TUTORIAL REPORT

CASE SCENARIO C
BLOCK XVII

Supervisor : dr. Thia Prameswarie, M. Biomed.

Tutorial Group 6

1. Mohammad Virgo Al- qausar 702017027

2. Siti Permata Putri 702017029
3. Nova Nuriza 702017086
4. M. Ilham Dendy P 702017074
5. Fatinah Fairuz Q 702017019
6. Nabilah Dwi Noprida 702017070
7. Hilma Tri Ayu Rizda 702017025
8. Amel Thalia Syahira 702017026
9. Retno Aqilah Fatma P 702017072
10. Mona Novrilia Nastri 702016049

MEDICAL FACULTY

UNIVERSITY MUHAMMADIYAH PALEMBANG

 2020

FOREWORD

Praise our thanks to Allah SWT for all his grace and grace so that we can
finish the tutorial scenario c block XVII. Sholawat as greetings always pour out to
our lord, the great prophet Muhammad and his family, friends and followers until the
end of the age.

We recognize that this tutorial report is far from perfect therefore we expect
constructive criticism and suggestions, in order to refine the next tasks. In completing
this tutorial task, we have much help, guidance and advice. On this occasion express
the respect and gratitude to:

1. dr. Thia Prameswarie, M. Biomed. as our supervisor.

2. All Members and related parties in the production of this report.

May Allah SWT give a reward for all the charity given to all those who
have supported us and hopefully this tutorial report useful for us and the development
of science. Hopefully we are always in the protection of Allah SWT. Amin.

Palembang, March 2020

Author
 TABLE OF CONTENTS

TITLE PAGE
FOREWORD ......................................................................................................................i

TABLE OF CONTENTS ....................................................................................................ii

CHAPTER I PRELIMINARY

1.1 Background.............................................................................................................1

1.2 Purpose and Objectives ..........................................................................................1

CHAPTER II DISSCUTION

2.1 Date of Tutorials ....................................................................................................2

2.2 Scenario of Case ....................................................................................................2

2.3 Clarification of Tems .............................................................................................4

2.4 Problem Identification............................................................................................4

2.5 Problem Analysis....................................................................................................6

2.6 Conculusion............................................................................................................30

2.7 Conceptual Framework...........................................................................................31

Bibliography.................................................................................................................32
 CHAPTER I

PRELIMINARY

1.1 Background

The reproduction system block is the seventeen block in sixth semester of the
Medical Education Competency Based Curriculum Faculty of Medicine,
Muhammadiyah University, Palembang.

The case study scenario tutorial c in blok XVII presents the case Mrs. Z, a 40
years old, G5P4A0, 36 weeks pregnant, came to the emergency department of
RSMP with a chief complain of blurry vision since one days ago. This complain
also followed with severe headache. Mrs. Z tries to relieve the complain by
taking some painkillers but the complain were not reduced. Mrs. Z also claims
that he often suffering from frequent headache but not as severe as this one, then
Mrs. Z brought to the village midwife, and the midwife said that Mrs. Z had high
blood pressure so she reffers her to the hospital.

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:

• As a report to the tutor who is part of the KBK learning system at the Faculty of
Medicine, Muhammadiyah University of Palembang.

• Can solve the case described in the scenario with the method of analysis and
learning of group discussion.

• Achieving the objectives of the tutorial learning method.

 CHAPTER II

DISCUSSION

2.1 Tutorial Date

Supervisor : dr. Thia Prameswarie, M. Biomed.

Moderator : M. Ilham Dendy P

Desk Secretary : Retno Aqilah Fatma P

Secretary Board : Amel Thalia S

Tutorial Time : 1. Monday, March 23rd, 2020

2. Thursday, March 26th, 2020

Tutorial rules :

1. Switch the phone off or in silence.

2. Raise your hand when going to argument

3. Permission when going out of the room

4. Relax and watch as the tutor gives directions

5. During the tutorial takes care of attitude and speech

2.2 SCENARIO C

Impending doom
Mrs. Z, a 40 years old, G5P4A0, 36 weeks pregnant, came to the emergency
department of RSMP with a chief complain of blurry vision since one days ago. This
complain also followed with severe headache. Mrs. Z tries to relieve the complain by
taking some painkillers but the complain were not reduced. Mrs. Z also claims that he
often suffering from frequent headache but not as severe as this one, then Mrs. Z
brought to the village midwife, and the midwife said that Mrs. Z had high blood
pressure so she reffers her to the hospital.
Since 3 days ago, Mrs. Z also complain of epigastric pain without nausea and
vommiting. Mrs. Z went to the Puskesmas, but the complain were not relieved. Mrs.
Z claimed that she had history of high blood pressure during the fourth pregnancym
and also she claimed that she is nine months pregnant and still able to feel the baby
movement. Mrs. Z only did ANC once during this pregnancy.

Physical examination:
General appearance: looks moderately sick, sensorium: compos mentis, GCS: 15
Vital Sign: BP: 190/120mmHg, Pulse: 84 x/m, RR: 20x/menit, Temp: 36,80C
Head: anemic conjungtive (-)
Thorax: cor and pulmo within normal range
Ekstremity: edeme extremity (+/+)

Obstetry Examination
External examination : Fundus uteri height 3 fingers below the procesus xiphoideus
(30cm), elongated, left back, lowest part is head, descending 5/5, HIS
1x/10minute/20seconds, Fetal Heart sound: 136x/minute.
Internal examination : soft portio, posterior, effacement 20%, opening 1 cm, head
hodge I-II, denominator difficult to determine, amniotic membrane complete.

Laboratory Examination:
Blood chemistry: Hb:12 g/dl, leucocyte : 9000/mm3, thrombocyte: 200.000/mm3
Urinalysus : Protein (++)

2.3 Clarification of Term

1 Headache Pain headache is some common symptoms inc

lude throbbing, squeezing, constant, unrelenti
ng, or intermittent. The location may be in one
part of the face or skull, or may be generalized
involving the whole head.

2 Blurry vision lack of sharpness of vision resulting in the ina

bility to see fine detail. thankyou moderator
3 High blood hypertension is systolic and diastolic blood pr
pressure essure.

4 Painkillers An analgesic or painkiller is any member of th

5 Epigastric pain
6 ANC
e group of drugs used to achieve analgesia, rel
ief from pain.
Feeling uncomfortable, suffering or pain caus
ed by stimulatormu or certain nerve endings e
pigastric
ANC also known as antenatal care is a type of
preventive healthcare to provide regular chec
k-ups that allow doctors or midwives to treat a
nd prevent potential health problems througho
 ut the course of the pregnancy and to promote
healthy lifestyles that benefit both mother and
child
7 His Uterine contractions during pregnancy that all
ow the fetus to be born.
8 Fundus Uteri the highest point of the uterus. Uterine fundal
height (tfu) is the distance between the symph
ysis pubis point and the uterine fundus
9 Amniotic water sac; extraembrional membranes in bird
membrane s, reptiles and mammals that line the chorion a
nd contain the fetus and amniotic fluid

10 Portio The part of the cervix that protrudes into the

vagina feels soft (dorland 2012)

2.4 Identification of Problem

1. Mrs. Z,a 40 years old, G5P4A0, 36 weeks pregnant, came to the emergency de
partment of RSMP with a chief complain of blurry vision since one days ago.
This complain also followed with severe headache. Mrs. Z tries to relieve the c
omplain by taking some painkillers but the complain were not reduced.
2. Mrs. Z also claims that he often suffering from frequent headache but not as se
vere as this one, then Mrs. Z brought to the village midwife, and the midwife s
aid that Mrs. Z had high blood pressure so she reffers her to the hospital.
3. Since 3 days ago, Mrs. Z also complain of epigastric pain without nausea and v
ommiting. Mrs. Z went to the Puskesmas, but the complain were not relieved.
4. Mrs. Z claimed that she had history of high blood pressure during the fourth pr
egnancym and also she claimed that she is nine months pregnant and still able t
o feel the baby movement. Mrs. Z only did ANC once during this pregnancy.
 5. Physical examination:
General appearance: looks moderately sick, sensorium: compos mentis, GCS:
15
Vital Sign: BP: 190/120mmHg, Pulse: 84 x/m, RR: 20x/menit, Temp: 36,80C
Head: anemic conjungtive (-)
Thorax: cor and pulmo within normal range
Ekstremity: edeme extremity (+/+)
6. Obstetry Examination
External examination : Fundus uteri height 3 fingers below the procesus
xiphoideus (30cm), elongated, left back, lowest part is head, descending 5/5,
HIS 1x/10minute/20seconds, Fetal Heart sound: 136x/minute.
Internal examination : soft portio, posterior, effacement 20%, opening 1 cm,
head hodge I-II, denominator difficult to determine, amniotic membrane
complete.
7. Laboratory Examination:
Blood chemistry: Hb:12 g/dl, leucocyte : 9000/mm 3, thrombocyte:
200.000/mm3
Urinalysus : Protein (++)

2.5 Problem Analysis

1. Mrs. Z,a 40 years old, G5P4A0, 36 weeks pregnant, came to the emergency de
partment of RSMP with a chief complain of blurry vision since one days ago.
This complain also followed with severe headache. Mrs. Z tries to relieve the c
omplain by taking some painkillers but the complain were not reduced.
a. How are anatomy and phsiology in the case?

Answer:

Anatomy
 Vagina
The vagina is the link between vaginal introitus and the uterus. The
anterior and posterior walls of the vagina are close to each other,
each ranging in length from 6-8 cm and 7-10 cm. The shape of the
folded inner vagina is called a rugae. In the middle there is a
harder part called the column rugarum. This fold allows the vagina
in labor to widen according to its function as a soft part of the birth
canal. There is no secretory gland in the vagina. The vagina can
get blood from (1) the uterine artery, which through its branches
into the cervix and the vagina gives blood to the middle 1/3 of the
upper vagina; (2) inferior vesical artery, which through its
branches provides blood to the middle 1/3 of the vagina; (3)
 arterial hemorrhoids mediana and arterial pedundus interna that
give blood to the lower 1/3.
 Uterus
Shaped advocate or pear slightly flattened towards the front back.
It's the size of a chicken egg and has a cavity. The walls consist of
smooth muscles. The length of the uterus is 7-7.5 cm, width above
5.25 cm, thickness 2.5 cm and wall thickness 1.25 cm. The
position of the uterus in a physiological state is anteversiofleksio
(the cervix goes forward and forms an angle with the vagina, while
the uterine corpus goes forward and forms an angle with the
uterine cervix). The uterus consists of (1) the uterine fundus; (2)
uterine corpus and (3) uterine cervix.
 Fallopian tube
The Fallopian tube consists of (1) interstitial pars, which is part of
the wall of the uterus (2) pars isthmic, is a medial portion of the
tube that is completely narrow; (3) pars ampularis, the part that is
shaped as a rather wide channel, where the conception occurs; and
(4) infundibulum, which is the end of the tube that opens to the
abdomen and has a fimbria.
 Ovaries (ovaries)
Women in general have 2 right and left ovaries. The mesovary
hangs the ovaries on the back of the left and right latent ligaments.
The ovary is about the size of a thumb with a length of about 4 cm,
width and thickness of about 1.5 cm (Prawirohardjo, 2016).

Physiology

 Ovaries
 The ovary is a pair of function is to produce mature eggs for
fertilization and production of steroid hormones in large quantities,
 Uterus (uterus)
The uterus in women is only one and is composed of thick
muscles. The lower uterus has a smaller size and is commonly
referred to as the cervix. Its main function is a place to support the
growth and development of the fetus.
 Vagina
is a female genitals that connects the external genitals with the
uterus. The vagina is made up of muscles stretching backwards.
The vaginal wall has many folds even though it is thinner than the
uterus. In addition, the mucus produced from the walls, the main
function of the vagina is as a channel to remove uterine mucus and
menstrual blood, sex tools and the birth canal during labor.
 Fallopian tube function:
1) As a way to transport the ovum from the ovary to the uterine
cavity.
2) To catch ova that are released during ovulation.
3) As a channel of spermatozoa ova and the results of conception.
4) The place of conception.
5) Place of growth and development of the results of conception
until reach the shape of the blastula that is ready for
implantation.

b. How is the physiology of pregnancy in the case ?

Answer:

Pregnancy Process
The process of pregnancy to childbirth is a chain of unity from
conception, nidation, introduction of adaptation, maintenance of
pregnancy, endocrine changes in preparation for welcoming the birth
of the baby, and delivery with readiness to care for the baby.

1) Ovulation
Ovulation is the process of releasing an ovum that is influenced by
a complex hormonal system. During the fertile period lasts 20-35
years, only 420 ovum can follow the process of maturation and
ovulation. Every month a woman releases one to two eggs from
the ovaries (ovulation) that are captured by the tassels (fimbriae)
and enter the egg. Release of eggs (ovum) only occurs once every
month, around the 14th day of the normal menstrual cycle of 28
days (Bandiyah, 2009).
2) Spermatozoa
Sperm looks like a tadpole consisting of an oval shaped head
rather flattened to contain the nucleus. The neck that connects the
head to the middle and tail that can vibrate so that sperm can move
quickly. The tail is about ten times the head length. Embryonally,
spermatogonia originates from the primitive cells of the testicular
tubules. After a baby is born, the amount of spermatogonia that
does not change until puberty. The process of formation of
spermatozoa is a complex process, spermatogonia originating from
primitive tubules, becoming the first spermatoside, becoming the
second spermatocytes, becoming spermatids, finally spermatozoa.
Most spermatozoa die and only a few hundred can reach the
fallopian tube. Spermatozoa that enter the female genetalia can live
for three days, so that enough time to hold a conception.
3) Fertilization (Conception / Fertilization)
 At the time of copulation between men and women (coitus /
coitus) sperm ejaculation occurs from the male reproductive tract
in the female vagina, which will release semen containing sperm
cells into the female reproductive tract. If intercourse occurs
during ovulation, then there is a possibility that sperm cells in the
female reproductive tract will meet with female eggs just released
at the time of ovulation. The meeting of sperm and egg cells is
what is referred to as conception / fertilization. Fertilization is the
union of ova (secondary oocytes) and spermatozoa which usually
takes place in the ampulla of the tube. According to Manuaba et
all, the whole conception process takes place as described below:
a) Ovum which is released in the process of ovulation, is covered
by corona radiate which contains a supply of nutrients.
b) In the ovum a nucleus is found in the form of metaphase in the
middle of the vitelus cytoplasm.
c) On the way, the corona radiata decrease in the zona pellucida.
Nutrients flow into vitelus, through the zona pellucida.
d) Conception occurs in the tube ampullary pars, the most
extensive place whose walls are full of bumps and covered
with cells that have cilia. Ovum has the longest life time in the
ampulla of the tube.
e) Ovum is ready for fertilization after 12 hours and lives for 48
hours.
4) Nidation or implantation
Nidation is the entry or implantation of the results of conception
into the endometrium. Generally, oxidation occurs in the front or
back of the uterus near the uterine fundus. Sometimes at the time
of the oxidation there is a little bleeding due to a decidual wound
called Hartman&39 sign. On the fourth day the results of the
 conception reach the blastula stage called blastocyst, a form which
on the outside is a trophoblast and inside it is called the inner cell
mass. This inner cell mass develops into a fetus and the trophoblast
will develop into the placenta. Since the trophoblast is formed,
hCG hormone production begins, a hormone that ensures that the
endometrium will receive (receptive) embryo implantation
5) Plasentation
The placenta is a vital organ for the promotion and treatment of
pregnancy and normal fetal development. This is described by the
fetal and maternal tissues to be an important nutrient transfer
instrument. Placentation is the process of forming the structure and
type of the placenta. After embryo oxidation into the endometrium,
placentation begins. In humans, placentation lasts until 12-18
weeks after fertilization. The growth of the placenta is getting
bigger and wider, generally reaching complete formation at around
16 weeks&39; gestation.

Changes in physiology during pregnancy.

With the occurrence of pregnancy, all female genitalia undergo

fundamental changes so as to support the development and growth of
the fetus in the womb. The placenta in its development secretes the
hormones somatomatropin, estrogen, and progesterone which cause
changes in:

1) The womb or uterus

During pregnancy the uterus will adapt to receive and protect the
results of conception (fetus, placenta, amnion) until delivery. The
uterus has an extraordinary ability to grow rapidly during
pregnancy and recover to its original state within a few weeks after
 delivery. In nonpregnant women the uterus weighs 70 grams and a
capacity of 10 ml or less. During pregnancy, the uterus will turn
into an organ that is able to accommodate the fetus, placenta, and
amniotic fluid by the end of pregnancy the total volume reaches 5
liters or even 20 liters or more with an average weight of 1100
grams.
2) Vagina (intercourse)
During pregnancy the increase in vascularization and hyperemia is
clearly seen in the skin and muscles in the perineum and vulva, so
that the vagina will look purplish, known as the Chadwicks sign.
These changes include thinning of the mucosa and loss of a
number of connective tissue and hypertrophy of smooth muscle
cells.
3) Ovaries
The process of ovulation during pregnancy will stop and
maturation of new follicles is also delayed. Only one corpus
luteum can be found in the ovary. These follicles will function
optimally during the 6-7 weeks of early pregnancy and after that
will act as a producer of progesterone in a relatively minimal
amount.
4) Breasts
The breasts experience growth and development in preparation for
breastfeeding at the time of lactation. Breast development cannot
be released from hormones during pregnancy, namely estrogen,
progesterone, and somatromatropin.
5) Maternal blood circulation
Maternal blood circulation is influenced by several factors,
including:
 a) The increased need for blood circulation so that it can meet the
need for development and growth of the fetus in the womb.
b) There is a direct relationship between arteries and veins in the
retro placenter circulation.
c) The influence of the hormones estrogen and progesterone is
increasing. As a result of these factors found some changes in
blood circulation (Prawirohardjo, 2016).

c. What is the meaning of Mrs. Z, a 40years old, G5P4A0, 36 weeks pregn

ant, came to the emergency department of RSMP with a chief complain
of blurry vision since one day ago?
Answer:
 The meaning of her status G5P4A0 is multiparous which are gravida
is five times, partus is four times, and no abortion history.
 The meaning of blurry vision since one day ago is visual acuity
which is one of symptoms of severe preeclampsia with impending
eclampsia. Severe preeclampsia with impending eclampsia
accompanied by severe headache, visual acuity, vomiting, epigastric
pain, and progressive rise in blood pressure (Angsar, 2016).
 The meaning of since one day ago is acute severe preeclampsia.

d. What are the etiology of blurry vision with women pregnant?

Answer:
Blurry vision can cause by severe headache. So there’s edema in the
brain and increase brain resistance that affects the central nervous
system, which can cause cerebral abnormalities and visual disturbances.
Blurry vision can be a pre-eclampsia sign (Lismalinda, 2015).
 e. How are the patophysiology of blurry vision with women pregnant?
Answer:

Risk factor

The implantation process is

interrupted & the formation
of a.spiralis is not maximal

Placental hypoxia

Inflammatory mediators
and oxidants

PGE2 (prostacyclin) +
unsaturated fat

Systemic vascular
endothelial dysfunction

Organ damage (blurry

vision)

f. What are the possibility of disease with blurred eyes?

Answer:
1) Severe preeclamsia
2) Retinal edema
3) Ablasio retinal
4) Skotoma
5) Diplopia
6) Ambilopia
 g. What is the meaning this complain also followed with severe headache?
Answer:

The meaning is mrs. Z experience symptoms of severe preeclampsia

with impending eclampsia where one of the symptoms there is severe
headache (Prawirohardjo, 2016).

h. What are etiology of severe headache in pregnant?

Answer:
Etiology of headaches in pregnancy: ischaemic stroke, cerebral venous
thrombosis, subarachnoid hemorrhage, pituitary tumor, eclampsia,
preeclampsia, idiopathic intracranial hypertension, and reversible cerebral
vasoconstriction syndrome (Negro, 2017).

i. How are the patophysiology of severe headache?

Answer:

Risk factors (Mother’s age, multigravida, history of preeclampsia in

aprevious pregnancy) → trophoblast cell invasion which is inadequate
in the muscle layer of A. spiralis → failure of A. spiralis remodelling
→ A. spiralis lumen is not distended and dilated → the muscle layers
of A. spiralis remain stiff and hard → decreased of placental blood
flow → hypoxic / ischemic placenta → Imbalance between ↓
proangiogenic factors (VEGF, PIGF) and ↑ antiangiogenic (sFlt-1) →
maternal endothelial dysfunction → decreased perfusion of oxygen
and nutrients to the brain → severe headache.

j. What is the meaning Mrs. Z tries to relieve the complain by taking

some painkillers but the complain were not reduced?
Answer:
 The meaning is inadequate treatment, because some of painkillers
only treat the symptomps or complain not treat caused of the complain
itself.

k. What is the possibility of the drug being consumed in the case ?

Answer:
 Acetaminophen
To relieve headaches in pregnant women, this drug works by
interacting with prostaglandins, a hormone produced in the body
and can cause inflammation and pain. The dose of this headache
drug is around 325 milligrams (mg) and is used once every 6
hours.
 Sumatriptan
is a drug used to treat migraines and cluster headaches. Included in
the category of drugs known as triptans, these headaches for
pregnant women affect certain natural substances such as serotonin
which cause narrowing of blood vessels in the brain. The
recommended dosage for adults is one tablet (25 mg, 50 mg, or
100 mg) and taken when symptoms occur.
l. How are the pharmacokinetics and pharmacodynamics of the drugs ?
Answer:
It is likely that the drugs given are analgesic drugs, such as
a) Paracetamol (acetaminophen)
In Indonesia, acetaminophen better known as paracetamol and
available as an over-the- counter drug, is one of the drugs that is often
used for mild to moderate treatment, paracetamol works by using a
weak PG.
 Pharmacokinetics
 Paracetamol is given orally, combined with an emptying rate and
blood concentration, up to 30%. Diaborbsi quickly and perfectly
through the digestive tract. The highest concentration in plasma is
within ½ hour and the remaining mass is 1-3 hours. In plasma 25%
of paracetamol is required plasma protein, metabolized by liver
microsomal enzymes. Excreted through the kidneys, a small
portion as paracetamol (3%) and mostly in a conjugated form.
 Pharmacodynamics
The analgesic effect of Paracetamol is to eliminate or reduce mild
to moderate pain. Its anti-inflammatory effect is very weak,
therefore Paracetamol is not used as an antireumatic. Paracetamol
is a weak inhibitor of prostaglandin biosynthesis (PG).
Paracetamol inhibits cyclooxygenase so that the conversion of
arachidonic acid to prostaglandins is disrupted. Each drug inhibits
cyclooxygenase differently. Paracetamol inhibits central
cyclooxygenase stronger than aspirin, this is what causes
paracetamol to be a strong antipyretic drug through its effects on
the central heat regulation. Paracetamol has only a mild effect on
peripheral cyclooxygenase. This is what causes Paracetamol to
only eliminate or reduce mild to moderate pain. Paracetamol does
not affect the pain caused by the direct effects of prostaglandins,
this shows that paracetamol inhibits prostaglandin synthesis and
not a direct blockage of prostaglandins.
 Indication
This drug is useful for mild to moderate pain such as headaches,
myalgia, postpartum pain and other conditions. It should not be
given too long because it might cause anti-pain nephropathy. If
therapeutic doses are not useful, large doses do not help Side
 effects In therapeutic doses an increase in liver enzymes can
sometimes occur without jaundice. Swallowing a dose of 15 g of
paracetamol, can cause fatal events can occur due to severe
hepatotoxicity with central lobules necrosis. The use of all types of
analgesics on a chronic basis especially combinations has the
potential to become analgesic nephropathy.
 Contraindicated
This drug is not recommended for someone who has G-6-PD
deficiency. The recommended dosage of tablets with 500 mg of
paracetamol or syrup containing 125mg / 5ml. And there is also a
dose for adults 300 mg-1g per time give with a maximum dose of
4 g / day, can be given 3 to 4 times a day with a maximum of 6
times a day (Wilman and Gan, 2009).
b) Ibuprofen
Ibuprofen is a pain reliever of non-steroidal anti-inflammatory drugs
(NSAIDs) which can be found in many drug stores. An important role
of the pharmacology of ibuprofen is its mechanism of action as an
anti-inflammatory, analgesic, and antipyretic agent through inhibition
of the production of the hormone prostaglandin.
 Pharmacodynamics
In general ibuprofen works as an anti-inflammatory, analgesic and
antipyretic. Inhibits prostaglandin synthesis in body tissues by
inhibiting at least 2 cyclooxygenase, COX-1 and COX-2
(Medscape) isoenzymes.
 Pharmacokinetics
The pharmacokinetics of ibuprofen in terms of absorption,
metabolism, distribution, and drug elimination.
o Absorption
 Ibuprofen is quickly absorbed, after oral consumption.
Bioavailability of the drug is 80%. Ibuprofen lysine, or
ibuprofen salt is absorbed faster than ibuprofen acid. The peak
concentration of ibuprofen lysine, or ibuprofen salt is about 45
minutes, while ibuprofen acid is about 90 minutes. The peak
concentration of ibuprofen in serum generally lasts for about 1-
2 hours. Bioavailability of the drug is hardly influenced by
food. There is also no interference with ibuprofen absorption,
if given together with antacids, both containing aluminum
hydroxide and magnesium hydroxide.
o Metabolism
Ibuprofen is rapidly metabolized in the liver, producing
metabolites such as propionic acid phenyl hydroxymethyl
propyl, and propionic acid phenyl carboxypropyl.
o Distribution
Ibuprofen is distributed throughout all body tissues, mainly
concentrated in synovial fluid. The presence of ibuprofen drugs
in synovial fluid is longer than in plasma. This drug is bound to
proteins around 90‒99%, especially with albumin.
o Elimination
The half-life of drugs in serum is around 1.8 to 2 hours.
Complete ibuprofen excretion in 24 hours, after the last dose.
About 45% ‒79% of the dose of the drug absorbed orally, is
found in urine, in the form of metabolites, while the free or
conjugated form of ibuprofen is about 1% and 14%,
respectively.
 Indication
 Ibuprofen is an anti-inflammatory drug (NSAID) that is used to
treat mild to moderate pain, and helps to relieve symptoms of
arthritis (osteoarthritis, rheumatoid arthritis, or juvenile arthritis),
such as inflammation, swelling, stiffness, and joint pain. Ibuprofen
does not cure arthritis, it only helps when you use or guide it. Side
effects Anti-inflammatory drugs can cause gastrointestinal
irritation and bleeding to occur, although not as often as aspirin. It
can also cause kidney disorders, heart failure and cirrhosis and
increase the risk of cardiovascular diseases such as myocardiac
infarction. Rare effects are skin erythema, thrombosipenia
headaches, reversible toxic takeopia (Wilman and Gan, 2009).
 Contraindicated
These drugs are contraindicated in people with allergic reactions,
bleeding disorders, duodenal ulcers, stomatitis, SLE, ulcerative
colitis, upper gastrointestinal disease, late pregnancy (can cause
early closure of ductus arteriosus). The recommended dose is 400
mg in 4 times a day (Wilman and Gan, 2009).

m. What is the relation between age, parity status, and gestational age
with this case?
Answer:
 The mean age of mothers with severe preeclampsia was
32.09±7.63 years. Some studies suggest that the age of mothers
over 35 years has a higher chance of developing preeclampsia than
the age of mothers under 35 years means that is one of risk factor
in this case.
  The mean gestational age of mothers with preeclampsia is over
30±2.4 weeks means that is one of risk factor in this case (Harini,
2018).
 Primigravida is one of the risk factors for hypertension in
pregnancy. In primigavida or mothers who are pregnant for the
first time often experience stress in experiencing labor so that
hypertension can occur in pregnancy or commonly called
preeclampsia / eclampsia. Primigravida is also one of the risk
factors causing preeclampsia / eclampsia, this is because in the first
pregnancy the formation of blocking antibodies against imperfect
placental antigens. So, theres no relation between this and this case
(Angsar, 2016).

2. What is the meaning Mrs. Z also claims that he often suffering from frequent
headache but not as severe as this one, then Mrs. Z brought to the village mid
wife, and the midwife said that Mrs. Z had high blood pressure so she reffers
her to the hospital?
a. What is the correlation between had high blood pressure with blurry
vision?
Answer:

Impending eclampsia clinical manifestation (Prawirohardjo, 2016 ).

b. What are the etiology of hypertension in women pregnant?

Answer:
Immunology factor, genetic factor, nutrition factor, endotel
factor,multigravida factor.

c. What are the risk factor of hypertension in women pregnant?

Answer:
 1) Maternal age
2) Primigravida
3) Gestasional age
4) Body mass index (IMT)
5) History of preeklamsia
6) Hiperhomosistemia
7) Metabolic syndrome
8) Environment
9) Socioecominics

d. What are the impact hypertension of women pregnant?

Answer:

The incidence of hypertension in pregnancy about 5-15%, and is

one in between 3 causes of mortality and maternal morbidity in
pregnancy (Prawirohardjo, 2016).. The impact of hypertension
pregnancy includes the risk of maternal death, figures prematurity,
birth weight low, and perinatal mortality rate increased (Rukiyah,
2010).

e. What are the classification of hypertension in pregnancy?

Answer:
1) Chronic hypertension is hypertension that arises before 20 weeks
&39;gestation or hypertension that is first diagnosed after 20
weeks' gestation and hypertension persists until 12 weeks
postpartum.
2) Preeclampsia is hypertension that arises after 20 weeks of
pregnancy accompanied by proteinuria.
3) Eclampsia is preeclampsia accompanied by seizures and / or coma.
 4) Chronic hypertension with superimposed preeclampsia is chronic
hypertension accompanied by signs of preeclampsia or chronic
hypertension with proteinuria
5) Gestational hypertension also called transient hypertension is
hypertension that arises in pregnancy without proteinurea and
hypertension disappears after 3 months postpartum or pregnancy
with signs of preeclampsia but without proteinuria (Prawirohardjo,
2016).

f. What the pathophysiology of hypertension of women pregnent?

Answer:
Risk factors (Mother’s age, multigravida, history of preeclampsia in a
previous pregnancy) → trophoblast cell invasion which is inadequate
in the muscle layer of A. spiralis → failure of A. spiralis remodelling
→ A. spiralis lumen is not distended and dilated → the muscle layers
of A. spiralis remain stiff and hard → decreased of placental blood
flow → hypoxic / ischemic placenta → Imbalance between ↓
proangiogenic factors (VEGF, PIGF) and ↑ antiangiogenic (sFlt-1) →
maternal endothelial dysfunction → vasospasm → vascular contriction
→ blood vessel resistance → hypertension.

3. Since 3 days ago, Mrs. Z also complain of epigastric pain without nausea and
vommiting. Mrs. Z went to the Puskesmas, but the complain were not relieved.
a. What the meaning Since 3 days ago, Mrs. Z also complained of
epigastric pain without nausea and vommiting ?

Answer:

The meaning is a symptomp of severe preeaclamsia in which there

is a disruption in the hepar due to the stretching of the glisson capsule
 and without nausea and vomitting is indicates that nothing
progressivity.

b. What is the etiology of epigastric pain ?

Answer:

 Abnormalities in the stomach: Akut and chronic gastritis, gastric

ulcers and gastric cancer.
 Abnormalities in the small intestine, the most common are;
duodenum, appendicitis
 Abnormalities in the duodenum that often provide complaints of
upper abdominal pain are duodenitis and duodenal ulcers
 Abnormalities in the liver: Viral hepatitis, liver abscesses, and liver
cancer.
 Abnormalities in the gallbladder and its ducts: Gallstones
(kholilitiasis), gallbladder stones (kholedokholitiasis) and
cholecystitis
 Abnormalities in the pancreas: Pancreatitis both acuta and chronic,
and pancreatic cancer
 Abnormalities in the heart
 Pregnancy.
It is very common to feel mild epigastric pain during pregnancy.
This is usually caused by acid reflux or pressure on the abdomen
of the expanding uterus. Changes in hormone levels throughout
pregnancy can also worsen acid reflux and epigastric pain.

c. How the pathophysiology of epigastric pain without nausea and

vomiting?

Answer:
 Risk Factor (Age 40 years, History of Hypertension, Gravida Status
G5P4A0) > Arteriol vasoconstriction> Vasospasme > Ischemic >
Periportal cell bleeding > Liver cell necrosis and increase liver
enzymes prostaglandin release free nerve end stimulus thalamus
cerebral cortex >epigastric pain.

d. What the meaning Mrs. Z went to the puskesmas, but the complain
were not relieved?

Answer:

That means it is only treat the symptoms (epigastric pain) not the
causal.

4. Mrs. Z claimed that she had history of high blood pressure during the fourth p
regnancym and also she claimed that she is nine months pregnant and still abl
e to feel the baby movement. Mrs. Z only did ANC once during this pregnanc
y.
a. What is the meaning Mrs. Z claimed that she had history of high
blood pressure during the fourth pregnancym and also she claimed
that she is nine months pregnant and still able to feel the baby
movement?

Answer:

She had history of pre-eclampsia and there’s nothing wrong with

the baby.

b. What is the relation between history of high blood pressure and

blurry vision complaints?

Answer:
 Impending eclampsia clinical manifestation (Prawirohardjo, 2016).

c. What is the meaning mrs z only did ANC once during this
pregnancy?

Answer:

The meaning is ANC examination incomplete,this can also

increase the risk of severe pre-eclampsia with impending eclampsia
due to not detected earlier.

d. How is the pathopysiology?

Answer:
cytotroipoblast
Fetal macrosomia
Immunology
Thrombophilia factor
Multiple
pregnancy Poor placentation
Acute
atherosis

Uteroplacental mismatch

Endothelial cell activation

Pre-eclamsia

Another patho
preeclamsia

Increased sensitivity to blood pressure

Decrese prostaglandin placental

iskemic
HCL increase Stimulate
medulla
oblongata and
simpatio nerve
Epigasrric pain

Uterus renin realese Tromboplastic realese

Endotelisis on
endotelisis glomelurus
Produce Angiotensinogen

Tromboplastine realese Increase capillary

Change be angiotensin I permeabitily on
protein
Activate/aggregation of trombosite,
Change be angiotensin fibrin debris
II helping with ACE proteinuria
enzyme in lung Inbalance trombocsan and protasicline

Systemic Vasocontraction

Cortex cerebri vosospasme

Systemic blood perfusion

Decresed Blood circulation

Increased peripheral
nutrition and o2 in the central
blood presusure
on brain visiom impaired

hipertension
headache Blurry vision

(Cunningham, 2012).
e. What are the impact and benefit Mrs. Z only dis ANC once during
this pregnancy?

Answer:
 Antenatal care is a health service provided by professional health
workers to improve the health status of pregnant women and their
fetuses.

 Benefit:
1) Can know various risks and complications of pregnancy so
that pregnant women can be directed to make a referral to
the hospital (manuaba, 2005).
2) According to prawidohardjo (2016) that the benefits of anc
services for:
o Help mothers and their families prepare for births and
emergencies that may occur
o Detect and treat complications arising during
pregnancy, whether of a medical, surgical or obstetric
nature.
o Improve and maintain the physical, mental and social
health of the mother and baby by providing education,
support, and immunization.
o Helps prepare mothers to breastfeed their babies,
through the normal postpartum period, as well as taking
care of the child physically, psychologically and
socially.
 Impact:
1) Pregnant women lack or do not know about proper care during
pregnancy
2) The danger of early pregnancy is not detected
3) Anemia during pregnancy which can cause undetectable
bleeding
 4) Pelvic deformities, spinal deformities or multiple pregnancies
that can cause difficult labor normally not detected.
5) Complications or comorbidities during pregnancy such as
chronic diseases such as heart, lung and genetic diseases such
as diabetes, hypertension or congenital defects, preeclampsia
cannot be detected (depkes, 2002).

f. What is the ANC examination schedule?

Answer:

1) Once visit during the first trimester (gestational age under 28

weeks).
2) Once visit during the second trimester (between 28-36 weeks&39;
gestation).
3) Twice visit during the third trimester (gestational age over 36
weeks) (Prawirohardjo, 2016).

g. What are that checked from ANC examination?

Answer:

The standards of care for pregnancy checkup services according to

Wagiyo (2016) are as follows:
1) Weight (T1)
Weight measurement is required for every pregnant woman to
visit. Increase in normal body weight during pregnancy by 0.5 kg
per week starting in the second trimester.
2) Measure Blood Pressure (T2)
 Normal blood pressure is 110/80 to 140/90 mmHg, if it is known
that the blood pressure of pregnant women is more than 140/90
mmHg, it is necessary to watch out for preeclampsia.
3) Measure the height of the Uterine Fundus (T3)
Is a way to measure the size of the uterus from the mother's
pubic bone to the limit of enlargement of the abdomen precisely at
the top of the uterine fundus. From this examination can be known
fetal growth in accordance with gestational age.
4) Provision of 90 Fe tablets in pregnancy (T4)
Fe tablets are blood boosting tablets.
5) Giving tetanus toxoid (T5) immunization
This immunization is recommended to prevent tetanus neonatorum
infection. Tetanus neonatorum disease caused by the entry of
Clostridium Tetani bacteria into the baby's body is an
infectious disease that can result in the death of infants with
symptoms of high heat, stiff neck, and seizures. TT immunization
is recommended 2 times during pregnancy, ie TT1 is given at the
initial visit and TT2 is done oada 4 weeks after TT1 injection.
6) Hb Check (T6)
7) VDRL / HIV examination (T7)
8) Breast care, breast exercises, and breast press massage (T8)
9) Maintenance of fitness or gymnastics for pregnant women (T9)
10) Dialogues in preparation for referrals (T10)
Usually the doctor or midwife will provide information about the
referral if there are known problems in pregnancy including birth
plans.
11) Urine protein examination for indications (T11)
12) Examination of urine reduction for indications (T12)
 13) Provision of iodine capsule therapy for goiter enndemic areas
(T13)
14) Provision of anti-malaria therapy for malaria endemic areas (T14).

5. Physical examination:
General appearance: looks moderately sick, sensorium: compos mentis, GCS:
15
Vital Sign: BP: 190/120mmHg, Pulse: 84 x/m, RR: 20x/menit, Temp: 36,80C
Head: anemic conjungtive (-)
Thorax: cor and pulmo within normal range
Ekstremity: edeme extremity (+/+)
a. What are the interpretation of physical examination?

Answer:

Examination Value Of Normal Value Of Interpretion

Examination Examination
General apperance Looks moderately Looks healthy Sick
sick
Sensorium Compos mentis Compos mentis Compos mentis

GCS 15 14 - 15 Compos mentis

Blood pressure 190 / 120 mmHg 120 / 80 mmHg Hypertension

Pulse 84 x /minute 64 – 100 x/minute Normal

Respiration rate 20 x/minute 16-20 x/minute Normal

Temperature 36,8 0 C 36-37 0 C Normal

Head Anemic Anemic No anemic

conjungtive(-) conjungtive(-)
Thorax Cor and pulmo normal Cor and pulmo normal Normal
range range
 Extremity Edema extremity (+/+) Edema extremity (-/-) Hypoalbuminemia

b. How the abnormal mechanism of physical examination?

Answer:
Abnormal invasion of
cytotrophoblast cells to a.
spiralis

Iskemik plasenta

Produce oxidant
(hydroxy radicals)

Convert unsaturated fats

into fat peroxides

Endhotelial Dysfunction

Capillary Permeabillity

hypertension Glomerular demage

Decrease in blood
Proteinuria Loss protein albumin
6. Obstetry Examination

Edeme extremity

Proteinuria
 External examination : Fundus uteri height 3 fingers below the procesus
xiphoideus (30cm), elongated, left back, lowest part is head, descending 5/5,
HIS 1x/10minute/20seconds, Fetal Heart sound: 136x/minute.
Internal examination : soft portio, posterior, effacement 20%, opening 1 cm,
head hodge I-II, denominator difficult to determine, amniotic membrane
complete.
a. What are the interpretation of obstetry examination?

Answer:

In the case, everything is normal.

7. Laboratory Examination:
Blood chemistry: Hb:12 g/dl, leucocyte : 9000/mm3, thrombocyte:
200.000/mm3
Urinalysus : Protein (++)
a. What are the interpretation of laboratory examination?

Answer:

Proteinuria.

b. How the abnormal mechanism of laboratory examination?

Answer:

The implantation process is

interrupted & the formation
of a.spiralis is not maximal
 Risk factor

Placental hypoxia

Inflammatory mediators and

oxidants

PGE2 (prostacyclin) +
unsaturated fat

Systemic vascular endothelial

dysfunction

protein comes out from the

blood vessels

Proteinuria

8. How to diagnose?

Answer:

1) Anameses : Mrs.z complain blurry vision since one days ago followed
with severe headache. Mrs.z has high blood pressure. She complain
epigastric pain without nausea and vomiting. Mrs.Z claimed she had
history of high blood pressure during fourth pregnancy and also she
 claimed that she is nine month and still feel baby movement. She only
did ANC once during this pregnancy.
2) Physical examination; BP 190/120 mmHg
3) Laboratory examination: protein (++)

9. What are differential diagnose?

Answer:

Severe Severe
HLLP Mild Preeclampsia
Preeclampsia Preeclampsia Syndrome
with without
Impending Impending
Eclampsia Eclampsia
Blurry Vision + - + -
Headache + - + _
Nausea and + - + -
Vomitting
Blood Pressure Systole ≥ 160 Systole ≥ 160 Systole ≥ Systole/ diastole >
/ diastole ≥ / diastole ≥ 160 / diastole 140/90 mmHg
110 mmHg 110 mmHg ≥ 110 mmHg

Proteinuria 5 gr/24h (+4) 5 gr/ 24h (+4) 5 gr/ 24h (+4) 300 mg/24 h (+1)

Trombosit <100.000 <100.000 ≤150.000/ml -

cell/mm3 cell/mm3

10. What are the additional examination?

Answer:

1) USG ( Ultrasonografi )
2) NST ( Non Stress Test )
3) Assess liver hepatocyte damage / dysfunction: ALT, LDH
 4) Assess intravascular hemolysis: LDH, and indirect bilirubin
5) Creatinine serum

11. What is working diagnose in this case?

Answer:

Severe preeclampsia with impending eclampsia.

a. What is the definition?

Answer:

Severe preeclampsia is a multisystemic disease characterized by the

development of hypertension after 20 weeks of gestation in a previously
normotensive woman, with the presence of proteinuria or in its absence of
sign or symptom indicative of target organ injury (Moussa, 2014).

b. How is the epidemiology?

Answer:

Preeclampsia is the second leading cause of maternal death in the

world after bleeding. Based on data from the World Health
Organization (WHO) in 2008, the incidence of preeclampsia
worldwide ranged from 0.51% to 38.4%. In developed countries, the
incidence of preeclampsia ranges from 5% to 6%, the frequency of
preeclampsia for each country varies due to many factors that
influence. In Indonesia the frequency of occurrence of preeclampsia is
around 3-10%, in Indonesia, preeclampsia is a cause of high maternal
mortality besides bleeding and infection, namely bleeding reaching
28%, preeclampsia by 24%, infection by 11%, complications of
peuperium by 8%, prolonged parturition by 5%, and abortion by 5%.
 The prevalence of cases of preeclampsia in Central Java has increased
every year, and is a major cause of maternal death with a percentage of
23.9%, followed by bleeding of 17.22% and infection of 4.04%
(Saraswati, 2016).

c. What are the etiology?

Answer:

Pre-eclampsia is a disorder of etiology that is not specifically known i

n pregnant women. This form of the syndrome is characterized by hyp
ertension, and proteinuria that occurs after the 20th week of pregnancy.
Several theories explain the causes of pre-eclampsia, including:

 Genetic factors
 Nutritional factors
 Endothelial cell dysfunction
 Placental perfusion
 Antigen-antibody reaction
 Decreased intravascular volume
 Changes in vascular reactivity
 Etc

d. What are the risk factor?

Answer:

Risk factors associated with (pre-)eclampsia include primiparity,

previous medical history (hypertension, diabetes mellitus and anti-
phospholipid syndrome), maternal age >35 years, obesity, physical activity,
and diet (Opitasari & Andayasari, 2014).
 e. What are the clinical manifestation?

Answer:

Impending pre-eclampsia clinical manifestation

 Severe headache
 Blurry vision
 Epigastric pain
 Highblood pressure
 Vomit (Prawirohardjo, 2016 ).

f. How is the patophysiology?

Answer:

Fetal macrosomia
cytotroipoblast
Thrombophilia
Immunology
Multiple factor
pregnancy
Poor placentation
Acute
atherosis

Uteroplacental mismatch

Endothelial cell activation

Another patho
Pre-eclamsia
preeclamsia

Increased sensitivity to blood pressure

Decrese prostaglandin placental

HCL increase Stimulate
medulla
oblongata and
simpatio nerve
Epigasrric pain

Uterus renin realese Tromboplastic realese

Endotelisis on
endotelisis glomelurus
Produce Angiotensinogen

Tromboplastine realese Increase capillary

Change be angiotensin I permeabitily on
protein
Activate/aggregation of trombosite,
Change be angiotensin fibrin debris
II helping with ACE proteinuria
enzyme in lung Inbalance trombocsan and protasicline

Systemic Vasocontraction

Cortex cerebri vosospasme

Systemic blood perfusion

Decresed Blood circulation

Increased peripheral
nutrition and o2 in the central
blood presusure
on brain visiom impaired

hipertension
headache Blurry vision

Sumber: (Cunningham, 2012).

12. How is the treatment?

Answer:
General handling.

 If the diastolic pressure is> 110 mmHg, antihypertensive pressure is given,

until the diastolic pressure is between 90-100 mmHg.
• Install RL (Ringer Lactate) infusion
• Measure the fluid balance, don't overdo it
• Urinary catheterization for published volume and proteinuria
• If the amount of urine <30 ml per hour:
 Infuse dilute 1 1/8 hour
• Don't leave the patient waiting. Seizures can lend aspiration Loss
of mother and fetus.
• Observe fetal vital signs, reflexes, and heart rate every hour.
• Pulmonary auscultation to look for signs of pulmonary edema. Is
crepitations signs of pulmonary edema. If pulmonary edema
occurs, stop administering fluids and Diuretics such as furosemide
40 mg intravenously are obtained.
• Blood clotting value by a bedside clotting test. If freezing does not
occur for 7 minutes, then there may be coagulapati

In patients who are already hospitalized with signs and symptoms of

severe preeclampsia, they must be immediately given a strong sedative
to prevent seizures. If after 12-24 hours the acute danger can be
overcome, can be given the best way to stop pregnancy. This action is
necessary to prevent further eclampsia. As a treatment to prevent the
occurrence of seizures can be given: (1) a solution of sulfas
magnesikus 40% with the use of other than calming, also lowering
blood pressure and increasing diuresis; (2) chlorpomazine 50 mg; (3)
diazepam 20 mg intramuscularly.
Performed therapy for complications: medical therapy by providing
drugs for complications.

- When gestational age <37 weeks: pregnancy is maintained as long

as possible while providing medical therapy.
- When gestational age ≥ 37 weeks: pregnancy is terminated after
receiving medical therapy for maternal stabilization. 
1) Management of severe preeclampsia includes seizure prevention,
treatment of hypertension, management of fluids, supportive
services for complications of the organs involved and the right
time for delivery.
2) People with severe preeclampsia should immediately be admitted
to the hospital for hospitalization and it is recommended to sleep
on their left side.
3) Fluid management in preeclampsia aims to prevent pulmonary
edema and oliguria.
4) Provision of anticonvulsant drugs in preeclampsia aims to prevent
seizures (eclampsia). Medications used as anticonvulsants:
- MgSO4 that is by giving an initial dose of 8 grams IM (4
grams of right buttocks and 4 grams of left buttocks) with a
further dose every 6 hours given 4 grams. 
The conditions for giving MgSO4 are:
o normal patella reflex,
o respiratory frequency> 16 times per minute,
o An antidote must be available, namely 10% Calcium
Gluconate (1 gram in 10 cc) given intravenously 3 minutes.
o MgSO4 administration must be stopped if intoxication
occurs, if it occurs then it is given:
 Calcium Gluconate injection of 10% (1 gram in 10 cc) and
after 24 hours postpartum. If there is refractory to the
administration of MgSO4, thiopental sodium, sodium
amobarbital, diazepam or phenytoin can be given
(Prawirohardjo, 2008).
5) The type of antihypertensive given is nifedipine 10-20 mg orally,
the initial dose is 10 mg, repeated after 30 minutes, the maximum
dose is 120 mg in 24 hours.
Blood pressure is gradually reduced, a) an initial reduction of 25%
from systolic pressure, b) blood pressure is reduced to <160/105
mmHg or MAP <125. 

13. What is the complication in this case?

Answer:

 Eclampsia
 Placental abruption
 Hypofibrinogenemia
 Brain hemorrhage.
 eye disorders
 pulmonary edema
 liver necrosis
 HELLP syndrome

14. What are the prognoses in this case?

Answer:

Dubia ad Bonam.
15. How is SKDU in this case?

Answer:

3B. Emergency.

Medical graduates are able to make clinical diagnoses and provide

preliminary therapy in emergencies to save lives or prevent the
severity and / or disability in patients. Medical graduates are able to
determine the most appropriate referral for subsequent patient
management. Medical graduates are also able to follow up after
returning from a referral.

16. What is the Islamic point of view in this case?

Answer:

Really repent Allah did not create a disease but also created a cure for
it except one disease. “That is an old disease (senile)”. In that case, we
must be patient and believe that God will provide acure for all ills and
nothing is impossible for us to recover, except for old diseases
(senile).

2.6 Conclusion
Mrs.Z 40 years old G5P4A0, 36 weeks pregnant, complain of blurry vision
since one day ago followed with severe headache because suffers severe
preeklampsia with impending eclampsia.

2.7 Conceptual framework

Risk Factor
- Maternal age
- Multigravida
- History of hypertension
 Pre- eclampsia

Increased sensitivity
to blood pressure

Angiotensin II Invlance tromboksan

release & protasiklin

Vasospasme in Vasocontriction
cortex cerebri systemic

Decrease of Blood circulation in Increase blood

nutrition and O2 the center of vision pressure
in the brain. impaired

Headache Blurry Vision Hypertension

Impending
Eclampsia

REFERENCES
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Pustaka Sarwono Prawirohardjo.

Cunningham F.G., 2012. Obstetri Williams. Cetakan 23, EGC, Jakarta.

Harini dkk. 2018. Perbedaan Kadar Kalsium Darah pada Kehamilan Preeklamsia
dengan Kehamilan Normotensi. Jurnal Kedokteran Brawijaya Vol. 30
http://jkb.ub.ac.id/index.php/jkb/article/view/2216.

Lismalinda. 2015. Buku Ajar Asuhan Kebidanan Kehamilan. Jakarta : Trans info
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Moussa, H.N.; Arian, S.E.; Sibai, B.M. Management of hypertensive disorders in

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Negro, A., Delaruelle, Z., Ivanova, T.A. et al. 2017. Headache and pregnancy.
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Opitasari, C & Andayasari, L. 2014. Parity, education level and risk for (pre-)
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