INTRODUCTION

Preeclampsia is a multi-system disorder characterized by the new onset of

hypertension and proteinuria or end-organ dysfunction or both in the last half of
pregnancy (table 1). Although most affected pregnancies deliver at term or near
term with good maternal and fetal outcomes, these pregnancies are at increased
risk for maternal and/or fetal mortality or serious morbidity [1,2].
DEFINITIONS OF PREGNANCY-RELATED HYPERTENSIVE DISORDERS
There are four major hypertensive disorders related to pregnancy [3,4]:
Preeclampsia Preeclampsia refers to the new onset of hypertension and
either proteinuria or end-organ dysfunction or both after 20 weeks of
gestation in a previously normotensive woman (table 1). Severe
hypertension and signs/symptoms of end-organ injury are considered the
severe spectrum of the disease (table 2) [4]. In 2013, the American College
of Obstetricians and Gynecologists removed proteinuria as an essential
criterion for diagnosis of preeclampsia with severe features. They also
removed massive proteinuria (5 grams/24 hours) and fetal growth
restriction as possible features of severe disease because massive
proteinuria has a poor correlation with outcome and fetal growth restriction
is managed similarly whether or not preeclampsia is diagnosed [4]. Oliguria
was also removed as a characteristic of severe disease.
Eclampsia refers to the development of grand mal seizures in a woman with
preeclampsia, in the absence of other neurologic conditions that could
account for the seizure. (See "Eclampsia".)
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) probably
represents a severe form of preeclampsia, but this relationship remains
controversial; HELLP may be an independent disorder. As many as 15 to
20 percent of affected patients do not have concurrent hypertension or
proteinuria, leading some experts to believe that HELLP syndrome is a
separate disorder from preeclampsia. (See "HELLP syndrome".)
Chronic/preexisting hypertension Chronic/preexisting hypertension is
defined as systolic pressure 140 mmHg and/or diastolic pressure 90
mmHg that antedates pregnancy or is present before the 20th week of
pregnancy (on at least two occasions) or persists longer than 12 weeks
postpartum. It can be primary (primary hypertension, formerly called
"essential hypertension") or secondary to a variety of medical disorders. (
Preeclampsia superimposed upon chronic/preexisting hypertension
Superimposed preeclampsia is defined by the new onset of either
proteinuria or end-organ dysfunction after 20 weeks of gestation in a
woman with chronic/preexisting hypertension. For women with
chronic/preexisting hypertension who have proteinuria prior to or in early

pregnancy, superimposed preeclampsia is defined by worsening or

resistant hypertension (especially acutely) in the last half of pregnancy or
development of signs/symptoms of the severe spectrum of the disease
(table 2).
The Revised Definition of Preeclampsia
According to the new ACOG guidelines, the diagnosis of preeclampsia no longer
requires the detection of high levels of protein in the urine (proteinuria). Evidence
shows organ problems with the kidneys and livers can occur without signs of
protein, and that the amount of protein in the urine does not predict how severely
the disease will progress
Preeclampsia is now to be diagnosed by persistent high blood pressure that
develops during pregnancy or during the postpartum period that is associated
with a lot of protein in the urine or the new development of decreased blood
platelets, trouble with the kidney or liver, fluid in the lungs, or signs of brain
trouble such as seizures and/or visual disturbances.
Other Big Changes in Diagnosis and Management
Evidence tells us that preeclampsia is a dynamic process. Diagnosing a
woman's condition as "mild preeclampsia" is not helpful because it is a
progressive disease, progressing at different rates in different women.
Appropriate care requires frequent re-evaluation for severe features of the
disease and appropriate actions outlined in the new guidelines.
Mild to moderate high blood pressure (140-159 mm Hg systolic or 90-159 mm
Hg diastolic measured on two occasions at least four hours apart) warrants close
evaluation and monitoring. High blood pressure greater than or equal to 160 mm
Hg systolic or greater than or equal to 110 mm Hg diastolic is a feature of severe
preeclampsia.
To prevent eclampsia (seizures), magnesium sulfate should be given if your
blood pressure is 160/110 or higher. If your blood pressure is less than 160/110
and you have other severe symptoms that usually precede seizures, you should
be given magnesium sulfate. Severe hypertension can be confirmed within a
short interval (minutes) to facilitate timely antihypertensive therapy.
Guidelines for the timing of delivery have been modified based on data indicating
best outcomes for mother and baby. One of the biggest changes in
preeclampsia management relates to the timing of delivery in women with
preeclampsia without severe features. Studies suggest that the best time of
delivery is at 37 weeks of gestation. It has been known for many years that
preeclampsia can worsen or become apparent for the first time after delivery. The
new guidelines include specific recommendations to improve outcomes for
women who have postpartum preeclampsia.

Cara pemberian magnesium sulfat :

1. Dosis awal sekitar 4 gram MgSO4 IV (20 % dalam 20 cc) selama 1
gr/menit kemasan 20% dalam 25 cc larutan MgSO4 (dalam 3-5 menit).
Diikuti segera 4 gr di bokong kiri dan 4 gram di bokong kanan (40 %
dalam 10 cc) dengan jarum no 21 panjang 3,7 cm. Untuk mengurangi
nyeri dapat diberikan 1 cc xylocain 2% yang tidak mengandung
adrenalin pada suntikan IM.
2. Dosis ulangan : diberikan 4 gram intramuskuler 40% setelah 6 jam
pemberian dosis awal lalu dosis ulangan diberikan 4 gram IM setiap 6
jam dimana pemberian MgSO4 tidak melebihi 2-3 hari.
3. Syarat-syarat pemberian MgSO4
Tersedia antidotum MgSO4 yaitu calcium gluconas 10%, 1 gram (10%
dalam 10 cc) diberikan intravenous dalam 3 menit.
Refleks patella positif kuat
Frekuensi pernapasan lebih 16 kali per menit.
Produksi urin lebih 100 cc dalam 4 jam sebelumnya (0,5
cc/kgBB/jam).
4. MgSO4 dihentikan bila
a. Ada tanda-tanda keracunan yaitu kelemahan otot, hipotensi, refleks
fisiologis menurun, fungsi jantung terganggu, depresi SSP, kelumpuhan
dan selanjutnya dapat menyebabkan kematian karena kelumpuhan
otot-otot pernapasan karena ada serum 10 U magnesium pada dosis
adekuat adalah 4-7 mEq/liter. Refleks fisiologis menghilang pada kadar
8-10 mEq/liter. Kadar 12-15 mEq terjadi kelumpuhan otot-otot
pernapasan dan lebih 15 mEq/liter terjadi kematian jantung.
b. Bila timbul tanda-tanda keracunan magnesium sulfat
Hentikan pemberian magnesium sulfat
Berikan calcium gluconase 10% 1 gram (10% dalam 10 cc) secara IV
dalam
waktu 3 menit.
Berikan oksigen.
Lakukan pernapasan buatan.
c. Magnesium sulfat dihentikan juga bila setelah 4 jam pasca
persalinan sudah
terjadi perbaikan (normotensif).
Cara pemberian mgso4

[if !supportLists]
[endif]Berikan dosis awal 4 g MgSO4 sesuai prosedur
untuk mencegah kejang atau kejang berulang.
Sambil menunggu rujukan, mulai dosis rumatan 6 g MgSO4 dalam 6 jam sesuai
prosedur.
Syarat pemberian MgSO4
[if !supportLists]
[endif]Tersedia Ca Glukonas 10%,

[if !supportLists]
[if !supportLists]

[endif]Ada refleks patella

[endif]Jumlah urin minimal0,5ml/kg BB/jam

Cara pemberian dosis awal

[if !supportLists]
[endif]Ambil 4 g larutan MgSO4 (10 ml larutan MgSO4
40%) dan larutkan dengan 10 ml akuades
[if !supportLists]
[endif]Berikan larutan tersebut secara perlahan IV selama
20 menit
[if !supportLists]
[endif]Jika akses intravena sulit, berikan masing-masing 5
g MgSO4 (12,5 ml larutan MgSO4 40%) IM di bokong kiri dan kanan
Cara pemberian dosis rumatan
Ambil 6 g MgSO4 (15 ml larutan MgSO4 40%) dan larutkan dalam 500 ml larutan
Ringer Laktat/Ringer Asetat, lalu berikan secara IV dengan kecepatan 28
tetes/menit selama 6 jam, dan diulang hingga 24 jam setelah persalinan atau
kejang berakhir (bila eklampsia)
Cara pemberian MgSO4 : dosis awal 2 gram intravena diberikan dalam 10 menit,
dilanjutkan dengan dosis pemeliharaan sebanyak 2 gram per jam drip infus (80
ml/jam atau 15-20 tetes/menit).
Syarat pemberian MgSO4 : - frekuensi napas lebih dari 16 kali permenit - tidak
ada tanda-tanda gawat napas - diuresis lebih dari 100 ml dalam 4 jam
sebelumnya - refleks patella positif.
MgSO4 dihentikan bila : - ada tanda-tanda intoksikasi - atau setelah 24 jam
pasca persalinan - atau bila baru 6 jam pasca persalinan sudah terdapat
perbaikan yang nyata.
Siapkan antidotum MgSO4 yaitu Ca-glukonas 10% (1 gram dalam 10 cc NaCl
0.9%, diberikan intravena dalam 3 menit).
Obat anti hipertensi diberikan bila tekanan darah sistolik lebih dari 160 mmHg
atau tekanan darah diastolik lebih dari 110 mmHg. Obat yang dipakai umumnya
nifedipin dengan dosis 3-4 kali 10 mg oral. Bila dalam 2 jam belum turun dapat
diberi tambahan 10 mg lagi.