STEP 1

Intrauterine Growth Restriction

A 20-year-old woman referred from midwife with note primagravida in 32 weeks of gestation
with gestational hypertension to Obgyn Polyclinic. From anamnesis, patient didn’t ANC regularly.
The blood pressure was 180/120mmHg and dipstick urine examination revealed proteinuria +3.
From fundal height measurement revealed 24 cm. The doctors in charge give Magnesium
sulphate solution intravenously to prevent eclampsia, anti-hypertensive drugs to decrease blood
pressure and planning to give dexamethasone every 12 hours for 2 days for lung maturation. The
doctor also plans to do fetal biometry measurement and fetal wellbeing using ultrasound.

Unfamiliar terms:

1. Fetal Biometry Measurement: Measurement of the fetal weight using the help of ultrasound

2. Dexamethasone: a corticosteroid drug

3. Eclampsia: Seizure that occur before or after delivery

STEP 2

1. What’s the diagnosis for this case?

2. Why the doctor have to give MgSO4? And why it can prevent eclampsia?

3. What’re the causes of gestational hypertension and proteinuria?

4. Why does the doctor use dexamethasone? How does it work?

5. What to measure in fetal biometry?

6. What’s the cause of IUGR?

7. What’re the sign and symptoms of preclamsia? What’s the danger of it?

8. The prognosis for the baby in IUGR condition?

9. Is the fundal height of 24 cm normal? What’s the expected normal fundal weight of each gestational
week?

10. Management of the IUGR and the prevention?

11. Is this an emergency condition? And how to manage it?

STEP 3

1. Why the doctor have to give MgSO4? And why it can prevent eclampsia?

 The MgSO4 prevent the exitacion by binding to the muscle receptor, by blocking the Ca channel.
  It’s an anticonvulsant therapy
 It shouldn’t be given more than 5 days: it could couse respiratory distress
 To prevent eclampsia the mother take antihypertention and corticosteroid drug

2. What’re the causes of gestational hypertension and proteinuria?

 Proteinuria: because of the hypertention, there’s a vascular leakage

 Hypertention: The placenta doesn’t attach correctly or poorly invasion on the endometrium
causing substantial cell circulating in blood.

3. Why does the doctor use dexamethasone? How does it work?

 Dexamethasone is useful for the maturation of the lung.

 There’re several studies that suggest using corticosteroid in preterm birth increase the survival
for the baby

4. What to measure in fetal biometry?

 To report the biparietal diameter, occipito frontal, head circumference, abdominal

circumference, femur length, crown rump length (1st trimester).

5. What’s the cause of IUGR?

 Maternal:
 Fetal
 placenta

6. What’re the sign and symptoms of preclamsia? What’s the danger of it?

 More than 140/90 mmHg

 Severe: 160/110 mmHg
 Proteinuria dipstick > +1
 Severe headache
 Nausea and vomiting
 Blurred vision
 Decrease urin output
 Decrease level of platelet (thrombocytopenia)
 Weight gain
 Shortness of breathe caused by fluid in lung
 Danger: preeclampsia could be the alarm for eclampsia which is seizure, very dangerous,
because it can cause coma and emergency condition (maternal mortality)

8. What’s the diagnosis for this case?

- Severe preeclampsia for the mother

- IUGR for the fetus

8. The prognosis for the baby in IUGR condition?

 Depends wheter it’s symmetric or asymmetric. Asymmetric have better prognosis because the
restriction happen in late stage of pregnancy.
 The later G.A the better the prognosis

9. Is the fundal height of 24 cm normal? What’s the expected normal fundal weight of each gestational
week?

10. Management of the IUGR and the prevention?

Management:

 Near term better if it’s terminated. If it’s IUGR added by oligohydramnion we should terminate
it if it’s > 34 weeks. Use Caesarean Section
  We need to make sure the lung mature enough. Use corticosteroid to make it mature.

11. Is this an emergency condition? And how to manage it?

 It is! Because the mother could die

 By termination of the pregnancy.

STEP 4

1. Why the doctor have to give MgSO4? And why it can prevent eclampsia?

 The MgSO4 prevent the exitacion by binding to the muscle receptor, by blocking the Ca channel.
 It’s an anticonvulsant therapy
 It shouldn’t be given more than 5 days: it could couse respiratory distress. Because of the
overdose, the intercostal muscle can be weakened.
 To prevent eclampsia the mother take antihypertention and corticosteroid drug
 Intramuscular transmission is better than intervascular.

2. What’re the causes of gestational hypertension and proteinuria?

 Proteinuria: because of the hypertention, there’s a vascular leakage

 Hypertention: The placenta doesn’t attach correctly or poorly invasion on the endometrium
causing substantial cell circulating in blood.
 Poor Placentation: a. spiralis in the placenta should be remodeled by tropoblast to increase the
lumen to increase blood flow. But in this case, a. spiralis will be narrowed so the blood flow isn’t
sufficient. It cause a low perfusion that cause ischemic placenta. Due to ischemic placenta, the
fragment will go throught the mother circulation. It leads to vascular leakage (proteinuria),
vasospasm (hypertention), and coagulation activated (thrombocytopenia).

3. Why does the doctor use dexamethasone? How does it work?

 Dexamethasone is useful for the maturation of the lung.

 There’re several studies that suggest using corticosteroid in preterm birth increase the survival
for the baby
 Mechanism of action for dexamethasone and the target of the drug

4. What to measure in fetal biometry?

 To report the biparietal diameter, occipito frontal, head circumference, abdominal

circumference, femur length, crown rump length (1st trimester).

5. What’s the cause of IUGR?

 Maternal
i) Nutritional
ii) Parity
iii) Social deprivation
iv) Vascular disease
 v) Anemia
vi) Antiphospolipid AB
vii) Ectopic pregnancy
viii) Chronic renal disease

 Fetal
i) Fetal infection
ii) Congenital anomaly
iii) Congenital malformation
iv) Chromosomal anomaly
v) Multiple gestation

 Placenta
1) Chorioangioma
2) Chronic partial placenta separation
3) Placenta previa
4) Poor placentation

6. What’re the sign and symptoms of preclamsia? What’s the danger of it?

 More than 140/90 mmHg

 Severe: 160/110 mmHg
 Proteinuria dipstick > +1
 Severe headache
 Nausea and vomiting
 Blurred vision
 Decrease urin output
 Decrease level of platelet (thrombocytopenia)
 Weight gain
 Shortness of breathe caused by fluid in lung
 Danger: preeclampsia could be the alarm for eclampsia which is seizure, very dangerous,
because it can cause coma and emergency condition (maternal mortality)

8. What’s the diagnosis for this case?

- Severe preeclampsia for the mother

- IUGR for the fetus

8. The prognosis for the baby in IUGR condition?

 Depends wheter it’s symmetric or asymmetric. Asymmetric have better prognosis because the
restriction happen in late stage of pregnancy.
  The later G.A the better the prognosis
 50% develop learning deficit 9 – 11 years old

9. Is the fundal height of 24 cm normal? What’s the expected normal fundal weight of each gestational
week?

10. Management of the IUGR and the prevention?

Management:

 Near term better if it’s terminated. If it’s IUGR added by oligohydramnion we should terminate
it if it’s > 34 weeks. Use Caesarean Section
 We need to make sure the lung mature enough. Use corticosteroid to make it mature.
11. Is this an emergency condition? And how to manage it?

 It is! Because the mother could die

 By termination of the pregnancy.

STEP 5

1. Mechanism of action for dexamethasone and the target of the drug

2. Management of the IUGR and the prevention?

3. Dosage regimen for MgSO4