Hypertensive Disorder Hypertensive Disorder in Pregnancyin Pregnancy

dr. Valleria, SpOGdr. Valleria, SpOG

Hypertensive Disorder in Hypertensive Disorder in PregnancyPregnancy

1.1. Gestational hypertension ( Hipertensi Gestational hypertension ( Hipertensi dalam Kehamilan )dalam Kehamilan )

2.2. PreeclampsiaPreeclampsia

3.3. EclampsiaEclampsia

4.4. Superimposed Preeclampsia Superimposed Preeclampsia

5.5. Chronic HypertensionChronic Hypertension

Hypertensive Disorder in Hypertensive Disorder in PregnancyPregnancy

One of the deadly triad (hemorrhage, One of the deadly triad (hemorrhage, infection)infection)

3,7 % of all pregnancy 3,7 % of all pregnancy

Gestasional hypertensionGestasional hypertension

BP BP >> 140/90 mmHg for first time during 140/90 mmHg for first time during pregnancypregnancy

No proteinuriaNo proteinuriaBP return to normal < 12 weeks post BP return to normal < 12 weeks post

partumpartumMay have other signs for preeclampsia May have other signs for preeclampsia

(epigastric discomfort, thrombpcytopenia)(epigastric discomfort, thrombpcytopenia)

PreeclampsiaPreeclampsia

Mild :Mild :- BP BP >> 140/90 mmHg after 20 weeks 140/90 mmHg after 20 weeks

gestationgestation- Proteinuria Proteinuria >> 300 mg/24 hours or 300 mg/24 hours or >> 1+ 1+

dipstickdipstick

PreeclampsiaPreeclampsiaSevereSevere

- BP BP >> 160/110 mm Hg 160/110 mm Hg- Proteinuria 2 g/24 hours or Proteinuria 2 g/24 hours or >> 2+ dipstick 2+ dipstick- Serum Creatinin > 1,2 mg/dLSerum Creatinin > 1,2 mg/dL- Platelets < 100.000/mm3Platelets < 100.000/mm3- Increase LDHIncrease LDH- Elevated AST/ALTElevated AST/ALT- Persistent headache or other cerebral or Persistent headache or other cerebral or

visual disturbancevisual disturbance- Persistent epigastric painPersistent epigastric pain

EclampsiaEclampsia

Seizures that cannot be attributed to other Seizures that cannot be attributed to other causes in women with preeclampsiacauses in women with preeclampsia

ComaComa

Superimposed preeclampsiaSuperimposed preeclampsia

New onset proteinuria New onset proteinuria >> 300mg/24 hours 300mg/24 hours in in hypertensive womenhypertensive women but no proteinuria but no proteinuria before 20 weeks gestasionbefore 20 weeks gestasion

Sign and symptoms severe preeclampsiaSign and symptoms severe preeclampsia

Chronic HypertensionChronic Hypertension

BP BP >> 140 mmHg before pregnancy or 140 mmHg before pregnancy or diagnosed before 20 weeks gestationdiagnosed before 20 weeks gestation

Risk Factor PreeclampsiaRisk Factor Preeclampsia

NulliparousNulliparousMultiple pregnancyMultiple pregnancyHistory of chronic hypertensionHistory of chronic hypertensionMaternal age over 35 yearsMaternal age over 35 yearsObesityObesity

Patophyisiology PreeclampsiaPatophyisiology Preeclampsia

Maternal vascular deseaseMaternal vascular deseaseFaulty placentationFaulty placentationExcessive trophoblastExcessive trophoblast

Reduced uteroplacental perfusionReduced uteroplacental perfusion

Endothelial activationEndothelial activation

Endothelial activation

Vasospasme Capillary leak Activation of coagulation

-Hypertension-Seizure-Oliguria-Abruption-Liver ischemia

EdemaProteinuriaHemoconcentration

Thrombocytopenia

Mild PreeclampsiaMild Preeclampsia

> 37 weeks gestasion : induction of labour> 37 weeks gestasion : induction of labour<< 37 weeks gestasion : 37 weeks gestasion :

- No medicationNo medication- No diuretikNo diuretik- Limitation activityLimitation activity- ANC 2x/weeks : Blood Pressure, proteinuria, ANC 2x/weeks : Blood Pressure, proteinuria,

refleks, fetal surveillancerefleks, fetal surveillance

ManagementManagement

1.1. Delivery is the cure for preeclampsiaDelivery is the cure for preeclampsia >> 35 weeks gestation : induction of labor 35 weeks gestation : induction of labor < 35 weeks gestation, no complication: < 35 weeks gestation, no complication:

expectant expectant ( the hope that few more weeks in ( the hope that few more weeks in utero will reduce the risk of neonatal mortality utero will reduce the risk of neonatal mortality and morbidity ) and morbidity )

- Anti hypertensionAnti hypertension- Lung maturation : dexametason 12 mg/day, 2 daysLung maturation : dexametason 12 mg/day, 2 days- Observation : Blood pressure, symptom impanding Observation : Blood pressure, symptom impanding

eclampsia, lab., fetal surveillance eclampsia, lab., fetal surveillance any disturbance any disturbance termination termination

ManagementManagement

2. Anti hypertensive Drug2. Anti hypertensive Drug- ββ-blocking agent : labetolol-blocking agent : labetolol- Calcium channel blocker : nifedipineCalcium channel blocker : nifedipine- ACE inhibitor ACE inhibitor

(Angiotensin-converting-enzyme): should be (Angiotensin-converting-enzyme): should be avoided : avoided : oligohidramnios, IUGR, limb oligohidramnios, IUGR, limb contractur, Persistent PDA, pulmonary contractur, Persistent PDA, pulmonary hypoplasia, etchypoplasia, etc

- Methyldopa : delayed onset (long-acting)Methyldopa : delayed onset (long-acting)

ManagementManagement

33. . Preventive and control convulsionPreventive and control convulsion- MgSOMgSO44 : control convulsion without central : control convulsion without central

nervous system depressionnervous system depression- i.v : 4-6 g loading dose diluted in 100 ml of i.v : 4-6 g loading dose diluted in 100 ml of

iv fluid 15-20 min, maintenance 1-2 g/ hour iv fluid 15-20 min, maintenance 1-2 g/ hour in 100 mlin 100 ml

- i.m : 4 g loading dose, 5 g i.m in both i.m : 4 g loading dose, 5 g i.m in both buttock / 4 hourbuttock / 4 hour

ManagementManagement

Before giving MgSOBefore giving MgSO44 : :1.1. The patellar refleks is presentThe patellar refleks is present2.2. Respiration are not depressed ( RR>16/min)Respiration are not depressed ( RR>16/min)3.3. Urin output > 100ml/4 hourUrin output > 100ml/4 hour

MgSoMgSo44 is discontinued 24 h after delivery is discontinued 24 h after delivery MgSOMgSO44 toxicity : respiratory depression, toxicity : respiratory depression,

paralysis, and arrestparalysis, and arrest Antidotum MgSOAntidotum MgSO44 : calcium gluconate : calcium gluconate

ComplicationComplication

1.1. EclampsiaEclampsia

- Generalized tonic-clonic seizuresGeneralized tonic-clonic seizures- Coma without convulsionComa without convulsion- Antepartum, intrapartum, postpartumAntepartum, intrapartum, postpartum- Cerebral edemaCerebral edema- ICUICU

ComplicationComplication

2. HELLP Syndrome2. HELLP Syndrome

- Hemolysis : fragmented erythrocyte, bilirubun > Hemolysis : fragmented erythrocyte, bilirubun > 1,2 ml/dL1,2 ml/dL

- Elevated Lever enzymes : SGOT > 72 IU/L, LDH Elevated Lever enzymes : SGOT > 72 IU/L, LDH > 600IU/L> 600IU/L

- Low Platelet count : < 100.000/mm3Low Platelet count : < 100.000/mm3- DICDIC- Tx : dexamethason 2 x 10 mg, then 2 x 5 mgTx : dexamethason 2 x 10 mg, then 2 x 5 mg

ComplicationComplication

33. . Pulmonary edemaPulmonary edema

- Tachypneu/dyspneaTachypneu/dyspnea- Respiratory distressRespiratory distress- Severe hypoxemiaSevere hypoxemia- Diffuse rales in both lungDiffuse rales in both lung- ICU, ventilatorICU, ventilator- FurosemidFurosemid

ComplicationComplication

4. Acut Renal Failure4. Acut Renal Failure

5. Hepatic rupture5. Hepatic rupture

6. Abruptio placentae6. Abruptio placentae

7. Cerebral hemorrhage7. Cerebral hemorrhage

8. Visual disturbances8. Visual disturbances

PreventionPrevention

Low dose aspirin ?Low dose aspirin ?Calcium?Calcium?Anti oxidant?Anti oxidant?