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Gestational hypertension ( Hipertensi dalam Kehamilan ) Preeclampsia Eclampsia Superimposed Preeclampsia Chronic Hypertension
1. Gestasional hypertension
BP > 140/90 mmHg for first time during pregnancy No proteinuria BP return to normal < 12 weeks post partum May have other signs for preeclampsia (epigastric discomfort, thrombpcytopenia)
2. Preeclampsia
Preeclampsia: Mild-Severe
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Mild : BP > 140/90 mmHg after 20 weeks gestation Proteinuria > 300 mg/24 hours or > 1+ dipstick
Preeclampsia
Severe
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BP > 160/110 mm Hg Proteinuria 2 g/24 hours or > 2+ dipstick Serum Creatinin > 1,2 mg/dL Platelets < 100.000/mm3 Increase LDH Elevated AST/ALT Persistent headache or other cerebral or visual disturbance Persistent epigastric pain
3. Eclampsia
Seizures that cannot be attributed to other causes in women with preeclampsia Coma
4. Superimposed preeclampsia
New onset proteinuria > 300mg/24 hours in hypertensive women but no proteinuria before 20 weeks gestasion Sign and symptoms severe preeclampsia
5. Chronic Hypertension
Patophyisiology Preeclampsia
Maternal vascular desease Faulty placentation Excessive trophoblast
Endothelial activation
Capillary leak
Activation of coagulation
Delivery is the cure for preeclampsia > 35 weeks gestation : induction of labor < 35 weeks gestation, no complication: expectant ( the hope that few more weeks in utero will reduce the risk of neonatal mortality and morbidity )
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Anti hypertension Lung maturation : dexametason 12 mg/day, 2 days Observation : Blood pressure, symptom impanding eclampsia, lab., fetal surveillance any disturbance termination
The patellar refleks is present Respiration are not depressed ( RR>16/min) Urin output > 100ml/4 hour
MgSo4 is discontinued 24 h after delivery MgSO4 toxicity : respiratory depression, paralysis, and arrest Antidotum MgSO4 : calcium gluconate
Severe Preeclampsia
> 35 weeks gestasion : termination of pregnancy < 35 weeks gestasion :
Find any complications if any termination of pregancy and treat complication No diuretik Limitation activity MgSO4 Antihypertensive agents Close observation for mother and baby
No medication if blood pressure not more than 140/90 mmHg No diuretik Limitation activity ANC 2x/weeks : Blood Pressure, proteinuria, refleks, fetal surveillance Close monitoring for complications
Find any complications during antenatal care Antihypertensive drugs control blood pressure If no complications wait until aterm with close monitoring If there is any complications consider pregnancy termination
Complication
1.
Eclampsia Generalized tonic-clonic seizures Coma without convulsion Antepartum, intrapartum, postpartum Cerebral edema ICU
Complication
2. HELLP Syndrome
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Hemolysis : fragmented erythrocyte, bilirubun > 1,2 ml/dL Elevated Lever enzymes : SGOT > 72 IU/L, LDH > 600IU/L Low Platelet count : < 100.000/mm3 DIC Tx : dexamethason 2 x 10 mg, then 2 x 5 mg
Complication
3. Pulmonary edema
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Tachypneu/dyspnea Respiratory distress Severe hypoxemia Diffuse rales in both lung ICU, ventilator Furosemid
Complication
4. Acute Renal Failure 5. Hepatic rupture 6. Abruptio placentae 7. Cerebral hemorrhage 8. Visual disturbances
Prevention
Low dose aspirin ? Calcium? Anti oxidant?