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RISK FACTORS FOR CAESAREAN SECTION


WITH SEVERE PRE-ECLAMPSIA
Counselor:
Syafrial, dr., Sp.OG

Presented By:
Agung Adhyaksa Bhaskara 4151131478
Nurul Pratiwi - 4151131

DEPARTMENT OF OBSTETRY AND GYNECOLOGY


JENDERAL ACHMAD YANI UNIVERSITY
FACULTY OF MEDICINE
CIMAHI
2015

CONTENTS

CONTENTS.............................................................................................................1
CHAPTER I INTRODUCTION..............................................................................2
CHAPTER II LITERATURE REVIEW..................................................................3
2.1

Definition...................................................................................................3

2.2

Sign and Symptoms...................................................................................4

2.3

Diagnosis...................................................................................................5

2.4

Management..............................................................................................6

2.5

Complication.............................................................................................7

2.6

Prognosis...................................................................................................7

CHAPTER III DISCUSSION..................................................................................8


CHAPTER IV SUMMARY...................................................................................10
REFERENCES.......................................................................................................11

CHAPTER II
LITERATURE REVIEW
2.1 Definition of Pre eclampsia
Pre eclampsia is one of several clinical diagnosis in hypertensive disorder in
pregnancy. Hypertensive disorders complicating pregnancy are common and form
one of the deadly triad, along with hemorrhage and infection, that contribute
greatly to maternal morbidity and mortality. In 2001, according to the National
Center for Health Statistics, gestational hypertension was identified in 150,000
women, or 3.7 percent of pregnancies (Martin and colleagues, 2002). Importantly,
Berg and colleagues (2003) reported that almost 16 percent of 3201 pregnancyrelated deaths in the United States from 1991 to 1997 were from complications of
pregnancy-related hypertension. These investigators also found that black women
in this country are 3.1 times as likely to die from preeclampsia as white women.
The term gestational hypertension is used now to describe any form of new-onset
pregnancy-related hypertension. It was adopted by the Working Group of the
NHBPEP (2000), which proposed a classification system based on clinical
simplicity to guide management. The term was chosen to emphasize the causeand-effect connection between pregnancy and its unique form of hypertension
preeclampsia and eclampsia. It is also meant to be a working term that is
purposefully vague, but it should convey that the development of hypertension in
a previously normotensive pregnant woman should and must be considered
potentially dangerous to both herself and her fetus. The classification of
hypertensive disorders complicating pregnancy by the Working Group of the
NHBPEP (2000) is shown in Table 1. There are five types of hypertensive disease:

1. Gestational hypertension (formerly pregnancy-induced hypertension that


included transient hypertension).
2. Preeclampsia.
3. Eclampsia.
4. Preeclampsia superimposed on chronic hypertension.
5. Chronic hypertension.
Pre-eclampsia is a multi-system syndrome unique to pregnancy characterized by
the new onset of hypertension and proteinuria during the second half of
pregnancy. Proteinuria is an important sign of preeclampsia, and Chesley (1985)
rightfully concluded that the diagnosis is questionable in its absence. Significant
proteinuria is defined by 24-hour urinary protein exceeding 300 mg per 24 hours,
or persistent 30 mg/dL (1+ dipstick) in random urine samples. The degree of
proteinuria may fluctuate widely over any 24-hour period, even in severe cases.
Therefore, a single random sample may fail to demonstrate significant proteinuria.
(Cunningham FG, Hauth JC, Leveno KJ, et al. Williams obstetrics 22th ed :
Hypertensive Disorders in Pregnancy. McGraw Hill, New York; 2005. p761-807)
2.2 Definition of Caesarean Section
Caesarean delivery is defined as the birth of a fetus through incisions in the
abdominal wall (laparotomy) and the uterine wall (hysterotomy). This definition
does not include removal of the fetus from the abdominal cavity in the case of
rupture of the uterus or in the case of an abdominal pregnancy. In some cases, and
most often because of emergent complications such as intractable hemorrhage,
abdominal hysterectomy is indicated following delivery. (Cunningham FG, Hauth
JC, Leveno KJ, et al. Williams bstetrics 22th Ed : Cesarean Delivery and
Peripartum Hysterectomy. McGraw Hill, New York; 2005. p587-606)

Cesarean deliveries and those performed for dystocia have been the leading
indications in both the United States and other western industrialized countries.
Although it is not possible to catalog comprehensively all appropriate indications
for cesarean delivery, over 85 percent are performed because of prior cesarean
delivery, dystocia, fetal distress, or breech presentation. Different literature show
that indication of caesarean delivery divided into two indications, which are
mother indications and fetus indications. Mother indications are, cephalopelvic
disproportional, tumors in delivery way, cervical/vaginal stenosis, plasenta previa,
history of uterian rupture. Fetus indications are breech or abnormal presentasion
and fetal distress. (Wiknjosastro H, Saifuddin AB, Rachmimhadhi T. Ilmu bedah
kebidanan Edisi 1. Bina Pustaka Sarwono Prawirohardjo. Jakarta. 2010. Page 13341.)
Maternal indications for Cesarean (Thevenet AN, When is primary cesarean.
Appropriate: maternal and obstetrical indications. Semin Perinatol. Elsevier, 2012.
p324-27)
Obstetrical indications
Distosia (CPD)

Malpresentation
Hypertensive disorders

Macrosomia

Multiple pregnancy
Others
Placenta previa
Vasa Previa

Medical Indications
Perinatal infection
HIV
HSV
Prior myomectomy
Pelvic/genital tract disorders
Obstructal fibroid, ca cervix, displaced
pelvic fracture
Others
Unrepaired cerebral aneurysm, aortic
dilatation, aortic dissection

Placenta acreta
Abruption

2.5 Management
Basic management objectives for any pregnancy complicated by preeclampsia are:
1. Termination of pregnancy with the least possible trauma to mother and
fetus.
2. Birth of an infant who subsequently thrives.
3. Complete restoration of health to the mother.
In certain women with preeclampsia, especially those at or near term, all three
objectives are served equally well by induction of labor. Therefore, the most
important information that the obstetrician has for successful management of
pregnancy, and especially a pregnancy that becomes complicated by hypertension,
is precise knowledge of the age of the fetus. (Cunningham FG, Hauth JC, Leveno
KJ, et al. Williams obstetrics 22th ed : Hypertensive Disorders in Pregnancy.
McGraw Hill, New York; 2005. p761-807)
Early Prenatal Detection
Traditionally, the frequency of prenatal visits is increased during the third
trimester to facilitate early detection of preeclampsia. Women with overt
hypertension (140/90 mm Hg or greater) are frequently admitted to the hospital
for 2 to 3 days to evaluate the severity of new-onset hypertension. Women with
persistent severe disease are observed closely, and many are delivered.
Conversely, women with mild disease are often managed as outpatients.
Management of women without overt hypertension, but in whom early
preeclampsia is suspected during routine prenatal visits, consists primarily of
increased surveillance. The protocol used successfully for many years at Parkland
Hospital in women with new-onset diastolic blood pressure readings between 81
and 89 mm Hg or sudden abnormal weight gain (more than 2 pounds per week

during the third trimester) includes return visits at 3- to 4-day intervals. Such
outpatient surveillance is continued unless overt hypertension, proteinuria, visual
disturbances, or epigastric discomfort supervene.
Antepartum Hospital Management
Hospitalization is considered at least initially for women with new-onset
hypertension, especially if there is persistent or worsening hypertension or
development of proteinuria. A systematic evaluation is instituted to include the
following:
1. Detailed examination followed by daily scrutiny for clinical findings such
as headache, visual disturbances, epigastric pain, and rapid weight gain.
2. Weight on admittance and every day thereafter.
3. Analysis for proteinuria on admittance and at least every 2 days thereafter.
4. Blood pressure readings in the sitting position with an appropriate-size
cuff every 4 hours, except between midnight and morning.
5. Measurements of plasma or serum creatinine, hematocrit, platelets, and
serum liver enzymes, the frequency to be determined by the severity of
hypertension.
6. Frequent evaluation of fetal size and amnionic fluid volume either
clinically or with sonography.
Reduced physical activity throughout much of the day is beneficial. Absolute bed
rest is not necessary, and sedatives and tranquilizers are not prescribed. Ample,
but not excessive, protein and calories should be included in the diet. Sodium and
fluid intakes should not be limited or forced. Further management depends on:
1. Severity of preeclampsia, determined by presence or absence of conditions
cited.
2. Duration of gestation.
3. Condition of the cervix.
Termination of Pregnancy
Delivery is the cure for preeclampsia. Headache, visual disturbances, or epigastric
pain are indicative that convulsions may be imminent, and oliguria is another

ominous sign. Severe preeclampsia demands anticonvulsant and usually


antihypertensive therapy followed by delivery. Treatment is identical to that
described subsequently for eclampsia. The prime objectives are to forestall
convulsions, to prevent intracranial hemorrhage and serious damage to other vital
organs, and to deliver a healthy infant.
With moderate or severe preeclampsia that does not improve after hospitalization,
delivery is usually advisable for the welfare of both mother and fetus. Labor
should be induced by intravenous oxytocin. Many clinicians favor preinduction
cervical ripening with a prostaglandin or osmotic dilator.Whenever it appears that
labor induction almost certainly will not succeed, or attempts at induction have
failed, cesarean delivery is indicated for more severe cases.
Once severe preeclampsia is diagnosed, the obstetrical propensity is for prompt
delivery. Labor induction to effect vaginal delivery has traditionally been
considered to be in the best interest of the mother. Several concerns, including an
unfavorable cervix precluding successful induction of labor, a perceived sense of
urgency because of the severity of preeclampsia, and the need to coordinate
neonatal intensive care, have led some practitioners to advocate cesarean delivery.
(Cunningham FG, Hauth JC, Leveno KJ, et al. Williams obstetrics 22th ed :
Hypertensive Disorders in Pregnancy. McGraw Hill, New York; 2005. p761-807)
Antihypertensive Drug Therapy
The use of antihypertensive drugs in attempts to prolong pregnancy or modify
perinatal outcomes in pregnancies complicated by various types and severities of
hypertensive disorders has been of considerable interest. At least three other
studies have been done to compare either the -blocking agent, labetalol, or
calcium-channel blockers, nifedipine and isradipine.

The use of angiotensin-converting enzyme (ACE) inhibitors during the second


and third trimesters should be avoided. Reported complications include
oligohydramnios, fetal growth restriction, bony malformations, limb contractures,
persistent patent ductus arteriosus, pulmonary hypoplasia, respiratory distress
syndrome, prolonged neonatal hypotension, and neonatal death.
Glucocorticoids
In attempts to enhance fetal lung maturation, glucocorticoids have been
administered to women with severe hypertension who are remote from term.
Treatment does not seem to worsen maternal hypertension, and a decrease in the
incidence of respiratory distress and improved fetal survival.
Magnesium Sulfate to Control Convulsions
In more severe cases of preeclampsia, as well as eclampsia, magnesium sulfate
administered parenterally is an effective anticonvulsant agent without producing
central nervous system depression in either the mother or the infant. It may be
given intravenously by continuous infusion or intramuscularly by intermittent
injection. The dosage schedule for severe preeclampsia is the same as for
eclampsia. Because labor and delivery is a more likely time for convulsions to
develop, women with preeclampsiaeclampsia usually are given magnesium
sulfate during labor and for 24 hours postpartum. Magnesium sulfate is not given
to treat hypertension. (Cunningham FG, Hauth JC, Leveno KJ, et al. Williams
obstetrics 22th ed : Hypertensive Disorders in Pregnancy. McGraw Hill, New
York; 2005. p761-807)

Magnesium Sulfate Dosage Schedules for Severe Preeclampsia and Eclampsia


Continuous Intravenous Infusion

1. Give 4- to 6-g loading dose of magnesium sulfate diluted in 100 mL of IV


fluid administered over 1520 min.
2. Begin 2 g/hr in 100 mL of IV maintenance infusion.
3. Measure serum magnesium level at 46 hr and adjust infusion to maintain
levels between 47 mEq/L (4.88.4 m/dL).
4. Magnesium sulfate is discontinued 24 hr after delivery.
Intermittent Intramuscular Injections
1. Give 4 g of magnesium sulfate (MgSO4 7H2O USP) as a 20% solution
intravenously at a rate not to exceed 1 g/min.
2. Follow promptly with 10 g of 50% magnesium sulfate solution, one-half (5
g) injected deeply in the upper outer quadrant of both buttocks through a 3inch-long, 20-gauge needle. (Addition of 1.0 mL of 2%lidocaine minimizes
discomfort.) If convulsions persist after 15 min, give up to 2 g more
intravenously as a 20% solution at a rate not to exceed 1 g/min. If the woman is
large, up to 4 g may be given slowly.
3. Every 4 hr thereafter give 5 g of a 50% solution of magnesium sulfate
injected deeply in the upper outer quadrant of alternate buttocks, but only after
ensuring that:
a. the patellar reflex is present
b. respirations are not depressed
c. urine output the previous 4 hr exceeded 100 mL
Magnesium sulfate is discontinued 24 hr after delivery.
(Cunningham FG, Hauth JC, Leveno KJ, et al. Williams obstetrics 22th ed :
Hypertensive Disorders in Pregnancy. McGraw Hill, New York; 2005. p761-807)
2.6 Complications
The most severe complications are maternal and fetal death. The common
complications

are

eclampsia,

placental

abruptions,

hemolysis,

cerebral

hemorrhage, retinal hemorrhage, pulmonary oedema, necrosis of liver or


subcapsular liver hematoma, renal disfunction, HELLP Syndrome in 20 percent
case. (Cunningham FG, Hauth JC, Leveno KJ, et al. Williams obstetrics 22th ed :
Hypertensive Disorders in Pregnancy. McGraw Hill, New York; 2005. p761-807)

CHAPTER III

DISCUSSION

Preeclampsia accounted for 3.1% of prelabor cesareans and 1.2% of laboring


cesareans in 1 large US cohort. However, preeclampsia alone, in general, is not an
appropriate indication for cesarean delivery, as 50% of patients with severe
preeclampsia before 34 weeks, and 1 in 3 before 28 week will successfully deliver
vaginally. Rapidly worsening preeclampsia (eg, progressive acute renal failure)
remote from delivery is advanced as an indication for cesarean, but this clinical
situation is exceedingly rare, and there are few data to suggest that outcomes are
better compared with waiting 24-48 hours for vaginal delivery. (Thevenet AN,
When is primary cesarean. Appropriate: maternal and obstetrical indications.
SeminPerinatol. Elsevier, 2012. p324-27)

The delivery should be well planned, done on the best day, performed in the best
place, by the best route and with the best support team. Timing affects the
outcome for both mother and baby. If the mother is unstable then delivery is
inappropriate and increases risk. Once stabilised with antihypertensive and
possibly anticonvulsant drugs then a decision should be made. In the absence of
convulsions, prolonging the pregnancy may be possible to improve the outcome
of a premature fetus, but only if the mother remains stable. Continued close
monitoring of mother and baby is needed. It seems ideal to achieve delivery,
particularly of premature infants, during normal working hours.

For pregnancies less than 34 weeks gestation, steroids should be given. The
benefits of steroid administration to the fetus peak between 48 hours and 6 days.
However, even if delivery is planned for within 24 hours, steroids may still be of
benefit and should be given. After 48 hours, further consideration should be given
to delivery, as further delay may not be advantageous to the baby or mother. In all
situations a planned elective delivery suiting all professionals is appropriate.
The mode of delivery should be discussed with the consultant obstetrician. If
gestation is under 34 weeks, induction of labour is unlikely to be successful and
consideration should be given to delivery by Caesarean section. After 34 weeks
gestation, vaginal delivery should be considered in a cephalic presentation.
Vaginal prostaglandins will increase the chance of success. Anti hypertensive
treatment should be continued throughout assessment and labour. In cases where
delivery does not occur vaginally within 12-24 hours, the mode of delivery should
be reconsidered by a senior obstetrician. In cases of severe pre-eclampsia even
when the baby has died or is not viable, it may be appropriate to expedite delivery
by caesarean section in the mothers interests if induction of labour is prolonged.
If blood pressure is controlled (150/80-100 mmHg), the second stage should not
be limited routinely. An epidural will normally be used. The third stage should be
managed with 5 units of i.v. syntocinon not ergometrine or syntometrine.
(The Diagnosis and Management of Pre-eclampsia and Eclampsia. Clin Pract
Guideline: Institute of Obstetricians and Gynaecologists, Royal College of
Physicians of Ireland. 2013)
In the other literature, mode of termination depended on period of gestation,
favourability of cervix and urgency of termination. Cervical priming agents like

PGE2 gel or PGE1were widely used if the cervix was found unfavourable. Labor
was accelerated by artificial rupture of membranes and syntocinon whenever
necessary. Caesarean section was performed for obstetric indications and when
urgent termination was indicated for unfavourable cervix, failure of induction and
fetal distress. The duration of labor, mode of delivery and indication for delivery
was noted. (Pradesh A. Risk factors for preeclampsia and its perinatal outcome.
The Shadan Institute of Medical Sciences, Ann Bio Res, 2013, p1-5.)

Indications of cesarean section in severe preeclampsia


Indications of cesarean
section

Total

p Value

Significance

Severe preeclampsia

81 (46,8%)

0,254

Not Significant

Fetal distress

34 (19,7%)

0,035

Significant

Unfavourable cervix

6 (3,5%)

0,943

Not Significant

Less fetal movement

10 (5,8%)

0,720

Not Significant

Contracted pelvis

9 (5,2%)

0,664

Not Significant

Post cesaream section

17 (9,8%)

0,104

Not Significant

IUGR/oligohydramnion
s

7 (4%)

0,919

Not Significant

Inductions failure

4 (2,3%)

0,666

Not Significant

Premature rupture of
membrane

3 (1,8%)

0,154

Not Significant

High floating head

2 (1,2%)

0,154

Not Significant

Obstructed labour

1 (0,6%)

0,316

Not Significant

Of the 173 patients of severe preeclampsia undergoing emergency cesarean


section 146 (84.5%) patients were administered spinal anesthesia (SA) and 27
(15.5%) patients received general anesthesia (GA) in our study as per choice of
anesthesiologists concerned. Of the various indications, a very high percentage of
patients underwent GA due to fetal distress (37% versus 16.4%; < 0.05). All
other indications for cesarean sectionwere similar in-between thepatients who
underwent spinal and general anesthesia. Chattopadhyay S, Das A, Pahari S.
Clinical study: Fetomaternal outcome in severe preeclamptic women undergoing
emergency cesarean section under either general or spinal anesthesia. Journal of
Pregnancy, India; 2014, p1-11

Antihypertensive and antiseizure therapy in antenatal, preoperative, and


intraoperative period
Antihypertensive
and antiseizure

Total

p Value

Labetalol

89 (51,4%)

< 0,001

Methyldopa

84 (48,6%)

< 0,001

Magnesium
sulphate

173 (100%)

> 0,05

Significance

Significant
Not Significant

Chattopadhyay S, Das A, Pahari S. Clinical study: Fetomaternal outcome in


severe preeclamptic women undergoing emergency cesarean section under either
general or spinal anesthesia. Journal of Pregnancy, India; 2014, p1-11

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