ASKEP KOMPLIKASI KEHAMILAN ; HYPEREMESIS GRAVIDARUM & PENATALAKSANAANNYA

NUR AFI DARTI

HIPEREMESIS GRAVIDARUM
Adalah keluhan mual & muntah pada ibu hamil yang berkelanjutan sehingga menimbulkan gangguan aktifitas sehari-hari Dapat menyebabkan cadangan karbohidrat habis dipakai untuk keperluan energi sehingga pembakaran tubuh beralih pada cadangan lemak dan protein. Multiple gestation, gestational trophoblastic disease, triploidy, trisomy 21 syndrome (Down syndrome), and hydrops fetalis have been associated with an increased incidence of hyperemesis gravidarum

Cont.

Mual dan muntah berlebihan atau tidak terkendali selama masa hamil, yang menyebabkan dehidrasi, ketidakseimbangan elektrolit, atau defisiensi nutrisi dan kehilangan BB

Hasil penelitian :
The condition has been shown to be more common in urban women than in rural women. One study identified increased risk in housewives and decreased risk in "white collar" or professional white women who consumed alcohol before conception, and in women over 35 years of age with a history of infertility

ETIOLOGI dan PATOFISIOLOGI

The etiology of nausea and vomiting of pregnancy remains unknown, but a number of possible causes have been investigated.

Cont.

Gastrointestinal tract dysfunction also has been suggested as a cause of nausea and vomiting of pregnancy. Progesterone was prescribed to resultant nausea and vomiting suggested that delayed gastric motility. Abnormalities of gastric electrical rhythm (gastric dysrhythmias). Suggested that chronic infection with Helicobacter pylori may play a role in hyperemesis gravidarum (61.8 % of pregnant women with hyperemesis were found to be positive for the H. pylori genome, compared with 27.6 % of pregnant women without hyperemesis)

Cont.

Psychologic factors are responsible for nausea and vomiting of pregnancy. Perubahan body image, life style Ambivalen terhadap kehamilan The roles of human chorionic gonadotropin and estrogen are controversial

Manifestasi Klinik
Grade I

Muntah berlangsung terus Makan berkurang BB menurun Kulit dehidrasi, tonus lemah Nyeri daerah epigastrium TD menurun & nadi meningkat Lidah kering Mata tampak cekung

 Grade II - Penderita tampak lebih lemah - Gejala dehidrasi makin tampak, mata cekung, turgor kulit makin kurang, lidah kering dan kotor - TD menurun, nadi meningkat - Mata ikterik - Gejala hemokonsentrasi (+) - Gangguan bab - Gangguan kesadaran - Nafas bau aseton

 Grade III - Muntah berkurang - KU menurun : TD turun, nadi & suhu meningkat, keadaan dehidrasi makin jelas - Gangguan faal hati - Gangguan kesadaran, komplikasi SSP (ensefalopati wernicke), nistagmus, diplopia, perubahan mental

Vomitus berlebihan dan persisten ; Penurunan BB Dehidrasi : ketidakseimbangan elektrolit dan cairan
Hipovolemia ; hipotensi, takikardi, peningkatan hematokrit, dan BUN, penurunan haluaran urine

Penurunan nutrisi ; hipoproteinemia, hipovitaminosis, kekurangan vit C dan B kompleks ; ikterik dan hemoragi

Maternal and Fetal Outcomes

Women with uncomplicated nausea and vomiting of pregnancy ("morning sickness") have been noted to have improved pregnancy outcomes, including fewer miscarriages, preterm deliveries, and stillbirths, as well as fewer instances of fetal low birth weight, growth retardation, and mortality. Increases in maternal adverse effects, including splenic avulsion, esophageal rupture, MalloryWeiss tears, pneumothorax, peripheral neuropathy, and preeclampsia, as well as increases in fetal growth restriction and mortality.

Treatment
The management of nausea and vomiting of pregnancy depends on the severity of the symptoms. Treatment measures range from dietary changes to more aggressive approaches involving antiemetic medications, hospitalization, or even total parenteral nutrition (TPN).

NONPHARMACOLOGIC THERAPY
Dietary Measures.
Initial treatment of women with mild nausea and vomiting of pregnancy (i.e., morning sickness) should include dietary changes :
To eat frequent, small meals To avoid smells and food textures. Solid foods, high in carbohydrates, and low in fat. Salty foods (e.g., salted crackers, potato chips), and Sour and tart liquids (e.g., lemonade) often are tolerated better than water.

Emotional Support.
Support from family members and medical and nursing staff. Consultation is indicated if a pregnant woman is depressed, domestic violence is suspected, or evidence of substance abuse or psychiatric illness exists.

Acupressure.

PHARMACOLOGIC THERAPY
Pharmacologic therapies not known to be associated with an increased risk of birth defects Pyridoxine (Vitamin B6) and Doxylamine.
vitamin B6 a dosage of 25 mg taken orally every eight hours (75 mg per day) or in combination with 25-mg doxylamine (Unisom) tablet 25-mg doxylamine (Unisom) tablet taken at night can be used alone. 10 mg of pyridoxine and 10 mg of doxylamine (a dosage of two tablets at night for mild symptoms and in a dosage of up to four tablets per day for more severe symptoms).

Antiemetics.
Phenothiazines prochlorperazine (Compazine) and chlorpromazine (Thorazine) in a dosage of 25 mg every 12 hours (50 mg per day) or Promethazine (Phenergan) given orally or rectally in a dosage of 25 mg every four hours (150 mg per day). If treatment with prochlorperazine or promethazine is unsuccessful, Trimethobenzamide (Tigan) or ondansetron (Zofran) of intravenous Women with severe nausea and vomiting of pregnancy or hyperemesis gravidarum ; Droperidol (Inapsine) and diphenhydramine (Benadryl) intravenous.

Cont.

Antihistamines and Anticholinergics.

Meclizine (Antivert), dimenhydrinate (Dramamine), and diphenhydramine

Motility Drugs.
Metoclopramide (Reglan) acts by increasing pressure at the lower esophageal sphincter, as well as speeding transit through the stomach.

Corticosteroids.
Methylprednisolone (Medrol), 16 mg three times daily (48 mg per day) followed by tapering over two weeks.

Cont.

Ginger.
Given has been used in teas, preserves, ginger ale, and capsule form. Ginger powder (1 g per day) was more effective than placebo. Ginger root contains thromboxane synthetase inhibitor, which may interfere with testosterone receptor binding in the fetus.

OTHER TREATMENTS
Intravenous Fluids.
Normal saline or lactated Ringer's solution Or Dextrose.

Enteral or Parenteral Nutrition.

for pregnant women who continue to vomit and lose weight despite aggressive treatment, rates of up to 100 mL per hour.

DIAGNOSA KEPERAWATAN
1. Defisit volume cairan b/d kehilangan cairan akibat vomitus, asupan cairan tidak adekuat 2. Perubahan nutrisi ; kurang dari kebutuhan tubuh b/d mual dan muntah menetap 3. Kecemasan b/d dampak hiperemesis terhadap kesejahteraan janin

dx. 1
Hasil yang diharapkan Keseimbangan cairan dan elektrolit kembali kekondisi normal, terbukti dengan turgor kulit normal, membran mukosa lembab, BB stabil, TTV dan hasil periksa lab dalam batas normal Muntah berkurang Asupan cairan adekuat

Cont.

Implementasi; Mengkaji dan mendokumentasi tanda-tanda kehilangan cairan dan elektrolit ; turgor kulit, membran mukosa, TTV dan BJ urine Menimbang BB setiap hari Memantau nilai lab, dan lapor terhadap hasil abnormal Mengkaji dan melaporkan warna, jumlah, frekuensi muntah Mempertahankan pencatatan akurat ; intake -output

Cont.

Memberikan cairan IV dan memantaunya sesuai instruksi Memberikan agen antiemetik sesuai program Mempertahankan status NPO sesuai program Jika masukan peroral dijinkan, ajarkan klien untuk mengkonsumsi cairan perlahan terhadap peningkatan jumlah sesuai toleransi

dx. 2
Hasil yang diharapkan Konsumsi oral mengandung zat gizi adekuat Nausea dan vomiting hilang Klien mampu menjelaskan komponen dari nutrisi yang adekuat dan mengungkapkan keinginan untuk mengikuti diet tersebut Klien toleransi terhadap program diet BB klien meningkat sesuai usia kehamilan

Cont.

Implementasi; Memulai pemberian asupan oral sesuai program dan kemampuan toleransi klien Memberikan sajian makanan menarik dalam jumlah kecil dan disesuaikan dengan pilihan klien Meningkatkan jumlah asupan makanan sesuai toleransi klien Memantau dan mencatat asupan oral klien Konsultasi dengan ahli gizi terkait penyusunan menu sesuai kebutuhan kehamilan meliputi ; jadwal, jumlah, jenis

Cont.

Mendiskusikan pentingnya nutrisi yang adekuat selama masa hamil Memverifikasi pemahaman klien tentang informasi diet Mengkaji kemauan klien untuk mengikuti rencana diet yang diprogramkan dan mendorongnya untuk mengikutinya Memantau BB klien

dx. 3
Hasil yang diharapkan Klien memverbalisasikan perasaannya dan kekhawatirannya tentang kesejahterannya janin

Cont.

Implementasi; Perawat memperlihatkan sikap menerima rasa kecemasan klien Mendorong klien untuk mengungkapkan perasaannya dan rasa khawatirnya Membantu klien mengidentifikasi kekuatan yang dimiliki dan mekanisme koping yang sebelumnya digunakan Memberikan informasi kepada klien tentang resiko potensial terhadap janinnya

Cont.

Mendorong klien untuk mendiskusikan kekhawatirannya/kecemasannya kepada perawat Membantu klien mengidentifikasi sumbersumber dukungan dan menggerakkan individu/kelompok yang dapat memberi klien dukungan berdasarkan pilihan klien sendiri Mengatur supaya klien mendapat konsultasi psikologis atau dari pekerja sosial sesuai kebutuhannya