BAB I PENDAHULUAN
1.1
Latar Belakang Di Indonesia Preeklampsia berat (PEB) merupakan salah satu penyebab utama kematian maternal dan perinatal di Indonesia. PEB diklasifikasikan kedalam penyakit hypertensi yang disebabkan karena kehamilan. PEB ditandai oleh adanya hipertensi sedang-berat, edema, dan proteinuria yang masif. Penyebab dari kelainan ini masih kurang dimengerti, namun suatu keadaan patologis yang dapat diterima adalah adanya iskemia uteroplacentol. Diagnosis perkembangan
dini buruk
dan PER
penanganan kearah
PEB
adekuat atau
dapat
mencegah
bahkan
eklampsia
penanganannya perlu segera dilaksanakan untuk menurunkan angka kematian ibu (AKI) dan anak. Semua kasus PEB harus dirujuk ke rumah sakit yang dilengkapi dengan fasilitas penanganan intensif maternal dan neonatal, untuk mendapatkan terapi definitif dan pengawasan terhadap timbulnya komplikasi-komplikasi. Pemeriksaan antenatal yang teratur dan secara rutin mencari tanda preeklampsia sangat penting dalam usaha pencegahan preeklampsia berat, di samping pengendalian terhadap faktor-faktor predisposisi yang lain Preeklampsia adalah penyakit pada wanita hamil yang secara langsung disebabkan oleh kehamilan. Pre-eklampsia adalah hipertensi
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disertai proteinuri dan edema akibat kehamilan setelah usia kehamilan 20 minggu atau segera setelah persalinan. Gejala ini dapat timbul sebelum 20 minggu bila terjadi. Preeklampsia hampir secara eksklusif merupakan penyakit pada nullipara. Biasanya terdapat pada wanita masa subur dengan umur ekstrem yaitu pada remaja belasan tahun atau pada wanita yang berumur lebih dari 35 tahun. Pada multipara, penyakit ini biasanya dijumpai pada keadaan-keadaan berikut : 1) Kehamilan multifetal dan hidrops fetalis. 2) Penyakit vaskuler, termasuk hipertensi essensial kronis dan diabetes mellitus. 3) Penyakit ginjal.
1.2 A.
Tujuan Tujuan Umum Umum Menganalisa hubungan antara beberapa faktor risiko terhadap terjadinya preeklampsia pada saat kehamilan
B. a.
Tujuan Khusus Mengukur besar risiko faktor umur ibu hamil terhadap terjadinya preeklampsia berat
b. c.
Mengukur besar risiko paritas terhadap terjadinya preeklampsia berat. Mengukur besar risiko jarak kehamilan terhadap terjadinya preeklampsia
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d.
Mengukur besar risiko kehamilan ganda terhadap terjadinya preeklampsia berat.
1.3 Manfaat Presentasi ini diharapkan dapat berguna bagi semua pihak yang berkepentingan. Adapun pihak-pihak yang kiranya dapat menggunakan hasil presentasi ini, yaitu: 1. Bagi instansi pelayanan kesehatan Dapat digunakan sebagai tambahan referensi dalam memberikan pendidikan kesehatan pada ibu dengan preeklampsia berat sehingga dapat mengurangi dan mencegah terjadinya tekanan darah tinggi, edema, dan proteinuria. 2. Bagi institusi pendidikan kesehatan Dapat digunakan sebagai dasar untuk melakukan asuhan keperawatan pada ibu dengan preeklampsia berat yang selanjutnya. 3. Bagi masyarakat Meningkatkan
pengetahuan
masyarakat
khususnya
ibu
dengan
preeklampsia berat tentang pentingnya pencegahan peningkatan tekanan darah
dan
meningkatkan
kesehatan
proteinuria, bahaya janin, dan edema. 4. Bagi penulis
khususnya
tentang
pencegahan
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Meningkatkan keterampilan dan pengetahuan dalam melakukan asuhan keperawatan pada ibu dengan preeklampsia berat serta menambah wawasan dalam pembuatan laporan praktek.
1.4 Metode Penulisan Metode penulisan yang dipakai dalam penulisan makalah presentasi ini adalah: 1. Studi Kepustakaan, dengan mempelajari buku-buku yang berhubungan dengan kasus pada ibu preeklampsia berat . 2. Studi
Kasus,
dengan de ngan
pengamatan pengamat an
langsung langsun g
pada
ibu
dengan
preeklampsia berat di RS.Khusus Ibu dan Anak Astana Anyar Kota Bandung. 3. Studi dokumenter dengan menggunakan kartu pasien.
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BAB II PEMBAHASAN
2.1
Pengertian Preeklampsia atau sering juga disebut toksemia adalah suatu kondisi yang bisa dialami oleh setiap wanita hamil. Preeklampsia adalah kumpulan gejala yang timbul pada ibu hamil, bersalin dan dalam masa nifas yang terdiri dari trias : hipertensi, proteinuri, dan edema. Pengertian preelamsia menurut beberapa referensi :
a.
Preeklampsia adalah perkembangan hipertensi, protein pada urin dan pembengkakan, dibarengi dengan perubahan pada refleks (Curtis, 1999).
b.
Preeklampsia adalah suatu penyakit vasospastik, vasospastik , yang melibatkan banyak sistem dan ditandai oleh hemokonsentrasi, hipertensi, dan proteinuria (Bobak, dkk., 2005).
c.
Preeklampsia adalah hipertensi yang timbul setelah 20 minggu kehamilan disertai dengan proteinuria (Prawirohardjo, 2008).
d.
Preeklampsia adalah timbulanya hipertensi disertai proteinuria dan edema akibat kehamilan setelah usia 20 minggu atau segera setelah persalinan (Mansjoer dkk, 2000).
E.
Pre eklamsi merupakan suatu kondisi spesifik kehamilan dimana hipertensi terjadi setelah minggu ke-20 pada wanita yang sebelumnya memiliki tekanan
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2.2
Etiologi Etiologi penyakit preeklamsia sampai saat ini belum diketahui dengan pasti. Banyak teori – – teori dikemukakan oleh para ahli yang mencoba menerangkan penyebabnya. Oleh karena itu disebut “penyakit teori” namun belum ada memberikan jawaban yang memuaskan. Preeklampsia ialah suatu kondisi yang hanya terjadi pada kehamilan manusia. Tanda dan gejala timbul hanya selama hamil dan menghilang dengan cepat setelah janin dan plasenta lahir. Tidak ada profil tertentu yang mengidentifikasi wanita yang akan menderita preeklampsia. Preeklampsia umumnya terjadi pada kehamilan yang pertama kali, kehamilan di usia remaja dan kehamilan pada wanita diatas 40 tahun. Faktor resiko yang lain adalah : ·
Riwayat kencing manis, kelainan ginjal, lupus atau rematoid arthritis arthriti s
·
Riwayat tekanan darah tinggi yang khronis sebelum kehamilan.
·
Kegemukan.
·
Riwayat mengalami preeklampsia sebelumnya.
·
Riwayat preeklampsia pada ibu atau saudara perempuan.
·
Mengandung lean alirbih dari satu orang bayi.
·
Gizi buruk
·
Gangguan aliran darah ke rahim. Akan tetapi, ada beberapa beberapa faktor resiko tertentu yang berkaitan
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Kira-kira
85%
preeklampsia
terjadi
pada
kehamilan
pertama.
Preeklampsia terjadi pada 14% sampai 20% kehamilan dengan janin lebih dari satu dan 30% pasien mengalami anomali rahim yang berat. Pada ibu yang mengalami hipertensi kronis atau penyakit ginjal, insiden dapat mencapai 25%. Preeklampsia ialah suatu penyakit yang tidak terpisahkan dari preeklampsia ringan sampai berat, sindrom HELLP, atau eklampsia (Bobak, dkk., 2005).
2.3 Manifestasi Klinis Diagnosis preeklamsia ditegakkan berdasarkan adanya dari tiga gejala, yaitu : - Edema - Hipertensi - Proteinuria Berat badan yang berlebihan bila terjadi kenaikan 1 kg seminggu beberapa
kali.
Edema
terlihat
sebagai
peningkatan
berat
badan,
pembengkakan kaki, jari tangan dan muka. Tekanan darah ≥ 140/90 mmHg
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atau kadar protein ≥ 1 g/l dalam urin yang dikeluarkan dengan kateter atau urin porsi tengah, diambil minimal 2 kali dengan jarak waktu 6 jam. Disebut preeklamsia berat bila ditemukan gejala : - Tekanan darah sistolik ≥ 160 mmHg atau diastolik ≥ 110 mmHg. - Proteinuria + ≥5 g/24 jam atau ≥ 3 pada tes celup. - Oliguria (<400 ml dalam 24 jam). - Sakit kepala hebat atau gangguan penglihatan. - Nyeri epigastrum dan ikterus. - Trombositopenia. Pertumbuhan janin terhambat. - Mual muntah - Nyeri epigastrium - Pusing Penurunan visus (Kapita Selekta Kedokteran edisi ke-3)
2.4
Patofisiologi Pada preeklampsia terjadi spasme pembuluh darah disertai dengan retensi garam dan air. Pada biopsi ginjal ditemukan spasme hebat arteriola glomerulus. Pada beberapa kasus, lumen arteriola sedemikian sempitnya sehingga hanya dapat dilakui oleh satu sel darah merah. Jadi jika semua arteriola dalam tubuh mengalami spasme, maka tenanan darah akan naik sebagai usaha untuk mengatasi tekanan perifer agar oksigenasi jaringan
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Patofisiologi
pre
eklamsi-eklamsi
setidaknya
berkaitan
dengan
perubahan fisiologis kehamilan. Adaptasi fisiologis normal pada kehamilan meliputi peningkatan volume plasma darah, vasodilatasi penurunan resistensi vaskular sistemik (systemic vascular resistance[SVRI]) , peningkatan curah jantung, dan dan penurunan penurunan tekanan tekanan osmotik osmotik koloid. koloid. Pada preeklamsia volume plasma yang beredar menurun sehingga terjadi hemokonsentrasi dan peningkatan hematokrit maternal. Perubahan ini membuat organ maternal menurun, termasuk perfusi ke unit janinuteroplasenta. Vasospasme siklik lebih lanjut menurunkan perfusi organ dengan menghancurkan sel-sel darah merah, sehingga kapasitas oksigen maternal menurun. Vasospasme merupakan akibat peningkatan sensifitas terhadap tekanan peredaran darah, seperti angiotensin II dan kemungkinan suatu ketidakseimbagan antara prostasiklin prostaglandin dan tromboksan A 2. Selain
kerusakan
endotelial
vasospasme
arterial
menyebabkan
peningkatan permeabilitas kapiler. Keadaan ini meningkatkan edema dan
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pada ibu baru dan ibu hamil dari pasangan baru (materi genetik yang berbeda). Predisposisi genetik dapat merupakan faktor imunologi lain. Frekuensi pre eklamsi dan eklamsi pada anak dan cucu wanita yang memiliki riwayat eklamsi, yang menunjukkan suatu gen resesif autoso yang mengatur respon imun maternal. Patofisiologi preeklampsia mempengaruhi sistem saraf pusat (SSP) dengan menginduksi edema otak dan meningkatkan resistensi otak. Komplikasi meliputi nyeri kepala, kejang, dan gangguan penglihatan (skotoma)
atau
perubahan
keadaan
mental
dan
tingkat
kesadaran.
Komplikasi yang mengancam jiwa ialah eklampsia atau timbul kejang (Bobak, dkk., 2005).
2.5
Patologi Berbagai teori mengenai asal preeklampsia telah diajukan, tetapi barubaru ini tidak terdapat penjelasan yang lengkap tentang penyebab gangguan ini. Respons imun abnormal, gangguan endokrin, predisposisi genetik,
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Vasospasme paling mungkin sebagai penyebab proses penyakit. Ketika vasospasme berlanjut, terjadi kerusakan pada dinding pembuluh darah, yang mengakibatkan mengalirnya trombosit dan fibrin ke dalam lapisan subendotel dinding pembuluh darah. Hal ini diketahui bahwa ibu yang mengalami preeklampsia mempunyai sensivitas pada angiotensin II, yang dianggap
menjadi
kontributor
utama
untuk
proses
vasospasme.
Vasokonstriksi juga berperan pada kerusakan sel darah merah ketika melewati
diameter
pembuluh
darah
yang
bgerkurang
ukurannya.
Vasospasme akhirnya menimbulkan hipoksia jaringan lokal pada berbagai sistem organ, termasuk plasenta, hati, paru, otak, dan retina. Vasospasme serebral berperan pada gejala sakit kepala dan gangguan penglihatan serta dapat berlanjut menjadi stroke. Vasospasme pada sistem ginjal berperan pada penurunan aliran darah ginjal. Sistem ginjal mengalami pembengkakan sel endotel glomerulus, lumen
kapiler
glomerulus
berkonstriksi,
dan
filtrasi
glomerulus
dan
selanjutnya menurun. Karena penurunan filtrasi, nitrogen urea darah serum,
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dan hemokonsentrasi. Hal ini pada gilirannya menempatkan kebutuhan pada jantung sebagai presoreseptor presoreseptor pada organ mayor memberi umpan balik untuk meningkatkan curah jantung. Riset tentang curah jantung pada preeklampsia masih menjadi konflik. Beberapa penelitian telah menetapkan penurunan curah jantung yang dikaitkan dengan peningkatan tahanan vaskular perifer, sedangkan penilitian lain menemukan bahwa beberapa ibu dengan preeklampsia secara nyata mengalami peningkatan curah jantung dan penurunan tahanan perifer sampai penyakit menjadi berat. Disfungsi hati pada preeklampsia dapat direntang dari perubahan enzim ringan sampai edema hepatik, edema subkapsular, atau hemoragi.
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Beberapa ibu yang mengalami preeklampsia berlanjut mengalami sindrom HELLP, yang dikaitkan dengan progresi cepat proses patologis dan mengakibatkan hasil janin dan maternal sebaliknya. Ibu yang mengalami sindrom
HELLP
kemungkinan
menunjukkan
subset
individual
yang
mengalami disfungsi endotel lebih berat, dan dianggap bahwa predisposisi ini mungkin bersifat genetik. Disamping efek tidak langsung penurunan perfusi maternal pada janin, proses vasospasme juga secara langsung mempengaruhi plasenta. Lesi plasenta yang adalah akibat infrak selanjutnya menurunkan perfusi ke janin, yang menimbulkan intrauterine growth restriction (IUGR) dan hipoksia. Komplikasi yang dikaitkan dengan preeklampsia berat meliputi gangguan
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• Usia kehamilan 37 minggu atau lebih • Adanya tanda-tanda tanda -tanda atau gejala impending eklampsia, kegagalan terapi konservatif yaitu setelah 6 jam pengobatan meditasi terjadi kenaikan desakan darah atau setelah 24 jam perawatan medisinal, ada gejala-gejala status quo (tidak ada perbaikan) b. Janin • Hasil fetal assesment jelek (NST dan USG ) • Adanya tanda IUGR (janin terhambat) c. Laboratorium • Adanya “HELLP Syndrome” (hemolisis dan peningkatan fungsi hepar, trombositopenia)
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jarum no 21 panjang 3,7 cm. Untuk mengurangi mengurangi nyeri dapat diberikan diberikan xylocain 2% yang tidak mengandung adrenalin pada suntikan IM. 2. Dosis ulang : diberikan 4 gr IM 40% setelah 6 jam pemberian dosis awal lalu dosis ulang 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 gr (10% dalam 10 cc) diberikan IV dalam 3 menit. • Refleks patella positif kuat. • Fr ekuensi ekuensi pernapasan lebih 16 x/menit. • Produksi urin lebih 100 cc dalam 4 jam sebelumnya (0,5 cc/KgBB/jam) 4.
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- Berikan oksigen - Lakukan pernapasan buatan • MgSO4 dihentikan juga bila setelah 4 jam pasca persalinan sedah terjadi perbaikan (normotensi). f. Deuretikum tidak diberikan kecuali bila ada tanda-tanda edema paru, payah jantung kongestif atau edema anasarka. anasarka. Diberikan Diberikan furosemid injeksi 40 mg IM. g. Anti hipertensi diberikan bila : 1. Desakan darah sistolik > 180 mmHg, diastolik > 110 mmHg atau MAP lebih 125 mmHg. Sasaran pengobatan adalah tekanan diastolik <105 mmHg (bukan < 90 mmHg) karena akan menurunkan perfusi plasenta.
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1. Indikasi : bila kehamilan paterm kurang 37 minggu tanpa disertai tandatanda inpending eklampsia dengan keadaan janin baik. 2. Pengobatan medisinal : sama dengan perawatan medisinal pada pengelolaan aktif. Hanya loading dose MgSO4 tidak diberikan IV, cukup intramuskular saja dimana gram pada pantat kiri dan 4 gram pada pantat kanan. 3. Pengobatan obstetri :
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2.7
Diagnosis Diagnosis preeklampsia dilakukan pada setiap kali pemeriksaan prenatal dengan mengukur tekanan darah ibu dan menguji protein urine. Diagnosis preeklampsia ringan ditegakkan berdasar atas timbulnya hipertensi disertai
proteinuria
dan/atau
edema
setelah
kehamilan
20
minggu
(Prawirohardjo, 2008). a. Hipertensi : sistolik/diastolik ≥140/90 mmHg. Kenaikan sistolik
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5.
Gangguan visus dan serebral : penurunan kesadaran, nyeri kepala, skotoma dan pandangan kabur.
6. Nyeri epigastrium atau nyeri pada kuadran kanan atas abdomen (akibat teregangnya kapsula Glisson). 7. Edema paru-paru dan sianosis. 8. Hemolisis mikroangiopatik. 9. Trombositopenia berat: < 100.000 sel/mm3 atau penurunan trombosit
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kejadian preeklampsia ringan dapat dilakukan nasehat tentang dan berkaitan dengan preeklampsia : a. Diet makanan. Makanan tinggi protein, rendah karbohidrat, cukup vitamin, rendah lemak. Makanan berorientasi pada empat sehat lima sempurna. b. Cukup istirahat. Istirahat yang cukup pada hamil semakin tua dalam arti bekerja seperlunya dan disesuaikan dengan kemampuan. Lebih banyak duduk atau berbaring kea rah punggung janin sehingga aliran darah menuju
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2.9
Penanganan Upaya pengobatan ditujukan untuk mencegah kejang, memulihkan organ vital pada keadaan normal, dan melahirkan bayi dengan trauma sekecil-kecilnya pada ibu dan bayi. Segera rawat pasien di rumah sakit. Berikan MgSO 4 , dalam infuse Dextrosa 5% dengan kecepatan 15-20 tetes per menit. Dosis awal MgSO 4 2
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Terminasi kehamilan adalah terapi defintif pada kehamilan > 36 minggu atau bila terbukti sudah adanya maturasi paru atau terdapat gawat
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2.10 Pemeriksaan Penunjang Preeklampsia Preeklampsia 1. Pemeriksaan spesimen urine mid-stream untuk menyingkirkan
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Pendidikan Pekerjaan
: SMP : swasta
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e. Riwayat alergi obat dan makanan: tidak ada alergi obat dan makanan
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