Morning Report of

Obgyn Coass

Wednesday, 19th August 2015

LIST OF THE PATIENTS

No
1

Identitas
Mrs. P
G1P0A0
25 years old
GA 39 weeks

Diagnosis

Terapi

Eclampsia on primigravide
1. Emergency C-section +
fullterm pregnancy not in labor yet
IUD insertion
with fetal distress
2.Severe pre eclampsia
protocol :
-. O2 8 lpm
-. Infusion of RL 12 tpm
-. MgSO4 20% 1gr/hour for
24 hours
-. Nifedipine 3x10 mg if
blood pressure 160 / 100
mmHg
3. Prophylaxis injection of
Cefazidine 2 g skin test
4. Laboratory checks
5. Informed consent
6. Consultation to anesthesia
department

CASE REPORT
I. ANAMNESIS
A. Patient identity

Name
: Mrs P
Age
: 39 years old
Adress
: Surakarta
Occupation
: Housewife
Date of entry
: 18th August 2015
Date of examination
: 18th August 2015

B. Main Complaint
Referrals from Kustati hospital with
information of severe pre eclampsia

C. History of Present Illness

A G1P0A0, 25 years old, GA 39 weeks, came to the
hospital, referrals from Kustati hospital with
information of severe pre eclampsia. The patient has
been given 4 gr of MgSO4 20%. Patient feels 9 months of
pregnancy. fetal movement is still perceived, regular
contraction yet to be felt, amniotic fluid have felt out
about 2 hours before going to hospital, mucus blood (-).
1st day of last period : 16-11-2014
Estimated birthdate
: 23-08-2015

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 1 year

G. Contraception history

Contraception : (-)

II. Physical Examination

Status generalis
General condition: good, compos mentis, nutrition status
overweight
Vital sign
Blood pressure : 170/110 mmHg
Resp. Rate
: 22x/menit
Heart rate
: 90 x/menit
Temperature
: 36,70 C

Cor : within
normal limits
Pulmo
:
vesicular -/-,
wheezing -/Abdomen :
Supple,
tenderness
(-),
palpated single fetus, intrauterine,
elongated,
head
presentation , back on the left
side, the head has entered the
pelvis
<
1/3
parts,
contractions (-), fetal heart
rate Genital:
(+) 140x/min, fundal
VT:37v/u
normal,
height
cmare
~ 3100
gr vagina wall
within normal limits, soft portio,
OUE is close, eff 10%, amniotic
fluid (-), skin membranes and
bookmarks can not be assessed,
head down in Hodge I, blood
mucus (-)

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

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

III. Laboratory Examination

USG (18th August 2015)

Appear vesica urinaria in sufficiently filled
condition, appear a single fetus, intra-uterine,
elongated, back on the left side, head presentation,
fetal heart rate (+)
FB BPD : 9 cm AC : 32 cm FL : 7,5 cm
EFBW : 3100gr
Placental insertion in the corpus uteri grade II
Amniotic fluid is enough
Major congenital abnormalities (-)
Conclusion :
currently, the fetus is in good condition

IV. Conclusion

A G1P0A0, 25 years old, GA 39 weeks, came to the hospital, referrals

from Kustati hospital with information of severe pre eclampsia .
The patient the patient has been given 4 gr of MgSO4 20%, sign of
labor still negative.
From physical examination we get supple abdomen, no tenderness,
palpated single fetus, intra-uterine, elongated, head presentation,
back on the left side, the head has entered the pelvis < 1/3 parts,
contractions (-), fetal heart rate (+) 140x/min. Pulmo : vesicular -/-,
wheezing -/-, and edema of the extremity.
VT: v/u are normal, vagina wall within normal limits, soft portio, OUE is
close, eff 10%, amniotic fluid (-), skin membranes and bookmarks can
not be assessed, head down in Hodge 1, blood mucus (-)
USG examination showed fetus still in good condition

V. DIAGNOSIS
Eclampsia on primigravide fullterm pregnancy not
in labor yet with fetal distress

VI. Therapy
1. Emergency C-section + IUD insertion
2.Severe pre eclampsia protocol :
-. O2 8 lpm
-. Infusion of RL 12 tpm
-. MgSO4 20% 1gr/hour for 24 hours
-. Nifedipine 3x10 mg if blood pressure 160 / 100 mmHg
3. Prophylaxis injection of Cefazidine 2 g skin test
4. Laboratory checks
5. Informed consent
6. Consultation to anesthesia department

LITERATURE
REVIEW

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.

Pathophisiology:Defective trophoblast invasion

hypoperfused
placenta
release factors (growth factors,
Cytokines)
vascular endothelial cell activation.

- Vasospasm
hypertension
- Endothelial cell damage
oedema,
hemoconcentration
- Kidneys,glomeruloendotheliosis
proteinuria,reduced uric excretion and oligouria.

 Liver,subendothelial fibrin deposition

elevated liver,hemorrhage,infarction,liver
rupture and epigastric pain.
Blood
thrombocytopenia,DIC,HELLP
syndrome.
Placental vasospasm
placental
infarction,placental abruption &
uteroplacental perfusion
IUGR.
CNS vasospasm&oedema
headache,
visual symptons(blurred vision,spots,
scotoma), hyperreflexia and convulsions.

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 > 11ommHg, systolic BP >
160mmHg
Proteinuria +++ or more
Altered mental status
Hyper-reflexia
Oliguria

HELLP SYNDROME
Is a severe form of pre-eclampsia
Affects approx 10% of women with severe
preeclampsia and 30-50% of women with
eclampsia.
Characterized by:
Hemolysis,
Elevated liver enzymes
Low platelet count.

Increased mortality rate and DIC

VI. COMPLICATIONS OF SEVERE PREECLAMPSIA AND ECLAMPSIA

Maternal complications
CVS
Haemoconcentration (cause: vasoconstriction and
vascular permeability)
Hamatological 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

Aldomet 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
Diuretics are not used except in the presence of
pulmonary edema

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

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 aldomet PO until BP back to
normal

CASE ANALYSIS

The Enforcement of the

Diagnosis
Blood pressure : 170/110 mmHg
Proteinuria
: +3
Extremity edema : (+)

Predisposition factors
High body mass index
Nullipara

Complication
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
seizure.

THANK YOU