Materi-dr. PE.pdf

PENATALAKSANAAN
PREEKLAMSIA
MASA KEHAMILAN,
PERSALINAN DAN NIFAS
DALIMAN
RS MARGONO SOEKARJO/
FK UNSOED
PURWOKERTO
Jumat, 08 Maret 2019 1
PENATALAKSANAAN PREEKLAMSIA,
SEMINAR POLTEKES, 09 MARET 2019,
DALIMAN.DM19

INSIDENSI
 KELAINAN
HIPERTENSI DALAM
KEHAMILAN (HDK)
MERUPAKAN
KOMPLIKASI 5 – 10%
DARI SELURUH
KEHAMILAN.
 PREEKLAMSIA
TERIDENTIFIKASI 3,9%
DARI SELURUH
KEHAMILAN.
 DI NEGARA MAJU 10–16 %
KEMATIAN IBU DISEBABKAN OLEH
KELAINAN HIPERTENSI.
 PROPORSI 3 PENYEBAB
KEMATIAN LAIN PERDARAHAN
13% , ABORSI 8 %, DAN SEPSIS
2%.
YANG PENTING, BAHWA LEBIH
DARI SETENGAH
HIPERTENSI YANG
DIHUBUNGKAN DENGAN
PENYEBAB KEMATIAN DAPAT
DICEGAH
DALIMAN.DM19

HIPERTENSI DALAM KEHAMILAN (HDK)
(Pregnancy-Related Hypertension, Preclampsia and Hypertensive disorder,
Hypertension in Pregnancy, Hypertensive Disorders, Hipertensive Emergencies)
Klasifikasi (ACOGTak Force for
Hypertension, 2013; NIH Working group
on Hypertension in Pregnancy):
1. Preeclampsia (PE) and
eclampsia (E) syndrome,
2. Chronic hypertension (CHTN) of any
etiology,
3. Preeclampsia superimposed on
chronic hypertension (SIPE),
4. Gestational hypertension (GHTN).
Klasifikasi :
I. Gestasional Hypertension,
II. Gestasional Proteinuria,
III. Preeclampsia and
Preeclampsia with severe
features.
IV. Chronic Hypertension,
V. Superimposed Preeclampsia,
VI. Superimposed Preeclampsia
with severe featrures
DALIMAN.DM19
Creasy & Resnik’s, 2019. Maternal-Fetal Medicine: Principles and Practice, 8th ed.
Cunningham et.al., 2018. Williams Obstetrics, 25th ed) Foley MR, et.al., 2018. Obstetrics, Intensive Care Manual, 5th ed.
Mularz A, et.al.,2017. OB/GYN, secrets, 4th ed.
Gabe, SG,. Et.al, 2017. Obstetrics; Normal and problem Pregnancies, 7ed.

ATYPICAL PREECLAMPSIA
The criteria for atypical
preeclampsia include
gestasional proteinuria or FGR
plus one or more of the following
symptoms of preeclampsia :
hemolysis, thrombocytopenia,
elevated liver enzymes, early signs
and symptoms of preeclampsia-
eclampsia earlier than 20 weeks,
and late postpartum preeclampsia-
eclampsia ( > 48 hours postpartum).
Gabbe et.al, 2017
DALIMAN.DM19

HIPERTENSI DALAM KEHAMILAN
Definisi dan kriteria
diagnostik :
1. Chronic hypertension,
2. Gestasional hypertension,
3. Preeclampsia without severe
features (“mild preeclampsia”),
4. Superimposed Preeclampsia,
5. Superimposed Preeclampsia with
severe features,
6. Preeclampsia with sevevre
features (“severe preeclampsia”).
7. HELLP syndrome,
8. Eclampsia.
Klasifikasi (ISSHP, 2000;
2014):
1. Chronic hypertension,
2. Gestasional hypertension,
3. Preeclampsia – de novo or
Superimposed on chronic
hypertension,
4. White-coat hypertension
DALIMAN.DM19
Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, 3th ed.
James D, et.al., 2017. High-Risk Pregnancy, managemant options, 5th ed.

Hipertensi Dalam Kehamilan (HDK)
1. Hipertensi (HTN) +,
2. Hipertensi (HTN) -,
3. Proteinuria (PU) +,
4. Proteinuria (PU) -,
5. Hasil laboratorium
(Lab) PEB,
6. Gejala atau tanda
(G&T) PEB.
HAMIL
HTN
+
HTN
-
PU +
PU-
LAB
PEB
G&T
PEB
DALIMAN.DM19

DEFINISI
KEHAMILAN:
• SEBELUM HAMIL,
• HAMIL ≤ 20 MGG,
• HAMIL > 20 MGG,
• PERSALINAN,
• NIFAS.
HIPERTENSI :
• TEKANAN DARAH ≥ 140/90 mmHg,
• White-coat Hypertension 
diperiksa TD ≥ 140/90 mmHg,
monitor 24 jam TD < 130/80 mmHg,
• Delta Hypertension  kenaikan
MAP setelah UK 28 mgg.
• Kenaikan Tek Sistolik > 30 mmHg,
Tek Diastolik > 15 mmHg.
DALIMAN.DM19

PENEGAKAN DIAGNOSIS HIPERTENSI
Tensimeter air raksa
 Menggunakan
tensimeter air
raksa, atau
 Tensimeter jarum atau
otomatis yang sudah
divalidasi. Pengukuran
tekanan darah (TD)
menggunakan alat otomatis
sering memberikan hasil yang
lebih rendah.
American Society of Hypertension
 Sebelum dilakukan pengukuran TD,
ibu duduk tenang selam 15 menit,
 Pengukuran pada posisi DUDUK
atau TERLENTANG, posisi lateral
kiri, kepala ditinggikan 30º, posisi
manset setingkat dengan jantung,
dan tekanan DIASTOLIK diukur
dengan mendengar bunyi
Korotkoff V (hilang bunyi). Pada
wanita dengan hipertensi kronik
pengukuran dilakukan pada kedua
lengan, dengan menggunakan hasil
pemeriksaan yang tertinggi.
DALIMAN.DM19

DELTA HIPERTENSI
DALIMAN.DM19
Cunningham et.al, 2018.
Williams Obstetrics, 25 ed

DEFINISI
Proteinuria + (posistif):
 ≥ 300 mg/ 24 jam
urine tampung,
 Rasio creatinin/
protein urine, 1 x
pemeriksaan, > 0,3
mg/ dL,
 Kualitatif dipstik 1+ (30
mg/ dL)
Lab Preklamsia Berat
(PEB):
• Trombositopenia ( <
100.000/ µL),
• Konsentrasi Creatinin serum
> 1,1 mg/ dL (2 x nilai
NORMAL, tanpa penyakit
ginjal lain),
• SGOT/ PT > 2 x NILAI ATAS
NORMAL.
DALIMAN.DM19

DEFINISI
Gejala dan tanda PEB:
1. Muncul gangguan baru
cerebral atau visual,
2. Edema paru atau SIANOSIS
3. Nyeri menetap epigastrik
atau kuadran kanan atas
yang tidak respon terapi
dan tidak ada alternatif
diagnosis.
DALIMAN.DM19

DIAGNOSIS HDK
HIPERTENSI
≥ 140/90
1
PROTEIN
URIA
POSITIF
2
PROTEINURIA
NEGATIF
2
LAB &
GEJALA
-TANDA
PEB
1. HTN + PU (-)(LAB PEB -, G&T PEB -) +
UK ≥ 20  HIPERTENSI GESTASIONAL
2. HTN + PU (-) (LAB PEB -, G&T PEB -) +
UK < 20  HIPERTENSI KRONIK
3. HTN + PU (+)/(-) (LAB PEB +, G&T PEB
+) + UK ≥ 20  SINDROMA
PREEKLAMSIA (PE)
4. HTN + PU (-)  PU (+)/ (-) (Kenaikan
HTN) pada UK ≥ 20  PREEKLAMSIA
SUPERIMPOSSED (SIPE).
MedScape, Kee-Hak Lim, MD; Ronald M Ramus,
MD Preeclampsia Updated: Feb 16, 2018
Cunningham et.al, 2018. Williams
Obstetrics, 25 ed and ACOG, 2013
DALIMAN.DM19

PREEKLAMSIA
HT
PROT
+/-
PE
HT (HIPERTENSI) :
 TEKANAN DARAH ≥
140/90.
 HIPERTENSI White Coats,
adalah DIPERIKSA (Dr/Per/
Bidan) ≥ 140/90, monitor 24
jam < 130/80, ≥ UK 20 mgg
 DELTA HIPERTENSI 
KENAIKAN MAP PADA
TRIMESTER III
 TEKANAN SISTOLIK NAIK
30, DIATOLIK NAIK 15.
DALIMAN.DM19

Sindroma PREEKLAMSIA
 Diskripsi yang paling baik, adalah sindroma spesifik
kehamilan yang pada hakekatnya dapat mempengaruhi setiap
sistem organ.
 Dasar diagnosis- paling sederhana- adalah TEKANAN DARAH
≥ 140/90 mmHg + POSITIF PROTEINURIA ( gambaran
kerusakan endothelial-karakteristik sindroma Preeklamsia)
 Abnormal ekskresi PROTEIN, adalah 300 mg/ 24 jam, atau
rasio protein : kreatinin urine ≥ 0,3, atau persisten 30
mg/dL (1+ dipstik).
DALIMAN.DM19

Sindroma Preeklamsia
 Menurut Sibai (2009) dan ACOG
(2013b): diagnosis sindroma
Preeklamsia dapat ditegakkan TIDAK
HARUS PROTEINURIA POSITIF.
 HIPERTENSI + DISFUNGSI
MULTIORGAN, seperti trombositopenia
(< 100.000), disfungsi renal (kreatinin >
1,1 mg/dL), nekrosis hepatoseluler
(disfungsi liver)( AST dan ALT > 2 X
NORMAL), pertubasi sistema syaraf
pusat/ SSP (nyeri kepala, gangguan
penglihatan, dan KEJANG), EDEMA
PULMONUM
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PREEKLAMSIA BERAT
(Gabbe, et.al, 2017; Cunningham, et.al 2018; Lim KH, 2018)
Jumat, 08 Maret 2019
DALIMAN.DM19
16
Ditandai (salah satu):
 Tek sistolik >/= 160 mmHg,
atau tekanan diastolik >/= 110
mmHg.
 Kegagalan fungsi hati,
 Insufisiensi ginjal progresif,
 Gangguan serebral atau
pandangan (baru muncul),
 Edema pulmonum,
 trombositopenia
HIPERTENSI (baru) tanpa
proteinuria, didiagnosis PE, jika
didapatkan salah satu :
 Trombositopenia,
 Serum kreatinin > 1,1 mg/dl, atau
2 kali lipat Normal,
 SGOT dan SGPT 2 kali Normal,
 Edema pulmonum,
 Gangguan serebral dan
pandangan.

Preeclampsia with severe features
(“severe preeclampsia”)
1. BP ≥160/110 mmHg (two occasions, >4 hours apart)
2. Thrombocytopenia (platelets <100,000/mm3) and/or evidence of
microangiopathic hemolytic anemia
3. Increased hepatic transaminases (AST and/or ALT) two times of the
upper limit of normal concentration for the particular laboratory
4. Progressive renal insufficiency (creatinine ≥1.1 mg/dL or a doubling
of the serum creatinine) or oliguria (<500 mL urine in 24 hours)) in
absence of other renal disease
5. Persistent headache or other cerebral or visual disturbances
(including grand mal seizures)
6. Persistent epigastric (or right upper quadrant) pain
7. Pulmonary edema or cyanosis
Preeclampsia with any one of the following criteria:
DALIMAN.DM19
Berghella V, 2017. Maternal-Fetal Evidence Based Guidelines, 3rd ed

Superimposed preeclampsia
One or more of the following
criteria:
1. New onset of proteinuria (≥300 mg in 24
hours without prior proteinuria) after 20
weeks in a woman with chronic HTN or
sudden increase in proteinuria in a
woman with known proteinuria before or
early in pregnancy
2. A sudden increase in
hypertension previously well
controlled or escalation of antihypertensive
medication to control BP
DALIMAN.DM19

Superimposed preeclampsia with severe
features
1. Severe range of BP (≥160/110 mmHg) despite escalation of
antihypertensive medication
2. Platelet count < 100,000/mm3.
3. Increased hepatic transaminases (AST and/or ALT) two times the upper
limit of normal concentration at a particular laboratory
4. New onset or worsening renal insufficiency (creatinine ≥1.1
mg/dL or a doubling of the serum creatinine)
5. Pulmonary edema
6. Persistent neurological symptoms (e.g., headache, visual changes)
Superimposed preeclampsia and one or more of the following
criteria:
DALIMAN.DM19

Eclampsia
Seizures (grand mal) in the presence of
preeclampsia and/or HELLP
syndrome.
DALIMAN.DM19

Eklamsia
SEKITAR 15% KASUS,
TANPA HIPERTENSI
DAN PROTEINURIA
SEBELUM EKLAMSIA,
LEBIH DARI 50%
KASUS TERJADI PADA
KASUS YANG TIDAK
DIDIAGNOSIS PRE-
EKLAMSIA, TETAPI
HANYA PENYAKIT
RINGAN, PRETERM,
DAN TANPA DAPAT
DICEGAH.
DALIMAN.DM19
HT PE PEB Ekl
85%
15% (-) HT dan (-) PU
15% ?
?
?

EKLAMSIA
1. Hanya 42%-43%
Eklamsia didahului
dengan PE  57%-
58% tidak didahului
PE
2. 30%-50% Eklamsia
tidak didahului
dengan PEB 
50%-70% didahului
PEB.
DALIMAN.DM19
PE PEB EKL
Creasy and Resnik’s, et.al., 2019. Maternal-
Fetal Medicine, Principle and Practice, 8th ed.
42%-43%
50%-70%
≠30%-50%
≠ 57%-58%
25%
MedScape, Kee-Hak Lim, MD; Ronald M
Ramus, MD Preeclampsia Updated: Nov 29, 2018

HELLP syndrome
• Hemolysis as evidenced by an abnormal peripheral smear in
addition to either serum LDH >600 IU/L or total bilirubin ≥1.2
mg/dL (≥20.52 μmol/L)
• Elevated liver enzymes as evidenced by an AST or ALT two
times the upper limit of normal concentration at a particular
laboratory
• Platelets <100,000 cells/mm3.
• If all the criteria are met, the syndrome is defined “complete”; if only
one or two criteria are present, the term “partial HELLP” is preferred.
Tennessee Classification (most commonly used)
DALIMAN.DM19

03/08/2019
PEMBELAJARAN TERFOKUS AMP, 150517,
DALIMAN.DM17
24
The basic management objectives
for any pregnancy complicated by
Preeclampsia are (Cunningham, 2018):
1. Termination of pregnancy with the least possible trauma
to mother and fetus
2. Birth of an infant who subsequently thrives
3. Complete restoration of health to the mother.
PENATALAKSANAAN
PREEKLAMSIA

PENCEGAHAN PE
Terminologi umum
PENCEGAHAN,
dibagi 3:
1. Pencegahan
PRIMER,
2. Pencegahan
SEKUNDER,
3. Pencegahan
TERSIER.
 PRIMER, artinya menghindari
terjadinya PENYAKIT,
 SEKUNDER, artinya
memutus proses terjadinya
PENYAKIT yang sedang
berlangsung sebelum timbul
GEJALA atau KEDARURATAN
KLINIS,
 TERSIER, berarti
pencegahan dari KOMPLIKASI
yang disesbabkan oleh proses
PENYAKIT TATALAKSANA
DALIMAN.DM19
PNPK PREEKLMASIA, HKFM POGI

PENCEGAHAN PRIMER
o Pencegahan
yang terbaik,
namun hanya
dapat dilakukan
apabila
penyebab PE
telah diketahui
dengan jelas.
o Dilakukan
dengan prediksi
dan mengontrol
FAKTOR RISIKO
PE 17
1. Umur > 40 th,
2. Nulipara,
3. Multipara dengan riwayat PE,
4. Multipara dengan kehamilan oleh pasangan BARU
(primipaternitas),
5. Multipara yang jarak kehamilan sebelumnya ≥ 7-10 th,
6. Riwayat PE sebelumnya,
7. Riwayat keluarga PE (IBU atau saudara perempuan),
8. Kehamilan multipel,
9. IDDM,
10. Penyakit GINJAL,
11. Penyakit GIGI,
12. APS,
13. Kehamilan dengan inseminasi dodor sperma, oosit atau embryo,
14. OBESITAS sebelum hamil,
15. BMI ≥ 35,
16. Takanan darah DIASTOLIK ≥ 80 mmHg
17. Proteinuria (dipstick ≥+1 pada 2 kali pemeriksaan berjarak 6 jam atau
secara kuantitatif 300 mg/ 24 jam)
DALIMAN.DM19
PNPK HKFM POGI. PREEKLAMSIA

Risk factors- Preeclampsia
Risk factors for preeclampsia and their odds
ratios are as follows[2] :
1. Nulliparity (3:1)
2. Age older than 40 years (3:1)  >35 th (1,2 :1 / 1,1-1,3)
3. Black race (1.5:1)
4. Family history (5:1)
5. Chronic renal disease (20:1)
6. Chronic hypertension (10:1)
7. Antiphospholipid syndrome (10:1)
8. Diabetes mellitus (2:1)
9. Twin gestation (but unaffected by zygosity) (4:1)
10. High body mass index (BMI > 30) (3:1)
11. Homozygosity for angiotensinogen gene T235 (20:1)
12. Heterozygosity for angiotensinogen gene T235 (4:1)
13. TEK SIS > 130, TEK DIASTOLIK > 80 mmHg UK < 20.
14. Interval KEHAMILAN > 7 TH,
15. RIWAYAT PE kehamilan sebelumnya (8,4:1 / 7,1-9,9),
16. Kehamilan dengan ASISSTED REPRODUCTIONS TECHNOLOGY (1,8:1).
17. Riwayat SOLUSIO PLASENTA (2,0:1/ 1,4-2,7), LAHIR MATI (2,4:1)
MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD Preeclampsia Updated: Nov 29, 2018
DALIMAN.DM19
James D., et.al., 2017. High-Risk
Pregnancy, Management Options. 5th ed
Gabbe et.al., 2017. Obstetrics, Normal adnd Problem Pregnancies, 7th ed.
Creasy and Resnik’s, et.al., 2019. Maternal-
Fetal Medicine, Principle and Practice, 8th ed.
Cunningham, 2018.
Williams Obstetrics,
25th ed.)

PENCEGAHAN SEKUNDER
1. Istirahat,
2. Restriksi
garam,
3. ASPIRIN dosis
rendah,
4. Suplemenatsi
KALSIUM,
5. Suplementasi
ANTIOKSIDAN.
KESIMPULAN (ASPIRIN DOSIS RENDAH)
1. Penggunaan Aspirin dosis rendah untuk
PENCEGAHAN PRIMER berhubungan dengan
penurunan risiko PE, persalinan PRETERM,
kematian janin atau neonatus dan BAYI KMK,
sedangkan untuk PENCEGAHAN SEKUNDER
berhubungan dengan penurunan risiko PE,
persalinan PRETEM < 37 mgg, dan BBL < 2500
gram.
2. Efek Asprin lebih nyata didapatkan pada
KELOMPOK RISIKO TINGGI,
3. Pemberian Aspirin dosis > 75 mg lebih baik untuk
menurunkan risiko PE, namun risiko yang
diakibatnya lebih tinggi.
REKOMENDASI
Aspirin dosis 75 mg atau kurang cukup aman
diberikan pada KELOMPOK RISIKO TINGGI
untuk menurunkan risiko PE baik sebagai
pencegahan PRIMER atau SEKUNDER.
03/08/2019 28
DALIMAN.DM17
Level evidence Ia, Rekomendasi A

PENCEGAHAN SEKUNDER
1. Istirahat,
2. Restriksi
garam,
3. ASPIRIN dosis
rendah,
4. Suplemenatsi
KALSIUM,
5. Suplementasi
ANTIOKSIDAN.
KESIMPULAN (KALSIUM)
1. Pemberian KALSIUM (1,5-2 gram)
berhubungan dengan penurunan HDK
dan PE pada wanita dengan ASUPAN
RENDAH KALSIUM dan risiko tinggi PE,
2. Pemberian Kalsium juga berhubungan
dengan penurunan risiko MORBIDITAS
BERAT dan MORTALITAS MATERNAL,
persalinan PRETERM, dan tekanan
darah diastolik > persentil 95 pada
masa kanak.
REKOMENDASI
Pemberian KALSIUM dapat dilakukan pada
WANITA yang MEMILIKI RISKO TINGGI
PE dan RENDAH ASUPAN KALSIUM
untuk mencegah terjadinya PE.
DALIMAN.DM19

TOG release: Low dose aspirin and calcium
supplementation for prevention of pre-eclampsia
• Low dose aspirin started before 16 weeks
gestation and calcium supplementation after 20
weeks gestation in low-intake populations can
prevent the onset of pre-eclampsia in pregnancies at
risk of the condition, states a new review published
today in The Obstetrician & Gynaecologist (TOG). It
is also possible to assess a woman’s risk of
developing pre-eclampsia from as early as 11 weeks
of pregnancy, say the authors.
18 July 2014
03/08/2019 30
DALIMAN.DM17

PENCEGAHAN SEKUNDER
Rekomendasi :
• Istirahat di rumah ( 4jm/ hr atau
2 x 15 menit + suplemen)
direkomendasikan untuk
pencegahan primer PE,
• Tirah baring TIDAK
direkomendasikan untuk
memperbaiki luaran pada wanita
dengan hipertensi (dengan atau
tanpa proteinuria)
Rekomendasi :
• Pembatasan garam
untuk mencegah PE dan
komplikasinya selama
kehamilan TIDAK
direkomendasikan.
DALIMAN.DM19

Clinical Risk Assessment for
Preeclampsia
Risk Level Risk Factors Recommendation
High History of preeclampsia, especially when
accompanied by an adverse outcome, Multifetal
gestation, Chronic hypertension, Type 1 or 2
diabetes, Renal disease, Autoimmune disease
(systemic lupus erythematous, antiphospholipid
syndrome)
Recommend low-dose
aspirin if the patient
has ≥1of these
high-risk factors
Moderate Nulliparity, Obesity (body mass index >30 kg/m2), Family history of
preeclampsia (mother or sister), Sociodemographic characteristics
(African American race, low socioeconomic status), Age ≥35 years
Personal history factors (e.g., low birthweight or small for
gestational age, previous adverse pregnancy outcome, >10-year
pregnancy interval)
Consider low-dose
aspirin if the patient
has severalof
these moderate-risk
factors.
Low Previous uncomplicated full-term delivery Do not recommend
low-dose aspirin
Timing Use of low-dose aspirin was initiated between 12 and 28 weeks of gestation. Evidence did not suggest additional benefit when
use of aspirin was started earlier (12 to 16 weeks) rather than later (≥16 weeks) in pregnancy in women at increased risk for
preeclampsia 1.
DALIMAN.DM19

Penanganan
 Hanya persalinan obat
preeklamsia.
 Pasien dengan PE tidak berat
perlu induksi setelah umur
kehamilan 37 mgg.
 Sebelumnya pasien biasanya diawasi
dengan ketat atau dirawat untuk
perkembangan, perburukan atau
komplikasi PE, dan imaturitas janin
ditangani ekspektatif dengan
pemberian kortikosteroid guna
memacu pematangan paru janin untuk
persiapan persalinan prematur.
 Pasien dengan PEB
induksi persalinan
seharusnya dilakukan
setelah umur
kehamilan 34 mgg.
 Dalam kasus ini, memberatnya
penyakit dipertimbangkan
dengan risiko prematuritas
janin.
 Dalam kondisi darurat kontrol
TD dan kejang harus
diprioritaskan.
DALIMAN.DM19
MedScape, Kee-Hak Lim, MD; Ronald
M Ramus, MD Preeclampsia Updated:
Nov 29, 2018

MgSO4 MgSO4ADALAH OBAT
PILIHAN UNTUK PENCEGAHAN
EKLAMSIA, MENURUNKAN 59%
RISIKO EKLAMSIA, 36%
SOLUSIO PLASENTA, 46%
(STATISTIK TIDAK SIGNIFIKAN)
KEMATIAN MATERNAL.
 SYARAT PEMBERIAN MgSO4 ADALAH
REFLEKS PATELLA +, URINE OUTPUT >30
CC/JAM, DAN REPIRASI > 16 KALI/MENIT,
SERTA TERSEDIA ANTIDOTUMNYA YAITU
Ca Gluconas.
 TOKSISITAS MgSO4 BERUPA
HILANGNYA REFLEKS PATELLA,
DEPRESI RESPIRASI, PERUBAHAN
KONDISI JANTUNG, CARDIAC
ARREST.
 DOSIS AWAL 4- 6 gram
iv BOLUS, DILANJUTKAN
DENGAN DRIPS 1-2
gram/ JAM.
 PEMBERIAN ULANG iv 2
gr (BB≤ 70 kg), ATAU 4
gr (BB> 70 kg), MINIMAL
3-5/ 5-10 MENIT
KEMUDIAN (JARANG),
 JIKA PERLU DAPAT DIBERIKAN
Na-AMOBARBITAL 250 mg IV
MINIMAL 3-5 MENIT
DALIMAN.DM19

REKOMENDASI PNPK-Preeklamsia
1. Pemberian MgSO4 pada PEB
berguna untuk mencegah terjadinya
kejang eklamsia atau kejang berulang.
2. Rute administrasi MgSO4 yang
dianjurkan adalah IV untuk
mengurangi nyeri pada lokasi sutikan.
3. MgSO4 merupakan pilihan utama
pada pasien PEB dibandingkan
diazepam atau fenitoin, untuk
mencegah terjadinya kejang/ eklamsia
atau kejang berulang.
DALIMAN.DM19

OBAT
ANTIHIPERTENSI
ALTERNATIF OBAT ANTIHIPERTENSI, ADALAH :
1. Labetalol 20 mg iv bolus, dilanjutkan
40 mg, 80 mg, 80 mg jika diperlukan,
setiap 10 menit dengan dosis
maksimal total 220 mg.
2.Nifedipin10-20 mg po, diulang
tiap 30 menit (bisa sampai 8 x per 24 jam)
(NHBPEP-WG,2000; RCOG,2006: dalam Cunningham 2014).
3. Hydralazine 5-10 mg iv/ im, tiap 20
menit, dosis maksimal 30 mg.
4. Sodium nitroprusside dimulai 0,25
ug/kg/min sampai dosis maksimal 5
ug/kg/min (second line).
DIBERIKAN APABILA
TEKANAN SISTOLIK
≥160 DAN ATAU TEKANAN
DIASTOLIK ≥110
DALIMAN.DM19
Cunningham, 2018. Williams Obstetrics, 25th ed.)

Sample Order Set for Severe Intrapartum or Postpartum Hypertension
Initial First-line Management With Immediate-Release Oral Nifedipine*
 Institute fetal surveillance if undelivered and fetus is viable.
1. If severe BP elevations persist for 15 minutes or more, administer nifedipine (10 mg
orally).
2. Repeat BP measurement in 20 minutes and record results. If either BP threshold is still
exceeded, administer nifedipine capsules (20 mg orally).
3. If BP is below thresh-old, continue to monitor BP closely. Repeat BP measurement in 20
minutes and record results. If either BP threshold is still exceeded, administer nifedipine
capsule (20 mg orally).
4. If BP is below thresh-old, continue to monitor BP closely. Repeat BP measurement in 20
minutes and record results. If either BP threshold is still exceeded, administer labetalol
(40 mg intravenously over 2 minutes) and obtain Give additional antihypertensive
medication per specific order.
 Once the aforementioned BP thresholds are achieved, repeat BP measurement every 10 minutes for 1 hour,
then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every hour for 4 hours.
Institute additional BP timing per specific order.
Notify physician if systolic blood pressure (BP) is greater than or equal to 160 mm Hg or if
diastolic BP is greater than or equal to 110 mm Hg.
DALIMAN.DM19
ACOG, 2017. COMMITTEE OPINION

DALIMAN.DM19
38
TERAPI HIPERTENSI KRONIK
1. PERUBAHAN GAYA HIDUP BERUPA DIET KAYA BUAH,
SAYUR, RENDAH LEMAK, MENGURANGI SATURASI DAN
TOTAL LEMAK, (MENGURANGI MASUKAN GARAM SAMPAI < 2,4 gram/
HARI  TIDAK DIANJURLKAN LAGI).
2. BEDREST DI RS DIHUBUNGKAN PENGURANGAN 42%
HIPERTENSI BERAT, 47% PERSALINAN PRETERM.
3. OBAT ANTIHIPERTENSI – METHYLDOPA, LABETALOL,
BETABLOKER, NIFEDIPIN, DIURETIK.
4. ACE-INHIBITOR KONTRAINDIKASI DIBERIKAN PADA TRIMESTER PERTAMA,
DIHUBUNGKAN DENGAN PENINGKATAN 2 KALI TERJADINYA MALFORMASI, DAN
JANGKA PANJANG IUGR, OLIGOHIDRAMNION, GAGAL GINJAL DAN KEMATIAN
NEONATUS.

MANAJEMEN CAIRAN pada
PEB
• Hindari pemberian
diuretik.
• Resusitasi volume cairan
yang agresif penyebab
utama untuk EDEMA
PULMONUM.
• Sedapat mungkin pasien harus
RESTRIKSI CAIRAN, minimal
sampai periode DIURESIS
POSTPARTUM.
TOTAL CAIRAN secara
umum seharusnya dibatasi
TIDAK LEBIH dari
1. 80 mL/jam, atau
2. 1 mL/kg/jam, atau
3. (60-125 ml/jam)
DALIMAN.DM19

Postpartum management
 Many patients will have a brief (up
to 6 hours) period of
oliguria following delivery
Magnesium sulfate seizure
prophylaxis is continued for 24
hours postpartum
 Liver function tests and platelet counts
must document decreasing values
prior to hospital discharge
 Elevated BP may be controlled
with nifedipine or labetalol
postpartum
 If a patient is discharged with BP
medication, reassessment and a BP
check should be performed, at the
latest, 1 week after discharge
 Unless a woman has undiagnosed
chronic hypertension, in most cases
of preeclampsia, the BP returns to
baseline by 12 weeks’ postpartum
 Patients should be carefully monitored
for recurrent preeclampsia,
which may develop up to 4 weeks
postpartum, and for eclampsia
that has occurred up to 6 weeks
after delivery
DALIMAN.DM19

DALIMAN.DM19
41
Offer women with pre-eclampsia who have
given birth transfer to community care if
all of the following criteria have been met:
 there are no symptoms of pre-eclampsia
 blood pressure, with or without
treatment, is 149/99 mmHg or lower
 blood test results are stable or improving.

DALIMAN.DM19
42
KOMPLIKASI PRE-EKLAMSIA
 IBU, BERUPA HELLP SYNDROME (20%), DIC (10%), EDEMA
PULMONUM (2-5%)( ok. Permeabilitas kapiler,
cardiogenic atau kombinasi keduanya, disamping
penurunan tekanan ONKOTIK ok. hipoALBUMIN),
SOLUSIO PLASENTA (1-4%), GAGAL GINJAL (1-2%), KEJANG
EKLAMSIA (<1%), PERDARAHAN SEREBRAL (<1%), PERDARAHAN
HEPAR (<1%) DAN KEMATIAN (JARANG).
 BAYI, BERUPA PERSALINAN PRETERM (15-60%), IUGR (10-25%),
KEMATIAN PERINATAL (1-2%), TRAUMA HIPOKSEMIA-
NEROLOGIK (<1%), MORBIDITAS KARDIOVASKULER JANGKA
PANJANG (TIDAK DIKETAHUI)
Berghella V., 2017. Maternal-Fetal Eviddence Based Guidelines, 3 th ed.

DALIMAN.DM19
43
KOMPLIKASI EKLAMSIA
KEMATIAN MATERNAL (1-2%) DI NEGARA
MAJU, LEBIH DARI (10%) DI NEGARA BERKEMBANG.
KEMATIAN PERINATAL (6-12%) DI NEGARA
MAJU, LEBIH DARI (25%) DI NEGARA BERKEMBANG.
 SOLUSIO PLASENTA (7-10%), DIC (7-11%), HELLP
(10-15%), EDEMA PULMONUM (3-5%), GAGAL GINJAL
(5-9%), PNEUMONIA ASPIRASI (2-3%),
CARDIOPULMONARY ARREST (2-5%), PERSALINAN
PRETERM (50%).

DALIMAN.DM19
44
MORBIDITAS DAN MORTALITAS
JANGKA PANJANG PENDERITA
PREEKLAMSIA, TERNYATA
MENINGKAT SECARA
BERMAKNA DIBANDINGKAN
BUKAN PENDERITA
PREEKLAMSIA, TERHADAP
KEJADIAN HIPERTENSI,
IHD, STROKE, DAN
PENYEBAB LAIN
KEMATIAN.
Long-term cardiovascular consequences of
preeclampsia. All differences p ≤.001 except p =
0.03 for all-cause mortality. (Data from Bellamy and
colleagues, 2007.)

Acute Treatment of Severe Hypertension in
Pregnancy
In the setting of severe
hypertension (SBP >160
mm Hg  93% STROKE H;
DBP >110 mm Hg  20%
STROKE H),
antihypertensive
treatment is
recommended.
The goal of hypertension
treatment is to lower BP
to prevent
cerebrovascular and
cardiac complications
while maintaining
uteroplacental blood
flow (ie, maintain BP
around 140/90 mm
Hg).
DALIMAN.DM19
Cunningham, 2018. Williams
Obstetrics, 25th ed.)

ANTIHYPERTENSIVE and PE
CONTROL of MILDLY increasing BP does not appear to
improve PERINATAL MORBIDITY or MORTALITY, and it
may, in fact, REDUCE BIRTH WEIGHT.
DALIMAN.DM19
Antihypertensive treatment decreases the
incidence of cerebrovascular problems, is dose
not alter the progression of PREECLAMPSIA.
MedScape, Kee-Hak Lim, MD; Ronald M Ramus, MD Preeclampsia
Updated: Nov 29, 2018

Prophylactic treatment with
magnesium sulfate
 Prophylactic treatment with magnesium sulfate is indicated for
all patients with severe preeclampsia. However,
no consensus exists as to whether patients with mild
preeclampsia need magnesium seizure prophylaxis.
 Although ACOG recommends magnesium sulfate in
severe preeclampsia, it has not recommended this
therapy in all cases of mild preeclampsia.
DALIMAN.DM19

DALIMAN.DM19
48
Some Indications for Delivery
with Early-Onset Severe Preeclampsia (Cunningham, 2018):
Maternal
1. Persistent severe headache or visual changes; eclampsia
2. Shortness of breath; chest tightness with rales and/or SaO2 < 94
percent breathing room air; pulmonary edema
3. Uncontrolled severe hypertension despite treatment
4. Oliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dL
5. Persistent platelet counts < 100,000/L,
6. AST or ALT > 2 x upper limit of normal with RUQ or epigastric pain,
7. Suspected abruption, progressive labor, and/or ruptured
membranes,
AFI = amnionic fluid index; EGA = estimated gestational age;
SaO2 = oxygen saturation.
From Sibai and Barton (2007).
≤ 72 JAM
Foley MR, et., 2018. Obstetric
Intensive Care Manual. 5th ed.
ONE OR MORE

DALIMAN.DM19
49
Fetal
1. Severe growth restriction—< 5th percentile for
EGA
2. Persistent severe oligohydramnios —AFI < 5 cm/
DVP < 2 cm.
3. Biophysical profile 4 done 4-6 hr apart
4. Reversed end-diastolic umbilical artery flow
5. Repetitive late or severe variable heart rate
deceleration,
6. Fetal death
Foley MR, et., 2018. Obstetric Intensive Care Manual. 5th ed
≤ 72 JAM
ONE OR MORE
MedScape, Kee-Hak Lim, MD; Ronald M Ramus,
MD Preeclampsia Updated: Nov 29, 2018

DALIMAN.DM19
50
Foley MR, et., 2018. Obstetric Intensive Care Manual. 5th ed
Penyebab EDEMA PULMONUM
1.CARDIAC (HIGH PRESSURES)  Cardiac dysfunction,
Pulmonary venous dysfunction, Pulmonary Embolism, Airway
Obstruction, Preeclampsia, Miscelaneous,  (decreased Left
Ventricular contractility, Mitral stenosis, Mitral regurgitation, INTRAVASCULAR
VOLUME OVERLOAD, dysrithmias), (Venous occlusive disease, Neurogenic
pulmonary vasoconstriction), (Amniotic fluid, thrombus, fat, air), (edema, astma,
foreign body), (Pulmonary hypertension), (Pneumothorax, tumor, one lung
anesthesia (down lung syndrome)).
2.NONCARDIOGENIC (PERMEABILITY)  Adult
Respiratory Disterss Syndrome (ARDS), Aspiration Syndrome,
Pulmonary Embolism, Abruptio Placentae, Dead Fetus
Syndrome, Sepsis.

EDEMA PULMONUM
DALIMAN.DM19
DIAGNOSIS  PROGRESIF nafas pendek, desaturasi, takhipnea,
kadang HIPERTENSI, bilateral RBBH, S3 Gallops (tidak selalu).
FAKTOR PREDISPOSIS  KELEBIHAN CAIRAN (fluid overload), PE, terapi
TOKOLITIK, HT tak terkontrol.
MANAJEMEN  posisi semi-Fowler, kepala dan dada ditinggikan, O2 10 L/m
sungkup (facemask) atau CPAP, puls oxymetri kontinyu dan monitor
cardiac, PEMBATASAN CAIRAN (30-50 ml/jam), kontrol faktor predisposisi.
Terapi farmakologi  MORFIN sulfat : 3-5 mg IV, FUROSEMID : 20-40 mg iv
dapat diulang – maksimal dosis 120 mg/jam-pelan untuk menghindari
INTOKSIKASI, NITROGLYCERIN 2 in of paste to chest atau 1 pill (1/150) IV,
HYDRALAZINE : 5-10 mg IV  HT BERAT.
DIAGNOSIS, FAKTOR PREDISPOSISI, MANAJEMEN,
TERAPI FARMAKOLOGI, MONITOR.
Foley MR, et., 2018. Obstetric Intensive Care Manual. 5TH ed.

Preparing for Clinical Emergencies
in Obstetrics and Gynecology
Examples of Tools for Managing Clinical
Emergencies
1. Availability of appropriate emergency
supplies in a resuscitation cart (crash cart) or
kit
2. Development of a rapid response team
3. Development of protocols that include
clinical triggers
4. Use of standardized communication tools for
huddles and briefs (eg, SBAR)
5. Implementation of emergency drills and
simulations
Abbreviation: SBAR, Situation–Background–Assessment–
Recommendation.
ABSTRACT: Patient care
emergencies may occur at any
time in any setting, particularly
the inpatient setting. It is
important that obstetrician–
gynecologists prepare themselves
by assessing potential
emergencies, establishing
early warning systems,
designating specialized first
responders, conducting
emergency drills, and
debriefing staff after actual
events to identify strengths
and opportunities for
improvement. Having such
systems in place may reduce or
prevent the severity of medical
emergencies.
ACOG COMMITTEE OPINION Number 590,
March 2014 (Replaces Committee Opinion
Number 487, April 2011) (Reaffirmed 2018)
DALIMAN.DM19

Wassalamu’alaikum
warahmatullahi wabarakaatuh
DALIMAN.DM19
53

CURICULUM VITAE (CV)
• Nama : DALIMAN, dr.Sp.OG(K)FM.
• T/ TL : Klaten, 3 Februari 1956.
• Alamat : Jl. Dr. Angka, 28. PURWOKERTO.
• Email : dalridaliman@yahoo.com
• Pendidikan :
 SD – SMA ,tamat 1974, Wonosobo.
 Dokter, FK UGM Angkatan 1975, tamat 1981.
 Spesialis Obgin, Sp.OG, FK UGM 1989, tamat 1993.
 Konsultan Fetomaternal, (K)FM, FK UGM 2009, tamat 2011.
• Pekerjaan :
 Kepala Puskesmas Nanga Sepauk, Sintang, Kalbar (1982-1987)
 Direktur RSUD Sintang, Kalbar (1987-1989).
 Tenaga Medis Fungsional, Sp.OG, RSUD Sintang, Kalbar (1994-1998).
 Wakil Direktur RSUD Margono Soekarjo (2000-2008).
 Wakil Dekan FK Unsoed (2001-2004)
 Dokter Pendidik Klinis RSUD Margogono Soekarjo/ FKIK Unsoed (2009-
SEKARAG).
DALIMAN.DM19
54

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