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Vol 35, No     3July 2011                                                                       Patients with hypertension...
Indones J98   Sutopo et al                                                                                Obstet Gynecolhy...
Vol 35, No 3July 20l l                                                          Potients with hypertension in pregnancy 99...
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Characteristics of patients with hypertension in pregnancy at sanglah hospital in 2009 2011


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Characteristics of Patients with Hypertension in Pregnancy at Sanglah Hospital in 2009-2011

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Characteristics of patients with hypertension in pregnancy at sanglah hospital in 2009 2011

  1. 1. ,(auau3al6 uI uolsueteoddg ql3,rr s1ueflud Jo sqlslJapuJuqalri}: II0Z ,tlaf 66 - 46 eEed 69 iaqurnp gg eiunp6 ,ftoloceu.f,e prru sclfilefsqo 5o Isu,rnof tIG *repIII TNIUiTflU
  2. 2. Vol 35, No 3July 2011 Patients with hypertension in pregnancy 97 Research Report Characteristics of Patients with Hypertension in Pregnancy at Sanglah HosPital Karakteristik Pasien Hipertensi dalam Kehumilan di Rumuh Sakit Urnum Pusat Sanglah Denpasar Hendrik Sutopo, I Gede Putu SurYa Department of Obstetrics and Gynecologt Medical Faculty of Udayana University/ Sanglah HosPital DenpasarAbstract Abstrak Objective: To report the profile of patients with Hypertension in Tajaan: Mengetahui profil penderita hipertensi dalam kehamilPregnancy (HIP) at Sanglah Hospital Denpasar from 2009 to 2010. an (HOt<) di RS7P Sanglah Denpasar dalam periode tahun 2p09 - Method: A retrospective descriptive study from all HIP patients 2010.at Sanglah Hospital Denpasar, Bali during January 2009 to Decem- Metode: Penelitian deskriptif retrospektif penderita HDK diber 2010. RS1P Sanglah Denpasar selama periode Januari 2009 sampai De- Result: The prevalence of HIP at Sanglah Hospital was 9.32%o, sember 2010.which consisted-of 132% gestational hypertension, 0.19% chronic Hasil: Angka kejadian HDK di RSUP Sanglah adalah 9,32ok,hypertension, l.36Yo mild preeclampsia, 4.70o/o severe preeclamp- terdiri dari hiperteisi gestasional sebesar 1,82o%, hipertensi kroniksii, O.AZy" superimposed preeclampsia, ar,d 0.82o/o eclampsia. From 0,19ok, preeHampsia rlngan 1,360/o, preeklampsia berat 4,700%, su-all of HIP cases, we found that the majority were nulliparous per imposed preeklampiia 0,43% dan eklampsia sebesar 0,8201. Dari ielurui kasus HDK, tnayoritas merupakan primigravida(47.23%), primipatemal (53.1%), and had hypertension at term(51.9%). Mbst of the cases were found at matemal age > 35 years (47,23%"), primipaternalitas (5j,1%o), dan diketahui tekanan darahOC.AZ{/,), followed by age < 20 years (13.47%). Most of them also iinggi pada saai aterm (51,9%o). HDK paling banyak -terdap-at padahad Ante Natal Care (ANC) frequency > 4 times (69.09%), and had kelompok usia > 35 tahun (14,62%o), diikuti oleh kelompok-usia <their ANC done by a midwife (52.76%) and followed with an obs- 20 tairun (13,47%0). Sebanyak 69,09% kasus HDK telah melakukantetrician (40.81%). The majority of the cases were referral cases antenatal care (ANC) 2 4x, dan ANC paling banyak di bidan(62.39%) mostly by midwives (22.45%). From all of the cases, we (52,76%0) kemudian di SpOG (40,81%0). Sebagian besar kasus HDKfound that total preterm labor was 35.14%, perinatal mortality was *erupoio, kasus rujukin (62,39%0) dengan mayoritas rujukan dari9.32oh and maternal mortality was 1.160%. Bida;/BKIA (22,45%0). Dari seluruh penderita HDK didapatkan to- Conclusion: The prevalence of HIP at Sanglah Hospital was tal persalinan prematur adalah 35,14%, kematian perinatal sebesar 9,320%, dan kematian matemal sebesar 1,16ok.higher than previous years. Most of them had already had ANCdone by health care providers, who were mostly midwives and ob- Kesimpulan: Angka kejadian HDK di RSUP Sanglah lebih ting-stetricians. Therefor, the quality of ANC seems to need an improve- gi dibandingkan dengan beberapa tahun sebelumnya. Mayoritasment by having an earlier referral system, so cases can be treated penderita HDK telah melakukan ANC di tenaga kes_ehatan, baik bi- -danearlier. maupun dokter spesialis kandungan. Dengan demikian kualitas ANC mingkin perlu ditingkatkan melalui sistem rujukan yang lebih [Indones J Obstet Gynecol 2011;35-3:979] dini, sehiiggi kasus HDK, khuswnya preeklampsia, dapat dita- Keywords: hypertension in pregnancy, preeclampsia and ngani lebih dini.eclampsia, descriptive [Maj Obstet Ginekol Indones 2011; 35-3: 97-9] Kata kunci: hipertensi dalam kehamilan, preeklampsia eklamp sia, deskriptif Coyespondence.. Hendrik Sutopo, Department of Obstetrics and Gynecology, Sanglah Hospital, Denpasar. Telephone: 08 I 6-6 1 5576, Email: hendrik2T I 1 @yahoo.com INTRODUCTION In Indonesia, the incidence of HIP ranges ftom3.4 to 8.5Yo and is the second cause of maternal death HIP is the terminology used to describe a wide spec- (24%) after hemorrhagic postpartum.5 Previous stu- trum of pregnant women with increased blood.pres- dies at Sanglah Hospital, it was reported that the pre- sure. Preeclampsia, which is a part of HIP, is a state valence of HIP from 2004 to 2005 to be 6.06% (mild of increased blood pressure in pregnancy that is ac- PE 2.460/0, severe P8 2.570 , and eclampsia 0.610/o6, companied by proteinuria in pregnancy. Worldwide, and2002 to 2003 to be 5.83% (mild PE 2.0304, severe preeclampsia is still a major cause of maternal and PE 2.460A, and eclampsia 0.39%).t In 1997 a special infant morbidity and mortality.l It complicates 5 to study at Sanglah Hospital reported that the prevalence 10 percent of all pregnancies in the world.2,3 In West- of severe preeclampsia was 1.82% and eclampsia ern countries, it is estimated that one third of babies 0.25Yo.8 born from preeclamptic patients have intrauterine There are a lot of risk factors for HIP, especially growth restriction.4 Preeclampsia also increases peri- preeclampsia, which can be grouped as follows: Nul- natal mortality in developed countries up to 5 fold.l liparity, primipaternality, hyperplasentosis, such as
  3. 3. Indones J98 Sutopo et al Obstet Gynecolhydatidiform mole, multiple pregnancy, diabetes mel- while 60% of diastolic ones were obtained at a rangelitus, hydrops fetalis, large baby, age less than 20 of 110-119 mmHg.years or more than 35 years, family history of pree- The proportion of HELLP syndrome from all HIPclampsia/eclampsia, renal disease and or hypertension cases was 15.7%. The highest prevalence of HELLPthat has already existed before the pregnancy, and syndrome was found in the eclampsia group (46.15%),obesity.9 followed by the severe preeclampsia (21.a%) and su- A lot of studies have been done for preeclampsia perimposed preeclampsia (18.75%). Most seizures into identify the risk factors, etiology, and intervention eclampsia occured during the antepartum periodfor the disease.l0 However, the evidence based medi- (80%), while the prevalence of intrapartum and post-cine shows that to this day, any efforts to prevent the partum seizures was 10%.onset of preeclampsia, has not been clinically proven Majority of HIP cases were delivered as spontane-sffsgliys.ll-13 ous vaginal delivery (36.44%), followed by Cesarean Section (CS) (34.11o/o) and forceps extraction (25. 47o/o). For the severe preeclampsia group, most deli- METHOD veries were assisted by forceps extraction (46.24%) followed by CS (42.77%). In the eclampsia group,This is a retrospective descriptive study in which data 53.33% were born by CS. Only 0.87%;o of HIP caseswas obtained from all HIP cases at Sanglah Hospital, were treated by conservative treatment because ofDenpasar from January 2009 to December 2010 the preterm gestational age.data were processed and calculated. From all HIP cases we found that the rate of infant birth weight being less than 2500 grams was 35.14%. Meanwhile, the prevalence of IUGR was 8.82%. The RESULTS perinatal mortality rate was 9.32o/o, which consisted of 3.20o/o intrauterine fetal demise and 6.l2oh earlyDuring the 2 years period of the study, 3,679 deliv- neonatal mortality. Viewed from the total number oferies were recorded and HIP was found in 343 cases perinatal deaths at Sanglah Hospital, HIP was associ-(9.23%) consisting consists of gestational hyperten- ated with 13.5% of perinatal mortality.sion (1.82%), chronic hypertension (0.19%), mild pre- From the total of 20 cases of maternal mortality ateclampsia (1.36%), severe preeclampsia (4.70o/o), su- Sanglah Hospital, it was found that four cases wereperimposed preeclampsia (0.a3%) and eclampsia related to HIP (20%). The four maternal cases was(0.82%). The prevalence of HIP in subjects with ma- 1.16% from total HIP cases. These four cases wereternal age < 20 years was 13.47o/o; age 20-35 years severe preeclampsia with pneumonia and sepsis,was 8.040/o, and age > 35 years was 14.620/o. Most of eclampsia with multi-organ failure, eclampsia withthe cases (53.1%) were primipaternal.It was revealed solutio placenta complicated by DIC, and (4) eclamp-that 4723% from all cases were nulliparous, 38.77% sia with complications of CVA (cerebrovascular ac-were the second or third pregnancy, and 13.99o/o were cident). From all maternal deaths, 50% of them suf-the fourth or more pregnancy. Nulliparous was the fered HELLP syndrome.major factor in each group for mild preeclampsia From all HIP cases, we found that the percentage(46%), severe preeclampsia (47.40%), and eclampsia of patients who stayed for 0-3 days in hospital was(63.3%). 52.770 , 4-7 days was 39.94o/o, and 8-10 days was From all cases, we found that 69.09% patients had 4.66%. Only 2.620/o of patients who stayed more thanANC frequency more than 4 times, and 27.98% had 10 days in hospital.ANC frequency between I to 4 times. Most of thecases had ANC done by midwives (52.76Yo), and fol- lowed by Obstetricians (40.81%). Only 2.95o/o sub- DISCUSSIONjects who never check their pregnancy. In every sub-group of HIP characteristic of ANC frequency > 4x From this study it was found that the prevalence ofpredominanted 77.6Yo for gestational hypertension, HIP (including mild PE, severe PE, and eclampsia)100% for chronic hypertension, 68yo for mild pree- was higher when compared with the previous yearsclampsia, 64.7% for severe preeclampsia,8l.25o/o for at Sanglah Hospital.SiPE, and 63.33% for eclampsia. The prevalence difference can be influenced by a Most of HIP cases at Sanglah Hospital (62.39%) lot of factors, such as patient characteristics, geneticwere referral cases and the major referrer (24.2%) factors, quality referral system and ANC to screenwere midwives, for the eclampsia group, the majority HIP cases, For patient characteristics, factors includeof referral cases came from other hospitals (52.9%). maternal age <20 years or >35 years, nulliparity, or Majority of the cases (51.90o/o) were known to primipaternality.3,tt,tz For genetic factors, currentlyhave high blood pressure at term or >37 weeks. For in Bali and especially at Sanglah Hospital, a lot ofeach subgroup of HIP, which were preeclampsia, su- patients were not Balinese. Since the patients wereperimposed preeclampsia and severe preeclampsia, more pluralistic, it further investigation is needed tohypertension in week 28-37 occrred in 70o/o, and 53%o see whether genetic factors (e.g certain ethnic) influ-of cases respectively. From most the severe pree- ence the occurence of HIP. On the other hand, theclampsia group, most systolic pressures (91.32%) win refferal system might be an important factor thatwere the range of 160-179 mmHg and diastolic pres- could alter the prevalence rate of HIP. There was astxe (73.99Yo) were in a range of 110-119 mmHg. tendency that patients with severe preeclampsia orFor the eclampsia group, 60oh of systolic blood pres- eclampsia in Bali would be referred to Sanglah Hos-sures were obtained at the range of 160-179 mmHg pital because of some reasons. We believed that these
  4. 4. Vol 35, No 3July 20l l Potients with hypertension in pregnancy 99refferal system could increase the proportion of HIP . CONCLUSIONcases at Sanglah Hospital, which in turn could affectthe data that we obtained. The prevalence of HIP at Sanglah Hospital was higher HIP cases were mostly found in the age group >35 than previous years. HIP cases were dominated byyears and was followed by age group <20 years. severe preeclampsia. The major characteristic of pa-These result was similar to most studies that show a tients in HIP were nulliparity and primipaternality.J-shaped curve for relationships between maternal Most of the cases already had ANC done by healthage and the incidence.la Older or younger maternal care providers, which only were midwives and doc-age means higher risk for HIP, means and higher in- tors. Thereby the quality of ANC needed to be im-cidence in those who more than 35 years old.3,l4 proved by earlier referral system to referral hospitals,Based on the number of pregnancies, the highest pre- so the cases could be treated earlier.valence of HIP was in nulliparous and primipaterna-lity. These findings also fit the literatures, where it is REFERENCESsaid to be associated with immunological processesbecause of exposure to paternal antigens.3,12,13 High 1 Roberts JM, Pearson G, Cutler J, Lindheimer M. Summaryprevalence rate of HIP in primipatemality cases of NHLBI Working Group on Research on Hypertensionshould be given more attention when performing During Pregnancy. Hypertension 2003; 4l: 437 -45ANC. Associated with the risk for preeclampsia, pri- 2. World Health Organizatton. Global Program to Conquermipaternality should be.regarded as nulliparous.l3,14 Preeclampsia/Eclampsia. 2002. [Citied 2010 Aug. 2] Avail- able from: www.preeclampsia.org/statistics.asp Most patients with HIP had an ANC frequency > 3. Habli M, Sibai BM. Hypertensive Disorders of Pregnancy.4x. Most of them checked their pregnancy at practices In: Gibbs RS, Karlan BY, Haney AF, Nygaard IE. Dan-run by midwife and then followed by Obtetricians, forths obstetrics and gynecology. l0th edition. Philadel- only 2.93oh cases who never controlled their preg- phia: Lippincott Williams & Wilkins, 2008:258-66nancy. This suggests that the ANC program had a 4. Auer J, Camoin L, Guillonneau F, Rigourd V, Chelbi ST,good coverage and the midwives were the primary Leduc M. Serum Profile in Preeclampsia and Intra-uterine Growth Restriction Revealed by iTRAQ Technology. J Pro-health provider for ANC. However in most cases teomics 2010: 73: 1004-17(51.90%) high blood pressure was known when ges- 5. Departemen Kesehatan Republik Indonesia. Survei Kese-tational age at term. While literature says that the ma- hatan Rumah Tangga Tahun 2001. Jakarta: Departemenjority of HIP cases are known in late pregnancy or Kesehatan RI, 2002near term.14 This differentiation may be related to the 6. Sudarmayasa IM, Surya IGP. Profil Penderita Hipertensiquality of the ANC which was still unoptimal. dalam Kehamilan di RSUP Sanglah Denpasar Periode I Januari 2004-31 Desember 2005. Program Pendidikan Dok- At Sanglah Hospital, the prevalence of HELLP ter Spesialis I LablSMF Obstetri dan Ginekologi FK syndrome appeared to be related with severity of the UNUD/RSUP Denpasar. 2006disease. It was obtained from our study that 500/o of 7. Oka AJ, Surya IGP. Profil Penderita Hipertensi dalam Ke-maternal deaths were accompanied by the presence of hamilan di RSUP Sanglah Denpasar Periode 1 Jautai2002HELLP syndrome. - 3 I Desember 2003. Program Pendidikan Dokter Spesialis From all of HIP in this study, most were delivered I LablSMF Obstetri dan Ginekologi FK UNUD/RSUP Den- pasar. 2004by spontaneous delivery Q6.44%), followed by CS 8. Ardhana K, Suwardewa TGA. Profil Preeklampsia berat (34.11%) and forceps extraction (25.47%), whereas dan Eklampsia di RSUP Denpasar tahun 1994-1996. Pro- only 0.29oh were done by for vacuum extraction. Es- gram Pendidikan Dokter Spesialis I LablSMF Obstetri danpecially for severe preeclampsia, most delivery were Ginekologi FK LINUD/RSUP Denpasar. 1997 done by forceps extraction (46.24%).It seems that we 9. Angsar MD. Hipertensi dalam Kehamilan. In: Saifuddinneed further evaluations to determine the best delivery AB, Rachimhadhi T, Winknjosastro GH. Ilmu Kebidananmethod for HIP cases, especially for severe pree- Sarwono Prawirohardjo. Edisi ke-4. Jakarta. PT Bina Pus- taka Sarwono Prawirohardjo. 2008. Hlm 532-5. clampsia and eclampsia, so maternal and perinatal 10. Gupta S, Agarwal A, Sharma RK. The Role of Placenta morbidity rate can be kept as low as possible. Oxidative Stress and Lipid Peroxidation in Preecampsia. Matemal mortality rate from HIP cases at Sanglah Obstetrical and Gynecological Survey 2005; 60(12): 807-16 Hospital was 1.16%. After we counted from the total 11. Reynolds C, Mabie WC, Sibai BM. Hipertensive States of 20 cases of all matemal deaths in 2-year periode of this Pregnancy. In: Current Obstetric and Gynecologic Diagno- study, matemal death related to HIP was counted as sis and Treatment. 9th edition. New Delhi: Mc Graw Hill, 2003:338-9 . many as 4 cases (20%). This was consistent with the 12. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse literature in developed countries, where matemal mor- DJ, Spong CY. Pregnancy hypertension. In: Williams Obs- tality rate related to HIP was between 15-200 .312,t4 tetrics 23d Edition. New York: Mc Graw Hill 2010; 709-10 13. Dildy GA, Belfort MA, Smulian JC. Preeclamsia Recur- rence and Prevention. Semin Parinatol 2007; 3ll. 135-41 14. Myers J, Brockelsby J. The epidemiology of preeclampsia. In: Baker PN, Kingdom JCP ed. Pre-Eclampsia, Current Pers-pectives on Management. New York: The Parthenon Publishing Grotry 2004; 25-34