Obsgyn discussion

by:first group
Members :
• HIMAMI FIRDAUSIYAH (6130014001)
• ANDRIANI AGUSTIN (6130014002)
• DINDA AYU P. (6130014003)
• M. RIZAL ZAKARIA A. (6130014004)
• RIZKY PUTRI S. Y. (6130014005)
• IMAM FADLI (6130014006)
• BAHTIAR NAWABIG H. (6130014007)
• SHINTA PARAMITHA P. S. (6130014008)
• MASTERIA CHOIRUNNISA (6130014009)
• DEVI AFIANA PUTRI (6130014010)
Scenario
• A 34-year-old pregnant woman, coming to the Emergency Unit
RSI jemursari with abdominal complaints of pain and headache
... What should you know and do?

Additional information :
1. Stomach ache and pain since 2 days ago
2. Vital sign .. TD 160/90 N.88 / mnt RR 18x / mnt
3. DJJ +142
4. VT 2 cm 5. Urine protein +3
Keywords
1. 34-year-old pregnant woman
2. Stomach ache
3. Headache since 2 days ago
4. Proteinuri +3
5. HPHT 5 May 2017
6. Check: February 12, 2018
 The problem……..
1. What is the patient's pregnancy age in the scenario?
2. Are there any signs of emergency?
3. What is the pathophysiology of pregnancy?
4. What are DD and DX on the scenario?
5. What is the classification of pre-eclampsy?
6. What is preeclamptic pathophysiology?
7. How to handle preeclampsia?
8. What are the physical and supplemental checks for pregnant people?
9. What are the risks of preeclampsia?
Answer
1. 40 weeks of pregnancy
2. There. Hypertension, age of woman, proteinuria
3. There are physiological changes that occur in pregnant women, from the start of
the cardiovascular digestive system
4. DD: mild preeclampsy Dx: hypertension, TTH
5. Classification of preeclampsis: mild and severe
6. ___
7. Control blood pressure, prevent seizures, anti hypertension, drugs for proteinuria
8. Physical examination: inspection, palpation, etc. Investigations: ultrasound
Special physical examination: Leopold, Fetal Heart Rate, Uter High Fundus
9. Age over 40 yrs, pregnancy rate, history of hypertension, obesity, family history
of preeclampsis, twins, distances of pregnancy too far
MIND MAPPING
1. What is the patient's pregnancy age in the
scenario?

40 weeks of pregnancy
2. Are there any signs of emergency?
Obstetric emergency is a clinical condition that, if not treated promptly,
will result in severe pain and even death of the mother and fetus. In
general there are 4 main causes of maternal death, fetus and newborn,
ie
1. bleeding
2. infection, sepsis
3. hypertension, preeclampsia, eclampsia
4. labor is stalled (dystocia)
Which includes obstetric emergencies, namely:
1. Abortion
2. Hydatidiform mole
3. Extrauterine Pregnancy (Ectopics)
4. Placenta previa
5. Solusio
6. Retention of Placenta (Placenta Inkompletus)
7. Uterine rupture
8. Postpartum Bleeding
9. Hemorrhagic Shock
10. Septic Shock (Bacteria, Endotoxin)
11. severe Preeclampsia and eclampsia
3. What is the pathophysiology of pregnancy?
4. What are DD and DX on the scenario?

• The diagnosis of mild preeclampsia is established by the minimum

criteria:
• Hypertension occurring after 20 weeks of gestation with systolic blood
pressure ≥ 140 mmHg or diastolic pressure ≥ 90 mmHg
• Proteinuria with urine protein ≥ 300 mg / 24 hours or ≥ 1+ using dip marks
• Edema of the arms, face and stomach, generalized edema
The diagnosis of severe preeclampsia is preeclampsia accompanied by one or more of the following
symptoms

• Systolic blood pressure ≥ 160 mmHg or diastolic blood pressure ≥ 110 mmHg in two circumstances with a period
of at least 6 hours with a bedrest in position
• Proteinuria of more than 5 g / dl in a 24-hour urine sample sample or ≥3+ with dip marks in two random urine
samples taken with a spacing of 4 hours or more
• Oliguria, urine production less than 500 cc / 24 hours
• Visus and cerebral dysfunction in the form of decreased consciousness, headache, scotoma, blurred vision
• Epigastric pain or pain in the right upper quadrant of the abdomen due to strain on the Glisson capsule
• Pulmonary edema or cyanosis
• Microangiopathic haemolysis
• Impaired hepatic function characterized by increased serum transaminase
• Increased plasma creatinine levels
• Thrombocytopenia (<100,000 cells / mm3 or rapidly declining platelets)
• Intrauterine fetal growth is inhibited
• The presence of HELLP syndrome (Hemolysis, Elevated liver enzymes, Low platelet)
differential diagnosis
• Kehamilan dengan sindrom nefrotik
• Kehamilan dengan payah jantung
• Hipertensi Kronis
• Penyakit Ginjal
• Edema Kehamilan
• Proteinuria Kehamilan
 5. What is the classification of pre-eclampsy?
The division of preeclampsia is divided Mild and Severe , the following is the classification
- Mild preeclampsia is the onset of hypertension with proteinuria and or edema after 20 weeks'
gestation or shortly after pregnancy. These symptoms may occur before 20 weeks of gestation in
trophoblast disease, the cause of mild preeclampsia is not known clearly. Symptoms of mild
preeclampsia include:

1. Increase in systolic blood pressure between 140-160 mmHg and diastolic blood pressure 90-110
mmHg
2. Proteinuria quantitatively> 0.3 g / l in 24 hours
3. Edema on pretibial, abdominal wall, lumbosacral, face or hand
4. Not accompanied by impaired organ function
- Severe preeclampsia is a pregnancy complication characterized by the onset of hypertension
160/110 mmHg or more with proteinuria and or edema at 20 weeks or more. Clinical
symptoms of severe preeclampsia include:

1. Systolic blood pressure> 160 mmHg or diastolic blood pressure> 110 mmHg
2. Platelets <100.000 / mm3
3. Proteinuria (> 3 g / liters / 24 h) or positive 3 or 4, on a quantitative examination may be
accompanied by:
a. Oliguria (urine <400 ml / 24 h)
b. Cerebral complaints, impaired vision
c. Abdominal pain
d. Liver disfunction
e. Intrauterine developmental disorders.
 6. What is preeclamptic pathophysiology?
• Pathophysiology of preeclampsia is associated with physiological changes in pregnancy.
• Includes increased blood plasma volume, vasodilation, decreased systemic vascular resistance,
increased cardiac output, and decreased colloid osmotic pressure.
• In preeclampsia, circulating plasma volume decreases, resulting in hemoconcentration and
increased maternal hematocrit.
• Makes the perfusion of meternal organs decrease, by destroying red blood cells, so the capacity
of maternal oxygen decreases.
• In addition to endothelial damage, arterial vasospasm contributes to increased capillary
permeability.
• In preeclampsia spasm occurs blood vessels accompanied by salt and water retention.
• So if all the arterioles in the body are spasmic, then blood pressure will rise, in an attempt to
overcome the increase in peripheral pressure so that tissue oxygenation can be satisfied.
• If Proteinuria may be caused by arteriole spasms resulting in changes in the glomerulus.
• The effect of this spasme on the placenta and uterus is the blood flow decreases to the placenta
and causes placental disturbance resulting in fetal growth disturbance and due to lack of oxygen
occurs emergency on the fetus.
7. How to handle preeclampsia?
a) GENERAL HANDLING
• If diastolic pressure> 110 mmHg, give
antihypertensives, up to diastolic pressure • Observe
between 90-100 mmHg.
• Install an infusion of RL (Ringer Lactate) • Auscultation of the lungs to look for signs
• Measure the fluid balance, do not reach
overload
• Urine catheterization for volume release
and proteinuria
• If the amount of urine <30 ml per hour:o
The fluid infusion is maintained 1 1/8
hourso Monitor for possible pulmonary
edema
• Do not leave patients alone. Seizures
accompanied by aspiration can result in
maternal and fetal death.
vital signs, reflexes, and fetal heart
rate every hour.
of pulmonary edema. Krepitasi is a sign of
pulmonary edema. In case of pulmonary
edema, stop fluid administration and give
diuretics such as intravenous 40 mg
furosemide.
• The value of blood coagulation by bedside
freezing test. If freezing does not occur
after 7 minutes, there may be coagulapati
b) ANTICONVULSANTSIN

the case of severe preeclampsia and eclampsia, magnesium

sulfate administered parenterally is an effective anti-seizure drug
without causing central nervous depression for both the mother and
the fetus. The drug may be administered intravenously via continuous
or intramuscular infusion with intermittent injection.
CONTINUOUS INTRAVENOUS INFUSION

• Give a 4 to 6 gram dose of MgSO4 diluted in 100 ml of fluid and

administered in 15-20 minutes.
• Start a maintenance infusion with a dose of 2 g / h in 100 ml of
intravenous fluid.
• Measure MgSO4 levels at 4-6 hours after administration and adjusted
infusion rate to maintain levels between 4 and 7 mEg / l (4.8-8.4 mg /
l).
• MgSO4 is stopped 24 hours after birth.
INTERMITTENT INTRAMUSCULAR INJECTION

• Give 4 grams of MgSO4 as an intravenous 20% solution at a rate not exceeding 1 g /

min. Proceed immediately with 10 grams of MgSO4 50%, part (5%) injected in the
upper lateral quadrant of the buttocks (addition of 1 ml of 2% lidocaine can reduce
pain). If the seizure persists after 15 minutes, give MgSO4 to 2 grams in 20%
intravenous solution at a rate not exceeding 1 g / min. If the woman is large, MgSo4
can be given up to 4 grams slowly.
• Every 4 hours thereafter, give 5 grams of 50% MgSO4 solution injected deeply into
the lateral quadrant over the left buttocks but after it is confirmed that:o Patellar
reflex (+)o There is no respiratory depressiono Urine expenditure during the
previous 4 hours exceeds 100 ml
• MgSO4 is stopped 24 hours after birth.
• Prepare antidotum If breathing occurs, provide help with a ventilator or give 2 g of
calcium gluconate (20 ml in 10% solution) intravenously slowly until breathing
begins again.
c) ANTIHYPERTENSIVES

The drug of choice is Nifedipine oral dose of 10 mg repeated every 30

minutes. Maximum dose of 120 mg per 24 hours. Nifedipine should not
be given sub-lingual, because the vasodilation effect is very fast, so it
should only be given orally (Cunningham, 2003).

d) LABOR

• In severe preeclampsia, labor must occur within 24 hours. If cesarean

section will be performed, note that there is no coagulopathy. Safe /
selected anesthesia is general anesthesia. Do not do local anesthesia,
whereas spinal anesthesia is associated with hypotension.
8. What are the physical examination and support for pregnant ?

• Physical examination: in the form of inspection, palpation, and

auscultation include checking blood pressure, weight, fundus uteri height,
fetal pulse rate, Leopold examination (determining where the fetus is in
the womb), and a thorough physical examination.

• Supporting investigation : Laboratory examination for blood hemoglobin

level, urinalysis (urine examination), blood type and rhesus, TORCH and
hepatitis test. It can also perform a range of other tests that are useful in
early detection of abnormalities in the fetus such as alpha feto protein
(AFP), ChorionVillius Sample (CVS), and Amniocentesis. Ultrasonogafi
ultrasound examination is useful to detect congenital abnormalities of the
fetus, the number of fetus, fetal heart movement, location of the placenta.
9.What are the risks of preeclampsia?
• Age less than 25 years old or more than 40 years old
• Parity of primigravida pregnancy and multipler pregnancy
• Race / ethnic group
• Diet / nutrition (obesity)
• Tropical climate
• Behavior / socio-economic
• Diabetes mellitus
• Hydatidiform mole
• History of preeclampsia in family
• History of preeclampsia, kidney disease, lupus, rheumaotid arthritis
 Conclusion..
The division of preeclampsia is divided into light and heavy classes, the following is the classification:

- Lightweight preeclampsia is the onset of hypertension with proteinuria and or edema after 20 weeks' gestation or shortly after pregnancy. These symptoms
can occur before 20 weeks of gestation in trophoblast disease, the cause of mild preeclampsia is not known clearly. Symptoms of mild preeclampsia include:
1. Increase in systolic blood pressure between 140-160 mmHg and diastolic blood pressure 90-110 mmHg
2. Proteinuria quantitatively> 0.3 g / l in 24 hours
3. Edema on pretibial, abdominal wall, lumbosacral, face or hand
4. Not accompanied by impaired organ function

- Preeclampsia Weight Preeclampsia Weight is a pregnancy complication characterized by the onset of hypertension 160/110 mmHg or more with
proteinuria and or edema in 20 weeks or more. Clinical symptoms of severe preeclampsia include:
1. Systolic blood pressure> 160 mmHg or diastolic blood pressure> 110 mmHg
2. Platelets <100.000 / mm3
3. Proteinuria (> 3 g / liters / 24 h) or positive 3 or 4, on a quantitative examination may be accompanied by:
a. Oliguria (urine <400 ml / 24 h)
b. Cerebral complaints, impaired vision
c. Abdominal pain
d. Liver disfunction
e. Intrauterine developmental disorders.