Tayangan Case 1

8/13/2019 Tayangan Case 1

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DIFFICULTY OF DIAGNOSISCEPHALOPELVIC DISPROPORTION

AT A PRIMIGRAVIDAWITH SEVERE PREECLAMPSIA

By: Yudha Pranata


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cephalopelvic

disproportion

failure to

progress

CERVICALEFFACEMENT

AND DILATATION

DESCENT OFPRESENTING PART

INTRODUCTION

ABNORMAL

PROGRESS OFLABOR


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PREGNANCY INDUCED

HYPERTENSION

IS ONE OF THE FACTOR THAT CAUSEDMATERNAL AND PERINATAL MORBIDITY AND MORTALITY

C-SECTION DUE TO DYSTOCIA

CONTRIBUTED 1/3 OF THE TOTALC-SECTION RATE


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IDENTITY

NAME

AGE

ADDRESS

EDUCATION

OCCUPATION

MEDICAL RECORD

DATE OF ADMISSION

: Mrs. H: 21 y.o

: Cibeunying Bandung

: Senior High School

: House wife

: 0504 xxxx: August 10 th, 2005 at 16.00


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ANAMNESIS Refered by :

Mid Wife A- RB Al-Islam Bandung

Letter of explanation :G1P0A0 term parturien 2nd stage +CPD + SEVERE PREECLAMPSIA(BP: 150/100 mmHg)

Chief complain :Baby wasnt delivered yet after 2hours bear down

G1P0 A0

HIGHBLOOD

PRESSURE

15 HOURS

BEFORE

ADMISSION

LABOR PAINTerm pregnantBaby wasnt delivered yetafter 2 hours bear down

Know hypertension 5 hours beforeadmission (160/110 mmHg)History of hypertension (-)Blurred vision, severe cephalgia, epigastricpain (-)


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Amnionic membrane (-) 6 hours before admission

clear, febris (-)

Fetal movement (+)


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OBSTETRIC HISTORY

1. This Pregnancy

Additional anamnesis : Marital history :

, 21 y.o, senior high school, house wife

, 22 y.o, STM, private employee


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Contraception : -

Last Menstrual Period : Nov, 5th 2004

Estimed birth pregnancy : August, 12th 2005

Prenatal care : midwife 11x,


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PATIENTS HOME VISIT

Lived with her parents and husband in semi permanenthouse 5 x 7 m2

Mother was only housewife, her husband was privateemployee

300 m from nearest midwife

5 times PNC at Padasuka PHC6 times at other midwife


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PHYSICAL EXAMINATION

General Condition : composmenthis, goodBlood Pressure : 160/110 mmHgPulse rate : 80 x/mntRespiration Rate : 20 x/mntTemperature : 36,50CBody Weight : 57 kgs

Body Height : 145 cmsLiver And Spleen : hard to assessOthers : within normal limits


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EXTERNAL EXAMINATION

Fundal height : 32 cm above the symphisis

Abdominal circumference: 102 cm

Fetal position : Head U back at left 3/5

Fetal heart rate : 136-140 x/mnt

Uterine Contraction: Once in 3-4 minutes, 40second, strong

Estimated fetal weight: 2800 grams


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INTERNAL EXAMINATION

Vulva/vaginal : No abnormalities

: Complete

Amnionic membrane : (-), residual fluid (+)

Head : St -1, caput (+) as big as egg


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PELVIC EXAMINATION

Promontorium : not palpable

Linea innominata : palpated 1/3 1/3

Sacrum : Concave

Spina ischiadica : not prominent

Pubic Arcus : >90 o

Side- wall : straight

Pelvic : good


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LABORATORY FINDINGS

Hemoglobins : 12,6 gr% Ureum/Creatinin : 22/1,48 mg/dl

Leucocytes : 24.400/mm3 Ur/Kr : 18/0,81

Ht : 38 % Blood Glucose : 85 mg/dl

Trombocytes : 312.000/mm3 Asam urat : 4,3 mg/dl

Urine : ++ Na : 138 mEq/dl

SGOT/SGPT : 23/23 U/L K : 2,6 mEq/dl


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DIAGNOSIS

G1P0A0 term pregnant 2 nd stage of labor +

severe preeclampsia +

cephalopelvic disproportion


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PLAN OF MANAGEMENT

KaEn 1B infussion, cross match, blood reserve

MgSO4 40% intramuscular injection (RB Al-Islam)

MgSO4 20% intravenous, then MgSO4 40%

intramuscular for maintenance dose

ECG, thoracal Ro, complete laboratory result Internal and neurology consult


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Planned to perform C-section due to cephalopelvicdisproportion

Informed consent

Anaesthesiologist consult

Contact perinatologist

Observation General condition, vital sign, fetal heartrate, uterine contraction


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Internal department consult

Dk/ - G1P0A0 term parturition 2nd stage of labor + CPD- severe preeclampsia

Advis : Low dietary salt Metyldopa 3x500 mg titration dose


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Neurologist consult

Dk/ - 2nd hypertension in pregnancy

Advis : Blood pressure regulation according to Internal

Department Consult if there was focal neurological deficit


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Observation

Time Uterine

contraction

FHR

(x/mnt)

BP

(mmHg)

PR

(x/mnt)

RR

(x/mnt)Information

16.00-17.00 3-41x/45 S 136-140 160/110 80 20 - Admission testBaseline 140-150 bpmVariability > 5 bpm Akseleration (+)Deceleration (-)- Informed consent- BP resucitation- Internal and

neurological consult

17.00-18.00 3-41x/45S 140-144 170/110 84 24

18.00-18.15 3-41x/45S 144-148 160/160 88 24

Internal Examination at 18.15:v/v : no abnormalities

: complete Amniotic membrane : (-)

Head : St -1, caput (+) as big as egg


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D/ G1P0A0 term parturition 2nd stage of labor +cephalopelvic disproportion + severe preeclampsia

T/ Planned to perform C-section due to cephalopelvicdisproportion Anaesthesiologist consultContact perinatologist and operation theatreObservation vital sign, FHR, uterine contraction


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The patient wasbrought to EMGoperating theatre

18.20

18.30

The patient arrived atEMG operating theatreUC : 3-41x/40 S FHS: 136-140 bpm

Cesareansection began.

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A male baby was born by headluxation

BW:2770 gr, BL:49,3 cmHead circumference: 34 cm

18.50 19.40

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The umbilical cord wasdelivered by gentlytraction of the cord


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Preoperative diagnosis :

G1P0A0 term parturition 2nd stage of labor + cephalopelvicdisproportion + severe preeclampsia

Postoperative diagnosis

P1A0 term delivery by C-section due to cephalopelvicdisproportion + severe preeclampsia

Type of surgery : SCTP + IUD insertion


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DISCUSSION

1 H t di g h l l i


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Inadequateuterus

contraction

Birth canal

resistention

Progresif progress ofcervical effacement anddilatation

Fetal descent

1. How to diagnose cephalopelvic

disproportion on this patient?

Abnormal

Labor progress


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Tabel 1. Clinical findings in woman with ineffectivelabor

Inadequate cerviks dilatation or fetal descentProtracted labor-slow progress Arrested labor-no progress

Inadequate expulsive effortFetopelvic diproportion

Excessive fetal sizeInadequate pelvic capacity

Malpresentation or position of the fetusRuptured membrane without labor


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American College ofObstetricians and

Gynecologists - ACOG (1995)

Abnormalities

caused dystocia

Abnormalities of the powers

Abnormalities involving the passenger

Abnormalities of the passage

Uterine contraction andmother power to beardown

attitude, size and fetal abnormalities

Pelvic bone andsoft tissue abnormalities


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Failure to progress

Dystocia

Abnormally slow progressof labor

Cephalopelvicdisproportion
http://www.doereport.com/enlargeexhibit.php?ID=614


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http://www.doereport.com/enlargeexhibit.php?ID=614


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Normally pelvic

Normally size

CEPHALOPELVIC DISPROPORTION

FETAL MOTHER

Contracted pelvic

Excessivefetal size

COMBINATION


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PELVICTYPE


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CEPHALOPELVICDISPROPORTION

Absolute Relative

Big fetal head or

Small pelvic bone

Normally pelvic capacityBut asynclitism (+)

Extension (+)


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TRUE DISPROPORTIONMOLDING WITHOUT

DESCENT OF PRESENTING PART

VAGINAL DELIVERY WAS IMPOSSIBLE


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ABDOMINOVAGINAL EXAMINATION( MULLER SIGN )

ABDOMINAL EXAMIINATION

( OSBORN SIGN )

X-RAY OR USG PELVIMETRY

EXAMINE THEDISPROPORTION


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PELVIC EXAMINATION WAS GOOD FETAL WAS NORMAL IN SIZE ABDOMINAL PALPATION WAS 3/5 INTERNAL EXAMINATION WAS AT STATION -1 COMPLETELY CERVICAL DILATATION CAPUT WAS (+)

IN THIS CASE

DISPROPORTION CAUSED BYMALPRESENTATION OR BY

MALPOSITION


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Tabel 1. Clinical findings in woman with ineffectivelabor

Inadequate cerviks dilatation or fetal descentProtracted labor-slow progress Arrested labor-no progress

Inadequate expulsive effortFetopelvic diproportionExcessive fetal sizeInadequate pelvic capacity

Malpresentation or malposition of the fetusRuptured membrane without labor


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MA L PRENTATION : NO N VERTEX PRESENTATION

BREECH PRESENTATION 3% BROW PRESENTATION 1/1500 DELIVERY FACE PRESENTATION 1/500 DELIVERY

MA L POSITION : A B NORMA L LY VERTEX POSITION

TO THE MATERNA L PELVIC

OCCIPITOLATERAL OCCIPITOPOSTERIOR


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TYPE OF PRESENTATION


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DIAGNOSIS OF SEVERE PREECLAMPSIA

Diastolic blood pressure > 110 mmHg Urinary protein >2 g/24 h or > 2+ Serum creatinin > 1.2 mg%

with oliguria < 400 ml/24 h

Trombocytopenia < 100.000 /mm3 Increase LDH levels Increase liver enzym Cephalgia with visual and cerebral disturbance Epigastric pain Pulmonal oedema with cyanosis HELLP syndrome


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MgSO4 Continuous intravein infusion

Initial dose : 4 g (20 cc MgSO4 20%) in 100 cc RL for15-20 minutesMaintenance dose : 10 g (50 cc MgSO4 20%) in 500 ccRL 1-2 g/h (20-30 gtt/minutes)

Intermitten intramuscularInitial dose : 4 g (20 cc MgSO4 20%) iv

with 1 g/minutesMaintenance dose : 4 g (10 cc MgSO4 40%) every 4 h


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C section in this case

No progress of labor No descent of presenting part Presenting part was still high

Spontaneous conversion to the face or vertekspresentation was rare

No indication for assisted delivery by vacuum or

forcipal extraction


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PROGNOSIS FOR THE NEXT DELIVERY

ASNM : CPD 1/250 DELIVERY AJPH : MORE THAN 65 % MOTHER WHO

HAD BEEN DIAGNOSED WITH CPD,

WERE ABLE TO DELIVERVAGINALLY IN NEXT PREGNANCIES


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Tayangan Case 1

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