Case presentation

Presented by : Ivena Iranny

IDENTITY
Name Mrs. E

Age
Address Education Occupation

37 y.o
Caringin Elementary school Housewife

Med. Record

4457**

Date of admission : September 4th 2013 at 13.10

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IDENTITY (HUSBAND)
Name Mr. A

Age
Address Education Occupation

39 y.o
Caringin Elementary school worker

Religion

Moslem

Date of admission : September 4th 2013 at 13.10

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HISTORY TAKING
From autoanamnesis : September 27th 2013, 7 am at Ponek RSUD Ciawi Primary subject : Patient referred by midwifes, bleeding from birth canal (++) 01.00 am (27\9) headache (+) n,v (+) weak (+) Problem : Excessive blood from birth canal
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HISTORY of PRESENT PREGNANCY

This is the fourth pregnancy Date of the first day of last menstrual is February, 27th 2013 Misscariage (-)

Past medical history and family history HBP (-) Diabetes (-) Asthma (-) Drug allergy (-) Heart D (-)
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Menarche Cycle Duration Pain LMP

: : : : :

12 yo 30 days 5-6 days moderate February, 27th of 2013

Married

Contaception LMP EBD ANC

:, 37 y.o, elementary school, housewife , 39 y.o, elementary school, labour : (+) oral (8 y) : February, 27th 2013 : November, 4th 2013 : Midwife/6x
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HISTORY TAKING
G4P3A0 9 months pregnancy Bleeding from the vagina (+) since 9 hours b.a Labor pain (+) since 5 hours b.a Fetal movement (+)

Midwife

Ciawi Hospital

PHYSICAL EXAMINATION

General Condition Blood Pressure Pulse Respiratory Temperature

Conscious 90/60 mmHg

96 bpm
24 tpm 36,570 C

EXTERNAL EXAMINATION

Fundal height Abdominal circumference Fetal presentation

32 cm 92 cm Head

FHR
Uterine contraction EBW

70-130 bpm (irreguler)

2-3x/10/25S + 3000 gr
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INTERNAL EXAMINATION

v/v

bleeding

AM

(-)

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LABORATORY FINDINGS

Hb : 11, 8 gr/dL Ht : 34% L : 13.600/mm3

Tr : 280.000/mm3

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Patient, women 37 yo, G4P3A0, reffer by midwifes, bleeding from birth canal (++) fr 01.00 am (27\9) headache (+) n,v (+) weak (+). USG result : PPT . LMP : february 27 th 2013. Past medical history (-). CTG non reactive (+)

Diagnosis G4P3A0 term parturient antepartum haemorrhage ; fetal distress

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DIAGNOSIS

G4P3A0 term parturient antepartum haemorrhage ; fetal distress

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MANAGEMENT

IVFD RL 20 gtt/mnt Plan for sectio caesarea Observe GC, vital sign, UC, FHR

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INTERNAL EXAMINATION
08,30
v/v bleeding (+)minimal

09.30
v/v bleeding(+)min 100\60

blood pressure 90|60

FHR IRREGULER

Blood pressure FHR

IRREGULER

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OBSERVATION

UC
07.30 08.30 3-4x/10/40 K

FHR (bpm)
70 90 130 (irreguler)

BP (mmHg)
90/60

P (x/mnt)
92

RR (x/mnt)
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Notes

Intrauterine recuscitation Continue monitoring Plan for c-section Informed consent Consult to anesthesiology PREPARE PRD 250CC or WB 500CC

08.30-10.00

3-4x/10/40 K

80-130

100/60

96

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Contact perinatology Prepare for operation Waiting operating room

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REVIEW of the literature

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Fetal distress is defined as depletion of oxygen and accumulation of carbon dioxide,leading to a state of hypoxia and acidosis during intra-uterine life.

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Placenta previa, placental abruptio Inappropriate use of oxytocin: too strong, too frequent and uncoordinated uterine contraction Cord prolapse, true entanglement, torsion Shock of mother

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Inadequate maternal blood oxygen saturation Utero-placental vascular sclerosis, stenosis Placental pathological changes Fetal factor: severe cardiovascular deformity, all causes leading to hemolytic anemia, etc

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Fetal heart rate abnormality early stage tacchycardia>160bpm; during severe hypoxia <120bpm CST shows late deceleration, variable deceleration fetal heart rate <100bpm, with frequent late decelrations indicating severe fetal hypoxia, may die intrauterine any moment

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Meconium stained amniotic fluid: green color, dirty, thick and little volume Fetal movement: early stage frequent fetal movement, subsequently reduced to absent Fetal acidosis: fetal scalp blood analysis

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Reduced or absent fetal movement Abnormal fetal monitoring Low fetal biophysical profile scoring Fetal retardation Reduced placental function Meconium stained amniotic fluid Abnormal fetal pulse oxymetry
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The Causes of Caesarian Sections Due to Fetal Distress in Labor Signs of Fetal Distress in Labor Number Percentage
Thick meconium 12%
Non reactive CTG 5% Abruptio placenta in labor 6%

Fetal heart deceleration 0.54%

Other abnormal CTG 77%

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Hypoxiaaccumulation of carbon dioxide Respiratory Acidosis FHRFHR FHR Intestinal peristalsis Relaxation of the anal sphincter Meconium aspiration Fetal or neonatal pneumonia

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Acute fetal distress: emergent treatment Chronic fetal distress: management plan depends on severity of the pregnancy complications, gestational age, fetal maturity, fetal distress condition

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Give oxygen: face mask or nasal prong continuous oxygen at 10L/min flow Search for cause, active management: if patient has supine hypotensive syndrome, lie the patient on left lateral position; if excessive oxytocin leading to uterine hyperstimulation, stop oxytocin immediately, use tocolytics when necessary
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Terminate pregnancy soonest possible:

Cervix not fully dilated with the following conditions, immediate caesarean section: (1)fetal heart rate <120bpm or >180bpm, accompanied by II degree meconium stained amniotic fluid; (2) III degree meconium stained amniotic fluid, with low amniotic fluid amount; (3) CST or OCT shows frequent late decelerations or severe variable decelerations; (4) fetal scalp blood pH <7.20
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 Fully dilated cervix:

fetal biparietal diameter, has descend below ischial spines, perform assisted vaginal delivery

Prepare for newborn resuscitation

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Routine management: left lateral position, give oxygen regularly (30mins, 2-3times/day) Active treatment of pregnancy complications Terminate pregnancy: pregnancy nearing term with less fetal movement or OCT shows late decelerations, severe variable decelerations, or biophysical profile <= 3 score, caesarean is indicated
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Expectant treatment: early gestation, low chance of survival if delivered, prolong pregnancy while inducing fetal lung maturation Must explain to the family that during the process of expectant treatment, there is risk of sudden fetal death, poor placental function might affect fetal growth, poor outcome.
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Thank you
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