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DISEASES OF
PREGNANCY
Irene Maria Elena
Departemen Kebidanan dan Kandungan
FK UKRIDA
HYPERTENSION ???
Is diagnosed when the blood
pressure is at least 140mmHg
systolic or 90mmHg diastolic
PROTEINURIA ???
Is defined as urinary protein of
at least 300mg/24 hours urine
sample, or
At least 1,000mg/random
sample of urine taken 6 hours
apart
Qualitatively, dipstick values of
traces to 1+ signify mild
proteinuria; while 2+ to 4+
signify heavy proteinuria
EDEMA ???
Is such a common finding that
its presence does not validate
the presence of preeclampsia
Criteria Required
Gestational hypertension
PreeclampsiaHypertension and :
Proteinuria
300 mg/24h, or
Protein : creatinine ratio 0.3 or
Dipstick 1+ presistenta
Or
Platelets < 100,000/L
Creatinine > 1.1 mg/dL or doubling of
baselineb
Serum transaminase levelsc twice normal
Headache,
visual
distrubances,
convulsions
---
Thrombocytopenia
Renal insufficiency
Liver involvement
Cerebral symptoms
Pulmonary edema
a
Etiology
1. Placental implantation with abnormal
trophoblastic invasion of uterine vessels
2. Immunological maladaptive tolerance
between maternal, paternal (placental), and
fetal tissues
3. Maternal maladaptation to cardiovascular or
inflammatory changes of normal pregnancy
4. Genetic factors inclyding inherited
predisposing genes and epigenetic influences.
Gestational Hypertension
HPN without proteinuria
occuring after 20 weeks AOG or
postpartum
BP returns to normal 12 weeks
postpartum
Without history of chronic
hypertension and without signs
and symptoms of preeclampsia
Preeclampsia
Hypertension with proteinuria
occurring after 20 weeks AOG
With or without edema :
common finding in pregnancy
Severe Preeclampsia
SBP 160 mmHg or
DBP 110 mmHg
Proteinuria :
4 grams / day
+2 on dipstick
Oliguria : < 400 cc / day
*Decreased Renal Blood Flow and Glomerular
Filtration Rate
Severe Preeclampsia
Intrauterine Growth Restriction
*Decrease uteroplacental blood flow
Hemolysis
*Manifests as increase serum
LDH,
hemoglobinuria, hyperbilirubinemia or the
presence of schistocytes
HELLP Syndrome
Triad of :
Hemolysis
Liver Enzymes elevated
Low Platelet count
Chronic HPN
BP 140/90 mmHg prior to
pregnancy or before 20 weeks
AOG and persists after 12 weeks
postpartum
Multiparity and hypertension in
a previous pregnancy help
support the diagnosis
Chronic HPN
Other causes :
Renal diseases
Interstitial Nephritis
Acute Chronic GN
SLE
Diabetic Glomerulosclerosis
Scleroderma
Polyarteritis Nodosa
Polycystic Kidney Disease
Renovascular Stenosis
Chronic Renal Failure
Renal Transplant
Chronic HPN
Endocrine Diseases :
Cushings Disease
Primary Hyperaldosteronism
Thyrotoxicosis
Pheochromocytoma
Acromegaly
Cardiac Disease :
Coarctation of the Aorta
Eclampsia
Presence of convulsions/seizures
in women with underlying
preeclampsia (hypertension and
proteinuria)
Seizures without preeclampsia :
Look for underlying neurologic or
other Central Nervous System
disorder
Pathophysiology
Underlying abnormality is
generalized vasospasm
Renal blood flow and GFR are
significantly lower in
preeclampsia/eclampsia
Afferent vasoconstriction eventually
leads to damage to the glomerular
membranes proteinuria
Cerebral vascular resistance is
always high in patient with
preeclampsia / eclampsia
Pathology
3 Major Pathologic Lesions :
1. Lack of decidualization of the
myometrial segments of the spiral
arteries
2. Glomerular capillary endotheliosis
3. Hemorrhage and necrosis in many
organs, presumably sec to arteriolar
vasoconstriction
PATHOGENESIS
Laboratory Tests
Hematocrit : increased
hemoconsentration
Proteinuria
Serum uric acid
Hemoglobinuria , increase LDH ,
increase SGPT , decdecrease platelet
count HELLP Syndrome
Laboratory Tests
Maternal serum alpha-protein
* levels > 2 multiples of median
Fibronectin
* inc levels vascular disruption
Hypocalciuria , Calcium : Creatinine
ratio
Antithrombin III levels,atrial
natriuretic peptides,
microalbuminuria
Doppler Velocimetry
Preeclampsia : increased afterload
and diminished blood flow in the
uteroplacental unit
Decrease blood flow : diastolic notch
Findings :
increase Systolic/Diastolic (SD)
ratio
Absence or Reverse End
Diastolic
(ARED) Flow : ominous sign
Doppler Velocimetry
Neilson and Alfirevic , 2002
1. Reduction in perinatal deaths
2. Fewer induction of labor and
admissions to hospital
3. No difference found for fetal
distress in labor
Conclusion : Doppler ultrasound in
high risk pregnancies appears to
improve obstetric outcomes and
help reduce perinatal deaths
Prevention
Low Dose Aspirin
High Dose Calcium
Dosage
Given : 60-80 mg / day
Platelet count serially monitored
Fetal monitoring :
Ductus arteriosus
urine volume
AFV
1. Control of Convulsions
Drug Of Choice : Magnesium Sulfate
(MgSO4)
Loading Dose :
4-6 gm slow IV over 15-20min in
100 ml fluid
AND
10 gm deep IM (5 gm IM into
each buttock)
1. Control of Convulsions
Maintenance :
2 gms /hr controlled IV infusion
or
5 gms deep IM q 4 hours
Mechanism Of Action :
(1) cerebral vasodilator
(2) increase uterine blood flow
(3) reduces levels of plasma endotheline-1
and
inc renal excretion of prostacyclin
(4) central anticonvulsant effect
(5) increase EDRF precursors
mEq/Ll
10
10-12
10-12
10
12
30-35
2. Control of HPN
Emergency parenteral therapy for severe HPN :
(1) Hydralazine : direct vasodilator
* IV boluses of 5- to 10-mg doses at 15- to
20-minute intervals
(2) Labetalol : Non-selective 1 and 1 blocker
* 20 mg initial IV bolus , may give another 40
mg after 10 min if BP response is inadequate
followed by another 40 mg then 80 mg q 10 min
Total dose should not exceed 220 mg
(3) Clonidine IM 75-150 mcg is the next
recommended drug
2. Control of HPN
(3) Nifedipine : 5 or 10 mg orally ,may
be and takes effect within 15-50
minutes ;
Drawback : difficult to control ; May
cause severe hypotension
(4) Na Nitroprusside : seldom used ;
fetal cyanide toxicity
Goal : BP 140 150 / 90 100 mmHg
DRUGS
Prefered agent : Methyldopa
200-500mg BID-QID (max
2g/day)
Second line :
Labetolol 100-400 mg BID-TID
(max 1200mg/day)
Nifedipine PA 10-20mg PO BIDTID (max 180mg/day); XL 2060 mg PO OD (max 120mg/day)
Eclampsia
Mild Preeclampsia
Hospitalization : baseline fetal
monitoring and lab exams
OPD follow up 2x a week : BP
monitoring , fetal surveillance
(NST , BPS , Doppler studies)
Medicantions : Methyldopa , low
dose ASA ,and high dose Ca
Deliver near term as possible
Summary
Delivery is the only definitive cure for
preeclampsia
Mgt of severe preeclampsia is based mainly on :
(1) control of convulsions,(2) control of HPN ,and
(3) best mode and timing of delivery of a viable
fetus
Timing and mode of delivery dictated by : AOG ,
prevailing maternal and fetal conditions , severity
of the disease and adequate NICU facilities
ECLAMPSIA
If MgSO4 is not available, other
options :
Diazepam
A loading dose of 10mg IV over
2 minutes, repeated if
convulsions recurred, followed
by an IV infusion of 40mg in
500ml normal saline for 24
hours
Phenytoin
The dose may be varied
according to the patients weight
Is only remommended for the
prevention of seizures
10mg diazepam IV should be
given
DELIVERY in ECLAMPSIA
antihipertensi
Ibu dengan hipertensi berat selama kehamilan
perlu mendapat terapi antihipertensi
Pilihan antihipertensi didasarkan terutama pada
pengalaman dokter dan ketersediaan obat
Ibu yang mendapatkan terapi antihipertensi
dimasa antenatal dianjurkan untuk melanjutkan
terapi antihipertensi hingga persalinan
Antihipertensi golongan ACE Inhibitor, ARB dan
Klorotiazid dikontraindikasikan pada ibu hamil
Dosis
Keterangan
Nifedipin
Dapat menyebabkan
hipoperfusi pada ibu
dan janin apabila
diberikan sublingual
Nikardipin
5mg/jam, dapat
ditritasi 2,5 mg/jam
tiap 5 menit hingga
max 10 mg/jam
metildopa
Pemeriksaan Penunjang
DPL
ABO dan Rh; uji pencocokan
silang
LDH, SGOT, SGPT
Serum ureum dan kreatinin
PT, APTT, Fibrinogen
USG terutama jika ada gawat
janin dan pertumbuhan janin
terhambat
Pertimbangan Persalianan/Terminasi
Kehamilan
Pada ibu dengan eklampsia, bayi harus
segera dilahirkan dalam 12 jam sejak
terjadinya kejang
Induksi persalinan dianjurkan bagi ibu
dengan PEB dengan janin yang belum viabel
atau tidak akan viabel dalam 1-2 minggu
Pada ibu dengan PEB, dimana janin sudah
viabel namun usia kehamilan belum
mencapai 34 minggu, manajemen ekspektan
dianjurkan, asalkan tidak terdapat
kontraindikasi
HELLP SYNDROME
The Tennesse Classification
(1) mod to severe
thrombocytopenia with platelets
100,000/ml or less
(2) AST 70 IU/L or greater
(3) LDH 600 IU/L or greater or
bilirubin 1.2 mg/dL or greater
THANK YOU
GOD BLESS US