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 wasnt delivered yet after 2 hours bear down
Term pregnant Baby wasnt 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 (+)

OBSTETRIC HISTORY
1. This Pregnancy

Additional anamnesis :

Marital history :
, 21 y.o, senior high school, house wife , 22 y.o, STM, private employee

 Contraception
Last Menstrual Period

: : Nov, 5th 2004

Estimed birth pregnancy : August, 12th 2005

Prenatal care : midwife 11x,

PATIENTS HOME VISIT

Lived with her parents and husband in semi permanent house 5 x 7 m2
Mother was only housewife, her husband was private employee 300 m from nearest midwife 5 times PNC at Padasuka PHC

6 times at other midwife

PHYSICAL EXAMINATION
General Condition Blood Pressure Pulse rate Respiration Rate Temperature Body Weight Body Height Liver And Spleen Others : composmenthis, good : 160/110 mmHg : 80 x/mnt : 20 x/mnt : 36,50C : 57 kgs : 145 cms : hard to assess : within normal limits

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, 40 second, strong Estimated fetal weight : 2800 grams

INTERNAL EXAMINATION
Vulva/vaginal : No abnormalities
: Complete

Amnionic membrane : (-), residual fluid (+)

Head : St -1, caput (+) as big as egg

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

LABORATORY FINDINGS
Hemoglobins : 12,6 gr%
Leucocytes : 24.400/mm3 Ht : 38 % Trombocytes : 312.000/mm3 Urine : ++

Ureum/Creatinin : 22/1,48 mg/dl

Ur/Kr : 18/0,81 Blood Glucose : 85 mg/dl Asam urat : 4,3 mg/dl Na : 138 mEq/dl

SGOT/SGPT : 23/23 U/L

K : 2,6 mEq/dl

DIAGNOSIS
G1P0A0 term pregnant 2nd stage of labor +
severe preeclampsia +

cephalopelvic disproportion

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

Internal and neurology consult

 Planned to perform C-section due to cephalopelvic disproportion

Informed consent

Anaesthesiologist consult
Contact perinatologist Observation General condition, vital sign, fetal heart rate, uterine contraction

Internal department consult

Dk/ - G1P0A0 term parturition 2nd stage of labor + CPD - 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

Observation
Time 16.00-17.00 17.00-18.00 18.00-18.15 Uterine contraction 3-41x/45 S 3-41x/45S 3-41x/45S 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 - Admission test Baseline 140-150 bpm Variability > 5 bpm Akseleration (+) Deceleration (-) - Informed consent - BP resucitation - Internal and neurological consult

Internal Examination at 18.15: v/v : no abnormalities : complete Amniotic membrane : (-) Head : St -1, 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, FHR, uterine contraction

The patient was brought to EMG operating theatre

Cesarean section began.

The umbilical cord was delivered by gently traction of the cord

18.30 18.20
The patient arrived at EMG operating theatre UC : 3-41x/40 S FHS: 136-140 bpm

18.50

19.40 18.55

18.40
A male baby was born by head luxation BW:2770 gr, BL:49,3 cm Head circumference: 34 cm

 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

PROBLEMS
1. How to diagnose cephalopelvic disproportion on this patient? 2. What is the connection between cephalopelvic

disproportion with malpresentation and malposition of the fetal head ? 3. How was the severe preeclampsia management in this patient ? 4. Was the C-section performed in this patient was the best

choice?
5. What is the prognosis for next labor in this patient?

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

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 position of the fetus Ruptured membrane without labor

American College of Obstetricians and Gynecologists - ACOG (1995) Abnormalities caused dystocia

Abnormalities of the powers

Uterine contraction and mother power to beardown

Abnormalities involving the passenger

attitude, 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

CEPHALOPELVIC DISPROPORTION

FETAL

MOTHER

Normally size Excessive fetal size

Contracted pelvic Normally pelvic

COMBINATION

PELVIC TYPE

CEPHALOPELVIC DISPROPORTION

Absolute

Relative

Big fetal head or Small pelvic bone

Normally pelvic capacity But asynclitism (+) Extension (+)

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

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 < 100.000 /mm3 Increase LDH levels Increase liver enzym Cephalgia with visual and cerebral disturbance Epigastric pain Pulmonal oedema with cyanosis HELLP syndrome

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

CASE PRESENTATION Monday, September 5th 2005

ECLAMPSIA THAT SHOULD BE AVOIDABLE IN G3P2A0

By Dini Pusianawati

Moderator Hartanto, dr

Resource person : Prof. Djamhoer MAS,dr,SpOG(K) MSPH Tita Husnitawati, dr, SpOG(K) Budi Handono, dr, SpOG(K)