R. HARYONO ROESHADI,. KLASIFIKASI : Report on the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy (AJOG.

Presentasi berjudul: "R. HARYONO ROESHADI,. KLASIFIKASI : Report on the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy (AJOG."— Transcript presentasi:

1 R. HARYONO ROESHADI,

2 KLASIFIKASI : Report on the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy (AJOG Vol 183:S1, July 2000)  HIPERTENSI GESTASIONAL : DIDAPATKAN DESAKAN DARAH ≥ 140/90 mmHg  PERTAMA KALINYA PD KEHAMILAN, TDK DISERTA DGN PROTEINURIA DAN DESAKAN DARAH KEMBALI NORMAL < 12 MGG PASCA PERSALINAN KLASIFIKASI : Report on the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy (AJOG Vol 183:S1, July 2000)  HIPERTENSI GESTASIONAL : DIDAPATKAN DESAKAN DARAH ≥ 140/90 mmHg  PERTAMA KALINYA PD KEHAMILAN, TDK DISERTA DGN PROTEINURIA DAN DESAKAN DARAH KEMBALI NORMAL < 12 MGG PASCA PERSALINAN

3  PREECLAMSIA : KRITERIA MINIMUM DESKAN DARAH ≥ 140/90 mmHg  UMUR KEHAMILAN 20 MGG, DISERTAI PROTEINURIA ≥ 300 mg/24 JAM ATAU DIPSTICK ≥ 1 +  ECLAMSIA KEJANG 2 PADA PREECLAMPSIA DISERTAI KOMA  PREECLAMSIA : KRITERIA MINIMUM DESKAN DARAH ≥ 140/90 mmHg  UMUR KEHAMILAN 20 MGG, DISERTAI PROTEINURIA ≥ 300 mg/24 JAM ATAU DIPSTICK ≥ 1 +  ECLAMSIA KEJANG 2 PADA PREECLAMPSIA DISERTAI KOMA

4  HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA  PROTEINURIA ≥ 300 MG/24 JAM PD ♀ HAMIL YG SUDAH MENGALAMI HIPERTENSI SEBELUMNYA. PROTEINURIA TIMBUL SETELAH KEHAMILAN 20 MGG  HIPERTENSI KRONIK DITEMUKANNYA DESAKAN DARAH ≥ 140/90 mmHg, SEBELUM KEHAMILAN ATAU SEBELUM KEHAMILAN 20 MGG DAN TDK MENGHILANG SETELAH 12 MGG PASCA PERSALINAN  HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA  PROTEINURIA ≥ 300 MG/24 JAM PD ♀ HAMIL YG SUDAH MENGALAMI HIPERTENSI SEBELUMNYA. PROTEINURIA TIMBUL SETELAH KEHAMILAN 20 MGG  HIPERTENSI KRONIK DITEMUKANNYA DESAKAN DARAH ≥ 140/90 mmHg, SEBELUM KEHAMILAN ATAU SEBELUM KEHAMILAN 20 MGG DAN TDK MENGHILANG SETELAH 12 MGG PASCA PERSALINAN

5 INTRODUCTION :  INDUCED BY PREGNANCY  DISEASE OF THEORIES  CLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUT ORGAN DYSFUNCTION / FAILURE  THIRD LEADING CAUSE OF MATERNAL MORTALITY  MORTALITY RATE:150.000 WOMEN A YEAR WORLD WIDE INTRODUCTION :  INDUCED BY PREGNANCY  DISEASE OF THEORIES  CLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUT ORGAN DYSFUNCTION / FAILURE  THIRD LEADING CAUSE OF MATERNAL MORTALITY  MORTALITY RATE:150.000 WOMEN A YEAR WORLD WIDE

6 YEARHOSPITALPERCENTAGEAUTHOR 1993 – 1997 1996 – 1997 1995 – 1998 2000 – 2002 2002RSPM 12 HOSPITALS RS. H.S. RSHAM – RSPM RSCM5,75 0,8 - 14 13,07,09,17 SIMANJUNTAK J. TRIBAWONO A. MEIZIA GIRSANG. E PRIYATINI INCIDENCE PE/E : 2% - 9% OF ALL PREGNANT WOMEN IN SEVERAL HOSPITAL IN INDONESIA

7 ETIOLOGY : NOT FULLY KNOWN  RISK FACTORS : NULLI PARITY / TEENAGE PREGNANCY NULLI PARITY / TEENAGE PREGNANCY HISTORY OF PREVIOUS PREGNANCY HISTORY OF PREVIOUS PREGNANCY FAMILY HISTORY OF PE/E FAMILY HISTORY OF PE/E MULTIPLE GESTATION MULTIPLE GESTATION PREEXISTING HYPERTENSION / RENAL DISEASE PREEXISTING HYPERTENSION / RENAL DISEASE D.M, ANTI PHOSPOLIPID ANTIBODY D.M, ANTI PHOSPOLIPID ANTIBODY HYDROPS FETALIS HYDROPS FETALIS HYDATIDIFORM MOLES HYDATIDIFORM MOLES  URYNARY TRACT INFECTION

8 PATHOGENESE :  CONTROVERSION : THE DISEASE OF THEORIES IMMUNITY, GENETIC VASC. DISEASE TROPHOBLAST  INADEQUATE TROPHOB. INVASION TO SPIRAL ARTERY OF PLACENTA INSUFF, PLACENTA  HYPOXIA IUGR OXYDATIVE STRESS ENDOTHELIAL DYSFUNCTION CIRCULATING FACTOR(S) CYTOKINES LIPID (IL-6, TNF-  ) PEROXIDES NEUTROPHIL ACTIVATION PLATELET ACTIVATION

9 ENDOTHELIAL DYSFUNCTION BLOOD ▪ THROMBOCYTOPENIA ▪ COAGULAPATHY ALTERED VASCULAR PERMEABILITY ▪ PERIPHERAL OEDEMA ▪ PULMONARY OEDEMA SYSTEMIC VASOCONSTRICTION ▪ HYPERTENSION KIDNEYS ▪ HYPERURICAEMIA ▪ PROTEINURIA ▪ RENAL FAILURE LIVER ▪ ABNORMAL FUNCTION TESTS ▪ HAEMORRHAGE CNS / EYES ▪ SEIZURES ▪ CORTICAL BLINDNESS ▪ RETINAL DETACHMENT & HAEMORRHAGE

10 CLINICAL CLASSIFICATION: PREECLAMPSIA-MILD PREECLAMPSIA-MILD -SEVERE IMPENDING ECLAMPSIA IMPENDING ECLAMPSIA ECLAMPSIA ECLAMPSIA HELLP SYNDROME HELLP SYNDROME CLINICAL CLASSIFICATION: PREECLAMPSIA-MILD PREECLAMPSIA-MILD -SEVERE IMPENDING ECLAMPSIA IMPENDING ECLAMPSIA ECLAMPSIA ECLAMPSIA HELLP SYNDROME HELLP SYNDROME

11 MILD PREECLAMPSIA :  BP  140/90 mmHg AFTER 20 WEEKS GESTATION  PROTEINURIA  300 mg/ 24 H OR 1+ DIPSTICK  WITH OR WITHOUT OTHER SYMPTOMS AND SIGN MILD PREECLAMPSIA :  BP  140/90 mmHg AFTER 20 WEEKS GESTATION  PROTEINURIA  300 mg/ 24 H OR 1+ DIPSTICK  WITH OR WITHOUT OTHER SYMPTOMS AND SIGN

12 SEVERE PREECLAMPSIA  BP  160/110 mmHG  PROTEINURIA 2.0 gr / 24 H OR  2 + DIPSTICK  HEADACHE, VISUAL OR CEREBRAL DISTURBANCE  EPIGASTRIC PAIN  OLIGURIA : < 400 – 500 CC/ 24 HOURS  HYPER REFLEX, MOTORIC EXCITATION, IMPAIRED CONSIOUSNESS, SUDDEN DETERIORATION  PLATELETS COUNT < 1000.000 / mm 3  BILIRUBIN  1,2 mg / DL  LDH > 600 IU/L  SGOT > 70 mg/DL SEVERE PREECLAMPSIA  BP  160/110 mmHG  PROTEINURIA 2.0 gr / 24 H OR  2 + DIPSTICK  HEADACHE, VISUAL OR CEREBRAL DISTURBANCE  EPIGASTRIC PAIN  OLIGURIA : < 400 – 500 CC/ 24 HOURS  HYPER REFLEX, MOTORIC EXCITATION, IMPAIRED CONSIOUSNESS, SUDDEN DETERIORATION  PLATELETS COUNT < 1000.000 / mm 3  BILIRUBIN  1,2 mg / DL  LDH > 600 IU/L  SGOT > 70 mg/DL

13 IMPENDING ECLAMPSIA  SEVERE PREECLAMPSIA WITH :  HEADACHE  NAUSEA AND VOMITING  BLURRED VISION, SCOTOMA, IMPAIRED CONSIOUSNESS, SUDDEN DETERIORATION  EPIGASTRIC PAIN IMPENDING ECLAMPSIA  SEVERE PREECLAMPSIA WITH :  HEADACHE  NAUSEA AND VOMITING  BLURRED VISION, SCOTOMA, IMPAIRED CONSIOUSNESS, SUDDEN DETERIORATION  EPIGASTRIC PAIN

14 ECLAMPSIA  SEVERE PREECLAMPSIA + CONVULSION  IS THE LEADING CAUSE OF 50.000 MATERNAL MORTALITY A YEAR WOLRD WIDE  75% OCCURRED ANTEPARTUM AND 25% POST PARTUM  40% OF SEIZURES OCCUR BEFORE HOSPITALIZATION  CEREBRAL HAEMORRHAGE, PULMONARY EDEMAARE THE MOST COMMON COMPLICATION ECLAMPSIA  SEVERE PREECLAMPSIA + CONVULSION  IS THE LEADING CAUSE OF 50.000 MATERNAL MORTALITY A YEAR WOLRD WIDE  75% OCCURRED ANTEPARTUM AND 25% POST PARTUM  40% OF SEIZURES OCCUR BEFORE HOSPITALIZATION  CEREBRAL HAEMORRHAGE, PULMONARY EDEMAARE THE MOST COMMON COMPLICATION

15 HELLP SYNDROME  COMPLICATION OF SEVERE PREECLAMPSIA  10-15% DIRECTLY FROM PREGNANCY HELLP SYNDROME  COMPLICATION OF SEVERE PREECLAMPSIA  10-15% DIRECTLY FROM PREGNANCY MANAGEMENT OF PREECLAMPSIA  ADEQUAT AND PROPER PRENATAL CARE  IDENTIFICATION OF WOMEN AT HIGH RISK  EARLY DETECTION BY THE RECOGNATION OF CLINICAL SIGNS AND SYMPTOMS  THE PROGRESSION OF CONDITION TO SEVERE STATE MANAGEMENT OF PREECLAMPSIA  ADEQUAT AND PROPER PRENATAL CARE  IDENTIFICATION OF WOMEN AT HIGH RISK  EARLY DETECTION BY THE RECOGNATION OF CLINICAL SIGNS AND SYMPTOMS  THE PROGRESSION OF CONDITION TO SEVERE STATE

16  MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY FAVOURABLE  MATERNAL AND PERINATAL OUTCOMES DEPEND ON :  GESTATIONAL AGE AT TIME OF DISEASE ONSET  SEVERITY OF DISEASE  QUAITY OF MANAGEMENT  PRESENCE OR ABSENCE OF PRE-EXISTING MEDICAL DISORDERS  MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY FAVOURABLE  MATERNAL AND PERINATAL OUTCOMES DEPEND ON :  GESTATIONAL AGE AT TIME OF DISEASE ONSET  SEVERITY OF DISEASE  QUAITY OF MANAGEMENT  PRESENCE OR ABSENCE OF PRE-EXISTING MEDICAL DISORDERS

17 MILD – PREECLAMPSIA  AMBULATORY CARE  BED REST : NOT NECESSARILY  REGULAR DIET, NO SALT RESTRICTION  PRENATAL VITAMIN  NO OTHER MEDICATION : ANTI HYPERTENSIVE, SEDATIVE, DIURETICS  ANTENAL VISIT : EVERY WEEK MILD – PREECLAMPSIA  AMBULATORY CARE  BED REST : NOT NECESSARILY  REGULAR DIET, NO SALT RESTRICTION  PRENATAL VITAMIN  NO OTHER MEDICATION : ANTI HYPERTENSIVE, SEDATIVE, DIURETICS  ANTENAL VISIT : EVERY WEEK

18 HOSPITAL CARE  PERSISTENT HYPERTENSION MORE THAN 2 WEEKS  PERSISTENT PROTENURIA MORE THAN 2 WEEKS  ABNORMAL LABORATORY TEST  ABNORMAL FETAL GROWTH  ONE OR MORE SIGN AND SYMPTOM SEVERE PE HOSPITAL CARE  PERSISTENT HYPERTENSION MORE THAN 2 WEEKS  PERSISTENT PROTENURIA MORE THAN 2 WEEKS  ABNORMAL LABORATORY TEST  ABNORMAL FETAL GROWTH  ONE OR MORE SIGN AND SYMPTOM SEVERE PE

19  OBSTETRIC MANAGEMENT ▪ GESTATIONAL AGE < 37 WEEKS ~SIGN AND SYMPTOM ARE NOT WORSENED  MAINTAIN UNTIL TERM ▪ GESTATIONAL AGE > 37 WEEKS ~WAIT UNTIL THE ONSET OF LABOR ~CERVIX IS FAVORABLE, INDUCTION OF LABOR  OBSTETRIC MANAGEMENT ▪ GESTATIONAL AGE < 37 WEEKS ~SIGN AND SYMPTOM ARE NOT WORSENED  MAINTAIN UNTIL TERM ▪ GESTATIONAL AGE > 37 WEEKS ~WAIT UNTIL THE ONSET OF LABOR ~CERVIX IS FAVORABLE, INDUCTION OF LABOR

20 SEVERE PREECLAMPSIA  MEDICAL TREATMENT  OBSTETRIC MANAGEMENT : ▪CONSERVATIVE : -PREGNANCY  37 WEEKS ▪ACTIVE: -PREGNANCY  37 WEEKS -FETAL INDICATION -FETAL INDICATION -MATERNAL INDICATION -MATERNAL INDICATION SEVERE PREECLAMPSIA  MEDICAL TREATMENT  OBSTETRIC MANAGEMENT : ▪CONSERVATIVE : -PREGNANCY  37 WEEKS ▪ACTIVE: -PREGNANCY  37 WEEKS -FETAL INDICATION -FETAL INDICATION -MATERNAL INDICATION -MATERNAL INDICATION

21 MEDICAL TREATMENT :  HOSPITALIZE  TOTAL BED REST  FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.  Mg SO 4 IV  ANTI HYPERTENSION :  HYDRALAZIN  LABETALOL  NIFEDIPINE :10 – 20 mg / ORALLY EVERY ½ - 1 H, MAX : 120 mg / 24 Hours  DIURETIC : NOT RECOMMENDED  ANTI OXYDANT : N-ACETYL CYSTEIN  CORTICOSTEROID + LUNG MATURITY  34 WEEKS MEDICAL TREATMENT :  HOSPITALIZE  TOTAL BED REST  FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.  Mg SO 4 IV  ANTI HYPERTENSION :  HYDRALAZIN  LABETALOL  NIFEDIPINE :10 – 20 mg / ORALLY EVERY ½ - 1 H, MAX : 120 mg / 24 Hours  DIURETIC : NOT RECOMMENDED  ANTI OXYDANT : N-ACETYL CYSTEIN  CORTICOSTEROID + LUNG MATURITY  34 WEEKS

22 OBSTETRIC MANAGEMENT  CONSERVATIVE MANAGEMENT:  GOAL : TO IMPROVE INFANT OUTCOME, WITHOUT COMPROMISING THE MOTHER PREGNANCY  37 WEEKS, IMPENDING ECLAMPSIA (-)  ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY  INDICATION FETAL : -PREGNANCY  37 WEEKS - IUGR AND ABNORMAL BIOPHYSICAL PROFILE OBSTETRIC MANAGEMENT  CONSERVATIVE MANAGEMENT:  GOAL : TO IMPROVE INFANT OUTCOME, WITHOUT COMPROMISING THE MOTHER PREGNANCY  37 WEEKS, IMPENDING ECLAMPSIA (-)  ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY  INDICATION FETAL : -PREGNANCY  37 WEEKS - IUGR AND ABNORMAL BIOPHYSICAL PROFILE

23 MATERNAL: - PERSISTENT HYPERTENTION - IMPENDING ECLAMPSIA -COMPLICATION : HELLP SYNDROME, ABRUPTIO PLAC., OLIGURIA -COMPLICATION : HELLP SYNDROME, ABRUPTIO PLAC., OLIGURIA  ROUTE OF DELIVERY : ▪VAGINAL DELIVERY IS PREFERABLE THAN CS. MATERNAL: - PERSISTENT HYPERTENTION - IMPENDING ECLAMPSIA -COMPLICATION : HELLP SYNDROME, ABRUPTIO PLAC., OLIGURIA -COMPLICATION : HELLP SYNDROME, ABRUPTIO PLAC., OLIGURIA  ROUTE OF DELIVERY : ▪VAGINAL DELIVERY IS PREFERABLE THAN CS.

24 ECLAMPSIA : PE + CONVULSION  BASIC MANAGEMENT :  CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)  STABILIZE THE MOTHER  CONTROL CONVULSION  CORRECT MATERNAL HYPOXEMIA / ACIDEMIA  PREVENT COMPLICATION : HYPERTENSION CRISIS  TERMINATE PREGNANCY  MEDICAL TREATMENT :  SAME AS SEVERE PREECLAMPSIA ECLAMPSIA : PE + CONVULSION  BASIC MANAGEMENT :  CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)  STABILIZE THE MOTHER  CONTROL CONVULSION  CORRECT MATERNAL HYPOXEMIA / ACIDEMIA  PREVENT COMPLICATION : HYPERTENSION CRISIS  TERMINATE PREGNANCY  MEDICAL TREATMENT :  SAME AS SEVERE PREECLAMPSIA

25 COMPLICATION : P.E AND ECLAMPSIA MOTHERBABY HELLP SYNDROME LIVER RUPTURED PULMONARY EDEMA RENAL FAILURE ABRUPTIO PLACENTAE DIC CEREBROL VASCULER ACCIDENT MATERNAL DEATH IUGR PREMATURE LABOR INTRA CRANIAL HAEMORRHAGE CEREBRAL PALSY PNEUMO THORAX IUFD

26 HIPERTENSI KRONIK DALAM KEHAMILAN  DEFINISI KLINIK:  HIPERTENSI YG DIDAPAT SEBELUM KEHAMILAN ATAU SEBELUM UMUR KEHAMILAN 20 MGG DAN HIPERTENSI TDK MENGHILANG SETELAH 12 MGG PASCA PERSALINAN  ETIOLOGI HIPERTENSI KRONIK DALAM KEHAMILAN  PRIMER (IDIOPATIK) : 90 %  SEKUNDER : 10 %, YG BERHUBUNGAN DGN PENY. GINJAL, PENY. ENDOKRIN (dm), PENY. HIPERTENSI DAN VASKULER HIPERTENSI KRONIK DALAM KEHAMILAN  DEFINISI KLINIK:  HIPERTENSI YG DIDAPAT SEBELUM KEHAMILAN ATAU SEBELUM UMUR KEHAMILAN 20 MGG DAN HIPERTENSI TDK MENGHILANG SETELAH 12 MGG PASCA PERSALINAN  ETIOLOGI HIPERTENSI KRONIK DALAM KEHAMILAN  PRIMER (IDIOPATIK) : 90 %  SEKUNDER : 10 %, YG BERHUBUNGAN DGN PENY. GINJAL, PENY. ENDOKRIN (dm), PENY. HIPERTENSI DAN VASKULER

27  DIAGNOSIS  BERDASARKAN RISIKO : -RISIKO RENDAH : HIPERTENSI RINGAN TANPA DISERTAI KERUSAKAN ORGAN -RISIKO TINGGI :HIPERTENSI BERAT / HIPERTENSI RINGAN DISERTAI PERUBAHAN PATOLOGIS, KLINIS MAUPUN BIOLOGI  KERUSAKAN ORGAN  KRITERIA RISIKO TINGGI PD HIPERTENSI KRONIK DLM KEHAMILAN -HIPERTENSI BERAT :  DESAKAN SISTOLIK ≥ 160 mmHg DAN  DESAKAN DIASTOLIK ≥ 110 mmHg, SEBELUM 20 MGG KEHAMILAN  DIAGNOSIS  BERDASARKAN RISIKO : -RISIKO RENDAH : HIPERTENSI RINGAN TANPA DISERTAI KERUSAKAN ORGAN -RISIKO TINGGI :HIPERTENSI BERAT / HIPERTENSI RINGAN DISERTAI PERUBAHAN PATOLOGIS, KLINIS MAUPUN BIOLOGI  KERUSAKAN ORGAN  KRITERIA RISIKO TINGGI PD HIPERTENSI KRONIK DLM KEHAMILAN -HIPERTENSI BERAT :  DESAKAN SISTOLIK ≥ 160 mmHg DAN  DESAKAN DIASTOLIK ≥ 110 mmHg, SEBELUM 20 MGG KEHAMILAN

28 -HIPERTENSI RINGAN < 20 MGG KEHAMILAN DGN :  PERNAH PREECLAMPSIA  UMUR IBU > 40 THN  HIPERTENSI ≥ 4 THN  ADANYA KELAINAN GINJAL  ADANYA DIABETES MELLITUS (KLAS B – KLAS F)  KARDIOMIOPATI  MEMINUMI OBAT ANTI HIPERTENSI SEBELUM HAMIL -HIPERTENSI RINGAN < 20 MGG KEHAMILAN DGN :  PERNAH PREECLAMPSIA  UMUR IBU > 40 THN  HIPERTENSI ≥ 4 THN  ADANYA KELAINAN GINJAL  ADANYA DIABETES MELLITUS (KLAS B – KLAS F)  KARDIOMIOPATI  MEMINUMI OBAT ANTI HIPERTENSI SEBELUM HAMIL

29  KLASIFIKASI HIPERTENSI KRONIK KLASIFIKASISISTOLIK (mmHg)DIASTOLIK (mmHg) NORMAL PREEHIPERTENSI HIPERTENSI STADIUM I HIPERTENSI STADIUM II < 120 120 – 139 140 – 159 ≥ 160 < 80 80 – 89 90 – 99 ≥ 110 (the 7 th Report of the Joint National Committee (JNC 7) MIMs Cardiovascular Guide th. 2003 – 2004)

30  PENGELOLAAN HIPERTENSI KRONIK DLM KEHAMILAN:  TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM KEHAMILAN -MENEKAN RISIKO PD IBU  KENAIKAN DESAKAN DARAH -MENGHINDARI PEMBERIAN OBAT2 YG MEMBAHAYAKAN JANIN  PEMERIKSAAN LABORATORIUM  PEMERIKSAAN (TEST) KLINIK SPESIALISTIK : -ECG -ECHOCARDIOGRAPHY -OPHTALMOLOGY -USG GINJAL  PENGELOLAAN HIPERTENSI KRONIK DLM KEHAMILAN:  TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM KEHAMILAN -MENEKAN RISIKO PD IBU  KENAIKAN DESAKAN DARAH -MENGHINDARI PEMBERIAN OBAT2 YG MEMBAHAYAKAN JANIN  PEMERIKSAAN LABORATORIUM  PEMERIKSAAN (TEST) KLINIK SPESIALISTIK : -ECG -ECHOCARDIOGRAPHY -OPHTALMOLOGY -USG GINJAL

31  PEMERIKSAAN (TEST) LABORATORIUM -FUNGSI GINJAL :CREATININE SERUM BUN SERUM, ASAM URAT, PROTEINURIA 24 JAM PEMERIKSAAN PROTEINURIA SECARA PERIODIK -FUNGSI HEPAR -HEMATOLOGIK:Hb, HEMATOKRIT, TROMBOSIT  PEMERIKSAAN (TEST) LABORATORIUM -FUNGSI GINJAL :CREATININE SERUM BUN SERUM, ASAM URAT, PROTEINURIA 24 JAM PEMERIKSAAN PROTEINURIA SECARA PERIODIK -FUNGSI HEPAR -HEMATOLOGIK:Hb, HEMATOKRIT, TROMBOSIT

32  PEMERIKSAAN KESEJAHTERAAN JANIN  ULTRASONOGRAPHY : - USG UTK DATA DASAR DIAMBIL 18-20 MGG KEHAMILAN -DIULANG PD UMUR KEHAMILAN 28-32 MGG DAN DIIKUTI SETIAP BLN -BILA DICURIGAI IUGR DI MONITOR DGN NST DAN PROFIL BIOFISIK  HIPERETENSI KRONIK DLM KEHAMILAN DGN PENYULIT KARDIOVASKULER ATAU PENY. GINJAL PERLU MENDAPAT PERHATIAN KHUSUS  PEMERIKSAAN KESEJAHTERAAN JANIN  ULTRASONOGRAPHY : - USG UTK DATA DASAR DIAMBIL 18-20 MGG KEHAMILAN -DIULANG PD UMUR KEHAMILAN 28-32 MGG DAN DIIKUTI SETIAP BLN -BILA DICURIGAI IUGR DI MONITOR DGN NST DAN PROFIL BIOFISIK  HIPERETENSI KRONIK DLM KEHAMILAN DGN PENYULIT KARDIOVASKULER ATAU PENY. GINJAL PERLU MENDAPAT PERHATIAN KHUSUS

33  PENGOBATAN MEDIKAMENTOSA INDIKASI PEMBERIAN ANTIHIPERTENSI:  RISIKO RENDAH HIPERTENSI: -IBU SEHAT DGN DESAKAN DIASTOLIK MENETAP  100 mmHg -DGN DISFUNGSI ORGAN DAN DESAKAN DIASTOLIK  90 mmHg  OBAT ANTIHIPERTENSI -PILIHAN PERTAMA: METHYLDOPA : 0.5-3.0 g/hr, DIBAGI DLM 2-3 DOSIS.: NEFEDIPINE : 30-120 g/hr, DLM SLOW- RELEASE TABLET  PENGOBATAN MEDIKAMENTOSA INDIKASI PEMBERIAN ANTIHIPERTENSI:  RISIKO RENDAH HIPERTENSI: -IBU SEHAT DGN DESAKAN DIASTOLIK MENETAP  100 mmHg -DGN DISFUNGSI ORGAN DAN DESAKAN DIASTOLIK  90 mmHg  OBAT ANTIHIPERTENSI -PILIHAN PERTAMA: METHYLDOPA : 0.5-3.0 g/hr, DIBAGI DLM 2-3 DOSIS.: NEFEDIPINE : 30-120 g/hr, DLM SLOW- RELEASE TABLET

34  PENGELOLAAN TERHADAP KEHAMILAN  SIKAP TERHDP KEHAMILANNYA PD HIPERTENSI KRONIK RINGAN : KONSERVATIF  DILAHIRKAN SEDAPAT MUNGKIN PERVAGINAM PD KEHAMILAN ATERM.  SIKAP TERHDP KEHAMILAN PD HIPERTENSI KRONIK BERAT : AKTIV  SEGERA KEHAMILAN DIAKHIRI (DITERMINASI)  ANESTESI : REGIONAL ANESTESI  HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA  PENGELOLAAN HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA SAMA DGN PENGELOLAAN PREECLAMPSIA BERAT.  PENGELOLAAN TERHADAP KEHAMILAN  SIKAP TERHDP KEHAMILANNYA PD HIPERTENSI KRONIK RINGAN : KONSERVATIF  DILAHIRKAN SEDAPAT MUNGKIN PERVAGINAM PD KEHAMILAN ATERM.  SIKAP TERHDP KEHAMILAN PD HIPERTENSI KRONIK BERAT : AKTIV  SEGERA KEHAMILAN DIAKHIRI (DITERMINASI)  ANESTESI : REGIONAL ANESTESI  HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA  PENGELOLAAN HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA SAMA DGN PENGELOLAAN PREECLAMPSIA BERAT.

35 HELLP SYNDROME PREGNANCY HYPERTENSION AND PROTEINURIA PREECLAMPSIA HELLP SYNDROME 10-14% CASE

36 HELLP SYNDROME  FIRST DISCRIBED BY WEINSTEIN 1982:  ACRONYM OF :H:HEMOLYSIS EL:ELEVATED LIVER ENZYM LP:LOW PLATETLED COUNT  INCIDENCE : 2%-12% AMONG PATIENTS WITH PREECLAMPSIA. 30% OCCURS IN POSTPARTUM HELLP SYNDROME  FIRST DISCRIBED BY WEINSTEIN 1982:  ACRONYM OF :H:HEMOLYSIS EL:ELEVATED LIVER ENZYM LP:LOW PLATETLED COUNT  INCIDENCE : 2%-12% AMONG PATIENTS WITH PREECLAMPSIA. 30% OCCURS IN POSTPARTUM

37 CRITERIA DIAGNOSTIC LABORATORY FINDING:  HEMOLYSIS  ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND BURR CELLS  TOTAL BILIRUBIN LEVEL > 1,2 mg/Dl  LACTATE DEHYDROGENASE LEVEL > 600  /L  ELEVATED LIVER FUCTION  SGOT LEVEL  70  / L (LDH)  LACTATE DEHYDROGENASE LEVEL > 600  /L  LOW PLATELET COUNT PLATELET COUNT < 100.000/m 3 CRITERIA DIAGNOSTIC LABORATORY FINDING:  HEMOLYSIS  ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND BURR CELLS  TOTAL BILIRUBIN LEVEL > 1,2 mg/Dl  LACTATE DEHYDROGENASE LEVEL > 600  /L  ELEVATED LIVER FUCTION  SGOT LEVEL  70  / L (LDH)  LACTATE DEHYDROGENASE LEVEL > 600  /L  LOW PLATELET COUNT PLATELET COUNT < 100.000/m 3 THE LABORATORY DIAGNOSTIC CRITERIA USED AT THE UNIVERSITY OF TENNESSEE DIVISION OF MATERNAL FETAL MEDECINE, MEMPHIS TN. WITLIN AND SIBAI (1999)

38  CLASS I : PLATELET  50.000/m 3 WITH : LDH  600  U/L SGOT  40  U/L  CLASS II : PLATELET  50.000/m 3 - < 100.000/m 3 WITH : LDH  600  U/L WITH : LDH  600  U/L SGOT  40  U/L  CLASS II : PLATELET  50.000/m 3 - < 150.000/m 3 WITH : LDH  600  U/L WITH : LDH  600  U/L SGOT  40  U/L  CLASS I : PLATELET  50.000/m 3 WITH : LDH  600  U/L SGOT  40  U/L  CLASS II : PLATELET  50.000/m 3 - < 100.000/m 3 WITH : LDH  600  U/L WITH : LDH  600  U/L SGOT  40  U/L  CLASS II : PLATELET  50.000/m 3 - < 150.000/m 3 WITH : LDH  600  U/L WITH : LDH  600  U/L SGOT  40  U/L CLASSIFICATION BASED ON PLATELET COUNT (MISSISIPPI):

39 MANAGEMENT OF HELLP SYNDROME  MATERNAL STABILISATION IS THE MAYOR PRIORITY  BEGIN WITH A STANDART MANAGEMENT OF SEVERE PREECLAMPSIA  HELLP SYNDROME IS NOT AN INDICATION FOR CS MANAGEMENT OF HELLP SYNDROME  MATERNAL STABILISATION IS THE MAYOR PRIORITY  BEGIN WITH A STANDART MANAGEMENT OF SEVERE PREECLAMPSIA  HELLP SYNDROME IS NOT AN INDICATION FOR CS

40 MEDICAL MANAGEMENT  SAME AS SEVERE PREECLAMPSIA  WHEN THROMBOCYTE COUNT IS < 50.000 mm 3, 10 UNITS OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE GIVEN  WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO THE ICU  WHEN THROMBOCYTE COUNTS IS < 50.000/mm 3 FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL THROMBOPLASTIN TIME, D-DIMMER MUST BE CHECKED TO FIND DIC MEDICAL MANAGEMENT  SAME AS SEVERE PREECLAMPSIA  WHEN THROMBOCYTE COUNT IS < 50.000 mm 3, 10 UNITS OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE GIVEN  WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO THE ICU  WHEN THROMBOCYTE COUNTS IS < 50.000/mm 3 FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL THROMBOPLASTIN TIME, D-DIMMER MUST BE CHECKED TO FIND DIC

41 OBSTETRIC MANAGEMENT  WHEN MOTHERS IS STABLE  TERMINATE THE PREGNANCY OR CONSERVATIVE MANAGEMENT.  CONSERVATIVE MANAGEMENT CAN BE DONE WHEN :  THE BLOOD PRESSURE < 160/110 m  g  THE OLIGURIA RESPONSE TO FLUID REPLACEMENT  THERE IS NO EPIGASTRIC PAIN  THE GESTATIONAL AGE IS < 34 WEEKS OBSTETRIC MANAGEMENT  WHEN MOTHERS IS STABLE  TERMINATE THE PREGNANCY OR CONSERVATIVE MANAGEMENT.  CONSERVATIVE MANAGEMENT CAN BE DONE WHEN :  THE BLOOD PRESSURE < 160/110 m  g  THE OLIGURIA RESPONSE TO FLUID REPLACEMENT  THERE IS NO EPIGASTRIC PAIN  THE GESTATIONAL AGE IS < 34 WEEKS

42 COMPLICATION  THE COMPLICATIONS THAT CAN OCCUR IN HELLP SYNDROME ARE : NEUROLOGIC DISORDER, PULMONARY EDEMA, ABRUPTIO PLACENTA, DIC AND  UGR COMPLICATION

43 1.HYPERTENSION, PROTEINURIA AND OTHERS SYMPTOMS-SIGN OF PREECLAMPSIA ARE INDUCED BY PREGNANCY 2.BESIDE HYPERTENSION AND PROTEINURIA, OTHER SYNDROMA OF PREECLAMPSIA ARE EPIGASTRIC PAIN, HEADCHE, VISUAL DISTURBANCE, OLIGURIA, CONVULSION, AND RENAL FAILURE. 3.THERE ARE STILL CONTROVERSION IN CLASSIFICASION, DIAGNOSTIC AND MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION. 4.IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN MANAGEMENT IS NEEDED. 5.IGNORANCE, POVERTY, LATE ADMITTANCE TO HOSPITAL WILL INCREASE FERINATAL - MATERNAL, MORBIDITY AND MORTALITY 1.HYPERTENSION, PROTEINURIA AND OTHERS SYMPTOMS-SIGN OF PREECLAMPSIA ARE INDUCED BY PREGNANCY 2.BESIDE HYPERTENSION AND PROTEINURIA, OTHER SYNDROMA OF PREECLAMPSIA ARE EPIGASTRIC PAIN, HEADCHE, VISUAL DISTURBANCE, OLIGURIA, CONVULSION, AND RENAL FAILURE. 3.THERE ARE STILL CONTROVERSION IN CLASSIFICASION, DIAGNOSTIC AND MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION. 4.IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN MANAGEMENT IS NEEDED. 5.IGNORANCE, POVERTY, LATE ADMITTANCE TO HOSPITAL WILL INCREASE FERINATAL - MATERNAL, MORBIDITY AND MORTALITY CONCLUSIONS :

44

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46 6.Robert JM, Carl A Hubel Oxydative Stress in Preeclampsia. AJOG 2004 : 190 : 117 – 8. 7.Sibai BM; “Diagnosis Prevention, and Management of Eclampsia”, Obstetrics & Gynecology, vol 105, number 2, February 2005, page 405 – 410. 8.Sibai BM, Gus Dekker GA, Michael Kupferminc Preeclampsia Lancet 2005, 365 : 785 – 99. 9.Lipstein H, et al. Current Consept of Eclampsia. American Journal of Emergency Mediciene 203; 21 (3) : 233 – 7. 10.Norwitz ER, Robinson JN, Rifke JT. Prevention of Preeclampsia : Is it Possible ? Clin Obstet Ginecology 1999, 42 (3) 436 – 54. 11.Audibert F, et al. Clinical Utility of Strict Diagnostic Creteria for the HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelets) Syndorome AJOG 1996; 175 : 460 – 4. 12.Weinstein L, Syndrome of Haemolysis, Elevated Liver Enzymes and Low Trombocyte Count : A severe Consequense of Hypertension in Pregnancy. Am J. Obstet Gynecol 1982; 42 : 159-167. 13.James N, Martin Jr, MD, Carlh. Rose, MD, Christian M. Briery, MD. Understanding and Managing Hellp Syndrome : The Integral Role of Aggressive Glucocorticoids for Mother and Child. A Jog 2005. 08. 044.

47 14.Magann EF, Martin RW, Jsaacs JD, et al. Corticosteroids for the Enhancement of Fetal Lung Maturity : Impact on the Gravida with Preeclampsia and the HELLP Syndrome. Aust MZ J Obstet Gynecol 1993; 33 : 127 – 30. 15.Martin JN, Perry KG, Blake PG, et al. Better Maternal Outcomes are Achieved with Dexamethasone Therapy for Postpartum HELLP (Hemolysis, Elevated Liver Enzymes and Low Thrombosit Counts) Syndrome. AmJ Obstet Gynecol 1997; 177 : 1011 – 7. 16.Pedoman Penanganan Penderita Preeklamsia Berat dan HELLP Syndrome, Satgas Penanganan Penderita Preeklamsia Berat dan HELLP Syndrome Bagian / UPF Ilmu Kebidanan dan Penyakit Kandungan FK – USU RSUD. Dr. Pirngadi Medan tahun 2002.