PERSAMAAN PERSEPSI

SKENARIO III

BLOK SISTEM REPRODUKSI I

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM MALANG
Semester Ganjil T.A 2013/2014

SKENARIO 3 Kehamilan pada Atlet marathon

This case study reports the clinical and physiological changes of a 33 year old
elite marathoner undertaking intensive endurance training during and following a twin
pregnancy. Prior to conception, the subject ran 155 km x week(-1) at an intensity
equivalent to 140-180 b x min(-1) which following consultation decreased to 107 +/- 19
km x week(-1) at an intensity equivalent to 130-140 b x min(-1) during pregnancy.
Physical exercise ceased 3 days prior to an elective Caesarean section following a 36
week gestation period and recommenced 8 days following the birth of healthy twins.
Medical assessments conducted ante/post partum indicated that both the twins and
mother were healthy. A field based test demonstrated that running velocity at a steady
state HR of 140 b x min(-1), 150 b x min(-1) and 160 b x min(-1) decreased by 20%, 15%
and 13% respectively between weeks 1 and 32 antepartum. Whole blood lactate ([La-]B),
oxygen uptake (VO2), ventilatory equivalent for oxygen (V(E)/VO2), HR and Borg rating of
perceived exertion (RPE) increased during a laboratory-based submaximal treadmill test
at 29 weeks antepartum in comparison to a test conducted 10 weeks post partum.
What does it mean?
URAIAN:
This case study reports the clinical and physiological changes of a 33 year old elite
marathoner undertaking intensive endurance training during and following a twin pregnancy.
Prior to conception, the subject ran 155 km x week(-1) at an intensity equivalent to 140-180 b
x min(-1) which following consultation decreased to 107 +/- 19 km x week(-1) at an intensity
equivalent to 130-140 b x min(-1) during pregnancy. Physical exercise ceased 3 days prior to an
elective Caesarean section following a 36 week gestation period and recommenced 8 days
following the birth of healthy twins. Medical assessments conducted ante/post partum
indicated that both the twins and mother were healthy. A field based test demonstrated that
running velocity at a steady state HR of 140 b x min(-1), 150 b x min(-1) and 160 b x min(-1)
decreased by 20%, 15% and 13% respectively between weeks 1 and 32 antepartum. Whole
blood lactate ([La-]B), oxygen uptake (VO2), ventilatory equivalent for oxygen (V(E)/VO2), HR
and Borg rating of perceived exertion (RPE) increased during a laboratory-based submaximal
treadmill test at 29 weeks antepartum in comparison to a test conducted 10 weeks post
partum. These data clearly demonstrate that it is possible for an elite endurance athlete to
maintain a high level of cardiovascular fitness during pregnancy with no apparent adverse
effects on maternal or foetal health. This will facilitate an earlier return to international
competition
(http://www.ncbi.nlm.nih.gov/pubmed/10496124)

Identifikasi kata kunci:

1. Wanita, 33 tahun, atlet maraton
2. Kehamilan kembar
3. Aktif latihan maraton
Daftar Masalah:
1. Apa saja anamnesa, pemeriksaan fisik dan pemeriksaan penunjang yang
diperlukan untuk menegakkan diagnosa pada pasien tersebut?
2. Apa saja penatalaksanaan farmakoterapi dan nonfarmakoterapi beserta
pencegahan tahap primer, sekunder dan tersier pada pasien tersebut?

3. Apa tinjauan kasus ini dari aspek bioetik, Keislaman, hukum dan hak asasi
manusia dalam kajian kehamilan pada wanita tersebut?
Brainstorming:
Mahasiswa mempelajari tentang Maternal Medicine (Hypertensive Disorders, Heart Disease in
Pregnancy, Diabetes and Endocrine Disease in Pregnancy, Renal Disease, Haematological
Problems in Pregnancy, Miscellaneous Medical Disorders)
Mahasiswa mempelajari tentang Fetal Medicine (Antenatal Screening, Disorders of Fetal
Growth and Assessment, Fetal Medical Conditions, Fetal Anomalies, Multiple Pregnancy)
Mahasiswa mempelajari tentang Antenatal screening
Mahasiswa mempelajari tentang Disorders of Fetal Growth and Assessment of
Fetal Well-being
Mahasiswa mempelajari tentang Fetal Medical Conditions
Learning Objectives
1. Mahasiswa mampu menjelaskan anamnesa, pemeriksaan fisik, diagnosa dan
penatalaksanaan) wanita pada keadaan hamil dan pre partureum (kondisi fisiologis)
2. Mahasiswa mampu menjelaskan kondisi-kondisi patologis pada wanita pada keadaan
hamil dan pre partureum beserta pengaruhnya terhadap janin
3. Mahasiswa mampu menjelaskan aspek primary, secondary dan tertiary prevention
pada wanita dengan kehamilan
4. Mahasiswa mampu menjelaskan aspek komunitas untuk menurunkan morbiditas dan
mortalitas ibu hamil dan janinnya
5. Mahasiswa mampu menjelaskan aspek rehabilitasi medik pada wanita hamil dan post
partum
Referensi
Jason J.S. Waugh and Maria C. Smith. 2012. OBG Dewhursts texbook of Obstetrics and
Gynaecology. Edited by Edmonds, K.D. Eight edition. Section 1. Part 4. Hypertensive
Disorders. Chapter 11. pg 101. Willey Blackwell. UK
Catherine Nelson-Piercy. 2012. OBG Dewhursts texbook of Obstetrics and Gynaecology.
Edited by Edmonds, K.D. Eight edition. Section 1. Part 4. Heart Disease in Pregnancy Chapter
12. pg 111. Willey Blackwell. UK
Anne Dornhorst and Catherine Williamson. 2012. OBG Dewhursts texbook of Obstetrics and
Gynaecology. Edited by Edmonds, K.D. Eight edition. Section 1. Part 4. Diabetes and
Endocrine Disease in Pregnancy. Chapter 13. pg 121. Willey Blackwell. UK
Sarah Winfi eld and John M. Davison. 2012. OBG Dewhursts texbook of Obstetrics and
Gynaecology. Edited by Edmonds, K.D. Eight edition. Section 1. Part 4. Renal Disease. Chapter
14. pg 137. Willey Blackwell. UK
Peter Clark, Andrew J. Thomson and Ian A. Greer. 2012. OBG Dewhursts texbook of
Obstetrics and Gynaecology. Edited by Edmonds, K.D. Eight edition. Section 1. Part 4.
Haematological Problems in Pregnancy Chapter 15. pg 151. Willey Blackwell. UK
Andrew McCarthy. 2012. OBG Dewhursts texbook of Obstetrics and Gynaecology.
Edited by Edmonds, K.D. Eight edition. Section 1. Part 4.. Miscellaneous Medical Disorders

Chapter 16. pg 173. Willey Blackwell. UK

Mapping Maternal Medicine

Preterm birth
Uterine Malformation and Incompetent Cervix
Toxic Habits in Pregnancy (smoking, alcohol,
illicit drug use)
Poor nutrition
Lack of prenatal care
Multiple Births
Maternal Infection
Abnormalities of the Placenta, Umbilical Cord &
Fetal Membranes
Disorders of Amniotic Fluid Levels
Mode of Delivery
Toxemia
NEONATAL ASPHYXIA

ANTENATAL CARE
Primary Prevention

Maternal History
Evaluation of Maternal-Fetal Risk Factors
Physical Assessment
Intrapartum Monitoring
High Risk Conditions

Partogram

Stages of labour

Maternal DOB,Gestation,Obs issues, VS,urinalysis

Fetalgestational, fetal heart, liquor
ProgressUterine contractions, cervical
dilatation,decent of presenting part,
caput/moulding,fetal position
Pain relief Support,Water,Opiates, Entonox, Epidural,
Complementary
Time of birth
Gender of infant
Birthweight
Apgar scores at 1/5 mins
Cord gas
Resuscitation
Complications

ANTENATAL=PRENATAL

Estimated Date of Confinement (EDC)

Secondary Prevention

Delivery

Pregnancy

Ultrasonography
Amniocentesis
Fetal Biophysical Profile
Nonstress/Contraction Stress Testing
Fetal Heart Rate Monitoring
Fetal Blood Scalp
Blood Analysis

ASSESSMENT OF THE FETUS

Delivery Date
None of the methods are exact
Ngeles Rule
Fundal Height
Quickening
Determination of Fetal Heart beat

Labour

Dx of labour
Regular painful contractions resulting
in progressive change of the cervix
+/- show
+/- rupture of membranes

Tertiary Prevention

MATERNAL-FETAL HEALTH

1st stageOnset of labour until full dilatation of cervix

2nd stageFull dilation of cervix until delivery of baby
3rd stageDelivery of baby until complete delivery of
placenta and membranes

Case Mapping
Pre conception

Women, 33 y.o, marathoners, pregnant

Hard Exercise

decreased Exercise

36 week gestation

Physical exercise ceased 3 days before

Delivery (an elective Caesarean section)

8 days following the birth of healthy twins

the twins and mother were healthy

These data clearly demonstrate that it is possible for an elite endurance athlete
to maintain a high level of cardiovascular fitness during pregnancy with no
apparent adverse effects on maternal or foetal health