Impending eclampsia and fetal

distress on multigravida preterm

pregnancy not yet in labor with CKD+
pericardial effusion+ hipoalbumin

Atika Rahmah G99172051

Edwin Oka Mustofa G99172065
Fernanda Ayu G99172077
Nadia Izzati G99171031

Pembimbing :
dr. Eric Edwin Yuliantara, Sp.OG
CASE DISCUSSION

2
Anamnesis

3
 IDENTITY
• Name : Mrs. TN
• Date of Birth : 25-12-1989
• Address : Winong, Boyolali
• Occupation : Housewife
• Date of Admission : 8 November 2018
• No. MR : 0143xxxx

• First Day of LMP : 08-04-2018

• EDD : 13-01-2019
• GA : 30+4 weeks

4
Chief Complaint • Severe
headache,nausea, and
vomitting

5
5
HISATOR Y OF P RE SENT ILL NESS

Mrs. TN, 29 y.o, GA 30+4 weeks, a referral from RSUD

Boyolali with information on G3P2A0, 30+4 weeks pregnant,
severe preeclampsia and fetal distress with a history of
CKD+ pericardial effusion+ hipokalemi (3.2) not yet in
labor. The patient assumes that she’s 7 months pregnant.
She feels severe headache and heartburn. Patient got the
first 20% MgSO4 injection and nifedipin 3 x 10 mg at RSUD
Bboyolali. Fetal motion is still present but began to feel
weakened. Regular contractions isn’t present yet. There’s
no amniotic water outflow. nausea (-), vomiting (-), 6
HIS TOR Y OF PAST ILLNESS
 Hypertension history : (+) since the first pregnancy (10 years ago)
 Diabetes history : Denied
 Asthma history : Denied
 Allergy history : Denied
 Cardiac problem history : Denied

7
HISTORY OF F AMILY ILL NES S
 Hypertension history : Denied
 Diabetes history : Denied
 Asthma history : Denied
 Allergy history : Denied
 Cardiac problem history : Denied

8
OBSTETR IC HISTORY

G3P2A0
I. A girl, 9 y.o, birth weight 2900gr, pervaginam
II. Agirl, 2 y.o, birth weight 2600gr, pervaginam with induction as indication of
severe preeclampsia.
III. Present pregnancy

9
Menstruation history
• Menarche : 13 y.o
• Duration : 7 days
• Cycle : regular

Marriage history
Married : 1 time
Duration : 10 years

Contraception history
Contraception (+) : injection every 3 months for 6 years
Physical examinati on

11
P HYS ICAL E XAMINATION
 General State : moderate ill, Compos Mentis
 Vital Sign
 Blood Pressure : 200/140mmHg
 Heart Rate : 56 x/minute
 Respiration Rate : 20x/minute
 Temperature : 36,5° C

12
 P HY SICAL EXAM INATION
Cor:
Inspection : Ictus cordis is not visible
Palpation : Ictus cordis is palpable in ICS VI
Anemic conjunctiva (-/-)
linea midclavicularis sinistra 2 cm to the lateral
Icteric Sclera (-/-)
Percussion : the border of the heart is widening to
caudolateral
Auscultation : BJ I-II :intensity decreases, regular,
noisy (-)

Pulmo : in normal state

Genital:
VT= V/U normal, vagina
Abdomen : normal, tender portio
Supel, pain on fundus uteri palpation (-), posterior curved, closed
single fetus, intrauterine, longitudinal, fetus’ OUE, head of fetus is
back on the left side, head presentation inside pelvis H.II, amniotic
enter 3/5 parts of pelvic, his (-), fetal heart sac & point of presentation
rate (+) 120x/min reguler, height of fundus is difficult to evaluate,
uteri: 32 cm. amnion (-) blood (-),
discharge (-) 13
LABOR ATO RY F INDINGS
 Hemoglobin : 10,1 g/dl ↓
 Hematokrit : 30 % ↓
 Leucocyte : 6,4 ribu/ul
 Thrombocyte : 262 ribu/ul
 Erythrocyte : 3,66 juta/ul ↓
 Blood Type :B
 PT : 12,1 detik
 APTT : 33,1 detik
 INR : 0,910
14

ULTRASONOGR APHY (US G)
• Single fetus, intrauterine, longitudinal, head presentation, fetal heart rate (+)
• Placenta insertion in corpus
• Amniotic fluid sufficient
• No findings of mayor congenital anomaly

• CONCLUSION
• Present fetal condition is good

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NON S TR ESS TES T
• Baseline 120
• Variability 5-10
• Acceleration (-)
• Deceleration (-)
• Fetal movement (+)
• Contraction (-)

• NST Category I
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 DIAGNOSIS
Impending eclampsia and fetal
distress on multigravida preterm
pregnancy not yet in labor with
CKD+ pericardial effusion+
hipoalbumin (2,7)
THER AP Y
o Pro SCTP em + IUD insertion
o Procedure for severe preeclampsia
o O2 3 lpm
o RL infused 12 dpm
o 20 % MgS04 injection 0.5gr/hour for 24 hours
o Nifedipin 3 x 10 mg
o Complete the blood test

18
FOLLOWUP
8/11/2018 18.00  SCTP-em
G3P2A0, 29 years, 30+4 weeks gestational age

S: Headache in forehead area, blurred vision, nausea (-), vomitus (-).

O: KU: Compos mentis
VS : BP: 140/90 mmHg HR : 98x/minute RR : 18x/minute T : 36,80C
Thorax : pulmo : vesicular base sound (+ / +), additional sound (- / -)
Cor: I-II heart sounds normal intensity, regular, noisy (-)
Abdomen: supple, NT (-), palpable intrauterine single fetus elongated, right back,
presentation of bottom, fetal heart rate (+) 95x / minute
Genital: inspeculo: vaginal wall is within normal limits, portio still closed, blood
flows from OUE (-)
A: impending eklampsia, fetal distress, partial HELLP syndrome in preterm
multigravida not yet in labor + hipoalbuminemia (2,7) + renal insufficiency
P: SCTP-emergency
Inform consent
Consult to anesthesiologist
Post-op instruction
1. Monitor the general condition, VS, signs of bleeding until 24 hrs post operation 2. P
2. Fasting until gut peristaltic movement (+)
3. PEB procedure:
• O2 according to the anesthesiologist advice
• Inj. MgSO4 1gr/hr -> pending
• Nifedipin 3x10mg
• Monitor KU/VS/BC/Eklampsia
• Inj. Ketorolac 30mg/8 hrs
• Vit. C 50 mg/12 hrs
8/11/2018 (2 hour instruction Post OP)
P3A0, 29 years old
S: pain post OP
O: KU: CM, fine
VS BP: 130/80 mmHg HR : 84x/minute RR : 22x/minute T : 36,30C
Eyes: conjunctiva anemis (- / -), sclera ikterik (- / -)
Thorax : pulmo : vesicular base sound (+ / +), additional sound (- / -)
Cor: I-II heart sounds normal intensity, regular, noisy (-)
Abdomen: supple, NT (+), wound post op (+) covered with verban, contraction (+), TFU 2 fingers below the belly
Genital: blood (+) lokhia (+).
A: Post SCTP-em + MOW a.i impending eklampsia, fetal distress, partial HELLP syndrome, breech presentation on
preterm pregnancy multipara + hipoalbumin (2,7) + renal insufficiency
P: : Inj Ketorolac 30mg/8 hrs
Vit. C 50 mg/12 hrs
PEB procedure :
- O2 according to the anesthesiologist advice
- Inj. Mg SO4 1gr/hr for 24 hrs
- Nifedipin 3 x 10 mg
09/11/2018

P3A0, 29 years old

S: dyspneu (-), cough (-), dizziness (-), nausea (-), blurred vision(-) P: PEB procedure :
O: KU: CM, fine • O2 3 lpm
VS BP: 149/87 mmHg HR : 67 x/minute RR : 18x/minute T : 36,30C • Inj. MgSO4 20% 1gr/hr for 24 hrs
SpO2: 98% with 3 lpm nasal canule • Nifedipin 3 x 10 mg
Eyes: conjunctiva anemis (- / -), sclera ikterik (- / -) • Monitor KU/VS/BC/impending signs
Thorax : pulmo : vesicular base sound (+ / +), additional sound (- / -) • Vip Albumin 3 x 2
Cor: I-II heart sounds normal intensity, regular, noisy (-) • Inj. Paracetamol 1 gr/8 hrs
Abdomen: supple, NT (+), wound post op (+) covered with verban, • Vit. C 3 x 50 mg
contraction (+), TFU 2 fingers below the belly • Another therapy according to anesthesiology,
Genital: blood (+) lokhia (+). cardiology, and internal medicine departments
• Move to HCU

A: Post SCTP-em + MOW a.i impending eklampsia, fetal distress,

partial HELLP syndrome, breech presentation on preterm pregnancy
multipara + hipoalbumin (2,7) + renal insufficiency (Ur: 118, Cr: 3,8) +
HHD NYHA II DPH 1
Laboratory findings 9/11/18
Examination Result Unit Reference

Creatinine 3.1 mg/dl 0.6-1.1

Ureum 113 mg/dl <50

Sodium 139 Mmol/L 136 - 145

Pottasium 2.9 Mmol/L 3.3 - 5.1

Calcium ion 0.75 Mmol/L 1.17 – 1.29

Magnesium 0.59 Mmol/L 0.46 – 0.60

10/11/2018
P3A0, 29 years old
• S: Vertigo-like dizziness, weakness, sleepiness
O: KU: CM, fine
VS BP: 148/92 mmHg HR : 67 x/minute RR : 16x/minute T :
36,50C SpO2: 100% with 3 lpm nasal canule P: O2 3 lpm
Eyes: conjunctiva anemis (- / -), sclera ikterik (- / -) • Inj. MgSO4 20% 1gr/hr for 24 hrs
Thorax : pulmo : vesicular base sound (+ / +), additional (pending)
sound (- / -) • Captopril 25 mg/8 hrs p.o
Cor: I-II heart sounds normal intensity, regular, noisy (-)
• Vip albumin 1 tab/8 hrs p.o
Abdomen: supple, NT (+), wound post op (+) covered with
verban, contraction (+), TFU 3 fingers below the belly, • Inj. Paracetamol 1 gr/ 8 hrs
peristaltic (+) • Vit. C 50 mg/ 12 hrs p.o
Genital: blood (-) lokhia (+). • IVFD RL 12 tpm
• Another therapy according to
• A: Post SCTP-em + MOW a.i impending eklampsia, fetal
anesthesiology, cardiology, and internal
distress, partial HELLP syndrome, breech presentation on
medicine departments
preterm pregnancy multipara + hipoalbumin (2,6) + renal
insufficiency (Ur: 113, Cr: 3,1) + imbalance electrolite (K+: • Consult to neurologist
2,9, Ca2+: 0.75) + HHD NYHA II DPH 2
11/11/2018
P3A0, 29 years old
• S: Dizziness (-), blurred vision (-)
O: KU: CM, fine P: O2 3 lpm
VS BP: 162/100 mmHg HR : 94 x/minute RR : 20x/minute T : 36,70C
SpO2: 100% • Inj. MgSO4 20% 1gr/hr for 24 hrs
(pending)
Eyes: conjunctiva anemis (- / -), sclera ikterik (- / -)
Thorax : pulmo : vesicular base sound (+ / +), additional sound (- / -) • Captopril 25 mg/8 hrs p.o
Cor: I-II heart sounds normal intensity, regular, noisy (-) • Vip albumin 1 tab/8 hrs p.o
Abdomen: supple, NT (+), wound post op (+) covered with verban, • Inj. Paracetamol 1 gr/ 8 hrs
contraction (+), TFU 3 fingers below the belly, peristaltic (+)
• Vit. C 50 mg/ 12 hrs p.o
Genital: blood (-) lokhia (+).
• IVFD RL 12 tpm
• A: Post SCTP-em + MOW a.i impending eklampsia, fetal distress, • Another therapy according to
partial HELLP syndrome, breech presentation on preterm anesthesiology, cardiology, and internal
pregnancy multipara + hipoalbumin (2,6) + renal insufficiency (Ur: medicine departments
113, Cr: 3,1) + imbalance electrolite (K+: 2,9, Ca2+: 0.75) + HHD
• Monitor KU/VS/BS/impending eklampsia
NYHA II DPH 3
Laboratory Findings (11/11/18)
Examination Result Unit Reference

Sodium 137 Mmol/L 136 - 145

Pottasium 3.2 Mmol/L 3.3 - 5.1

Chloride 107 Mmol/L 98 - 106

12/11/2018
P3A0, 29 years old
• S: Dizziness (-), blurred vision (-)
O: KU: CM, fine
VS BP: 150/90 mmHg HR : 88 x/minute RR : 20x/minute T : P: O2 3 lpm
36,80C SpO2: 100% Eyes: conjunctiva anemis (- / -), sclera ikterik • Inj. MgSO4 20% 1gr/hr for 24 hrs (finish)
(- / -)
Thorax : pulmo : vesicular base sound (+ / +), additional sound • Captopril 25 mg/8 hrs p.o
(- / -) • Vip albumin 1 tab/8 hrs p.o
Cor: I-II heart sounds normal intensity, regular, noisy (-) • Inj. Paracetamol 1 gr/ 8 hrs
Abdomen: supple, NT (+), wound post op (+) covered with
verban, contraction (+), TFU 3 fingers below the belly, peristaltic • Vit. C 50 mg/ 12 hrs p.o
(+) • IVFD RL 12 tpm
Genital: blood (-) lokhia (+). • Another therapy according to
anesthesiology, cardiology, and internal
• A: Post SCTP-em + MOW a.i impending eklampsia, fetal medicine departments
distress, partial HELLP syndrome, breech presentation on
• Move to regular room
preterm pregnancy multipara + hipoalbumin (2,6) + renal
insufficiency (Ur: 113, Cr: 3,1) + electrolit imbalance (K+: 3.2,
Cl-: 107) + HHD NYHA II DPH 4
Laboratory Findings (12/11/18)

Examination Result Unit Reference

Creatinine 0.7 mg/dl 0.6-1.1

Ureum 45 mg/dl <50

13/11/2018
P3A0, 29 years old
• S: Dizziness (-), blurred vision (-) P:
O: KU: CM, fine • PEB procedure: finished
VS BP: 168/80 mmHg HR : 86 x/minute RR : 20x/minute T : 36,80C • Vip albumin 2 tab/8 hrs p.o ->
SpO2: 100% Eyes: conjunctiva anemis (- / -), sclera ikterik (- / -) T.A.P
Thorax : pulmo : vesicular base sound (+ / +), additional sound
• Paracetamol tab 500 mg/ 8 hrs p.o
(- / -)
Cor: I-II heart sounds normal intensity, regular, noisy (-) • Vit. C 50 mg/ 12 hrs p.o
Abdomen: supple, NT (+), wound post op (+) covered with verban, • Another therapy according to the
contraction (+), TFU 3 fingers below the belly, peristaltic (+) cardiologist
Genital: blood (-) lokhia (+). • Allowed to go home

• A: Post SCTP-em + MOW a.i impending eklampsia, fetal distress,

partial HELLP syndrome, breech presentation on preterm
pregnancy multipara + hipoalbumin (2,6) + electrolit imbalance
(K+: 3.2, Cl-: 107) + HHD NYHA II DPH 5
Clasification Of Hypertension During pregnancy
Preeclampsia
 Hypertensive disorders of pregnancy
They are divided into four categories :
• 1-gestational hypertension
• 2-chronic hypertension
• 3-chronic hypertension with superimposed
preeclampsia
• 4- preeclampsia-eclampsia
 DEFINITION
• Pregnancy-specific syndrome that reduce organ perfusion due to vasospasm and
endothelial activation.
• The diagnostic criteria for preeclampsia are:
• Hypertension
BP≥140/90 mmHg after 20 weeks gestation.
• Proteinuria
Proteinuria may not be a feature in some woman with the preeclampsia
syndrome, so the Task Force (2013) suggested other diagnostic criteria.
Diagnosis
Indicators
of
Preeclamp
sia
Severity
Severity Of Preeclampsia
 HELLP Syndrome

• A particularly severe and serious form of preeclampsia is HELLP syndrome

characterized by hemolysis, elevated liver enzymes, and low platelets.
• Prompt recognition is vital to improving outcomes.
• Due to the different number of assays used to measure liver enzymes,
clinicians should be familiar with the upper limit values used in their own
laboratory.
• Criteria for HELLP syndrome are:
• LDH > 600 IU/L (more than 2 times the upper limit of normal values) or
• bilirubin > 1.2 mg/dL,
• AST > 70 IU/L (more than 2 times the upper limit of normal values), and
• platelets < 100,000/μL.(Sibai, 2004)
• Proteinuria may or may not be present with HELLP syndrome
 Pathophysiology
• The precise mechanism for the development of preeclampsia is
unknown
• The pathophysiology of preeclampsia likely involves both maternal and fetal/placental
factors.
• A major component in the development of preeclampsia is the excessive placental
production of antagonists to both vascular epithelial growth factors( VEGF) and
transforming growth factorB ( TGF-B )
• These antagonists to VEGF and TGF-B disrupt endothelial and renal glomerular
function resulting in edema , hypertension and proteinuria
• In addition there appears to be a heritable component and oxidative stress and
abnormal placental implantation can further increase the risk of developing the
disease
 Prevention
• In women with history of a delivery at less than 34 0/7 weeks gestation Or
with history of preeclampsia in multiple pregnancies
• Daily low dose aspirin therapy is suggested
• Low dose aspirin is not associated with increasd bleeding or placental
abruption
• Supplementation with antioxidant ( vit C , E) or magnesium
• folic acid or fish oils or algal oils or garlic is not recommended
in prevention of preeclampsia
• Supplementation of calcium in women with preeclampsia is only indicated in
those who are calcium deficient
• Bed rest and salt restriction are not recommended in prevention pf
preeclampsia
 SCREENING
• Screening for traditional risk factors for preeclampsia is of value
at the first prenatal visit to identify women at high risk of
developing the disease, as these women are offered low-
dose aspirin therapy to reduce their risk of developing the
disease.
• All pregnant women are at risk for preeclampsia, and evidence
supports routinely screening for the disorder by measuring blood
pressure at all provider visits throughout pregnancy
• The value of any laboratory or imaging test for screening has
not been established
 Proteinuria
• Proteinuria may be defined as: ≥ 300 mg per 24-hour
urine collection (or this amount extrapolated from a timed
study—for instance, if the patient has a 12 hour urine
collection)
• Protein/creatinine ratio ≥ 0.3mg/dL
• Dipstick reading of 1+ (this is used only if other methods are
not yet available, and is to be used only as a screening tool
at this facility)
 Treatment
• Prophylactic
• Curative
 Treatment
Prophylactic
• Proper antenatal care:
– To detect the high risk patients who may develop PIH through
the screening tests.
– Early detection of cases who have already developed PIH and examine them more
frequently.
• Low dose aspirin:
– It inhibits thromboxane production from the platelets and the
AII binding sites on platelets.
– A low dose (60 mg daily) selectively inhibits thromboxane due to higher concentration
of such a low dose in the portal circulation than systemic affecting the platelets when
they pass through the portal circulation. The Prostacyclin production from the
systemic vessels will not be affected.
 Treatment
Curative
• Delivery of the foetus and placenta is the only real
treatment of pre-eclampsia.
• As the conditions are not always suitable for this, the
treatment aims to prevent or minimize the maternal and
foetal complications till reasonable maturation of the
foetus.
Medical treatment
Antihypertensives
• Blood pressure readings > 160/110 require
antihypertensive drugs
• Goal of treatment to decrease BP to 140/90 not more
 Obstetric measures
• Timing of delivery
• Method of delivery
• Intrapartum care
• Postpartum care
 Timing of delivery
• depends on Severity of disease ,Fetal maturitya and
Condition of cervix

• A:>37wk terminate without delay

• B: <37wk, expectant management at least till 34wks
• C: unstable maternal or fetal conditions irrespective of gestational age,
should be delivered as soon as the maternal status is stabilized –
immediate delivery
start seizure prophylaxis and steroids if<34wks
• Immediate Delivery
• In the emergency setting, control of BP and seizures should be
priorities.

• Don’t wait
• Don’t hesitate
• Within 6 hour
• Terminate
 Method of delivery:

– Vaginal delivery may be commenced in vertex presentation

by:
• amniotomy + oxytocin if the cervix is favourable.
• prostaglandin vaginal tablet (PGE2) if the cervix is not favourable.
– Caesarean section is indicated in:
• Foetal distress.
• Late deceleration occurs with oxytocin challenge test.
• Failure of induction of labour.
• Other indications as contracted pelvis, and
malpresentations.
 Intrapartum care:

– Close monitoring of the foetus is indicated.

– Proper analgesia to the mother.
– Anti-Hypertensives may be given if needed.
– 2nd stage of labour may be shortened by forceps.
 Postpartum care

– Methergin (Ergometrine) is better avoided as it may increase

the blood pressure.
– Continue observation of the mother for 48 hours.
– Anti- hypertensive drugs are continued in a decreasing
dose for 48 hours.
 Management of Eclampsia :
• Prompt delivery of fetus to achieve cure
• Avoidance of diuretics & hyper osmotic agents
• Limitation of I.V fluid
• Intermittent antihypertensive to control BP judiciously
• Control of convulsion by MgSO4 (IM/IV route)
• Protection & supporting care during convulsion
• Protection in a railed cot Protection of airway &
• prevention of tongue bite
• Correction of hypoxia & acidosis
• Managed in Eclampsia room.
 CONCLUSION
• Hypertensive syndrome that occurs in pregnant women after 20 weeks' gestation, consisting of
new-onset, persistent hypertension with either proteinuria or evidence of systemic
involvement.
• It require close assessment and monitoring for pre-eclampsia and its
complications.
• Blood pressure readings > 160/110 require pharmacologic treatment
• Goal of ttt to decrease BP to 140/90 not more
• Nifedipine , labetalol and methyldopa are approved for treatment of hypertensive disorders
of pregnancy
• Patients with gestational hypertension and preeclampsia should be monitored with regular
labs , sonograms and antenatal testing
• Delivery of fetus and placenta is a definitive treatment of preeclampsia
• Delivery results in resolution of the disease.
• During delivery -- Main stays of management include antihypertensive
therapy, seizure control, and fluid restriction
• hypertensive disorders in pregnancy are an indication of early delivery
• Timing of delivery is based upon a combination of factors, including disease severity, maternal and
fetal condition, and gestational age.
• Magnesium sulphate injection is indicated in severe preeclampsia
For prevention of eclampsia
• It is also preferred agent for treatment of eclampsia
• Hypertensive disorders of pregnancy can be present in postpartum
period
• Preeclampsia is associated with increase risk of cardiovascular
disease later in life
• Initiation of daily low dose aspirin late in the first trimester is
indicated for prevention of preeclampsia in certain high risk women
• Can occur in subsequent pregnancies; therefore, women should
be counselled about the risk
• Following delivery, the patient should be fluid restricted in order
to wait for the natural diuresis.
• A platelet transfusion is recommended prior to Caesarean
section or vaginal delivery when the platelet count is < 20 x 109
ml.
• Methyldopa should be avoided postnatally.
• All women with severe pre-eclampsia should return to the hospital
for post-natal review within 12 weeks of delivery to debrief,
complete any outstanding investigations and plan for the next
pregnancy.