MORNING REPORT

OF OBGYN COASS
Thursday, 13th August 2015

LIST OF THE PATIENTS

No
1

Identitas
Mrs. W
G2P1A0
42 years old
GA 37 weeks

Diagnosis
Pulmonary edema, Severe
Preeclampsia, IUFD, Breech
presentation, on secundigravida
fullterm pregnancy, not yet in
labor with history of SC 6 years
ago

Terapi
1. Emergency C-section +
IUD insertion
2.Severe pre eclampsia
protocol :
-. O2 3 lpm
-. Infusion of RL 12 tpm
-. MgSO4 20% initial dose
-. Nifedipine 3x10 mg if
blood pressure 160 / 100
mmHg
3. Hemodinamic
stabilization
4. Prophylaxis injection of
Cefazolin 2 g skin test
5. Consultation with
Cardiology, Pulmonology,
and anaesthesiology
department

N
o

Identitas

Diagnosis

Terapi

Mrs. M
P2A2
33 years old

Hypovolemic shock e.c internal

bleeding post SCTP

1. Laparotomy
exploration (em)
2. Resuscitation O2 rnm
5 lpm, two line IVFD
3. Prophylaxis injection of
Cefazolin 2 g skin test
4. Prepare for blood supply
5. Anasthesiology and
Cardiology dept
consultation

Mrs. D
G4P3A0
45 years old

2 days PROM on multigravide

fullterm, in labor, stage I latent
phase

1. Lead the delivery

2. Induction of oxitocin 5
IU in 500 cc ringer lactate
3. Prophylaxis with vicilin
inj 1 gr
4. Lab. test

No
4

Identitas
Mrs. R
G5P4A0
35 years old
GA 40 weeks

Diagnosis
18 hours PROM on multigravide
fullterm, in labor, stage I latent
phase

Terapi
1. Lead the delivery
2. Induction of oxitocin 5 IU
in 500 cc ringer lactate
3. Prophylaxis with vicilin
inj 1 gr
4. Lab. Test

CASE REPORT
I. ANAMNESIS
A. PATIENT IDENTITY
Name

: Mrs W

Age

: 42 years old

Adress

: Baki, Sukoharjo

Occupation

: Housewife

Date of entry

: 13th August 2015

Date of examination
MR number

: 13th August 2015

: 01 31 04 20

B. Main Complaint
Dyspneu

C. History of Present Illness

A G2P1A0, 42 years old, GA 37 weeks, came to the hospital
refferal from RSUD Klaten, with pulmonary oedema, severe

preeclampsia,
IUFD,
with
breech
presentation
on
secundigravida fullterm pregnancy not yet in labor, with
history of SC 6 years ago. Patient feels 8 months of
pregnancy. fetal movement is not perceived since the day
before, regular contraction (-), amniotic fluid have not felt out,
mucus blood (-), blurred sight (-), headache(-), nausea & vomitus
(-).
1st day of last period

: 27-11-2014

Estimated birthdate : 3-9-2015

1st pregnancy : female, 2800 grams, 6 years, SC with indication
of transversal presentation.
2nd pregnancy : this pregnancy

D. History of previous illness

Asthma history
: denied
DM history
: denied
Hypertension history : denied
Heart disease history : denied
Allergy history
: denied

E. Menstrual history
Menarche
: 13 years old
Length of menstruation : 6-7 days
Menstrual cycle
: 28 days

F. Marriage History
Married once for 7 years

G. Contraception history

injection for 3 months

II. Physical Examination

STATUS GENERALIS

General condition: well, compos mentis, nutrition statu

is well
Vital sign
Blood pressure
Resp. Rate
Heart rate

: 180/120 mmHg
: 28x/menit

: 92 x/menit

Temperature

: 36,70 C

Cor : within
normal limits
Pulmo
:
vesicular +/
+, wheezing
-/fine
crackles +/+
Abdomen :
Supple,
tenderness
(-),
palpated single fetus, intrauterine, elongated, breech
presentation , back on the left
side, the breech has not yet
entered
the
pelvis,
contractions -, fetal heart rate
(-)
Genital:
VT: v/u are normal, vagina wall
within normal limits, soft portio,
OUE is closed, eff 10%, amniotic
fluid (-), skin membranes and
indicator cannot be assessed,

CA (-/-)
SI (-/-)

Extremity
Edema : (+/+)
Acral coldness: (-/-)

III. Laboratory Examination

Blood laboratory (13rd August 2015)

Hb
: 14.2
Hct
: 43
AE
: 4.80.106
AL
: 18.5.103 ()
AT
: 275.103
PT/APTT
: 12,4 / 34,3
GDS
: 272 ()
SGOT
: 37 ()
SGPT
: 13
Albumine : 3,1 ()
Creatinine : 2.6 ()
Ureum
: 56 ()
LDH
: 531 ()
Na / K
: 134 ()/ 4,1
HBsAg
: non reaktif
qualitative protein
: +3

USG (13th August 2015)

Appear vesica urinaria in sufficiently filled
condition, appear single fetus, intra-uterine,
elongated, back on the left side,
breechpresentation, fetal heart rate (-)
FB BPD : 9,4 cm
AC : 36,01 cm FL : 8,3
cmEFW : 3911 gr
Placental insertion at corpus uteri grade II
Amniotic fluid is enough
Conclusion :
currently, the fetus has no sign of life

IV. Conclusion
A G2P1A0, 42 years old, GA 37 weeks, came to the hospital,
refferal
with
pulmonary
oedema,
severe

preeclampsia, IUFD, with breech presentation on

secundigravida fullterm pregnancy not yet in labor,
with history of SC 6 years ago
From physical examination we got fine crackles +/+, Supple
abdomen, tenderness (-), palpated single fetus, intrauterine, elongated, breech presentation, back on the left
side, the breech has not yet entered the pelvis,
contractions -, fetal heart rate (-)

VT: v/u are normal, vagina wall within normal limits,

soft portio, OUE is closed, eff 10%, amniotic fluid (-),
skin membranes and indicator cannot be assessed
USG examination showed single fetus has no sign of life

V. DIAGNOSIS
Pulmonary edema, Severe Preeclampsia, IUFD, Breech presentation, on
secundigravida fullterm pregnancy, not yet in labor with history of SC 6
years ago

VI. Therapy
1. Emergency C-section + IUD insertion

2.Severe pre eclampsia protocol :

-. O2 3 lpm
-. Infusion of RL 12 tpm
-. MgSO4 20% initial dose
-. Nifedipine 3x10 mg if blood pressure 160 / 100 mmHg
3. Hemodinamic stabilization
4. Prophylaxis injection of Cefazolin 2 g skin test
5. Consultation with Cardiology, Pulmonology, and anaesthesiology department

LITERATURE
REVIEW

PRE ECLAMPSIA

PREECLAMPSIA: DEFINITION

Hypertension
> 140/90
relative no longer considered diagnostic

Proteinuria
> 300 mg/24 hours or 1+ on urine dipstick
not mandatory for diagnosis; may occur late

Edema (non-dependent)
so common & difficult to quantify it is rarely evoked to make or refute the
diagnosis

DEFINITION OF PREECLAMPSIA
The presence of hypertension of at least
140/90 mm Hg recorded on two separate
occasions at least 4 hours apart and in the
presence of at least 300 mg protein in a
24 hours collection of urine arrising de novo
after the 20th week gestation in a previously
normotensive women and resolving
completetly by the sixth postpartum week.

RISK FACTORS

Nulliparity (3.1)
Age >40 years (3:1)
Black race (1.5:1)
Family history (5:1)
Chronic renal disease (20:1)
Chronic hypertension (10:1)
Antiphospholipid syndrome (10:1)
Diabetes mellitus (2:1)
Twin gestation (but unaffected by zygosity) (4:1)
High body mass index (3:1)
Homozygosity for angiotensinogen gene T235 (20:1)
Heterozygosity for angiotensinogen gene T235 (4:1)

IV. CLASSIFICATION OF PRE ECLAMPSIA:

ACCORDING TO SEVERITY
1. Mild pre-eclampsia
2. Moderate pre-eclampsia
3. Severe pre-eclampsia
4. Mild to Moderate Pre eclampsia
Diagnostic Features

Systolic BP is 140 -160 mmHg

Diastolic BP is 90 100 mmHg
Proteinuria up to ++

2. SEVERE PRE-ECLAMPSIA
Also called Imminent eclampsia
Symptoms
Severe & persistent occipital or frontal
headaches
Visual disturbance: blurred vision,
photophobia
Epigastric and/or right upper-quadrant
pain
Signs
Diastolic BP > 110mmHg, systolic BP >
160mmHg
Proteinuria +++ or more

VI. COMPLICATIONS OF SEVERE PREECLAMPSIA AND ECLAMPSIA

Maternal
complications
CVS
Haemoconcentration (cause: vasoconstriction and
vascular permeability)
Hematological changes HELLP DIC
Kidneys
Decr RBF GFR RTN and RCN acute RF
Proteinuria due to permeability to large protein,
Oliguria both renal perfusion and GFR decrease.

COMPLICATIONS OF SEVERE PRE

ECLAMPSIA AND ECLAMPSIA CONT
Brain
Cerebral edema
Infarction, cerebral hemorrhage
Blindness: Due to - retinal artery
vasospasms and retinal detachment
Fever 39C: a grave sign, may be a
consequence of intracranial
hemorrhage.
Coma may be a result of CVA

COMPLICATIONS OF SEVERE PRE

ECLAMPSIA AND ECLAMPSIA CONT
RS : Pulmonary oedema and cyanosis
Utero-placental perfusion

Vasospasms decr perfusion distress and death

Histological changes in the placental bed: acute artherosis lipid rich
cells of the uteroplacental arteries

Fetal complications

IUFD, IUGR

MAJOR CAUSES OF MATERNAL DEATH

Pulmonary oedema
Cardiac failure,
Renal failure
Cerebrovascular accident (CVA)

VII. WORK UP - INVESTIGATIONS

Urine analysis
Proteinuria

A 24-hour urine collection

Quantity of urine and protein

Uric acid level:

GFR and creatinine clearance decrease in uric
acid levels.

LFT Transaminases
USS fetal wellbeing, if the GA is <
20/40 R/O moles.

VIII. MANAGEMENT OF PRE ECLAMPSIA

1. MILD - MOD PRE ECLAMPSIA
A: Dispensary & Health centre
Antihypertensives

Methyldopa 250 mg 8 hourly for 7 days,

Bed rest at home

REFER within one week to Hospital for
further management

MANAGEMENT OF PRE ECLAMPSIA

1. MILD - MOD PRE ECLAMPSIA cont
B. Hospital
Antihypertensives: Aldomet,
Bed rest at home,
Fetal movements monitoring,
Schedule antenatal clinic every 2 weeks up to
32 wks and weekly thereafter

MANAGEMENT OF PRE ECLAMPSIA

1. MILD - MOD PRE ECLAMPSIA cont
B. Hospital
Strongly advice the woman to deliver in a
hospital
Plan delivery at 38/40
Advice the mother to come to the health
facility in case of severe headache, blurred
vision, nausea or upper abdominal pain.
Manage as severe pre-eclampsia: If not
responding to treatment i.e. if the systolic
BP is > 160 mmHg, or the diastolic BP is >
100mmHg or there is proteinuria +++

MANAGEMENT OF SEVERE PRE ECLAMPSIA

AND ECLAMPSIA
Note: Severe pre-eclampsia is managed
like
eclampsia
Management protocol for eclampsia
Keep airway clear
Control convulsions
Control BP
Control fluid balance
Antibiotics
Investigations
Deliver the mother

MANAGEMENT

CONT

BP CONTROL
Keep SBP between 140 -160 mm Hg and DBP
between 90 -110 mm Hg
?Why these levels: Avoid potential reduction
in either uteroplacental blood flow or
cerebral perfusion pressure.
Drugs:
Anti HPTs: Hydralazine, nifedipine, or
labetalol

MANAGEMENT: CONTROL
CONVULSIONS
I. An overview on MgSO4.
Mechanism:
Cerebral vasodilator reducing cerebral
vasospasm ischemia (brain).
Superior to other anti-convulsants used
to control and prevent fits;
Important part of mgt of eclampsia
Recurrence rate after MgSO4 = 10 -15%

Improves maternal and fetal outcome

MANAGEMENT CONT
Frist dose: MgSo4 40%, 4-6 gram in 100 ml RL loading for 15-20 minute
Maintance dose: Mgso4 40 % 1gr/hour, for 24 hours

Post delivery:
Continue observation for at least 48 hrs post
delivery
Record and monitor BP and urine output for at
least 48 hours after delivery,
Keep the pt in hospital until BP stabilizes,
Continue with methyldopa PO until BP back to
normal

S
I
E
S
S LY
A
C NA
A

THE ENFORCEMENT OF THE

DIAGNOSIS

Blood pressure
Proteinuria

: 180/120 mmHg

: +3

Extremity edema

: (+)

PREDISPOSITION FACTORS
Age >40 years (3:1)
Diabetes mellitus (2:1)
High body mass index (3:1)

COMPLICATION

RS : Pulmonary oedema
The patients with pre-eclampsia usually have
generalised arterial vasospasm resulting in
an increased systemic vascular resistance
(increased after load), reduced plasma
volume (decreased pre-load), and increased
left
ventricular
stroke
work
index
(hyperdynamic heart).In addition, renal
function is impaired, serum albumin is
reduced and capillary permeability is
increased due to endothelial damage. All
these changes predispose to an increased
risk of pulmonary edema.

THANK YOU