R. HARYONO ROESHADI, R. HARYONO ROESHADI, ,,

KLASIFIKASI :KLASIFIKASI :Report on the National High Blood Pressure Education Program Working Group on High Blood Pressure in Report on the National High Blood Pressure Education Program Working Group on High Blood Pressure in g m W g p H gPregnancy (AJOG Vol 183:S1, July 2000)

g m W g p H gPregnancy (AJOG Vol 183:S1, July 2000)

HIPERTENSI GESTASIONAL :

DIDAPATKAN DESAKAN DARAH ≥ 140/90 mmHg → PERTAMA

HIPERTENSI GESTASIONAL :

DIDAPATKAN DESAKAN DARAH ≥ 140/90 mmHg → PERTAMA g

KALINYA PD KEHAMILAN, TDK DISERTA DGN PROTEINURIA

DAN DESAKAN DARAH KEMBALI NORMAL < 12 MGG PASCA

g

KALINYA PD KEHAMILAN, TDK DISERTA DGN PROTEINURIA

DAN DESAKAN DARAH KEMBALI NORMAL < 12 MGG PASCA DAN DESAKAN DARAH KEMBALI NORMAL < 12 MGG PASCA

PERSALINAN

DAN DESAKAN DARAH KEMBALI NORMAL < 12 MGG PASCA

PERSALINAN

PREECLAMSIA :

KRITERIA MINIMUM

PREECLAMSIA :

KRITERIA MINIMUMKRITERIA MINIMUM

DESKAN DARAH ≥ 140/90 mmHg → UMUR KEHAMILAN 20 MGG,

KRITERIA MINIMUM

DESKAN DARAH ≥ 140/90 mmHg → UMUR KEHAMILAN 20 MGG,

DISERTAI PROTEINURIA ≥ 300 mg/24 JAM ATAU DIPSTICK ≥ 1 + DISERTAI PROTEINURIA ≥ 300 mg/24 JAM ATAU DIPSTICK ≥ 1 +

ECLAMSIA

KEJANG2 PADA PREECLAMPSIA DISERTAI KOMA

ECLAMSIA

KEJANG2 PADA PREECLAMPSIA DISERTAI KOMA

HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA

PROTEINURIA ≥ 300 MG/24 JAM PD ♀ HAMIL YG SUDAH

HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA

PROTEINURIA ≥ 300 MG/24 JAM PD ♀ HAMIL YG SUDAH → PROTEINURIA ≥ 300 MG/24 JAM PD ♀ HAMIL YG SUDAH

MENGALAMI HIPERTENSI SEBELUMNYA. PROTEINURIA

→ PROTEINURIA ≥ 300 MG/24 JAM PD ♀ HAMIL YG SUDAH

MENGALAMI HIPERTENSI SEBELUMNYA. PROTEINURIA

TIMBUL SETELAH KEHAMILAN 20 MGGTIMBUL SETELAH KEHAMILAN 20 MGG

HIPERTENSI KRONIK

DITEMUKANNYA DESAKAN DARAH ≥ 140/90 mmHg, SEBELUM

HIPERTENSI KRONIK

DITEMUKANNYA DESAKAN DARAH ≥ 140/90 mmHg, SEBELUM g,

KEHAMILAN ATAU SEBELUM KEHAMILAN 20 MGG DAN TDK

MENGHILANG SETELAH 12 MGG PASCA PERSALINAN

g,

KEHAMILAN ATAU SEBELUM KEHAMILAN 20 MGG DAN TDK

MENGHILANG SETELAH 12 MGG PASCA PERSALINANMENGHILANG SETELAH 12 MGG PASCA PERSALINANMENGHILANG SETELAH 12 MGG PASCA PERSALINAN

NTRODUCT ON NTRODUCT ON INTRODUCTION :

INDUCED BY PREGNANCY

INTRODUCTION :

INDUCED BY PREGNANCY

DISEASE OF THEORIES

CLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUT

DISEASE OF THEORIES

CLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUTCLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUT

ORGAN DYSFUNCTION / FAILURE

CLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUT

ORGAN DYSFUNCTION / FAILURE

THIRD LEADING CAUSE OF MATERNAL MORTALITY

MORTALITY RATE : 150 000 WOMEN A YEAR WORLD

THIRD LEADING CAUSE OF MATERNAL MORTALITY

MORTALITY RATE : 150 000 WOMEN A YEAR WORLD MORTALITY RATE : 150.000 WOMEN A YEAR WORLD

WIDE

MORTALITY RATE : 150.000 WOMEN A YEAR WORLD

WIDE

INCIDENCEINCIDENCEPE/E : 2% PE/E : 2% 9% OF ALL PREGNANT WOMEN 9% OF ALL PREGNANT WOMEN PE/E : 2% PE/E : 2% -- 9% OF ALL PREGNANT WOMEN 9% OF ALL PREGNANT WOMEN

IN SEVERAL HOSPITAL IN INDONESIA IN SEVERAL HOSPITAL IN INDONESIA

YEARYEAR HOSPITALHOSPITAL PERCENTAGE PERCENTAGE AUTHORAUTHOR

IN SEVERAL HOSPITAL IN INDONESIA IN SEVERAL HOSPITAL IN INDONESIA

1993 1993 –– 1997 1997

1996 1996 –– 1997 1997

RSPMRSPM

12 HOSPITALS12 HOSPITALS

5,755,75

0,8 0,8 -- 1414

SIMANJUNTAK J.SIMANJUNTAK J.

TRIBAWONO A.TRIBAWONO A.

1995 1995 –– 19981998

2000 2000 –– 20022002

RS. H.S.RS. H.S.

RSHAM RSHAM –– RSPMRSPM

13,013,0

7,07,0

MEIZIAMEIZIA

GIRSANG. EGIRSANG. E

20022002 RSCM RSCM

,,

9,179,17 PRIYATINIPRIYATINI

ETIOLOGY : NOT FULLY KNOWNETIOLOGY : NOT FULLY KNOWNRISK FACTORS :RISK FACTORS :

NULLI PARITY / TEENAGE PREGNANCYNULLI PARITY / TEENAGE PREGNANCYNULLI PARITY / TEENAGE PREGNANCYNULLI PARITY / TEENAGE PREGNANCY

HISTORY OF PREVIOUS PREGNANCYHISTORY OF PREVIOUS PREGNANCY

FAMILY HISTORY OF PE/EFAMILY HISTORY OF PE/E

MULTIPLE GESTATIONMULTIPLE GESTATION

PREEXISTING HYPERTENSION / RENAL DISEASEPREEXISTING HYPERTENSION / RENAL DISEASE

D.M, ANTI PHOSPOLIPID ANTIBODYD.M, ANTI PHOSPOLIPID ANTIBODY

HYDROPS FETALISHYDROPS FETALIS

HYDATIDIFORM MOLESHYDATIDIFORM MOLESHYDATIDIFORM MOLESHYDATIDIFORM MOLES

•• URYNARY TRACT INFECTIONURYNARY TRACT INFECTION

PATHOGENESE : PATHOGENESE :

CONTROVERSION : THE DISEASE OF THEORIESCONTROVERSION : THE DISEASE OF THEORIES

IMMUNITY, GENETIC INADEQUATE TROPHOB INVASION TOVASC. DISEASE

TROPHOBLAST

INADEQUATE TROPHOB. INVASION TO SPIRAL ARTERY OF PLACENTA

INSUFF PLACENTAINSUFF, PLACENTA→ HYPOXIA IUGR

CIRCULATING FACTOR(S)CIRCULATING FACTOR(S)CYTOKINES LIPID

(IL-6, TNF-α) PEROXIDES

OXYDATIVE STRESS

ENDOTHELIAL DYSFUNCTIONNEUTROPHILACTIVATION

PLATELETACTIVATIONACTIVATION ACTIVATION

ENDOTHELIAL DYSFUNCTION

BLOOD ALTERED VASCULAR PERMEABILITY

SYSTEMIC VASOCONSTRICTION

KIDNEYS

▪ THROMBOCYTOPENIA▪ COAGULAPATHY

PERMEABILITY

▪ PERIPHERAL OEDEMA▪ PULMONARY OEDEMA

VASOCONSTRICTION

▪ HYPERTENSION▪ HYPERURICAEMIA▪ PROTEINURIA▪ RENAL FAILURE

LIVER

▪ ABNORMAL FUNCTION TESTS

CNS / EYES▪ SEIZURES▪ CORTICAL BLINDNESS

RETINAL DETACHMENTTESTS▪ HAEMORRHAGE

▪ RETINAL DETACHMENT & HAEMORRHAGE

CLINICAL CLASSIFICATION:CLINICAL CLASSIFICATION:CLINICAL CLASSIFICATION:CLINICAL CLASSIFICATION:PREECLAMPSIAPREECLAMPSIA -- MILDMILD

-- SEVERESEVERE

PREECLAMPSIAPREECLAMPSIA -- MILDMILD

-- SEVERESEVERE-- SEVERESEVERE

IMPENDING ECLAMPSIAIMPENDING ECLAMPSIA

-- SEVERESEVERE

IMPENDING ECLAMPSIAIMPENDING ECLAMPSIAIMPENDING ECLAMPSIAIMPENDING ECLAMPSIA

ECLAMPSIAECLAMPSIA

IMPENDING ECLAMPSIAIMPENDING ECLAMPSIA

ECLAMPSIAECLAMPSIA

HELLP SYNDROMEHELLP SYNDROMEHELLP SYNDROMEHELLP SYNDROME

MILD PREECLAMPSIA :

• BP ≥ 140/90 mmHg AFTER 20 WEEKS GESTATION

MILD PREECLAMPSIA :

• BP ≥ 140/90 mmHg AFTER 20 WEEKS GESTATION• BP ≥ 140/90 mmHg AFTER 20 WEEKS GESTATION

• PROTEINURIA ≥ 300 mg/ 24 H OR 1+ DIPSTICK

• BP ≥ 140/90 mmHg AFTER 20 WEEKS GESTATION

• PROTEINURIA ≥ 300 mg/ 24 H OR 1+ DIPSTICK

• WITH OR WITHOUT OTHER SYMPTOMS AND SIGN• WITH OR WITHOUT OTHER SYMPTOMS AND SIGN

SEVERE PREECLAMPSIASEVERE PREECLAMPSIA• BP ≥ 160/110 mmHG

• PROTEINURIA 2.0 gr / 24 H OR ≥ 2 + DIPSTICK

• BP ≥ 160/110 mmHG

• PROTEINURIA 2.0 gr / 24 H OR ≥ 2 + DIPSTICK

• HEADACHE, VISUAL OR CEREBRAL DISTURBANCE

• EPIGASTRIC PAIN

• HEADACHE, VISUAL OR CEREBRAL DISTURBANCE

• EPIGASTRIC PAIN

• OLIGURIA : < 400 – 500 CC/ 24 HOURS • HYPER REFLEX, MOTORIC EXCITATION, IMPAIRED • OLIGURIA : < 400 – 500 CC/ 24 HOURS • HYPER REFLEX, MOTORIC EXCITATION, IMPAIRED HYPER REFLEX, MOTORIC EXCITATION, IMPAIRED

CONSIOUSNESS, SUDDEN DETERIORATION • PLATELETS COUNT < 1000 000 / mm3

HYPER REFLEX, MOTORIC EXCITATION, IMPAIRED CONSIOUSNESS, SUDDEN DETERIORATION

• PLATELETS COUNT < 1000 000 / mm3• PLATELETS COUNT < 1000.000 / mm

• BILIRUBIN ≥ 1,2 mg / DL

LDH > 600 IU/L

• PLATELETS COUNT < 1000.000 / mm

• BILIRUBIN ≥ 1,2 mg / DL

LDH > 600 IU/L• LDH > 600 IU/L

• SGOT > 70 mg/DL

• LDH > 600 IU/L

• SGOT > 70 mg/DL

IMPENDING ECLAMPSIAIMPENDING ECLAMPSIA• SEVERE PREECLAMPSIA WITH :

∗ HEADACHE

• SEVERE PREECLAMPSIA WITH :

∗ HEADACHE

∗ NAUSEA AND VOMITING

∗ BLURRED VISION, SCOTOMA, IMPAIRED CONSIOUSNESS,

∗ NAUSEA AND VOMITING

∗ BLURRED VISION, SCOTOMA, IMPAIRED CONSIOUSNESS, , , ,

SUDDEN DETERIORATION

∗ EPIGASTRIC PAIN

, , ,

SUDDEN DETERIORATION

∗ EPIGASTRIC PAIN∗ EPIGASTRIC PAIN∗ EPIGASTRIC PAIN

ECLAMPSIAECLAMPSIAECLAMPSIAECLAMPSIA

•• SEVERE PREECLAMPSIA + CONVULSIONSEVERE PREECLAMPSIA + CONVULSION•• SEVERE PREECLAMPSIA + CONVULSIONSEVERE PREECLAMPSIA + CONVULSION

•• IS THE LEADING CAUSE OF 50.000 MATERNAL MORTALITY IS THE LEADING CAUSE OF 50.000 MATERNAL MORTALITY A YEAR WOLRD WIDEA YEAR WOLRD WIDE

•• IS THE LEADING CAUSE OF 50.000 MATERNAL MORTALITY IS THE LEADING CAUSE OF 50.000 MATERNAL MORTALITY A YEAR WOLRD WIDEA YEAR WOLRD WIDEA YEAR WOLRD WIDEA YEAR WOLRD WIDE

•• 75% OCCURRED ANTEPARTUM AND 25% POST PARTUM75% OCCURRED ANTEPARTUM AND 25% POST PARTUM

A YEAR WOLRD WIDEA YEAR WOLRD WIDE

•• 75% OCCURRED ANTEPARTUM AND 25% POST PARTUM75% OCCURRED ANTEPARTUM AND 25% POST PARTUM

•• 40% OF SEIZURES OCCUR BEFORE HOSPITALIZATION40% OF SEIZURES OCCUR BEFORE HOSPITALIZATION•• 40% OF SEIZURES OCCUR BEFORE HOSPITALIZATION40% OF SEIZURES OCCUR BEFORE HOSPITALIZATION

•• CEREBRAL HAEMORRHAGE, PULMONARY EDEMACEREBRAL HAEMORRHAGE, PULMONARY EDEMA ARE THE ARE THE MOST COMMON COMPLICATIONMOST COMMON COMPLICATION

•• CEREBRAL HAEMORRHAGE, PULMONARY EDEMACEREBRAL HAEMORRHAGE, PULMONARY EDEMA ARE THE ARE THE MOST COMMON COMPLICATIONMOST COMMON COMPLICATION

HELLP SYNDROMEHELLP SYNDROMEHELLP SYNDROMEHELLP SYNDROME•• COMPLICATION OF SEVERE PREECLAMPSIACOMPLICATION OF SEVERE PREECLAMPSIA•• 1010--15% DIRECTLY FROM PREGNANCY15% DIRECTLY FROM PREGNANCY•• COMPLICATION OF SEVERE PREECLAMPSIACOMPLICATION OF SEVERE PREECLAMPSIA•• 1010--15% DIRECTLY FROM PREGNANCY15% DIRECTLY FROM PREGNANCY

MANAGEMENT OF PREECLAMPSIAMANAGEMENT OF PREECLAMPSIA•• ADEQUAT AND PROPER PRENATAL CAREADEQUAT AND PROPER PRENATAL CARE

MANAGEMENT OF PREECLAMPSIAMANAGEMENT OF PREECLAMPSIA•• ADEQUAT AND PROPER PRENATAL CAREADEQUAT AND PROPER PRENATAL CARE•• IDENTIFICATION OF WOMEN AT HIGH RISKIDENTIFICATION OF WOMEN AT HIGH RISK•• EARLY DETECTION BY THE RECOGNATION OF CLINICAL EARLY DETECTION BY THE RECOGNATION OF CLINICAL •• IDENTIFICATION OF WOMEN AT HIGH RISKIDENTIFICATION OF WOMEN AT HIGH RISK•• EARLY DETECTION BY THE RECOGNATION OF CLINICAL EARLY DETECTION BY THE RECOGNATION OF CLINICAL

SIGNS AND SYMPTOMS SIGNS AND SYMPTOMS •• THE PROGRESSION OF CONDITION TO SEVERE STATETHE PROGRESSION OF CONDITION TO SEVERE STATE

SIGNS AND SYMPTOMS SIGNS AND SYMPTOMS •• THE PROGRESSION OF CONDITION TO SEVERE STATETHE PROGRESSION OF CONDITION TO SEVERE STATETHE PROGRESSION OF CONDITION TO SEVERE STATETHE PROGRESSION OF CONDITION TO SEVERE STATETHE PROGRESSION OF CONDITION TO SEVERE STATETHE PROGRESSION OF CONDITION TO SEVERE STATE

•• MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY

•• MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY FAVOURABLEFAVOURABLEFAVOURABLEFAVOURABLE

•• MATERNAL AND PERINATAL OUTCOMES DEPEND ON :MATERNAL AND PERINATAL OUTCOMES DEPEND ON :∗∗ GESTATIONAL AGE AT TIME OF DISEASE ONSETGESTATIONAL AGE AT TIME OF DISEASE ONSET

•• MATERNAL AND PERINATAL OUTCOMES DEPEND ON :MATERNAL AND PERINATAL OUTCOMES DEPEND ON :∗∗ GESTATIONAL AGE AT TIME OF DISEASE ONSETGESTATIONAL AGE AT TIME OF DISEASE ONSETGESTATIONAL AGE AT TIME OF DISEASE ONSETGESTATIONAL AGE AT TIME OF DISEASE ONSET∗∗ SEVERITY OF DISEASESEVERITY OF DISEASE∗∗ QUAITY OF MANAGEMENTQUAITY OF MANAGEMENT

GESTATIONAL AGE AT TIME OF DISEASE ONSETGESTATIONAL AGE AT TIME OF DISEASE ONSET∗∗ SEVERITY OF DISEASESEVERITY OF DISEASE∗∗ QUAITY OF MANAGEMENTQUAITY OF MANAGEMENT∗∗ QUAITY OF MANAGEMENTQUAITY OF MANAGEMENT∗∗ PRESENCE OR ABSENCE OF PREPRESENCE OR ABSENCE OF PRE--EXISTING MEDICAL EXISTING MEDICAL

DISORDERSDISORDERS

∗∗ QUAITY OF MANAGEMENTQUAITY OF MANAGEMENT∗∗ PRESENCE OR ABSENCE OF PREPRESENCE OR ABSENCE OF PRE--EXISTING MEDICAL EXISTING MEDICAL

DISORDERSDISORDERSDISORDERSDISORDERSDISORDERSDISORDERS

MILD MILD PREECLAMPSIAPREECLAMPSIAMILD MILD PREECLAMPSIAPREECLAMPSIAMILD MILD –– PREECLAMPSIAPREECLAMPSIA•• AMBULATORY CAREAMBULATORY CARE

MILD MILD –– PREECLAMPSIAPREECLAMPSIA•• AMBULATORY CAREAMBULATORY CARE

∗∗ BED REST : NOT NECESSARILYBED REST : NOT NECESSARILY∗∗ REGULAR DIET, NO SALT RESTRICTIONREGULAR DIET, NO SALT RESTRICTION∗∗ BED REST : NOT NECESSARILYBED REST : NOT NECESSARILY∗∗ REGULAR DIET, NO SALT RESTRICTIONREGULAR DIET, NO SALT RESTRICTION∗∗ PRENATAL VITAMINPRENATAL VITAMIN∗∗ NO OTHER MEDICATION : ANTI HYPERTENSIVE, NO OTHER MEDICATION : ANTI HYPERTENSIVE, ∗∗ PRENATAL VITAMINPRENATAL VITAMIN∗∗ NO OTHER MEDICATION : ANTI HYPERTENSIVE, NO OTHER MEDICATION : ANTI HYPERTENSIVE,

SEDATIVE, DIURETICSSEDATIVE, DIURETICS∗∗ ANTENAL VISIT : EVERY WEEKANTENAL VISIT : EVERY WEEK

SEDATIVE, DIURETICSSEDATIVE, DIURETICS∗∗ ANTENAL VISIT : EVERY WEEKANTENAL VISIT : EVERY WEEK

HOSPITAL CAREHOSPITAL CAREHOSPITAL CAREHOSPITAL CAREHOSPITAL CAREHOSPITAL CARE•• PERSISTENT HYPERTENSION MORE THAN 2 WEEKSPERSISTENT HYPERTENSION MORE THAN 2 WEEKS

HOSPITAL CAREHOSPITAL CARE•• PERSISTENT HYPERTENSION MORE THAN 2 WEEKSPERSISTENT HYPERTENSION MORE THAN 2 WEEKS

•• PERSISTENT PROTENURIA MORE THAN 2 WEEKSPERSISTENT PROTENURIA MORE THAN 2 WEEKS

•• ABNORMAL LABORATORY TESTABNORMAL LABORATORY TEST

•• PERSISTENT PROTENURIA MORE THAN 2 WEEKSPERSISTENT PROTENURIA MORE THAN 2 WEEKS

•• ABNORMAL LABORATORY TESTABNORMAL LABORATORY TEST

•• ABNORMAL FETAL GROWTHABNORMAL FETAL GROWTH

ONE OR MORE SIGN AND SYMPTOM SEVERE PEONE OR MORE SIGN AND SYMPTOM SEVERE PE

•• ABNORMAL FETAL GROWTHABNORMAL FETAL GROWTH

ONE OR MORE SIGN AND SYMPTOM SEVERE PEONE OR MORE SIGN AND SYMPTOM SEVERE PE•• ONE OR MORE SIGN AND SYMPTOM SEVERE PEONE OR MORE SIGN AND SYMPTOM SEVERE PE•• ONE OR MORE SIGN AND SYMPTOM SEVERE PEONE OR MORE SIGN AND SYMPTOM SEVERE PE

•• OBSTETRIC MANAGEMENTOBSTETRIC MANAGEMENT▪▪ GESTATIONAL AGE < 37 WEEKSGESTATIONAL AGE < 37 WEEKS

•• OBSTETRIC MANAGEMENTOBSTETRIC MANAGEMENT▪▪ GESTATIONAL AGE < 37 WEEKSGESTATIONAL AGE < 37 WEEKSGESTATIONAL AGE < 37 WEEKSGESTATIONAL AGE < 37 WEEKS

~~ SIGN AND SYMPTOM ARE NOT WORSENED SIGN AND SYMPTOM ARE NOT WORSENED →→

MAINTAIN UNTIL TERMMAINTAIN UNTIL TERM

GESTATIONAL AGE < 37 WEEKSGESTATIONAL AGE < 37 WEEKS

~~ SIGN AND SYMPTOM ARE NOT WORSENED SIGN AND SYMPTOM ARE NOT WORSENED →→

MAINTAIN UNTIL TERMMAINTAIN UNTIL TERMMAINTAIN UNTIL TERMMAINTAIN UNTIL TERMMAINTAIN UNTIL TERMMAINTAIN UNTIL TERM

▪▪ GESTATIONAL AGE > 37 WEEKSGESTATIONAL AGE > 37 WEEKS

~~ WAIT UNTIL THE ONSET OF LABORWAIT UNTIL THE ONSET OF LABOR

▪▪ GESTATIONAL AGE > 37 WEEKSGESTATIONAL AGE > 37 WEEKS

~~ WAIT UNTIL THE ONSET OF LABORWAIT UNTIL THE ONSET OF LABOR

~~ CERVIX IS FAVORABLE, INDUCTION OF LABORCERVIX IS FAVORABLE, INDUCTION OF LABOR~~ CERVIX IS FAVORABLE, INDUCTION OF LABORCERVIX IS FAVORABLE, INDUCTION OF LABOR

SEVERE PREECLAMPSIASEVERE PREECLAMPSIA•• MEDICAL TREATMENTMEDICAL TREATMENT

SEVERE PREECLAMPSIASEVERE PREECLAMPSIA•• MEDICAL TREATMENTMEDICAL TREATMENT•• MEDICAL TREATMENTMEDICAL TREATMENT

•• OBSTETRIC MANAGEMENT :OBSTETRIC MANAGEMENT :

•• MEDICAL TREATMENTMEDICAL TREATMENT

•• OBSTETRIC MANAGEMENT :OBSTETRIC MANAGEMENT :•• OBSTETRIC MANAGEMENT :OBSTETRIC MANAGEMENT :▪▪ CONSERVATIVE : CONSERVATIVE : -- PREGNANCY PREGNANCY ≤≤ 37 WEEKS37 WEEKS

•• OBSTETRIC MANAGEMENT :OBSTETRIC MANAGEMENT :▪▪ CONSERVATIVE : CONSERVATIVE : -- PREGNANCY PREGNANCY ≤≤ 37 WEEKS37 WEEKS

▪▪ ACTIVEACTIVE : : -- PREGNANCY PREGNANCY ≥≥ 37 WEEKS37 WEEKS-- FETAL INDICATIONFETAL INDICATION

▪▪ ACTIVEACTIVE : : -- PREGNANCY PREGNANCY ≥≥ 37 WEEKS37 WEEKS-- FETAL INDICATIONFETAL INDICATIONFETAL INDICATIONFETAL INDICATION-- MATERNAL INDICATIONMATERNAL INDICATION

FETAL INDICATIONFETAL INDICATION-- MATERNAL INDICATIONMATERNAL INDICATION

MEDICAL TREATMENT :MEDICAL TREATMENT :•• HOSPITALIZEHOSPITALIZE

MEDICAL TREATMENT :MEDICAL TREATMENT :•• HOSPITALIZEHOSPITALIZE•• HOSPITALIZEHOSPITALIZE•• TOTAL BED RESTTOTAL BED REST•• FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.

•• HOSPITALIZEHOSPITALIZE•• TOTAL BED RESTTOTAL BED REST•• FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.,,•• Mg SOMg SO4 4 IVIV•• ANTI HYPERTENSION :ANTI HYPERTENSION :

,,•• Mg SOMg SO4 4 IVIV•• ANTI HYPERTENSION :ANTI HYPERTENSION :

∗∗ HYDRALAZINHYDRALAZIN∗∗ LABETALOLLABETALOL

NIFEDIPINENIFEDIPINE 1010 20 / ORALLY EVERY ½20 / ORALLY EVERY ½ 1 H1 H

∗∗ HYDRALAZINHYDRALAZIN∗∗ LABETALOLLABETALOL

NIFEDIPINENIFEDIPINE 1010 20 / ORALLY EVERY ½20 / ORALLY EVERY ½ 1 H1 H∗∗ NIFEDIPINE NIFEDIPINE :: 10 10 –– 20 mg / ORALLY EVERY ½ 20 mg / ORALLY EVERY ½ -- 1 H,1 H,MAX : 120 mg / 24 HoursMAX : 120 mg / 24 Hours

•• DIURETICDIURETIC : NOT RECOMMENDED: NOT RECOMMENDED

∗∗ NIFEDIPINE NIFEDIPINE :: 10 10 –– 20 mg / ORALLY EVERY ½ 20 mg / ORALLY EVERY ½ -- 1 H,1 H,MAX : 120 mg / 24 HoursMAX : 120 mg / 24 Hours

•• DIURETICDIURETIC : NOT RECOMMENDED: NOT RECOMMENDED•• DIURETIC DIURETIC : NOT RECOMMENDED: NOT RECOMMENDED•• ANTI OXYDANT : NANTI OXYDANT : N--ACETYL CYSTEINACETYL CYSTEIN•• CORTICOSTEROID + LUNG MATURITYCORTICOSTEROID + LUNG MATURITY ≤≤ 34 WEEKS34 WEEKS

•• DIURETIC DIURETIC : NOT RECOMMENDED: NOT RECOMMENDED•• ANTI OXYDANT : NANTI OXYDANT : N--ACETYL CYSTEINACETYL CYSTEIN•• CORTICOSTEROID + LUNG MATURITYCORTICOSTEROID + LUNG MATURITY ≤≤ 34 WEEKS34 WEEKSCORTICOSTEROID LUNG MATURITY CORTICOSTEROID LUNG MATURITY ≤≤ 34 WEEKS34 WEEKSCORTICOSTEROID LUNG MATURITY CORTICOSTEROID LUNG MATURITY ≤≤ 34 WEEKS34 WEEKS

OBSTETRIC MANAGEMENTOBSTETRIC MANAGEMENTOBSTETRIC MANAGEMENTOBSTETRIC MANAGEMENT•• CONSERVATIVE MANAGEMENT:CONSERVATIVE MANAGEMENT:

∗∗ GOAL GOAL : : TO IMPROVE INFANT OUTCOME TO IMPROVE INFANT OUTCOME

•• CONSERVATIVE MANAGEMENT:CONSERVATIVE MANAGEMENT:

∗∗ GOAL GOAL : : TO IMPROVE INFANT OUTCOME TO IMPROVE INFANT OUTCOME ∗∗ GOAL GOAL : : TO IMPROVE INFANT OUTCOME, TO IMPROVE INFANT OUTCOME, WITHOUT COMPROMISING THE MOTHERWITHOUT COMPROMISING THE MOTHER

PREGNANCY PREGNANCY ≤≤ 37 WEEKS, IMPENDING ECLAMPSIA (37 WEEKS, IMPENDING ECLAMPSIA (--))

∗∗ GOAL GOAL : : TO IMPROVE INFANT OUTCOME, TO IMPROVE INFANT OUTCOME, WITHOUT COMPROMISING THE MOTHERWITHOUT COMPROMISING THE MOTHER

PREGNANCY PREGNANCY ≤≤ 37 WEEKS, IMPENDING ECLAMPSIA (37 WEEKS, IMPENDING ECLAMPSIA (--))PREGNANCY PREGNANCY ≤≤ 37 WEEKS, IMPENDING ECLAMPSIA (37 WEEKS, IMPENDING ECLAMPSIA ( ))

•• ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCYACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY

PREGNANCY PREGNANCY ≤≤ 37 WEEKS, IMPENDING ECLAMPSIA (37 WEEKS, IMPENDING ECLAMPSIA ( ))

•• ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCYACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY•• ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCYACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY

∗∗ INDICATIONINDICATION

•• ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCYACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY

∗∗ INDICATIONINDICATION

FETAL FETAL : : -- PREGNANCY PREGNANCY ≥≥ 37 WEEKS37 WEEKS

-- IUGR AND ABNORMAL IUGR AND ABNORMAL BIOPHYSICAL PROFILEBIOPHYSICAL PROFILE

FETAL FETAL : : -- PREGNANCY PREGNANCY ≥≥ 37 WEEKS37 WEEKS

-- IUGR AND ABNORMAL IUGR AND ABNORMAL BIOPHYSICAL PROFILEBIOPHYSICAL PROFILEBIOPHYSICAL PROFILEBIOPHYSICAL PROFILEBIOPHYSICAL PROFILEBIOPHYSICAL PROFILE

MATERNALMATERNAL : : -- PERSISTENT HYPERTENTIONPERSISTENT HYPERTENTIONMATERNALMATERNAL : : -- PERSISTENT HYPERTENTIONPERSISTENT HYPERTENTION-- IMPENDING ECLAMPSIAIMPENDING ECLAMPSIA-- COMPLICATION : HELLP SYNDROME, COMPLICATION : HELLP SYNDROME, -- IMPENDING ECLAMPSIAIMPENDING ECLAMPSIA-- COMPLICATION : HELLP SYNDROME, COMPLICATION : HELLP SYNDROME,

ABRUPTIO PLAC., OLIGURIAABRUPTIO PLAC., OLIGURIAABRUPTIO PLAC., OLIGURIAABRUPTIO PLAC., OLIGURIA

ROUTE OF DELIVERY :ROUTE OF DELIVERY :▪▪ VAGINAL DELIVERY IS PREFERABLE THAN CS.VAGINAL DELIVERY IS PREFERABLE THAN CS.ROUTE OF DELIVERY :ROUTE OF DELIVERY :▪▪ VAGINAL DELIVERY IS PREFERABLE THAN CS.VAGINAL DELIVERY IS PREFERABLE THAN CS.

ECLAMPSIA : PE + CONVULSIONECLAMPSIA : PE + CONVULSIONECLAMPSIA : PE + CONVULSIONECLAMPSIA : PE + CONVULSIONBASIC MANAGEMENT :BASIC MANAGEMENT :

CONTROL THE CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)AIRWAY, BREATHING, CIRCULATION (ABC)BASIC MANAGEMENT :BASIC MANAGEMENT :

CONTROL THE CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)AIRWAY, BREATHING, CIRCULATION (ABC)STABILIZE THE MOTHERSTABILIZE THE MOTHERCONTROL CONVULSIONCONTROL CONVULSIONSTABILIZE THE MOTHERSTABILIZE THE MOTHERCONTROL CONVULSIONCONTROL CONVULSIONCORRECT MATERNAL HYPOXEMIA / ACIDEMIACORRECT MATERNAL HYPOXEMIA / ACIDEMIAPREVENT COMPLICATION : HYPERTENSION CRISIS PREVENT COMPLICATION : HYPERTENSION CRISIS CORRECT MATERNAL HYPOXEMIA / ACIDEMIACORRECT MATERNAL HYPOXEMIA / ACIDEMIAPREVENT COMPLICATION : HYPERTENSION CRISIS PREVENT COMPLICATION : HYPERTENSION CRISIS TERMINATE PREGNANCYTERMINATE PREGNANCYTERMINATE PREGNANCYTERMINATE PREGNANCY

MEDICAL TREATMENT :MEDICAL TREATMENT :SAME AS SEVERE PREECLAMPSIASAME AS SEVERE PREECLAMPSIA

MEDICAL TREATMENT :MEDICAL TREATMENT :SAME AS SEVERE PREECLAMPSIASAME AS SEVERE PREECLAMPSIASAME AS SEVERE PREECLAMPSIASAME AS SEVERE PREECLAMPSIASAME AS SEVERE PREECLAMPSIASAME AS SEVERE PREECLAMPSIA

COMPLICATION : P.E AND ECLAMPSIACOMPLICATION : P.E AND ECLAMPSIA

MOTHERMOTHER BABYBABY

HELLP SYNDROMEHELLP SYNDROME

LIVER RUPTUREDLIVER RUPTURED

IUGR IUGR

PREMATURE LABORPREMATURE LABORLIVER RUPTUREDLIVER RUPTURED

PULMONARY EDEMAPULMONARY EDEMA

PREMATURE LABORPREMATURE LABOR

INTRA CRANIAL HAEMORRHAGEINTRA CRANIAL HAEMORRHAGE

RENAL FAILURERENAL FAILURE

ABRUPTIO PLACENTAEABRUPTIO PLACENTAE

CEREBRAL PALSYCEREBRAL PALSY

PNEUMO THORAXPNEUMO THORAX

DICDIC

CEREBROL VASCULER ACCIDENT CEREBROL VASCULER ACCIDENT

IIUFDUFD

MATERNAL DEATHMATERNAL DEATH

HIPERTENSI KRONIK DALAM KEHAMILANHIPERTENSI KRONIK DALAM KEHAMILANHIPERTENSI KRONIK DALAM KEHAMILANHIPERTENSI KRONIK DALAM KEHAMILANDEFINISI KLINIK:DEFINISI KLINIK:

HIPERTENSI YG DIDAPAT SEBELUM KEHAMILAN ATAU HIPERTENSI YG DIDAPAT SEBELUM KEHAMILAN ATAU DEFINISI KLINIK:DEFINISI KLINIK:

HIPERTENSI YG DIDAPAT SEBELUM KEHAMILAN ATAU HIPERTENSI YG DIDAPAT SEBELUM KEHAMILAN ATAU SEBELUM UMUR KEHAMILAN 20 MGG DAN HIPERTENSI TDK SEBELUM UMUR KEHAMILAN 20 MGG DAN HIPERTENSI TDK MENGHILANG SETELAH 12 MGG PASCA PERSALINANMENGHILANG SETELAH 12 MGG PASCA PERSALINANSEBELUM UMUR KEHAMILAN 20 MGG DAN HIPERTENSI TDK SEBELUM UMUR KEHAMILAN 20 MGG DAN HIPERTENSI TDK MENGHILANG SETELAH 12 MGG PASCA PERSALINANMENGHILANG SETELAH 12 MGG PASCA PERSALINAN

ETIOLOGI HIPERTENSI KRONIK DALAM KEHAMILANETIOLOGI HIPERTENSI KRONIK DALAM KEHAMILANETIOLOGI HIPERTENSI KRONIK DALAM KEHAMILANETIOLOGI HIPERTENSI KRONIK DALAM KEHAMILANPRIMER (IDIOPATIK) : 90 %PRIMER (IDIOPATIK) : 90 %SEKUNDER : 10 %, YG BERHUBUNGAN DGN PENY. SEKUNDER : 10 %, YG BERHUBUNGAN DGN PENY. PRIMER (IDIOPATIK) : 90 %PRIMER (IDIOPATIK) : 90 %SEKUNDER : 10 %, YG BERHUBUNGAN DGN PENY. SEKUNDER : 10 %, YG BERHUBUNGAN DGN PENY. ,,GINJAL, PENY. ENDOKRIN (dm), PENY. HIPERTENSI DAN GINJAL, PENY. ENDOKRIN (dm), PENY. HIPERTENSI DAN VASKULERVASKULER

,,GINJAL, PENY. ENDOKRIN (dm), PENY. HIPERTENSI DAN GINJAL, PENY. ENDOKRIN (dm), PENY. HIPERTENSI DAN VASKULERVASKULERVASKULERVASKULERVASKULERVASKULER

DIAGNOSISDIAGNOSISBERDASARKAN RISIKO :BERDASARKAN RISIKO :

DIAGNOSISDIAGNOSISBERDASARKAN RISIKO :BERDASARKAN RISIKO :-- RISIKO RENDAH : RISIKO RENDAH : HIPERTENSI RINGAN TANPA DISERTAI HIPERTENSI RINGAN TANPA DISERTAI

KERUSAKAN ORGANKERUSAKAN ORGAN-- RISIKO RENDAH : RISIKO RENDAH : HIPERTENSI RINGAN TANPA DISERTAI HIPERTENSI RINGAN TANPA DISERTAI

KERUSAKAN ORGANKERUSAKAN ORGAN-- RISIKO TINGGI RISIKO TINGGI :: HIPERTENSI BERAT / HIPERTENSI HIPERTENSI BERAT / HIPERTENSI

RINGAN DISERTAI PERUBAHAN RINGAN DISERTAI PERUBAHAN -- RISIKO TINGGI RISIKO TINGGI :: HIPERTENSI BERAT / HIPERTENSI HIPERTENSI BERAT / HIPERTENSI

RINGAN DISERTAI PERUBAHAN RINGAN DISERTAI PERUBAHAN PATOLOGIS, KLINIS MAUPUN BIOLOGI PATOLOGIS, KLINIS MAUPUN BIOLOGI →→ KERUSAKAN ORGANKERUSAKAN ORGANPATOLOGIS, KLINIS MAUPUN BIOLOGI PATOLOGIS, KLINIS MAUPUN BIOLOGI →→ KERUSAKAN ORGANKERUSAKAN ORGAN

KRITERIA RISIKO TINGGI PD HIPERTENSI KRONIK DLM KRITERIA RISIKO TINGGI PD HIPERTENSI KRONIK DLM KEHAMILANKEHAMILANKRITERIA RISIKO TINGGI PD HIPERTENSI KRONIK DLM KRITERIA RISIKO TINGGI PD HIPERTENSI KRONIK DLM KEHAMILANKEHAMILANKEHAMILANKEHAMILAN-- HIPERTENSI BERAT : HIPERTENSI BERAT :

⇒⇒ DESAKAN SISTOLIK ≥ 160 mmHg DANDESAKAN SISTOLIK ≥ 160 mmHg DAN

KEHAMILANKEHAMILAN-- HIPERTENSI BERAT : HIPERTENSI BERAT :

⇒⇒ DESAKAN SISTOLIK ≥ 160 mmHg DANDESAKAN SISTOLIK ≥ 160 mmHg DAN⇒⇒ DESAKAN DIASTOLIK ≥ 110 mmHg, SEBELUM 20 MGG DESAKAN DIASTOLIK ≥ 110 mmHg, SEBELUM 20 MGG

KEHAMILANKEHAMILAN⇒⇒ DESAKAN DIASTOLIK ≥ 110 mmHg, SEBELUM 20 MGG DESAKAN DIASTOLIK ≥ 110 mmHg, SEBELUM 20 MGG

KEHAMILANKEHAMILAN

-- HIPERTENSI RINGAN < 20 MGG KEHAMILAN DGN :HIPERTENSI RINGAN < 20 MGG KEHAMILAN DGN :PERNAH PREECLAMPSIAPERNAH PREECLAMPSIA

-- HIPERTENSI RINGAN < 20 MGG KEHAMILAN DGN :HIPERTENSI RINGAN < 20 MGG KEHAMILAN DGN :PERNAH PREECLAMPSIAPERNAH PREECLAMPSIA⇒⇒ PERNAH PREECLAMPSIAPERNAH PREECLAMPSIA

⇒⇒ UMUR IBU > 40 THNUMUR IBU > 40 THN⇒⇒ PERNAH PREECLAMPSIAPERNAH PREECLAMPSIA⇒⇒ UMUR IBU > 40 THNUMUR IBU > 40 THN⇒⇒ HIPERTENSI ≥ 4 THNHIPERTENSI ≥ 4 THN⇒⇒ ADANYA KELAINAN GINJALADANYA KELAINAN GINJAL⇒⇒ HIPERTENSI ≥ 4 THNHIPERTENSI ≥ 4 THN⇒⇒ ADANYA KELAINAN GINJALADANYA KELAINAN GINJAL⇒⇒ ADANYA DIABETES MELLITUS (KLAS B ADANYA DIABETES MELLITUS (KLAS B –– KLAS F)KLAS F)⇒⇒ KARDIOMIOPATIKARDIOMIOPATI⇒⇒ ADANYA DIABETES MELLITUS (KLAS B ADANYA DIABETES MELLITUS (KLAS B –– KLAS F)KLAS F)⇒⇒ KARDIOMIOPATIKARDIOMIOPATI⇒⇒ MEMINUMI OBAT ANTI HIPERTENSI SEBELUM HAMILMEMINUMI OBAT ANTI HIPERTENSI SEBELUM HAMIL⇒⇒ MEMINUMI OBAT ANTI HIPERTENSI SEBELUM HAMILMEMINUMI OBAT ANTI HIPERTENSI SEBELUM HAMIL

KLASIFIKASI HIPERTENSI KRONIKKLASIFIKASI HIPERTENSI KRONIK

KLASIFIKASI SISTOLIK (mmHg) DIASTOLIK (mmHg)NORMAL < 120 < 80NORMALPREEHIPERTENSIHIPERTENSI STADIUM IHIPERTENSI STADIUM II

< 120120 – 139140 – 159≥ 160

< 8080 – 8990 – 99≥ 110HIPERTENSI STADIUM II ≥ 160 ≥ 110

(the 7th Report of the Joint National Committee (JNC 7)MIMs Cardiovascular Guide th. 2003 – 2004))

PENGELOLAAN HIPERTENSI KRONIK DLM KEHAMILAN:PENGELOLAAN HIPERTENSI KRONIK DLM KEHAMILAN:TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM

PENGELOLAAN HIPERTENSI KRONIK DLM KEHAMILAN:PENGELOLAAN HIPERTENSI KRONIK DLM KEHAMILAN:TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM KEHAMILANKEHAMILAN-- MENEKAN RISIKO PD IBU MENEKAN RISIKO PD IBU →→ KENAIKAN DESAKAN DARAHKENAIKAN DESAKAN DARAH

TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM TUJUAN PENGOBATAN HIPERTENSI KRONIK DLM KEHAMILANKEHAMILAN-- MENEKAN RISIKO PD IBU MENEKAN RISIKO PD IBU →→ KENAIKAN DESAKAN DARAHKENAIKAN DESAKAN DARAH-- MENGHINDARI PEMBERIAN OBAT2 YG MEMBAHAYAKAN MENGHINDARI PEMBERIAN OBAT2 YG MEMBAHAYAKAN

JANINJANIN-- MENGHINDARI PEMBERIAN OBAT2 YG MEMBAHAYAKAN MENGHINDARI PEMBERIAN OBAT2 YG MEMBAHAYAKAN

JANINJANIN

PEMERIKSAAN LABORATORIUMPEMERIKSAAN LABORATORIUMPEMERIKSAAN LABORATORIUMPEMERIKSAAN LABORATORIUMPEMERIKSAAN (TEST) KLINIK SPESIALISTIK :PEMERIKSAAN (TEST) KLINIK SPESIALISTIK :-- ECGECGPEMERIKSAAN (TEST) KLINIK SPESIALISTIK :PEMERIKSAAN (TEST) KLINIK SPESIALISTIK :-- ECGECG-- ECHOCARDIOGRAPHYECHOCARDIOGRAPHY-- OPHTALMOLOGYOPHTALMOLOGY-- ECHOCARDIOGRAPHYECHOCARDIOGRAPHY-- OPHTALMOLOGYOPHTALMOLOGY-- USG GINJALUSG GINJAL-- USG GINJALUSG GINJAL

PEMERIKSAAN (TEST) LABORATORIUMPEMERIKSAAN (TEST) LABORATORIUMFUNGSI GINJAL FUNGSI GINJAL CREATININE SERUM BUN SERUM ASAM CREATININE SERUM BUN SERUM ASAM

PEMERIKSAAN (TEST) LABORATORIUMPEMERIKSAAN (TEST) LABORATORIUMFUNGSI GINJAL FUNGSI GINJAL CREATININE SERUM BUN SERUM ASAM CREATININE SERUM BUN SERUM ASAM -- FUNGSI GINJAL :FUNGSI GINJAL : CREATININE SERUM BUN SERUM, ASAM CREATININE SERUM BUN SERUM, ASAM

URAT, PROTEINURIA 24 JAMURAT, PROTEINURIA 24 JAM-- FUNGSI GINJAL :FUNGSI GINJAL : CREATININE SERUM BUN SERUM, ASAM CREATININE SERUM BUN SERUM, ASAM

URAT, PROTEINURIA 24 JAMURAT, PROTEINURIA 24 JAMPEMERIKSAAN PROTEINURIA SECARA PEMERIKSAAN PROTEINURIA SECARA PERIODIKPERIODIKPEMERIKSAAN PROTEINURIA SECARA PEMERIKSAAN PROTEINURIA SECARA PERIODIKPERIODIK

-- FUNGSI HEPARFUNGSI HEPAR-- HEMATOLOGIKHEMATOLOGIK :: Hb, HEMATOKRIT, TROMBOSITHb, HEMATOKRIT, TROMBOSIT-- FUNGSI HEPARFUNGSI HEPAR-- HEMATOLOGIKHEMATOLOGIK :: Hb, HEMATOKRIT, TROMBOSITHb, HEMATOKRIT, TROMBOSIT

PEMERIKSAAN KESEJAHTERAAN JANINPEMERIKSAAN KESEJAHTERAAN JANINULTRASONOGRAPHY ULTRASONOGRAPHY ::

PEMERIKSAAN KESEJAHTERAAN JANINPEMERIKSAAN KESEJAHTERAAN JANINULTRASONOGRAPHY ULTRASONOGRAPHY ::ULTRASONOGRAPHY ULTRASONOGRAPHY ::-- USG UTK DATA DASAR DIAMBIL 18USG UTK DATA DASAR DIAMBIL 18--20 MGG KEHAMILAN20 MGG KEHAMILAN-- DIULANG PD UMUR KEHAMILAN 28DIULANG PD UMUR KEHAMILAN 28--32 MGG DAN DIIKUTI 32 MGG DAN DIIKUTI

ULTRASONOGRAPHY ULTRASONOGRAPHY ::-- USG UTK DATA DASAR DIAMBIL 18USG UTK DATA DASAR DIAMBIL 18--20 MGG KEHAMILAN20 MGG KEHAMILAN-- DIULANG PD UMUR KEHAMILAN 28DIULANG PD UMUR KEHAMILAN 28--32 MGG DAN DIIKUTI 32 MGG DAN DIIKUTI

SETIAP BLNSETIAP BLN-- BILA DICURIGAI IUGR DI MONITOR DGN NST DAN PROFIL BILA DICURIGAI IUGR DI MONITOR DGN NST DAN PROFIL

SETIAP BLNSETIAP BLN-- BILA DICURIGAI IUGR DI MONITOR DGN NST DAN PROFIL BILA DICURIGAI IUGR DI MONITOR DGN NST DAN PROFIL

BIOFISIKBIOFISIKBIOFISIKBIOFISIK

HIPERETENSI KRONIK DLM KEHAMILAN DGN PENYULIT HIPERETENSI KRONIK DLM KEHAMILAN DGN PENYULIT KARDIOVASKULER ATAU PENY. GINJAL PERLU MENDAPAT KARDIOVASKULER ATAU PENY. GINJAL PERLU MENDAPAT HIPERETENSI KRONIK DLM KEHAMILAN DGN PENYULIT HIPERETENSI KRONIK DLM KEHAMILAN DGN PENYULIT KARDIOVASKULER ATAU PENY. GINJAL PERLU MENDAPAT KARDIOVASKULER ATAU PENY. GINJAL PERLU MENDAPAT PERHATIAN KHUSUSPERHATIAN KHUSUSPERHATIAN KHUSUSPERHATIAN KHUSUS

PENGOBATAN MEDIKAMENTOSAPENGOBATAN MEDIKAMENTOSAINDIKASI PEMBERIAN ANTIHIPERTENSI:INDIKASI PEMBERIAN ANTIHIPERTENSI:PENGOBATAN MEDIKAMENTOSAPENGOBATAN MEDIKAMENTOSAINDIKASI PEMBERIAN ANTIHIPERTENSI:INDIKASI PEMBERIAN ANTIHIPERTENSI:

RISIKO RENDAH HIPERTENSI:RISIKO RENDAH HIPERTENSI:-- IBU SEHAT DGN DESAKAN DIASTOLIK MENETAP IBU SEHAT DGN DESAKAN DIASTOLIK MENETAP ≥≥ 100 100 RISIKO RENDAH HIPERTENSI:RISIKO RENDAH HIPERTENSI:-- IBU SEHAT DGN DESAKAN DIASTOLIK MENETAP IBU SEHAT DGN DESAKAN DIASTOLIK MENETAP ≥≥ 100 100

mmHgmmHg-- DGN DISFUNGSI ORGAN DAN DESAKAN DIASTOLIK DGN DISFUNGSI ORGAN DAN DESAKAN DIASTOLIK ≥≥ 90 90

mmHgmmHg-- DGN DISFUNGSI ORGAN DAN DESAKAN DIASTOLIK DGN DISFUNGSI ORGAN DAN DESAKAN DIASTOLIK ≥≥ 90 90

mmHgmmHgmmHgmmHg

OBAT ANTIHIPERTENSIOBAT ANTIHIPERTENSI-- PILIHAN PERTAMAPILIHAN PERTAMA : METHYLDOPA : 0.5: METHYLDOPA : 0.5--3.0 g/hr, DIBAGI DLM 3.0 g/hr, DIBAGI DLM OBAT ANTIHIPERTENSIOBAT ANTIHIPERTENSI-- PILIHAN PERTAMAPILIHAN PERTAMA : METHYLDOPA : 0.5: METHYLDOPA : 0.5--3.0 g/hr, DIBAGI DLM 3.0 g/hr, DIBAGI DLM

22--3 DOSIS.3 DOSIS. : NEFEDIPINE : 30: NEFEDIPINE : 30--120 g/hr, DLM SLOW120 g/hr, DLM SLOW--RELEASE TABLETRELEASE TABLET

22--3 DOSIS.3 DOSIS. : NEFEDIPINE : 30: NEFEDIPINE : 30--120 g/hr, DLM SLOW120 g/hr, DLM SLOW--RELEASE TABLETRELEASE TABLET

PENGELOLAAN TERHADAP KEHAMILANPENGELOLAAN TERHADAP KEHAMILANSIKAP TERHDP KEHAMILANNYA PD HIPERTENSI KRONIK SIKAP TERHDP KEHAMILANNYA PD HIPERTENSI KRONIK

PENGELOLAAN TERHADAP KEHAMILANPENGELOLAAN TERHADAP KEHAMILANSIKAP TERHDP KEHAMILANNYA PD HIPERTENSI KRONIK SIKAP TERHDP KEHAMILANNYA PD HIPERTENSI KRONIK RINGAN : KONSERVATIF RINGAN : KONSERVATIF →→ DILAHIRKAN SEDAPAT MUNGKIN DILAHIRKAN SEDAPAT MUNGKIN PERVAGINAM PD KEHAMILAN ATERM.PERVAGINAM PD KEHAMILAN ATERM.RINGAN : KONSERVATIF RINGAN : KONSERVATIF →→ DILAHIRKAN SEDAPAT MUNGKIN DILAHIRKAN SEDAPAT MUNGKIN PERVAGINAM PD KEHAMILAN ATERM.PERVAGINAM PD KEHAMILAN ATERM.SIKAP TERHDP KEHAMILAN PD HIPERTENSI KRONIK BERAT : SIKAP TERHDP KEHAMILAN PD HIPERTENSI KRONIK BERAT : AKTIV AKTIV →→ SEGERA KEHAMILAN DIAKHIRI (DITERMINASI)SEGERA KEHAMILAN DIAKHIRI (DITERMINASI)SIKAP TERHDP KEHAMILAN PD HIPERTENSI KRONIK BERAT : SIKAP TERHDP KEHAMILAN PD HIPERTENSI KRONIK BERAT : AKTIV AKTIV →→ SEGERA KEHAMILAN DIAKHIRI (DITERMINASI)SEGERA KEHAMILAN DIAKHIRI (DITERMINASI)ANESTESI : REGIONAL ANESTESIANESTESI : REGIONAL ANESTESIANESTESI : REGIONAL ANESTESIANESTESI : REGIONAL ANESTESI

HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIAHIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIAPENGELOLAAN HIPERTENSI KRONIK DGN SUPERIMPOSED PENGELOLAAN HIPERTENSI KRONIK DGN SUPERIMPOSED

HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIAHIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIAPENGELOLAAN HIPERTENSI KRONIK DGN SUPERIMPOSED PENGELOLAAN HIPERTENSI KRONIK DGN SUPERIMPOSED PREECLAMPSIA SAMA DGN PENGELOLAAN PREECLAMPSIA PREECLAMPSIA SAMA DGN PENGELOLAAN PREECLAMPSIA BERAT.BERAT.PREECLAMPSIA SAMA DGN PENGELOLAAN PREECLAMPSIA PREECLAMPSIA SAMA DGN PENGELOLAAN PREECLAMPSIA BERAT.BERAT.

HELLP SYNDROMEHELLP SYNDROMEHELLP SYNDROMEHELLP SYNDROME

PREGNANCY

HYPERTENSION AND PROTEINURIA

PREECLAMPSIA

10-14% CASE

PREECLAMPSIA

HELLP SYNDROME

HELLP SYNDROMEHELLP SYNDROMEHELLP SYNDROMEHELLP SYNDROME•• FIRST DISCRIBED BY WEINSTEIN 1982FIRST DISCRIBED BY WEINSTEIN 1982::•• ACRONYM OF :ACRONYM OF : HH :: HEMOLYSISHEMOLYSIS•• FIRST DISCRIBED BY WEINSTEIN 1982FIRST DISCRIBED BY WEINSTEIN 1982::•• ACRONYM OF :ACRONYM OF : HH :: HEMOLYSISHEMOLYSIS

ELEL :: ELEVATED LIVER ENZYMELEVATED LIVER ENZYMLPLP :: LOW PLATETLED COUNTLOW PLATETLED COUNTELEL :: ELEVATED LIVER ENZYMELEVATED LIVER ENZYMLPLP :: LOW PLATETLED COUNTLOW PLATETLED COUNTLPLP :: LOW PLATETLED COUNTLOW PLATETLED COUNT

•• INCIDENCE : INCIDENCE : 2%2% 12% AMONG PATIENTS WITH 12% AMONG PATIENTS WITH

LPLP :: LOW PLATETLED COUNTLOW PLATETLED COUNT

•• INCIDENCE : INCIDENCE : 2%2% 12% AMONG PATIENTS WITH 12% AMONG PATIENTS WITH •• INCIDENCE : INCIDENCE : 2%2%--12% AMONG PATIENTS WITH 12% AMONG PATIENTS WITH PREECLAMPSIA.PREECLAMPSIA.

•• INCIDENCE : INCIDENCE : 2%2%--12% AMONG PATIENTS WITH 12% AMONG PATIENTS WITH PREECLAMPSIA.PREECLAMPSIA.30% OCCURS IN POSTPARTUM30% OCCURS IN POSTPARTUM30% OCCURS IN POSTPARTUM30% OCCURS IN POSTPARTUM

CRITERIA DIAGNOSTICCRITERIA DIAGNOSTICLABORATORY FINDING:LABORATORY FINDING:CRITERIA DIAGNOSTICCRITERIA DIAGNOSTICLABORATORY FINDING:LABORATORY FINDING:LABORATORY FINDING:LABORATORY FINDING:•• HEMOLYSISHEMOLYSIS

∗∗ ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND

LABORATORY FINDING:LABORATORY FINDING:•• HEMOLYSISHEMOLYSIS

∗∗ ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND BURR CELLSBURR CELLS

∗∗ TOTAL BILIRUBIN LEVEL > 1,2 mg/DlTOTAL BILIRUBIN LEVEL > 1,2 mg/Dl∗∗ LACTATE DEHYDROGENASE LEVEL > 600 LACTATE DEHYDROGENASE LEVEL > 600 μμ/L/L

BURR CELLSBURR CELLS∗∗ TOTAL BILIRUBIN LEVEL > 1,2 mg/DlTOTAL BILIRUBIN LEVEL > 1,2 mg/Dl∗∗ LACTATE DEHYDROGENASE LEVEL > 600 LACTATE DEHYDROGENASE LEVEL > 600 μμ/L/L∗∗ LACTATE DEHYDROGENASE LEVEL > 600 LACTATE DEHYDROGENASE LEVEL > 600 μμ/L/L

•• ELEVATED LIVER FUCTIONELEVATED LIVER FUCTION∗∗ SGOT LEVEL SGOT LEVEL ≥≥ 70 70 / L (LDH)/ L (LDH)

∗∗ LACTATE DEHYDROGENASE LEVEL > 600 LACTATE DEHYDROGENASE LEVEL > 600 μμ/L/L

•• ELEVATED LIVER FUCTIONELEVATED LIVER FUCTION∗∗ SGOT LEVEL SGOT LEVEL ≥≥ 70 70 / L (LDH)/ L (LDH)∗∗ SGOT LEVEL SGOT LEVEL ≥≥ 70 70 μμ / L (LDH)/ L (LDH)∗∗ LACTATE DEHYDROGENASE LEVEL > 600 LACTATE DEHYDROGENASE LEVEL > 600 μμ/L/L∗∗ SGOT LEVEL SGOT LEVEL ≥≥ 70 70 μμ / L (LDH)/ L (LDH)∗∗ LACTATE DEHYDROGENASE LEVEL > 600 LACTATE DEHYDROGENASE LEVEL > 600 μμ/L/L

•• LOW PLATELET COUNTLOW PLATELET COUNTPLATELET COUNT < 100.000/mPLATELET COUNT < 100.000/m33

•• LOW PLATELET COUNTLOW PLATELET COUNTPLATELET COUNT < 100.000/mPLATELET COUNT < 100.000/m33

THE LABORATORY DIAGNOSTIC CRITERIA USED AT THE UNIVERSITY OF TENNESSEE DIVISION OF MATERNAL FETAL MEDECINE, MEMPHIS TN. WITLIN AND SIBAI (1999)

CLASSIFICATION BASED ON PLATELET COUNT CLASSIFICATION BASED ON PLATELET COUNT

•• CLASS I : PLATELET CLASS I : PLATELET ≤≤ 50.000/m50.000/m33•• CLASS I : PLATELET CLASS I : PLATELET ≤≤ 50.000/m50.000/m33

(MISSISIPPI):(MISSISIPPI):

WITH : WITH : LDH LDH ≥≥ 600 600 μμU/LU/LSGOT SGOT ≥≥ 40 40 μμU/LU/L

WITH : WITH : LDH LDH ≥≥ 600 600 μμU/LU/LSGOT SGOT ≥≥ 40 40 μμU/LU/L

•• CLASS II : CLASS II : PLATELET PLATELET ≤≤ 50.000/m50.000/m3 3 -- < 100.000/m< 100.000/m33•• CLASS II : CLASS II : PLATELET PLATELET ≤≤ 50.000/m50.000/m3 3 -- < 100.000/m< 100.000/m33

WITH : WITH : LDH LDH ≥≥ 600 600 μμU/LU/LSGOT SGOT ≥≥ 40 40 μμU/LU/L

WITH : WITH : LDH LDH ≥≥ 600 600 μμU/LU/LSGOT SGOT ≥≥ 40 40 μμU/LU/L

•• CLASS II : CLASS II : PLATELET PLATELET ≤≤ 50.000/m50.000/m3 3 -- < 150.000/m< 150.000/m33

WITHWITH LDHLDH ≥≥ 600600 U/LU/L•• CLASS II : CLASS II : PLATELET PLATELET ≤≤ 50.000/m50.000/m3 3 -- < 150.000/m< 150.000/m33

WITHWITH LDHLDH ≥≥ 600600 U/LU/LWITH : WITH : LDH LDH ≥≥ 600 600 μμU/LU/LSGOT SGOT ≥≥ 40 40 μμU/LU/L

WITH : WITH : LDH LDH ≥≥ 600 600 μμU/LU/LSGOT SGOT ≥≥ 40 40 μμU/LU/L

MANAGEMENT OF HELLP SYNDROMEMANAGEMENT OF HELLP SYNDROMEMANAGEMENT OF HELLP SYNDROMEMANAGEMENT OF HELLP SYNDROME

•• MATERNAL STABILISATION IS THE MAYOR PRIORITYMATERNAL STABILISATION IS THE MAYOR PRIORITY•• MATERNAL STABILISATION IS THE MAYOR PRIORITYMATERNAL STABILISATION IS THE MAYOR PRIORITY

•• BEGIN WITH A STANDART MANAGEMENT OF SEVERE BEGIN WITH A STANDART MANAGEMENT OF SEVERE •• BEGIN WITH A STANDART MANAGEMENT OF SEVERE BEGIN WITH A STANDART MANAGEMENT OF SEVERE

PREECLAMPSIAPREECLAMPSIAPREECLAMPSIAPREECLAMPSIA

•• HELLP SYNDROME IS NOT AN INDICATION FOR CSHELLP SYNDROME IS NOT AN INDICATION FOR CS•• HELLP SYNDROME IS NOT AN INDICATION FOR CSHELLP SYNDROME IS NOT AN INDICATION FOR CS

MEDICAL MANAGEMENTMEDICAL MANAGEMENTMEDICAL MANAGEMENTMEDICAL MANAGEMENT

•• SAME AS SEVERE PREECLAMPSIASAME AS SEVERE PREECLAMPSIA•• SAME AS SEVERE PREECLAMPSIASAME AS SEVERE PREECLAMPSIA

•• WHEN THROMBOCYTE COUNT IS < 50.000 mmWHEN THROMBOCYTE COUNT IS < 50.000 mm33, 10 UNITS , 10 UNITS OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE GG

•• WHEN THROMBOCYTE COUNT IS < 50.000 mmWHEN THROMBOCYTE COUNT IS < 50.000 mm33, 10 UNITS , 10 UNITS OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE OF THROMBOCYTE OR FRESH WHOLE BLOOD MUST BE GGGIVENGIVEN

•• WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO

GIVENGIVEN

•• WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO WHEN PATIENT IS COMATOUS, SHE MUST BE TAKEN TO THE ICUTHE ICU

WHEN THROMBOCYTE COUNTS IS < 50 000/WHEN THROMBOCYTE COUNTS IS < 50 000/ 33

THE ICUTHE ICU

WHEN THROMBOCYTE COUNTS IS < 50 000/WHEN THROMBOCYTE COUNTS IS < 50 000/ 33•• WHEN THROMBOCYTE COUNTS IS < 50.000/mmWHEN THROMBOCYTE COUNTS IS < 50.000/mm33

FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL THROMBOPLASTIN TIME DTHROMBOPLASTIN TIME D DIMMER MUST BE CHECKEDDIMMER MUST BE CHECKED

•• WHEN THROMBOCYTE COUNTS IS < 50.000/mmWHEN THROMBOCYTE COUNTS IS < 50.000/mm33

FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL FIBRINOGEN LEVEL, PROTHROMBINE TIME, PARTIAL THROMBOPLASTIN TIME DTHROMBOPLASTIN TIME D DIMMER MUST BE CHECKEDDIMMER MUST BE CHECKEDTHROMBOPLASTIN TIME, DTHROMBOPLASTIN TIME, D--DIMMER MUST BE CHECKED DIMMER MUST BE CHECKED TO FIND DICTO FIND DICTHROMBOPLASTIN TIME, DTHROMBOPLASTIN TIME, D--DIMMER MUST BE CHECKED DIMMER MUST BE CHECKED TO FIND DICTO FIND DIC

OBSTETRIC MANAGEMENTOBSTETRIC MANAGEMENTWHEN MOTHERS IS STABLEWHEN MOTHERS IS STABLE →→ TERMINATE THETERMINATE THE

OBSTETRIC MANAGEMENTOBSTETRIC MANAGEMENTWHEN MOTHERS IS STABLEWHEN MOTHERS IS STABLE →→ TERMINATE THETERMINATE THE•• WHEN MOTHERS IS STABLE WHEN MOTHERS IS STABLE →→ TERMINATE THE TERMINATE THE PREGNANCY OR CONSERVATIVE MANAGEMENT.PREGNANCY OR CONSERVATIVE MANAGEMENT.

•• WHEN MOTHERS IS STABLE WHEN MOTHERS IS STABLE →→ TERMINATE THE TERMINATE THE PREGNANCY OR CONSERVATIVE MANAGEMENT.PREGNANCY OR CONSERVATIVE MANAGEMENT.

•• CONSERVATIVE MANAGEMENT CAN BE DONE CONSERVATIVE MANAGEMENT CAN BE DONE •• CONSERVATIVE MANAGEMENT CAN BE DONE CONSERVATIVE MANAGEMENT CAN BE DONE WHEN :WHEN :∗∗ THE BLOOD PRESSURE < 160/110 m THE BLOOD PRESSURE < 160/110 m μμggWHEN :WHEN :∗∗ THE BLOOD PRESSURE < 160/110 m THE BLOOD PRESSURE < 160/110 m μμgg∗∗ THE OLIGURIA RESPONSE TO FLUID THE OLIGURIA RESPONSE TO FLUID

REPLACEMENTREPLACEMENT∗∗ THE OLIGURIA RESPONSE TO FLUID THE OLIGURIA RESPONSE TO FLUID

REPLACEMENTREPLACEMENT∗∗ THERE IS NO EPIGASTRIC PAINTHERE IS NO EPIGASTRIC PAIN∗∗ THE GESTATIONAL AGE IS < 34 WEEKSTHE GESTATIONAL AGE IS < 34 WEEKS∗∗ THERE IS NO EPIGASTRIC PAINTHERE IS NO EPIGASTRIC PAIN∗∗ THE GESTATIONAL AGE IS < 34 WEEKSTHE GESTATIONAL AGE IS < 34 WEEKS

COMPLICATIONCOMPLICATIONCOMPLICATIONCOMPLICATIONCOMPLICATIONCOMPLICATION•• THE COMPLICATIONS THAT CAN OCCUR IN THE COMPLICATIONS THAT CAN OCCUR IN

COMPLICATIONCOMPLICATION•• THE COMPLICATIONS THAT CAN OCCUR IN THE COMPLICATIONS THAT CAN OCCUR IN

HELLP SYNDROME ARE : NEUROLOGIC HELLP SYNDROME ARE : NEUROLOGIC

DISORDER PULMONARY EDEMA ABRUPTIODISORDER PULMONARY EDEMA ABRUPTIO

HELLP SYNDROME ARE : NEUROLOGIC HELLP SYNDROME ARE : NEUROLOGIC

DISORDER PULMONARY EDEMA ABRUPTIODISORDER PULMONARY EDEMA ABRUPTIODISORDER, PULMONARY EDEMA, ABRUPTIO DISORDER, PULMONARY EDEMA, ABRUPTIO

PLACENTA, DIC AND PLACENTA, DIC AND μμUGR UGR

DISORDER, PULMONARY EDEMA, ABRUPTIO DISORDER, PULMONARY EDEMA, ABRUPTIO

PLACENTA, DIC AND PLACENTA, DIC AND μμUGR UGR

1.1. HYPERTENSION, PROTEINURIA AND OTHERS SYMPTOMSHYPERTENSION, PROTEINURIA AND OTHERS SYMPTOMS--SIGN OF SIGN OF 1.1. HYPERTENSION, PROTEINURIA AND OTHERS SYMPTOMSHYPERTENSION, PROTEINURIA AND OTHERS SYMPTOMS--SIGN OF SIGN OF CONCLUSIONS :CONCLUSIONS :

,,PREECLAMPSIA ARE INDUCED BY PREGNANCYPREECLAMPSIA ARE INDUCED BY PREGNANCY

,,PREECLAMPSIA ARE INDUCED BY PREGNANCYPREECLAMPSIA ARE INDUCED BY PREGNANCY

2.2. BESIDE HYPERTENSION AND PROTEINURIA, OTHER SYNDROMA OF BESIDE HYPERTENSION AND PROTEINURIA, OTHER SYNDROMA OF PREECLAMPSIA ARE EPIGASTRIC PAIN, HEADCHE, VISUAL DISTURBANCE, PREECLAMPSIA ARE EPIGASTRIC PAIN, HEADCHE, VISUAL DISTURBANCE, OLIGURIA, CONVULSION, AND RENAL FAILURE.OLIGURIA, CONVULSION, AND RENAL FAILURE.

2.2. BESIDE HYPERTENSION AND PROTEINURIA, OTHER SYNDROMA OF BESIDE HYPERTENSION AND PROTEINURIA, OTHER SYNDROMA OF PREECLAMPSIA ARE EPIGASTRIC PAIN, HEADCHE, VISUAL DISTURBANCE, PREECLAMPSIA ARE EPIGASTRIC PAIN, HEADCHE, VISUAL DISTURBANCE, OLIGURIA, CONVULSION, AND RENAL FAILURE.OLIGURIA, CONVULSION, AND RENAL FAILURE.OLIGURIA, CONVULSION, AND RENAL FAILURE.OLIGURIA, CONVULSION, AND RENAL FAILURE.

3.3. THERE ARE STILL CONTROVERSION IN CLASSIFICASION, DIAGNOSTIC THERE ARE STILL CONTROVERSION IN CLASSIFICASION, DIAGNOSTIC

OLIGURIA, CONVULSION, AND RENAL FAILURE.OLIGURIA, CONVULSION, AND RENAL FAILURE.

3.3. THERE ARE STILL CONTROVERSION IN CLASSIFICASION, DIAGNOSTIC THERE ARE STILL CONTROVERSION IN CLASSIFICASION, DIAGNOSTIC AND MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION. AND MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION.

44 IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN

AND MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION. AND MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION.

44 IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN 4.4. IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN MANAGEMENT IS NEEDED.MANAGEMENT IS NEEDED.

4.4. IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN IN PATIENTS WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN MANAGEMENT IS NEEDED.MANAGEMENT IS NEEDED.

5.5. IGNORANCE, POVERTY, LATE ADMITTANCE TO HOSPITAL WILL INCREASE IGNORANCE, POVERTY, LATE ADMITTANCE TO HOSPITAL WILL INCREASE FERINATAL FERINATAL -- MATERNAL, MORBIDITY AND MORTALITYMATERNAL, MORBIDITY AND MORTALITY

5.5. IGNORANCE, POVERTY, LATE ADMITTANCE TO HOSPITAL WILL INCREASE IGNORANCE, POVERTY, LATE ADMITTANCE TO HOSPITAL WILL INCREASE FERINATAL FERINATAL -- MATERNAL, MORBIDITY AND MORTALITYMATERNAL, MORBIDITY AND MORTALITY

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