Preeclampsia

Team poli RSCM

Introduction

• Preeclampsia is much more than

hypertension and protein- uria
complicating pregnancy – it is a
syndrome affecting virtually every organ
system.
• Early preeclampsia (onset <34 weeks) is
associated with greater morbidity than
late-onset preeclampsia.
RISK FACTORS
 • During pre-eclampsia, the invasive
cytotrophoblasts fail to transform
epithelial phenotype into endothelial
phenotype ( endovascular extravillous
trophoblast), instead the invasion of
the spiral arterioles is shallow and
these remain as small caliber
Pathophysiology resistance vessel leads  defective
uteroplacental circulation and
subsequently placental perfusion
worsens.
• The process of pseudovasculogenesis
decreases resistance in blood vessels
and thereby increases blood flow to
placenta so that it can sustain the
growing fetus by providing essential
nutrients and oxygen.
• In pre-eclampsia, the placenta
becomes hypoxic within the intervillous
space which might trigger tissue
oxidative stress and increase placental
apoptosis and necrosis finally leading
to endothelial dysfunction and an
exaggerated inflammatory response
 • Kegagalan invasi trofoblast  hanya
Shallowing (implantasi hanya sampai
Pathophysiology desidua) trofoblast ada 3
(endovaskular trofoblast, intersitial
extravillous trofoblast, ekstravillous
trofoblast)
• Gangguan remodelling vascular  kaliber
mengecil  iskemia plasenta 
mengeluarkan radikal bebas  masuk
sirkulasi maternal  disfungsi endotel
sistemik di maternal
 • Kegagalan invasi trofoblast  hanya
Shallowing (implantasi hanya sampai
Pathophysiology desidua) trofoblast ada 3
(endovaskular trofoblast, intersitial
extravillous trofoblast, ekstravillous
trofoblast)
• Gangguan remodelling vascular  kaliber
mengecil  iskemia plasenta 
mengeluarkan radikal bebas  masuk
sirkulasi maternal  disfungsi endotel
sistemik di maternal
Pathophysiology
Pathophysiology
 Immunology of PE: Two Stage Model
Pathophysiology
 Role of Seminal Exposure

Pathophysiology
Complications
Diagnostic
Diagnostic

Pengukuran tekanan darah dilakukan pada posisi duduk nyaman,

cuff pada lengan atas sejajar dengan atrium kiri, pasien tenang dan tidak
berbicara selama pemeriksaan. Pengukuran dilakukan setelah 5 menit
 Preeklampsia
ringan vs berat
– ACOG 2013 tidak
merekomendasika
n pembagian ini,
Classification karena morbiditas
dan mortalitas tetap
meningkat signifikan
pada keduanya.
– Disarankan:
preeclampsia
without severe
features
Perubahan pada Kriteria ACOG 2013
• Proteinuria tidak secara absolut dibutuhkan untuk
diagnosis preeklamsia.

• Proteinuria masif (> 5 g) dihapuskan dari kriteria

beratnya preeklampsia, karena hubungan antara jumlah
protein urin dan luaran kehamilan sangat minimal.

• Pertumbuhan janin terhambat dihapuskan dari kriteria

beratnya preeklampsia, karena tatalaksananya sama
saja pada pasien dengan atau tanpa preeklamsia.
 Temuan yang Membutuhkan Pengawasan
Lebih
Bila diagnosis preeklamsia belum ditegakkan tetapi
ditemukan gejala/tanda berikut, diperlukan pengawasan
lebih ketat:
• New-onset headache or visual disturbances
• Nyeri abdomen, terutama kuadran kanan atas atau
epigastrium
Observation • PJT
• New-onset proteinuria pada paruh kedua masa
kehamilan

• Peningkatan TD sistolik > 30 mmHg atau diastolik > 15

mmHg
Edema atau peningkatan berat badan yang cepat bukan
kriteria diagnostik dan tidak sensitif maupun spesifik
untuk preeklamsia.
 Upaya Pencegahan yang
Direkomendasikan
• Aspirin dosis rendah (60-80 mg / hari)
– Direkomendasikan pada perempuan dengan risiko
tinggi
– RR 0.90 (0.84-0.97), penurunan risiko hingga 17%.
– Efek samping minimal.
PREVENTION

• Kalsium (1.5-2 g / hari)

– Direkomendasikan pada perempuan hamil dengan
baseline calcium intake rendah (< 600 mg/hari)
– RR 0.45 (0.31-0.65) pada semua perempuan hamil.
– RR 0.36 (0.20-0.65) pada perempuan hamil dengan
baseline calcium intake rendah.
 Upaya Pencegahan yang
Tidak Direkomendasikan

• Suplementasi antioksidan dengan Vit C dan Vit E

• Bed rest
• Pembatasan asupan garam
PREVENTION
• Penggunaan diuretik
ANTENATAL
CARE
management
management
management
Magnesium
Magnesium
Magnesium
Antihypertension
 • Atenolol is associated with an increase in
fetal growth restriction.
• ACE inhibitors and ARBs would appear to
be contraindicated because of
unacceptable fetal adverse effects.
• Diuretics are relatively contraindicated for
hypertension and should be reserved for
Antihypertension
pulmonary oedema.
 • The regimen of fluid restriction should be
maintained until there is a postpartum
diuresis, as oliguria is common with severe
pre-eclampsia. If there is associated
maternal haemorrhage, fluid balance is
more difficult and fluid restriction is
inappropriate.
Fluid balance
 • Prolonging the pregnancy at very early
gestations may improve the outcome for
the premature infant but can only be
considered if the mother remains stable
• Pregnancy was prolonged for a mean of 7
days and 15 days, respectively, at
gestations of 28–34 weeks and 28–32
weeks, with no increase in maternal
complications.
Prolonging
pregnancy
 • Vaginal delivery is generally preferable
but, if gestation is below 32 weeks,
caesarean section is more likely as the
success of induction is reduced.
• After 34 weeks with a cephalic
presentation, vaginal delivery should be
considered
Mode of delivery
Post delivery
 • Women who deliver with severe pre-
eclampsia (or eclampsia) should have
continued close observation postnatally.
• As eclampsia has been reported up to 4
weeks postnatally, the optimum length of
inpatient postnatal stay is unclear but the
incidence of eclampsia and severe pre-
eclampsia falls after the fourth
postpartum day.
Post delivery
 • Anti-hypertensive therapy should be
continued after delivery. Although,
initially, blood pressure may fall, it usually
rises again at around 24 hours
postpartum.
• After pre-eclampsia, blood pressure can
take up to 3 months to return to normal.
During this time, blood pressure should
not be allowed to exceed 160/110 mmHg.
Post delivery