14/04/2015

StafFetomaternal,DepartemenObstetri&GinekologiFKUI/RSUPN
CiptoManukusumo
Anggota
Pelatih/Adva Peserta
Fasilitator PokJa
nvedTrainer International
Advanced HIV/AIDS&
Jaringan Pelatih Course
PelatihBasic LabourAnd Pelatih
Nasiona Resusitasi Sexual
SurgicalSkill Risk PMTCT
Pelatihan Neonatus Reproductive
POGI,tahun Management Kementerian
Klinik Perinasia, Healthand
2004 (ALARM) Kesehatan
Kesehatan tahun2004 Right,
sekarang. POGI,tahun Republik
Reproduksi, sekarang. Swedia,
2005 Indonesia,
tahun2005 Pebruari
sekarang tahun2007
sekarang. 2009
sekarang.

TujuanPembicaraan TujuanPembicaraan
Epidemiologi LatarBelakang Epidemiologi LatarBelakang
Definisi Definisi
FisiologiImplantasiPlasenta FisiologiImplantasiPlasenta
BeberapateoritentangPreeklampsia BeberapateoritentangPreeklampsia
Tatalaksana Tatalaksana
Pencegahan Pencegahan
Kesimpulan Kesimpulan
Tera Tera
 14/04/2015

Goal4:Menurunkanangkakematianbalita
Target4a:Menurunkan2/3angkakematianbalita. Lainlain
12% Perdarahan
Komplmasa 30%
puerpureum
8%
Goal5:Meningkatkankesehatanmaternal Emboliobst
3%
Target5a:Menurunkanangkakematianmaternal.
Target5b:Aksesuniversalkesehatanreproduksipadatahun2015. P.lama/macet
5%

Abortus
5%
Goal6:MemberantaspenyakitHIV/AIDS,malariadan
penyakitlainnya. Infeksi
12%
Target6a:MenghentikandanmengurangipenyebaranHIV/AIDS Pre/Eklampsia
Target6b:AksesuniversaldanPengobatanbagiseluruhpenderitaHIV/AIDS
25%
Target6c:Menghentikandanmengurangiinsidensmalaria.

PrakiraanWaktumenujuKematianuntuk
KasusKegawatdaruratanObstetri
Penyebab Waktu
Anak:
PerdarahanPostpartum 2jam Jangka Pendek: Jangka Panjang: CerebralPalsy
Perdarahan Antepartum 12jam HELLP, Gagal Ginjal Kronik, DMtipe 2
CVD Penyakit Kardio Vaskular
RupturUteri 1hari Edemapulmonum,
Peny.Kardio Vaskular,
Obesitas
DMtipe 2
Eklampsia/PEB 2hari Eklamsia PCO
Teratozoospermia
PersalinanMacet 3hari
Infeksi 6hari
Hypertension 2007;49(5):1056-62, JClin Endocrinol Metab 2006;91(4):12338

BrileyA,BewleyS.Managementofobstetrichemorrhage:obstetricmanagement.In:BrileyA,BewleyS,editors.TheObstetricHematologyManual.
Cambridge:CambridgeUniversityPress;2010.p.15158.
 14/04/2015

TherevisedISSHPdefinitionpreeclampsia
TujuanPembicaraan (2014)
Epidemiologi LatarBelakang Hypertension developing after 20 weeks gestation and the
coexistence of one or more of the following new onset conditions:
Definisi
1. Proteinuria
FisiologiImplantasiPlasenta 2. Othermaternalorgandysfunction:
BeberapateoritentangPreeklampsia Renalinsufficiency(creatinine >90umol/L)
Liver involvement (elevated transaminasesand/or severe right upper
Tatalaksana quadrant or epigastric pain)
Pencegahan Neurological complications
Haematological complications
Kesimpulan 3. Uteroplacental dysfunction
Tera Fetalgrowthrestriction

Theclassification,diagnosisandmanagementofthehypertensivedisordersofpregnancy:Arevised
statementfromtheISSHP.PregnancyHypertension:AnInternationalJournalofWomensCardiovascular
Health4(2014)97104

Consideredseverelyelevated:>160 Doesnotpredictclinicaloutcome
mmHgsystolicor>110mmHgdiastolic.
A spoturineprotein/creatinine ratio>30mg/mmol
Nottorelyonasinglereading,
appropriatesizedcuff Thereisnoclearconsensusontheamountofproteinuriato
InthecaseofseverelyelevatedBPnotto beconsideredsevere(between>3and5g/l)
waitfor6hapart,butin1530m NOTCONSIDERPROTEINURIAFORDEFININGSEVERE
Suggestmercurysphygmomanometry or
sphygmomanometry usingaliquidcrystal
PREECLAMPSIA
device.Ifanautomateddeviceistobe
usedthenitshouldhavebeenvalidated
foruseinpregnancy.

AndreaL.Tranquilli,MarkA.Brown,Gerda G.Zeeman,Gustaaf Dekker,Baha M.Sibai.Thedefinition AndreaL.Tranquilli,MarkA.Brown,Gerda G.Zeeman,Gustaaf Dekker,Baha M.Sibai.Thedefinition

ofsevereandearlyonsetpreeclampsia.StatementsfromtheInternationalSocietyfortheStudyof ofsevereandearlyonsetpreeclampsia.StatementsfromtheInternationalSocietyfortheStudyof
HypertensioninPregnancy(ISSHP) HypertensioninPregnancy(ISSHP)
 14/04/2015

Hipertensi
bukan
penyakit tapi
merupakan
Diseaseoftheories reaksi tubuh

Insiden:16.3%,MM:1.9%,MP:9.9%
Implantasi
Th/Definitif:Lahirkan dengan segala risiko yangtak
Pencegahan:upaya terbaik,hasil tidak bermakna??????? sempurna

Hipertensi terjadi
sebagai
mekanisme
kompensasi
Buku Tahunan 19931994, BMJ 2007;335(7627):974,
penuhi kebutuhan
Hypertension 2007;49(5):1056-62, JClin Endocrinol Metab 2006;91(4):12338

TujuanPembicaraan
Epidemiologi LatarBelakang
Definisi
FisiologiImplantasiPlasenta
BeberapateoritentangPreeklampsia
Tatalaksana
Pencegahan
Kesimpulan
Tera
 14/04/2015

TujuanPembicaraan
Prooxidant antioxidant Balance
Epidemiologi LatarBelakang ROSdan RNSberperan penting pd PEE
Scr langsung induksi disfungsi endothelial
Definisi Induksi hipertensi dan proteinuria melalui:

FisiologiImplantasiPlasenta RAS
inflammasi
BeberapateoritentangPreeklampsia Insulinresistan
Tatalaksana Pro antiangiogenic
menurunkan NOdgmeningkatkan
Pencegahan ADMAdan menurunkan HO1

Kesimpulan FailureSMCmodification
Poiseuilles+Bernoullis Kantung elastis
Bertahanan rendah
Diameter : 4 6 X Arus tinggi
Tera Aliran drh:tonik O2 hipertensi
Bebas regulasi neurovascular
Syncytial knot:aptototic sincytrophoblast
Exp.Physiol 1997; 82;377 - 87

Debriske sirkulasi maternal sitokin disfungsi endotel

PerkembanganPreeklampsia Twostagemodelofdevelopmentofpreeclampsia

Skemasekuenkejadiansepanjangkehamilansampaitimbulgejalaklinispreeklampsia.EC,
endothelialcell;HO1,haemoxygenase1;TGF,transforminggrowthfactor. CHRISTOPHERW.G.REDMAN,IANL.SARGENTANDROBERTN.TAYLOR.ImmunologyofNormalPregnancy
RammaW,AhmedA.Isinflammationthecauseofpreeclampsia?BiochemSocTrans.2011Dec;39(6):161927. andPreeclampsia.Chesleys Hypertensive Disorder inPregnancy
 14/04/2015

Possiblepathophysiologicalprocessesinpreeclampsia
Fourstagemodelofdevelopmentofpreeclampsia

CHRISTOPHERW.G.REDMAN,IANL.SARGENTANDROBERTN.TAYLOR.ImmunologyofNormalPregnancy
andPreeclampsia.Chesleys Hypertensive Disorder inPregnancy
AV=anchoringvillus.COE=coelomiccavity.CY=cytotrophoblast.DB=deciduabasalis.DC=deciduacapsularis.DP=deciduaparietalis.
EN=endothelium.ET=extravilloustrophoblast.FB=fetalbloodvessel.FV=floatingvillus.GL=gland.IS=intervillousspace.JZ=junctional
zonemyometrium.MB=maternalblood,leavingtheintervillousspacewithvariouscomponentssuchasantiangiogenicfactors.
MV=maternalvein.SA=spiralartery.SM=smoothmuscle.ST=stroma.SY=syncytiotrophoblast.TM=tunicamedia.UC=uterinecavity.sFlt
1=solubleformofthevascularendothelialgrowthfactorreceptor.CentrepaneloffigureadaptedfromKarumanchietal,18with
permissionfromElsevier.
SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.

Thepathophysiologicalprocesses FaktorfaktorRisikodanPatogenesis
involvedinpreeclampsia Preeklampsia.

AT1AA,angiotensinIIreceptor1autoantibodies;HELLP,hemolysis,elevatedliverenzymes,and
lowplatelets;PlGF,placentalgrowthfactor;sFlt1,solubleFmsliketyrosinekinase1;VEGF,
vascularendothelialgrowthfactor.
UratoAC,NorwitzER.Aguidetowardsprepregnancymanagementofdefectiveimplantationandplacentation.BestPract
ResClinObstetGynaecol.2011Jun;25(3):36787.
Genetik,faktorlingkungandanfaktorimunmenyebabkanplasentasiyangdangkaldanperfusiuteroplasentaselamaakhir
kehamilandanmemicupelepasanfaktorfaktoryangmempengaruhipembuluhdarahsistemikdanmenyebabkan
vasokonstriksiumum,resistensipembuluhdarahmeningkatdanpreeklampsia.Faktorfaktorbioaktiftersebutbisamelukai
ginjalmenyebabkanvolumeplasmameningkatdanhipertensiberat,sertaendotheliosisglomerulusdanproteinuria.Dapat
pulameningkatkanpermeabilitaspembuluhdarahotakdanmenyebabkanedemasehinggaeklampsia..
ReslanOM,KhalilRA.Molecularandvasculartargetsinthepathogenesisandmanagementofthehypertensionassociated
withpreeclampsia.CardiovascHematolAgentsMedChem.2010Oct1;8(4):20426.
 14/04/2015

Summaryofthepathogenesisofpreeclampsia

Immunefactors(suchasAT1
AA),oxidativestress,NKcell
abnormalities,andother
factors maycauseplacental
dysfunction,whichinturnleads
tothereleaseofanti
angiogenic factors(suchassFlt1
andsEng)andother
inflammatorymediatorsto
induce hypertension,
proteinuria,andother
complicationsofpreeclampsia.

WangA,Rana S,Karumanchi SA.Preeclampsia:theroleofangiogenic factorsinitspathogenesis.Physiology(Bethesda).2009Jun;24:14758.

AnneCathrine Staff,etal.RedefiningPreeclampsiaUsingPlacentaDerivedBiomarkers.Hypertension.2013;61:932942

Genetik Overlappingroleofhypertension,capillaryleak,maternal
Immunologik symptoms, andfibrinolysis/hemolysis inthespectrumof
EtiologicFactors Nutrisi atypicalpreeclampsia
Infeksi

Perubahan pada angiogenesis

Fetoplacental

Pathophysiology
Lain2:
Kegagalan
Stress VEGF
Invasi
Oxidative TNF
Trophoblast
dll

Disfungsi Endothel

ClinicalManifestation Hypertensi &Proteinuria

PREEKLAMPSIA
SibaiBM,StellaCL.Diagnosisandmanagementofatypicalpreeclampsiaeclampsia.AmJObstet
Gynecol.2009May;200(5):481e17.
 14/04/2015

PREECLAMPSIA
TujuanPembicaraan
Epidemiologi LatarBelakang
Definisi
FisiologiImplantasiPlasenta
BeberapateoritentangPreeklampsia
Tatalaksana
Pencegahan
Kesimpulan
Tera

TujuanPembicaraan
Epidemiologi LatarBelakang FIRST,deliveryisalwaysappropriatetherapyforthemother
butnotbesoforthefetus
Definisi
SECOND,thesignsandsymptomsofpreeclampsiaarenot
FisiologiImplantasiPlasenta pathogenetically important(loweringbloodpressuredonot
BeberapateoritentangPreeklampsia alleviatetheimportantpathophysiologicchanges
Tatalaksana THIRD,thepathogenicchangesorpreeclampsiaarepresent
Konservatif longbeforeclinicalcriteriafordiagnosisareevident
Eklampsia
Antihipertensi
Balanscairan

F.GaryCunningham.Hypertensivedisorders.WilliamsObstetricsed 24th
 14/04/2015

Antepartummanagementoptionsforwomenwithpre
Antepartummanagementoptionsforwomenwithpre
eclampsiabygestationalageatdiagnosis
eclampsiabygestationalageatdiagnosis

NICU=neonatalintensivecareunit.*Asdefinedlocally(usuallybetween23weeks[+0days]and24weeks[+6days]gestation). Unpublised NICU=neonatalintensivecareunit.*Asdefinedlocally(usuallybetween23weeks[+0days]and24weeks[+6days]gestation). Unpublised

datafromPIERS.86ChanceoflivingtodischargefromaNICU withoutmajormorbidity(grade3intraventricularhaemorrhage,stage3or4 datafromPIERS.86ChanceoflivingtodischargefromaNICU withoutmajormorbidity(grade3intraventricularhaemorrhage,stage3or4
retinopathyofprematurity,necrotisingenterocolitis,andchroniclungdisease). retinopathyofprematurity,necrotisingenterocolitis,andchroniclungdisease).
SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144. SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.

Suggestedantepartummanagementoptionsforwomen
withpreeclampsiaatanystageofdiagnosis SEIZUREPROPHYLAXISANDTREATMENT

Optionalassessmentandsurveillance IntheMagpiestudy,10,000preeclamptic womenwererandomized

toreceivemagnesiumsulfateorplacebo.
Onadmission,ondayofdelivery,andadditional Magnesiumsulfateclearlyreducedtheriskofeclampsia inthistrial,
testingas indicatedbychangesinclinicalstate. anditwasshowntobesuperiortootherprophylacticmedications,
includingphenytoin,anddiazepam.
Maternal
Blood:haemoglobin,plateletcount,creatinine,
uricacid,AST orALT,furthertestingifindicated
Fetal
CTG,ultrasound,AFI,umbilicalarteryDoppler
RCTofMgSO4prophylaxiswithplacebooractivedruginwomenwithgestationalhypertension

JAMESM.ALEXANDERANDF.GARYCUNNINGHAM.ClinicalManagement..Chesleys Hypertensive
SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.
Disorder inPregnancy
 14/04/2015

RandomizedcomparativetrialsofMagnesiumSulfate
withAnotherAnticonvulsanttoPreventRecurrent
Eclamptic Convulsions

Inwomenwithnormalrenalfunction,thehalftimeforexcretionis
about4hours.
Becauseexcretiondependsondeliveryofafilteredloadof
magnesiumthatexceedstheTmax,thehalftimeofexcretionis
prolongedinwomenwithadecreasedGFR

Magnesium slows or blocks neuromuscular and cardiac conducting

system transmission, decreases smooth muscle contractility, and
depresses central nervous system irritability

JAMESM.ALEXANDERANDF.GARYCUNNINGHAM.ClinicalManagement..Chesleys Hypertensive
Disorder inPregnancy

Suggestedantepartummanagementoptionsforwomen
withpreeclampsiaatanystageofdiagnosis

MgSO4 Inhibitionofuterinecontractilityismagnesiumdose
Regimen:MgSO44gIVloadingdoseover1520min, dependent
followedbyaninfusionof1g/h;recurrentseizure(s) Serumlevelsofatleast810mEq/Larenecessarytoinhibit
treated withadditional24gIVloadingdose(s);clinical uterinecontractions(WattMorse,1995)
monitoring bymeasurementofurinaryoutput,
respiratoryrate,and tendonreflexes.
Eclampsiaprophylaxis
Yes;forseverepreeclampsiaduringinitialstabilisation
and peripartum(delivery+24h)
Eclampsiatreatment
Yes

JAMESM.ALEXANDERANDF.GARYCUNNINGHAM.ClinicalManagement..Chesleys Hypertensive
SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.
Disorder inPregnancy
 14/04/2015

CerebralBloodFlow

LossofAutoregulation
Riskof
hypertensive
encephalopathy
Normotensive

Poorlycontrolled
Riskof
ischemia hypertensive

50 100 150 200 250

MeanArterialPressure(MAP)

JASONG.UMANS,EDGARDOJ.ABALOSANDF.GARYCUNNINGHAM.Antihypertensive treatment.Chesleys
AdaptedwithpermissionfromVaronJ,MarikPE.Chest. 2000;118:214227. Hypertensive Disorder inPregnancy

RandomizedPlaceboControlledTrialsofAntihypertensiveTherapyforEarly
MildHypertensionDuringPregnancy DRUGSFORTREATMENTOFSEVEREHYPERTENSIONINPREGNANCY

Drug Dose Onset Duration AdverseEffects

Hydralazine 510mgIVq20min 1020min 36h Tachycardia,headache,flushing,

aggravationofangina
Labetalol 2040mgIVq10min1 1020min 36h Scalptingling,vomiting,heartblock
mg/kgasneeded
Nifedipine 1020mgPOq2030min 1015min 45h Headache,tachycardia,synergistic
interactionwithmagnesiumsulfate
Nicardipine 515mg/hIV 510min 14h Tachycardia,headache,phlebitis

Sodium 0.255g/kg/minIV Immediate 12min Nausea,vomiting,muscletwitching,

nitroprusside thiocyanate andcyanideintoxication
Nitroglycerin 5100g/minIV 25min 35min Headache,methemoglobinemia,
tachyphylaxis

JASONG.UMANS,EDGARDOJ.ABALOSANDF.GARYCUNNINGHAM.Antihypertensive treatment.Chesleys Hypertensive Disorder in

Pregnancy
 14/04/2015

NocurrentagreementastowhatlevelBPshouldbe Suggestedantepartummanagementoptionsforwomen
maintainedwhenantihypertensives areinstitutedfornon withpreeclampsiaatanystageofdiagnosis
urgentindicationsinpregnancy
Antihypertensivetherapy
TheCanadianguidelinesrecommend130155/90105 Severehypertension(systolicBP160mmHgordiastolicBP 110mm
mmHgintheabsenceofcomorbidconditions Hg)
Nifedipinecapsule(5mgorallyforfirstdose,10mgorallysubsequently)
TheNICEguidelinesrecommendkeepingBPbelow150mmHg every30min;
systolicandbetween80and100mmHg diastolic Nifedipineintermediateacting (10mgorally)every45min;
Labetalol(100mgorally)every 45min,maximum1200mg/day;
Labetalol(20mgIVfirstdose,repeat2080mgIVevery30min,or12
mg/min, maximum300mg);
Hydralazine(510mgIV)every30min,maximum20mg
Nifedipinecapsulesaresafetousecontemporaneously withMgSO4;
nifedipinecapsulesshouldnotbeusedin womenwithknown
coronaryarterydisease,aortic stenosis,orlongstandingdiabetes(eg,
>15years);after twoconsecutivedosesofacutetherapy(ie,
nifedipine, labetalol,hydralazine),startorincreasemaintenance
therapywithagentslistedbelow
Theclassification,diagnosisandmanagementofthehypertensivedisordersofpregnancy:Arevised
statementfromtheISSHP.PregnancyHypertension:AnInternationalJournalofWomensCardiovascular
Health4(2014)97104 SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.

Suggestedantepartummanagementoptionsforwomen Managementofmaternalfluidbalancebefore,duringand
withpreeclampsiaatanystageofdiagnosis afterdeliveryisachallengefortheclinician.
Antihypertensivetherapy
Nonseverehypertension(systolicBP<160mmHganddiastolic BP90 Thematernalplasmavolumeexpansionisattenuatedin
109mmHg) preeclampsia (deficitsof600800ml/m2)
Labetalol(100400mgorally24timesdaily,maximum 1200mg/day);
Recommendation65125ml/hour
Intermediateactingnifedipine(1020mg orally23timesdaily,
maximum120mg/day); becauseofthepotentialriskofpulmonaryedema,cautionmustbe
Nifedipine sustainedreleasepreparation(2060mgorallydaily, takeninpreeclamptic oreclamptic womensimultaneouslyreceiving
maximum120mg/day);methyldopa(250500mgorally 24timesdaily, magnesiumsulfateforseizureprophylaxis
maximum2g/day);
otherblockers (otherthanatenolol)
Intheabsenceofrenaldisease,prepregnancydiabetes,or other
indicationsforstrictmaintenanceofstrict normotension,whetherBP
targetsshouldbehigh normotension(eg,diastolicBP85mmHg)or
nonsevere hypertension(eg,diastolicBP105mmHg)isunknown;
ACE inhibitors,ARBs,atenolol,andprazosinshouldbeavoided
T.Engelhardt,F.M.MacLennan.Fluid managementinpreeclampsia.InternationalJournalof
Obstetric Anesthesia.1999
GloriaT.Too,andJamesB.Hill.Hypertensivecrisisduringpregnancyandpostpartumperiod
SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.
 14/04/2015

FluidManagement
Rapidfluidinfusion asignificantincreaseinalveolar Oliguria(<15mL/h)iscommoninpreeclampsia,particularly
arterialoxygendifference(AaDO,)andshuntfraction(Qs/Qt) postpartum.
Intheabsenceofpreexistingrenaldiseaseorarising
creatinine,oliguriashouldbetoleratedoverhours,toavoid
volumedependentpulmonaryoedema

Vasodilator therapy alone appears to improve tissue

oxygenation without affecting Qs/Qt LauraA.Magee,Anouk Pels,MichaelHelewa,Evelyne Rey,PetervonDadelszen,Onbehalfofthe
CanadianHypertensiveDisordersofPregnancy(HDP)WorkingGroup1.Diagnosis,evaluation,and
F.GaryCunningham.Hypertensivedisorders.WilliamsObstetricsed 24th managementofthehypertensivedisordersofpregnancy

Suggestedantepartummanagementoptionsforwomen
withpreeclampsiaatanystageofdiagnosis TujuanPembicaraan
Plasmavolumeexpansion Epidemiologi LatarBelakang
No;becauseofrisksofmaternalmortality Definisi
associatedwith pulmonaryoedema,inwomen FisiologiImplantasiPlasenta
withseverepreeclampsia infusionofsodium
BeberapateoritentangPreeklampsia
containingfluidsmightneedtobe restricted
andbalancedagainsturineoutputover4hor Tatalaksana
more andcreatinineconcentrations Pencegahan
Thromboprophylaxis Kesimpulan
Yes;ifonbedrestfor4daysormore Tera

SteegersEA,vonDadelszenP,DuvekotJJ,PijnenborgR.Preeclampsia.Lancet.2010Aug21;376(9741):63144.
 14/04/2015

Faktor faktor Risiko Preeclampsia TheStrengthoftheAssociationofSelectedRiskFactorsfor

Preeclampsia (1)
Faktor maternal Inheren Umur <20atau 3540
Nulliparitas RiskFactorAssociatedwith Reference OR(95%CI)
Diri/kel.Dg.riw. PEatau peny.Kardiovaskular
Wanita yg terlahir PJT
Preeclampisa
Preeclampsiainapreviouspregnancy Hnat18 3,88(2,985,05)
Kondisi medis Obesitas
Hipertensi Kronik
Duckitt48 7,19(5,858,83)
Peny Ginjal kronis Firstpregnancy CondeAgudelo49 2,38(2,282,49)
DM(IR,type1,dan GDM) Duckitt48 2,91(1,286,61)
APS
Peny Jaringan Ikat (SLE dsb) Multifetalgestation Sibai50 2,62(2,033,38)
Thrombophilia CondeAgudelo49 2,10(1,902,32)
Stress
Duckitt48 2,93(2,044,21)
Pregnancyspecific Kehamilan majemuk Chronichypertension CondeAgudelo49 1,99(1,782,22)
Oocyte donation
UTI Gestationaldiabetes CondeAgudelo49 1,93(1,662,25)
Janin dg kelainan Pregestationaldiabetes Duckitt48 3,56(2,544,99)
Mola Hydatidosa
Hydrops fetalis
Vascularandconnectivetissuedisease Stamilio51 6,9(1,142,3)
Anomali Structural Nephropathy:Urinarytractinfection AbiSaid52 4,23(1,2714,06)
Paparan dgsperma terbatas Barriercontraception
Antiphospholipidantibodysyndrome Robertson53 2,73(1,654,51)
Faktor Paternal
Pertama kalimenjadi ayah Duckitt48 9,72(4,3421,75)
Donorinsemination

Suami dg riwayat preeklampsia dengan pasangan terdahulu

Lancet 2001;357:20915 DildyGA,3rd,BelfortMA,SmulianJC.Preeclampsiarecurrenceandprevention.SeminPerinatol.2007Jun;31(3):13541.

TheStrengthoftheAssociationofSelectedRiskFactorsfor
Preeclampsia (2) Methodstopreventpreeclampsia(1)
Pregnancyoutcome Recommendation
RiskFactorAssociatedwith Reference OR(95%CI)
Dietandexercise(I) Noreductioninpre Insufficientevidenceto
Preeclampisa
Proteinorsalt(II) eclampsia recommend*
Geneticfactors(eg,thrombophilias) Robertson53
restriction
FactorVLeidenheterozygosity 2,19(1,463,27)
Magnesiumorzinc Noreductioninpre Notrecommended*
Prothrombinheterozygosity 2,54(1,524,23)
supplementation(I) eclampsia
MTHFRhomozygosity 1,37(1,071,76)
Fishoil Noeffectinlowriskorhigh Insufficientevidenceto
Hyperhomocysteinemia 3,49(1,2110,11)
supplementationand risk recommend*
Obesity(BMI>35kg/m2) Sibai1 3,38(1,916,00)
othersourcesoffatty populations
Maternalage>35years CondeAgudelo49 1,67(1,581,77) acids(I)
Familyhistoryofpreeclampsia Duckitt48 2,90(1,704,93) Calcium Reducedpreeclampsiain Recommendedforwomen
Fetalmalformation CondeAgudelo49 1,26(1,161,37) supplementation(I) thoseathighriskandwith athighriskofgestational
Abnormalmaternalserummarkers Dugoff54 lowbaselinedietarycalciumhypertension,andin
(AFP,hCG,uE3,InhibinA) intake communitieswithlow
InhibinA>2,0MOM 2,39(1,753,26) Noeffectonperinatal dietarycalciumintake
2abnormalmarkers 3,65(2,794,78) outcome
AfricanAmericanrace Tucker55 1,2(0,81,7) Levelsofevidence(IIV)asoutlinedbytheUSPreventiveTaskForce.*Insufficientevidence=small
trialsorinconclusiveresults

DildyGA,3rd,BelfortMA,SmulianJC.Preeclampsiarecurrenceandprevention.SeminPerinatol.2007Jun;31(3):13541. SibaiB,DekkerG,KupfermincM.Preeclampsia.Lancet.2005Feb26Mar4;365(9461):78599.
 14/04/2015

ReviewsandRandomizedClinicalTrialsforPreeclampsia
Methodstopreventpreeclampsia(2) RecurrencePrevention
Pregnancyoutcome Recommendation
Lowdoseaspirin(I) 19%reductioninriskofpre Considerinhighrisk OddsRatio
Agent Study Population N
eclampsia,16%reductionin populations (95%CI)
fetalorneonataldeaths Aspirin Coomarasamy33 Highrisk 12,416 0,86(0,790,94)
Heparinorlow Reducedpreeclampsiain Lackofrandomisedtrials, Duley32 Highrisk 33,439 0,81(0,750,88)
molecularweight womenwithrenaldisease not recommended Calcium Hofmeyr34 Metaanalysislowrisk 15,206 0,48(0,330,69)
heparin(III3) andinwomenwith Metaanalysishighrisk 587 0,22(0,120,42)
thrombophilia Magnesium Spatling35 Generallowrisk 568 NS
Antioxidantvitamins(C,Reducedpreeclampsiain Insufficientevidenceto Sibai36 Normotensive 374 NS
E)(II) onetrial recommend* primigravidas
Antihypertensive Riskofwomendeveloping Noevidenceto Fishoil Makrides37 Allrisk 1,683 0,86(0,591,27)
medications inwomen severehypertension recommendforprevention VitaminsC+E Poston41 Highrisk 2,41 0,97(0,801,17)
withchronic reducedbyhalf,butnotrisk Rumbold42 Nulliparouswomen 1,877 1,20(0,821,75)
hypertension(I) of preeclampsia Heparin Mello46 Angiotensin 80 0,26(0,080,86)
Levelsofevidence(IIV)asoutlinedbytheUSPreventiveTaskForce.*Insufficientevidence=small convertingenzyme
trialsorinconclusiveresults polymorphismin
nonthrombophilic
womenwithhistoryof
preeclampsia
SibaiB,DekkerG,KupfermincM.Preeclampsia.Lancet.2005Feb26Mar4;365(9461):78599. DildyGA,3rd,BelfortMA,SmulianJC.Preeclampsiarecurrenceandprevention.SeminPerinatol.2007Jun;31(3):13541.

SummaryofStudiesthatPresenttheRiskforRecurrenceof
Preeclampsia Longtermhealthrisks
Author StudyPopulation RateofRecurrence Hypertensivedisorder
Campbell7 Preeclampsia(n=279) Preeclampsia7,5% FutureRisk Severepreeclampsia,
Gestational
Preeclampsia HELLPsyndromeor
Sibai9 Secondtrimesterseverepreeclampsia(n Anypreeclampsia65% hypertension
eclampsia
=169) <28weeks21% Gestational Riskrangesfrom
Riskrangesfromabout1in8
2836weeks21% hypertensionin about1in6(16%)to
(13%)toabout1in2(53%).
3740weeks24% futurepregnancy about1in2(47%).
Ifbirthwasneeded
vanRijn8 Preeclampsiawithdelivery<34weeks Preeclampsia25% Riskuptoabout1in6(16%). before34weeksriskis
Sullivan12 HELLP(n=161) Preeclampsia43% Riskrangesfrom1in
Preeclampsiain Noadditionalriskifinterval about1in4(25%).
50(2%)toabout1in
HELLP27% futurepregnancy
14(7%).
beforenextpregnancy<10 Ifbirthwasneededbefore
Sibai11 HELLP(n=192) Preeclampsia19% years. 28weeksriskisabout1in
2(55%).
HELLP3% Cardiovascular
Chames13 HELLPwithdelivery<28weeks(n=62) Preeclampsia55% Increasedriskofhypertensionanditscomplications.
disease
HELLP6% Ifnoproteinuria andno
Adelusi14 Eclampsia(n=64) Eclampsia16% hypertensionat68week
Endstage
postnatalreview,relativerisk
Sibai16 Eclampsia(n=366) Preeclampsia22% kidneydisease
increasedbutabsoluterisklow.
Eclampsia2% Nofollowupneeded.
Trogstad17 Preeclampsiasingleton(n=19,960) Preeclampsia14,1% Thrombophilia Routinescreeningnotneeded.
Preeclampsiatwins(n=325) Preeclampsia6,8%
DildyGA,3rd,BelfortMA,SmulianJC.Preeclampsiarecurrenceandprevention.SeminPerinatol.2007Jun;31(3):13541. NICE2010QuickRef
 14/04/2015

Upayapencegahan Kontrasepsi
Pil AKDR
Prakonsepsi optimalkanstatus KOK KIK KOP KIP Implan
Kondar
AKDR
LNG
Tubektomi
RiwayatTD
nutrisi tinggiselama
kehamilan 2 2 1 1 1 1 1 A
Multivitamindanmineral,proteindanmixkarbohidrat (sekarangTD
normal)
Bereskaninfeksi:periodontitis,UTI,cervicovaginitis Sistolik 140
159atau 3 3 1 2 1 1 1 C
Upayakanberatbadanideal diastolik9099
Sistolik 160
Olahragateratur ordiastolik 4 4 2 3 2 1 2 S
100
Saathamil KOK=Kontrasepsioralkombinasi;KIK=Kontrasepsiinjeksikombinasi;KOP=Kontrasepsioral
progestin;KIP=Kontrasepsiinjeksiprogestin;Kondar=kontrasepsidarurat;AKDR=alat
Pertahankanupayaprakonsepsi kontrasepsidalamrahim;AKDRLNG=alatkontrasepsidalamrahimLevonorgestrel.

KateJKerber,JosephEdeGraftJohnson,ZulfiqarABhutta,PiusOkong,AnnStarrs,JoyELawn.Continuumofcareformaternal,newborn,and KateJKerber,JosephEdeGraftJohnson,ZulfiqarABhutta,PiusOkong,AnnStarrs,JoyELawn.Continuumofcarefor
childhealth:fromslogantoservicedelivery. Lancet2007;370:135869 maternal,newborn,andchildhealth:fromslogantoservicedelivery. Lancet2007;370:135869
 14/04/2015

Kesimpulan
Preeklampsiamasihmerupakansalahsatu
penyebabkematianmaternal.
Pengertianmendalamtentangpatofisiologi
preeklampsiaakanmengurangidampak
preeklampsia.