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DIFFICULTY OF DIAGNOSIS CEPHALOPELVIC DISPROPORTION AT A PRIMIGRAVIDA WITH SEVERE PREECLAMPSIA

By:

Yudha Pranata

INTRODUCTION
PROGRESS OF LABOR
CERVICAL EFFACEMENT AND DILATATION

DESCENT OF PRESENTING PART ABNORMAL

cephalopelvic disproportion

failure to progress

• PREGNANCY INDUCED HYPERTENSION
IS ONE OF THE FACTOR THAT CAUSED MATERNAL AND PERINATAL MORBIDITY AND MORTALITY

• C-SECTION DUE TO DYSTOCIA
CONTRIBUTED 1/3 OF THE TOTAL C-SECTION RATE

IDENTITY
NAME AGE ADDRESS EDUCATION OCCUPATION MEDICAL RECORD : Mrs. H
: 21 y.o : Cibeunying Bandung

: Senior High School
: House wife : 0504 xxxx

DATE OF ADMISSION : August 10th, 2005 at 16.00

• 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 wasn’t delivered yet after 2 hours bear down
Term pregnant Baby wasn’t delivered yet after 2 hours bear down

ANAMNESIS

15 HOURS
G1 P 0 A 0
HIGH BLOOD PRESSU RE

BEFORE ADMISSION  LABOR PAIN

 Know hypertension 5 hours before admission (160/110 mmHg)  History of hypertension (-)  Blurred vision, severe cephalgia, epigastric pain (-)

 Amnionic membrane (-) 6 hours before admission clear. febris (-)  Fetal movement (+) .

This Pregnancy Additional anamnesis :  Marital history : ♀. house wife ♂.o. private employee .OBSTETRIC HISTORY 1. 22 y. 21 y. senior high school.o. STM.

5th 2004  Estimed birth pregnancy : August. . 12th 2005  Prenatal care : midwife 11x. Contraception  Last Menstrual Period : : Nov.

her husband was private employee • 300 m from nearest midwife • 5 times PNC at Padasuka PHC 6 times at other midwife .PATIENT’S HOME VISIT • Lived with her parents and husband in semi permanent house 5 x 7 m2 • Mother was only housewife.

good : 160/110 mmHg : 80 x/mnt : 20 x/mnt : 36.50C : 57 kgs : 145 cms : hard to assess : within normal limits .PHYSICAL EXAMINATION          General Condition Blood Pressure Pulse rate Respiration Rate Temperature Body Weight Body Height Liver And Spleen Others : composmenthis.

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. strong Estimated fetal weight : 2800 grams . 40 second.

caput (+) as big as egg .INTERNAL EXAMINATION Vulva/vaginal : No abnormalities  : Complete Amnionic membrane : (-). residual fluid (+) Head : St -1.

PELVIC EXAMINATION Promontorium Linea innominata Sacrum Spina ischiadica Pubic Arcus Side.wall Pelvic : not palpable : palpated 1/3 – 1/3 : Concave : not prominent : >90 o : straight : good .

81 Blood Glucose : 85 mg/dl Asam urat : 4.3 mg/dl Na : 138 mEq/dl SGOT/SGPT : 23/23 U/L K : 2.400/mm3 Ht : 38 % Trombocytes : 312.6 mEq/dl .000/mm3 Urine : ++ Ureum/Creatinin : 22/1.48 mg/dl Ur/Kr : 18/0.6 gr% Leucocytes : 24.LABORATORY FINDINGS Hemoglobins : 12.

DIAGNOSIS • G1P0A0 term pregnant 2nd stage of labor + severe preeclampsia + cephalopelvic disproportion .

cross match. thoracal Ro. then MgSO4 40% intramuscular for maintenance dose • ECG. blood reserve • MgSO4 40% intramuscular injection (RB Al-Islam) • MgSO4 20% intravenous. complete laboratory result • Internal and neurology consult .PLAN OF MANAGEMENT • KaEn 1B infussion.

uterine contraction . vital sign. fetal heart rate.• Planned to perform C-section due to cephalopelvic disproportion • Informed consent • Anaesthesiologist consult • Contact perinatologist • Observation General condition.

G1P0A0 term parturition 2nd stage of labor + CPD .Internal department consult Dk/ .severe preeclampsia Advis : • Low dietary salt • Metyldopa 3x500 mg titration dose .

Neurologist consult Dk/ .2nd hypertension in pregnancy Advis : • Blood pressure regulation according to Internal Department • Consult if there was focal neurological deficit .

00 18.00-18.Internal and neurological consult Internal Examination at 18.00-17.Informed consent .00-18.15: v/v : no abnormalities  : complete Amniotic membrane : (-) Head : St -1.Observation Time 16.BP resucitation .15 Uterine contraction 3-4’1x/45” S 3-4’1x/45”S 3-4’1x/45”S FHR (x/mnt) 136-140 140-144 144-148 BP (mmHg) 160/110 170/110 160/160 PR (x/mnt) 80 84 88 RR (x/mnt) 20 24 24 Information .00 17.Admission test Baseline 140-150 bpm Variability > 5 bpm Akseleration (+) Deceleration (-) . caput (+) as big as egg .

D/ G1P0A0 term parturition 2nd stage of labor + cephalopelvic disproportion + severe preeclampsia T/ Planned to perform C-section due to cephalopelvic disproportion Anaesthesiologist consult Contact perinatologist and operation theatre Observation vital sign. uterine contraction . FHR.

20 The patient arrived at EMG operating theatre UC : 3-4’1x/40” S FHS: 136-140 bpm 18. The umbilical cord was delivered by gently traction of the cord 18.40 18.50 19.55 18.3 cm Head circumference: 34 cm .30 18.The patient was brought to EMG operating theatre Cesarean section began.40 A male baby was born by head luxation BW:2770 gr. BL:49.

• Preoperative diagnosis : G1P0A0 term parturition 2nd stage of labor + cephalopelvic disproportion + severe preeclampsia • Postoperative diagnosis P1A0 term delivery by C-section due to cephalopelvic disproportion + severe preeclampsia • Type of surgery : SCTP + IUD insertion .

How to diagnose cephalopelvic disproportion on this patient? 2. How was the severe preeclampsia management in this patient ? 4. What is the connection between cephalopelvic disproportion with malpresentation and malposition of the fetal head ? 3. What is the prognosis for next labor in this patient? . Was the C-section performed in this patient was the best choice? 5.PROBLEMS 1.

DISCUSSION .

1. How to diagnose cephalopelvic disproportion on this patient? Labor progress Progresif progress of cervical effacement and dilatation Fetal descent Abnormal Inadequate uterus contraction Birth canal resistention .

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Clinical findings in woman with ineffective labor Inadequate cerviks dilatation or fetal descent Protracted labor-slow progress Arrested labor-no progress Inadequate expulsive effort Fetopelvic diproportion Excessive fetal size Inadequate pelvic capacity Malpresentation or position of the fetus Ruptured membrane without labor .Tabel 1.

ACOG (1995)  Abnormalities caused dystocia Abnormalities of the powers Uterine contraction and mother power to beardown Abnormalities involving the passenger attitude.American College of Obstetricians and Gynecologists . size and fetal abnormalities Abnormalities of the passage Pelvic bone and soft tissue abnormalities .

Dystocia Abnormally slow progress of labor Cephalopelvic disproportion Failure to progress .

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CEPHALOPELVIC DISPROPORTION FETAL MOTHER Normally size Excessive fetal size Contracted pelvic Normally pelvic COMBINATION .

PELVIC TYPE .

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CEPHALOPELVIC DISPROPORTION Absolute Relative Big fetal head or Small pelvic bone Normally pelvic capacity But asynclitism (+) Extension (+) .

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TRUE DISPROPORTION MOLDING WITHOUT DESCENT OF PRESENTING PART VAGINAL DELIVERY WAS IMPOSSIBLE .

EXAMINE THE DISPROPORTION ABDOMINAL EXAMIINATION ( OSBORN SIGN ) ABDOMINOVAGINAL EXAMINATION ( MULLER SIGN ) X-RAY OR USG PELVIMETRY .

IN THIS CASE • 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 (+) DISPROPORTION CAUSED BY MALPRESENTATION OR BY MALPOSITION .

Tabel 1. Clinical findings in woman with ineffective labor Inadequate cerviks dilatation or fetal descent Protracted labor-slow progress Arrested labor-no progress Inadequate expulsive effort Fetopelvic diproportion Excessive fetal size Inadequate pelvic capacity Malpresentation or malposition of the fetus Ruptured membrane without labor .

MALPRENTATION : NON VERTEX PRESENTATION • BREECH PRESENTATION 3% • BROW PRESENTATION 1/1500 DELIVERY • FACE PRESENTATION 1/500 DELIVERY MALPOSITION : ABNORMALLY VERTEX POSITION TO THE MATERNAL PELVIC • OCCIPITOLATERAL • OCCIPITOPOSTERIOR .

TYPE OF PRESENTATION .

ILLUSTRATION OF PRESENTATION .

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000 /mm3 • Increase LDH levels • Increase liver enzym • Cephalgia with visual and cerebral disturbance • Epigastric pain • Pulmonal oedema with cyanosis • HELLP syndrome .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.

MgSO4 • Continuous intravein infusion Initial dose : 4 g (20 cc MgSO4 20%) in 100 cc RL for 15-20 minutes Maintenance dose : 10 g (50 cc MgSO4 20%) in 500 cc RL 1-2 g/h (20-30 gtt/minutes) • Intermitten intramuscular Initial dose : 4 g (20 cc MgSO4 20%) iv with 1 g/minutes Maintenance dose : 4 g (10 cc MgSO4 40%) every 4 h .

LOW SALT DIETARY • NOT SIGNIFICANTLY REDUCED BLOOD PRESSURE • SALT RESTRICTIF MAY CAUSE DECREASE OF RBF AND PLACENTAE .

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 verteks presentation was rare • No indication for assisted delivery by vacuum or forcipal extraction .

PROGNOSIS FOR THE NEXT DELIVERY ASNM : CPD 1/250 DELIVERY AJPH : MORE THAN 65 % MOTHER WHO HAD BEEN DIAGNOSED WITH CPD. WERE ABLE TO DELIVER VAGINALLY IN NEXT PREGNANCIES .

CONCLUSION • Diagnose of CPD in this case was not strongly enough • CPD caused by malpresentation was dystocia • Severe preeclampsia management in this case was inadequat • C-section should be performed by adequat indication • The next labor can performed by vaginally delivery .

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dr. Djamhoer MAS. SpOG(K) . dr.CASE PRESENTATION Monday. September 5th 2005 ECLAMPSIA THAT SHOULD BE AVOIDABLE IN G3P2A0 By Dini Pusianawati Moderator Hartanto. SpOG(K) Budi Handono. dr. dr Resource person : Prof.SpOG(K) MSPH Tita Husnitawati.