Professional Documents
Culture Documents
Presented By:
Agung Adhyaksa Bhaskara 4151131478
Nurul Pratiwi - 4151131
CONTENTS
CONTENTS.............................................................................................................1
CHAPTER I INTRODUCTION..............................................................................2
CHAPTER II LITERATURE REVIEW..................................................................3
2.1
Definition...................................................................................................3
2.2
2.3
Diagnosis...................................................................................................5
2.4
Management..............................................................................................6
2.5
Complication.............................................................................................7
2.6
Prognosis...................................................................................................7
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:
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
are
eclampsia,
placental
abruptions,
hemolysis,
cerebral
CHAPTER III
DISCUSSION
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.)
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
10 (5,8%)
0,720
Not Significant
Contracted pelvis
9 (5,2%)
0,664
Not Significant
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
2 (1,2%)
0,154
Not Significant
Obstructed labour
1 (0,6%)
0,316
Not Significant
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