Morning Report of Obgyn Coass

Wednesday, 19th August 2015

LIST OF THE PATIENTSNo Identitas Diagnosis Terapi

1 Mrs. PG1P0A025 years oldGA 39 weeks

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

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 checks5. Informed consent6. Consultation to anesthesia

department

CASE REPORT

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

I. ANAMNESIS

A. Patient identity

Referrals from Kustati hospital with information of severe pre eclampsia

B. Main Complaint

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 : 16-11-2014Estimated birthdate : 23-08-2015

C. History of Present Illness

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

D. History of previous illness

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

• Married once for 1 year

Contraception : (-)

E. Menstrual history

F. Marriage History

G. Contraception history

Status generalis

• General condition: good, compos mentis, nutrition status is overweight

• Vital sign Blood pressure : 170/110 mmHgResp. Rate : 22x/menitHeart rate : 90 x/menitTemperature : 36,70 C

II. Physical Examination

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

Abdomen :Supple, 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, fundal height 37 cm ~ 3100 gr

Abdomen :Supple, 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, fundal height 37 cm ~ 3100 gr

Cor : within normal limitsPulmo : vesicular -/-, wheezing -/-

Cor : within normal limitsPulmo : vesicular -/-, wheezing -/-

Genital: 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 I, blood mucus (-)

Genital: 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 I, blood mucus (-)

ExtremityEdema : (+/+)Acral coldness: (-/-)

ExtremityEdema : (+/+)Acral coldness: (-/-)

Blood laboratory (9th August 2015)

• Hb : 8,8 (↓)• Hct : 31 (↓)• AE : 4,46.106

• AL : 12,2.103 (↑)• AT : 415.103

• PT/APTT : 12,8 / 30,8• GDS : 86• SGOT : 17• SGPT : 7• Albumine : 3,4 (↓)• Creatinine : 0,7• Ureum : 40• LDH : 416 (↑)• Na / K : 137 / 3,4• HBsAg : non reaktif• qualitative protein : +3

III. Laboratory Examination

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 cmEFBW : 3100grPlacental insertion in the corpus uteri grade IIAmniotic fluid is enoughMajor congenital abnormalities (-)Conclusion : currently, the fetus is in good condition

USG (18th August 2015)

• 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

IV. Conclusion

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

1. Emergency C-section + IUD insertion2.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 mmHg3. Prophylaxis injection of Cefazidine 2 g skin test4. Laboratory checks5. Informed consent6. Consultation to anesthesia department

V. DIAGNOSIS

VI. Therapy

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-eclampsia2. Moderate pre-eclampsia3. 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 eclampsiaSymptoms• 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 PRE-ECLAMPSIA 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 39ºC: 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.

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