R.

HARYONO ROESHADI, ,

KLASIFIKASI :
Report on the National High Blood Pressure Education Program g m Working W g Group p on High H g Blood Pressure in Pregnancy (AJOG Vol 183:S1, July 2000) F HIPERTENSI GESTASIONAL : DIDAPATKAN DESAKAN DARAH 140/90 mmHg g 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, g, SEBELUM KEHAMILAN ATAU SEBELUM KEHAMILAN 20 MGG DAN TDK MENGHILANG SETELAH 12 MGG PASCA PERSALINAN

INTRODUCTION NTRODUCT ON :
F INDUCED BY PREGNANCY F DISEASE OF THEORIES F CLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUT ORGAN DYSFUNCTION / FAILURE F THIRD LEADING CAUSE OF MATERNAL MORTALITY F MORTALITY RATE : 150.000 150 000 WOMEN A YEAR WORLD WIDE

INCIDENCE
PE/E : 2% - 9% OF ALL PREGNANT WOMEN
IN SEVERAL HOSPITAL IN INDONESIA
YEAR 1993 1997 1996 1997 1995 1998 2000 2002 2002 HOSPITAL RSPM 12 HOSPITALS RS. H.S. RSHAM RSPM RSCM PERCENTAGE 5,75 0,8 - 14 13,0 7,0 , 9,17 AUTHOR SIMANJUNTAK J. TRIBAWONO A. MEIZIA GIRSANG. E PRIYATINI

ETIOLOGY : NOT FULLY KNOWN

F RISK FACTORS :
y NULLI PARITY / TEENAGE PREGNANCY y HISTORY OF PREVIOUS PREGNANCY y FAMILY HISTORY OF PE/E y MULTIPLE GESTATION y PREEXISTING HYPERTENSION / RENAL DISEASE y D.M, ANTI PHOSPOLIPID ANTIBODY y HYDROPS FETALIS y HYDATIDIFORM MOLES URYNARY TRACT INFECTION

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

INSUFF, PLACENTA INSUFF 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:
y PREECLAMPSIA - MILD - SEVERE y IMPENDING ECLAMPSIA y ECLAMPSIA y 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 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 1010 -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 PREPRE-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 , DEXTROSE 5%. FLUID THERAPY : RINGER LACTATE, Mg SO4 IV ANTI HYPERTENSION : HYDRALAZIN LABETALOL NIFEDIPINE : 10 20 mg / ORALLY EVERY - 1 H H, MAX : 120 mg / 24 Hours DIURETIC : NOT RECOMMENDED ANTI OXYDANT : N N-ACETYL CYSTEIN CORTICOSTEROID + LUNG MATURITY 34 WEEKS

OBSTETRIC MANAGEMENT
CONSERVATIVE MANAGEMENT: GOAL : TO IMPROVE INFANT OUTCOME, 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
F BASIC MANAGEMENT :
( CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC) ( STABILIZE THE MOTHER ( CONTROL CONVULSION ( CORRECT MATERNAL HYPOXEMIA / ACIDEMIA ( PREVENT COMPLICATION : HYPERTENSION CRISIS ( TERMINATE PREGNANCY

F 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 MATERNAL DEATH IUGR PREMATURE LABOR INTRA CRANIAL HAEMORRHAGE CEREBRAL PALSY PNEUMO THORAX IUFD

BABY

HIPERTENSI KRONIK DALAM KEHAMILAN

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

F 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

F 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) )

F PENGELOLAAN HIPERTENSI KRONIK DLM KEHAMILAN:

( TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM KEHAMILAN MENEKAN RISIKO PD IBU KENAIKAN DESAKAN DARAH MENGHINDARI PEMBERIAN OBAT2 YG MEMBAHAYAKAN JANIN F PEMERIKSAAN LABORATORIUM " PEMERIKSAAN (TEST) KLINIK SPESIALISTIK : ECG ECHOCARDIOGRAPHY OPHTALMOLOGY USG GINJAL

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

F PEMERIKSAAN KESEJAHTERAAN JANIN

( ULTRASONOGRAPHY : USG UTK DATA DASAR DIAMBIL 1818-20 MGG KEHAMILAN DIULANG PD UMUR KEHAMILAN 2828-32 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

F 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 : 0.50.5-3.0 g/hr, DIBAGI DLM 2-3 DOSIS. : NEFEDIPINE : 3030-120 g/hr, DLM SLOWSLOWRELEASE TABLET

F 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 F 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 1982: : ACRONYM OF : H EL LP INCIDENCE : : : : HEMOLYSIS ELEVATED LIVER ENZYM LOW PLATETLED COUNT

2%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 GIVEN WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO THE ICU
3 WHEN THROMBOCYTE COUNTS IS < 50 50.000/mm 000/

FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL THROMBOPLASTIN TIME, TIME DD-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 DISORDER, EDEMA, ABRUPTIO PLACENTA, DIC AND UGR

CONCLUSIONS :
1. HYPERTENSION, , PROTEINURIA AND OTHERS SYMPTOMSSYMPTOMS-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 4. MANAGEMENT IS NEEDED. 5. IGNORANCE, POVERTY, LATE ADMITTANCE TO HOSPITAL WILL INCREASE FERINATAL - MATERNAL, MORBIDITY AND MORTALITY

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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.
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14. Magann EF, Martin RW, Jsaacs JD, et al. Corticosteroids for the Enhancement of Fetal Lung Maturity : Impact on the Gravida with P Preeclampsia l i and d the th HELLP S Syndrome. d A Aust t MZ J Obstet Ob t t Gynecol G l 1993; 33 : 127 30. 15. Martin JN, Perry KG, Blake PG, et al. Better Maternal Outcomes are Achie ed with Achieved ith Dexamethasone De amethasone Therap Therapy for Postpartum Postpart m 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 16. Syndrome, Satgas Penanganan Penderita Preeklamsia Berat dan HELLP Syndrome Bagian / UPF Ilmu Kebidanan dan Penyakit Kandungan FK USU RSUD. Dr. Pirngadi Medan tahun 2002.