hipertensi dalam kehamilan€¦ · hipertensi dalam kehamilan clinical findings chronic...
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HIPERTENSI
DALAM
KEHAMILAN
dr Dwirani Amelia, SpOG
Disampaikan dalam Seminar Workshop Update Manajemen Penatalaksanaan
Kegawat Daruratan MaternalDepok, 1 September 2019
Penatalaksanaan
Kegawat Daruratan Maternal
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Jangka Pendek:
HELLP,
CVD
Edema pulmonum,
Eklamsia
Jangka Panjang:
Gagal GinjalKronik,
Peny. KardioVaskular,
DM tipe 2
Anak:
Cerebral Palsy
DM tipe 2
Penyakit Kardio
Vaskular
Obesitas
PCO
Teratozoospermia
Hypertension 2007;49(5):1056-62, J Clin Endocrinol Metab 2006;91(4):1233-8
Preeklamsia: Tidak lagi semata-mata hanya penyakit kehamilan
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Kasus -1
Seorang ibu usia 25 tahun datang ke BPM untukmemeriksakan kehamilannya yang pertama ini. Selamaini periksa hamil 2 kali dikatakan tidak ada kelaianan. Akhir-akhir ini ibu mengeluh beberapa kali sakit kepalatetapi membaik dengan berisitirahat.
Saat diperiksa bidan keadaan umum baik, tekanandarah ibu 170/100 mmHg, nadi 100x/menit, pernafasan20x/menit.
Kehamilannya saat ini 36 minggu, janin tunggal, hidup, presentasi kepala dengan taksiran berat janin 2500 gram, belum inpartu.
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Pertanyaan:
Apakah ibu menderita Pre eklampsia Berat?
Apakah ibu perlu mendapatkan Magnesium Sulfat?
Apakah ibu perlu mendapatkan obat anti hipertensi?
Apakah ada indikasi untuk melakukan terminasi
kehamilan?
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Kasus – 2
Ny. R 41 tahun, pada kehamilannya yang keempat,
akan tetapi merupakan kehamilan pertamanya dengan
suami keduanya ini, datang memeriksakan
kehamilannya. Kehamilan sebelumnya, yang terakhir 11
tahun yang lalu, selalu berjalan aman dan lancar
Tidak ada keluhan berarti yang dirasakannya, selain
perutnya yang bertambah besar dan terasa berat. Saat
diperiksa bidan pada kehamilan 32 minggu, didapatkan
tekanan darah 180/110mmHg.
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Pertanyaan:
Apakah ibu menderita Pre eklampsia Berat?
Apakah ibu perlu mendapatkan Magnesium Sulfat?
Apakah ibu perlu mendapatkan obat anti hipertensi?
Apakah ada indikasi untuk melakukan terminasi
kehamilan?
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History
400BC, Hipocrates: kehamilan dg sakitkepala, bengkak dankejang adalah buruk. Disebabkan olehgangguankeseimbangan cairan.
Akhir 1800-an: teori toxin – ibu hamil dengan sakitkepala dan edema. Diterapi denganmembuang darah = membuang toxin.
tahun 1793, Bossier de Sauvages: membedakanantara eklampsiadengan epilepsi
1797, Demanet: edema sangat berkaitan denganeklampsia
1840, Pierre Rayer: adanya protein dalamurin
1843, John Lever: proteinuria padaeklampsia bukan akibatpenyakit pada ginjal
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1896, ditemukan Scipione Riva-Rocci’s mercury manometer untuk mengukur tekanan darah sejak itu
diketahui bahwa Preeklampsia adalah gangguan pada
tekanan darah
1903: kondisi preeklampsia dimasukkan ke dalam text-
book
1961: preeklampsia-eklampsia merupakan kondisi spesifik
komplikasi obstetri
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Apa yang terjadi?
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Teori plasentasi abnormal
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http://hyper.ahajournals.org/content/51/4/970
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http://hyper.ahajournals.org/content/51/4/970
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http://hyper.ahajournals.org/content/51/4/970
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Diagnosis
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Hipertensi dalam kehamilan
Clinical FindingsChronic
Hypertension
Gestational
HypertensionPreeclampsia
Time of onset
hypertension< 20 weeks
Usually in third
trimester≥ 20 weeks
Degree of
hypertensionMild or severe Mild Mild or severe
Proteinuria Absent Absent Usually present
Serum urate > 5.5
mg/dl (0.33 mmol/L)Rare Absent
Present in almost all
cases
Hemoconcentration Absent Absent Severe disease
Thrombocytopenia Absent Absent Severe disease
Hepatic dysfunction Absent Absent Severe disease
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American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy,
author. Hypertension in pregnancy / developed by the Task Force on Hypertension in Pregnancy.@2013
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American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy,
author. Hypertension in pregnancy / developed by the Task Force on Hypertension in Pregnancy.@2013
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Penegakan diagnosis
Tensimeter
Dipstix protein urin
Pemeriksaan darah tepi rutin
Pemeriksaan darah lain: enzym hepar, fungsi ginjal, asam
urat
Ultrasonografi
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Prediksi?
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Attempts to predict preeclampsia during early pregnancy using
clinical risk factors have revealed modest predictive values, with
detection of 37% of those who developed early-onset preeclampsia
and 29% who developed late-onset preeclampsia, with false-
positive rates of 5% (5). A study, which used an algorithm that
included known risk factors for preeclampsia in nulliparous women,
detected 37% of women who developed preeclampsia with a false-
positive rate of 10% (positive LR = 3.6) (6).
American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy,
author. Hypertension in pregnancy / developed by the Task Force on Hypertension in Pregnancy.@2013
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PN
PK
PO
GI
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PN
PK
PO
GI
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PN
PK
PO
GI
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PN
PK
PO
GI
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Prediksi lain: Doppler
Doppler arteri uterina
✓ Terjadi peningkatan resistensi aliran arteri uterina
✓ Pemeriksaan arteri uterina menggunakan Doppler
lebih baik dalam memprediksi early onset
preeclampsia
✓ Pemeriksaan Doppler arteri uterina memiliki nilai
prediktif yang rendah
✓ Tantangan terbesar pada teknik ini adalah adanya
variasi antar pemeriksa yang tinggi – akurasi prediksi
rendah
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Prediksi lain: Biomarkers
Pemeriksaan Biomarkers
✓ Angiogenesis-related biomarkers (sFLT-1, VEGF, PIGF)
✓ Placental protein-13
✓ Other developing biomarkers
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Asam urat -- positive predictive value of 91.4% for a cutoff
of 5.2 mg/dL
Rasio sFlt-1/PGIF ≥85 -- positive predictive value of 86.0%
and a positive LR of 12.2 for predicting adverse maternal–
fetal outcomes occurring within 2 weeks of presentation
Prediksi outcome
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Prediksi preeklampsia berat/eklampsia
Anamnesis yang adekuat untuk mengevaluasi faktor risiko jauh lebih
bermanfaat untuk prediksi preeklampsia berat/eklampsia
dibandingkan dengan pemeriksaan biomarkers saja atau doppler
saja
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Pencegahan
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0.01 0.1 0.2 0.5 1 2 5 10
Progesterone 0.21 (0.03, 1.77)
Nitric oxide donors and precursors 0.83 (0.49, 1.41)
Diuretics 0.68 (0.45, 1.03)
Antiplatelets 0.81 (0.75, 0.88)
Antihypertensives v none 0.99 (0.84, 1.18)
Marine oils 0.86 (0.59, 1.27)
Magnesium 0.87 (0.57, 1.32)
Garlic 0.78 (0.31, 1.93)
Energy/protein restriction 1.13 (0.59, 2.18)
Isocaloric balanced protein supplementation 1.00 (0.57, 1.75)
Balanced protein/energy intake 1.20 (0.77, 1.89)
Nutritional advice 0.98 (0.42, 1.88)
Calcium 0.48 (0.33, 0.69)
Antioxidants 0.61 (0.50, 0.75)
Altered dietary salt 1.11 (0.46, 2.66)
Rest alone for normal BP 0.05 (0.00, 0.83)
Exercise 0.31 (0.01, 7.09)
Bed rest for high BP 0.98 (0.80, 1.20)
Ambulatory BP
1
4
4
43
19
4
2
1
2
1
3
1
12
7
2
1
2
1
0
128
170
1391
33439
2402
1683
474
100
284
782
512
136
15206
6082
631
32
45
228
0
Relative Risk (95% Confidence Interval)
RR (95% CI)Intervention No of RCTs No of women
Pencegahan Primer pada
Preeklamsia
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Aspirin
Rekomendasi
Aspirin dosis 75 mg atau kurang, cukup aman diberikan
pada kelompok risiko tinggi untuk menurunkan risiko
preeklampsia baik sebagai pencegahan primer atau
sekunder. Diberikan setidaknya di akhir trimester 1.
WHO: Level evidence Ia, Rekomendasi A
ACOG: Quality of Evidence Moderate
Strength of recommendation Qualified
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Pencegahan-Kalsium
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 (WHO)
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Intake Kalsium Harian
Minimum daily calcium intake, Adult WRA (1000−1200 mg/day)
Minimum daily calcium intake, Pregnant Women (1300−1500 mg/day)
Source: Calcium and Prevention of Pre-Eclampsia: Summary of Current Evidence, Monitoring, Evaluation and Research Task Force of the PE/E
working group 2010
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Intake tinggi serat pada awal kehamilan dapat menurunkan risiko PELevel Evidence: 2; Am J Hipertens 2008; 21(8): 903-8
Bawang putih tidak cukup bukti untuk direkomendasikan dlm pencegahan
PECochrane Library 2006, Issue 3, CD 006065
Diet rendah garamTidak berdampak signifikanCochrane Library 2005, Issue 4, CD 005548
Folic acid& other B-vits• Defisiensi vit B12 secara biokimia dapat memicu perubahan biokimis pada
kejadian PE
• Tidak ada bukti salah satu jenis vit B dapat mencegah PE • (Shrama& Mittal, 2006).
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Tidak berdampak terhadap risiko PE atau luaran klinisLevel 2 evidence; Cochrane Library 2008 Issue 1: CD004227
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• Vit C (1,000 mg/hari) + vit E (400 IU/ hari)Tidak menurunkan kejadian PElevel 2 evidence (Obstet Gynecol 2007 Dec;110(6):1311
• Dapat meningkatkan BBLR dan Still Birth(Lancet 2006 Apr 8;367(9517):1145
•
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Life style
Bed rest dan pembatasan aktifitas – tidak berguna untuk mencegah
preeklampsia/eklampsia
Olah raga sedang dan teratur pada wanita tidak hamil akan
memperbaiki profil vaskuler, menurunkan kejadian hipertensi dan
kardiovaskuler
Olah raga sedang juga diduga dapat menstimulasi angiogenesis
plasenta dan memperbaiki disfungsi endotel maternal
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Manajemen PE/E
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HipertensiSistolik > 140 mmHg
Diastolik > 90 mmHg
PrehipertensiSistolik 120 – 139 mmHg
Diastolik 80 – 89 mmHg
NormotensiSistolik 90 – 120 mmHg
Diastolik 60 – 80 mmHg
HypotensiSistolik < 90 mmHg
Diastolik < 60 mmHg
Chobanian AV, Bakris GL, Black HR, et al. (May 2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA 289 (19): 2560–72.
Waspadai
Th/ & Rujuk
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Tatalaksana pada Preeklampsia
Tatalaksana Umum
✓ Ibu hamil dengan preeklampsia harus segera dirujuk ke
Rumah Sakit
Tatalaksana Khusus
✓ Pencegahan dan tatalaksana kejang
✓ Pemberian antihipertensi
✓ Terminasi kehamilan
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Pencegahan dan tatalaksana kejang
Bila terjadi kejang, perhatikan jalan napas, pernapasan
(oksigen), dan sirkulasi (cairan intravena).
MgSO4 diberikan secara intravena kepada ibu dengan
eklampsia (sebagai tatalaksana kejang) dan
preeklampsia berat (sebagai pencegahan kejang).
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Magnesium Sulfat & Kematian Maternal
pada Preeklampsia/Eklampsia
19%
11%
8%
8% 8%
0%
20%
40%
60%
80%
100%
2002 2003 2004 2005 2006
% o
f M
ag
ne
siu
m S
ulfa
te U
se
d
0%
5%
10%
15%
20%
25%
Ca
se
fa
tality
ra
te
MgSO4 use % Case fatality rate
Penggunaan Magnesium Sulfate di Purulia, West Bengal, India, 2002–2006
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MgSO4 efek pada janin
Menurunkan angka kejadian cerebral palsy hingga30%
Kuban KC, Leviton A, Pagano M, Fenton T, Strassfeld R, Wolff M. Maternal toxemia is associated with reduced incidence of germinal matrix hemorrhage in premature babies. J Child Neurol. 1992;7:70–6.
O’Shea TM, Klinepeter KL, Dillard RG. Prenatal events and the risk of cerebral palsy in very low birth weight infants. Am J Epidemiol. 1998;15:362–9.
MgSO4 bersifat neuroprotektor bagi janin
Magpie Trial Follow-Up Study Collaborative Group The Magpie Trial: a randomized trial comparing magnesium sulphate with placebo for pre-eclampsia. Outcome for children at 18 months. BJOG. 2007;114:289–99
Marret S, Marpeau L, Zupan-Simunek V, Eurin D, Lévêque C, Hellot MF, Bénichou J, PREMAG trial group Magnesium sulphate given before very-preterm birth to protect infant brain: the randomized controlled PREMAG trial*. BJOG. 2007;114:310–8.
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PN
PK
PO
GI
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Anti hipertensi
Ibu dengan hipertensi berat selama kehamilan perlu
mendapat terapi antihipertensi.
Pilihan antihipertensi didasarkan terutama pada
pengalaman dokter dan ketersediaan obat.
Ibu yang mendapat terapi antihipertensi di masa
antenatal dianjurkan untuk melanjutkan terapi
antihipertensi hingga persalinan
Terapi antihipertensi dianjurkan untuk hipertensi
pascasalin berat.
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Pilihan anti hipertensi
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PNPK POGI
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Terminasi Kehamilan
Pada ibu dengan eklampsia, bayi harus segera dilahirkan
dalam 12jam sejak terjadinya kejang.
Induksi persalinan dianjurkan bagi ibu dengan
preeklampsia berat dengan janin yang belum viable
atau tidak akan viable dalam 1-2 minggu.
Pada ibu dengan preeklampsia berat, dimana janin
sudah viable namun usia kehamilan belum mencapai 34
minggu, manajemen ekspektan dianjurkan, asalkan tidakterdapat kontraindikasi (lihat algoritma di halaman
berikut). Lakukan pengawasan ketat.
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Pada ibu dengan preeklampsia berat, dimana usia
kehamilan antara 34 dan 37 minggu, manajemen
ekspektan boleh dianjurkan, asalkan tidak terdapat
hipertensi yang tidak terkontrol, disfungsi organ ibu, dan
gawat janin. Lakukan pengawasan ketat.
Pada ibu dengan preeklampsia berat yang
kehamilannya sudah aterm, persalinan dini dianjurkan.
Pada ibu dengan preeklampsia atau hipertensigestasional ringan yang sudah aterm, induksi persalinan
dianjurkan.
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PN
PK
PO
GI
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PN
PK
PO
GI
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PNPK POGI
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Tatalaksana pada Eklampsia
▪ Airway
▪ Breathing
▪ Circulation
▪ Magnesium sulphate
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Penanganan Umum
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ORANG PERTAMA
✓ Quick check :
kesadaran,
hemodinamik/sirkulasi
✓ Mulai dari JAGA JALAN
NAFAS
✓ Koordinator
✓ Tatalaksana awal
ORANG KEDUA
✓ Asisten orang pertama
✓ Tatalaksana awal sesuai
arahan orang pertama
✓ Ambil sampel darah
✓ IV line – MgSO4
✓ Pemberian Nifedipine
✓ Memasang kateter
✓ dokumentasiORANG KETIGA
✓ Sirkuler
✓ Komunikasi
✓ Asisten orang kedua
✓ dokumentasi
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Penanganan Khusus
Cegah Kejang
Kontrol Tekanan Darah
Terminasi Kehamilan
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MgSO4 40% MgSO4 20%
Kalsium Glukonas
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PROGNOSIS : dubia
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for saving my Mom’s life…