Preeclampsia with severe feature

DI SUSUN OLEH :
Bella Pricylla Juliana (1310070100176)
Rifa Maisaroh (71170891078)
Karina Putri Utama (71170891290)

DOKTER PEMBIMBING
dr. Fadjrir, M.ked (OG), Sp. OG
Chapter 1
INTRODUCTION
 introduction
Hypertension in pregnancy is a most problem in pregnant women
and is a 5-15% complication in pregnancy. The three main causes of
maternal death are bleeding (30%), hypertension in pregnancy
(25%), and infection (12%). Hypertension in pregnancy includes
preeclampsia is the number two main cause of maternal deaths
worldwide.

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CHAPTER ii
PREECLAMPSIA
DEFINITION
Preeclampsia is defined as a specific condition in
pregnancy that is characterized by placental dysfunction and
a maternal response to systemic inflammation with
endothelial activation and coagulation established based on
the presence of specific hypertension caused by pregnancy
accompanied by other organ system disorders at gestational
age above 20 weeks .

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 Etiology and Pathophysiology
STILL UNCLEAR
-Variety of errors from factors that include the mother, placenta, and fetus.
-Hypertension as the most common presenting symptom should not be
viewed as the initial pathogenic process.
-The factors currently considered to be the most important in the
mechanism of PE are:
‐ Maternal immunologic intolerance
‐ Abnormal placental implantation
‐ Genetic, nutritional, and environmental factors
‐ Cardiovascular and inflammatory changes

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 Severe Features of Preeclampsia
1. BP ( S ≥160mmhg or D ≥110mmhg ), on two occasions min 4 hours apart
2. Thrombocytopenia (<100.000/microliter)
3. Abnormally elevated blood concentrations of liver enzymes (twice normal), severe
persistent right upper quadrant or epigastric pain unresponsive to medication
and not an alternative diagnoses, or both
4. Serum creatinine concentration >1,1 mg/dl or twice normal concentration (0,6-1,2
mg/dl) in the absence of other renal disease
5. Pulmonary edema
6. New-onset cerebral or visual disturbances
7. Fetal growth disorders is a sign of uteroplacental circulation disorders:
Oligohydramnios, Fetal Growth Restriction (FGR) or absent orreversed end
diastolic velocity (ARDV)
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Diagnosis Criteria

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PE Management Without severe feature

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With severe feature (GA<34 weeks)

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 Administration of anti-seizure medication
- Loading dose: initial dose4 grams of MgSO4 intravena,
(40% in 10 cc) for 15 minutes.

- Maintanance dose : Infused with 6 grams in Ringer's

solution / 6 hours, or given 4 or 5 grams of IM.
Furthermore maintanance dose is given 4 grams of i.m
every 4-6 hours.

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 Chapter III
CASE REPORT

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Anamnesis
Mrs. R, 36 yo, G5P2A2, Javanese, Moslem, elementary
school graduated, housewife
Chief complaint: High Blood Pressure
‐ This was felt by the patient since approximately 1 days agobefore
admitted toPirngadi General Hospital
‐ History of high blood pressure during pregnancy , in previous
pregnancies and before pregnancy (+).
‐ Intermittent Headache (+)
‐ History of heartburn (-). History of blurred vission (+). History of Seizure
(-).
‐ History of blood mucus discharge from the genitals (+), History of
heartburn to give birth (-). History of discharge of water from the
genitals (+). History of trauma (-). History of taking medication during
pregnancy (-). Urination and defecation in normal limits. Patient was
referred from Grand Medistra Hospital with a diagnosis of

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‐ History of Previous Illness: Hipertension
‐ History of Drug Usage : Nifedipine 1x10 mg
‐ Menstrual history
- First day of recent menstruation : 02/17/2018
- Estimated of delivery date: 11/24/2018
- ANC: 2x to midwife,

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 Childbirth History
1. Girl, 3200 grams, aterm, Sectio caesaria,
Obstetrician, Hospital, 16 years, Healty
2. Mola Hidatidosa
3. Boy, 2800 grams, aterm, Vaginal delivery, Midwife,
Clinic, 12 years, Healty
4. This pregnancy

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Physical examination

‐ Sensorium: Compos mentis Anemic: -

‐ BP: 160/100 mmHg Icteric: -
‐ HR: 90 bpm Cyanosis: -
‐ RR: 22 cpm Dyspnoe: -
‐ Temp: 37.5 ◦C Edema: -
‐ His: 3x20”/10
‐ FHR: 170bpm, regular

‐ Head: Within normal limits

‐ Eyes: conjunctiva anemia (-/ -), sclera icteric (- / -), light reflexes (+ / +),
isochoric pupil
‐ Neck: Lymph node enlargement 21
was not found
Thorax
‐ Inspection: Symmetrical fusiform
‐ Palpation: Stem fremitus right = left
‐ Percussion: Sonor in both lung fields
‐ Auscultation:
- Heart: S1 (-) S4 (-) S4 (-) S4 (-) regular, Murmur (-)
- Lungs: Respiratory sounds: Vesicular
Additional sounds: (-)
Extremities
‐ Warm, CRT <2 seconds, pretibial edema (- / -)

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Obstetric Status:
‐ Abdomen: Asymmetric enlargement, Soepel, Peristaltic (+)
within normal limits
‐ His: 3x20”/10”
‐ FHR: (+), 170 bpm, Regular
‐ Motion: (+)

Internal Examination
‐ VT (after MgSo4 regimen): - Servix axial complete , EFF 100%,
Head of station II-III, Teraba caput 2x3 cm UUK arah jam 12,
amniotic band (-)
‐ ST : - blood mucus (+), amniotic fluid (+)
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USG TAS
‐ Single Fetus, Head Presentation, alive
‐ FM (+)
‐ FHr (+) 172 bpm
‐ BPD 84.3 mm
‐ HC 25.6 mm
‐ AC 35.2 mm
Placenta Fundal grade III
‐ FL 60 mm
‐ EFW 4280 grams
‐ MVP 63.8 cm
 Lab October 5th 2018
Test Result Unit References
Hemoglobin 11.9 g/dl 12-16
Eritrosit 4.35 106/µL 4.0-5.40
Leukosit 18.84 103/µL 4.0-11.0
Hematokrit 35.4 % 36.0-48.0
Platelet 327 103/µL 150-400
Ureum 15 mg/dl 10.0-50.0
SGOT 20 U/L 0.00-40.00
SGPT 12 U/L 0.00-40.00
Creatinin 0.66 mg/dl 0.6-1.2
Uric Acid 6.00 mg/dl 3.5-7.0
Glukosa ad random 135 mg/dl <140
Natrium 138 mmol/L 136-155
Kalium 4.5 mmol/L 3.50-5.50
Klorida 113 mmol/L 95.00- 103.00
APTT 36.8 Detik 28.6- 42.7
INR 0,93 Detik 1-1.3
Anti HCV Non Reaktif Negatif
Anti HIV Non Reaktif Negatif
URINE Test, october 5th 2018

Test Result References

Warna Kuning Kuning

Kekeruhan Jernih Jernih

Protein Poitif ++ Negatif

Sedimen Eritrosit 0-1/lpb <3/lpb

Sedimen Leukosit 2-4/lpb <5/lpb

Sedimen Renal Epitel Negatif Negatif

Reduksi Negatif Negatif

Bilirubin Negatif Negatif

PH 5.0 4.6-8.0
 DIAGNOSIS
Prev Sc 1x+ PE with severe feature + MG + IUP (37-38)weeks + Head Presentation +
Alive Fetus+ Inpartu+ Fetal Distress

THERAPY
Insertion of Urinary Catheter  came out initial urin 200cc
MgSO4 20% (4gr) 20cc Bolus
MgSO4 40% (12gr) 30cc 14 drips/minute in 12 hours
Nifedipin 10mg  if blood presure> 160/100 mmHg , give ekstra nifedipin 10 mg
Ceftriaxon Injection 2gr (skin test)

PLANNING
Consult to Department of Anesthesia
Consult to Department of Perinatology
Sectio caesaria cito
 Sectio Caesaria Report
The mother is laid on the operating table in supine position with an infusion and catheter
installed properly. Operators wash their hands by Fuerbringer method and use personal
protective equipment such as Cap, Mask, Boots, sterile clothes and sterile gloves.
Spinal anesthesia is performed, awaited and the patient is asked to raise her legs. The
patient stated her legs were numb and getting difficult to move. The operator provides pain
stimulation in the patient's abdomen. The patient felt no pain.
Performed aseptic and antiseptic actions on the operating field with Povidone Iodine, then
closed it with sterile ducts except the operating field.
Time Out

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‐ Under spinal anesthesia, a Pfannenstiel’s incision is performed on the Pelvic Line.
Cutaneous and subcutaneous 10 cm long is showed. By tucking the anatomical tweezers
underneath, the fascia is cut to the right and to the left, the muscle is blunted bluntly. Using
two clamps, the visceralis peritoneum is clamped and cut up and down. Uterine appeared
according to gestational age.

‐ Corporal incisions are performed on the uterine corpus to the sub endometrium, then the
endometrium is penetrated with the fingers and blunted bluntly in the direction of the
incision. The membranes are broken, it showed clear amniotic water, the breech appear.

‐ Babies are born with head presentation, then a baby boy with 4410 grams of BBL, -
cm PBL, APGAR SCORE 0, anus was found. The umbilical cord is clamped on both sides
with a distance of ± 5 cm from the center of the baby and cut in between.

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‐ Clamping of the edges of the uterine wound using four oval clamps, then
management at stage 3 with IV IU oxytocin injection IV. Then the placenta is born
with restrained umbilical cord stretching. Identification of the placenta, impression:
The placenta was born complete. The uterus is cleaned with gauze, impression:
Clean.

‐ Suturing with interruptus suture on the corpus of the uterus with Vicryl No. 1.0,
starting from ± 1 cm from the end of the wound. Continuous suture suturing is done
by penetrating the myometrium to the endometrium, then passed to the end of the
wound. Then an evaluation of bleeding was carried out, impression: Controlled
bleeding, adequate contraction. The identification of the left and right ovarian tubes,
the impression of no abnormalities.

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‐ The abdominal wall is sewn layer by layer as follows: Peritoneum is stitched
continuously suture with plain catgut yarn No.2.0. Stitched muscle in a simple
interrupted suture with chromic Catgut 2.0 thread. The fascia is simply suture by
interrupted suture with Vicryl 1.0. The cuticle is sutured with Vicryl 2.0 thread
subcutaneously.

‐ Stitching is completed, the wound is dressed with Sofratulle, gauze, and Hypafix.

‐ The surgery is completed.

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CONDITION OF PATIENT POST SURGERY
‐ Sensorium: Compos Mentis
‐ Blood Pressure: 130/70 mmHg
‐ Pulse: 120 bpm
‐ Respiration: 20 cpm
‐ Temperature: 36.8 ° C

‐ POST SURGERY THERAPY

‐ IVFD RL + Oxytocin 1 amp 10 IU  20 drips/minute
‐ IVFD RL + MgSO4 40% 30cc  14 drips/minute
‐ Ceftriaxone Injection 1 gram/12 hours
‐ Ketorolac Injection 30 mg / 8 hours
‐ Ranitidin Injection 50 mg / 12 hours

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 POST SURGERY PLANNING

‐ Monitor vital signs, uterine contractions, and vaginal

bleeding, eclampsia post partum signs

‐ Complete blood check 2 hours after surgery for cesarean

section

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 Monitoring
Waktu 04.00 04.15 04.30 04.45 05.00 05.30 06.00

Tekanan darah (mmHg) 130/60 130/60 130/60 130/60 130/90 140/80 140/80

Nadi (menit) 126x/i 129x/i 126x/i 120x/i 125 x/i 130x/i 128x/i

Pernapasan (menit) 20x/i 20 x/i 20x/i 20 x/i 20 x/i 20 x/i 20 x/i

Suhu 37.5oC 36.8oC 36.8oC 36.5oC 36.5oC 36.7oC 36.7C

Perdarahan + + + + + + +

Kontraksi uterus + + + + + + +

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Chapter IV
FOLLOW UP

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 DATE Follow Up
5th - 6th October 2018 S : Post operation SC
O : Sens : CM
BP : 130/70 mmHg
Pulse : 126 x/ mnt
RR : 22 x/mnt
Temp : 36,8oC
SL : Abdomen : Soepel, peristaltic (-) tympani (+)
TFU : 1 finger below the umbilicus, strong contraction
P/V : Lochia rubra (+)
BAK : (+) via catheter, OUP: 300cc
BAB : (-), Flatus (-)
A : Post SC a/i Fetal Distress + Macrosmia+ Prec SC 1x+ Post Sterilitation Pomeroy + PE with severe
feature + NH0
P : - IVFD RL + MgSO4 40% 30cc  14 drips/m
- IVFD RL + Oxytocin 10 IU  20 drips/m
- Inj. Ceftriaxone 1 gr/12 h
- Inj. chetorolac 30 mg / 8 h
- Inj. Ranitidin 50 mg / 12 h
- Nifedipin 4x10mg IF 36
BP > 160/100 mmHg
R/ Monitoring of vital sign, uterus contraction, bleeding from vagina, balance cairan
DATE FOLLOW UP

7th October S: Surgical pain

2018 O: SP: Sens: CM
TD: 130/80 mmHg
Pulse: 90 x / minute
Respiratory: 20 x / ominute
Temperature: 36.7 C
SL: Abdomen: Soepel, peristalsis ( +) Normal
TFU: 2 fingers below the center of
L / O: covered with verban, dry wound
P / V: Lochia rubra (+)
BAK: (+) spontaneously
CHAPTER: (-), flatus (+)
A: Post SC a / i Fetal Distress + Macrosmia + Prec SC 1x + Post Sterilization Pomeroy + PE
with severe feature + NH2
P: Cefadroxil 2x500mg
As. Mefenamat 3x500mg
B.comp 2x1
Nifedipine 4x10mg
Bromocriptine 2x2.5mg
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R / infusion aff aff, aff catheter, mobilization
DATE FOLLOW UP
8th October 2018 S: Surgical pain
O: SP: Sens: CM
TD: 130/60 mmHg
Pulse: 80 x / minute
Respiratory: 20 xo/ minute
Temperature: 36 C
SL: Abdomen: Soepel, peristalsis ( +) Normal
TFU: 2 fingers below the umbilicus, strong contraction
L / O: covered with verban, dry-looking wound
P / V: Lochia rubra (-)
BAK: (+) spontaneous
BAB: (-), flatus (+)
A: Post SC a / i Fetal Distress + Macrosmia + Prec SC 1x + Post Sterilization Pomeroy +
PE with severe feature + NH3
P: Cefadroxil 2x500mg
As. Mefenamat 3x500mg
B.comp 2x1
Nifedipine 4x10mg
Bromocriptin 2x25mg
R / PBJ, Control to PIH, October 3811, 2018
 Case Discussion
THEORY CASE
definition
preeclampsia is defined as a specific condition in pregnancy characterized by 4 22012
Mrs. R 36 years, G P with a gestational age of 37-38 weeks comes
placental dysfunction and a maternal response to systemic inflammation with with blood pressure 160/100 mmHg with neurological symptoms of
endothelial activation and coagulation established based on the presence of headache and blurred vision (+). And there are proteiuria (++).
specific hypertension caused by pregnancy accompanied by other organ
system disorders over 20 weeks' gestation such as platelets <100,000 / μl,
renal impairment characterized by serum creatinine> 1.1 mg / dL or an
increase in serum creatinine levels in conditions where there are no other
kidney abnormalities, increased LDH which marks microangiopathic hemolysis,
liver disorders characterized by an increase in SGOT / SGPT, there are
neurological symptoms of headache, visual disturbances and pulmonary
edema
.
Diagnosis Results of examination when the patient first arrived
Diagnosis is based on the criteria of severe preeclampsia if one Sens: compos mentis Anemis : -
or more of the following symptoms are found TD: 160/100 mmHg IkterikPulses : -
Systolic blood pressure ≥160 mmHg and diastolic blood pressure : 90 x / i Cyanosis: -
≥ 110 mmHg. This blood pressure does not decrease even RR: 20 x / i Dyspnoe: -
though pregnant women have been hospitalized and have Temp: 37,8oc Edema: -
undergone bed rest.
accompanied by neurological symptoms of headache (+)
Proteinuria is more than 5 g / 24 hours or (++ / +++) in a
qualitative examination of
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 THEORY

Oligouria, in urine production is less than 500 cc / 24 hours • Laboratory examination (05 October 2018)
Increase in plasma creatinine Hb: 11.9 g / d
Visceral and cerebral disorders such as decreased Ht: 35.4%
consciousness, headache, scotoma and blurred vision Leu: 18.84 / µL
Pain epigastrium or pain in the right upper quadrant of the Plt: 327,000 / µL
abdomen (due to stretching of capsule Glisson) Ur: 15.00 mg / dl
Pulmonary edema and cyanosis Cr: 0.66 mg / dl
Microangiopathic hemolysis Ur.a cid: 6 mg / dl
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Severe thrombocytopenia <100,000 cells / mm or rapid SGOT: 20 U / l
decrease in platelets SGPT: 12 U / l
Disorders of liver function (hepatocellular damage ie increased
alanine and asparate aminotransferase
Fetal growth intrauterine obstructed • Urinalisa examination (October 5, 2018)
Yellow, clear, protein (++)

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Management of • Patients treated on October 5, 2018 to October 8,
•Hospitalization 2018.
•Giving anticonvulsant medication in the form of • Therapy:
MgSO . The way magnesium sulfate works cannot be
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Loading Dose: Inj. MgSO44 Gram 20% 20cc ->
fully understood. One mechanism of action is to cause bolus slow (10-15min)
vasodilation through relaxation of smooth muscles, Maintenance Dose: IVFD RL 500 cc + MgSO4 12
including peripheral blood vessels and uterus, so that in grams 40% 30cc 14gtt / minute
addition to anticonvulsants, magnesium sulfate is also Nifedipine 10mg / 30 minutes if blood pressure>
useful as an antihypertensive and tocolytic 160/100, max 120 mg / 24 hours
•blood pressure cut for antihypertensive use, namely
≥160 / 110 mmHg and MAP ≥ 126 mmHg.
•first-line
Nifedipineantihypertension, a dose of 10-20 mg
orally, repeated after 30 minutes maximum 120 mg
in 24 hours.

Second-line antihypertensive
•sodium nitroprusside 0.25 µg iv / kg / minute, infusion,
increased 0.25 µg iv / kg / 5 minutes.
•Diazokside 30-60 mg / iv / iv / 5 minutes or
intravenous infusion 10 mg / minute / titrated 41
 THANK you !
Any questions?

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