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Gestational Hypertension
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Ny. 25 th G1 mengeluh nyeri kepala dan
pandangan kabur selama bulan terakhir
kehamilannya.
Ia mencari saran medis dan pengobatan
dari seorang Dr.SpOG. Yang
meresepkan obat padanya.
Ia pulang kerumah tetapi keluhannya tidak
menghilang meskipun telah meminum
obat yang diberikan
Suaminya membawanya ke Rumah Sakit
Umum karena KEJANG.
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Masalah/Diagnosis?
Eklampsia imminens Eklampsia
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Objectives
Definisi Diagnosis
Manajemen
- Penilaian Fetal / Maternal
- Terapi Anti-Hipertensi- Terapi Anti-Kejang
- Transport
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Insidens
10% dari kehamilan mengalami komplikasi hipertensi
- 1/3 nya dengan proteinuria
Mayoritas preeklampsia terjadi pada nulipara
- Risiko kematian meningkat pada pada ibu hamil usia lanjut
- Risiko meningkat pada kehamilan pertama dengan pasangan baru
- Risiko meningkat pada hipertensi kronik, penyakit ginjal dan diabetes melitus
Preeklampsia merupakan penyebab terbanyak kematian maternal langsung (direc
maternal mortality) maupun Near Miss Maternal.
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Definisi
Hipertensi kronik
Hipertensi gestasional
- tanpa proteinuria
- dengan proteinuria
- dengan proteinuria dan penyulit Hipertensi kronik superimposed hipertensi gestasional
dengan proteinuria
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Definisi
HipertensiNilai mutlak 140/90 mmHg
peningkatan 30/15 mmHg
Tekanan darah diastolik 90 mmHg
Posisi duduk pada lengan setinggi jantung Manset dengan ukuran yang tepat
Dengan sfigmomanometer air raksa
Bunyi Korotkoff I dan IV
Diulang 4 jam kecuali sangat tinggi.
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Definisi
Proteinuria
- Proteinurin 2+ dengan pemeriksaan dipstick
- proteinurin 300 mg/dL urin 24jam
proteinuria mengindikasikan disfungsi glomerular
Pemeriksaan urin 24 jam harus diperiksa bila
dengan pemeriksaan dipstich protein 1+
edema terjadi akibat vasospasme and penurunantekanan onkotik, tetapi bukan merupakan kriteria
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Biochemical and biophysical markers defining fetal/placental and maternal
etiologies that determine the risk of developing pre-eclampsia
Risk of
developingpre-
eclampsia
Fetal/
Placental
factors
Maternal
Predisposition/
susceptibility
Trophoblast invasion
-PLGF
- IGFBP-1, PAPP-A
- Doppler US
- HLA-G
Placental hypoxia
-sFlt-1
- VEGF
- PLGF
Reactive oxygen species-
lipid peroxides
-activin/inhibin
- CRH/CRHBP
-PAI-2
Metabolic syndrome
- BMI, leptin
- Insulin, SHBG
- Glucose
Endothelial function:
- PAI-1
- Fibronectin
- VCAM/CAM
Pro-oxidants
8 epi-PGF2a
Antioxidant reserve- Vit C
- Vit Eimmune function
Immune function
-AT1R autoantibodies
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Perubahan fisiologik dan patologik plasentasi
Dikutip:
Redman and Ian L. Sargent
Science June 2005 Vol 308
1592
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Tanda-tanda semakin beratnya kondisi
Hipertensi gestasional dengan penyulit
Tekanan darah diastolik > 110 mmHg
Hasil pemeriksaan laboratorium
trombosit, LFT's, uric acid
Ginjal - proteinuria > 3 g/d, oliguria
SSP - kejang, nyeri kepala, gangguan visus
Keterlibatan organ lainParu-paru, hati, hematologik
Tanda-tanda gangguan pertumbuhan janin
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Gestational HypertensionInternationalanajemen
Pertama-tama mengurangi stres Penilaian keadaan ibu dan janin
Terapi hipertensi bila dBP > 110 mmHg
Terapi terhadap keluhan mual dan muntah
Terapi nyeri uluhati
Terapi Antikejang
Terminasi kehamilan dengan cara dan waktu yang tepat
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Komponen tekanan darah adalah reseptor adrenergik
Ketidaknyamanan sedapat mungkin dikurangi Beberapa komponen
quiet, dimly lit, isolated room
well planned management protocol
clear explanation of plan to patient/family
minimization of negative stimuli consistent, confident team approach
nursing, obstetrics, anaesthesia, hematology, pediatrics
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Gestational HypertensionInternationalPenilaian Maternal - Klinis
Tekanan darah
- assess severity- consistency in measuring
- relationship of high BP to CVA not seizure
Susunan Saraf Pusat
- presence and severity of headache
- vision disturbances - blurring, scotomata
- tremulousness, irritability, hyperreflexia, somnolenc
- nausea and vomiting
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Gestational HypertensionInternationalAssessment of Mother -
Clinical
Hematologic- edema- bleeding, petechiae
Hepatic- RUQ and epigastric pain- nausea and vomiting
Renal- urine output and colour
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Assessment of Mother
Laboratory
Hematologic
- hemoglobin, platelets, blood film
- PTT, INR, fibrinogen, FDP
- LDH, uric acid, bilirubin
Hepatic
- ALT, AST
- (glucose, ammonia to R/O AFLP)
Renal
- proteinuria
- creatinine, urea, uric acid8/25/2014
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Manfaat NACysteine (flumucil) sebagai antioksidan
untuk mencegah timbulnya Preeklampsia Berat
0
20
40
60
80
100
120
140
160
Sistolik Diastolik
Dosis NAC: 2 x 600 m
Kel. Kontrol
Kel. Studi
Sumber: Wibowo N, Angsar D, Wiknjosastro G., dkk (2005
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Assessment of Fetus
Fetal movement
Fetal heart rate assessment
Ultrasound for growth
Biophysical profile
Amniotic fluid volume
Doppler flow studies
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Treatment
Nausea and Vomiting
- antiemetic of choice
RUQ / Epigastric Pain
- morphine 2 - 4 mg IV
- antacid- minimize palpation
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Anti-hypertensive Therapy - Goals
minimize risk of maternal CVA
maximize maternal condition for safe delivery
gain time for further assessment
- facilitate vaginal delivery if possible- prolong gestation where appropriate/feasible
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Anti-hypertensive Agents - Acute Therapy
Arteriolar Dilators- hydralazine
-Blockers
- labetalol
Calcium Channel Blockers
- nifedipine
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Anti-hypertensive Agents - Maintenance
Therapy
Centrally Acting Sympatholytic Agents methyl-dopa
-Blockers atenolol labetalol
Calcium Channel Blockers nifedipine
ACE inhibitors are contraindicated in pregnancy
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Methyldopa
centrally acting a2-receptor agonist, oral agent
long history of safe use in pregnancy, well tolerated
some concern regarding ability to control BP
not for use in acute settings
Dosage - 500 - 3000 mg po in 2 - 4 divided doses
Cautions - drug of choice in essential hypertension
Benefits - minimal side-effects and safe
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1-receptor antagonist, oral agent
cardiac output,
renin release, vasomotor inhibitor onset of action in 1 hour peak levels in 2-4 hours
long half life once a day dosing
Dosage - 50 -100 mg po OD Cautions - DM, asthma, baseline FH, variability present
risk of IUGR with chronic use
Benefits - often only agent needed
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Gestational HypertensionInternationalLabetalolNormodyne, Trandate)
combined 1 and -blocker with ISA
intravenous rapid onset useful for hypertensive crisis
can be used orally
Dosage - maximum 300 mg IV dose
- 20 mg IV followed by 20-80 mg IV titrated to BP Cautions - concern re: fetal responses to hypoxia
Benefits - dependable, titratable, familiar
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Nifedipine
calcium channel blocker, oral agent
direct relaxation of vascular smooth muscle
rapid onset of action if regular capsule used
Dosage - Adalat-PA 10 mg bid 40 mg bid
Side Effects - magnesium toxicity, edema,
flushing,headache, palpitations, tocolytic
use of short acting form discouraged
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Stabilisasi hipertensi berat
Nifedipine, -blocker, tujuan maintain diastolic BP at 90 - 100 mmHg monitor fetal status while treating BP
Pencegahan kejang Monitor volume intravaskular
Foley catheter seldom experience ARF do not fluid overload seldom require CVP line
Terminasi kehamilan
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Sulit diramalkan siap yang akan kejang
- Tidak berbanding lurus dengan beratnya hipertensi daproteinuria
high 'number needed to treat' to prevent seizure
agents not innocuous nor completely effective
MgSO4 is agent of choice when seizure prophylaxis is felt t
be indicated
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Kadar Mg serum pada regimen IV dan IM
Pemberian drip IV lebih
stabil dibandingkan
dengan pemberian IM
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close observation for side effects weakness, respiratory paralysis, somnolence
especially high risk in those with oliguria orreceiving Ca2+ channel blockers
ANTIDOTE
stop magnesium infusion 10% Calcium gluconate 10 mL IV over 3 minutes
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Transport
consider transport only if resources limited and
maternal/fetal condition permits
maternal BP and symptoms stable
fetal status reassuring appropriate anti-hypertensive agents started
MgSO4 started if appropriate
discuss with accepting centre and patient/family
MgSO4 and anti-hypertensives potentially fatal in overdose
G t ti l H t i
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Terminasi kehamilan
37 weeks with gestational hypertension
34 weeks with severe gestational hypertension
< 34 weeks with any of:
- poorly controlled dBP
- lab evidence of worsening end-organ involvement
- suspected fetal compromise
- uncontrolled seizures
- symptoms unresponsive to appropriate therapy
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G t ti l H t i
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Delivery - The Cure
timely delivery minimizes maternal and neonatal morbidit
and mortality
optimize maternal status before interventions to deliver
delay delivery to gain fetal maturity and to allow transfe
only when maternal and fetal condition allow it
gestational hypertension is a progressive disease, expectan
management is potentially harmful in presence of sever
disease or suspected fetal compromise
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G t ti l H t i
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Peri- and Postpartum Management
do not drop BP too low risking fetal compromise
do not fluid overload
epidural analgesia is favoured in the absence of
low platelets or coagulopathy
multi-specialty approach
patient must be monitored post-partum
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Gestational Hypertension
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Mechanism of ActionStimulation of intracellular
cyclic-GMP results in vascular smooth
muscle relaxation of both arterial and
venous vasculature.
Increased venous pooling decreases left
ventricular pressure preload) and arterial
dilatation decreases arterial resistance
afterload).
Therefore, this reduces cardiac oxygen
demand by decreasing left ventricular
pressure and systemic vascular resistance
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