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Hypertensive Disorder in Pregnancy
dr. Valleria, SpOG
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Hypertensive Disorder inPregnancy
1. Gestational hypertension ( Hipertensidalam Kehamilan )
2. Preeclampsia3. Eclampsia4. Superimposed Preeclampsia
5. Chronic Hypertension
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Hypertensive Disorder inPregnancy
One of the deadly triad (hemorrhage,
infection)3,7 % of all pregnancy
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1. Ges tas ion al hy p er ten s ion
BP > 140/90 mmHg for first time duringpregnancyNo proteinuriaBP return to normal < 12 weeks postpartum
May have other signs for preeclampsia(epigastric discomfort, thrombpcytopenia)
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2. Preec lam p s ia
Preeclampsia: Mild-Severe
Mild :- BP > 140/90 mmHg after 20 weeks
gestation- Proteinuria > 300 mg/24 hours or > 1+
dipstick
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Preeclampsia
Severe- BP > 160/110 mm Hg- Proteinuria 2 g/24 hours or > 2+ dipstick- Serum Creatinin > 1,2 mg/dL- Platelets < 100.000/mm3- Increase LDH- Elevated AST/ALT- Persistent headache or other cerebral or
visual disturbance- Persistent epigastric pain
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3. Eclam p s ia
Seizures that cannot be attributed to other
causes in women with preeclampsiaComa
Eklampsia imminens severe headache or visual disturbances
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4. Sup er im p o sed preeclam p sia
New onset proteinuria > 300mg/24 hours
in hypertensive women but no proteinuriabefore 20 weeks gestasionSign and symptoms severe preeclampsia
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5. Chro n ic Hyp er ten s ion
BP > 140 mmHg before pregnancy or diagnosed before 20 weeks gestation
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Risk Facto r Preec lam p sia
NulliparousMultiple pregnancy
History of chronic hypertensionMaternal age over 35 yearsObesity
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Patop hy is io log y Preec lam ps ia
Maternal vascular deseaseFaulty placentationExcessive trophoblast
Reduced uteroplacental perfusion
Endothelial activation
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Endothelial activation
Vasospasme Capillary leak Activation of coagulation
-Hypertension-Seizure-Oliguria- Abruption-Liver ischemia
EdemaProteinuriaHemoconcentration
Thrombocytopenia
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Gen eral Man ag em en t o f Sev ere Preec lam p s ia
1. Delivery is the cure for preeclampsia> 35 weeks gestation : induction of labor < 35 weeks gestation, no complication:
expectant ( the hope that few more weeks inutero will reduce the risk of neonatal mortalityand morbidity )
- Anti hypertension-
Lung maturation : dexametason 12 mg/day, 2 days- Observation : Blood pressure, symptom impandingeclampsia, lab., fetal surveillance any disturbance
termination
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Gen eral Managem ent o f Sev ere Preeclampsia
2. Anti hypertensive Drug- -blocking agent : labetolol- Calcium channel blocker : nifedipine- ACE inhibitor
(Angiotensin-converting-enzyme): should beavoided : oligohidramnios, IUGR, limb
contractur, Persistent PDA, pulmonaryhypoplasia, etc
- Methyldopa : delayed onset (long-acting)
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Gen eral Managem ent o f Sev ere Preeclampsia
3. Preventive and control convulsion- MgSO 4 : control convulsion without central
nervous system depression- i.v : 4-6 g loading dose diluted in 100 ml of
iv fluid 15-20 min, maintenance 1-2 g/ hour in 100 ml
- i.m : 4 g loading dose, 5 g i.m in bothbuttock / 4 hour
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General Man ag em ent o f Sev er Preeclampsia
Before giving MgSO 4 :1. The patellar refleks is present
2. Respiration are not depressed ( RR>16/min)3. Urin output > 100ml/4 hour MgSo 4 is discontinued 24 h after delivery
MgSO 4 toxicity : respiratory depression,paralysis, and arrest Antidotum MgSO 4 : calcium gluconate
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Severe Preeclampsia
> 35 weeks gestasion : termination of pregnancy< 35 weeks gestasion :- Find any complications if any termination
of pregancy and treat complication- No diuretik-
Limitation activity- MgSO4- Antihypertensive agents- Close observation for mother and baby
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Man agem en t o f Mild Preeclampsia
> 37 weeks gestation : termination of pregnancy< 37 weeks gestation :
- No medication if blood pressure not more than 140/90
mmHg- No diuretik- Limitation activity- ANC 2x/weeks : Blood Pressure, proteinuria, refleks,
fetal surveillance- Close monitoring for complications
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Management of chronichypertension/gestational
hypertension
Find any complications during antenatal care
Antihypertensive drugs control bloodpressureIf no complications wait until aterm with close
monitoringIf there is any complications consider pregnancy termination
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Compl ica t ion
1. Eclampsia
- Generalized tonic-clonic seizures- Coma without convulsion- Antepartum, intrapartum, postpartum
- Cerebral edema- ICU
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Compl ica t ion
2. HELLP Syndrome
- Hemolysis : fragmented erythrocyte, bilirubun >
1,2 ml/dL- Elevated Lever enzymes : SGOT > 72 IU/L, LDH
> 600IU/L- Low Platelet count : < 100.000/mm3- DIC- Tx : dexamethason 2 x 10 mg, then 2 x 5 mg
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Compl ica t ion
3. Pulmonary edema
- Tachypneu/dyspnea- Respiratory distress- Severe hypoxemia- Diffuse rales in both lung- ICU, ventilator - Furosemid
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Compl ica t ion
4. Acute Renal Failure5. Hepatic rupture
6. Abruptio placentae7. Cerebral hemorrhage8. Visual disturbances
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Prevent ion
Low dose aspirin ?Calcium?
Anti oxidant?
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