Our no.

1 Mother Killer:

PRECLAMPSIA
M . A DYA F. D I L M Y
PP POGI- POGI JAYA

DIVISI FETOMATERNAL, DEPARTEMEN OBSTETRI & GINEKOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA

RSUPN DR. CIPTO MANGUNKUSUMO-RS UNIVERSITAS INDONESIA

Today’s Talk & Discussion
1. Definition
2. Update on Diagnostic Criteria of Hypertension in Pregnancy
3. Principles of Preeclampsia management
4. Emergency Preeclampsia/Eclampsia Management Algorithms
Definition
Preeclampsia is a pregnancy-specific condition defined by de novo
hypertension (greater than 140 mm Hg systolic or 90 mm Hg
diastolic) that occurs after 20 weeks of gestation or postpartum,
accompanied by either proteinuria (greater than 300 mg/24 hours)
or other maternal organ dysfunction 1
Preeclampsia can progress to the obstetric emergency of eclampsia,
which refers to the onset of seizures in patients with preeclampsia

Mol BW et al: Pre-eclampsia. Lancet. 387(10022):999-1011, 2016

Diagnosis
Diagnosis of preeclampsia requires evidence of
hypertension (greater than 140 mm Hg systolic or 90 mm Hg
diastolic)
◦ On at least 2 occasions 4 hours apart and either proteinuria (24-
hour urine protein level greater than 300 mg) or
◦ The presence of maternal organ dysfunction that can be shown
with results of blood, renal, and liver function tests 2

2: American College of Obstetricians and Gynecologists et al: Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in
Pregnancy. Obstet Gynecol. 122(5):1122-31, 2013
Diagnostic Criteria

Pengukuran tekanan darah dilakukan pada posisi duduk nyaman,

cuff pada lengan atas sejajar dengan atrium kiri, pasien tenang dan tidak
berbicara selama pemeriksaan. Pengukuran dilakukan setelah 5 menit

Proteinuria is not absolutely required for the diagnosis of preeclampsia

 Preeklampsia ringan
vs berat
◦ ACOG 2013 tidak
merekomendasikan
pembagian ini, karena
morbiditas dan mortalitas
tetap meningkat
signifikan pada
keduanya.
◦ Disarankan:
preeclampsia without
severe features
Maternal Hemodynamic Physiology

Decrease in Vascular
resistance –>
Lower Overall MAP/BP
Evidence Quality
RISK FACTORS OF
PREECLAMPSIA
Risk Factors
Risk Factor (vs. Reference Group) Unadjusted Relative Risk (95% CI)
Nulliparity (vs. multiparity) 2.91 (1.28–6.61)
Maternal age ≥40 (vs. <40), nulliparous women 1.68 (1.23–2.29)
Maternal age ≥40 (vs. <40), multiparous women 1.96 (1.34–2.87)
Previous preeclampsia (vs. none) 7.19 (5.85–8.83)
Twin (vs. singleton pregnancy) 2.93 (2.04–4.21)
Preexisting diabetes (vs. none) 3.56 (2.54–4.99)
Antiphospholipid antibodies 9.72 (4.34–21.75)

Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ. 2005;330:7491.
Signs and Symptoms of Preeclampsia and Eclampsia
Gastrointestinal Features Cerebral Features
Headache
Nausea
Dizziness

Vomiting Tinnitus

Drowsiness
Epigastric pain
Change in respiratory rate

Hematemesis Tachycardia

Fever
Renal Features
Visual Features

Oliguria Diplopia

Scotomata
Anuria
Blurred vision

Hematuria Amaurosis

Hemoglobinuria
Pathophysiology: Vasoactive elements

Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ. 2005;330:7491.
4 stages of PE
 STAGE I: Abnormal placentation STAGE II: Maternal Syndrome

Immunological Endothelial
deviations/abnormalities Dysfunction
(Infection, obesity, Autoimmune,
Chronic inflammation) Defective vascular
remodeling

Reduced
Abnormal placental PREECLAMPSIA
GENETIC Local &
perfusion à ⏈ IUGR
Predisposition placentation Systemic
Ischemia & IUFD
Inflammation
Hypoxia PRETERM LABOR

Vascular Deviations of Apoptosis,

abnormalities Autophagy, necrosis
(Chronic HT, Hx of PE,
Hx of cardio-cerebro-
vascular disease,
Kidney disease,
Diabetes Melitus) Angiogenic Imbalance

v OXIDATIVE STRESS
v Nutritional status
Cerebrovascular consequences
 “Impending Eclampsia””
Symptom Patients (%) With the Symptom

Headache 83
Hyperreflexia 80
Proteinuria 80
Edema 60
Clonus 46
Visual signs 45
Epigastric pain 20
Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ. 2005;330:7491.
Management Principles
1. TERMINATION OF PREGNANCY
2. Anti-Seizure
Prophylaxis/Management
3. Blood Pressure Control
Seizure
Prophylaxis/
Treatment :
MgSO4-7H2O
 Magnesium Toxicity
Effect Serum Level (mEq/L)
Anticonvulsant prophylaxis 4.8–8.4
Loss of deep tendon reflexes 7–10
Respiratory paralysis 10–13
Electrocardiographic changes >15
Cardiac arrest >25
Antihypertensive Agents
Drug Route First Dose Repeat Dosing Interval Maximum Mechanism of Side Effects
Between Doses Dosage Action and
Contraindicatio
ns
Hydralazine IV or IM 5 mg 5–10 mg 20–40 min — Direct dilation Hypotension
of arterioles Headache
Nonreassuring
fetal status

Labetalol IV 10–20 mg 20 mg 20–30 min 300 mg/d α- and β- Contraindicate

40 mg Adrenergic d in asthma,
80 mg blocker heart disease,
congestive
heart failure

Nifedipine PO 10 mg 10–20 mg 30 min after 20 mg/dose Calcium Reflex

first dose channel tachycardia
Every 2–6 h blocker Headache
thereafter
Pharmacology of Antihypertensive Agents

Drug Onset Maximum Duration

Hydralazine 10–20 min 20–40 min 3–8 h
Labetalol 1–2 min 10 min 6–16 h
Nifedipine 5–10 min 10–20 min 4–8 h
Side Effects of Antihypertensive drugs in Pregnancy
Agent Maternal Neonatal
Thiazide Electrolyte depletion, serum uric acid increase, Thrombocytopenia
thrombocytopenia, hemorrhagic pancreatitis

Methyldopa Lethargy, fever, hepatitis, hemolytic anemia,

positive Coombs' test result

Hydralazine Flushing, headache, tachycardia, palpitations,

lupus syndrome
Prazosin Hypotension with first dose; little information on
use in pregnancy
Clonidine Rebound hypertension; little information on use in
pregnancy
Propranolol Increased uterine tone with possible decrease in Depressed respiration
placental perfusion

Labetalol Tremulousness, flushing, headache Depressed respiration

Reserpine Nasal stuffiness, depression, increased sensitivity Nasal congestion, increased respiratory tract
to seizures secretions, cyanosis, anorexia

Nifedipine Orthostatic hypotension, headache, tachycardia None demonstrated in humans

Management Algorithms
Lorie M. Harper MD, MSCI, Alan Tita MD, PhD and S.
Ananth Karumanchi MD. Pregnancy Related Hypertension.
Creasy and Resnik's Maternal-Fetal Medicine: Principles and
Practice, 48, 810-838.e9
Lorie M. Harper MD, MSCI, Alan Tita MD, PhD and S.
Ananth Karumanchi MD. Pregnancy Related Hypertension.
Creasy and Resnik's Maternal-Fetal Medicine: Principles and
Practice, 48, 810-838.e9
Emergency Eclampsia
Management
Long-Term Prognosis
Preeclampsia and Later-Life Cardiovascular Disease
Disorder in Second Disorder in First Pregnancy
a
Pregnancy
Gestational Preeclampsia or Chronic Superimposed Total
Hypertension Eclampsia Hypertension Preeclampsia N = 896
n = 511 n = 151 n = 200 n = 34

Normal 153 (29.9%) 63 (41.7%) 24 (12%) 2 (5.9%) 242 (27%)

Gestational 239 (46.8%) 52 (34.4%) 69 (34.5%) 10 (29.4%) 370 (41.3%)

hypertension

Preeclampsia 25 (4.9%) 17 (11.3%) 6 (3%) 4 (11.8%) 52 (5.8%)

Chronic 82 (16%) 16 (10.6%) 91 (45.5%) 14 (41.2%) 203 (22.7%)

hypertension

Superimposed 12 (2.3%) 3 (2%) 10 (5%) 4 (11.8%) 29 (3.2%)

preeclampsia

All recurrences 358 (70.1%) 88 (58.3%) 176 (88%) 32 (94%) 654 (73%)
REVIEW
Preeklamsia: Tidak lagi semata-mata hanya penyakit kehamilan
Andrea L. Tranquillia, Beatrice Landia, Stefano R. Giannubiloa,*, Baha M. Sibaib

Risk of developing disease after preeclampsia

Relative risk
Hipertensi kronis 2.5 [23]-3.7 [2]
Penyakit kardiovaskular, jika preeklamsia berhubungan dengan IUGR 3.9 [6]
Penyakit jantung iskemik (secara menyeluruh) 2.16 [2]
Penyakit jantung iskemik preeklamsia ringan 2.0 [24]
Penyakit jantung iskemik preeklamsia berat 5.36 [24]
Kematian dari penyakit jantung iskemik 1.38 [26]
Kematian dari penyakit peredaran darah 1.30 [26]
Kematian dari penyakit kardiovaskular; preeklamsia > 34 minggu HR 2.08 [25]
Kematian dari penyakit kardiovaskular; preeklamsia < 34 minggu HR 9.54 [25]
Kematian dini (dalam 25 tahun) 2.71 [20]
Stroke Non-fatal 1.76 [2]
Stroke fatal 2.98 [2]
Preeklamsia stroke > 37 minggu 0.98 [2]
Preeklamsia stroke < 37 minggu 5.98 [2]
Tromboembolisme vena 1.19 [2]
Penyakit ginjal stadium akhir 4.7 [41]
Diabetes mellitus tipe 2 1.40 [8]-3.8 [3]
Hipothiroidisme 1.7 [49]
kanker HR 0.92 [15]-0.86 [26]

Dalam kurung : referensi yang disitasi didalam teks

HR: Hazard ratio

Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 2 (2012) 350-357

Prevention, Prediction, and Early Diagnosis of Obstetric Syndrome

Epidemiological &
Demographic Risk Co-Morbidities Biomarkers
Factors

Comprehensive Risk stratification

INTERVENTION
(Lifestyle, Nutritional, Pharmacologic, Advanced: Genetic, Stem cell?)
PREDIKSI DAN PENCEGAHAN
Berbagai temuan biomarker – belum ada tes dgn
sensitivitas dan spesifitas yang tinggi.
Butuh pemeriksaan yang kompleks.
Identifikasi faktor risiko PE dan mengontrolnya.
 Faktor – faktor Risiko Preeklamsia
Faktor maternal Inheren • Umur < 20 atau 35–40
• Nulliparitas
• Diri/kel. Dg. riw. PE atau peny. Kardiovaskular
• Wanita yg terlahir PJT

Kondisi medis • Obesitas

• Hipertensi Kronik
• Peny Ginjal kronis
• DM (IR, type 1, dan GDM)
• APS
• Peny Jaringan Ikat (SLE dsb)
• Thrombophilia
• Stress

Kehamilan Spesifik • Kehamilan majemuk

• Oocyte donation
• UTI
• Janin dg kelainan
• Mola Hydatidosa
• Hydrops fetalis
• Anomali Structural

Faktor Paternal Paparan dg semen & sperma • Barrier contraception

terbatas • Pertama kali menjadi ayah
• Donor insemination

Suami dg riwayat preeklampsia dengan pasangan terdahulu

Lancet 2001;357:209–15
Pencegahan Primer
Doppler
Cochrane: Doppler utero-plasenta tidak
menunjukkan perbedaan kejadian hipertensi
pada ibu (RR 1,08; 95% CI 0,87 – 1,93)
Melakukan pengambilan data medis secara terperinci untuk mengevaluasi faktor risiko
adalah pilihan satu-satunya dan terbaik sebagai pendekatan untuk mendeteksi
preeklamsia ; dan seharusnya tetap menjadi metode untuk mendeteksi preeklamsia
sampai penelitian dapat membuktikan bahwa aspirin atau intervensi lain dapat
menurunkan insidensi preeklamsia pada wanita yang risiko tinggi berdasarkan tes prediksi
trimester pertama.
Tes prediksi untuk preeklamsia pada saat ini mungkin saja dapat merugikan lebih banyak
wanita daripada mendapatkan keuntungannya dikarenakan angka prediksi positif yang
rendah. Tes ini membutuhkan lebih banyak wanita yang dapat diidentifikasikan sebagai
risiko tinggi dan berpotensi untuk menjalankan pengawasan intensif agar dapat
mendeteksi adanya kasus preeklamsia onset dini.
The American College of Obstetricians and Gynecologists tidak merekomendasikan
skrining untuk memprediksi preeklamsia lebih dari memperoleh data medis yang sesuai
untuk mengevaluasi faktor risiko.
Pencegahan
Istirahat di rumah 4 jam/hari di rekomendasikan untuk
pencegahan primer maupun sekunder preeklampsia
Level evidence I a, Rekomendasi A
Pembatasan garam untuk mencegah preeklampsia
dan komplikasinya tidak direkomendasikan.
Level evidence I a, Rekomendasi A
Pencegahan-sekunder
Pemberian kalsium (1,5 – 2 g kalsium elemental/hari) berhubungan dengan
penurunan hipertensi dalam kehamilan dan preeklampsia terutama pada wanita
dengan asupan rendah kalsium dan risiko tinggi preeklampsia.

Rekomendasi:
Pemberian kalsium dapat diberikan pada wanita yang memiliki risiko tinggi
preeklampsia dan rendah asupan kalsium untuk mencegah terjadinya
preeklampsia.
Level of evidence I a, Rekomendasi A
Rekomendasi
Aspirin dosis 75 mg atau kurang cukup aman diberikan pada kelompok risiko
tinggi untuk menurunkan risiko preeklampsia baik sebagai pencegahan primer
atau sekunder.
Level evidence Ia, Rekomendasi A
. Aspirin dosis rendah sebagai prevensi preeklampsia
sebaiknyabdigunakan sebelum 20 minggu.

Level evidence III, Rekomendasi C

Aspirin
Tidak berdampak terhadap risiko PE atau luaran klinis
Level 2 evidence; Cochrane Library 2008 Issue 1: CD004227
• Vit C (1,000 mg/hari) + vit E (400 IU/ hari)
Tidak menurunkan kejadian PE
level 2 evidence (Obstet Gynecol 2007 Dec;110(6):1311
• Dapat meningkatkan BBLR dan Still Birth
(Lancet 2006 Apr 8;367(9517):1145

Rekomendasi

Pemberian Vitamin C dan E tidak direkomendasikan untuk diberikan

dalam pencegahan preeklampsia.

Level of evidence Ia, Rekomendasi A.

•
7. Make & Design your own CPGs that is
suitable for your Clinic/Hospital
Pedoman Nasional Pelayanan Kedokteran

DIAGNOSIS
DAN TATA LAKSANA

PRE-EKLAMSIA

Perkumpulan Obstetri dan Ginekologi Indonesia

Himpunan Kedokteran Feto Maternal
2016
Take Home Message
1. Proteinuria is NOT A MUST for diagnosis of Preeclampsia
2. Preeclampsia with/without “Severe Features” (XXX Mild Preeclampsia)
3. History of Previous Preeclampsia significantly increase the chances of another preeclampsia
and also long term cardiovascular-metabolic risks
4. The MAIN PRINCIPLE for management is TERMINATION OF PREGNANCY
5. Priority for seizure prophylaxis and Blood Pressure Control
6. Eclampsia: START with Basic/Advanced LIFE SUPPORT
7. PREVENTION: in Hi RISK mothers( history, MAP, Doppler w/wo markers):
1. Calcium 1500 – 2000mg/day
2. VitD3 25-OH target 40-60 ng/mil
3. Aspirin before 16-20 wga
4. Control co-morbidity
 ありがとうございます

9/26/22 49
CASE EXAMPLE
KASUS
Ny. 18 thn, C:
◦ TD: 180/120 mmHg
Dikatakan hamil kehamilan ke 1,
usia kehamilan 8 bulan ◦ FN: 96x/mnt
◦ CR<2
Diantar keluarganya dikatakan DJJ:155x/mnt

mengeluh Nyeri Kepala dan sesak A:

nafas sejak 6 jam ◦ Bebas
Berbicara meracau, posisi duduk B:
◦ Spontan,
◦ FP: 30x/menit

26 September 2022 DIDO.DILMY@GMAIL.COM

 Dx/
Preklamsia Perburukan
Kasus 1 dengan Edema Paru Th??
Akut ◦ Nasal Kanul 4 lt/mnt
PF G1 Hamil 8 Bulan ◦ Semifowler
◦TSB, Janin Tunggal Hidup
Delirium ◦ Nifedipin 20 mg PO
◦Kesan: Obesitas Morbid ◦ (Target: 160/100mmHg)
◦ Pasang kateter urin
◦Jantung: Gallop +
◦ Pasang IV Line: cek H2TL
◦Paru: Ronchi ++/++ (basal ◦ MgSO4 4gr IV Bolus
paru) perlahan
◦Edema tungkai ++++ ◦ Furosemide 40 mg IV
◦Sat O2: 94% ◦ Rujuk/Konsul

26 September 2022 DIDO.DILMY@GMAIL.COM