Diannisa Ikarumi

Physiological delivery
Pathological delivery Spontaneous Vaccum-extraction Major operation Cesarean section Gynecology Oncology Hysteroscopy-Laparoscopy

1 case 2 cases 6 2 3 1 cases cases cases case

Minor operation Curretage Sterilization

1 case

1.

Mrs. LS, 22yo, G1P0A0 Breech presentation, primigravida 30 weeks 3 days pregnancy, with sepsis, CKD stage V, HHD, pneumonia, anemia (Maternal Fetal Medicine)
Mrs. HN, 33yo, G1P0A0 Multiple gestation/triplet (breech-transverse-transverse), IUFD of second fetus , 32 weeks 3 days pregnancy, with anemia, moderate renal insufficiency & epulis granulomatosus (Maternal Fetal Medicine)

2.

3.

Mrs. S, 25yo, G3P0A2 Multigravida Nullipara, 34 weeks pregnancy, with ITP (Progress report-Maternal Fetal Medicine)

A woman came with main complaint breathing difficulty 1 day before and ithcyness since 2 months. Patient was diagnosed suffering from kidney faillure and treated with hemodyalisis (3x) and PRC transfusion (3packs). She also complaining edema in all extremities. High blood pressure since 2 weeks before No complaints in micturition and defecation

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(-)

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 (<34) T Bil 2.22mg/dl D Bil 1.95 mg/dl (0-0.3)
Na 135mmol/l (136-145) K 6.2 mmol/l (3.5-5.1) Cl 102 mmol/l (98-107)

LDH 625U/l (240-480)

PPT 11.6 (12.7) APTT 28.9(31.7) INR 0.8

1/12

2/12

4/12

5/12

7/12

BUN mg/dl Crea mg/dl Hb g/dl WBC x 103/ l RBC x 106/ l

Hct % Plt x 103/ l Na mmol/l K mmol/l Cl mmol/l

35.8 4.09

59 6.94 7.3 12.3 2.5

21.4 446

67 7.4 6.8 7.7 2.27

19.5 378 134 4.8 108

31.8 3.59

6 1.28

138 4.2 103

136 3.6 106

142 2.3 100

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 reactive neutrophilia Conclusion Anemia of chronic disease with bacterial infection

ECG STC HR 120 ncomplete RBBB

USG (6/12/13)
singleton fetus, breech presentation, FHR visible, movement present. No anomaly visible.

BPD: 6.88cm AC: 24.7cm FL: 5.48cm EFW 1279 grams GA: 28wks 3days

Sepsis Breech presentation Primigravida 30 weeks 3 days pregnancy 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. Dexamethasone 5mg/12h/iv Methyldopa 250mg/8hrs/oral Paracetamol 500mg/oral/prn Folic acid 3x1 Ca CO3 3x1 Transfusion of PRC

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 & renal ultrasound Echocardiography Check for dysmorphic erythrocyte Urine culture observe UC & FHR NST

Pregnancy 30weeks

TERMINATIVE OR CONSERVATIVE

Anemia

Hypertensive Heart Disease

Pneumonia

A pathophysiological process that results in endstage renal disease through a progressive loss of nephron number & function. Multiple etiologies ie diabetes (33%), hypertension (24%), glomerulonefritis (17%), polycystic kidney disease (15%) must be present for at least 3 months. Successful pregnancy outcome in general may be more related to renal insufficiency and proteinuria than to the specific underlying disorder.

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

Patient referred from Aisyah Hospital, Muntilan with preterm triplet pregnancy with severe preeclampsia susp. HELLP syndrome. Patient complained of gum bleeding 2 days before admision. No history of spontaneous bleeding before No symptoms of delivery Routine ANC in midwives and doctor No history of hypertension, parents suffer from hypertension

General condition: conscious, good, not anemic 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 (-)

Triplet fetus, intrauterine Placenta at fundus Triamnion, monochorion Adequate amniotic fluid

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

Fetal I FHR baseline 135 bpm Variability >5 Acceleration + Deceleration Movement + NST reactive

Fetal II FHR baseline 125 bpm Variability >5 Acceleration + Deceleration Movement + NST reactive

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 (<34)
Na 133mmol/l (136-145) K 6.1 mmol/l (3.5-5.1) Cl 108 mmol/l (98-107)
PPT 12.9 (14.6) APTT 38.1(31.9) INR 0.8

LDH 450U/l (240-480)

Urinalysis Peripheral blood exam Proteinuria +3 Anemia with abnormal (600mg/dl) morphology of RBC Bacteriuria 158/Ul (anisositosis) and (<100) increased erythropoetic Patologic cylinder response. 5.54/Ul (<0.5) Leucocytosis, reactive Hematuria 187/Ul (<25) neutrophil & monocyte Conclusion Anemia susp hemolytic process & inflammation

3/12/13 WBC x 103/ l RBC x 106/ l Hb g/dl Hct % Plt x 103/ l 8.34 3.34 8.2 26.1 223

7/12/13 10.20 2.50 6.2 19.8 220

8/12/13 12.3 2.35 5.9 18.9 209

Na mmol/l
K mmol/l Cl mmol/l

133
6,1 108

129
5,36 99

Albumin g/dl
BUN mg/dl Crea mg/dl

2,78
18 1,06 54 1.75

Fibrinogen mg/dl
D dimer ng/ml

328 (215-325)
3200 (200)

Multiple gestation (triplet), IUFD fetus II 32 wks 2dys pregnancy Anemia MH susp iron deficiency High output heart failure 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

BP: 120/80mmHg HR: 86bpm RR: 24x/min T: 35.6 0C FHR I 155bpm FHR II 158bpm No uterine contraction

Plan: Echocardiography Monitor DIC score and urine output NST

UO: 3ml/kgBW/h

Renal insufficiency

When to deliver Mode of delivery Disease progression

Anemia

Epulis granulomatous

High output heart failure

Multiple Gestation: Complicated Twin, Triplet, and High-Order Multifetal Pregnancy. ACOG. 2004.

Complications of Triplet Pregnancy

Gestational Diabetes (2239%) The incidence of preeclampsia is 2.6 times higher in twin gestations than in singleton gestations and is higher in triplet gestations than in twin gestations. It is significantly more likely to occur earlier and to be severe Acute fatty liver (7%) Preterm delivery and 4963% of these infants weigh less than 2,500 g 36% of triplet pregnancies are born < 32 wga

Multiple Gestation: Complicated Twin, Triplet, and High-Order Multifetal Pregnancy. ACOG. 2004.

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 35 wga

Route of Delivery for Triplet Gestations

Cesarean delivery

Multiple Gestation: Complicated Twin, Triplet, and High-Order Multifetal Pregnancy. ACOG. 2004.

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

A woman G3P0A2 34 weeks pregnancy was diagnosed 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 platelet count was not achieved Re admitted with Plt 2 x 103/ l, given inj. Methylprednisolon 125mg/6h/iv

Recurrent early pregnancy loss Abortus sebelumnya kapan dan berapa minggu, apakah BO atau fetal death? Kemungkinan SLE cek anti ds DNA

GC: conscious, not anemic Vital sign: within normal limit Singleton baby, longitudinal lie, head presentation, fundal height 23 cm, uterine contraction (-), FHR 150 bpm

FHR baseline 135 bpm Variability >5 Acceleration + Deceleration Movement + NST reactive

Singleton baby, longitudinal lie, cephalic presentation, movement (+), FHR (+), placenta at posterior corpus , 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

28/11 WBC x 103/ l RBC x 106/ l Hb g/dl Hct % Plt x 103/ l SGOT SGPT Na mmol/l 15.4 4.4 13.1 37.8 5 27 26 141

30/11 20.4 3.8 11.1 33.1 20

3/12 19.4 4 11.5 34.8 117

6/12 19.4 4.1 11.7 35.1 139

8/12 21.4 4.3 123 37 107

K mmol/l
Cl mmol/l

3.8
104

Albumin g/dl
BUN mg/dl

3.8
4.2

Crea mg/dl
Random BG

0.41
113 254 (74-140)

Fasting BG

155 (<100)

2h BG 153 (<140)

Multigravida nullipara 34 weeks pregnancy IUGR Immune Thrombocytopenia (ITP) Hyperglycemia

Conservative management Observation of UC & FHR Inj. Methylprednisolon 62.5mg/12h/iv Inj. Omeprazole 40mg/12h/iv SF 1 tab/24h/oral

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

Hematol Oncol Clin North PMC 2010 December

The most feared consequence of fetal thrombocytopenia is the risk of intracranial hemorrhage. However, no association of intracranial hemorrhage with the mode of delivery was observed Since neonatal intracranial hemorrhage is an extremely rare complication of maternal ITP & that cesarean deliveries may be associated with significant maternal morbidity, it is recommended that c-section be performed solely for maternal indications.
Hematol Oncol Clin North PMC 2010 December

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