clinical conference 091213
TRANSCRIPT
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Diannisa Ikarumi
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Physiological delivery 1 case
Pathological delivery Spontaneous 2 cases Vaccum-extraction -
Major operation Cesarean section 6 cases Gynecology 2 cases Oncology 3 cases
Hysteroscopy-Laparoscopy 1 case
Minor operation Curretage - Sterilization 1 case
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1. Mrs. LS, 22yo, G1P0A0
Breech presentation, primigravida 30 weeks 3 days pregnancy,
with sepsis, CKD stage V, HHD, pneumonia, anemia
(Maternal Fetal Medicine)
2. Mrs. HN, 33yo, G1P0A0
Multiple gestation/triplet (breech-transverse-transverse), IUFDof second fetus , 32 weeks 3 days pregnancy, with anemia,
moderate renal insufficiency & epulis granulomatosus(Maternal Fetal Medicine)
3. Mrs. S, 25yo, G3P0A2Multigravida Nullipara, 34 weeks pregnancy, with ITP
(Progress report-Maternal Fetal Medicine)
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A woman came with main complaintbreathing difficulty 1 day before andithcyness since 2 months.
Patient was diagnosed suffering from kidneyfaillure and treated with hemodyalisis (3x)and PRC transfusion (3packs).
She also complaining edema in allextremities. High blood pressure since 2weeks before
No complaints in micturition and defecation
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Conscious, anemic and icteric
Vital sign: BP:130/90mmHg, P:108bpm,
RR:28x/min, T: 36.5oC On auscultation: Heart gallop, rhonci present
Edema anasarca
Abd palpation: singleton baby, breech
presentation, FH 18 cm, UC(-), FHR 142bpm
BE: normal vulva, smooth vaginal wall, cervix
normal,(-), bloody show(-), AF(-)
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WBC 21 .6 x 103/ l(neutrofilia)
RBC 3.16 x 106/ l Hb 8.9 g/dl Hct 26.9% Plt 448 x 103/ l MCV 85.2fl (80-99) MCH 28.3pg (27-31) MCHC 34.3g/dl (33-37) RDW 12.8% (11.5-14.5)
Retikulosit 0.8 % (0.5-1.5) Sat. index 19% (26-50) Feritin 435 (9.3-159) TIBC 223 (228-428) IBC 180 (112-346)
Creat 7.77 mg/dl (0.6-1.3) BUN 76mg/dl (7-18) Alb 2.15g/dl CCT 10.7 SGOT 24 l (15-37) SGPT 34 l (
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1/12 2/12 4/12 5/12 7/12
BUN
mg/dl
35.8 59 67 31.8 6
Crea
mg/dl
4.09 6.94 7.4 3.59 1.28
Hb
g/dl
7.3 6.8
WBC
x 103/ l
12.3 7.7
RBCx 106/ l
2.5 2.27
Hct
%
21.4 19.5
Plt
x 103
/ l
446 378
Na
mmol/l
138 134 136 142
K
mmol/l
4.2 4.8 3.6 2.3
Clmmol/l
103 108 106 100
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Urinalysis Proteinuria +3 Pale leucocyte +1 Bacteriuria (-)
Sputum exam BTA negative Gram (+) coccus positive Gram (-) basil positive
Chest X-ray Bronchopneumonia Pulmonary edema Cor normal
Negative blood culture
Peripheral blood exam Normochromic-normocytic
anemia Abnormal morphology of RBC
(anisositosis) Leucocytosis, absolute reactiveneutrophilia
ConclusionAnemia of chronic disease with
bacterial infection
ECG STC HR 120 ncomplete RBBB
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USG
(6/12/13)
singleton fetus,breechpresentation,FHR visible,
movementpresent. Noanomaly visible.
BPD: 6.88cm
AC: 24.7cmFL: 5.48cmEFW 1279 gramsGA: 28wks 3days
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Sepsis Breech presentation
Primigravida 30
weeks 3 dayspregnancy CKD stg V susp GNC Pneumonia HHD Anemia Hyperbilirubinemia Hyperkalemia Hypoalbuminemia
O2 3lpm (NK) Inf. NaCl 0.9% 20 dpm Inj. Cefoperazone 1g/12h/iv
Inj. Dexamethasone5mg/12h/iv Methyldopa 250mg/8hrs/oral Paracetamol 500mg/oral/prn Folic acid 3x1 Ca CO3 3x1 Transfusion of PRC
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BP: 130/90mmHg HR: 98bpm RR: 24x/min
T: 36.5 oC
FHR: 142bpm UO: 0.4ml/kgBW/hr
Plan: Serial hemodyalisis
2-4x/week
Abdominal & renalultrasound
Echocardiography Check for dysmorphic
erythrocyte Urine culture observe UC & FHR NST
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Pregnancy 30weeks Anemia
Hypertensive Heart DiseasePneumonia
TERMINATIVE
ORCONSERVATIVE
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A pathophysiological process that results in end-stage renal disease through a progressive loss ofnephron number & function.
Multiple etiologies ie diabetes (33%),hypertension (24%), glomerulonefritis (17%),polycystic kidney disease (15%) must be presentfor at least 3 months.
Successful pregnancy outcome in general maybe more related to renal insufficiency andproteinuriathan to the specific underlyingdisorder.
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In this patient, conservative management until
34weeks gestation may be considered, if the
following criteria met:
1. Blood pressure can be controlled 140/90mmHg
2. Optimal glomerular filtration rate,
achieved by 5-7x hemodyalisis per week
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Patient referred from Aisyah Hospital, Muntilanwith preterm triplet pregnancy with severepreeclampsia susp. HELLP syndrome.
Patient complained of gum bleeding 2 daysbefore admision. No history of spontaneousbleeding before
No symptoms of delivery Routine ANC in midwives and doctor No history of hypertension, parents suffer from
hypertension
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General condition: conscious, good, notanemic
palpation : triple fetus, breech presentation,FH 38 cm, UC (-), FHR I : 148 bpm, FHR II : 155
bpm, FHR III: 157 bpm
BE : normal vulva, smooth vaginal wall,
cervix normal, (-), breech presentation,
sacrum in H1, Bloody show (-), AF (-)
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Triplet fetus,
intrauterine
Placenta atfundus
Triamnion,
monochorion
Adequateamniotic fluid
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Fetus I : FHR present, BPD 7.24cm~29 wks AC 25.82cm~30wks FL 5.56cm~29wks 2dys EFW 1484 g
Fetus II: FHR present BPD 7.14cm~28 wks 5dys AC 23.6cm~28wks FL 5.82cm~30wks 3dys EFW 1230 g
Fetus III: FHR present BPD 7.25cm~29 wks 1 dys AC 23.65cm~28wks FL 5.4cm~28wks 4dys EFW 1235 g
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Fetal IFHR baseline 135 bpmVariability >5Acceleration +Deceleration Movement +NST reactive
Fetal IIFHR baseline 125 bpm
Variability >5Acceleration +Deceleration Movement +NST reactive
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WBC 8.34 x 103/ l RBC 3.34 x 106/ l Hb 8.2 g/dl Hct 26.1% Plt 223 x 103/ l MCV 78.3fl (80-99) MCH 24.6pg (27-31) MCHC 31.5g/dl (33-37) RDW 17.3% (11.5-14.5) Retikulosit 1.7% (0.5-1.5) Sat. index 8% (26-50) Fe 40 Feritin 57.3 (9.3-159) TIBC 479 (228-428) IBC 439 (112-346)
Creat 1.06mg/dl (0.6-1.3) BUN 18mg/dl (7-18) Alb 2.78g/dl SGOT 27 l (15-37) SGPT 19 l (
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Urinalysis Proteinuria +3
(600mg/dl)
Bacteriuria 158/Ul(
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WBC x 103/ l 8.34 10.20 12.3
RBC x 106/ l 3.34 2.50 2.35
Hb g/dl 8.2 6.2 5.9
Hct % 26.1 19.8 18.9
Plt x 103/ l 223 220 209
Na mmol/l 133 129
K mmol/l 6,1 5,36
Cl mmol/l 108 99
Albumin g/dl 2,78
BUN mg/dl 18 54
Crea mg/dl 1,06 1.75
Fibrinogen mg/dl 328 (215-325)
D dimer ng/ml 3200 (200)
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Multiple gestation(triplet), IUFD fetus II
32 wks 2dys
pregnancy Anemia MH susp irondeficiency
High output heartfailure
Epulis granulomatous Mild renal
insufficiency
Conservative management Observation of UC & FHR Transfusion of PRC Inj. Dexamethason
5mg/12h/iv SF 1 tab/24h/oral Erithromycin 500mg/6h/oral
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BP: 120/80mmHg
HR: 86bpm
RR: 24x/min
T: 35.6 0C
FHR I 155bpm
FHR II 158bpm
No uterine contraction
UO: 3ml/kgBW/h
Plan:
Echocardiography
Monitor DIC score and
urine output NST
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Renal insufficiency Anemia
Epulis granulomatous High output heart failure
When to deliver
Mode of deliveryDisease progression
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Multiple Gestation: Complicated Twin,
Triplet, and High-Order Multifetal
Pregnancy. ACOG. 2004.
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Multiple Gestation: Complicated Twin,
Triplet, and High-Order Multifetal
Pregnancy. ACOG. 2004.
Complications of Triplet Pregnancy
Gestational Diabetes (2239%) The incidence of preeclampsiais 2.6 times higher in twin
gestations than in singleton gestations and is higherintriplet gestations than in twin gestations. It is significantly
more likely to occur earlierand to be severe Acute fatty liver (7%)
Preterm delivery and 4963% of these infants weigh less
than 2,500 g36% of triplet pregnancies are born < 32 wga
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Multiple Gestation: Complicated Twin,
Triplet, and High-Order Multifetal
Pregnancy. ACOG. 2004.
Timing of Delivery in Multiple Gestations
At 35 completed weeks of gestation for triplets Fetal and neonatal morbidity and mortality begin to increase
in twin and triplet pregnancies extended beyond 37 and 35wga
Route of Delivery for Triplet GestationsCesarean delivery
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Consult to nephrology
Close monitoring of maternal and fetal
wellbeing. (in patient care)
Fetal doppler velocimetry
Monitor DIC score, repeat in 2 days
Conservative management can be
considered until 34 weeks gestation Mode of delivery: planned cesarean section
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A woman G3P0A2 34 weeks pregnancy wasdiagnosed ITP since 2010
Main complain are petechiae & gum
bleeding since 1 week before admitted Patient had dexamethasone 40 mg every
day before admision
Poor drug compliance, target for plateletcount was not achieved
Re admitted with Plt 2 x 103/ l, given inj.Methylprednisolon 125mg/6h/iv
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Recurrent early pregnancy loss
Abortus sebelumnya kapan dan berapa
minggu, apakah BO atau fetal death?
Kemungkinan SLEcek anti ds DNA
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GC: conscious, not anemic
Vital sign: within normal limit
Singleton baby, longitudinal lie, head
presentation, fundal height 23 cm, uterinecontraction (-), FHR 150 bpm
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FHR baseline 135 bpm
Variability >5
Acceleration +
Deceleration Movement +
NST reactive
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Singleton baby,longitudinal lie,cephalic presentation,
movement (+), FHR (+),placenta at posteriorcorpus , AFI 8,68
BPD 8,01~32 wga AC 23,78~28 wga Fl 5,0~27 wga EFW 1444 gr Umb RI 0.59
28/11 30/11 3/12 6/12 8/12
WBC x 103/ l 15.4 20.4 19.4 19.4 21.4
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5 4 4 9 4 9 4 4
RBC x 106/ l 4.4 3.8 4 4.1 4.3
Hb g/dl 13.1 11.1 11.5 11.7 123
Hct % 37.8 33.1 34.8 35.1 37
Plt x 103/ l 5 20 117 139 107
SGOT 27
SGPT 26
Na mmol/l 141
K mmol/l 3.8
Cl mmol/l 104
Albumin g/dl 3.8
BUN mg/dl 4.2
Crea mg/dl 0.41
Random BG 113 254 (74-140)
Fasting BG 155(
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Multigravida
nullipara 34 weeks pregnancy
IUGR Immune
Thrombocytopenia
(ITP) Hyperglycemia
Conservative
management
Observation of UC & FHR
Inj. Methylprednisolon62.5mg/12h/iv
Inj. Omeprazole
40mg/12h/iv
SF 1 tab/24h/oral
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BP: 130/70mmHg
HR: 94bpm
RR: 28x/min
T: 36 0C
FHR: 136bpm
No uterine contraction
UO: 1.85ml/kgBW/h
Plan:
NST
Monitor for
spontaneous bleeding Consult to
endocrinology for
hyperglycemia
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Hematol Oncol Clin North PMC 2010 December
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The most feared consequence of fetalthrombocytopenia is the risk of intracranialhemorrhage.
However, no association of intracranial hemorrhagewith the mode of delivery was observed
Since neonatal intracranial hemorrhage is anextremely rare complication of maternal ITP & thatcesarean deliveries may be associated with
significant maternal morbidity, it is recommendedthat c-section be performed solely for maternalindications.
Hematol Oncol Clin North PMC 2010 December
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Conservative management until term gestation Mode of delivery: vaginal delivery, unless
obstetrics indication present
Make sure a good drugs compliance Close monitoring of maternal and fetal
wellbeing. (out patient care) Clinical evaluation for ITP symptoms and
corticosteroids related toxicities ie diabetes,hypertension, placental abruption, bone loss,premature labor
Laboratory evaluation
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