1. Pregnancy-induced hypertension includes preeclampsia, eclampsia and HELLP syndrome. It is a leading cause of maternal and neonatal morbidity and mortality worldwide. 2. The causes are multifactorial and not fully understood. Risk factors include nulliparity, previous preeclampsia, family history, multiple gestation, chronic hypertension and diabetes. 3. Clinical manifestations vary from mild to severe, including hypertension, proteinuria, organ dysfunction of liver, kidneys, brain and coagulation system. Management involves medical treatment, fetal monitoring and timely delivery depending on gestational age and severity of disease.

2. INTRODUCTION :
 INDUCED BY PREGNANCY
 DISEASE OF THEORIES
 CLINICAL MANIFESTATION : HYPERTENSION WITH OR WITHOUT
ORGAN DYSFUNCTION / FAILURE
 THIRD LEADING CAUSE MATERNAL MORTALITY IN OBSTETRIC
 MORTALITY RATE : 150.000 WOMEN A YEAR WORLD
WIDE

3. YEAR HOSPITAL PERCENTAGE AUTHOR
1993 – 1997
1996 – 1997
1995 – 1998
2000 – 2002
2002
RSPM
12 HOSPITALS
RS. H.S.
RSHAM – RSPM
RSCM
5,75
0,8 - 14
13,0
7,0
9,17
SIMANJUNTAK
J.
TRIBAWONO A.
MEIZIA
GIRSANG. E
PRIYATINI
INCIDENCE
P.E AND E : 2% - 9% OF ALL PREGNANT WOMEN
IN SEVERAL HOSPITAL IN INDONESIA

4. ETIOLOGY : NOT FULLY UNDERSTOOD
 RISK FACTOR :
 NULLI PARITY / TEENAGE PREGNANCY
 HISTORY OF PREVIOUS PREGNANCY
 FAMILY HISTORY OF P.E AND E
 MULTIPLE GESTATION
 PREEXISTING HYPERTENSION / RENAL DISEASE
 D.M, ANTI PHOSPOLIP ANTIBODY
 HYDROPS FETALIS
 HYDATIDIFORM MOLES
 URYNARY TRACT INFECTION

5. PATHOGENESE :
 CONTROVERSION : THE DISEASE OF THEORIES
IMMUNITY, GENETIC
VASC. DISEASE
TROPHOBLAST 
INADEQUATE TROPHOB. INVASION TO
SPIRAL ARTERY OF PLACENTA
INSUFF, PLACENTA
 HYPOXIA IUGR
OXYDATIVE STRESS
ENDOTHELIAL DYSFUNCTION
CIRCULATING FACTOR(S)
CYTOKINES LIPID
(IL-6, TNF-) PEROXIDES
NEUTROPHIL
ACTIVATION
PLATELET
ACTIVATION

6. ENDOTHELIAL DYSFUNCTION
BLOOD
▪ THROMBOCYTOPENIA
▪ COAGULAPATHY
ALTERED VASCULAR
PERMEABILITY
▪ PERIPHERAL OEDEMA
▪ PULMONARY OEDEMA
SYSTEMIC
VASOCONSTRICTION
▪ HYPERTENSION
KIDNEYS
▪ HYPERURICAEMIA
▪ PROTEINURIA
▪ RENAL FAILURE
LIVER
▪ ABNORMAL FUNCTION
TESTS
▪ HAEMORRHAGE
CNS / EYES
▪ SEIZURES
▪ CORTICAL BLINDNESS
▪ RETINAL DETACHMENT
& HAEMORRHAGE

7. CLINICAL CLASSIFICATION:
 PREECLAMPSIA - MILD
- SEVERE
 IMPENDING ECLAMPSIA
 ECLAMPSIA
 HELLP SYNDROME

8. MILD PREECLAMPSIA :
 BP  140/90 mmHg AFTER 20 WEEKS GESTATION
 PROTEINURIA  300 mg/ 24 H OR 1+ DIPSTICK

9. SEVERE PREECLAMPSIA
 BP  160/110 mmHG
 PROTEINURIA 2.0 gr / 24 H OR  2 + DIPSTICK
 HEADACHE, VISUAL OR CEREBRAL DISTURBANCE
 EPIGASTRIC PAIN
 OLIGURIA : < 400 – 500 CC/ 24 HOURS
 HYPER REFLEX, MOTORIC EXCITATION, IMPAIRED
CONSIOUSNESS, SUDDEN DETERIORATION
 PLATELETS COUNT < 1000.000 / mm3
 BILIRUBIN  1,2 mg / DL
 LDH > 600 IU/L
 SGOT > 70 mg/DL

10. IMPENDING ECLAMPSIA
 SEVERE PREECLAMPSIA WITH :
 HEADACHE
 NAUSEA AND VOMITING
 BLURRED VISION, SCOTOMA, IMPAIRED CONSIOUSNESS,
SUDDEN DETERIORATION
 EPIGASTRIC PAIN

11. ECLAMPSIA
 SEVERE PREECLAMPSIA + CONVULSION
 IS THR LEADING CAUSES OF 50.000 MATERNAL MORTALITY
A YEAR WOLRD WIDE
 75% OCCURRED ANTEPARTUM AND 25% POST PARTUM
 40% OF SEIZURES OCCURE BEFORE HOSDITALIZATION
 CEREBRAL HAEMORRHAGE, PULMONARY EDEMA FAILURE
ARE THE MOST COMMON COMPLICATION

12. HELLP SYNDROME
 COMPLICATION OF SEVERE PREECLAMPSIA
 10-15% DIRECTLY FROM PREGNANCY
MANAGEMENT OF PREECLAMPSIA
 ADEQUAT AND PROPER PRENATAL CARE
 IDENTIFICATION OF WOMEN AT HIGH RISK
 EARLY DETECTION BY THE RECOGNATION OF CLINICAL
SIGNS AND SYMPTOMS
 THE PROGRESSION OF CONDITION TO SEVERE STATE

13.  MATERNAL AND PERINATAL OUTCOME IN WOMEN WITH MILD
PREECLAMPSIA, > 36 WEEKS GESTATION ARE USUALLY
FAVOURABLE
 MATERNAL AND PERINATAL OUTCOMES DEPEND ON :
 GESTATIONAL AGE AT TIME OF DISEASE ONSET
 SEVERITY OF DISEASE
 QUAITY OF MANAGEMENT
 PRESENCE OR ABSENCE OF PRE-EXISTING MEDICAL
DISORDERS

14. MILD – PREECLAMPSIA
 AMBULATORY CARE
 BED REST : NOT NECESSARILY
 REGULAR DIET, NO SALT RESTRICTION
 PRENATAL VITAMIN
 NO OTHER MEDICATION : ANTI HYPERTENSIVE,
SEDATIVE, DIURETICS
 ANTENAL VISIT : EVERY WEEK

15. HOSPITAL CARE
 PERSISTENT HYPERTENSION MORE THAN 2 WEEKS
 PERSISTENT PROTENURIA MORE THAN 2 WEEKS
 ABNORMAL LABORATORY TEST
 ABNORMAL FETAL GROWTH
 ONE OR MORE SIGN AND SYMPTOM SEVERE PE

16. OBSTETRIC MANAGEMENT
 GESTATIONAL AGE < 37 WEEKS
▪ SIGN AND SYMPTOM ARE NOT WORSENED  MAINTAIN
UNTIL TERM
 GESTATIONAL AGE > 37 WEEKS
▪ WAIT UNTIL THE ONSET OF LABOR
▪ CERVIX IS FAVORABLE, INDUCTION OF LABOR

17. SEVERE PREECLAMPSIA
 MEDICAL TREATMENT
 OBSTETRIC MANAGEMENT :
▪ CONSERVATIVE : - PREGNANCY  37 WEEKS
▪ ACTIVE : - PREGNANCY  37 WEEKS
- FETAL INDICATION
- MATERNAL INDICATION

18. MEDICAL TREATMENT :
 HOSPITALIZE
 TOTAL BED REST
 FLUID THERAPY : RINGER LACTATE, DEXTROSE 5%.
 Mg SO4 IV
 ANTI HYPERTENSION :
 HYDRALAZIN
 LABETALOL
 NIFEDIPINE : 10 – 20 mg / ORALLY EVERY ½ - 1 H,
MAX : 120 mg / 24 Hours
 DIURETIC : NOT RECOMMENDED
 ANTI OXYDANT : N-ACETYL CYSTEIN
 CORTICOSTEROID + LUNG MATURITY  34 WEEKS

19. OBSTETRIC MANAGEMENT
 CONSERVATIVE MANAGEMENT:
 GOAL : TO IMPROVE INFANT OUTCOME,
WITHOUT COMPROMISING THE MOTHER
PREGNANCY  37 WEEKS, IMPENDING ECLAMPSIA (-)
 ACTIVE MANAGEMENT : TO TERMINATE THE PREGNANCY
 INDICATION
FETAL : - PREGNANCY  37 WEEKS
- IUGR AND ABNORMAL
BIOPHYSICAL PROFILE

20. MATERNAL : - PERSISTENT HYPERTENTION
- IMPENDING ECLAMPSIA
- COMPLICATION : HELLP SYNDROME,
ABRUPTIO PLAC., OLIGURIA
 ROUTE OF DELIVERY :
▪ VAGINAL DELIVERY IS PREFERABLE THAN CS.

21. ECLAMPSIA : PE + CONVULSION
 BASIC MANAGEMENT :
 CONTROL THE AIRWAY, BREATHING, CIRCULATION (ABC)
 STABILIZE THE MOTHER
 CONTROL CONVULSION
 CORRECTION MATERNAL HYPOXEMIA / ACIDEMIA
 PREVENT COMPLICATION : HYPERTENSION CRISIS
 TERMINATED PREGNANCY
 MEDICAL TREATMENT :
 SAME AS SEVERE PREECLAMPSIA

22. COMPLICATION : P.E AND ECLAMPSIA
MOTHER BABY
HELLP SYNDROME
LIVER RUPTURED
PULMONARY EDEMA
RENAL FAILURE
ABRUPTIO PLACENTAE
DIC
CEREBROL VASCULER ACCIDENT
MATERNAL DEATH
IUGR
PREMATURE LABOR
INTRA CRANIAL HAEMORRHAGE
CEREBRAL PALSY
PNEUMO THORAX
IUFD

23. HELLP SYNDROME
PREGNANCY
HYPERTENSION AND
PROTEINURIA
PREECLAMPSIA
HELLP SYNDROME
10-14% CASE

24. HELLP SYNDROME
 FIRST DISCRIBED BY WEINSTEIN 1982:
 ACRONYM OF : H : HARMOLYSIS
EL : ELEVATED LIVER ENZYM
LP : LOW PLATETLED COUNT
 INCIDENCE : 2%-12% AMONG PATIENTS WITH
PREECLAMPSIA.
30% OCCURS IN POSTPARTUM

25. LABORATORY FINDING
 HEMOLYSIS
 ABNORMAL PERIPHERAL SMEAR : SCHISTOCYTES AND
BURR CELLS
 TOTAL BILIRUBIN LEVEL > 1,2 mg/Dl
 LACTATE DEHYDROGENASE LEVEL > 600 /L
 ELEVATET LIVER FUCTION
 SGOT LEVEL  70  / L (LDH)
 LACTATE DEHYDROGENASE LEVEL > 600 /L
 LOW PLATELET COUNT
PLATELET COUNT < 100.000/m3

26. 1. HYPERTENSION, PROTEINURIA AND OTHERS SYNDROMA OF
PREECLAMPSIA ARE INDUCED BY PREGNANCY
2. BESIDE HYPERTENSION AND PROTEINURIA, OTHERS SYNDOREMA OF
PREECLAMPSIA ARE EPIGASTRIC PAIN, HEADCHE, VISUAL DISTURBANCE,
OLIGURIA, CONVULSION, AND RENAL FAILURE.
3. THERE ARE STILL CONTROVERSION IN CLASSIFICASION, DIAGNOSTIC
AND MANAGEMENT OF PREGNANCY INDUCED HYPERTENSION.
4. IN PATIENT WITH MULTI ORGAN DYSFUNCTION / FAILURE MULTIDISIPLIN
MANAGEMENT IS NEEDED.
5. IGNORANCE, POVERTY, LATE ADMITTED TO HOSPITAL WILL INCREASE
FERINATAL - MATERNAL, MORBIDITY AND MORTALITY
CONCLUSIONS :

28. REFERENCES :
1. Baker PN., Kingdom J., “Preeclampsia” Current Perspectives on
Management. The Parthenon Publishing Group, New York, USA,
2004 page 133 – 143.
2. Brown MA. Diagnosis and Classification of Preeclampsia and
Hypertensive Disorders of Pregnancy in Belfort MA, Thornton S,
Saade GR. “Hypertension in Pregnancy”, Marcel Dekker, Inc. New
York, 2003, page 1 – 14.
3. Cronic Hypertension in Pregnancy; ACOG Practice Buletin; number
29, July 2001.
4. Churchil D. Beevers DG. Deinitions and Classification Systems of
the Hypertensive Disorders in Pregnancy in Churchiil D, Beevers
DG. “Hypertension in Pregnancy”. BMJ Books, London, 1999.
5. Cuningham FG, Mac Donald PC, Grant NF, et al. Hypertensive
Disorders in Pregnancy. In : William Obstetrics. 21th ed. Conecticut
: Appleton and Lange, 2001 : 567 – 609.
6. Dekker GA, Sibai BM. Ethiology and Pathogenesis of Preeclampsia
: Current Concept. AmJ Obstet Gynecol 1998; 179 : 1359 – 75.

29. 7. Deeker GA, “Risk Factor for Preeclampsia” in Clinical Obstetrics
and Ginecology, Vol 42:422, 1999.
8. Daignosis and Management of Preeclampsia and Eclampsia; ACOG
Practice Bulletin, number 33, January 2002.
9. Dieckmann; WJ “The Toxemias of Pregnancy” 2nd edition, St.
Louis, The C.V. Mosby Co., 1952.
10. Dikman AM, Hypertension in Pregnancy, Proposal for Clinical
Practice Guide-line in Indonesia, 1st. ed. English Version, March
2005.
11. Girsang ES. Analisa Tekanan Darah dan Proteinuria sebagai Faktor
Prognosi. Kematian Maternal dan Perinatal pada Preeeklamsia
Berat dan Eklamia. Tesis Bagian Obgin FK. USU RSUP. H. Adam
Malik / RSUD Dr. Pirngadi Medan, 2004.
12. Lockwood CJ dan Paidas MJ. Preeclampsia and Hypertensive
Disorders in Wayne R, Cohen Complications of Pregnancy, 5th ed.
Philadelphia : Lippicott Williams dan Wilkins, 2000 : 207 – 26.
13. Magann EF, Martin RW, Jsaacs JD, et al. Corticosteroids for the
Enhancement of Fetal Lung Maturity : Impact on the Gravida with
Preeclampsia and the HELLP Syndrome. Aust MZ J Obstet Gynecol
1993; 33 : 127 – 30.

30. 14. Martin JN, Perry KG, Blake PG, et al. Better Maternal Outcomes are
Achieved with Dexamethasone Therapy for Postpartum HELLP
(Hemolysis, Elevated Liver Enzymes and Low Thrombosit Counts)
Syndrome. AmJ Obstet Gynecol 1997; 177 : 1011 – 7.
15. Pedoman Penanganan Penderita Preeklamsia Berat dan HELLP
Syndrome, Satgas Penanganan Penderita Preeklamsia Berat dan
HELLP Syndrome Bagian / UPF Ilmu Kebidanan dan Penyakit
Kandungan FK – USU RSUD. Dr. Pirngadi Medan tahun 2002.
16. “Report of the National High Blood Pressure Education Program
Working Group on High Blood Pressure in Pregnancy”, National
High Blood Pressure Education Program Working Group on High
Blood Pressure in Pregnancy, Am.J.Ob. Gynecology; 183, S1, 2000.
17. Satgas Gestosis POGI. “Panduan Pengelolaan Hypertensi dalam
Kehamilan di Indonesia” edisi 1985.
18. Sibai BM; “Diagnosis Prevention, and Management of Eclampsia”,
Obstetrics & Gynecology, vol 105, number 2, February 2005, page
405 – 410.