Dr. H. NUSWIL BERNOLIAN, SpOG(K)Dr. H. ISKANDAR ZULQARNAIN, SpOG(K)

Emergencies

Emergencies: situation that requires abrupt response and life-threateningMany emergency cases found in Obstetrics, Yet our discussion talks about Pre-eclampsia/ eclampsia and haemorrhage

haemorrhage emergency cases :1. Gestational age < 20 mgg : Abortion, ectopic pregnancy, hyperemetics, MolaKehamilan > 20 mgg : Placentae previa, placental abruption, uterine rupture2. Labour: Placentae previa, passage laceration, retained placentae3. puerperium : uterine atony, passage laceration, retained placentae

Incidence of Pre-eclampsia & Eclampsia in pregnant women ranges from 4-9%, nulliparous and multiparous, 3-7%, 0,8-5%, respectivelyIncidence rate of Pre-eclampsia in Indonesia ranges from 3-10% Pre-eclampsia/ Eclampsia

Hypetension in pregnancyIs the cause of maternal and neonatal morbidity and mortality, besides haemorrhage and infectionIn Indonesia, Pre-eclampsia & Eclampsia result in 30-40% perinatal death

Classification of Hypertension in pregnancy :Gestational hypertension:raising blood pressure found within up to 12 weeks of gestational age to puerperiumChronic hypetension: hypertension occurring before being pregnant, whilst pregnant, then after puerperiumSuperimposed Pre-eclampsia: symptoms and signs of Pre-eclampsia arising after 20 weeks of gestational age in women who formerly has had hypertensionMild Pre-eclampsia, severe Pre-eclampsia, Eclampsia : found in clinical sign characteristic

Trias Pre-eclampsia: blood pressure 140/90 mmHg, Proteinuria, and edema.

Yet edema has been excluded from diagnosis criterion due to edema found in normal pregnancy

Etiology and Pathogenesis Etiology and pathogenesis of Pre-eclampsia currently has not been completely understood, it remains controversy

Mayor Hypothesis resulting in Pre-eclampsia: immunologic factors , genetics, vascular diseases

mild Pre-eclampsia blood pressure 140/90, but < 160/110 mmHG and proteinuria +1 severer Pre-eclampsia if blood pressure > 160/110 mmHg, Proteinuria +2, may be accompanied by subjective complaints such as epigastric pain, headache, vision disorder, and oliguria

Management of severe Pre-eclampsia:A. Medicines- bedrest- oxygen - catheter insertion- IVFD : acetic Ringer , colloid- Anti-seizure : Magnesium sulphate - Antihypetension: Nifedipine

B. obstetric managementin controlled condition mother, make decision whether to terminate the pregnancy or conservative treatment. If cervix is ripen and no obstetric contraindications may be performed labour induction with oxitocin drip and amniotomy, accelerated second stage with VE/FE

Eclampsia Acute abnormalities in pregnant women in labour or puerperium characterized by seizure and or comatoseThe convulsion occurring after 20 weeks of gestational age, in a woman, without previous attack abnormalityLittle number of women with Eclampsia has normal blood pressure

Strategies to prevent Eclampsia- Antenatal care and knowing hypetension

- Identification and pre-Eclampsia care by trained helper

- Born at estimated date- 3.4% women with severe Pre-eclampsia will experience convulsion

- Eclampsia is at the first rank in maternal mortality in Hospital in Nepal*

Management of Eclampsia : A. Medicines- Anti seizure : MgSO4- IVFD : acetic ringer , lactic ringer - care during seizure attack: cared at isolated room, insert tongue spatula to the mouth, slime suction- insert catheter cared at ICU

B. obstetric managementall pregnancies with Eclampsia has to be terminated without any concern to gestational age and fetal well being

Early Assessment and management in Eclampsia : - asking for help personnels mobilization - quick evaluation in breathing and sensorium - check airways, blood pressure and pulse - left side lying - protect from being injured but not tied - start IV infusion with big hollow needle (size16 gauge) - administer oxygen 4 L/minutes

Do not leave mother alone without any guardian

Anti Hypetension drugs :- Methyl Dopa- Nifedipine- LabetololPrinciples:Start with anti hypertensive drugs if diastolic blood pressure > 110 mm HgMaintain diastolic blood pressure 90-100 mm Hg to prevent cerebral hemorrhage*

Anti convulsion drugs :- Magnesium sulphate- Diazepam*Management post convulsion :- Prevent advanced convulsion- Control blood pressure- Preparation for delivery (if remain unborn)

Sulphates MagnesiumUse Magnesium sulphate in:- women with Eclampsia- women with severe pre-Eclampsia who has to deliver the baby- start magnesium sulphate while taking decision to terminate

Continue therapy till 24 hours after delivering or last convulsion

*

ABORTIONDefinition :termination of pregnancy before conception may be viable outside the womb (

Provocative abortion = abortionAbortion resulted in particular effort to terminate the pregnancy1. medically provocative Abortion2. criminal Abortion

Incidence: WHO 10% pregnancy Sarwono 10-15%

Etiology :Zygotic development abnormalityPlacentae abnormality Maternal abnormality Genital tract abnormality

managemnet :Imminence Abortus :a. bedrestb. Mild sedativec. Tocolyticsd. Hormone

ManagementIncipients and incomplete Abortion :a. General condition improvementb. Curretagec. Uterotonicsd. Antibiotics

ManagementComplete abortion: no special treatment Anemia : SF, roborantia, transfusion

ManagementMissed Abortion :a. check CT, BT, COTb. < 12 mgg : laminaria-curretagec. > 12 mgg : estradiol benzoas laminaria / pitosin drip

ManagementSeptic Abortus :a. care at ICUb. = Abortus infeksiosac. Dexamethasoned. curretage 24 jam afterwarde. no improvement : HTSOBf. HT, considered: - Uterus > 16 weeks- C.welchii infection- provocative abortion- uterine perforation

ectopic pregnancyDefinition :egg which is fertilised, implanted and grow outside endometrium of uterine cavity

location :a. Tuba fallopiib. Uterusc. Ovariumd. Intraligamentse. Abdominalf. combination between in and outside uterine

Frequency : 0 14,6%Etiology :mostly unknownpredisposing factors1. narrow tuba Lumen 2. tuba wall3. outside tuba4. other factors

Risk factors :1. PID2. IUD (inflammation obstruction )3. history of ectopic pregnancy4. history of abdominal surgery

DIAGNOSIS :varying dependent on quick diagnosis, implantation, location, rupture

Anamnesis :- delayed menstruation- lower abdominal pain- radiating pain to the shoulder- vaginal haemorrhage- Tenesmus

General examination: - being sick and pale- shocks signs- distended abdomen and tenderness

Gynecologic examination :Early pregnancy signsOUE (portio) shake painBigger uterine sizeCD protruded and touching pain, retrouterine hematocheleSometimes mild increasing of body temperature

LaboratoriumHb, leucocytesPregnancy test (PT)Progesteron

USG : gestational sac outside uterine cavity or fluid in CDCULDOSYNTHESIS

Management :1. improving general condition, infusion and transfusion2. immediate laparatomy3. chemotherapy

Placentae PREVIADEFINITION :abnormal lying placente is in lower segment of uterine, covering half or total of OUI

Classification :1. total Placentae previa 2. partial Placentae previa 3. marginal Placentae previa 4. low lying Placentae

Frequency : 0,4 0,6 %Etiology :no clear explanationpredisposition :1. decreasing decidua vascularisation2. endo / miometrium damage3. big Placentae 4. unknown etiology

Pathogenesis :corpus endometrium damage bad implantation lower segment of uterine2. Nutrition needs > Normal extended Placentae SBR / OUISymptoms :- early spot - fresh blood- night - of the mother (baby 10%)

Diagnosis :1. Anamnesis : no pain haemorrhage, no cause2. Vaginal examination: lower part is not engaged to pelvic inlet yet3. Inspeculo :OUI haemorrhage4. USG (indirect) 5. Fornix palpation cervix canal

ManagementExpectativeaim: not born prematurelyrequirements:1. < 37 weeks2. inactive bleeding3. not in labour yet4. good maternal condition (Hb>8 g%)5. live fetus

ManagementActiverequirements :1. > 37 weeks / EFW > 2500 g2. active haemorrhage, poor general condition3. inlabour4. lower part engaged to pelvic inlet5. dead fetus, major congenital

TreatmentGeneral condition improvement:Infusion, shock managementShock cleared & ensure diagnosis, decide the termination :poor condition: cesarean sectiongood condition: on operation table of vaginal examinationLabour : cesarean section Vaginally

Placental abruptionDefinition :Placental abruption from implantation site which is normal before fetal birth in gestational age > 28 weeks

Frequency : 2% repeated labour 1 in 6-25 pregnancies

Etiology / predisposes :1. Hypertension in pregnancy8. Trauma, VL2. Multiparity9. alcoholism;3. Older maternal age10. smoking4. Short umbilical cord11. uterine tumor5. Abrupt uterin decompression6. Pressure in VCL12. uterine abnormality 7. Nutrition deficiency, folic acid

Diagnosisclinical features :Unpainful bleedingBlackishAnemia / shockTender Uterinefetal part Cannot be assessedNo fetal heart rateConcealed haemorrhage in Placentae

Management Expectative criterion : 1. good condition2. gestational age < 37 weeks, EFQW < 2500 g3. mild placental abruption

Management Activecriteria : 1. poor condition2. gestational age > 37 mgg, EFW > 2500 g3. mild, moderatem severe placental abruptionTreatment : improve the condition- obstetric treatment

****Many researchers have tried to predict who will get eclampsia. Only a small portion of women who do have eclamptic fits had elevated diastolic blood pressure or elevated mean arterial pressure in the second trimester of pregnancy. We cannot, therefore, predict who will get eclampsia.**When a patient seizes, it is important to ensure that the airway is clear, oxygen is being delivered to the tissues and the patient cannot harm herself.Treatment includes antihypertensives and anticonvulsants. Antihypertensives include hydralazine, labetolol and nifedipine. The goal is to lower blood pressure, but not to drop it too much or too fast, as that can cause intracranial hemorrhage.**The anticonvulsant of choice is magnesium sulfate.**Start magnesium as soon as you make the decision to deliver the patientContinue for 24 hours postpartum or after last seizure