pdeipreeklampsia eklampsia dr didi
DESCRIPTION
rumahTRANSCRIPT
PREEKLAMPSIA/EKLAMPSIA
5/19/09
Didi DANUKUSUMO, Dr.Sp.OG(K) Division of Maternal Fetal Medicine
Department of Obstetrics and Gynecology Fatmawati General Hospital/
Faculty of Medicine University of Indonesia, Jakarta
Ny.25thG1mengeluhnyerikepaladanpandangankaburselamabulanterakhirkehamilannya.
IamencarisaranmedisdanpengobatandariseorangDr.SpOG.Yangmeresepkanobatpadanya.
Iapulangkerumahtetapikeluhannyatidakmenghilangmeskipuntelahmeminumobatyangdiberikan
SuaminyamembawanyakeRumahSakitUmumkarenaKEJANG.
Masalah/Diagnosis? EklampsiaimminensEklampsia
Objectives Definisi
Diagnosis
Manajemen PenilaianFetal/Maternal TerapiAnti‐Hipertensi TerapiAnti‐Kejang Transport
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Insidens 10%darikehamilanmengalamikomplikasihipertensi
1/3nyadenganproteinuria
Mayoritaspreeklampsiaterjadipadanulipara Risikokematianmeningkatpadapadaibuhamilusia“lanjut” Risikomeningkatpadakehamilanpertamadenganpasanganbaru Risikomeningkatpadahipertensikronik,penyakitginjaldandiabetesmelitus
Preeklampsiamerupakanpenyebabterbanyakkematianmaternallangsung(directmaternalmortality)maupunNearMissMaternal.
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Definisi
Hipertensikronik Hipertensigestasional
tanpaproteinuria denganproteinuria denganproteinuriadanpenyulit
Hipertensikroniksuperimposedhipertensigestasionaldenganproteinuria
Unclassifiableantenatally
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Definisi Proteinuria
Proteinurin≥2+denganpemeriksaandipstick proteinurin≥300mg/dLurin24jam
proteinuriamengindikasikandisfungsiglomerular Pemeriksaanurin24jamharusdiperiksabiladenganpemeriksaandipstichprotein≥1+
edematerjadiakibatvasospasmeandpenurunantekananonkotik,tetapibukanmerupakankriteriadiagnostik.
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5/19/09 - Dahulu disebut Preeklampsia berat
Manajemen Pertama‐tamamengurangistres
Penilaiankeadaanibudanjanin
TerapihipertensibiladBP>110mmHg
Terapiterhadapkeluhanmualdanmuntah
Terapinyeriuluhati
TerapiAntikejang
Terminasikehamilandengancaradanwaktuyangtepat
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PenilaianMaternal‐Klinis Tekanandarah
assessseverity consistencyinmeasuring relationshipofhighBPtoCVAnotseizure
SusunanSarafPusat presenceandseverityofheadache visiondisturbances‐blurring,scotomata tremulousness,irritability,hyperreflexia,somnolence nauseaandvomiting
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AssessmentofMother‐Clinical Hematologic
edema bleeding,petechiae
Hepatic RUQandepigastricpain nauseaandvomiting
Renal urineoutputandcolour
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AssessmentofMother‐Laboratory Hematologic
hemoglobin,platelets,bloodfilm PTT,INR,fibrinogen,FDP LDH,uricacid,bilirubin
Hepatic ALT,AST (glucose,ammoniatoR/OAFLP)
Renal proteinuria creatinine,urea,uricacid
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AssessmentofFetus Fetalmovement
Fetalheartrateassessment
Ultrasoundforgrowth
Biophysicalprofile
Amnioticfluidvolume
Dopplerflowstudies
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Treatment NauseaandVomiting
antiemeticofchoice
RUQ/EpigastricPain morphine2‐4mgIV antacid minimizepalpation
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Anti‐hypertensiveTherapy‐Goals minimizeriskofmaternalCVA
maximizematernalconditionforsafedelivery
gaintimeforfurtherassessment facilitatevaginaldeliveryifpossible prolonggestationwhereappropriate/feasible
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Anti‐hypertensiveAgents‐AcuteTherapy ArteriolarDilators
hydralazine
ß‐Blockers labetalol
CalciumChannelBlockers nifedipine
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Methyldopa centrallyactinga2‐receptoragonist,oralagent
longhistoryofsafeuseinpregnancy,welltolerated
someconcernregardingabilitytocontrolBP
notforuseinacutesettings
Dosage‐500‐3000mgpoin2‐4divideddoses
Cautions‐drugofchoiceinessentialhypertension
Benefits‐minimalside‐effectsandsafe
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Labetalol(Normodyne,Trandate)
combinedα1andß‐blockerwithISA
intravenousrapidonsetusefulforhypertensivecrisis
canbeusedorally
Dosage‐maximum300mgIVdose 20mgIVfollowedby20‐80mgIVtitratedtoBP
Cautions‐concernre:fetalresponsestohypoxia
Benefits‐dependable,titratable,familiar
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PencegahanKejang Sulitdiramalkansiapyangakankejang
Tidak berbanding lurus dengan beratnya hipertensidanproteinuria
high'numberneededtotreat'topreventseizure
agentsnotinnocuousnorcompletelyeffective
MgSO4isagentofchoicewhenseizureprophylaxisisfelttobeindicated
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MagnesiumSulfate obstetricalstandardbutnotusedinothersettings
superiortophenytoinforprophylaxis
superiortophenytoinordiazepaminpreventingrecurrence
Dosage‐4gIVfollowedby1‐4g/hourIVor4gIMq4h
SideEffects‐weakness,paralysis,cardiactoxicity
Monitor‐reflexes,respiration,levelofconsciousness
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Magnesium sulphate 6 g (15 ml of MgSO4 40%) In 500 ml Ringer Lactate/
Dextrose 5%
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Transport considertransportonlyifresourceslimitedandmaternal/fetalconditionpermits
maternalBPandsymptomsstable
fetalstatusreassuring
appropriateanti‐hypertensiveagentsstarted
MgSO4startedifappropriate
discusswithacceptingcentreandpatient/family
MgSO4andanti‐hypertensivespotentiallyfatalinoverdose
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Terminasikehamilan ≥37weekswithgestationalhypertension ≥34weekswithseveregestationalhypertension <34weekswithanyof:
poorlycontrolleddBP labevidenceofworseningend‐organinvolvement suspectedfetalcompromise uncontrolledseizures symptomsunresponsivetoappropriatetherapy
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Delivery‐TheCure timely delivery minimizes maternal and neonatal morbidity andmortality
optimizematernalstatusbeforeinterventionstodeliver delaydeliverytogainfetalmaturityandtoallowtransferonlywhenmaternalandfetalconditionallowit
gestational hypertension is a progressive disease, expectantmanagement is potentially harmful in presence of severe disease orsuspectedfetalcompromise
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Peri‐andPostpartumManagement donotdropBPtoolowriskingfetalcompromise donotfluidoverload epiduralanalgesiaisfavouredintheabsenceoflowplateletsorcoagulopathy
multi‐specialtyapproach patientmustbemonitoredpost‐partum
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