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Octaviana Y

INTRODUCTION
Incidence of heart disease in pregnancy
1- 4%
Heart disease in pregnancy maternal
death (60 70 %)

IDENTITY
Name
Age
Address
Education
Occupation
Admission Date

: Mrs. CS
: 33 years old
: Tegal Lega,
Bandung
: Senior High School
: Housewife
: 4-12-2008 at 23.55

HISTORY
Accompanied by : Midwife
Notification :
G3P2A0 term pregnant; severe
preeclampsia; dyspneu
Chief complaint : dyspneu

History Taking
G3P2A0 8 months pregnant complained dyspneu
since 5 days b.a.
Dyspneu deffort (+)
Orthopneu (+)
Hypertension was known since 7 months pregnant.
History of hypertension before pregnant (-)
Signs of impending eclampsia (-)
Labor pain (-)
Amnionic membrane (+)
Fetal movement (+)

ADDITIONAL HISTORY
OBSTETRIC HISTORY
1. TBA, term, 3000 g, spontaneous, , 9 yo, live
2. TBA, term, 2500 g, spontaneous, , 6 yo, live
3. Current pregnancy

LMP
PNC

: April 9th, 2008


: Midwife, 10 times

PHYSICAL EXAMINATION
STATUS PRAESENS
Consciousness
: inadequate contact,
dyspneu, cyanotic
BloodPressure : 180/120 mmHg
Pulse Rate
: 136 bpm
Respiration Rate
: 40 tpm
Temperature : 36,5 C
Cor
: gallop(+), murmur(+)
Pulmo : rales +/+
Oedema : +/+

OBSTETRICAL EXAMINATION
External Examination
FH
: 29 cm
AC
: 96 cm
FL
: head, 5/5 back at the left side
FHR
: 116-120 bpm
UC
: (-)
EBW
: 2000 gram

LABORATORY FINDINGS

Hb : 14,4 gr %
Lekocyte : 22.000/mm3
Hct : 45 %
Thrombocyte
: 425.000/mm3
Urine protein
: +++
PT/aPTT : 9,8/29.2 seconds
AST/ALT : 23/16 U/L
Ureum/Creatinin : 17/0,81 mg/dL
Blood Sugar
: 230 mg/dL
LDH
: 400 U/L
Na/K
: 137/3,0 mEq/L

DIAGNOSIS
G3P2A0 33-34 weeks pregnant + heart failure
FC.IV + severe preeclampsia + respiratory failure
MANAGEMENT
General condition stabilization
O2 8-10 L/min (face mask), O2 sat 67% ETT
insertion
IVFD, crossmatch, blood reserve, complete lab
exam, folley catheter insertion
Furosemide (forced diuretic) observe diuretic
response
Consult to Internal Dept, anesthesiology, and
Neurology

MANAGEMENT
Report to consultant on duty, advice :
general condition stabilization
resuscitation
postpone pregnancy termination until general
condition stable
ECG (sinus tachycardia), chest X-Ray
(cardiomegally with lung edema)
Informed consent
General condition, vital signs, uterine contraction,
and fetal heart rate observation

Internal Dept. Reply


G3P2A0 33-34 weeks pregnant +
severe preeclampsia
Dilated peripartum cardiomyopathy
Heart failure FC IV + respiratory failure
Acute Kidney Injury (AKI)

Advices
Bed rest
Ventilator, NGT insertion
Low salt diet 1500 kcal/day, per NGT, protein 1
g/kgBW/day
Furosemid infusion starting from 10
mg/hourresponse (-) titration dose
(20mg/hour)response(-) renal support dyalisis
Routine urine examination
Blood Gas Analysis examination after intubation
Echocardiography examination
Vital signs and I-O monitoring

Neurology Dept Reply


Diagnosis
According to Internal Dept
Th/
Blood pressure regulation according to
Internal Dept

Dec 4 , 2008 at
23.55
th

Dec 5th, 2008 at


03.00 & 06.15

Dec 5th, 2008


at 18.45

IUFD

ICU

08.20

07.15

ADM
Plan to
perform csection

D/: G3P2A0 33-34


weeks pregnant +
heart failure FC IV +
severe preeclampsia
+ respiratory failure
GC stabilization
Postpone
pregnancy
termination

Report to
consultant on duty

GC stabilization
Postpone
pregnancy
termination

14.30
Born a
male baby

Dec
8th,
2008

PROBLEMS
1. How was the management of this
patient in Hasan Sadikin Hospital?
2. What factors are responsible to
maternal death in this case?

DISCUSSION

Management for this patient in


Hasan Sadikin Hospital

Cardiovascular changes during pregnancy


Period

Changes

Antepartum

1.Blood volume increases 50%


2.Perifer vascular resistance decreases 20%
3.Systolic blood pressure decreases 5-10 mmHg,
diastolik decreases 10-15 mmHg
4.CVP (10 cmH2O)
5.Heart rate increases by 10 to 20 beats per minute,
6.Cardiac output increases 30-50% (from 5-10
weeks, the levels peak by 20 to 24 weeks of
pregnancy
7. Right ventricle ejection fraction increases
8. Hypercoagulation
9.Changes in ECG: left axis deviation 150, low
voltage QRS, inversion of T wave in lead III, Q wave
in lead III and AVF,
10.Changes in thorax X-ray

Intrapartum

1.CO increases 20-30% during delivery


2. Every contraction causes 300-500 ml blood from
uterus to systemic circulation
3.Blood pressure increases 10-20 mmHg in every
contraction
4.Supine position decrease CO 30%
5.Oxygen consumption increases 100%

Postpartum

1.Cardiac output increase 10-20% in the beginning of


post partum period
2.Stroke volume increases
3.Bradycardia reflex

Diagnosis
G3P2A0 33-34 weeks pregnant +
heart failure FC IV + severe
preeclampsia + respiratory failure

Diagnosis and evaluation of


cardiac disease in pregnancy
Detailed historical information
Physical examination:
murmur( grade 3/6) or radiate to carotid
pathologic
JVE, peripheral cyanosis, clubbing, pulmonary
crackle
Cardiac and respiratory failure

Echocardiography
X-Ray

ETIOLOGY
Nutritional deficiencies
Myocarditis
Infections
Autoimmune

Idiopathic
The incidence of peripartum cardiomyopathy
is greater in multiparous women and in those
with preeclampsia and twin pregnancies

IBU HAMIL
Dengan kelainan
jantung
Riwayat:
Demam Reumatik
Aktivitas terbatas
Dispnea

Foto thorax
EKG
Analisis gas darah
Ekhokardiografi

RSHS, 2005

Diagnosis
Klasifikasi
Konseling

Kelas 3-4
ANC, perhatian khusus
pada fungsi vital
pertimbangkan

Fungsi jantung
Gagal jantung

Aborsi

< 20
minggu

Kondisi stabil/
Kelas 1-2

> 20 minggu

Perawatan jantung
intensif
Tirah baring
Pantau kesejahteraan janin dengan ketat
Gawat janin
Kelas 3-4

Seksio sesarea

Observasi postpartum
Konseling konsepsi

TATA LAKSANA
PENYAKIT JANTUNG
DALAM KEHAMILAN

Janin baik
Perawatan intrapartum intensif
Partus pervaginam

THIS
PATIENT
D/: G3P2A0 33-34
weeks pregnant +
heart failure FC IV +
severe preeclampsia

HR : 136 bpm

Digitalis should be
considered
Termination should
be considered

General condition
stabilization

Severe preeclampsia
Respiratory failure
Heart failure FC IV

Decision for
termination after 7
hours stabilization

Intra Uterine Fetal Death

Delivery by c-section was an obstetrical


indication (eminent fetal death) even
though the vaginal delivery is the
preferred one in patients with
hemodynamically stable

Tedoldi M, Manfroi AG. Risk factors associated with peripartum cardiomyopathy. JLUMHS september december 2008. 119-22.

When heart failure occurs during


pregnancy, delivery of the fetus
reduces the haemodynamic stresses
on the heart

Ray NA, Murphy S, Shutt AG. General aspects of heart disease in pregnancy.

Treatment of peripartum
cardiomyopathy
Salt restriction and the use of
diuretics
If systolic dysfunction, the use of
vasodilators to reduce afterload
Atrial arrhythmias should be treated
with digoxin.

Treatment of peripartum
cardiomyopathy (Cont.)
Patient with poor cardiac output
Anticoagulation is indicated for the risk
of thromboembolism.
Unfractionated or LMW heparin are the
choice during pregnancy.

The use of - blocker


The application in peripartum
cardiomyopathy is unclear.

Peripartum management
Pain control is necessary
Hemodynamic monitoring
Shorten second stage of labor (head traction)
Positioning the patient on her left side

Postpartum monitoring
Because hemodynamics do not return to baseline for many days after
delivery require monitoring for at least 72 hours

American College of
Obstetrics and Gynecology

Antibiotic prophylaxis is
recommended during vaginal
delivery

Anesthetic consideration in this


patient
Careful monitoring of fluid balance
CVP line

Early critical care referral for unstable patient


Critical patients will require Swan-Ganz
monitoring, artificial ventilation and inotropic
support.

Factors that responsible to


maternal death in this case

Multiple Organ Dysfunction Syndrome


Stage 1
The patient has increased volume requirements and mild
respiratory alkalosis which is accompanied by oliguria,
hyperglycemia and increased insulin requirements.
Stage 2
The patient is tachypneic, hypocapnia and hypoxemic. Moderate
liver dysfunction and possible hematologic abnormalities.
Stage 3
The patient develops shock with azotemia and acidbase disturbances. Significant coagulation abnormalities
Stage 4
The patient is vasopressor dependent and oliguric or anuric.
ischemic colitis and lactic acidosis follow.

Conclusions
1. Inadequate management
2. Multiple Organ Dysfunction Syndrome
causing maternal death

Thank you

ralat
LABORATORY FINDINGS (Dec 7th, 2008)

Hb
Lekocyte
Hct
Thrombocyte
PT/aPTT
AST/ALT
Ureum/Creatinin
Blood Sugar
Na/K

: 11.3 gr %
: 10.900/mm3
: 35 %
: 183.000/mm3
: 13.6/47.3 seconds
: 23/16 U/L
: 179/4.56 mg/dL
: 113 mg/dL
: 140/2.9 mEq/L

Case Presentation I
Monday, March 16th, 2009

MODE OF DELIVERY ON RETAINED OF


SECOND TWIN WITH TRANSVERSE LIE
Presented by :
dr. Aditya Muliakusumah

Moderator :
dr. Dina Erasvina

Resource Person :
dr. Ahmad Yogi Pramatirta, SpOG, MKes.