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

PREECLAMSIA :

KRITERIA MINIMUM
DESKAN DARAH 140/90 mmHg UMUR KEHAMILAN 20 MGG, DISERTAI PROTEINURIA 300 mg/24 JAM ATAU DIPSTICK 1 + ECLAMSIA KEJANG2 PADA PREECLAMPSIA DISERTAI KOMA

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

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

INCIDENCE
PE/E : 2% - 9% OF ALL PREGNANT WOMEN
IN SEVERAL HOSPITAL IN INDONESIA
YEAR 1993 1997 HOSPITAL RSPM PERCENTAGE 5,75 AUTHOR SIMANJUNTAK J.

1996 1997
1995 1998 2000 2002

12 HOSPITALS
RS. H.S. RSHAM RSPM

0,8 - 14
13,0 7,0

TRIBAWONO A.
MEIZIA GIRSANG. E

2002

RSCM

9,17

PRIYATINI

ETIOLOGY : NOT FULLY KNOWN

RISK FACTORS :
NULLI PARITY / TEENAGE PREGNANCY HISTORY OF PREVIOUS PREGNANCY FAMILY HISTORY OF PE/E MULTIPLE GESTATION PREEXISTING HYPERTENSION / RENAL DISEASE D.M, ANTI PHOSPOLIPID ANTIBODY

HYDROPS FETALIS
HYDATIDIFORM MOLES URYNARY TRACT INFECTION

PATHOGENESE :
CONTROVERSION : THE DISEASE OF THEORIES
IMMUNITY, GENETIC VASC. DISEASE TROPHOBLAST INADEQUATE TROPHOB. INVASION TO SPIRAL ARTERY OF PLACENTA

INSUFF, PLACENTA HYPOXIA

IUGR

CIRCULATING FACTOR(S) CYTOKINES LIPID (IL-6, TNF-) PEROXIDES

OXYDATIVE STRESS

NEUTROPHIL ACTIVATION

ENDOTHELIAL DYSFUNCTION

PLATELET ACTIVATION

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

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

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

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 / mm3 BILIRUBIN 1,2 mg / DL LDH > 600 IU/L SGOT > 70 mg/DL

IMPENDING ECLAMPSIA
SEVERE PREECLAMPSIA WITH : HEADACHE

NAUSEA AND VOMITING

BLURRED VISION, SCOTOMA, IMPAIRED CONSIOUSNESS, SUDDEN DETERIORATION

EPIGASTRIC PAIN

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 EDEMA ARE THE MOST COMMON COMPLICATION

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

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

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

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

 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

SEVERE PREECLAMPSIA

MEDICAL TREATMENT
OBSTETRIC MANAGEMENT :

CONSERVATIVE : ACTIVE : -

PREGNANCY 37 WEEKS
PREGNANCY 37 WEEKS

FETAL INDICATION
MATERNAL INDICATION

MEDICAL TREATMENT :
HOSPITALIZE TOTAL BED REST FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%. Mg SO4 IV ANTI HYPERTENSION : HYDRALAZIN LABETALOL NIFEDIPINE : 10 20 mg / ORALLY EVERY - 1 H, MAX : 120 mg / 24 Hours DIURETIC : NOT RECOMMENDED ANTI OXYDANT : N-ACETYL CYSTEIN CORTICOSTEROID + LUNG MATURITY 34 WEEKS

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

MATERNAL : - PERSISTENT HYPERTENTION - IMPENDING ECLAMPSIA - COMPLICATION : HELLP SYNDROME,

ABRUPTIO PLAC., OLIGURIA

ROUTE OF DELIVERY :

VAGINAL DELIVERY IS PREFERABLE THAN CS.

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

COMPLICATION : P.E AND ECLAMPSIA

MOTHER
HELLP SYNDROME LIVER RUPTURED PULMONARY EDEMA RENAL FAILURE ABRUPTIO PLACENTAE DIC CEREBROL VASCULER ACCIDENT IUGR

BABY

PREMATURE LABOR INTRA CRANIAL HAEMORRHAGE CEREBRAL PALSY PNEUMO THORAX IUFD

MATERNAL DEATH

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

 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

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

 KLASIFIKASI HIPERTENSI KRONIK

KLASIFIKASI
NORMAL PREEHIPERTENSI HIPERTENSI STADIUM I HIPERTENSI STADIUM II

SISTOLIK (mmHg)
< 120 120 139 140 159 160

DIASTOLIK (mmHg)
< 80 80 89 90 99 110

(the 7th Report of the Joint National Committee (JNC 7) MIMs Cardiovascular Guide th. 2003 2004)

 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

 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 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

 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 SLOWRELEASE TABLET

 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.

HELLP SYNDROME

PREGNANCY

10-14% CASE

HYPERTENSION AND PROTEINURIA

PREECLAMPSIA

HELLP SYNDROME

HELLP SYNDROME
FIRST DISCRIBED BY WEINSTEIN 1982: ACRONYM OF : H : HEMOLYSIS

EL
LP INCIDENCE :

:
:

ELEVATED LIVER ENZYM

LOW PLATETLED COUNT

2%-12% AMONG PATIENTS WITH PREECLAMPSIA. 30% OCCURS IN POSTPARTUM

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/m3
THE LABORATORY DIAGNOSTIC CRITERIA USED AT THE UNIVERSITY OF TENNESSEE DIVISION OF MATERNAL FETAL MEDECINE, MEMPHIS TN. WITLIN AND SIBAI (1999)

CLASSIFICATION BASED ON PLATELET COUNT (MISSISIPPI):

CLASS I : PLATELET 50.000/m3

WITH : LDH 600 U/L SGOT 40 U/L CLASS II : PLATELET 50.000/m3 - < 100.000/m3 WITH : LDH 600 U/L SGOT 40 U/L
CLASS II : PLATELET 50.000/m3 - < 150.000/m3 WITH : LDH 600 U/L SGOT 40 U/L

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

MEDICAL MANAGEMENT
SAME AS SEVERE PREECLAMPSIA WHEN THROMBOCYTE COUNT IS < 50.000 mm3, 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/mm3 FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL THROMBOPLASTIN TIME, D-DIMMER MUST BE CHECKED TO FIND DIC

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

COMPLICATION
THE COMPLICATIONS THAT CAN OCCUR IN HELLP SYNDROME ARE : NEUROLOGIC

DISORDER, PULMONARY EDEMA, ABRUPTIO

PLACENTA, DIC AND UGR

CONCLUSIONS :
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

REFERENCES :
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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.

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.