Case Report

G2P1A0 gravid 32-33 weeks Stage 1 Parturition on

Active Phase with Mild Preeclampsia

Counsellor
dr. Gioseffi Sp.OG

Presented by
Edwinda Desy Ratu (112014021)

OBSTETRICS AND GYNECOLOGY CLERKSHIP

FACULTY OF MEDICINE KRIDA WACANA CHRISTIAN UNIVERSITY
CIAWI GENERAL HOSPITAL, BOGOR
Period July 27th 2015 October 3rd 2015

Hospitalised at Ciawi general hospital on Thursday, September 3rd, 2015 (at 09.30 am)
Reffered from the Obstetric and Gynecology policlinic
Patients Identity

Name

: Mrs. TN

Age

: 30 years old

Occupation

: House wife

Education

: Junior High School

Race

: Sundanese

Religion

: Moslem

Address

: Bendungan village, 03/01 Ciawi, Bogor

Patients Husbands Identity

Name

: Mr. L

Age

: 36 years old

Occupation

: Self - employed

Education

: Junior High School

Race

: Sundanese

Religion

: Moslem

Address

: Bendungan village, 03/01 Ciawi, Bogor

Anamnesis
With auto anamnesa on September 3rd, 2015 (at 12.45 am)
Chief complaint: A contraction
Present Illness:
Patient came to the Obstetric and Gynecology policlinic on September 3rd, 2015 to
control her pregnancy. Patient said she had a contraction since 10 pm last night (02/09/2015)
with a regular interval and stronger contraction after each interval. Headache (-), blurred
vision (-), epigastric pain (-), nausea and vomitus (-). Blood and secrete (-). This is her 2nd
pregnancy. She has no history of miscarriage. The first child was born normally at the right
term and helped by the midwife. 1 week before the patient was hospitalized because of severe
preeclampsia and got MgSO4 treatment.

Patients first day of the last period of menstruation is Descember 1 st, 2014. The labor
estimacy date is September 7th, 2015. Patient has a regular pregnancy checkup for 8 times
during her pregnancy. History of USG in Ciawi hospital and the result was normal.
Past Medical History:
-

Hypertension (-)

Diabetes (-)

Heart Disease (-)

Asthma (-)

Head trauma (-)

Epilepsy (-)

Irregular menstruation cycle (-)

Food and Drugs Allergy (-)

Menstruation History:
-

Menarche

: 12 years old

Menstrual cycle

: 28 days

Duration

: 7 days

Menstrual pain

: (-)

Marriage History:
First marriage, during her 26th years old.
Contraseption history:
There is no contraception history
Operation History:
There is no operation history
Antenatal Care:
Regular, monthly visit to midwife, supplement: fe & folic acid (+), Anti hypertensive oral (-)

Physical Examination
on September 3rd, 2015. (at 12.45 am)

General Situation : Moderate pain

Awareness

: Compos Mentis

Vital Sign

Blood pressure

: 140/100 mmHg

Heart Rate

: 76 x/min

Respiratory rate

: 18 x/min

Temperature

: 36.5oc

Body weight
Body height

: 66 kg
: 165 cm

GENERAL EXAMINATION
Head

Eye

: conjunctiva anemic -/- ; sclera icteric -/-

Ear

: pain -/- ; secret -/-

Nose

: deviation septum -/- ; secret -/-

Throat

: Tonsil T1 T1 normal, pharynx hyperaemic (-)

Mouth

: oral hygiene (+); mucosa normal

Neck

: trachea in the middle, lymph nodes and thyroid normal

Thorax

Mammae

Pulmo

: normal, inverted nipple (-)

inspection

: symetric, retraction (-)

palpation

: fremitus tactil right = left

percusion

: sonor +/+

auscultation

: vesicular +/+; rhonchi -/-; wheezing -/-

inspection

: pulse of ictus cordis can not be seen

palpation

: pulse of ictus cordis can not palpable

percussion

: dull, heart margins within normal limits

auscultation

: Heart sounds I/II regular, gallop (-), murmur (-)

Cor

Abdomen
Inspection

: bulge, striae gravidarum (+)

Auscultation

: bowel sound (+) normal

Percusion

: timpany

Palpation

: epigastric pain (+),defense musculaire (-)

Genital
Vulva/ vaginal no abnormalities, blood (-), secret (+)
Extremities
-

Warm hand and feet

Oedema -/-;+/+

CRT <2 seconds

Reflexes

: KPR +/+

Obstetric and gynecologic Abdominal Examination

Leopold 1 : breech, Fundal Height :23 cm
Leopold 2 : Fetal back on the right side, fetal heart rate : 117 times/minute
Leopold 3 : vertex
Leopold 4 : already engaged of the presenting part
External genitalia
Inspection

: Vulva and Vagina are within normal conditions,Bleeding (-), secret (+)

Internal Genitalia
Vaginal touch
Vulva and Vagina are within normal conditions, portio was not thin, external uterine ostium
opened, diameter 4 cm. Amnion (+). Presentation of the babys vertex on Hodge 2. On glove
findings, fresh blood (-), secrete (+).

Workup
Laboratory findings on September 3rd, 2015 ( 04.00 pm)

Haematology

Acidity (Ph)

: 5,5

Hb

: 12.6 g/dl

Concentration

: 1,030

Ht

: 42 %

Proteinuria

:+

Leucocyte

: 9500 /l

Glucose

: Normal

Platelet count

: 240000 /l

Ketones

:-

CT

: 1030

Bilirubin

: Normal

BT

: 230

Eritrocyte

: (-)

Blood Type

: AB, Rh (+)

Urobilinogen

: (-)

Leukocyte

: (-)
: (-)

Chemistry

Blood glucose

:93 mg/dL

Nitrit

SGOT

: 37 U/L

White Blood Cells: 20-25

SGPT

: 25 U/L

Red Blood Cells : 50-55

Ephitelial Cells

: 1-3

Urinalysis

Color

: Yellow

Bacteria

: (-)

Cloudiness

: Moderate

Yeasts

: (-)

Casts

: (-)

Crystals

: (-)

cloudiness

Imuno Serology

HbsAg

: Non-reactive

HIV 1-2 Rapid

: Non-reactive

Resume
A 30 years old woman come to the policlinic with a contraction since 10 pm (2/9/2015) with
a regular interval and stronger contraction after each interval. Secrete (+).
1 week ago she was hospitalized because of severe preeclampsia and got MgSO4 treatment
for 2 days. This is her 2nd pregnancy, no history of miscarriage.
The date of first day of the last period of menstruation is December 1 st 2014. Patient has a
regular pregnancy checkup for 8 times during her pregnancy. History of USG in Ciawi
hospital and the result was normal.
From the general physical examination,the patient looks moderate pain/compos mentis
Vital signs:
Blood pressure

: 140/100 mmHg

Heart Rate

: 76 x/min

Respiratory rate

: 18 x/min

Temperature

: 36.5oc

Abdomen looks bulge, striae gravidarum (+). On the palpation, epigastric pain (-), palpated
the breech on the fundus with fundal height 23 cm. Back of the baby is at right side with fetal
heart rate : 117 times/minute. Presentation of vertex and already engaged of the presenting
part. The external genitalia is within normal condition with blood (-) and secret (+). Lower
extremities looks oedema. On the vaginal touche: Vulva and Vagina are within normal
conditions, portio was thin, external uterine ostium opened with diameter 4 cm. Amnion (+).
Presentation of the babys breech on Hodge 2. On glove findings, secret (+).
From the laboratories finding :
Urinalysis

Protein

:+

Working Diagnosis :
G2P1A0 gravid 32-33 weeks stage 1 parturition on active phase with mild preeclampsia
Management:
Advice from ObsGyn specialist

IVFD RL 500 cc (18 - gauge cannula x 1 ) 20 tpm, cross match, blood reserve
Dower Catheter no 16
Monitoring of vital signs and contraction

Prepare for vaginal delivery

Nifedipine 3x10 mg tab PO
Metyldopa 3 x 500 mg tab PO

(3/9/2015) 10.30 am : vaginal delivery

Born a baby boy
Weight : 2150 gram
Height : 45 cm
Head round : 30 cm
Chest round : 31 cm
A/S 8/9
Follow Up (September 4th , 2015, at 07.00 AM on VK)
S

: Breast milk +/+

: Compos Mentis

Vital Sign:

BP

: 130/ 90 mmHg

Pulse

: 84 x/mins

RR

: 20 x/mins

Temperature

: 36,2oC

General exam :
Eye

: CA -/- , SI -/-

Thorax

: C/P within normal limit

Abdomen

: flat, supple, bowel sound +, fundal height at 2 fingers below

umbilical, uterine contraction: good

Gen

: v/v normal, lochia(+)

Extremities

: Oedema -/-;- /-

: P2A0 post vaginal delivery day 1 with mild precclampsia

: Cefadroxil 500 mg tab (2 x 1)

Mefenamic acid 500 mg tab (3 x 1)
SF tab (1 x 1)
Nifedipine 10 mg (1x1)

Follow Up ( September 5th , 2015, at 07.00 AM on VK)

S

: Breast milk +/+

: Compos Mentis

Vital Sign:

General exam
Eye
Thorax
Abdomen

BP

: 130/ 80 mmHg

Pulse

: 88 x/mins

RR

: 18 x/mins

Temperature

: 36.5oC

:
: CA -/- , SI -/: C/P within normal limit
: flat, supple, bowel sound + normal, fundal height at 2 fingers below

umbilical, uterine contraction: good

Gen
: v/v normal, lochia(+)minimal
Extremities : Oedema -/-; -/A

: P2A0 post vaginal delivery day 2 with mild preecclampsia

: Cefadroxil 500 mg tab (2 x 1)

Mefenamic acid 500 mg tab (3 x 1)
SF (1 x 1)
Nifedipine (1x1)
Allowed to dicharge from hospital. Control to obgyn policlinic 7 days later

General discussion

The diagnose of this patient is G2P1A0 gravid 32-33 weeks stage 1 parturition on
active phase with mild preeclampsia

Case analysis
A 30 years old woman come to the policlinic for her preeclampsia control. She also had a
contraction since 10 pm (2/9/2015) with a regular interval and stronger contraction after
each interval. Secrete (+).
1 week ago she was hospitalized because of severe preeclampsia and got MgSO4
treatment for 2 days. This is her 2nd pregnancy, no history of miscarriage.
The date of first day of the last period of menstruation is December 1 st 2014. Patient has a
regular pregnancy checkup for 8 times during her pregnancy. History of USG in Ciawi
hospital and the result was normal.
From the general physical examination,the patient looks moderate pain/compos mentis

Vital signs:
Blood pressure

: 140/100 mmHg

Heart Rate

: 76 x/min

Respiratory rate

: 18 x/min

Temperature

: 36.5oc

Abdomen looks bulge, striae gravidarum (+). On the palpation, epigastric pain (-),
palpated the breech on the fundus with fundal height 23 cm. Back of the baby is at right
side with fetal heart rate : 117 times/minute. Presentation of vertex and havent engaged
of the presenting part. The external genitalia is within normal condition with blood (-) and
secret (+). Lower extremities looks oedema. On the vaginal touche: Vulva and Vagina are
within normal conditions, portio was thin, external uterine ostium opened with diameter 4
cm. Amnion (+). Presentation of the babys breech on Hodge 2. On glove findings, secret
(+).
From the laboratories finding

Urinalysis

Protein

:+

Theory
Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm
that occurs after 20 weeks' gestation and can present as late as 4-6 weeks post partum. It
is clinically defined by hypertension and proteinuria, with or without pathologic edema.[1]
Mild preeclampsia is defined as the presence of hypertension (BP 140/90 mm Hg) on 2
occasions, at least 6 hours apart, but without evidence of end-organ damage, in a woman
who was normotensive before 20 weeks' gestation. In a patient with preexisting essential
hypertension, preeclampsia is diagnosed if SBP has increased by 30 mm Hg or if DBP has
increased by 15 mm Hg.[1]
Risk factors for preeclampsia and their odds ratios are as follows :

Nulliparity

Age >40 years

Family history

Chronic renal disease

Chronic hypertension

Antiphospholipid syndrome

Diabetes mellitus

Twin gestation (but unaffected by zygosity)

High body mass index

Low social-economic status

Signs and symptoms[1]

Because the clinical manifestations of preeclampsia can be heterogeneous, diagnosing
preeclampsia may not be straightforward. Mild to moderate preeclampsia may be
asymptomatic. Many cases are detected through routine prenatal screening.
Patients with severe preeclampsia display end-organ effects and may complain of the
following:

Headache

Visual disturbances: Blurred, scintillating scotomata

Altered mental status

Blindness: May be cortical or retinal

Dyspnea

Edema: Sudden increase in edema or facial edema

Epigastric or right upper quadrant abdominal pain

Weakness or malaise: May be evidence of hemolytic anemia

Clonus: May indicate an increased risk of convulsions

In case:
From this anamensis, we get information about risk factors of preeclampsia in this patient
such as low socialeconomic status.
And then we find manifestations of mild preeclampsia such as high blood pressure. It
happened in 32 weeks of gestation. And usually mild to moderate preeclampsia may be
asymptomatic.
Case analysis:

From the laboratories finding

Urinalysis
Protein
:+

Theory:
Pre-eclampsia was classified into severe and nonsevere/mild (figure 1). Some symptoms
are considered to be ominous. Headaches or visual disturbances such as scotomata can be
premonitory symptoms of eclampsia. Epigastric or right upper quadrant pain frequently
accompanies hepatocellular necrosis, ischemia, and edema that ostensibly stretches Glisson
capsule. This characteristic pain is frequently accompanied by elevated serum hepatic
transaminase levels. Finally, thrombocytopenia is also characteristic of worsening
preeclampsia as it signifies platelet activation and aggregation as well as microangiopathic
hemolysis. Other factors indicative of severe pre-eclampsia include renal or cardiac
involvement and obvious fetal growth restriction, which also attests to its duration.
As will be discussed, the more profound these signs and symptoms, the less likely they can be
temporized, and the more likely delivery will be required. A caveat is that differentiation
between nonsevere and severe gestational hypertension or preeclampsia can be misleading
because what might be apparently mild disease may progress rapidly to severe disease.[2]
Table 1. indicators of severity of gestational hypertensive disorders[2]

In case:
From physical examination and laboratory findings, we can get information about high blood
presure, upper and lower extremities oedema and proteinuria +1 that manifest of mild
preeclampsia.
On laboratory findings there protein + were signed.

from anamnesis, physical examination, and laboratory finding, we can diagnose this patient
as Mild/Non Severe Pre-eclampsia.
Management:
Advice from ObsGyn specialist

IVFD RL 500 cc (18 - gauge cannula x 1 ) 20 tpm

Dower Catheter no 16
Monitoring of vital signs and contraction
Prepare for vaginal delivery
Nifedipine 3x10 mg tab PO
Metyldopa 3 x 500 mg tab PO

Theory:
The basic management objectives for any pregnancy complicated by preeclampsia are: (1)
termination of pregnancy with the least possible trauma to mother and fetus, (2) birth of an
infant who subquently thrives, and (3) complete restoration of health to the mother. In many
women with preeclampsia, especially those at or near term, all three objectives are served
equally well by induction of labor.[2]
Consideration of Delivery[2]
Headache, visual disturbance, or epigastric pain are indicative that convulsions may be
imminent, and oliguria is another ominous sign. Severe preeclampsia demands anticonvulsat
and frequently antihypertensive therapy, followed by delivery. Treatment is identical to that
described subsequently for eclampsia. The prime objectives are to forestall convulsions, to
prevent intracranial hemmorage and serious damage to other vital organs, ant to deliver a
healthy newborn.
When the fetus is preterm, the tendency is to temporize in the hope that a few more weeks in
utero will reduce the risk of neonatal death or serious morbidity from prematurity. As
discussed, such as a policy certainly justified in midler cases. Assessments of fetal well-being
and placental function are performed, especially when the fetus is immature. Most
recommend= frequent performance of various test to assess fetal well-being as described by
the American College of Obstetric and Gynecologists (2012). These include the nonstress test
or the biophysical profile. Measurement of the lecithin-sphingomyelin ration in amnionic
fluid may provide evidence of lung maturity.
With moderate or severe preeclapsia that dies not improve after hospitalization, delivery is
usually advisable for the welfare of both mother and fetus. This is true even when the servix
is unfavorable. Labor induction is carried out, usually with preinduction cervical ripening

from prostaglandin or osmotic dilator. Whenever it appears that induction almost certainly
will not succeed or attempts have failed, then caesarean delivery is indicated.
For a woman near term, with a soft, partially effaced cervix, even milder degrees of
preeclampsia probably carry more risk to the mother and her fetus-infant than does induction
of labor. The decision to deliver late preterm fetuses is now clear. Excessive neonatal
morbidity in women delivered before 38 weeks despite having stable, mild, nonproteinuric
hypertension. The Netherlands study of 4316 newborns delivered between 34 and 36 weeks,
and the higher caesarean delivery rates were associated with more respiratory complications.
Hospitalization versus Outpatient Management
For women with mild to moderate stable hypertension whether or not preeclampsia has
been confirmed surveillance is continued in the hospital, at home for some reliable patients,
or in a day-care unit. At least intuitively, reduced physical activity throughout much of the
day seems beneficial. Several observational studies and randomized trials have addresses the
benefits of inpatient care and outpatient management.[3]
Antihypertensive treatment[4,5,6]
Antihypertensive treatment is useful only in severe pre-eclampsia because the sole proven
benefit of such management is to diminish the risk of maternal complications (cerebral
hemorrhage, eclampsia, or acute pulmonary edema). There is no international consensus
concerning antihypertensive treatment in pre-eclampsia. The four drugs authorized for the
treatment of hypertension in severe preeclampsia in France are nicardipine, labetalol,
clonidine, and dihydralazine. There is no ideal target blood pressure value, and too aggressive
a reduction in blood pressure is harmful to the fetus. Therapy with a single agent is advised as
first-line treatment, followed by combination treatment when appropriate. The algorithm for
antihypertensive treatment proposed by French experts is shown in Figure 1.

Figure 1. antihypertensive therapy for pre-eclampsia

Source:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148420/figure/f1-vhrm-7-467/

In case:
We gave supportive care such iv line, and dower catheter for control fluid balance. And we
replaced patient to left lateral decubitus to improve uterine blood flow.
The drug of choice to treat hypertension is nifedipine p.o 3 x 10 mg
We didnt use Magnesium Sulfate therapy because the patient was not in severe preeclampsia
Delivery is happened because the patient already had a contraction.
We prepared for vaginal delivery. (from gynecology examination findings)
BP should be assessed with the goal of maintaining the diastolic BP at less than 110 mm Hg
with administration of antihypertensive medications as needed (nifedipine)

References

1. Shah AK, Steinberg G, Zwanger M. Preeclampsia. Downloaded from

http://emedicine.medscape.com/article/1476919-overview#a1. On September
5th 2015.
2. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL,
et al. Hypertensive disorder. In: Williams obstetric. 24th ed. New York:
McGraw Hill, 2014.p.730-52.
3. Uzan J, Carbonnell M, Piconne O, Asmar R, Ayuobi JM. Pre-eclampsia:
pathophysiology, diagnosis, and management.
4. Duley L, Henderson-Smart J, Meher S. Drugs for treatment of very high blood
5.

pressure during pregnacy. Cochrane Database Syst Rev. 2006;(3):CD001449.

Olsen KS, Beier-Holgersen R. Fetal death following labetalol administration

in pre-eclampsia. Acta Obstet Gynecol Scand. 1992;7:145147.

6. Gabbe. Obstetrics: Normal and Problem Pregnancies. Hypertension. 5th ed.
Churchill Livingstone, An Imprint of Elsevier; 2007. [Full Text].