PENATALAKSANAAN PREEKLAMSIA MASA KEHAMILAN,...

PENATALAKSANAAN

PREEKLAMSIA

MASA KEHAMILAN,

PERSALINAN DAN NIFAS

DALIMAN RS MARGONO SOEKARJO/

FK UNSOED

PURWOKERTO

Jumat, 08 Maret 2019 1 PENATALAKSANAAN PREEKLAMSIA,

SEMINAR POLTEKES, 09 MARET 2019, DALIMAN.DM19

INSIDENSI

KELAINAN

HIPERTENSI DALAM

KEHAMILAN (HDK) MERUPAKAN

KOMPLIKASI 5 – 10% DARI SELURUH

KEHAMILAN.

PREEKLAMSIA

TERIDENTIFIKASI 3,9%

DARI SELURUH

KEHAMILAN.

DI NEGARA MAJU 10–16 % KEMATIAN IBU DISEBABKAN OLEH

KELAINAN HIPERTENSI.

PROPORSI 3 PENYEBAB

KEMATIAN LAIN PERDARAHAN

13% , ABORSI 8 %, DAN SEPSIS

2%.

YANG PENTING, BAHWA LEBIH

DARI SETENGAH

HIPERTENSI YANG

DIHUBUNGKAN DENGAN

PENYEBAB KEMATIAN DAPAT

DICEGAH



HIPERTENSI DALAM KEHAMILAN (HDK) (Pregnancy-Related Hypertension, Preclampsia and Hypertensive disorder,

Hypertension in Pregnancy, Hypertensive Disorders, Hipertensive Emergencies)

Klasifikasi (ACOG Tak Force for

Hypertension, 2013; NIH Working group

on Hypertension in Pregnancy):

1. Preeclampsia (PE) and eclampsia (E) syndrome,

2. Chronic hypertension (CHTN) of any etiology,

3. Preeclampsia superimposed on chronic hypertension (SIPE),

4. Gestational hypertension (GHTN).

Klasifikasi : I. Gestasional Hypertension,

II. Gestasional Proteinuria,

III. Preeclampsia and Preeclampsia with severe features.

IV. Chronic Hypertension,

V. Superimposed Preeclampsia,

VI. Superimposed Preeclampsia with severe featrures



Creasy & Resnik’s, 2019. Maternal-Fetal Medicine: Principles and Practice, 8th ed.

Cunningham et.al., 2018. Williams Obstetrics, 25th ed) Foley MR, et.al., 2018. Obstetrics, Intensive Care Manual, 5th ed.

Mularz A, et.al.,2017. OB/GYN, secrets, 4th ed.

Gabe, SG,. Et.al, 2017. Obstetrics; Normal and problem Pregnancies, 7ed.

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-

eclampsia ( > 48 hours postpartum).

Gabbe et.al, 2017



HIPERTENSI DALAM KEHAMILAN

Definisi dan kriteria diagnostik :

1. Chronic hypertension,

2. Gestasional hypertension,

3. Preeclampsia without severe features (“mild preeclampsia”),

4. Superimposed Preeclampsia,

5. Superimposed Preeclampsia with severe features,

6. Preeclampsia with sevevre features (“severe preeclampsia”).

7. HELLP syndrome,

8. Eclampsia.

Klasifikasi (ISSHP, 2000; 2014):

1. Chronic hypertension,

2. Gestasional hypertension,

3. Preeclampsia – de novo or Superimposed on chronic hypertension,

4. White-coat hypertension



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

James D, et.al., 2017. High-Risk Pregnancy, managemant options, 5th ed.

Hipertensi Dalam Kehamilan (HDK)

1. Hipertensi (HTN) +,

2. Hipertensi (HTN) -,

3. Proteinuria (PU) +,

4. Proteinuria (PU) -,

5. Hasil laboratorium (Lab) PEB,

6. Gejala atau tanda (G&T) PEB.

HAMIL

HTN +

HTN -

PU +

PU-

LAB PEB

G&T PEB



DEFINISI

KEHAMILAN:

• SEBELUM HAMIL,

• HAMIL ≤ 20 MGG,

• HAMIL > 20 MGG,

• PERSALINAN,

• NIFAS.

HIPERTENSI : • TEKANAN DARAH ≥ 140/90 mmHg,

• White-coat Hypertension diperiksa TD ≥ 140/90 mmHg, monitor 24 jam TD < 130/80 mmHg,

• Delta Hypertension kenaikan MAP setelah UK 28 mgg.

• Kenaikan Tek Sistolik > 30 mmHg, Tek Diastolik > 15 mmHg.



PENEGAKAN DIAGNOSIS HIPERTENSI

Tensimeter air raksa

Menggunakan

tensimeter air

raksa, atau

Tensimeter jarum atau

otomatis yang sudah

divalidasi. Pengukuran

tekanan darah (TD)

menggunakan alat otomatis

sering memberikan hasil yang

lebih rendah.

American Society of Hypertension

Sebelum dilakukan pengukuran TD,

ibu duduk tenang selam 15 menit,

Pengukuran pada posisi DUDUK

atau TERLENTANG, posisi lateral

kiri, kepala ditinggikan 30º, posisi

manset setingkat dengan jantung,

dan tekanan DIASTOLIK diukur

dengan mendengar bunyi

Korotkoff V (hilang bunyi). Pada

wanita dengan hipertensi kronik

pengukuran dilakukan pada kedua

lengan, dengan menggunakan hasil

pemeriksaan yang tertinggi.



DELTA HIPERTENSI



Cunningham et.al, 2018. Williams Obstetrics, 25 ed

DEFINISI

Proteinuria + (posistif):

≥ 300 mg/ 24 jam urine tampung,

Rasio creatinin/ protein urine, 1 x pemeriksaan, > 0,3 mg/ dL,

Kualitatif dipstik 1+ (30 mg/ dL)

Lab Preklamsia Berat (PEB):

• Trombositopenia ( < 100.000/ µL),

• Konsentrasi Creatinin serum > 1,1 mg/ dL (2 x nilai NORMAL, tanpa penyakit ginjal lain),

• SGOT/ PT > 2 x NILAI ATAS NORMAL.



DEFINISI

Gejala dan tanda PEB:

1. Muncul gangguan baru cerebral atau visual,

2. Edema paru atau SIANOSIS

3. Nyeri menetap epigastrik atau kuadran kanan atas yang tidak respon terapi dan tidak ada alternatif diagnosis.




DIAGNOSIS HDK

HIPERTENSI

≥ 140/90

1

PROTEINURIA

POSITIF 2

PROTEINURIA NEGATIF

2

LAB & GEJALA-TANDA

PEB

1. HTN + PU (-)(LAB PEB -, G&T PEB -) +

UK ≥ 20 HIPERTENSI GESTASIONAL

2. HTN + PU (-) (LAB PEB -, G&T PEB -) +

UK < 20 HIPERTENSI KRONIK

3. HTN + PU (+)/(-) (LAB PEB +, G&T PEB

+) + UK ≥ 20 SINDROMA

PREEKLAMSIA (PE)

4. HTN + PU (-) PU (+)/ (-) (Kenaikan

HTN) pada UK ≥ 20 PREEKLAMSIA

SUPERIMPOSSED (SIPE).

MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD Preeclampsia Updated: Feb 16, 2018

Cunningham et.al, 2018. Williams Obstetrics, 25 ed and ACOG, 2013




PREEKLAMSIA

HT

PROT +/-

PE

HT (HIPERTENSI) :

TEKANAN DARAH ≥

140/90.

HIPERTENSI White Coats,

adalah DIPERIKSA (Dr/Per/

Bidan) ≥ 140/90, monitor 24

jam < 130/80, ≥ UK 20 mgg

DELTA HIPERTENSI

KENAIKAN MAP PADA

TRIMESTER III

TEKANAN SISTOLIK NAIK

30, DIATOLIK NAIK 15.



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 + 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).

Jumat, 08 Maret 2019 14

PENATALAKSANAAN PREEKLAMSIA, SEMINAR POLTEKES, 09 MARET 2019,

DALIMAN.DM19

Sindroma Preeklamsia

Menurut Sibai (2009) dan ACOG

(2013b): diagnosis sindroma

Preeklamsia dapat ditegakkan TIDAK

HARUS PROTEINURIA POSITIF.

HIPERTENSI + DISFUNGSI

MULTIORGAN, seperti trombositopenia

(< 100.000), disfungsi renal (kreatinin >

1,1 mg/dL), nekrosis hepatoseluler

(disfungsi liver)( AST dan ALT > 2 X

NORMAL), pertubasi sistema syaraf

pusat/ SSP (nyeri kepala, gangguan

penglihatan, dan KEJANG), EDEMA

PULMONUM



PREEKLAMSIA BERAT (Gabbe, et.al, 2017; Cunningham, et.al 2018; Lim KH, 2018)

Jumat, 08 Maret 2019 PENATALAKSANAAN PREEKLAMSIA,


16

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

HIPERTENSI (baru) tanpa

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.

Preeclampsia with severe features

(“severe preeclampsia”)

1. BP ≥160/110 mmHg (two occasions, >4 hours apart)

2. Thrombocytopenia (platelets <100,000/mm3) and/or evidence of

microangiopathic hemolytic anemia

3. Increased hepatic transaminases (AST and/or ALT) two times of the

upper limit of normal concentration for the particular laboratory

4. Progressive renal insufficiency (creatinine ≥1.1 mg/dL or a doubling

of the serum creatinine) or oliguria (<500 mL urine in 24 hours)) in

absence of other renal disease

5. Persistent headache or other cerebral or visual disturbances

(including grand mal seizures)

6. Persistent epigastric (or right upper quadrant) pain

7. Pulmonary edema or cyanosis

Preeclampsia with any one of the following criteria:



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

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




Superimposed preeclampsia with severe features

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)

Superimposed preeclampsia and one or more of the following criteria:




Eclampsia Seizures (grand mal) in the presence of

preeclampsia and/or HELLP syndrome.




Eklamsia SEKITAR 15% KASUS,

TANPA HIPERTENSI

DAN PROTEINURIA

SEBELUM EKLAMSIA,

LEBIH DARI 50% KASUS TERJADI PADA

KASUS YANG TIDAK

DIDIAGNOSIS PRE-

EKLAMSIA, TETAPI

HANYA PENYAKIT

RINGAN, PRETERM,

DAN TANPA DAPAT

DICEGAH.



HT PE PEB Ekl

85%

15% (-) HT dan (-) PU

15% ?

?

?

EKLAMSIA

1. Hanya 42%-43% Eklamsia didahului dengan PE 57%-58% tidak didahului PE

2. 30%-50% Eklamsia tidak didahului dengan PEB 50%-70% didahului PEB.



PE PEB EKL

Creasy and Resnik’s, et.al., 2019. Maternal-Fetal Medicine, Principle and Practice, 8th ed.

42%-43%

50%-70%

≠30%-50%

≠ 57%-58%

25%

MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD Preeclampsia Updated: Nov 29, 2018

HELLP syndrome

• 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.

Tennessee Classification (most commonly used)




03/08/2019 PEMBELAJARAN TERFOKUS AMP, 150517,

DALIMAN.DM17 24

The basic management objectives

for any pregnancy complicated by

Preeclampsia are (Cunningham, 2018):

1. Termination of pregnancy with the least possible trauma

to mother and fetus

2. Birth of an infant who subsequently thrives

3. Complete restoration of health to the mother.

PENATALAKSANAAN

PREEKLAMSIA

PENCEGAHAN PE Terminologi umum

PENCEGAHAN,

dibagi 3:

1. Pencegahan

PRIMER,

2. Pencegahan

SEKUNDER,

3. Pencegahan

TERSIER.

PRIMER, artinya menghindari

terjadinya PENYAKIT,

SEKUNDER, artinya

memutus proses terjadinya

PENYAKIT yang sedang

berlangsung sebelum timbul

GEJALA atau KEDARURATAN

KLINIS,

TERSIER, berarti

pencegahan dari KOMPLIKASI

yang disesbabkan oleh proses

PENYAKIT TATALAKSANA



PNPK PREEKLMASIA, HKFM POGI

PENCEGAHAN PRIMER o Pencegahan

yang terbaik,

namun hanya

dapat dilakukan

apabila

penyebab PE

telah diketahui

dengan jelas.

o Dilakukan

dengan prediksi

dan mengontrol

FAKTOR RISIKO

PE 17

1. Umur > 40 th,

2. Nulipara,

3. Multipara dengan riwayat PE,

4. Multipara dengan kehamilan oleh pasangan BARU

(primipaternitas),

5. Multipara yang jarak kehamilan sebelumnya ≥ 7-10 th,

6. Riwayat PE sebelumnya,

7. Riwayat keluarga PE (IBU atau saudara perempuan),

8. Kehamilan multipel,

9. IDDM,

10. Penyakit GINJAL,

11. Penyakit GIGI,

12. APS,

13. Kehamilan dengan inseminasi dodor sperma, oosit atau embryo,

14. OBESITAS sebelum hamil,

15. BMI ≥ 35,

16. Takanan darah DIASTOLIK ≥ 80 mmHg

17. Proteinuria (dipstick ≥+1 pada 2 kali pemeriksaan berjarak 6 jam atau

secara kuantitatif 300 mg/ 24 jam)



PNPK HKFM POGI. PREEKLAMSIA

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) >35 th (1,2 :1 / 1,1-1,3)

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)

10. High body mass index (BMI > 30) (3:1)

11. Homozygosity for angiotensinogen gene T235 (20:1)

12. Heterozygosity for angiotensinogen gene T235 (4:1)

13. TEK SIS > 130, TEK DIASTOLIK > 80 mmHg UK < 20.

14. Interval KEHAMILAN > 7 TH,

15. RIWAYAT PE kehamilan sebelumnya (8,4:1 / 7,1-9,9),

16. Kehamilan dengan ASISSTED REPRODUCTIONS TECHNOLOGY (1,8:1).

17. Riwayat SOLUSIO PLASENTA (2,0:1/ 1,4-2,7), LAHIR MATI (2,4:1)




James D., et.al., 2017. High-Risk Pregnancy, Management Options. 5th ed

Gabbe et.al., 2017. Obstetrics, Normal adnd Problem Pregnancies, 7th ed.

Creasy and Resnik’s, et.al., 2019. Maternal-Fetal Medicine, Principle and Practice, 8th ed.

Cunningham, 2018. Williams Obstetrics, 25th ed.)

PENCEGAHAN SEKUNDER

1. Istirahat,

2. Restriksi

garam,

3. ASPIRIN dosis

rendah,

4. Suplemenatsi

KALSIUM,

5. Suplementasi

ANTIOKSIDAN.

KESIMPULAN (ASPIRIN DOSIS RENDAH)

1. Penggunaan Aspirin dosis rendah untuk

PENCEGAHAN PRIMER berhubungan dengan

penurunan risiko PE, persalinan PRETERM,

kematian janin atau neonatus dan BAYI KMK,

sedangkan untuk PENCEGAHAN SEKUNDER

berhubungan dengan penurunan risiko PE,

persalinan PRETEM < 37 mgg, dan BBL < 2500

gram.

2. Efek Asprin lebih nyata didapatkan pada

KELOMPOK RISIKO TINGGI,

3. Pemberian Aspirin dosis > 75 mg lebih baik untuk

menurunkan risiko PE, namun risiko yang

diakibatnya lebih tinggi.

REKOMENDASI

Aspirin dosis 75 mg atau kurang cukup aman

diberikan pada KELOMPOK RISIKO TINGGI

untuk menurunkan risiko PE baik sebagai

pencegahan PRIMER atau SEKUNDER.

03/08/2019 28 PEMBELAJARAN TERFOKUS AMP, 150517,

DALIMAN.DM17

Level evidence Ia, Rekomendasi A

PENCEGAHAN SEKUNDER

1. Istirahat,

2. Restriksi

garam,

3. ASPIRIN dosis

rendah,

4. Suplemenatsi

KALSIUM,

5. Suplementasi

ANTIOKSIDAN.

KESIMPULAN (KALSIUM)

1. Pemberian KALSIUM (1,5-2 gram) berhubungan dengan penurunan HDK

dan PE pada wanita dengan ASUPAN

RENDAH KALSIUM dan risiko tinggi PE,

2. Pemberian Kalsium juga berhubungan

dengan penurunan risiko MORBIDITAS

BERAT dan MORTALITAS MATERNAL,

persalinan PRETERM, dan tekanan

darah diastolik > persentil 95 pada

masa kanak.

REKOMENDASI

Pemberian KALSIUM dapat dilakukan pada

WANITA yang MEMILIKI RISKO TINGGI

PE dan RENDAH ASUPAN KALSIUM

untuk mencegah terjadinya PE.




TOG release: Low dose aspirin and calcium supplementation for prevention of pre-eclampsia

• Low dose aspirin started before 16 weeks

gestation and calcium supplementation after 20 weeks gestation in low-intake populations can prevent the onset of pre-eclampsia in pregnancies at risk of the condition, states a new review published today in The Obstetrician & Gynaecologist (TOG). It is also possible to assess a woman’s risk of developing pre-eclampsia from as early as 11 weeks of pregnancy, say the authors.

18 July 2014

03/08/2019 30 PEMBELAJARAN TERFOKUS AMP, 150517,

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PENCEGAHAN SEKUNDER

Rekomendasi :

• Istirahat di rumah ( 4jm/ hr atau 2 x 15 menit + suplemen) direkomendasikan untuk pencegahan primer PE,

• Tirah baring TIDAK direkomendasikan untuk memperbaiki luaran pada wanita dengan hipertensi (dengan atau tanpa proteinuria)


Rekomendasi :

• Pembatasan garam untuk mencegah PE dan komplikasinya selama kehamilan TIDAK direkomendasikan.




Clinical Risk Assessment for Preeclampsia

Risk Level Risk Factors Recommendation

High History of preeclampsia, especially when accompanied by an adverse outcome, Multifetal gestation, Chronic hypertension, Type 1 or 2 diabetes, Renal disease, Autoimmune disease (systemic lupus erythematous, antiphospholipid syndrome)

Recommend low-dose aspirin if the patient

has ≥1 of these

high-risk factors

Moderate Nulliparity, Obesity (body mass index >30 kg/m2), Family history of preeclampsia (mother or sister), Sociodemographic characteristics (African American race, low socioeconomic status), Age ≥35 years Personal history factors (e.g., low birthweight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval)

Consider low-dose aspirin if the patient

has several of

these moderate-risk factors.

Low Previous uncomplicated full-term delivery Do not recommend low-dose aspirin

Timing Use of low-dose aspirin was initiated between 12 and 28 weeks of gestation. Evidence did not suggest additional benefit when use of aspirin was started earlier (12 to 16 weeks) rather than later (≥16 weeks) in pregnancy in women at increased risk for preeclampsia 1.



https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication

Penanganan Hanya persalinan obat

preeklamsia. Pasien dengan PE tidak berat

perlu induksi setelah umur kehamilan 37 mgg.

Sebelumnya pasien biasanya diawasi dengan ketat atau dirawat untuk perkembangan, perburukan atau komplikasi PE, dan imaturitas janin ditangani ekspektatif dengan pemberian kortikosteroid guna memacu pematangan paru janin untuk persiapan persalinan prematur.

Pasien dengan PEB induksi persalinan seharusnya dilakukan setelah umur kehamilan 34 mgg.

Dalam kasus ini, memberatnya penyakit dipertimbangkan dengan risiko prematuritas janin.

Dalam kondisi darurat kontrol TD dan kejang harus diprioritaskan.



MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD Preeclampsia Updated:

Nov 29, 2018

MgSO4 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.

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



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.




OBAT ANTIHIPERTENSI

ALTERNATIF OBAT ANTIHIPERTENSI, ADALAH :

1. Labetalol 20 mg iv bolus, dilanjutkan 40 mg, 80 mg, 80 mg jika diperlukan, setiap 10 menit dengan dosis maksimal total 220 mg.

2.Nifedipin 10-20 mg po, diulang

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).

DIBERIKAN APABILA

TEKANAN SISTOLIK ≥160 DAN ATAU TEKANAN

DIASTOLIK ≥110




Sample Order Set for Severe Intrapartum or Postpartum Hypertension

Initial First-line Management With Immediate-Release Oral Nifedipine*

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.

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.



ACOG, 2017. COMMITTEE OPINION



38

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.

MANAJEMEN CAIRAN pada

PEB • Hindari pemberian

diuretik.

• Resusitasi volume cairan yang agresif penyebab utama untuk EDEMA PULMONUM.

• Sedapat mungkin pasien harus RESTRIKSI CAIRAN, minimal sampai periode DIURESIS POSTPARTUM.

TOTAL CAIRAN secara umum seharusnya dibatasi TIDAK LEBIH dari

1. 80 mL/jam, atau

2. 1 mL/kg/jam, atau

3. (60-125 ml/jam)





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

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





41

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%)( ok. Permeabilitas kapiler, cardiogenic atau kombinasi keduanya, disamping penurunan tekanan ONKOTIK ok. hipoALBUMIN),

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)

Berghella V., 2017. Maternal-Fetal Eviddence Based Guidelines, 3 th ed. Cunningham, 2018. Williams Obstetrics, 25th ed.)



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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%).



44

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.)

Acute Treatment of Severe Hypertension in Pregnancy

In the setting of severe

hypertension (SBP >160 mm Hg 93% STROKE H;

DBP >110 mm Hg 20% STROKE H), antihypertensive treatment is

recommended.

The goal of hypertension treatment is to lower BP to prevent cerebrovascular and cardiac complications while maintaining uteroplacental blood flow (ie, maintain BP

around 140/90 mm Hg).




ANTIHYPERTENSIVE and PE

CONTROL of MILDLY increasing BP does not appear to improve PERINATAL MORBIDITY or MORTALITY, and it may, in fact, REDUCE BIRTH WEIGHT.



Antihypertensive treatment decreases the incidence of cerebrovascular problems, is dose not alter the progression of PREECLAMPSIA.


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.

Although ACOG recommends magnesium sulfate in severe preeclampsia, it has not recommended this

therapy in all cases of mild preeclampsia.






48

Some Indications for Delivery with Early-Onset Severe Preeclampsia (Cunningham, 2018):

Maternal

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,

AFI = amnionic fluid index; EGA = estimated gestational age; SaO2 = oxygen saturation.

From Sibai and Barton (2007).

≤ 72 JAM

Foley MR, et., 2018. Obstetric Intensive Care Manual. 5th ed.

ONE OR MORE




49

Fetal

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. 5th ed

≤ 72 JAM ONE OR MORE

MedScape, Kee-Hak Lim, MD; Ronald M Ramus,

MD Preeclampsia Updated: Nov 29, 2018



50

Foley MR, et., 2018. Obstetric Intensive Care Manual. 5th ed

Penyebab EDEMA PULMONUM

1.CARDIAC (HIGH PRESSURES) Cardiac dysfunction,

Pulmonary venous dysfunction, Pulmonary Embolism, Airway

Obstruction, Preeclampsia, Miscelaneous, (decreased Left

Ventricular contractility, Mitral stenosis, Mitral regurgitation, INTRAVASCULAR VOLUME OVERLOAD, dysrithmias), (Venous occlusive disease, Neurogenic pulmonary vasoconstriction), (Amniotic fluid, thrombus, fat, air), (edema, astma,

foreign body), (Pulmonary hypertension), (Pneumothorax, tumor, one lung anesthesia (down lung syndrome)).

2.NONCARDIOGENIC (PERMEABILITY) Adult

Respiratory Disterss Syndrome (ARDS), Aspiration Syndrome, Pulmonary Embolism, Abruptio Placentae, Dead Fetus Syndrome, Sepsis.

EDEMA PULMONUM



DIAGNOSIS PROGRESIF nafas pendek, desaturasi, takhipnea, kadang HIPERTENSI, bilateral RBBH, S3 Gallops (tidak selalu).

FAKTOR PREDISPOSIS KELEBIHAN CAIRAN (fluid overload), PE, terapi TOKOLITIK, HT tak terkontrol.

MANAJEMEN posisi semi-Fowler, kepala dan dada ditinggikan, O2 10 L/m sungkup (facemask) atau CPAP, puls oxymetri kontinyu dan monitor cardiac, PEMBATASAN CAIRAN (30-50 ml/jam), kontrol faktor predisposisi.

Terapi farmakologi MORFIN sulfat : 3-5 mg IV, FUROSEMID : 20-40 mg iv dapat diulang – maksimal dosis 120 mg/jam-pelan untuk menghindari INTOKSIKASI, NITROGLYCERIN 2 in of paste to chest atau 1 pill (1/150) IV, HYDRALAZINE : 5-10 mg IV HT BERAT.

DIAGNOSIS, FAKTOR PREDISPOSISI, MANAJEMEN, TERAPI FARMAKOLOGI, MONITOR.

Foley MR, et., 2018. Obstetric Intensive Care Manual. 5TH ed.

Preparing for Clinical Emergencies in Obstetrics and Gynecology

Examples of Tools for Managing Clinical Emergencies

1. Availability of appropriate emergency supplies in a resuscitation cart (crash cart) or kit

2. Development of a rapid response team

3. Development of protocols that include

clinical triggers 4. Use of standardized communication tools for

huddles and briefs (eg, SBAR)

5. Implementation of emergency drills and simulations

Abbreviation: SBAR, Situation–Background–Assessment–Recommendation.

ABSTRACT: Patient care emergencies may occur at any time in any setting, particularly the inpatient setting. It is important that obstetrician–gynecologists prepare themselves

by assessing potential emergencies, establishing early warning systems, designating specialized first responders, conducting emergency drills, and debriefing staff after actual events to identify strengths and opportunities for improvement. Having such systems in place may reduce or prevent the severity of medical emergencies.

ACOG COMMITTEE OPINION Number 590, March 2014 (Replaces Committee Opinion

Number 487, April 2011) (Reaffirmed 2018)



Wassalamu’alaikum warahmatullahi wabarakaatuh



53

CURICULUM VITAE (CV) • Nama : DALIMAN, dr.Sp.OG(K)FM.

• T/ TL : Klaten, 3 Februari 1956.

• Alamat : Jl. Dr. Angka, 28. PURWOKERTO.

• Email : [email protected]

• Pendidikan :

SD – SMA ,tamat 1974, Wonosobo.

Dokter, FK UGM Angkatan 1975, tamat 1981.

Spesialis Obgin, Sp.OG, FK UGM 1989, tamat 1993.

Konsultan Fetomaternal, (K)FM, FK UGM 2009, tamat 2011.

• Pekerjaan :

Kepala Puskesmas Nanga Sepauk, Sintang, Kalbar (1982-1987)

Direktur RSUD Sintang, Kalbar (1987-1989).

Tenaga Medis Fungsional, Sp.OG, RSUD Sintang, Kalbar (1994-1998).

Wakil Direktur RSUD Margono Soekarjo (2000-2008).

Wakil Dekan FK Unsoed (2001-2004)

Dokter Pendidik Klinis RSUD Margogono Soekarjo/ FKIK Unsoed (2009- SEKARAG).



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