Hipertensi Dalam Kehamilan(1)

7/23/2019 Hipertensi Dalam Kehamilan(1)

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Hypertension in

Pregnancy

Dwi Nurrianadwi _nurri @ yahoo.com



Hypertension inPregnancy

A common complication of pregnancy

Associated with between 5-8% of pregnanciest has serious repercussions for both fetal andmaternal well being




!he outcomes depend upon the nature of thehypertension a"ecting the pregnancy# which

can range from mild gestational hypertensionto se$ere preeclampsia with its associatedmultisystemic complications




!he most important cause of hypertension inpregnancy is pre-eclampsia

t remains a leading cause of maternal andperinatal mortality

t responsible for o$er && &&& maternal

deaths each year worldwide



Classifcations



Classifcations



Diagnosis'(ypertension

' )lood pressure should ideally be measured with

the patient either*' sitting

' supine# in the left lateral position# with a +&o tilt

' the sphygmomanometer at heart le$el



Diagnosis

' (ypertension' !he diastolic blood pressure , oroto" 5 /50 the

disappearance of sounds1

' !wo diastolic blood pressure recordings o$er 2& mm(gtaen o$er 3 h apart are necessary to e4clude transientrises secondary to stress andor white-coat hypertension



Hypertension

!he le$el currently accepted as signi6cant is apressure greater than 73&2& mm(g

!he absolute blood pressure le$el pro$ides thebest guide to fetal and maternal prognosis

A diastolic blood pressure of 2& mm(gcorresponds to the point of the cur$e ine4ion

abo$e which perinatal mortality is signi6cantlyincreased



Diagnosis

9roteinuria

' n pregnancy# protein e4cretion may increase

signi6cantly by up to &.+ gl of protein per 3 h/&.5 g3 h1 which is accepted as normal

' t is recommended that a 3 h measurement ofurinary protein be made



Preeclampsia

(ypertension of at least 73& 2& mm(g on twoseparate occasions at least 3 h apart arising deno$o in a pre$iously normotensi$e woman after

the &th wee of gestation and accompaniedby signi6cant proteinuria# all resol$ing by :wees postpartum



Preeclampsia

or more# of the following symptomsbeing present

hypertension

proteinuria

symptoms including headache#photophobia#$isual disturbance# epigastricpain# alteration in the conscious state



Preeclampsia

Arising of the diastolic blood pressure of75mm(g and the systolic blood pressure ofgreater than +&mm(g abo$e booing

$alues should be regarded as signi6cant ifother features of pre-eclampsia syndromeare present



Chronic Hypertension

(ypertension present prepregnancy ordiagnosed before the &thwee

!he hypertension is diagnosed duringpregnancy but does not resol$e postpartum



Gestational

hypertensionA rise in blood pressure in the absence ofproteinuria detected after mid-pregnancy

;ften a de6niti$e diagnosis can only be maderetrospecti$ely



Etiology o

Preeclampsia<enetic

9redisposition

=aulty interplaybetween in$adingtrophoblast and

decidua

Decreased bloodsupply to feto-placental unit

>elease of circulatingfactor/s1

?ndothelial cell alteration

(ypertension9roteinuria <>



Pathophysiology !he hematological system

(emodynamics

A mared reduction in circulatingplasma $olume in conunction with a

redistribution of e4tracellular uid9latelets

A reduction in platelet countpredates the clinical signs of thedisease and may be due to animmunologically mediatedconsumption



Pathophysiology !he hematological system

Boagulation cascade

A di"use $ascular damage inassociation with laying down of 6brin

is suggesti$e of acti$ation ofcoagulation

!he hypercoagulability seen innormal pregnancy is further

increased

>egulatory proteins

anti-thrombin # protein B andprotein C and the le$els of all theproteins are reduced



Pathophysiology

!he hematological system

=ibrinolytic system

9lasminogen is con$erted to

plasmin# which then acts on6brinogen to form 6brin# 6brindegradation products and D-dimers



Pathophysiology !he i$er

Bhanges in li$er function arethought to occur secondary to$asoconstriction of the hepatic

$ascular bed !he histological e$ents obser$edinclude periportal 6brin deposition#haemorrhage and hepatocellular

necrosisn se$ere cases of hepaticin$ol$ement# complications such ashepatic rupture or infarction may be

seen



Pathophysiology

!he idney

!he initial change is that of defecti$etubular function leading to a reduceduric acid clearance and hencehyperuricaemia

!his precedes the impairment ofglomerular 6ltration , a relati$e loss

of intermediate weight proteins suchas albumin and transferrin ,proteinuria

t causes a reduction in plasma

oncotic pressure and thede$elopment of oedema



Pathophysiology

!he idney

!he characteristic# but notpathognomonic lesion# is glomerularendotheliosis# /swelling of theendothelium and 6brin depositioncausing a reduction in the capillarylumen# which resol$es post partum1

>arely acute renal failure may resultdue to acute tubular or corticalnecrosis leading to maternal death



Pathophysiology

!he )rain

!he pathophysiology of eclampsia isnot fully elucidated

;ne possible e4planation is thatlocaliEed cerebral $asospasm# andhence reduced perfusion# causesabnormal electrical acti$ity#

therefore triggering an eclamptic 6t



Pathophysiology

!he )rain

A further theory is that endothelialinury is caused by $ascular o$er

distension due to hypertensiono$ercoming the cerebralautoregulation , cerebral oedemadue to leaage of uid into theinterstitial space

!he main areas a"ected are theoccipital and parietal lobes , $isualdisturbances

!he commonest cause of death seenin eclam sia is intracerebral



Investigations used todistinguish preeclampsia

Faternal n$estigations =etal n$estigations

(ematological(epatic =unction>enal =unction

rine !ests

)lood pressuremonitoring

B!<ltrasound

Doppler

)iophysical pro6le



DiagnosingPreeclampsia

Faternal

(aematological*

CeGuential platelet counts are usefulin monitoring se$ere diseaseprogression rather than for initialdiagnosis

n the cases of reduced plateletcounts# clotting studies should beperformed




Faternal

(epatic function

Fonitoring of hepatic in$ol$ementby means of li$er function tests#/especially lactic dehydrogenase#aspartate and alaninetransaminases1# may aid diagnosis

and decisions regarding diseasese$erity




Faternal

>enal function

A rise in serum creatinine andurea suggests diseasedeterioration

Another nonspeci6c measure ofrenal function is serum uric acidle$els




Faternal

rine tests* A mid-stream urine toe4clude urinary tract infection

and a 3 h collection to identifysigni6cant proteinuria shouldfollow initial dipstic

)lood pressure* !his may be

monitored as often as e$ery75min during the acute phase ofse$ere disease




=etal

!he cardiotocograph /B!<1

t must be emphasiEed that the B!<only pro$ides a snapshot $iew offetal health and further monitoringmay be usti6ed when other factorsare considered# such as the presence

of pre-eclampsia or intra-uterinegrowth restriction




=etal

• ltrasonography

• !he use of ultrasound $aries fromsimple measurements such as fetalsiEe# gestation# growth andpresentation to calculation of thebiophysical pro6le and Doppler

studies



Treatments



Chronic Hypertension

!he aim of treatment is to reduce maternalcomplications whilst being safe for the fetus

!he drug of choice is methyldopa# although

labetalol is an alternati$e



Preeclampsia

Antihypertensi$es* hydralaEine# labetalol#methyldopa#nifedipine

Anticoagulants*magnesiumsulphate

Cteroids* de4amethasone

Aspirin

Cupporti$emanagement

Deli$ery







Decision o Delivery

!he aim of management is to stabilise thepatient and enable appropriate decisions tobe made regarding the timing and mode of

deli$ery

!he route of deli$ery is inuenced by suchfactors as gestation# the presence of other

complications# /such as malpresentation1#and the urgency with which progression todeli$ery must be made



POST!T!" #O""O$%&P

Bounselling regarding future pregnancies playsan important role in postnatal managementand psychological reco$ery

9atients ha$e a 7&-5% chance of de$elopingpre-eclampsia in subseGuent pregnancies

!he ris is higher if other factors such as anti-phospholipid syndrome are present# anddepends on the gestational age at presentation



'is( #actors or Preeclampsia



Prophyla)is againstpreeclampsia

Aspirin inhibits platelet thrombo4ane releasebut does not a"ect the production ofprostacyclin in the endothelial cells

mpro$ing the outcome of se$erepreeclampsia

t should be initiated early in subseGuent

pregnancies# especially in the early onsetpreeclampsia

ow-dose aspirin can reduce the ris ofse$ere recurrent preeclampsia by about 75%

G t ti l



Gestationalhypertension

!his is not associated with proteinuria

t appears after the &th wee of pregnancy

t will return to normal post-natally

!rue non-proteinuric gestational hypertension isnot associated with an increase in maternal orfetal morbidity



'eerences *

Duc(ett '!+ ,enny "+ -ar(er P. Hypertension in Pregnancy. Curr O/stet Gynaecol+0112*II* 3%4

Hayman '. Hypertension in Pregnancy. Cur O/stet Gynaecol+ 0114*245 2621

Soydemir #+ ,enny ". Hypertension in Pregnancy. Cur O/stet Gynaecol+ 0117* 275

8296801

!han Hou

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Hipertensi Dalam Kehamilan(1)