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HYPERTENSION
FRANS O H PRASETYADI
INTRODUCTION
TERMINOLOGY AND
CLASSIFICATION
The
GESTATIONAL HYPERTENSION
BP
140/90
For the 1st time during pregnancy
No proteinuria
BP returns to normal < 12 weeks
postpartum
Final diagnosis made only postpartum
May have other signs or symptoms of PE,
i.e. :
epigastric discomfort or thrombocytopenia
PREECLAMPSIA
Minimum criteria
BP 140/90 after 20 weeks of gestation
Proteinuria 300 mg/24 hr or 1+ dipstick
Increased certainty of preeclampsia
BP 160/110
Proteinuria 2.0 g/24 hr or 2+ dipstick
Serum creatinine > 1.2 mg/dL unless known to be previously
elevated
Platelets < 100,000/mm3
Microangiopathic hemolysis ( LDH )
Elevated ALT or AST
Persistent headache or other cerebral or visual disturbance
Persistent epigastric pain
ECLAMPSIA
Seizures
SUPERIMPOSED PREECLAMPSIA
New
CHRONIC HYPERTENSION
BP
PREECLAMPSIA
Major cause of
- Maternal mortality ( 15-20% in developed
countries ) and morbidities ( acute and long-term)
- Perinatal deaths
- Preterm birth
- IUGR, oligohydramnios, abnormal oxygenation
Those morbidities & mortalities are in women
who :
-develop the disorder before 33 weeks gestation
-in those w/ pre-existing medical disorders
-in those from developing countries
PREECLAMPSIA
Neonatal complications
abruptio
Preterm
DIC
placentae ( 1-4% )
Pulmonary
oedema/aspiration
(2-5%)
ARF
(1-5%)
Eclampsia
Liver
( <1% )
failure or haemorrhage
(<1%)
Stroke
Death
( rare )
( rare )
Long-term
morbidity
cardiovascular
delivery (15-
67%)
Fetal
growth restriction
(10-25%)
Hypoxia-neurologic
injury
(<1%)
Perinatal
death ( 1-2%)
Long-term
cardiovascular
morbidity assiciated w/
LBW ( fetal origin of adult
DIAGNOSIS PE
Hipertensi
Gestasional
Preeklampsia
Eklampsia
Superimposed
preeklamsia
Hipertensi kronis
RISK FACTORS
-Limited sperm exposure
-Primipaternity
-Rheumatic disease
-Maternal infections
-Maternal or pregnancy-related
risk factors
-Extremes of maternal age
-Multifetal gestation
-PE in a previous pregnancy
In pregnancy, the spiral arteries are remodeled by extravillous trophoblast cells and NK cells. The left panel
shows the nonpregnant endometrium in the secretory phase of the menstrual cycle just before menstruation. The
right panel shows the endometrium in the second half of normal pregnancy when the spiral arteries are remodeled
to a depth that penetrates the myometrium. The middle panel shows the situation in preeclampsia where the
extent and depth of remodeling is less than in normal pregnancy. These vascular changes are effected by
extravillous trophoblast cells (EVT) with the help of activated NK cells. In the process, the enlarged vessels
become lined with endovascular trophoblast cells (ENVT)
Maternal
Vasculer
disease
Faulty
Placentation
Genetic,
immunologic,
or inflamatory
factors
Reduced
uteroplacental
perfusion
Excessive
Trophoblasts
Noxious
agents:
Cytokines,
Lipid
Peroxidases
Vasoactive
agents:
Prostaglandin
s, nitric Oxide,
Endothelins
Endothelial
Activation
Activation of
Coagulation
Vasospasm
Capillary leak
Hypertension
Seizures
Oliguria
Liver ischemia
Abruption
Trombocytopenia
Reduced
Edema
uteroplacental
Hemoconcentrati
perfusion
on
Proteinuria
Aktivasi, agregasi,
konsumsi + volume
dan usia platelet
trombositopenia
Waktu thrombin
meningkat
Defisiensi faktor
pembekuan
karena penyakit
penyerta
Fibronectin
cenderung
meningkat
Hemolisis LDH,
perubahan bentuk
eritrosit.
Akibat gangguan
endotelhemolisis
mikroangiopati
Berhubungan
dengan:
Tekanan
afterload
Tekanan Preload
Ekstravasasi
cairan
CO meningkat
CO menurun +
Hemokonsentra
resitensi perifer
si
meningkat
Hati-hati pada
perdarahan
waktu
persalinan
RAA system
menurun akibat
retensi air + Na
Vasopressin
tetap
Atrial
natriuretik
peptide
menurun
Kerusakan
endotel retensi
cairan edema
generalisata
Elektrolit
cenderung tetap
normal
Pada kejang
eklamsia pH
dan bicarbonat
Hiperperfusi
Perdarahan akibat
ruptur arteri Kehilangan
Edema, iskemi, autoregulasi
aliran darah
hyperemia,trombosis
, perdarahan serebral
Klirens
plasenta
menurun
Laju aliran
darah
plasenta
menurun
Infark arteri
retina
Ablasio retina
Edema korteks
dan defek visual
Prediction of PE
No known biomarkers
No efective predictors
Prevention of PE
Diet
Protein
or salt (II)restriction
Pregnancy
outcome
Mg or Zn supplementation (I)
No reduction in PE
No reduction in PE
Calcium
supplementation (I)
Low-dose
aspirin (I)
Heparin
Antioxidant
medications in women
w/ chronic HT
Recommendation
Insuff. evidence to recommend
Not recommended*
Insufficient evidence to
recomm.*
Recommended for women at high
risk of gestational HT, & in
communities w/ low dietary
calcium intake
Consider in high-risk populations
Management of PE
Delivery or expectant?
Management of PE
Preeclampsia
Maternal & fetal
assessment
Gestational age 38 weeks
At 34 weeks gestation:
- Severe PE
- Labour or rupture of membranes
- Abnormal fetal testing
YES
Deliver
NO
Mild disease
Hospital or office
management
Severe disease
22 32 weeks
< 23 weeks
33 34 weeks
Maternal and
fetal assessment
Worsening maternal
or fetal condition
38 weeks
Labour or rupture of
membranes
Steroids
Anti-HT
Daily assessment of
maternal-fetal
conditions
Delivery at 34 weeks
Steroids
Delivery after 48 h