Diapositiva 1

Morning Report of Obgyn CoassThursday, 13th August 2015List of the patientsNoIdentitasDiagnosisTerapi1Mrs. WG2P1A042 years oldGA 37 weeksPulmonary edema, Severe Preeclampsia, IUFD, Breech presentation, on secundigravida fullterm pregnancy, not yet in labor with history of SC 6 years ago Emergency C-section + IUD insertionSevere pre eclampsia protocol :O2 3 lpmInfusion of RL 12 tpmMgSO4 20% initial doseNifedipine 3x10 mg if blood pressure 160 / 100 mmHg3. Hemodinamic stabilization4. Prophylaxis injection of Cefazolin 2 g skin test5. Consultation with Cardiology, Pulmonology, and anaesthesiology departmentNoIdentitasDiagnosisTerapi2Mrs. MP2A233 years old Hypovolemic shock e.c internal bleeding post SCTP Laparotomy exploration (em) Resuscitation O2 rnm 5 lpm, two line IVFD Prophylaxis injection of Cefazolin 2 g skin test Prepare for blood supply Anasthesiology and Cardiology dept consultation3Mrs. DG4P3A045 years old2 days PROM on multigravide fullterm, in labor, stage I latent phase Lead the delivery Induction of oxitocin 5 IU in 500 cc ringer lactate Prophylaxis with vicilin inj 1 gr Lab. testNoIdentitasDiagnosisTerapi4

Mrs. RG5P4A035 years oldGA 40 weeks18 hours PROM on multigravide fullterm, in labor, stage I latent phase

Lead the delivery Induction of oxitocin 5 IU in 500 cc ringer lactate Prophylaxis with vicilin inj 1 gr Lab. TestCase reportA. Patient identityName: Mrs WAge : 42 years oldAdress: Baki, SukoharjoOccupation : HousewifeDate of entry : 13th August 2015Date of examination : 13th August 2015MR number : 01 31 04 20I. ANAMNESISDyspneuB. Main ComplaintA 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: 27-11-2014Estimated birthdate: 3-9-2015

1st pregnancy : female, 2800 grams, 6 years, SC with indication of transversal presentation.2nd pregnancy : this pregnancyC. History of Present IllnessAsthma history: deniedDM history: deniedHypertension history: deniedHeart disease history: deniedAllergy history: deniedD. History of previous illnessMenarche : 13 years oldLength of menstruation: 6-7 daysMenstrual cycle : 28 daysMarried once for 7 yearsinjection for 3 monthsE. Menstrual historyF. Marriage HistoryG. Contraception historyStatus generalisGeneral condition: well, compos mentis, nutrition status is wellVital sign Blood pressure : 180/120 mmHgResp. Rate : 28x/menitHeart rate : 92 x/menitTemperature : 36,70 C

II. Physical Examination

CA (-/-) SI (-/-)Abdomen :Supple, tenderness (-), palpated single fetus, intra-uterine, elongated, breech presentation , back on the left side, the breech has not yet entered the pelvis, contractions -, fetal heart rate (-)Cor : within normal limitsPulmo : vesicular +/+, wheezing -/- fine crackles +/+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, ExtremityEdema : (+/+)Acral coldness: (-/-)11III. Laboratory Examination

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 cmFL : 8,3 cmEFW : 3911 grPlacental insertion at corpus uteri grade IIAmniotic fluid is enoughConclusion : currently, the fetus has no sign of lifeUSG (13th August 2015)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 agoFrom physical examination we got fine crackles +/+, Supple abdomen, tenderness (-), palpated single fetus, intra-uterine, 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 assessedUSG examination showed single fetus has no sign of lifeIV. ConclusionPulmonary edema, Severe Preeclampsia, IUFD, Breech presentation, on secundigravida fullterm pregnancy, not yet in labor with history of SC 6 years ago Emergency C-section + IUD insertionSevere pre eclampsia protocol :O2 3 lpmInfusion of RL 12 tpmMgSO4 20% initial doseNifedipine 3x10 mg if blood pressure 160 / 100 mmHg3. Hemodinamic stabilization4. Prophylaxis injection of Cefazolin 2 g skin test5. Consultation with Cardiology, Pulmonology, and anaesthesiology departmentV. DIAGNOSISVI. TherapyLITERATURE REVIEW PRE ECLAMPSIAPreeclampsia: DefinitionHypertension> 140/90relative no longer considered diagnosticProteinuria> 300 mg/24 hours or 1+ on urine dipsticknot mandatory for diagnosis; may occur lateEdema (non-dependent)so common & difficult to quantify it is rarely evoked to make or refute the diagnosisDefinition of preeclampsia The presence of hypertension of at least 140/90 mm Hg recorded on two separateoccasions 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 previouslynormotensive 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 SEVERITYMild pre-eclampsiaModerate pre-eclampsiaSevere pre-eclampsia

Mild to Moderate Pre eclampsia Diagnostic Features Systolic BP is 140 -160 mmHgDiastolic BP is 90 100 mmHgProteinuria up to ++Also called Imminent eclampsiaSymptomsSevere & persistent occipital or frontal headaches Visual disturbance: blurred vision, photophobia Epigastric and/or right upper-quadrant pain SignsDiastolic BP > 110mmHg, systolic BP > 160mmHgProteinuria +++ or moreAltered mental status Hyper-reflexiaOliguria2. Severe pre-eclampsia Maternal complicationsCVS Haemoconcentration (cause: vasoconstriction and vascular permeability)Hematological changes HELLP DIC

Kidneys Decr RBF GFR RTN and RCN acute RFProteinuria due to permeability to large protein,Oliguria both renal perfusion and GFR decrease.VI. COMPLICATIONS OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIACOMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA contBrain Cerebral edema Infarction, cerebral hemorrhageBlindness: Due to - retinal artery vasospasms and retinal detachmentFever 39C: a grave sign, may be a consequence of intracranial hemorrhage.Coma may be a result of CVACOMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA contRS : Pulmonary oedema and cyanosis

Utero-placental perfusionVasospasms decr perfusion distress and deathHistological changes in the placental bed: acute artherosis lipid rich cells of the uteroplacental arteries Fetal complicationsIUFD, IUGRMAJOR CAUSES OF MATERNAL DEATHPulmonary oedema Cardiac failure,Renal failure Cerebrovascular accident (CVA)

VII. WORK UP - INVESTIGATIONSUrine analysisProteinuriaA 24-hour urine collection Quantity of urine and proteinUric acid level: GFR and creatinine clearance decrease in uric acid levels.LFT TransaminasesUSS fetal wellbeing, if the GA is < 20/40 R/O moles.VIII. MANAGEMENT OF PRE ECLAMPSIAMILD - MOD PRE ECLAMPSIAA: Dispensary & Health centreAntihypertensivesMethyldopa 250 mg 8 hourly for 7 days, Bed rest at homeREFER within one week to Hospital for further managementMANAGEMENT OF PRE ECLAMPSIA1. MILD - MOD PRE ECLAMPSIA contB. HospitalAntihypertensives: Aldomet, Bed rest at home,Fetal movements monitoring,Schedule antenatal clinic every 2 weeks up to 32 wks and weekly thereafter MANAGEMENT OF PRE ECLAMPSIA1. MILD - MOD PRE ECLAMPSIA contB. HospitalStrongly advice the woman to deliver in a hospital Plan delivery at 38/40Advice 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 ECLAMPSIANote: Severe pre-eclampsia is managed like eclampsia

Management protocol for eclampsiaKeep airway clearControl convulsionsControl BPControl fluid balanceAntibioticsInvestigationsDeliver the motherMANAGEMENT CONTBP CONTROLKeep 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 edemaI. 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 eclampsiaRecurrence rate after MgSO4 = 10 -15%Improves maternal and fetal outcomeMANAGEMENT: CONTROL CONVULSIONSFrist dose: MgSo4 40%, 4-6 gram in 100 ml RL loading for 15-20 minuteMaintance dose: Mgso4 40 % 1gr/hour, for 24 hoursPost delivery: Continue observation for at least 48 hrs post deliveryRecord 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 normalMANAGEMENT CONTCASE ANALYSISThe Enforcement of the DiagnosisBlood pressure: 180/120 mmHgProteinuria: +3Extremity edema: (+)Predisposition factorsAge >40 years (3:1)Diabetes mellitus (2:1)High body mass index (3:1)ComplicationRS : Pulmonary oedemaThe 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