HYPERTENSIVE

DISORDERS IN
PREGNANCY
Rio Edward Pusdi Jaya Simanjuntak., dr.,
SpOG

Department of Obstetrics & Gynecology,

Bayukarta Hospital
Karawang 2015

Kecenderungan AKI di Indonesia

SDKI 2012 : 359/100.000 kelahiran hidup

Penyebab baik buruknya hasil proses

reproduksi multifaktorial
karakteristik
ibu hamil
akses ke pelayanan
kesehatan
sarana dan sistem pelayanan
serta penggunaan sarana
kesehatan
gambaran demografi yang tidak menguntungkan

Alma Alta
tahun 1978

Health for all by the year 2000

Nairobi

Safe Motherhood Initiative

Cairo
tahun 1994

tahun 1987

International Conference on Population

and Development (ICPD)

WHO
Making Pregnancy Safer (MPS)
PBB
tahun 2000

tahun 1999

Millenium Development Goals

(MDGs)

Target yang
memerlukan
kerja keras:

Angka
kematian ibu
Lingkungan
akses air bersih
HIV/AIDs

GOAL 5: MENINGKATKAN
KESEHATAN IBU
Indikator

Target

Pencapaian

Keterangan

Target 5a: Mengurangi 75% AKI dalam kurun waktu 1990 dan 2015
AKI per 100,000
kelahiran hidup
Pertolongan persalinan
oleh tenaga kesehatan
terlatih (%)

102

Meningkat

228 (SDKI, 2007)

Off track

74,87 % (Susenas, 2008)

Meningkat namun memerlukan

perhatian khusus (need special
attention) melalui penyediaan
tenaga kesehatan strategis

Iron Supplements,
Malaria Intermittent treatment
and Antiretroviral for HIV

Oxytocin and Manual

Compression

Magnesium Sulfate

Patogram

Family Planning and

Postabortion Care

Antibiotics
Tetanus Toxoid Immunization Clean Delivery

*Other direct causes include: ectopic pregnancy, embolism, anesthesiarelated

*indirect causes include: anemia, malaria, heart disease
Adapted from: Maternal Health Around the World World Health Organization, Geneva, 1997

Trias main cause of maternal death

Preeclampsia/eclampsia
Haemorrhage
Infection

Hasan Sadikin Hospital

20

- 30% of maternal death

30 - 40% of perinatal death

Classification :
I.
II.

Gestational Hypertension

(Hypertension, No proteinuria, BP normal < 12 weeks

postpartum)
Preeclampsia
( Hypertension + proteinuria)

III. Eclampsia

IV. Superimposed Preeclampsia (on chronic

hypertension)
V.

(Hypertension before 20 weeks gestation + proteinuria)

Chronic Hypertension

( Hypertension before 20 weeks gestation, until > 12

weeks postpartum , No proteinuria)
(Working Group on High Blood Pressure in Pregnancy, July 2000)

Hypertension :

> 140/90 mmHg

Protein uria

> 0.3 gr/L/24 hs or

> 1
gr/L/6 hs or
1+ qualitative test (dipstic test)

Preeclampsia/Eclampsia

Etiology : unknown
Predisposing factors :

1. Primigravida
2. Hyperplacentosis
hydatidiform mole
gemelli
diabetes mellitus
hydrops fetalis
giant baby
3. Age (< 15 years ; > 35 years)
4. Familial & genetic
5. Kidney disease and chronic hypertension

Theories of potential causes

Abnormal trophoblastic invasion of uterine vessels

Immunological intolerance between maternal and

fetoplacental tissues

Maternal maladaptation to cardiovascular or

inflammatory changes of normal pregnancy

Dietary deficiencies

Genetic influences

Pathophysiology
Inhibition
Immunologic
reaction

of

trophoblast

Hypoxia

Endothelial

invasion

Free radical

dysfunction

Vasoconstrictor

Vasodilator

- Thromboxane
- Endothelin
- etc

- No
- Prostacyclin
- etc

Permeability
Coagulation

DIC

Maternal & Fetal Consequences

1. Cardiovascular changes
Hypertension
Cardiac out put
Thrombocytopenia
Coagulation disorders
Haemorrhages
DIC
Decrease blood plasm volume
Increase permeability
Edema

2. Placenta
Necrosis
Intrauterine growth restriction
Fetal distress
Abruptio placentae
3. Kidney :
Capillary endotheliosis
Decrease uric acid clearance
Decrease glomerular filtration rate
Oliguria
Proteinuria
Kidney / renal failure

4. Brain :

Edema
Hypoxia
Seizure / convulsion
Cerebrovascular accident / hemorrhage
Coma

5. Liver :

Liver function test alteration

Increase levels of liver enzym
Icterus
HELLP syndrome
(hemolysis, elevated liver enzym, low
platelet caunt)
Edema
Hemorrhage/sub capsular hematoma
Perinatal hemorrhage, necrosis

6. Eye

Papil edema
Ischemia
Amaurosis
Hemorrhage
Retinal detachment
Blindness

7. Lung :

Edema
Ischemia
Necrosis
Hemorrhage
Respiratory failure

Diagnosis
Preeclampsia :
Pregnancy of 20 weeks or more
Hypertension
Proteinuria
Eclampsia :
Preeclampsia with
Convulsion / Seizure

Prognosis
Maternal death due to

PE : + 0,5%
Ecl : +

Perinatal death + 20%

5%

Hipertensi dalam Kehamilan

Diagnosis :
1. PRE EKLAMSIA BERAT
Diastolik 110 mmHg
Proteinuri 2g/24 jam atau +2 (dipstick)
Kreatinin >1.2 mg% dengan oligouri
Trombosit < 100.000/mm3
HELLP syndrome sign
IUGR
Edema Paru + Sianosis
2. IMPENDING ECLAMPSIA
PEB + GEJALA SUBYEKTIF (Nyeri Kepala Hebat / Nyeri Ulu hati /
Pandangan Kabur)
3. EKLAMSIA
PEB + KEJANG
(Pedoman Diagnosis Dan Terapi Obstetri Dan Ginekologi RS Dr Hasan Sadikin. 2005)

Penatalaksanaan Hipertensi dalam Kehamilan

ANTI KEJANG :
Sulfas magnesicus (MgSO4) 20% dan 40%.
Syarat pemberian harus dipenuhi
PEMBERIAN :
A. Pemberian intravena (dengan infusion pump)
1. Dosis Awal : 4 gr (20cc MgSO4 20%) dilarutkan ke dalam 100 cc RL,
diberikan selama 15-20 menit
2. Dosis pemeliharaan : 10 gram (50 cc MgSO4 20%) dalam 500 cc cairan
RL diberikan dengan kecepatan 1-2 gram/jam (20-30 tetes permenit)
B. Pemberian Intramuskuler berkala
1. Dosis awal 4 gram (20cc MgSO4 20%) IV (1gr/menit). Konservatif : 8 gram
MgSO4 IM
2. Dilanjutkan 4 gram (10cc MgSO4 40%) tiap 4 - 6 jam IM.
Tambahkan 1 cc Lidokain 2%
(Pedoman Diagnosis Dan Terapi Obstetri Dan Ginekologi RS Dr Hasan Sadikin. 2005)

Antihipertensi diberikan bila :

1. Tekanan darah :
- Sistolik > 180 mmHg
- Diastolik > 110 mmHg

Obat-obat antihipertensi yang diberikan :

Obat pilihan adalah hidralazin, yang diberikan 5 mg
i.v. pelan-pelan selama 5 menit. Dosis dapat diulang
dalam waktu 15-20 menit sampai tercapai tekanan
darah yang diinginkan.

Apabila hidralazin tidak tersedia, dapat diberikan :

Nifedipin : 10 mg, dan dapat diulangi setiap 30

menit (maksimal 120 mg/24 jam) sampai terjadi
penurunan tekanan darah.
Labetalol 10 mg i.v. Apabila belum terjadi
penurunan tekanan darah, maka dapat diulangi
pemberian 20 mg setelah 10 menit, 40 mg pada 10
menit berikutnya, diulangi 40 mg setelah 10
menit kemudian, dan sampai 80 mg pada 10
menit berikutnya.

Treatment
Severe preeclampsia

conservative : < 37 weeks, no fetal

distress and signs of impending eclampsia

Severe headache
Severe visual disturbance
Vomiting
Epigastric pain
Progressive increase of Blood pressure

Active : pregnancy termination

Prognosis

Eden criteria (1922)

Prolonged coma

Pulse rate > 120 x/m

Temperature > 1030 F

Systolic pressure > 200 mmHg

Seizure > 10 x

Proteinuria > 10 gr/ltr

No edema

CHRONIC HYPERTENSION
(Coincidental hypertension)

Definition :
Hypertension (> 140/90 mmHg)
< 20 weeks gestation
Persists long after delivery

Underlying disorders :
Essential familial hypertension

(Hypertensive vascular disease)

Arterial abnormalities
Renovascular hypertension
Coartation of the aorta
Endocrine disorders
diabetes
cushing syndrome
primary aldosteronism
pheochromocytoma
thyrotoxicosis

 Glomerulonephritis (acute & chronis)

Renoprival hypertension

chronic gromerulo nephritis

chronic renal insufficiency
diabetic nephropathy
Conective tissue diseases
lupus erythematosus
scleroderma
periartenitis nodosa
Poly cystic kidney disease
Acute renal failure
Obesity

KEJANG EKLAMSI
Selama 60-75 detik
Fase I : 15-20 detik facial twitching
Fase II : 60 detik tonik konik seluruh tubuh
Apneu
Koma
Hiperventilasi

Pencegahan kejang ulangan

Magnesium

sulfat: drug of choice

Dosis inisial 4 gram 15 20 menit
Dosis pemeliharaan 2 g/jam.
Jika terjadi kejang, berikan bolus 2 g dalam
35 menit.
Jika pasien masih tetap kejang, berikan 250
mg sodium amobarbital dalam 35 menit.
Pertimbangkan intubasi
Pantau tanda-tanda toksisitas magnesium

Toksisitas Magnesium
Manifestasi

Kadar (mg/dL)

Hilangnya refleks patela

8 - 12

Penglihatan ganda

8 - 12

Merasa hangat, flushing

9 - 12

Somnolen

10 - 12

Meracau

10 - 12

Paralisis otot

15 - 17

Henti napas

15 17

Henti jantung

30 - 35

Interventions that are recommended for prevention or treatment

of pre-eclampsia and eclampsia (WHO 2011)

Interventions that are recommended for prevention or treatment of

pre-eclampsia and eclampsia (WHO 2011)

Interventions that are recommended for prevention or treatment of

pre-eclampsia and eclampsia (WHO 2011)

Interventions that are recommended for prevention or treatment of

pre-eclampsia and eclampsia (WHO 2011)

Interventions that are recommended for prevention or treatment of

pre-eclampsia and eclampsia (WHO 2011)