PATHOGENESIS Nephritic
syndrome vs PE

COMPARISON

1. Yamamoto Y, Aoki S. Systemic lupus erythematosus: strategies to improve pregnancy outcomes. Int J Womens Health. 2016;8:265-72.
2. Cavallasca JA, Costa CA, del Rosario Maliandi M, Musuruana JL. Hot topics in lupus pregnancy. World Journal of Rheumatology. 2013;3(3):32-9.
Comparison

Comparison
Stanhope TJ, White WM, Moder KG, Smyth A, Garovic VD. Obstetric nephrology: lupus and lupu
nephritis in pregnancy. Clin J Am Soc Nephrol. 2012;7(12):2089-99.

TATALAKSANA NEPHRITIC
SYNDROME

Nephritic syndrome treatments
• mainly supportive
• The treatment consists of:
• Antihypertensives: Anti-hypertensives are administered in patients with elevated blood pressure
despite dietary salt, fluid restriction, and loop diuretics. In severe cases, hypertension is treated
with ACE inhibitors, ARBs, and nifedipine.
• Diuretics: Loop diuretics may be administered to excrete excess sodium and water retained in the
body. It helps to decrease fluid retention in the body. The reduced fluid load on kidneys helps speed
up the healing process.
• Corticosteroids: Help relieve the inflammation in the kidney and promote healing.
• Immunomodulators: Immunosuppressive drugs reduce and block the antigenic effects of the
inciting agents. It is most useful for rapidly progressive glomerulonephritis. The use of
corticosteroids and immunomodulators is controversial in certain causes of the nephritic syndrome,
including staphylococcal endocarditis. It can aggravate the sepsis and result in increased mortality.
• Antibiotics: Post streptococcal GN patients with evidence of streptococcal infection are
administered penicillin. Erythromycin is preferred for patients allergic to penicillin. Early treatment
of streptococcal infection with antibiotics reduces the severity and incidence of glomerulonephritis
• Dialysis: In some cases, the disease has a fulminating course leading to renal failure. In such cases,
renal replacement therapy with dialysis is performed.
• Rodriguez-Iturbe B, Haas M. Post-Streptococcal Glomerulonephritis. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes : Basic Biology to Clinical Manifestations [Internet]. University of Oklahoma Health Sciences Center;
Oklahoma City (OK): Feb 10, 2016. [PubMed]
• Glassock RJ, Alvarado A, Prosek J, Hebert C, Parikh S, Satoskar A, Nadasdy T, Forman J, Rovin B, Hebert LA. Staphylococcus-related glomerulonephritis and poststreptococcal glomerulonephritis: why defining "post" is important in understanding and
treating infection-related glomerulonephritis. Am J Kidney Dis. 2015 Jun;65(6):826-32. [PubMed]

• Activity: usually no restriction ,
except massive edema,heavy
hypertension and infection.
• Diet:
• Hypertension and edema: Low salt diet
(<2gNa/ day) only during period of
edema or salt-free diet
• Severe edema: Restricting fluid intake
• Avoiding infection: very important.
• Diuresis:
• Hydrochlorothiazide (HCT) ：2mg/kg.d
• Antisterone ： 2～4mg/kg.d
• Dextran ： 10～15ml/kg , after 30～60m,
• followed by Furosemide (Lasix) at
2mg/kg .
• Prednisone tablets at a dose of 60
mg/m2/day (maximum daily dose, 80
mg divided into 2-3 doses) for at least
4 consecutive weeks.
• After complete absence of
proteinuria, prednisone dose should
be tapered to 40 mg/m2/day given
every other day as a single morning
dose.
• The alternate-day dose is then slowly
tapered and discontinued over the
next 2-3 mo.

Principal treatment of pregnancy with glomerular
disease
Blom K, Odutayo A, Bramham K, Hladunewich MA. Pregnancy and glomerular disease: a systematic review of
the literature with management guidelines. Clinical Journal of the American Society of Nephrology.
2017;12(11):1862-72.

Referensi: Knight CL,
Nelson-Piercy C.
Management of systemic
lupus erythematosus
during pregnancy:
challenges and solutions.
Open Access Rheumatol.
2017 Mar 10;9:37-53. doi:
10.2147/OARRR.S87828.

Referensi: Knight CL,
Nelson-Piercy C.
Management of systemic
lupus erythematosus
during pregnancy:
challenges and solutions.
Open Access Rheumatol.
2017 Mar 10;9:37-53. doi:
10.2147/OARRR.S87828.

TATALAKSANA PEB

Prinsip penanganan PEB
• Pencegahan kejang
• Pengobatan hipertensi
• Pengelolaan cairan
• Pengobatan suportif lainnya
• Waktu yang tepat persalinan
Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG. Williams’ Obstetric. 24th edition. USA: McGraw-Hill; 2012.
Anwar M, Baziad A, Prabowo P (eds). Ilmu Kandungan. Edisi Ketiga; Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2011
Angsar MD. Hipertensi dalam Kehamilan. In: Saifuddin AB, Rachimhadhi T, Wiknjosastro GH, editors. Ilmu kebidanan Sarwono Prawirohardjo. 4th ed. Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2014.
The Diagnosis and Management of Pre-Eclamsia and Eclamsia-Clinical Practice Guideline. Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and Clinical Strategy and Programmes Directorate, Health Service Executive
2013.
Hypertensive disorders. In: Cunningham FG, et al. William obstetrics.24 th ed. Newyork: McGraw-Hill;2014. p.731

Penanganan PEB
• Preeklampsia berat  harus segera masuk rumah sakit  rawat inap
dan tirah baring
• Pengelolaan cairan  monitoring input dan output & perhatikan
tanda-tanda edema paru
• Infus
• Foley cateter
• Pemberian obat antikejang
• MgSO4
Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG. Williams’ Obstetric. 24th edition. USA: McGraw-Hill; 2012.
Anwar M, Baziad A, Prabowo P (eds). Ilmu Kandungan. Edisi Ketiga; Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2011
Angsar MD. Hipertensi dalam Kehamilan. In: Saifuddin AB, Rachimhadhi T, Wiknjosastro GH, editors. Ilmu kebidanan Sarwono Prawirohardjo. 4th ed. Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2014.
The Diagnosis and Management of Pre-Eclamsia and Eclamsia-Clinical Practice Guideline. Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and Clinical Strategy and Programmes Directorate, Health Service Executive
2013.
Hypertensive disorders. In: Cunningham FG, et al. William obstetrics.24 th ed. Newyork: McGraw-Hill;2014. p.731

Cara pemberian MgSO4
• Dosis awal 4 g : (10 ml larutan MgSO4 40% atau 20
ml larutan MgSO4 20% )  larutkan dalam 10 ml
akuades atau NaCl 100cc berikan secara IV
selama 20 menit
• Jika akses IV sulit: masing-masing 5 g MgSO4 (12.5 ml
larutan MgSO4 40%) secara IM di bokong kiri dan kanan
• Rumatan: 6 g MgSO4 (15 ml larutan MgSO4 40%)
larutkan dalam 500 ml Ringer Laktat/Ringer Asetat
 berikan secara IV (kecepatan 28 tetes/menit
selama 6 jam)
• Diulang hingga 24 jam setelah persalinan atau kejang
berakhir (pada eklampsia)
Syarat: tersedia Ca Glukonas 10%, ada
refleks patella, RR > 16x/menit, dan
jumlah urin 0,5 ml/kgBB/jam

Cara pemberian MgSO4
• Lakukan PF setiap jam (tekanan darah, frekuensi nadi, frekuensi nafas,
refleks patella, jumlah urin
• Bila frekuensi pernapasan < 16x/menit dan/atau tidak ada refleks
tendon patella, dan/atau oliguria  segera hentikan MgSO4
• Jika terjadi depresi napas  Ca glukonas 1 g IV (10 ml larutan 10%)
bolus dalam 10 menit
• Jika terjadi eklampsia, berikan MgSO4 2 g IV perlahan (15-20 menit)
• Bila masih kejang, pertimbangkan diazepam 10 mg IV selama 2 menit
Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG. Williams’ Obstetric. 24th edition. USA: McGraw-Hill; 2012.
Anwar M, Baziad A, Prabowo P (eds). Ilmu Kandungan. Edisi Ketiga; Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2011
Angsar MD. Hipertensi dalam Kehamilan. In: Saifuddin AB, Rachimhadhi T, Wiknjosastro GH, editors. Ilmu kebidanan Sarwono Prawirohardjo. 4th ed. Jakarta: Bina Pustaka
Sarwono Prawirohardjo; 2014.
The Diagnosis and Management of Pre-Eclamsia and Eclamsia-Clinical Practice Guideline. Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and
Clinical Strategy and Programmes Directorate, Health Service Executive 2013.
Hypertensive disorders. In: Cunningham FG, et al. William obstetrics.24 th ed. Newyork: McGraw-Hill;2014. p.731

• Diuretik (bila edema paru, gagal jantung, atau edema anasarka)
 furosemide
• Antihipertensi  nifedipin/nikardipin/metildopa
• Kortikosteroid untuk pematangan paru
Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG. Williams’ Obstetric. 24th edition. USA: McGraw-Hill; 2012.
Anwar M, Baziad A, Prabowo P (eds). Ilmu Kandungan. Edisi Ketiga; Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2011
Angsar MD. Hipertensi dalam Kehamilan. In: Saifuddin AB, Rachimhadhi T, Wiknjosastro GH, editors. Ilmu kebidanan Sarwono Prawirohardjo.
4th ed. Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2014.
The Diagnosis and Management of Pre-Eclamsia and Eclamsia-Clinical Practice Guideline. Institute of Obstetricians and Gynaecologists, Royal
College of Physicians of Ireland and Clinical Strategy and Programmes Directorate, Health Service Executive 2013.
Hypertensive disorders. In: Cunningham FG, et al. William obstetrics.24 th ed. Newyork: McGraw-Hill;2014. p.731

Indikasi tatalaksana Aktif/Agresif
Ibu
• Umur kehamilan ≥
37 minggu
• Impending
eclampsia
• Kegagalan terapi
konservatif
• Solusio placenta
• Onset persalinan,
ketuban
pecah/perdarahan
Janin
• Fetal distress
• IUGR
• Oligohidramnion
Hasil Lab
• Tanda sindroma
HELLP
Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG. Williams’ Obstetric. 24th edition. USA: McGraw-Hill; 2012.
Anwar M, Baziad A, Prabowo P (eds). Ilmu Kandungan. Edisi Ketiga; Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2011
Angsar MD. Hipertensi dalam Kehamilan. In: Saifuddin AB, Rachimhadhi T, Wiknjosastro GH, editors. Ilmu kebidanan Sarwono Prawirohardjo. 4th ed. Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2014.
The Diagnosis and Management of Pre-Eclamsia and Eclamsia-Clinical Practice Guideline. Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and Clinical Strategy and Programmes Directorate, Health Service Executive
2013.
Hypertensive disorders. In: Cunningham FG, et al. William obstetrics.24 th ed. Newyork: McGraw-Hill;2014. p.731

Indikasi konservatif
• Preterm ≤ 37 minggu
• Tanpa disertai tanda-tanda impending eclampsia
• Keadaan janin baik
• Observasi dan evaluasi, kehamilan tidak diakhiri
• MgSO4 dihentikan jika gejala ibu sudah termasuk preeklampsia ringan,
maksimal 24 jam
Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG. Williams’ Obstetric. 24th edition. USA: McGraw-Hill; 2012.
Anwar M, Baziad A, Prabowo P (eds). Ilmu Kandungan. Edisi Ketiga; Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2011
Angsar MD. Hipertensi dalam Kehamilan. In: Saifuddin AB, Rachimhadhi T, Wiknjosastro GH, editors. Ilmu kebidanan Sarwono Prawirohardjo. 4th ed. Jakarta: Bina Pustaka Sarwono Prawirohardjo; 2014.
The Diagnosis and Management of Pre-Eclamsia and Eclamsia-Clinical Practice Guideline. Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland and Clinical Strategy and Programmes Directorate, Health Service Executive
2013.
Hypertensive disorders. In: Cunningham FG, et al. William obstetrics.24 th ed. Newyork: McGraw-Hill;2014. p.731