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 MINIMUMDESKAN DARAH 140/90 mmHg UMUR KEHAMILAN 20 MGG, DISERTAI PROTEINURIA 300 mg/24 JAM ATAU DIPSTICK 1 +

ECLAMSIAKEJANG2 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 KRONIKDITEMUKANNYA DESAKAN DARAH 140/90 mmHg, SEBELUM KEHAMILAN ATAU SEBELUM KEHAMILAN 20 MGG DAN TDK MENGHILANG SETELAH 12 MGG PASCA PERSALINAN

INTRODUCTION :INDUCED BY PREGNANCYDISEASE OF THEORIESCLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUTORGAN DYSFUNCTION / FAILURE

THIRD LEADING CAUSE OF MATERNAL MORTALITYMORTALITY RATE:150.000 WOMEN A YEAR WORLD WIDE

INCIDENCEPE/E : 2% - 9% OF ALL PREGNANT WOMEN IN SEVERAL HOSPITAL IN INDONESIA

YEARHOSPITALPERCENTAGE AUTHOR1993 1997 1996 1997 1995 19982000 20022002RSPM12 HOSPITALSRS. H.S.RSHAM RSPMRSCM 5,750,8 - 1413,07,09,17SIMANJUNTAK J.TRIBAWONO A.MEIZIAGIRSANG. EPRIYATINI

ETIOLOGY : NOT FULLY KNOWNRISK FACTORS :NULLI PARITY / TEENAGE PREGNANCYHISTORY OF PREVIOUS PREGNANCYFAMILY HISTORY OF PE/EMULTIPLE GESTATIONPREEXISTING HYPERTENSION / RENAL DISEASED.M, ANTI PHOSPOLIPID ANTIBODYHYDROPS FETALISHYDATIDIFORM MOLESURYNARY TRACT INFECTION

PATHOGENESE : CONTROVERSION : THE DISEASE OF THEORIESIMMUNITY, GENETIC VASC. DISEASE TROPHOBLAST INADEQUATE TROPHOB. INVASION TO SPIRAL ARTERY OF PLACENTAINSUFF, PLACENTA HYPOXIAIUGROXYDATIVE STRESSENDOTHELIAL DYSFUNCTION CIRCULATING FACTOR(S) CYTOKINES LIPID (IL-6, TNF-) PEROXIDESNEUTROPHILACTIVATIONPLATELETACTIVATION

ENDOTHELIAL DYSFUNCTIONBLOOD

THROMBOCYTOPENIA COAGULAPATHY

ALTERED VASCULAR PERMEABILITY

PERIPHERAL OEDEMA PULMONARY OEDEMASYSTEMIC VASOCONSTRICTION

HYPERTENSIONKIDNEYS

HYPERURICAEMIA PROTEINURIA RENAL FAILURELIVER

ABNORMAL FUNCTION TESTS HAEMORRHAGECNS / EYES SEIZURES CORTICAL BLINDNESS RETINAL DETACHMENT & HAEMORRHAGE

CLINICAL CLASSIFICATION:PREECLAMPSIA-MILD-SEVERE

IMPENDING ECLAMPSIAECLAMPSIAHELLP SYNDROME

MILD PREECLAMPSIA :BP 140/90 mmHg AFTER 20 WEEKS GESTATIONPROTEINURIA 300 mg/ 24 H OR 1+ DIPSTICKWITH OR WITHOUT OTHER SYMPTOMS AND SIGN

SEVERE PREECLAMPSIABP 160/110 mmHGPROTEINURIA 2.0 gr / 24 H OR 2 + DIPSTICKHEADACHE, VISUAL OR CEREBRAL DISTURBANCEEPIGASTRIC PAINOLIGURIA : < 400 500 CC/ 24 HOURS HYPER REFLEX, MOTORIC EXCITATION, IMPAIRED CONSIOUSNESS, SUDDEN DETERIORATION PLATELETS COUNT < 1000.000 / mm3BILIRUBIN 1,2 mg / DLLDH > 600 IU/LSGOT > 70 mg/DL

IMPENDING ECLAMPSIASEVERE PREECLAMPSIA WITH :HEADACHENAUSEA AND VOMITINGBLURRED VISION, SCOTOMA, IMPAIRED CONSIOUSNESS, SUDDEN DETERIORATIONEPIGASTRIC 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 EDEMAARE THE MOST COMMON COMPLICATION

HELLP SYNDROMECOMPLICATION OF SEVERE PREECLAMPSIA10-15% DIRECTLY FROM PREGNANCYMANAGEMENT OF PREECLAMPSIAADEQUAT AND PROPER PRENATAL CAREIDENTIFICATION OF WOMEN AT HIGH RISKEARLY 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 FAVOURABLEMATERNAL AND PERINATAL OUTCOMES DEPEND ON :GESTATIONAL AGE AT TIME OF DISEASE ONSETSEVERITY OF DISEASEQUAITY OF MANAGEMENTPRESENCE OR ABSENCE OF PRE-EXISTING MEDICAL DISORDERS

MILD PREECLAMPSIAAMBULATORY CAREBED REST : NOT NECESSARILYREGULAR DIET, NO SALT RESTRICTIONPRENATAL VITAMINNO OTHER MEDICATION : ANTI HYPERTENSIVE, SEDATIVE, DIURETICSANTENAL VISIT : EVERY WEEK

HOSPITAL CAREPERSISTENT HYPERTENSION MORE THAN 2 WEEKSPERSISTENT PROTENURIA MORE THAN 2 WEEKSABNORMAL LABORATORY TESTABNORMAL FETAL GROWTHONE OR MORE SIGN AND SYMPTOM SEVERE PE

OBSTETRIC MANAGEMENTGESTATIONAL 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 PREECLAMPSIAMEDICAL TREATMENT

OBSTETRIC MANAGEMENT :CONSERVATIVE : -PREGNANCY 37 WEEKS

ACTIVE: -PREGNANCY 37 WEEKS -FETAL INDICATION -MATERNAL INDICATION

MEDICAL TREATMENT :HOSPITALIZETOTAL BED RESTFLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.Mg SO4 IVANTI HYPERTENSION :HYDRALAZINLABETALOLNIFEDIPINE :10 20 mg / ORALLY EVERY - 1 H,MAX : 120 mg / 24 HoursDIURETIC : NOT RECOMMENDEDANTI OXYDANT : N-ACETYL CYSTEINCORTICOSTEROID + LUNG MATURITY 34 WEEKS

OBSTETRIC MANAGEMENTCONSERVATIVE MANAGEMENT:GOAL : TO IMPROVE INFANT OUTCOME, WITHOUT COMPROMISING THE MOTHERPREGNANCY 37 WEEKS, IMPENDING ECLAMPSIA (-)

ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCYINDICATIONFETAL : -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 + CONVULSIONBASIC MANAGEMENT :CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)STABILIZE THE MOTHERCONTROL CONVULSIONCORRECT MATERNAL HYPOXEMIA / ACIDEMIAPREVENT COMPLICATION : HYPERTENSION CRISIS TERMINATE PREGNANCY

MEDICAL TREATMENT :SAME AS SEVERE PREECLAMPSIA

COMPLICATION : P.E AND ECLAMPSIA

MOTHERBABYHELLP SYNDROMELIVER RUPTUREDPULMONARY EDEMARENAL FAILUREABRUPTIO PLACENTAEDICCEREBROL VASCULER ACCIDENT MATERNAL DEATHIUGR PREMATURE LABORINTRA CRANIAL HAEMORRHAGECEREBRAL PALSYPNEUMO THORAXIUFD

HIPERTENSI KRONIK DALAM KEHAMILANDEFINISI 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 KEHAMILANPRIMER (IDIOPATIK) : 90 %SEKUNDER : 10 %, YG BERHUBUNGAN DGN PENY. GINJAL, PENY. ENDOKRIN (dm), PENY. HIPERTENSI DAN VASKULER

DIAGNOSISBERDASARKAN 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 PREECLAMPSIAUMUR IBU > 40 THNHIPERTENSI 4 THNADANYA KELAINAN GINJALADANYA DIABETES MELLITUS (KLAS B KLAS F)KARDIOMIOPATIMEMINUMI OBAT ANTI HIPERTENSI SEBELUM HAMIL

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

KLASIFIKASISISTOLIK (mmHg)DIASTOLIK (mmHg)NORMALPREEHIPERTENSIHIPERTENSI STADIUM IHIPERTENSI STADIUM II< 120120 139140 159 160< 8080 8990 99 110

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 LABORATORIUMPEMERIKSAAN (TEST) KLINIK SPESIALISTIK :-ECG-ECHOCARDIOGRAPHY-OPHTALMOLOGY-USG GINJAL

PEMERIKSAAN (TEST) LABORATORIUM-FUNGSI GINJAL :CREATININE SERUM BUN SERUM, ASAM URAT, PROTEINURIA 24 JAMPEMERIKSAAN 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 MEDIKAMENTOSAINDIKASI 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 SLOW- RELEASE TABLET

PENGELOLAAN TERHADAP KEHAMILANSIKAP 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 PREECLAMPSIAPENGELOLAAN HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA SAMA DGN PENGELOLAAN PREECLAMPSIA BERAT.

HELLP SYNDROME PREGNANCYHYPERTENSION AND PROTEINURIAPREECLAMPSIAHELLP SYNDROME10-14% CASE

HELLP SYNDROMEFIRST DISCRIBED BY WEINSTEIN 1982:ACRONYM OF :H:HEMOLYSISEL:ELEVATED LIVER ENZYMLP:LOW PLATETLED COUNT

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

CRITERIA DIAGNOSTICLABORATORY FINDING:HEMOLYSISABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND BURR CELLSTOTAL BILIRUBIN LEVEL > 1,2 mg/DlLACTATE DEHYDROGENASE LEVEL > 600 /LELEVATED LIVER FUCTIONSGOT LEVEL 70 / L (LDH)LACTATE DEHYDROGENASE LEVEL > 600 /L

LOW PLATELET COUNTPLATELET COUNT < 100.000/m3THE LABORATORY DIAGNOSTIC CRITERIA USED AT THE UNIVERSITY OF TENNESSEE DIVISION OF MATERNAL FETAL MEDECINE, MEMPHIS TN. WITLIN AND SIBAI (1999)

CLASS I : PLATELET 50.000/m3WITH : LDH 600 U/LSGOT 40 U/L

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

CLASS II : PLATELET 50.000/m3 - < 150.000/m3 WITH : LDH 600 U/LSGOT 40 U/LCLASSIFICATION BASED ON PLATELET COUNT (MISSISIPPI):

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 MANAGEMENTWHEN MOTHERS IS STABLE TERMINATE THE PREGNANCY OR CONSERVATIVE MANAGEMENT.

CONSERVATIVE MANAGEMENT CAN BE DONE WHEN :THE BLOOD PRESSURE < 160/110 m gTHE OLIGURIA RESPONSE TO FLUID REPLACEMENTTHERE IS NO EPIGASTRIC PAINTHE GESTATIONAL AGE IS < 34 WEEKS

COMPLICATIONTHE COMPLICATIONS THAT CAN OCCUR IN HELLP SYNDROME ARE : NEUROLOGIC DISORDER, PULMONARY EDEMA, ABRUPTIO PLACENTA, DIC AND UGR

HYPERTENSION, PROTEINURIA AND OTHERS SYMPTOMS-SIGN OF PREECLAMPSIA ARE INDUCED BY PREGNANCY

BESIDE HYPERTENSION AND PROTEINURIA, OTHER SYNDROMA OF PREECLAMPSIA ARE EPIGASTRIC PAIN, HEADCHE, VISUAL DISTURBANCE, OLIGURIA, CONVULSION, AND RENAL FAILURE.

THERE ARE STILL CONTROVERSION IN CLASSIFICASION, DIAGNOSTIC AND MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION.

IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN MANAGEMENT IS NEEDED.

IGNORANCE, POVERTY, LATE ADMITTANCE TO HOSPITAL WILL INCREASE FERINATAL - MATERNAL, MORBIDITY AND MORTALITYCONCLUSIONS :

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