Preeklamsi case

7/25/2019 Preeklamsi case

1/16

Case Report

G2P1A0 gravid 32-33 weeks Stage 1 Parturition on

Active Phase with Mild Preeclapsia

Counsellor

dr! Giose""i Sp!#G

Presented by

$dwinda %es& Ratu '11201(021)

#*S+$+R,CS A% G.$C#/#G. C/$RS,P

AC/+. # M$%,C,$ R,%A 4ACAA CR,S+,A ,5$RS,+.

C,A4, G$$RA/ #SP,+A/6 *#G#R

Period 7ul& 28th2019 : #cto;er 3rd2019

1


2/16

Hospitalised at Ciawi general hospital on Thursday, September 3rd, 2015 (at 0!30 am"

#e$$ered $rom the %bstetri& and 'yne&ology poli&lini&

Patient


3/16

Patient8s $irst day o$ the last period o$ menstruation is 9es&ember 1st, 201! The labor

estima&y date is September :th, 2015! Patient has a regular pregnan&y &he&6up $or ; times

during her pregnan&y! History o$


4/16

Ph&sical $>aination

on September 3rd, 2015! (at 12!5 am"

'eneral Situation ) *oderate pain

+wareness ) Compos *entis

Bital Sign )

.lood pressure ) 10100 mmHg

Heart #ate ) : min

#espiratory rate ) 1; min

Temperature ) 3!5o&

.ody weight ) 6g

.ody height ) 15 &m

G$$RA/ $?AM,A+,#

ead

ye ) &onDun&ti/a anemi& E s&lera i&teri&

ar ) pain E se&ret

ose ) de/iation septum E se&ret

Throat ) Tonsil T1 FT1 normal, pharyn hyperaemi& (" *outh ) oral hygiene (A"E mu&osa normal

e&6 ) tra&hea in the middle, lymph nodes and thyroid normal

+hora>

*ammae ) normal, in/erted nipple ("

Pulmo

inspe&tion ) symetri&, retra&tion ("

palpation ) $remitus ta&til right G le$t

per&usion ) sonor AA

aus&ultation ) /esi&ular AAE rhon&hi E whee7ing

Cor

inspe&tion ) pulse o$ i&tus &ordis &an not be seen

palpation ) pulse o$ i&tus &ordis &an not palpable

per&ussion ) dull, heart margins within normal limits

aus&ultation ) Heart sounds === regular, gallop (", murmur ("

4


5/16

A;doen

=nspe&tion ) bulge, striae gra/idarum (A"

+us&ultation ) bowel sound (A" normal

Per&usion ) timpany

Palpation ) epigastri& pain (A",de$ense mus&ulaire ("

Genital

Bul/a /aginal no abnormalities, blood (", se&ret (A"

$>treities

4arm hand and $eet

%edema EAA

C#T 2 se&onds

#e$lees ) IP# AA

#;stetric and g&necologic A;doinal $>aination

eopold 1 ) bree&h, >undal Height )23 &m

eopold 2 ) >etal ba&6 on the right side, $etal heart rate ) 11: timesminute

eopold 3 ) /erte

eopold ) already engaged o$ the presenting part

$>ternal genitalia

=nspe&tion ) Bul/a and Bagina are within normal &onditions,.leeding (", se&ret (A"

,nternal GenitaliaBaginal tou&hJ

Bul/a and Bagina are within normal &onditions, portio was not thin, eternal uterine ostium

opened, diameter &m! +mnion (A"! Presentation o$ the baby8s /erte on Hodge 2! %n glo/e

$indings, $resh blood (", se&rete (A"!

4orkup

/a;orator& "indings on Septe;er 3rd6 2019 ' 0(!00 p)

5


6/16

Haematology

Hb ) 12! gdl

Ht ) 2 K

eu&o&yte ) 500 Ll Platelet &ount ) 20000 Ll

CT ) 1083088

.T ) 283088

.lood Type ) +., #h (A"

Chemistry

.lood glu&ose )3 mgd

S'%T ) 3:


7/16

Resue

+ 30 years old woman &ome to the poli&lini& with a &ontra&tion sin&e 10 pm (22015" with

a regular inter/al and stronger &ontra&tion a$ter ea&h inter/al! Se&rete (A"!

1 wee6 ago she was hospitali7ed be&ause o$ se/ere pree&lampsia and got *gS% treatment

$or 2 days! This is her 2nd pregnan&y, no history o$ mis&arriage!

The date o$ $irst day o$ the last period o$ menstruation is 9e&ember 1 st201! Patient has a

regular pregnan&y &he&6up $or ; times during her pregnan&y! History o$


8/16

Prepare $or /aginal deli/ery

i$edipine 310 mg tab P%

*etyldopa 3 500 mg tab P%

(32015" 10!30 am ) /aginal deli/ery

.orn a baby boy

4eight ) 2150 gram

Height ) 5 &m

Head round ) 30 &m

Chest round ) 31 &m

+S ;

ollow p(September th , 2015, at 0:!00 +* on BI"

S ) .reast mil6 AA

% ) Compos *entis

Bital Sign) .P ) 130 0 mmHg

Pulse ) ; mins

## ) 20 mins

Temperature ) 3,2oC

'eneral eam )

ye ) C+ , S=

Thora ) CP within normal limit

+bdomen ) $lat, supple, bowel sound A, $undal height at 2 $ingers below

umbili&al, uterine &ontra&tion) good

'en ) // normal, lo&hia(A"

tremities ) %edema E

+ ) P2+0 post /aginal deli/ery day 1 with mild pre&&lampsia

P ) Ce$adroil 500 mg tab (2 1"

*e$enami& a&id 500 mg tab (3 1"

S> tab (1 1"

i$edipine 10 mg (11"

ollow p( September 5th, 2015, at 0:!00 +* on BI"

S ) .reast mil6 AA


9/16

% ) Compos *entis

Bital Sign) .P ) 130 ;0 mmHg

Pulse ) ;; mins

## ) 1; mins

Temperature ) 3!5oC

'eneral eam )

ye ) C+ , S=

Thora ) CP within normal limit

+bdomen ) $lat, supple, bowel sound A normal, $undal height at 2 $ingers below

umbili&al, uterine &ontra&tion) good

'en ) // normal, lo&hia(A"minimal

tremities ) %edema E

+ ) P2+0 post /aginal deli/ery day 2 with mild pree&&lampsia

P ) Ce$adroil 500 mg tab (2 1"

*e$enami& a&id 500 mg tab (3 1"

S> (1 1"

i$edipine (11"

+llowed to di&harge $rom hospital! Control to obgyn poli&lini& : days later

General discussion

The diagnose o$ this patient is '2P1+0 gra/id 3233 wee6s stage 1 parturition on

a&ti/e phase with mild pree&lampsia

Case analysis

+ 30 years old woman &ome to the poli&lini& $or her pree&lampsia &ontrol! She also had a

&ontra&tion sin&e 10 pm (22015" with a regular inter/al and stronger &ontra&tion a$ter

ea&h inter/al! Se&rete (A"!

1 wee6 ago she was hospitali7ed be&ause o$ se/ere pree&lampsia and got *gS%

treatment $or 2 days! This is her 2nd pregnan&y, no history o$ mis&arriage!

The date o$ $irst day o$ the last period o$ menstruation is 9e&ember 1 st201! Patient has a

regular pregnan&y &he&6up $or ; times during her pregnan&y! History o$


10/16

Bital signs)

.lood pressure ) 10100 mmHg

Heart #ate ) : min

#espiratory rate ) 1; minTemperature ) 3!5o&

+bdomen loo6s bulge, striae gra/idarum (A"! %n the palpation, epigastri& pain (",

palpated the bree&h on the $undus with $undal height 23 &m! .a&6 o$ the baby is at right

side with $etal heart rate ) 11: timesminute! Presentation o$ /erte and ha/en8t engaged

o$ the presenting part! The eternal genitalia is within normal &ondition with blood (" and

se&ret (A"! ower etremities loo6s oedema! %n the /aginal tou&he) Bul/a and Bagina are

within normal &onditions, portio was thin, eternal uterine ostium opened with diameter

&m! +mnion (A"! Presentation o$ the baby8s bree&h on Hodge 2! %n glo/e $indings, se&ret

(A"!

>rom the laboratories $inding )


11/16

+ntiphospholipid syndrome

9iabetes mellitus

Twin gestation (but una$$e&ted by 7ygosity"

High body mass inde

ow so&iale&onomi& status

Signs and s&ptos@1

.e&ause the &lini&al mani$estations o$ pree&lampsia &an be heterogeneous, diagnosing

pree&lampsia may not be straight$orward! *ild to moderate pree&lampsia may be

asymptomati&! *any &ases are dete&ted through routine prenatal s&reening!

Patients with se/ere pree&lampsia display endorgan e$$e&ts and may &omplain o$ the

$ollowing)

Heada&he

Bisual disturban&es) .lurred, s&intillating s&otomata

+ltered mental status

.lindness) *ay be &orti&al or retinal

9yspnea

dema) Sudden in&rease in edema or $a&ial edema

pigastri& or right upper uadrant abdominal pain

4ea6ness or malaise) *ay be e/iden&e o$ hemolyti& anemia

Clonus) *ay indi&ate an in&reased ris6 o$ &on/ulsions

=n &ase)

>rom this anamensis, we get in$ormation about ris6 $a&tors o$ pree&lampsia in this patient

su&h aslow so&iale&onomi& status!

+nd then we $ind mani$estations o$ mild pree&lampsia su&h as high blood pressure! =t

happened in 32 wee6s o$ gestation! +nd usually mild to moderate pree&lampsia may be

asymptomati&!

Case analysis)


12/16

>rom the laboratories $inding )


13/16

$rom anamnesis, physi&al eamination, and laboratory $inding, we &an diagnose this patient

as MildBon Severe Pre-eclapsia!

*anagement)

Advice "ro #;sG&n specialist

=B>9 # 500 && (1; gauge &annula 1 "20 tpm

9ower Catheter no 1

*onitoring o$ /ital signs and &ontra&tion

Prepare $or /aginal deli/ery

i$edipine 310 mg tab P%

*etyldopa 3 500 mg tab P%

Theory)

The basi& management obDe&ti/es $or any pregnan&y &ompli&ated by pree&lampsia are) (1"termination o$ pregnan&y with the least possible trauma to mother and $etus, (2" birth o$ an

in$ant who subuently thri/es, and (3" &omplete restoration o$ health to the mother! =n many

women with pree&lampsia, espe&ially those at or near term, all three obDe&ti/es are ser/ed

eually well by indu&tion o$ labor!2Q

Consideration o$ 9eli/ery2Q

Heada&he, /isual disturban&e, or epigastri& pain are indi&ati/e that &on/ulsions may be

imminent, and oliguria is another ominous sign! Se/ere pree&lampsia demands anti&on/ulsat

and $reuently antihypertensi/e therapy, $ollowed by deli/ery! Treatment is identi&al to that

des&ribed subseuently $or e&lampsia! The prime obDe&ti/es are to $orestall &on/ulsions, to

pre/ent intra&ranial hemmorage and serious damage to other /ital organs, ant to deli/er a

healthy newborn!

4hen the $etus is preterm, the tenden&y is to tempori7e in the hope that a $ew more wee6s in

utero will redu&e the ris6 o$ neonatal death or serious morbidity $rom prematurity! +s

dis&ussed, su&h as a poli&y &ertainly Dusti$ied in midler &ases! +ssessments o$ $etal wellbeing

and pla&ental $un&tion are per$ormed, espe&ially when the $etus is immature! *ost

re&ommendG $reuent per$orman&e o$ /arious test to assess $etal wellbeing as des&ribed by

the +meri&an College o$ %bstetri& and 'yne&ologists (2012"! These in&lude the nonstress test

or the biophysical profile! *easurement o$ the le&ithinsphingomyelin ration in amnioni&

$luid may pro/ide e/iden&e o$ lung maturity!

4ith moderate or se/ere pree&lapsia that dies not impro/e a$ter hospitali7ation, deli/ery is

usually ad/isable $or the wel$are o$ both mother and $etus! This is true e/en when the ser/i

is un$a/orable! abor indu&tion is &arried out, usually with preindu&tion &er/i&al ripening


14/16

$rom prostaglandin or osmoti& dilator! 4hene/er it appears that indu&tion almost &ertainly

will not su&&eed or attempts ha/e $ailed, then &aesarean deli/ery is indi&ated!

>or a woman near term, with a so$t, partially e$$a&ed &er/i, e/en milder degrees o$

pree&lampsia probably &arry more ris6 to the mother and her $etusin$ant than does indu&tion

o$ labor! The de&ision to deli/er late preterm $etuses is now &lear! &essi/e neonatal

morbidity in women deli/ered be$ore 3; wee6s despite ha/ing stable, mild, nonproteinuri&

hypertension! The etherlands study o$ 31 newborns deli/ered between 3 and 3 wee6s,

and the higher &aesarean deli/ery rates were asso&iated with more respiratory &ompli&ations!

Hospitali7ation /ersus %utpatient *anagement

>or women with mild to moderate stable hypertension F whether or not pree&lampsia has

been &on$irmed F sur/eillan&e is &ontinued in the hospital, at home $or some reliable patients,

or in a day&are unit! +t least intuiti/ely, redu&ed physi&al a&ti/ity throughout mu&h o$ the

day seems bene$i&ial! Se/eral obser/ational studies and randomi7ed trials ha/e addresses the

bene$its o$ inpatient &are and outpatient management!3Q

+ntihypertensi/e treatment,5,Q

+ntihypertensi/e treatment is use$ul only in se/ere pree&lampsia be&ause the sole pro/en

bene$it o$ su&h management is to diminish the ris6 o$ maternal &ompli&ations (&erebral

hemorrhage, e&lampsia, or a&ute pulmonary edema"! There is no international &onsensus

&on&erning antihypertensi/e treatment in pree&lampsia! The $our drugs authori7ed $or the

treatment o$ hypertension in se/ere pree&lampsia in >ran&e are ni&ardipine, labetalol,

&lonidine, and dihydrala7ine! There is no ideal target blood pressure /alue, and too aggressi/e

a redu&tion in blood pressure is harm$ul to the $etus! Therapy with a single agent is ad/ised as

$irstline treatment, $ollowed by &ombination treatment when appropriate! The algorithm $or

antihypertensi/e treatment proposed by >ren&h eperts is shown in >igure 1!
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148420/figure/f1-vhrm-7-467/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148420/figure/f1-vhrm-7-467/


15/16

>igure 1! antihypertensi/e therapy $or pree&lampsia

Source:http://wwwncbinlmnihgov/pmc/articles/!"C#$%&%'(/figure/f$)vhrm)*)%+*/

=n &ase)

4e ga/e supporti/e &are su&h i/ line, and dower &atheter $or &ontrol $luid balan&e ! +nd we

repla&ed patient to le$t lateral de&ubitusto impro/e uterine blood $low!

The drug o$ &hoi&e to treat hypertension is ni$edipine p!o 3 10 mg

4e didn8t use *agnesium Sul$ate therapy be&ause the patient was not in se/ere pre

e&lampsia

9eli/ery is happened be&ause the patient already had a &ontra&tion!

4e prepared $or /aginal deli/ery! ($rom gyne&ology eamination $indings"

.P should be assessed with the goal o$ maintaining the diastoli& .P at less than 110 mm Hg

with administration o$ antihypertensi/e medi&ations as needed (ni$edipine"

Re"erences


16/16

1! Shah +I, Steinberg ', Vwanger *! Pree&lampsia! 9ownloaded $rom

http)emedi&ine!meds&ape!&omarti&le1:1o/er/iewWa1! %n September

5th2015!

2! Cunningham >', e/eno I-, .loom S, Spong CM, 9ashe -S, Ho$$man .,

et al! Hypertensi/e disorder! =n) 4illiams obstetri&! 2th ed! ew Mor6)

*&'raw Hill, 201!p!:3052!

3!

Documents

Preeklamsi case