Hipertensi Dalam Kehamilan(1)
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Transcript of Hipertensi Dalam Kehamilan(1)
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Hypertension in
Pregnancy
Dwi Nurrianadwi _nurri @ yahoo.com
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Hypertension inPregnancy
A common complication of pregnancy
Associated with between 5-8% of pregnanciest has serious repercussions for both fetal andmaternal well being
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Hypertension inPregnancy
!he outcomes depend upon the nature of thehypertension a"ecting the pregnancy# which
can range from mild gestational hypertensionto se$ere preeclampsia with its associatedmultisystemic complications
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Hypertension inPregnancy
!he most important cause of hypertension inpregnancy is pre-eclampsia
t remains a leading cause of maternal andperinatal mortality
t responsible for o$er && &&& maternal
deaths each year worldwide
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Classifcations
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Classifcations
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Diagnosis'(ypertension
' )lood pressure should ideally be measured with
the patient either*' sitting
' supine# in the left lateral position# with a +&o tilt
' the sphygmomanometer at heart le$el
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Diagnosis
' (ypertension' !he diastolic blood pressure , oroto" 5 /50 the
disappearance of sounds1
' !wo diastolic blood pressure recordings o$er 2& mm(gtaen o$er 3 h apart are necessary to e4clude transientrises secondary to stress andor white-coat hypertension
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Hypertension
!he le$el currently accepted as signi6cant is apressure greater than 73&2& mm(g
!he absolute blood pressure le$el pro$ides thebest guide to fetal and maternal prognosis
A diastolic blood pressure of 2& mm(gcorresponds to the point of the cur$e ine4ion
abo$e which perinatal mortality is signi6cantlyincreased
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Diagnosis
9roteinuria
' n pregnancy# protein e4cretion may increase
signi6cantly by up to &.+ gl of protein per 3 h/&.5 g3 h1 which is accepted as normal
' t is recommended that a 3 h measurement ofurinary protein be made
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Preeclampsia
(ypertension of at least 73& 2& mm(g on twoseparate occasions at least 3 h apart arising deno$o in a pre$iously normotensi$e woman after
the &th wee of gestation and accompaniedby signi6cant proteinuria# all resol$ing by :wees postpartum
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Preeclampsia
or more# of the following symptomsbeing present
hypertension
proteinuria
symptoms including headache#photophobia#$isual disturbance# epigastricpain# alteration in the conscious state
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Preeclampsia
Arising of the diastolic blood pressure of75mm(g and the systolic blood pressure ofgreater than +&mm(g abo$e booing
$alues should be regarded as signi6cant ifother features of pre-eclampsia syndromeare present
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Chronic Hypertension
(ypertension present prepregnancy ordiagnosed before the &thwee
!he hypertension is diagnosed duringpregnancy but does not resol$e postpartum
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Gestational
hypertensionA rise in blood pressure in the absence ofproteinuria detected after mid-pregnancy
;ften a de6niti$e diagnosis can only be maderetrospecti$ely
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Etiology o
Preeclampsia<enetic
9redisposition
=aulty interplaybetween in$adingtrophoblast and
decidua
Decreased bloodsupply to feto-placental unit
>elease of circulatingfactor/s1
?ndothelial cell alteration
(ypertension9roteinuria <>
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Pathophysiology !he hematological system
(emodynamics
A mared reduction in circulatingplasma $olume in conunction with a
redistribution of e4tracellular uid9latelets
A reduction in platelet countpredates the clinical signs of thedisease and may be due to animmunologically mediatedconsumption
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Pathophysiology !he hematological system
Boagulation cascade
A di"use $ascular damage inassociation with laying down of 6brin
is suggesti$e of acti$ation ofcoagulation
!he hypercoagulability seen innormal pregnancy is further
increased
>egulatory proteins
anti-thrombin # protein B andprotein C and the le$els of all theproteins are reduced
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Pathophysiology
!he hematological system
=ibrinolytic system
9lasminogen is con$erted to
plasmin# which then acts on6brinogen to form 6brin# 6brindegradation products and D-dimers
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Pathophysiology !he i$er
Bhanges in li$er function arethought to occur secondary to$asoconstriction of the hepatic
$ascular bed !he histological e$ents obser$edinclude periportal 6brin deposition#haemorrhage and hepatocellular
necrosisn se$ere cases of hepaticin$ol$ement# complications such ashepatic rupture or infarction may be
seen
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Pathophysiology
!he idney
!he initial change is that of defecti$etubular function leading to a reduceduric acid clearance and hencehyperuricaemia
!his precedes the impairment ofglomerular 6ltration , a relati$e loss
of intermediate weight proteins suchas albumin and transferrin ,proteinuria
t causes a reduction in plasma
oncotic pressure and thede$elopment of oedema
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Pathophysiology
!he idney
!he characteristic# but notpathognomonic lesion# is glomerularendotheliosis# /swelling of theendothelium and 6brin depositioncausing a reduction in the capillarylumen# which resol$es post partum1
>arely acute renal failure may resultdue to acute tubular or corticalnecrosis leading to maternal death
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Pathophysiology
!he )rain
!he pathophysiology of eclampsia isnot fully elucidated
;ne possible e4planation is thatlocaliEed cerebral $asospasm# andhence reduced perfusion# causesabnormal electrical acti$ity#
therefore triggering an eclamptic 6t
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Pathophysiology
!he )rain
A further theory is that endothelialinury is caused by $ascular o$er
distension due to hypertensiono$ercoming the cerebralautoregulation , cerebral oedemadue to leaage of uid into theinterstitial space
!he main areas a"ected are theoccipital and parietal lobes , $isualdisturbances
!he commonest cause of death seenin eclam sia is intracerebral
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Investigations used todistinguish preeclampsia
Faternal n$estigations =etal n$estigations
(ematological(epatic =unction>enal =unction
rine !ests
)lood pressuremonitoring
B!<ltrasound
Doppler
)iophysical pro6le
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DiagnosingPreeclampsia
Faternal
(aematological*
CeGuential platelet counts are usefulin monitoring se$ere diseaseprogression rather than for initialdiagnosis
n the cases of reduced plateletcounts# clotting studies should beperformed
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DiagnosingPreeclampsia
Faternal
(epatic function
Fonitoring of hepatic in$ol$ementby means of li$er function tests#/especially lactic dehydrogenase#aspartate and alaninetransaminases1# may aid diagnosis
and decisions regarding diseasese$erity
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DiagnosingPreeclampsia
Faternal
>enal function
A rise in serum creatinine andurea suggests diseasedeterioration
Another nonspeci6c measure ofrenal function is serum uric acidle$els
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DiagnosingPreeclampsia
Faternal
rine tests* A mid-stream urine toe4clude urinary tract infection
and a 3 h collection to identifysigni6cant proteinuria shouldfollow initial dipstic
)lood pressure* !his may be
monitored as often as e$ery75min during the acute phase ofse$ere disease
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DiagnosingPreeclampsia
=etal
!he cardiotocograph /B!<1
t must be emphasiEed that the B!<only pro$ides a snapshot $iew offetal health and further monitoringmay be usti6ed when other factorsare considered# such as the presence
of pre-eclampsia or intra-uterinegrowth restriction
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DiagnosingPreeclampsia
=etal
• ltrasonography
• !he use of ultrasound $aries fromsimple measurements such as fetalsiEe# gestation# growth andpresentation to calculation of thebiophysical pro6le and Doppler
studies
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Treatments
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Chronic Hypertension
!he aim of treatment is to reduce maternalcomplications whilst being safe for the fetus
!he drug of choice is methyldopa# although
labetalol is an alternati$e
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Preeclampsia
Antihypertensi$es* hydralaEine# labetalol#methyldopa#nifedipine
Anticoagulants*magnesiumsulphate
Cteroids* de4amethasone
Aspirin
Cupporti$emanagement
Deli$ery
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Decision o Delivery
!he aim of management is to stabilise thepatient and enable appropriate decisions tobe made regarding the timing and mode of
deli$ery
!he route of deli$ery is inuenced by suchfactors as gestation# the presence of other
complications# /such as malpresentation1#and the urgency with which progression todeli$ery must be made
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POST!T!" #O""O$%&P
Bounselling regarding future pregnancies playsan important role in postnatal managementand psychological reco$ery
9atients ha$e a 7&-5% chance of de$elopingpre-eclampsia in subseGuent pregnancies
!he ris is higher if other factors such as anti-phospholipid syndrome are present# anddepends on the gestational age at presentation
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'is( #actors or Preeclampsia
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Prophyla)is againstpreeclampsia
Aspirin inhibits platelet thrombo4ane releasebut does not a"ect the production ofprostacyclin in the endothelial cells
mpro$ing the outcome of se$erepreeclampsia
t should be initiated early in subseGuent
pregnancies# especially in the early onsetpreeclampsia
ow-dose aspirin can reduce the ris ofse$ere recurrent preeclampsia by about 75%
G t ti l
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Gestationalhypertension
!his is not associated with proteinuria
t appears after the &th wee of pregnancy
t will return to normal post-natally
!rue non-proteinuric gestational hypertension isnot associated with an increase in maternal orfetal morbidity
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'eerences *
Duc(ett '!+ ,enny "+ -ar(er P. Hypertension in Pregnancy. Curr O/stet Gynaecol+0112*II* 3%4
Hayman '. Hypertension in Pregnancy. Cur O/stet Gynaecol+ 0114*245 2621
Soydemir #+ ,enny ". Hypertension in Pregnancy. Cur O/stet Gynaecol+ 0117* 275
8296801
!han Hou