Clinical Conference 091213

8/13/2019 Clinical Conference 091213

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Diannisa Ikarumi


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Physiological delivery 1 case

Pathological delivery Spontaneous 2 cases Vaccum-extraction -

Major operation Cesarean section 6 cases Gynecology 2 cases Oncology 3 cases

Hysteroscopy-Laparoscopy 1 case

Minor operation Curretage - Sterilization 1 case


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1. Mrs. LS, 22yo, G1P0A0

Breech presentation, primigravida 30 weeks 3 days pregnancy,

with sepsis, CKD stage V, HHD, pneumonia, anemia

(Maternal Fetal Medicine)

2. Mrs. HN, 33yo, G1P0A0

Multiple gestation/triplet (breech-transverse-transverse), IUFDof second fetus , 32 weeks 3 days pregnancy, with anemia,

moderate renal insufficiency & epulis granulomatosus(Maternal Fetal Medicine)

3. Mrs. S, 25yo, G3P0A2Multigravida Nullipara, 34 weeks pregnancy, with ITP

(Progress report-Maternal Fetal Medicine)


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A woman came with main complaintbreathing difficulty 1 day before andithcyness since 2 months.

Patient was diagnosed suffering from kidneyfaillure and treated with hemodyalisis (3x)and PRC transfusion (3packs).

She also complaining edema in allextremities. High blood pressure since 2weeks before

No complaints in micturition and defecation


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Conscious, anemic and icteric

Vital sign: BP:130/90mmHg, P:108bpm,

RR:28x/min, T: 36.5oC On auscultation: Heart gallop, rhonci present

Edema anasarca

Abd palpation: singleton baby, breech

presentation, FH 18 cm, UC(-), FHR 142bpm

BE: normal vulva, smooth vaginal wall, cervix

normal,(-), bloody show(-), AF(-)


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WBC 21 .6 x 103/ l(neutrofilia)

RBC 3.16 x 106/ l Hb 8.9 g/dl Hct 26.9% Plt 448 x 103/ l MCV 85.2fl (80-99) MCH 28.3pg (27-31) MCHC 34.3g/dl (33-37) RDW 12.8% (11.5-14.5)

Retikulosit 0.8 % (0.5-1.5) Sat. index 19% (26-50) Feritin 435 (9.3-159) TIBC 223 (228-428) IBC 180 (112-346)

Creat 7.77 mg/dl (0.6-1.3) BUN 76mg/dl (7-18) Alb 2.15g/dl CCT 10.7 SGOT 24 l (15-37) SGPT 34 l (


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1/12 2/12 4/12 5/12 7/12

BUN

mg/dl

35.8 59 67 31.8 6

Crea

mg/dl

4.09 6.94 7.4 3.59 1.28

Hb

g/dl

7.3 6.8

WBC

x 103/ l

12.3 7.7

RBCx 106/ l

2.5 2.27

Hct

%

21.4 19.5

Plt

x 103

/ l

446 378

Na

mmol/l

138 134 136 142

K

mmol/l

4.2 4.8 3.6 2.3

Clmmol/l

103 108 106 100


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Urinalysis Proteinuria +3 Pale leucocyte +1 Bacteriuria (-)

Sputum exam BTA negative Gram (+) coccus positive Gram (-) basil positive

Chest X-ray Bronchopneumonia Pulmonary edema Cor normal

Negative blood culture

Peripheral blood exam Normochromic-normocytic

anemia Abnormal morphology of RBC

(anisositosis) Leucocytosis, absolute reactiveneutrophilia

ConclusionAnemia of chronic disease with

bacterial infection

ECG STC HR 120 ncomplete RBBB


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USG

(6/12/13)

singleton fetus,breechpresentation,FHR visible,

movementpresent. Noanomaly visible.

BPD: 6.88cm

AC: 24.7cmFL: 5.48cmEFW 1279 gramsGA: 28wks 3days


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Sepsis Breech presentation

Primigravida 30

weeks 3 dayspregnancy CKD stg V susp GNC Pneumonia HHD Anemia Hyperbilirubinemia Hyperkalemia Hypoalbuminemia

O2 3lpm (NK) Inf. NaCl 0.9% 20 dpm Inj. Cefoperazone 1g/12h/iv

Inj. Dexamethasone5mg/12h/iv Methyldopa 250mg/8hrs/oral Paracetamol 500mg/oral/prn Folic acid 3x1 Ca CO3 3x1 Transfusion of PRC


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BP: 130/90mmHg HR: 98bpm RR: 24x/min

T: 36.5 oC

FHR: 142bpm UO: 0.4ml/kgBW/hr

Plan: Serial hemodyalisis

2-4x/week

Abdominal & renalultrasound

Echocardiography Check for dysmorphic

erythrocyte Urine culture observe UC & FHR NST


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Pregnancy 30weeks Anemia

Hypertensive Heart DiseasePneumonia

TERMINATIVE

ORCONSERVATIVE


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A pathophysiological process that results in end-stage renal disease through a progressive loss ofnephron number & function.

Multiple etiologies ie diabetes (33%),hypertension (24%), glomerulonefritis (17%),polycystic kidney disease (15%) must be presentfor at least 3 months.

Successful pregnancy outcome in general maybe more related to renal insufficiency andproteinuriathan to the specific underlyingdisorder.


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In this patient, conservative management until

34weeks gestation may be considered, if the

following criteria met:

1. Blood pressure can be controlled 140/90mmHg

2. Optimal glomerular filtration rate,

achieved by 5-7x hemodyalisis per week


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Patient referred from Aisyah Hospital, Muntilanwith preterm triplet pregnancy with severepreeclampsia susp. HELLP syndrome.

Patient complained of gum bleeding 2 daysbefore admision. No history of spontaneousbleeding before

No symptoms of delivery Routine ANC in midwives and doctor No history of hypertension, parents suffer from

hypertension


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General condition: conscious, good, notanemic

palpation : triple fetus, breech presentation,FH 38 cm, UC (-), FHR I : 148 bpm, FHR II : 155

bpm, FHR III: 157 bpm

BE : normal vulva, smooth vaginal wall,

cervix normal, (-), breech presentation,

sacrum in H1, Bloody show (-), AF (-)


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Triplet fetus,

intrauterine

Placenta atfundus

Triamnion,

monochorion

Adequateamniotic fluid


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Fetus I : FHR present, BPD 7.24cm~29 wks AC 25.82cm~30wks FL 5.56cm~29wks 2dys EFW 1484 g

Fetus II: FHR present BPD 7.14cm~28 wks 5dys AC 23.6cm~28wks FL 5.82cm~30wks 3dys EFW 1230 g

Fetus III: FHR present BPD 7.25cm~29 wks 1 dys AC 23.65cm~28wks FL 5.4cm~28wks 4dys EFW 1235 g


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Fetal IFHR baseline 135 bpmVariability >5Acceleration +Deceleration Movement +NST reactive

Fetal IIFHR baseline 125 bpm

Variability >5Acceleration +Deceleration Movement +NST reactive


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WBC 8.34 x 103/ l RBC 3.34 x 106/ l Hb 8.2 g/dl Hct 26.1% Plt 223 x 103/ l MCV 78.3fl (80-99) MCH 24.6pg (27-31) MCHC 31.5g/dl (33-37) RDW 17.3% (11.5-14.5) Retikulosit 1.7% (0.5-1.5) Sat. index 8% (26-50) Fe 40 Feritin 57.3 (9.3-159) TIBC 479 (228-428) IBC 439 (112-346)

Creat 1.06mg/dl (0.6-1.3) BUN 18mg/dl (7-18) Alb 2.78g/dl SGOT 27 l (15-37) SGPT 19 l (


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Urinalysis Proteinuria +3

(600mg/dl)

Bacteriuria 158/Ul(


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WBC x 103/ l 8.34 10.20 12.3

RBC x 106/ l 3.34 2.50 2.35

Hb g/dl 8.2 6.2 5.9

Hct % 26.1 19.8 18.9

Plt x 103/ l 223 220 209

Na mmol/l 133 129

K mmol/l 6,1 5,36

Cl mmol/l 108 99

Albumin g/dl 2,78

BUN mg/dl 18 54

Crea mg/dl 1,06 1.75

Fibrinogen mg/dl 328 (215-325)

D dimer ng/ml 3200 (200)


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Multiple gestation(triplet), IUFD fetus II

32 wks 2dys

pregnancy Anemia MH susp irondeficiency

High output heartfailure

Epulis granulomatous Mild renal

insufficiency

Conservative management Observation of UC & FHR Transfusion of PRC Inj. Dexamethason

5mg/12h/iv SF 1 tab/24h/oral Erithromycin 500mg/6h/oral


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BP: 120/80mmHg

HR: 86bpm

RR: 24x/min

T: 35.6 0C

FHR I 155bpm

FHR II 158bpm

No uterine contraction

UO: 3ml/kgBW/h

Plan:

Echocardiography

Monitor DIC score and

urine output NST


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Renal insufficiency Anemia

Epulis granulomatous High output heart failure

When to deliver

Mode of deliveryDisease progression


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Multiple Gestation: Complicated Twin,

Triplet, and High-Order Multifetal

Pregnancy. ACOG. 2004.


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Complications of Triplet Pregnancy

Gestational Diabetes (2239%) The incidence of preeclampsiais 2.6 times higher in twin

gestations than in singleton gestations and is higherintriplet gestations than in twin gestations. It is significantly

more likely to occur earlierand to be severe Acute fatty liver (7%)

Preterm delivery and 4963% of these infants weigh less

than 2,500 g36% of triplet pregnancies are born < 32 wga


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Timing of Delivery in Multiple Gestations

At 35 completed weeks of gestation for triplets Fetal and neonatal morbidity and mortality begin to increase

in twin and triplet pregnancies extended beyond 37 and 35wga

Route of Delivery for Triplet GestationsCesarean delivery


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Consult to nephrology

Close monitoring of maternal and fetal

wellbeing. (in patient care)

Fetal doppler velocimetry

Monitor DIC score, repeat in 2 days

Conservative management can be

considered until 34 weeks gestation Mode of delivery: planned cesarean section


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A woman G3P0A2 34 weeks pregnancy wasdiagnosed ITP since 2010

Main complain are petechiae & gum

bleeding since 1 week before admitted Patient had dexamethasone 40 mg every

day before admision

Poor drug compliance, target for plateletcount was not achieved

Re admitted with Plt 2 x 103/ l, given inj.Methylprednisolon 125mg/6h/iv


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Recurrent early pregnancy loss

Abortus sebelumnya kapan dan berapa

minggu, apakah BO atau fetal death?

Kemungkinan SLEcek anti ds DNA


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GC: conscious, not anemic

Vital sign: within normal limit

Singleton baby, longitudinal lie, head

presentation, fundal height 23 cm, uterinecontraction (-), FHR 150 bpm


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FHR baseline 135 bpm

Variability >5

Acceleration +

Deceleration Movement +

NST reactive


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Singleton baby,longitudinal lie,cephalic presentation,

movement (+), FHR (+),placenta at posteriorcorpus , AFI 8,68

BPD 8,01~32 wga AC 23,78~28 wga Fl 5,0~27 wga EFW 1444 gr Umb RI 0.59

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WBC x 103/ l 15.4 20.4 19.4 19.4 21.4


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5 4 4 9 4 9 4 4

RBC x 106/ l 4.4 3.8 4 4.1 4.3

Hb g/dl 13.1 11.1 11.5 11.7 123

Hct % 37.8 33.1 34.8 35.1 37

Plt x 103/ l 5 20 117 139 107

SGOT 27

SGPT 26

Na mmol/l 141

K mmol/l 3.8

Cl mmol/l 104

Albumin g/dl 3.8

BUN mg/dl 4.2

Crea mg/dl 0.41

Random BG 113 254 (74-140)

Fasting BG 155(


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Multigravida

nullipara 34 weeks pregnancy

IUGR Immune

Thrombocytopenia

(ITP) Hyperglycemia

Conservative

management

Observation of UC & FHR

Inj. Methylprednisolon62.5mg/12h/iv

Inj. Omeprazole

40mg/12h/iv

SF 1 tab/24h/oral


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BP: 130/70mmHg

HR: 94bpm

RR: 28x/min

T: 36 0C

FHR: 136bpm

No uterine contraction

UO: 1.85ml/kgBW/h

Plan:

NST

Monitor for

spontaneous bleeding Consult to

endocrinology for

hyperglycemia


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Hematol Oncol Clin North PMC 2010 December


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The most feared consequence of fetalthrombocytopenia is the risk of intracranialhemorrhage.

However, no association of intracranial hemorrhagewith the mode of delivery was observed

Since neonatal intracranial hemorrhage is anextremely rare complication of maternal ITP & thatcesarean deliveries may be associated with

significant maternal morbidity, it is recommendedthat c-section be performed solely for maternalindications.

Hematol Oncol Clin North PMC 2010 December


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Conservative management until term gestation Mode of delivery: vaginal delivery, unless

obstetrics indication present

Make sure a good drugs compliance Close monitoring of maternal and fetal

wellbeing. (out patient care) Clinical evaluation for ITP symptoms and

corticosteroids related toxicities ie diabetes,hypertension, placental abruption, bone loss,premature labor

Laboratory evaluation


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Clinical Conference 091213

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