Pembaharuan Panduan HKFM

“ Preeklampsia”

Dr. Ernawati, dr. SpOG. Subsp. KFm

Div. Fetomaternal, dept Obgin Fakultas Kedokteran Universitas Airlangga
RS. Dr Soetomo Surabaya Indonesia
• Definisi & Klasifikasi
• Skrining
• Tatalaksana Kehamilan
• Tatalaksana Penyakit
• MgSO4
• Obat Anti Hipertensi

ACOG
ISSHP
NICE
 Klasifikasi HDK
ISSHP 2018 NICE 2019 ACOG 2013
Hypertension in Pregnancy: Hypertensive Disorders of Hypertension in Pregnancy:
Hypertension Known before pregnancy or Pregnancy: • Chronic Hypertension
present in the first 20 week • Chronic Hypertension • Gestational Hypertension
• Chronic Hypertension • Gestational Hypertension • Preeclampsia
ü Essential • Preeclampsia • Chronic Hypertension
ü Secondary Superimposed
• White-coat Hypertension Preeclampsia
• Masked Hypertension
Hypertension arising de novo or after 20 weeks:
• Transient Gestational Hypertension
• Gestational Hypertension
• Preeclampsia de novo or Superimposed on
Chronic Hypertension
 Kriteria Diagnosis Preeklampsia
ISSHP NICE ACOG

Preeclampsia is gestational New onset hypertension (>140 BP > 140/90 mmHg 4 hours apart
hypertension accompanied by ≥1 of mm Hg systolic or >90mm Hg after 20 weeks gestation or BP >
the following new-onset conditions diastolic) after 20 weeks and: 160/110 mmHg within a short
at or after 20 weeks’ gestation: • Proteinuria (urine protein : interval and
• Proteinuria creatinine ratio ≥30 • Proteinuria
• Maternal organ dysfunction (AKI, mg/mmol, or albumin : • Organ dysfunction
liver involvement, neurological, creatinine ratio ≥8 mg/mmol, (thrombocytopenia, renal
hematologycal complications) or ≥1 g/L [2+] on dipstick insufficiency, impaired liver
• Uteroplacental dysfunction (IUGR, testing) function, pulmonary edema,
stillbirth, abnormal UA doppler) • Other maternal organ new onset headache)
dysfunction (renal or liver
involvement, neurological or
haematological complications
• Uteroplacental dysfunction
(such as IUGR ,abnormal
umbilical artery Doppler
waveform analysis, or
stillbirth)
qTidak ada lagi istilah Preeklampsia Ringan
qHanya Preeklampsia + gejala berat
qGejala berat
• BP > 160/110 mm Hg • Insufisiensi renal

• Thrombocytopenia • Edema paru

• Nyeri kepala hebat
• Gangguan fungsi liver
• Gangguan penglihatan)
- ACOG
SKRINING PE Usia Kehamilan 11 – 28 minggu (Ideal < 16 minggu)

2 faktor risiko (+) 1 faktor risiko (+)

Faktor Risiko Moderat:
• Nulipara, primipara Faktor Risiko Tinggi:
• Primipaternitas • Riwayat PE • Abnormal DV Arteri
• Usia > 35 tahun • Hipertensi Kronis Uterina
• Jarak kehamilan sebelum > 10 • Penyakit Autoimun • sFlt-1/PlGF ratio
tahun • Diabetes
• Obesitas (BMI > 30 kg/m2)
• Penyakit Ginjal
• Riwayat keluarga PE/ penyakit
kardiovaskular
• Riwayat IUGR
• Kadar TG >
• Durasi hubungan seksual < 6
bulan sebelum hamil
• Kehamilan multiple
• IVF

Kehamilan Risiko Tinggi Preeklampsia

• Aspirin 75 – 160 mg/hari (ideal dimulai < 16 minggu) sampai usia kehamilan 36-37 minggu
• Suplementasi kalsium 1,2-2.5 g/hari sampai persalinan
Tatalaksana Preeklampsia
• Tatalaksana hipertensi
• Ibu dengan PE dilakukan evaluasi awal di RS
• PE dengan gejala berat harus diberikan MgSO4 untuk prevensi kejang

• Monitoring kondisi janin meliputi biometri, volume air ketuban, UA doppler dan
dievaluasi tiap 2 minggu jika hasil normal

• Monitoring maternal meliputi: tekanan darah, protein urine, gejala klinis, pemeriksan lab
1-2x/minggu (Hb, trombosit, fungsi liver, BUN, SK, dan asam urat)
• Terminasi kehamilan
 Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 27 (2022) 148–169

Contents lists available at ScienceDirect

Pregnancy Hypertension: An International

TATALAKSANA HIPERTENSI
Journal of Women's Cardiovascular Health
journal homepage: www.elsevier.com/locate/preghy

The 2021 International Society for the Study of Hypertension in Pregnancy

classification, diagnosis & management recommendations for
international practice☆
Laura A Magee a, *, Mark A. Brown b, David R. Hall c, Sanjay Gupte d, Annemarie Hennessy e,
S. Ananth Karumanchi f, Louise C. Kenny g, Fergus McCarthy h, Jenny Myers i, Liona C. Poon j,
Sarosh Rana k, Shigeru Saito l, Anne Cathrine Staff m, n, Eleni Tsigas o, Peter von Dadelszen a
Penurunan TD pada HT ringan-sedang dalam
a
b
c
Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, UK
Departments of Renal Medicine & Medicine, St. George Hospital & University of New South Wales, Sydney, Australia
Department of Obstetrics & Gynaecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
kehamilan :
new england
d
Secretary General, World Organization Gestosis, Gupte Hospital, Pune, India

The
• Mengurangi resiko terjadinya luaran komposit :
e
School of Medicine, Western Sydney University and South Western Sydney Local Health District, Sydney, Australia
f
Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
g

journal of medicine
Faculty of Health & Life Sciences, University of Liverpool and INFANT Centre, Cork University Maternity Hospital, Cork, Ireland
h
Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
i
Maternal & Fetal Health Research Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK

PEB, prematuritas iatrogenic < 35 mgg, solusio

j
Department of Obstetrics and Gynaecology, Chinese University of Hong Kong, Chair of Hypertension in Pregnancy Subcommittee FIGO Pregnancy and NCD Committee,
Hong Kong
k
Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA
l
Department of Obstetrics and Gynecology, Graduate School of Medicine and Pharmaceutical Science for Research, University of Toyama, Japan

plasenta, kematian perinatal & PE secara

m
n
Faculty of Medicine, University of Oslo,in
established and1812 May 12, 2022
Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway vol. 386 no. 19
Global Pregnancy Collaboration (Member, Steering and Executive Committees), USA
o
Preeclampsia Foundation, USA

Treatment for Mild Chronic Hypertension during Pregnancy

A R T I C L E I N F O

Keywords: All L. Plante,

units managing
A B S T R A C T
A.T. Tita, J.M. Szychowski, K. Boggess, L. Dugoff, B. Sibai, K. Lawrence, B.L. Hughes, J. Bell, K. Aagaard,
R.K. Edwards, K. Gibson, D.M. Haas, T.hypertensive
Metz, B. pregnant
Casey, women
S. Esplin,
shouldS. Longo,
maintain and M. Hoffman,
review G.R. Saade,
uniform departmental manage-
umum
Hypertension ment protocols and conduct regular audits of maternal & fetal outcomes.
K.K. Hoppe, J. Foroutan, M. Tuuli, M.Y. Owens, H.N. Simhan, H. Frey, T. Rosen, A. Palatnik, S. Baker, P. August,

• Menurunkan terjadinya PE
Pregnancy The cause(s) of pre-eclampsia and the optimal clinical management of the hypertensive disorders of pregnancy
U.M. Reddy, W. Kinzler, E. Su, I. Krishna,
Pre-eclampsia N. Nguyen,
remain uncertain; therefore, M.E. Norton,
we recommend thatD. Skupski,
every Y.Y.
hypertensive El-Sayed,
pregnant woman D. Ogunyemi,
be offered an opportunity
Hypertension
Outcome
to participate
Z.S. Galis, L. Harper, N. Ambalavanan,
Maternal
in research,
N.L. Geller, S.clinical
Oparil,trialsG.R.
and follow-up
Cutter,studies.
and W.W. Andrews, for the Chronic
Perinatal Hypertension and Pregnancy (CHAP) Trial Consortium*

AHA SCIENTIFIC STATEMENT

BACKGROUND
a bs t r ac t
• Menurunkan prematur < 37 mgg
The benefits and safety of the treatment of mild chronic hypertension (blood pressure, The authors’ full names, academic de-
Hypertension in Pregnancy: Diagnosis, Blood • Menurunkan HT berat
Abbreviations: ABPM, ambulatory 24-hour blood pressure monitoring; ACR, albumin:creatinine ratio; AKI, acute kidney injury; ART, assisted reproductive
<160/100
technology;mm Hg)daily;
BID, twice during pregnancy
BMI, body mass index;are uncertain.
BP, blood Datachronic
pressure; CKD, are needed on FGR,
kidney disease; whether a grees,
fetal growth andFIGO,
restriction; affiliations are listed
International in the
Federation of
Gynecology Appendix. Dr. Tita HELLP
can besyndrome,
contactedHae-at
strategy of and Obstetrics;
targeting GPP, good
a blood practice point;
pressure HBPM,
of less thanhome blood mm
140/90 pressure
Hgmonitoring;
reduces HDP, hypertensive disorder
the incidence of pregnancy;

Pressure Goals, and Pharmacotherapy:

atita@ uab . edu or at the Department
molysis, Elevated Liver enzymes, Low Platelet syndrome; ISSHP, International Society for the Study of Hypertension in Pregnancy; ISUOG, International Society for of
ofUltrasound
adverse inpregnancy
Obstetrics andoutcomes
Gynecology;without compromising
IV, intravenous; LA, long-acting;fetal
MgSOgrowth. Obstetrics and Gynecology, Center for
4, magnesium sulphate; MR, modified release; NICU, neonatal intensive care unit;

• Tidak meningkatkan terjadinya IUGR

PA, prolonged action; PlGF, placental growth factor; QAM, every morning; QID, four times daily; QPM, every evening; OR, odds ratio; PrCr, protein:creatinine ratio;
Women’s Reproductive Health, Marnix
METHODS
A open-label,
release.
☆
Scientific
multicenter, Statement From
randomized trial, we assigned pregnantthe
women American
with
mild chronic hypertension and singleton fetuses at a gestational age of less than 23
Heart
RCT, randomised controlled trial; RR, relative risk; sFlt-1, soluble fms-like tyrosine kinase-1; TID, three times daily; WHO, World Health Organization; XL, extended-
In this
E. Heersink School of Medicine, Univer-

This document has been endorsed by World Organization Gestosis and the Japanese Society for the Study of Hypertension
sity of Alabama at Birmingham, 619 19th
in Pregnancy.
St. S., Birmingham, AL 35249.

Association
* Corresponding author at: Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, Becket House, 1 Lambeth Palace
weeks to receive antihypertensive medications recommended for use in pregnancy
Road, Room BH.05.11, London SE1 7EU, UK.
(active-treatment group) or to receive no such treatment unless severe hypertension
E-mail address: [email protected] (L.A. Magee).
*A complete list of the investigators in
the CHAP Trial Consortium is provided
in the Supplementary Appendix, avail-
(systolic
Vesna pressure,
D. Garovic, ≥160
MD, PhD,mmFAHA,Hg; Chair;
or diastolic pressure,
Ralf Dechend, ≥105 mm
MD; Thomas Hg) developed
Easterling, MD; S. Ananthable Karumanchi,
https://doi.org/10.1016/j.preghy.2021.09.008 at NEJM.org.MD;
(control
Received
Suzannegroup). The2021;
28 September
McMurtry primary
Baird, DNP,outcome
Accepted 30
RN; was
September
Laura aMagee,
2021
A. composite of preeclampsia
MD, FRCPC; Sarosh Rana, with
MD,severe
MPH; Jane V. Vermunt, MBChB, MSc;
Available online
features, 9 Octoberindicated
medically 2021 preterm birth This article was published on April 2, 2022,
Phyllis August,
2210-7789/© MD, MPH,Society
2021 International FAHA, forVice Chair;
the Study onat less ofthan
behalf
of Hypertension inthe
35 weeks’
American
Pregnancy.
gestation,
Heart
Published
pla-Council on Hypertension;
byAssociation
Elsevier B.V. All rights reserved.
at NEJM.org. Council on
cental abruption,
the Kidney or fetal orDisease,
in Cardiovascular neonatal death.
Kidney The Disease
in Heart safety outcome was small-for-
Science Committee; Council on Arteriosclerosis, Thrombosis and
gestational-age
Vascular Biology; birth weight
Council below the
on Lifestyle and10th percentile for
Cardiometabolic gestational
Health; Council onage. Second-Vascular Disease; and Stroke Council
Peripheral
N Engl J Med 2022;386:1781-92. 9
DOI: 10.1056/NEJMoa2201295
ary outcomes included composites of serious neonatal or maternal complications, Copyright © 2022 Massachusetts Medical Society.
preeclampsia, and preterm birth.
 Tatalaksana Hipertensi

TD > 160/110 mmHg TD 140/90 – 160/110 mmHg

• Rekomendasi terapi anti

• Urgen terapi dengan anti hipertensi untuk mencegah HT
hipertensi berat dan komplikasinya
• Pilihan obat: oral nifedipine, iv • Oral methyldopa, nifedipine,
labetolol atau hydralazine labetolol, oxpronolol,
hydralazine

• Target TD Diastolik < 85 mmHg atau Sistolik < 160 mmHg atau (110-140 mm Hg)
• Obat anti HT harus dikurangi atau dihentikan jika TD diastolik < 80 mmHg
 BP (blood pressure), dBP (diastolic blood pressure).

Pilihan terapi pada Hipertensi ringan-sedang

* If at any time, sBP is ≥ 155 mmHg, BP should be considered very high and actions taken accordingly.

Table 7
Maintenance therapy and suggested dose titration of antihypertensive therapy for non-urgent control of hypertension in pregnancy (modified from Magee et al 2020)
[147].

Laura A Magee, et al. ISSHP

classification, diagnosis &
management
LA (long-acting), MR (modified release), PA (prolonged action), XL (extended release). recommendations for
* Starting doses are higher than generally recommended for adults given more rapid clearance in pregnancy. international practice,
† When a medication is at high (or maximum) dosage, consider using a different medication to treat any severe hypertension that may develop). pregnancy hypertensiun
11
2021☆
 Magee and von Dadelszen, Maternal-Fetal Medicine (2021) 3:2 www.maternal-fetalmedicine.org

TERAPI HIPERTENSI BERAT

Magee and von Dadelszen, Maternal-Fetal Medicine (2021) 3:2 ∗ ∗

Figure 4. Suggested dose titration of antihypertensive therapy for urgent control of hypertension in pregnancy (modified from Magee LA et al.86). When
 MgSO4 Untuk Prevensi EKLAMPSIA

• Sentral (reseptor NMDA)

• Perifer (Neuromuscular Junction,
Vascular)
§ Menghambat kalsium masuk ke sel
§ Mengurangi rilis presinaps Asetilkolin pada
endplate
§ Mengurangi sensitivitas motor endplate
terhadap Asetilkolin
 MgSO4 REGIMEN

Pritchard Regimen Zuspan Regimen

• Loading dose 4g bolus iv slowly • Loading dose 4g bolus iv slowly
5-10 minutes followed by 10g im 5-10 minutes
(5g in each buttock) • Maintenance dose: 1-2 g/hour
• Maintenance dose: 5g alternate syringe pump
buttock every 4 hour Dosis Terapeutik: 4.8 – 8.4 mg/dL

SM diberikan saat admisi, PE Berat, onset persalinan, induksi, atau sebelum

terminasi
Cara pemberian: dosis awal + dosis pemeliharaaan
 WAKTU PERSALINAN
Pasien dengan PE dilakukan terminasi kehamilan saat atau segera setelah usia
kehamilan 37+0 minggu atau jika terjadi preeklampsia dengan gambaran berat

Hypitat trial I Hypitat trial-II

• Induksi menurunkan resiko komplikasi • Pd PE terminasi segera pd uk
PE sebesar 30% ( maternal mortality, 34-37 mgg mengurangi resiko
maternal morbidity (eclampsia, HELLP, luaran buruk maternal namun
edema paru, thromboembolic, solusio,
HT berat), dan HPP meningkatkan resiko RDS
• Induksi menurunkan angka SC • Persalinan lebih baik
• Induksi tidak berpengaruh pada luaran menunggu > 37 mgg atau jika
bayi ada perburukan
Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol 2020; 135:e237.
15
 Planned early delivery or expectant management for late
preterm pre-eclampsia (PHOENIX): a randomised controlled
trial
Lucy C Chappell, Peter Brocklehurst, Marcus E Green, Rachael Hunter, Pollyanna Hardy, Edmund Juszczak, Louise Linsell, Virginia Chiocchia,
Melanie Greenland, Anna Placzek, John Townend, Neil Marlow, Jane Sandall, Andrew Shennan, on behalf of the PHOENIX Study Group*

Summary
Background In women with late preterm pre-eclampsia, the optimal time to initiate delivery is unclear because Lancet
limitation of maternal disease progression needs to be balanced against infant complications. The aim of this trial Publish
was to determine whether planned earlier initiation of delivery reduces maternal adverse outcomes without substantial August

• Terdapat peningkatan risiko ggn • Persalinan segera pd PE

http://d
worsening of neonatal or infant outcomes, compared with expectant management (usual care) in women with late
S0140-
preterm pre-eclampsia.
See Com

neurodevelopmental à mengurangi morbiditas ibu

*Study
Methods In this parallel-group, non-masked, multicentre, randomised controlled trial done in 46 maternity units in the a
across England and Wales, we compared planned delivery versus expectant management (usual care) with individual Depart

keterlambatan perkembangan namun meningkatkan NICU

randomisation in women with late preterm pre-eclampsia from 34 to less than 37 weeks’ gestation and a singleton or Childre
dichorionic diamniotic twin pregnancy. The co-primary maternal outcome was a composite of maternal morbidity or Course
recorded systolic blood pressure of at least 160 mm Hg with a superiority hypothesis. The co-primary perinatal London
(Prof L C

pd bayi yg dilakukan persalinan admisi bayi, namun kematian

outcome was a composite of perinatal deaths or neonatal unit admission up to infant hospital discharge with a non- Prof J Sa
inferiority hypothesis (non-inferiority margin of 10% difference in incidence). Analyses were by intention to treat, Prof A S
together with a per-protocol analysis for the perinatal outcome. The trial was prospectively registered with the ISRCTN Birmin

dini (34-37 mgg) dibandingkan perinatal tdk berbeda

registry, ISRCTN01879376. The trial is closed to recruitment but follow-up is ongoing. Univers
(Prof P
P Hardy
Findings Between Sept 29, 2014, and Dec 10, 2018, 901 women were recruited. 450 women (448 women and 471 infants

dengan persalinan > 37 mgg.

Pre-ecla
analysed) were allocated to planned delivery and 451 women (451 women and 475 infants analysed) to expectant (M E Gr

• Keputusan terminasi harus

management. The incidence of the co-primary maternal outcome was significantly lower in the planned delivery
group (289 [65%] women) compared with the expectant management group (338 [75%] women; adjusted relative risk
Depart
and Po
(R Hunt

• Persalinan lebih baik pd uk > 37 didiskusikan dengan ibu &

0·86, 95% CI 0·79–0·94; p=0·0005). The incidence of the co-primary perinatal outcome by intention to treat was Institut
significantly higher in the planned delivery group (196 [42%] infants) compared with the expectant management (Prof N
College
group (159 [34%] infants; 1·26, 1·08–1·47; p=0·0034). The results from the per-protocol analysis were similar. There

mgg untuk mencegah komplikasi kesepakatan dokter & pasien

and Na
were nine serious adverse events in the planned delivery group and 12 in the expectant management group. Epidem
Trials U
Interpretation There is strong evidence to suggest that planned delivery reduces maternal morbidity and severe Depart

jangka pendek & Panjang bayi

Health,
hypertension compared with expectant management, with more neonatal unit admissions related to prematurity but
Oxford
no indicators of greater neonatal morbidity. This trade-off should be discussed with women with late preterm L Linsel
pre-eclampsia to allow shared decision making on timing of delivery. M Green
J Towne
Funding National Institute for Health Research Health Technology Assessment Programme. Corresp
16 Prof Luc
of Wom
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. School
• Pasien late-term PE terminasi dapat 99.5%
> 85 (EO
ditunda sd usia kehamilan >37 minggu Diagnosis PE)
specificity
the woman has
atau jika terjadi preeklampsia dengan >110 (LO PE
gambaran berat PE)

• Keputusan waktu terminasi harus 36.7% PPV

merupakan keputusan bersama dengan High risk to
Rule-in 38 - 85 (EO PE) develop PE
keluarga mempertimbangkan 38 - 110 (LO PE) WITHIN 4
keuntungan dan kerugiannya WEEKS

• Dapat dilakukan pemeriksaan tambahan

untuk lebih menguatkan bahwa resiko RULE
99.3% NPV
< 38 will not develop
perburukan ibu rendah jika persalinan OUT
(EO & LO PE) PE for next 1
ditunda dg pemeriksaan biomarker week

(sflt/PlgF )

17
ALGORITMA
TATALAKSANA
PREEKLAMPSIA
ALGORITMA
TATALAKSANA
PREEKLAMPSIA
BERAT
KAMI TUNGGU DI SURABAYA

20
TERIMA KASIH