superiortophenytoinordiazepaminpreventingrecurrence

 Dosage‐4gIVfollowedby1‐4g/hourIVor4gIMq4h

 SideEffects‐weakness,paralysis,cardiactoxicity

 Monitor‐reflexes,respiration,levelofconsciousness

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Magnesium sulphate 6 g (15 ml of MgSO4 40%) In 500 ml Ringer Lactate/

Dextrose 5%

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Transport considertransportonlyifresourceslimitedandmaternal/fetalconditionpermits

 maternalBPandsymptomsstable

  fetalstatusreassuring

 appropriateanti‐hypertensiveagentsstarted

 MgSO4startedifappropriate

 discusswithacceptingcentreandpatient/family

 MgSO4andanti‐hypertensivespotentiallyfatalinoverdose

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Terminasikehamilan ≥37weekswithgestationalhypertension  ≥34weekswithseveregestationalhypertension <34weekswithanyof:

 poorlycontrolleddBP  labevidenceofworseningend‐organinvolvement suspectedfetalcompromise uncontrolledseizures symptomsunresponsivetoappropriatetherapy

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Delivery‐TheCure timely delivery minimizes maternal and neonatal morbidity andmortality

 optimizematernalstatusbeforeinterventionstodeliver delaydeliverytogainfetalmaturityandtoallowtransferonlywhenmaternalandfetalconditionallowit

 gestational hypertension is a progressive disease, expectantmanagement is potentially harmful in presence of severe disease orsuspectedfetalcompromise

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Peri‐andPostpartumManagement donotdropBPtoolowriskingfetalcompromise donotfluidoverload epiduralanalgesiaisfavouredintheabsenceoflowplateletsorcoagulopathy

 multi‐specialtyapproach patientmustbemonitoredpost‐partum

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