Dr. H.

NUSWIL BERNOLIAN, SpOG(K)

Dr. H. ISKANDAR ZULQARNAIN, SpOG(K)

Emergencies

Emergencies: situation that requires

abrupt response and life-threatening
Many emergency cases found in
Obstetrics, Yet our discussion talks about
Pre-eclampsia/ eclampsia and
haemorrhage

haemorrhage emergency cases

1. Gestational age < 20 mgg : Abortion,

ectopic pregnancy, hyperemetics, Mola
Kehamilan > 20 mgg : Placentae
previa,
placental
abruption, uterine rupture
2. Labour: Placentae previa, passage
laceration, retained placentae
3. puerperium : uterine atony, passage
laceration, retained placentae

 Pre-eclampsia/ Eclampsia

Incidence of Pre-eclampsia & Eclampsia

in pregnant women ranges from 4-9%,
nulliparous and multiparous, 3-7%, 0,85%, respectively
Incidence rate of Pre-eclampsia in
Indonesia ranges from 3-10%

Hypetension in pregnancy

Is the cause of maternal and neonatal

morbidity and mortality, besides
haemorrhage and infection
In Indonesia, Pre-eclampsia & Eclampsia
result in 30-40% perinatal death

Classification of Hypertension in pregnancy :

Gestational hypertension:raising blood pressure

found within up to 12 weeks of gestational age to
puerperium
Chronic hypetension: hypertension occurring
before being pregnant, whilst pregnant, then after
puerperium
Superimposed Pre-eclampsia: symptoms and
signs of Pre-eclampsia arising after 20 weeks of
gestational age in women who formerly has had
hypertension
Mild Pre-eclampsia, severe Pre-eclampsia,
Eclampsia : found in clinical sign characteristic

Trias Pre-eclampsia: blood pressure

140/90 mmHg, Proteinuria, and edema.

Yet edema has been excluded from

diagnosis criterion due to edema found in
normal pregnancy

Etiology and Pathogenesis

Etiology and pathogenesis of Pre-eclampsia

currently has not been completely
understood, it remains controversy

Mayor Hypothesis resulting in Pre-eclampsia:

immunologic factors , genetics, vascular
diseases

 mild Pre-eclampsia

blood pressure 140/90, but

< 160/110 mmHG and proteinuria +1

severer Pre-eclampsia
o if blood pressure > 160/110 mmHg,
Proteinuria +2, may be accompanied by
subjective complaints such as epigastric pain,
headache, vision disorder, and oliguria

Management of severe Preeclampsia:

A. Medicines
- bedrest
- oxygen
- catheter insertion
- IVFD : acetic Ringer , colloid
- Anti-seizure : Magnesium sulphate
- Antihypetension: Nifedipine

B. obstetric management
in controlled condition mother, make decision whether
to terminate the pregnancy or conservative treatment.
If cervix is ripen and no obstetric contraindications may
be performed labour induction with oxitocin drip and
amniotomy, accelerated second stage with VE/FE

 Eclampsia
Acute abnormalities in pregnant women in
labour or puerperium characterized by
seizure and or comatose
The convulsion occurring after 20 weeks of
gestational age, in a woman, without
previous attack abnormality
Little number of women with Eclampsia has
normal blood pressure

Strategies to prevent Eclampsia

- Antenatal care and knowing
hypetension
- Identification and preEclampsia care by trained
helper

- 3.4% women with severe

Pre-eclampsia will
experience convulsion
- Eclampsia is at the first
rank in maternal mortality
in Hospital in Nepal

- Born at estimated date

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Management of Eclampsia :

A. Medicines
- Anti seizure : MgSO4
- IVFD : acetic ringer , lactic ringer
- care during seizure attack: cared at isolated
room, insert tongue spatula to the mouth, slime
suction
- insert catheter cared at ICU

B. obstetric management
all pregnancies with Eclampsia has to be
terminated without any concern to gestational
age and fetal well being

Early Assessment and management in

Eclampsia :
- asking for help personnels mobilization
- quick evaluation in breathing and sensorium
- check airways, blood pressure and pulse
- left side lying
- protect from being injured but not tied
- start IV infusion with big hollow needle (size16 gauge)
- administer oxygen 4 L/minutes

Do not leave mother alone without any guardian

Anti Hypetension drugs :

- Methyl Dopa
- Nifedipine
- Labetolol
Principles:

Start with anti hypertensive drugs if diastolic blood

pressure > 110 mm Hg

Maintain diastolic blood pressure 90-100 mm Hg to

prevent cerebral hemorrhage

15

Anti convulsion drugs :

- Magnesium sulphate
- Diazepam

Management post convulsion :

- Prevent advanced convulsion
- Control blood pressure
- Preparation for delivery (if remain unborn)

16

Sulphates Magnesium

Use Magnesium sulphate in:

- women with Eclampsia
- women with severe pre-Eclampsia who has
to deliver the baby
- start magnesium sulphate while taking
decision to terminate

Continue therapy till 24 hours after delivering

or last convulsion
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 ABORTION
Definition :
termination of pregnancy before conception
may be viable outside the womb (<500 g or <
20 weeks)
Spontaneus Abortion = miscarriage
Abortion may happen naturally with any
external factors

Provocative abortion = abortion

Abortion resulted in particular effort to
terminate the pregnancy
1. medically provocative Abortion
2. criminal Abortion
Incidence: WHO 10% pregnancy
Sarwono 10-15%

Etiology :
A.
B.
C.
D.

Zygotic development
abnormality
Placentae abnormality
Maternal abnormality
Genital tract abnormality

managemnet :

Imminence Abortus :
a. bedrest
b. Mild sedative
c. Tocolytics
d. Hormone

Management

Incipients and incomplete

Abortion :
a. General condition improvement
b. Curretage
c. Uterotonics
d. Antibiotics

Management

Complete abortion:
no special treatment
Anemia : SF, roborantia, transfusion

Management

Missed Abortion :
a. check CT, BT, COT
b. < 12 mgg : laminaria-curretage
c. > 12 mgg :
estradiol benzoas
laminaria / pitosin drip

Management

Septic Abortus :
a. care at ICU
b. = Abortus infeksiosa
c. Dexamethasone
d. curretage 24 jam afterward
e. no improvement : HTSOB
f. HT, considered:
- Uterus > 16 weeks
- C.welchii infection
- provocative abortion
- uterine perforation

 ectopic pregnancy
Definition :
egg which is fertilised, implanted and grow
outside endometrium of uterine cavity
location : a. Tuba fallopii
b. Uterus
c. Ovarium
d. Intraligaments
e. Abdominal
f. combination between in and outside uterine

Frequency : 0 14,6%
Etiology :
mostly unknown
predisposing factors
1. narrow tuba Lumen
2. tuba wall
3. outside tuba
4. other factors

Risk factors :
1. PID
2. IUD (inflammation obstruction )
3. history of ectopic pregnancy
4. history of abdominal surgery
DIAGNOSIS :
varying dependent on quick diagnosis,
implantation, location, rupture

Anamnesis :
- delayed menstruation
- lower abdominal pain
- radiating pain to the shoulder
- vaginal haemorrhage
- Tenesmus
General examination:
- being sick and pale
- shocks signs
- distended abdomen and tenderness

Gynecologic examination :

Early pregnancy signs

OUE (portio) shake pain
Bigger uterine size
CD protruded and touching
pain, retrouterine hematochele
Sometimes mild increasing of
body temperature

Laboratorium

Hb, leucocytes
Pregnancy test (PT)
Progesteron

USG :
gestational sac outside uterine cavity or
fluid in CD
CULDOSYNTHESIS

Management :

1. improving general condition, infusion

and transfusion
2. immediate laparatomy
3. chemotherapy

 Placentae PREVIA
DEFINITION :
abnormal lying placente is in lower
segment of uterine, covering half or
total of OUI
Classification :
1. total Placentae previa
2. partial Placentae previa
3. marginal Placentae previa
4. low lying Placentae

Frequency : 0,4 0,6 %

Etiology :
no clear explanation
predisposition :
1. decreasing decidua vascularisation
2. endo / miometrium damage
3. big Placentae
4. unknown etiology

Pathogenesis :
corpus endometrium damage
bad implantation lower segment of
uterine
2. Nutrition needs > Normal
extended Placentae SBR / OUI
Symptoms :
- early spot
- fresh blood
- night
- of the mother (baby 10%)
1.

Diagnosis :
1. Anamnesis :
no pain haemorrhage, no cause
2. Vaginal examination:
lower part is not engaged to pelvic
inlet yet
3. Inspeculo :
OUI haemorrhage
4. USG (indirect)
5. Fornix palpation cervix canal

Management

Expectative
aim: not born prematurely
requirements:1. < 37 weeks
2. inactive bleeding
3. not in labour yet
4. good maternal condition
(Hb>8 g%)
5. live fetus

Management

Active
requirements :1. > 37 weeks / EFW >
2500 g
2. active haemorrhage, poor general
condition
3. inlabour
4. lower part engaged to pelvic inlet
5. dead fetus, major congenital

Treatment

General condition improvement:

Infusion, shock management
Shock cleared & ensure diagnosis,
decide the termination :
poor condition: cesarean section
good condition: on operation table of
vaginal examination
Labour : cesarean section Vaginally

 Placental abruption
Definition :
Placental abruption from implantation
site which is normal before fetal birth in
gestational age > 28 weeks
Frequency : 2% repeated labour 1 in 625 pregnancies

Etiology / predisposes :
1. Hypertension in pregnancy 8. Trauma, VL
2. Multiparity
9. alcoholism;
3. Older maternal age
10. smoking
4. Short umbilical cord
11. uterine tumor
5. Abrupt uterin decompression
6. Pressure in VCL 12. uterine abnormality
7. Nutrition deficiency, folic acid

Diagnosis

clinical features :
Unpainful bleeding
Blackish
Anemia / shock
Tender Uterine
fetal part Cannot be assessed
No fetal heart rate
Concealed haemorrhage in Placentae

Management

Expectative
criterion :
1. good condition
2. gestational age < 37
weeks, EFQW < 2500 g
3. mild placental abruption

Management

Active
criteria :

1. poor condition
2. gestational age > 37
mgg, EFW > 2500 g
3. mild, moderatem
severe placental abruption

Treatment : improve the conditionobstetric treatment