Skenario KasusSkenario Kasus

Ibu A, 19 tahun, G1 hamil 39 minggu, dikirim bidan dengan tekanan darah 200/110mmHg. Merasakan mules-mules sejak 1 hari, dan saat datang ke bidan BJJ 140dpm dan dalam fase aktif dg pembukaan 5cm, porsio tipis, lunak, kepala di H2+, ubun2 kecil kiri depan.

Tiba di UGD, tekanan darah 210/110mmHg, protein +3. His 3x/10menit/40detik, fase aktif dg pembukaan 8cm, kepala H3, UUK depan. Saat petugas melakukan pemeriksaan ibu tiba-tiba kejang menyeluruh.

Skenario KasusSkenario Kasus

Ibu B, 35 tahun, G5P3A1 hamil 38mgg dengan riwayat kejang menyeluruh di rumah. Tiba di UGD, kesadaran kompos mentis, tekanan darah 180/100mmHg, nadi 96x/mnt, pernafasan 24x/menit. Ibu segera diberikan MgSO4 bolus dilanjutkan dengan MgSO4 rumatan dan dipindahkan ke kamar bersalin

Saat datang ibu dalam keadaan fase aktif dengan pembukaan 6 cm. Duapuluh menit setelah pemberian bolus MgSO4 ibu kejang-kejang menyeluruh.

Obstetric EmergenciesObstetric Emergencies

Kondisi khusus dalam Kondisi khusus dalam emergensi obstetriemergensi obstetri

A. PEB/ EklampsiaB. Perdarahan Post PartumC. Distosia BahuD. Prolaps Tali Pusat

Top EmergenciesTop Emergencies

Severe pre-eclampsia

Antepartum haemorrhage

Postpartum haemorrhage

Pre-eclampsiaPre-eclampsia A pregnancy-induced hypertension ≥ 20 weeks gestation Previously normotensive ≥140/90 mmHg on at least two

occasions + proteinuria ≥ 0.3g in 24h ± oedema Multisystem disease

RCOG Green top guidelines The management of severe pre-eclampsia/eclampsiahttp://www.rcog.org.uk/files/rcog-corp/GTG10a230611.pdf

Severe pre-eclampsiaSevere pre-eclampsia

Diastolic blood pressure ≥ 110 mmHg on two occasions

Or systolic blood pressure ≥ 170mmHg on two occasions

Significant proteinuria (at least 1g/litre)

RCOG Green top guidelines The management of severe pre-eclampsia/eclampsiahttp://www.rcog.org.uk/files/rcog-corp/GTG10a230611.pdf

Risk factorsRisk factors

First pregnancy (primigravida) Age <20 or >35 yrs Previous Hx or FHx Multiple pregnancy Certain underlying medical conditions

• Pre-existing hypertension (superimposed pre-eclampsia)• Pre-existing renal disease• Pre-existing diabetes• Antiphospholipid antibodies

Clinical featuresClinical features

History• Usu. asymptomatic • Headache• Drowsiness• Visual disturbance• Nausea/vomiting• Epigastric pain

Examination• Oedema (hands and face)• Proteinuria on dipstick• Epigastric tenderness (liver involvement)

Complications Complications (multisystem)(multisystem) Head/brain

• Eclampsia, Stroke/ cerebrovascular haemorrhage

Heart• Heart failure

Lung• Pulmonary oedema, Bronchial aspiration, ARDS

Liver• Hepatocellular injury, liver failure, liver rupture

Kidneys• Renal failure, oliguria

Vascular• Uncontrolled hypertension, DIC• HELLP

Complications (fetal)Complications (fetal) IUGR Oligohydramnios Placental infarcts Placental abruption Uteroplacental insufficiency Prematurity PPH

InvestigationsInvestigations Maternal

• FBC – platelets (HELLP)• Coag screen if platelets abnormal• U&Es (urate, renal failure)• LFTs (liver involvement)

Fetal• USS

• Fetal size/growth, amniotic fluid volume, umbilical cord blood flow

• CTG

ManagementManagement No cure except delivery; Aim to minimise

risk to mother in order to permit continued fetal growth

Antihypertensives• Methyldopa• Labetalol• Nifedipine

Eclampsia• Magnesium sulphate

Induction of labour• Antenatal steroids

Antepartum haemorrhageAntepartum haemorrhage

Top 5 causes:

1.Uteroplacental causesa) Placental abruption

b) Placenta praevia

c) Uterine rupture

2.Cervical lesions

3.Vaginal infections (?)

4.Vasa praevia

5.Unexplained

Bleeding at > 24weeks (<24 weeks is miscarriage)

DefinitionsDefinitions Placental abruption: part of the placenta becomes detached from the uterus

Placenta Praevia: The placenta is inserted wholly or in part into the lower segment of the uterus and therefore lies in front of the presenting part.

** AVOID PV exam; placenta

praevia may bleed catastrophically **

Signs and symptomsSigns and symptoms

Placental abruption Placenta praevia

Shock out of keeping with visible loss

Shock in proportion to visible loss

Pain constant No pain

Tender, tense uterus (hypertonic) Uterus not tender (hypotonic)

Normal lie and presentation Both may be abnormal

Fetal heart absent/distressed Fetal heart usually normal

Coagulation problems Coagulation problems rare

Beware pre-eclampsia, DIC, anuria Small bleeds before large

StemsStems 30-year-old multiparous woman presents with scant

vaginal bleeding, severe hypotension and a tender uterus at 36 weeks gestation. Fetal heart sounds are undetected.

Abruptio Placentae A 22-year-old primigravid woman is seen at clinic at 28

weeks. She is noted to have ankle oedema and a BP of 160/110mmHg. Her urine demonstrates presence of protein.

Pre-eclampsia A 20-year-old primigravid woman is brought into casualty

following a fit in her 36th week of pregnancy. She is noted to have a BP of 170/110mmHg and 2+ of protein

Eclampsia

Postpartum haemorrhagePostpartum haemorrhage

Estimated blood loss ≥ 500ml

Primary: within 24hrs of delivery

Secondary: 24hrs-6weeks post delivery

Causes (4 Ts)Causes (4 Ts)

Tone: uterine atony

Tissue: retained placenta or

retained products,

Trauma: cervical or perineal, or

ruptured uterus,

Thrombin: coagulation disorder

Risk factorsRisk factors

Top 5 (from a gynaecologist!)APHMultiple pregnancyRetained placentaMediolateral episiotomyEmergency LSCS

Risk factorsRisk factorsAntenatal • Proven abruption

• Placenta praevia• Multiple pregnancy • Pre-eclampsia• Previous PPH• Obesity• Anaemia

Apparent during labour • Caesarean section• Instrumental delivery• Long labour > 12 hours • Pyrexia in labour• Retained placenta• Mediolateral episiotomy

Antenatal or intrapartum • Morbidly adherent placenta

Most cases of PPH have no identifiable risk factors

PPH – signsPPH – signs

Pale Confused Increased HR, reduced BP (late

sign) Reduced urine output Obvious or hidden bleeding

PPH ManagementPPH Management

Top 5

1.Call for help

2.ABCa) O2

b) Large bore IV access x 2

c) FBC, coag, cross match

d) Urinary catheter

3.Identify cause(s) of PPH

4.Control bleeding

5.Replace the blood loss

Top 5:Top 5: stages in management stages in management

1. Ensure 3rd stage complete – if not MROP

2. Rub uterine fundus to stimulate contraction +/- bimanual compression if required to stop uterine bleeding

3. Assess for cervical/vaginal wall/perineal tears – if present, repair

Top 5:Top 5: stages in management stages in management

4. Medical management of atony with oxytocic medicines

a) Syntocinon

b) Ergometrine

c) Carboprost

d) Misoprostol

5. Surgical managementa) Intra uterine balloon device

b) B lynch suture if at Caesarean section

c) Uterine artery embolisation/ligation

d) Hysterectomy

Past paperPast paperA 24-year-old primigravida presents at 32 weeks in a previously uneventful pregnancy. She is symptom free apart from marked facial oedema, but her BP is sustained at 145/105mmHg and there is proteinuria (+) on testing. You arrange her admission for further investigation and management.

a)List 4 investigations that would help you assess the maternal condition

Past paperPast paperAbnormal examination shows a fundal height of 26cm with apparently reduced liquor volume

b)List 3 ways ultrasound can be used to help assess the fetal condition

c)What other investigations would help reassure you about fetal well-being?

d)Delivery of the baby by caesarean section is planned, in the fetal and maternal interest. How can the administration of steroids help the survival of the pre-term infant?

e)What is the most likely diagnosis in this mother’s instance?

Thank youThank you