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INTRODUCTION
Incidence of heart disease in pregnancy
1- 4%
Heart disease in pregnancy maternal
death (60 70 %)
IDENTITY
Name
Age
Address
Education
Occupation
Admission Date
: Mrs. CS
: 33 years old
: Tegal Lega,
Bandung
: Senior High School
: Housewife
: 4-12-2008 at 23.55
HISTORY
Accompanied by : Midwife
Notification :
G3P2A0 term pregnant; severe
preeclampsia; dyspneu
Chief complaint : dyspneu
History Taking
G3P2A0 8 months pregnant complained dyspneu
since 5 days b.a.
Dyspneu deffort (+)
Orthopneu (+)
Hypertension was known since 7 months pregnant.
History of hypertension before pregnant (-)
Signs of impending eclampsia (-)
Labor pain (-)
Amnionic membrane (+)
Fetal movement (+)
ADDITIONAL HISTORY
OBSTETRIC HISTORY
1. TBA, term, 3000 g, spontaneous, , 9 yo, live
2. TBA, term, 2500 g, spontaneous, , 6 yo, live
3. Current pregnancy
LMP
PNC
PHYSICAL EXAMINATION
STATUS PRAESENS
Consciousness
: inadequate contact,
dyspneu, cyanotic
BloodPressure : 180/120 mmHg
Pulse Rate
: 136 bpm
Respiration Rate
: 40 tpm
Temperature : 36,5 C
Cor
: gallop(+), murmur(+)
Pulmo : rales +/+
Oedema : +/+
OBSTETRICAL EXAMINATION
External Examination
FH
: 29 cm
AC
: 96 cm
FL
: head, 5/5 back at the left side
FHR
: 116-120 bpm
UC
: (-)
EBW
: 2000 gram
LABORATORY FINDINGS
Hb : 14,4 gr %
Lekocyte : 22.000/mm3
Hct : 45 %
Thrombocyte
: 425.000/mm3
Urine protein
: +++
PT/aPTT : 9,8/29.2 seconds
AST/ALT : 23/16 U/L
Ureum/Creatinin : 17/0,81 mg/dL
Blood Sugar
: 230 mg/dL
LDH
: 400 U/L
Na/K
: 137/3,0 mEq/L
DIAGNOSIS
G3P2A0 33-34 weeks pregnant + heart failure
FC.IV + severe preeclampsia + respiratory failure
MANAGEMENT
General condition stabilization
O2 8-10 L/min (face mask), O2 sat 67% ETT
insertion
IVFD, crossmatch, blood reserve, complete lab
exam, folley catheter insertion
Furosemide (forced diuretic) observe diuretic
response
Consult to Internal Dept, anesthesiology, and
Neurology
MANAGEMENT
Report to consultant on duty, advice :
general condition stabilization
resuscitation
postpone pregnancy termination until general
condition stable
ECG (sinus tachycardia), chest X-Ray
(cardiomegally with lung edema)
Informed consent
General condition, vital signs, uterine contraction,
and fetal heart rate observation
Advices
Bed rest
Ventilator, NGT insertion
Low salt diet 1500 kcal/day, per NGT, protein 1
g/kgBW/day
Furosemid infusion starting from 10
mg/hourresponse (-) titration dose
(20mg/hour)response(-) renal support dyalisis
Routine urine examination
Blood Gas Analysis examination after intubation
Echocardiography examination
Vital signs and I-O monitoring
Dec 4 , 2008 at
23.55
th
IUFD
ICU
08.20
07.15
ADM
Plan to
perform csection
Report to
consultant on duty
GC stabilization
Postpone
pregnancy
termination
14.30
Born a
male baby
Dec
8th,
2008
PROBLEMS
1. How was the management of this
patient in Hasan Sadikin Hospital?
2. What factors are responsible to
maternal death in this case?
DISCUSSION
Changes
Antepartum
Intrapartum
Postpartum
Diagnosis
G3P2A0 33-34 weeks pregnant +
heart failure FC IV + severe
preeclampsia + respiratory failure
Echocardiography
X-Ray
ETIOLOGY
Nutritional deficiencies
Myocarditis
Infections
Autoimmune
Idiopathic
The incidence of peripartum cardiomyopathy
is greater in multiparous women and in those
with preeclampsia and twin pregnancies
IBU HAMIL
Dengan kelainan
jantung
Riwayat:
Demam Reumatik
Aktivitas terbatas
Dispnea
Foto thorax
EKG
Analisis gas darah
Ekhokardiografi
RSHS, 2005
Diagnosis
Klasifikasi
Konseling
Kelas 3-4
ANC, perhatian khusus
pada fungsi vital
pertimbangkan
Fungsi jantung
Gagal jantung
Aborsi
< 20
minggu
Kondisi stabil/
Kelas 1-2
> 20 minggu
Perawatan jantung
intensif
Tirah baring
Pantau kesejahteraan janin dengan ketat
Gawat janin
Kelas 3-4
Seksio sesarea
Observasi postpartum
Konseling konsepsi
TATA LAKSANA
PENYAKIT JANTUNG
DALAM KEHAMILAN
Janin baik
Perawatan intrapartum intensif
Partus pervaginam
THIS
PATIENT
D/: G3P2A0 33-34
weeks pregnant +
heart failure FC IV +
severe preeclampsia
HR : 136 bpm
Digitalis should be
considered
Termination should
be considered
General condition
stabilization
Severe preeclampsia
Respiratory failure
Heart failure FC IV
Decision for
termination after 7
hours stabilization
Tedoldi M, Manfroi AG. Risk factors associated with peripartum cardiomyopathy. JLUMHS september december 2008. 119-22.
Ray NA, Murphy S, Shutt AG. General aspects of heart disease in pregnancy.
Treatment of peripartum
cardiomyopathy
Salt restriction and the use of
diuretics
If systolic dysfunction, the use of
vasodilators to reduce afterload
Atrial arrhythmias should be treated
with digoxin.
Treatment of peripartum
cardiomyopathy (Cont.)
Patient with poor cardiac output
Anticoagulation is indicated for the risk
of thromboembolism.
Unfractionated or LMW heparin are the
choice during pregnancy.
Peripartum management
Pain control is necessary
Hemodynamic monitoring
Shorten second stage of labor (head traction)
Positioning the patient on her left side
Postpartum monitoring
Because hemodynamics do not return to baseline for many days after
delivery require monitoring for at least 72 hours
American College of
Obstetrics and Gynecology
Antibiotic prophylaxis is
recommended during vaginal
delivery
Conclusions
1. Inadequate management
2. Multiple Organ Dysfunction Syndrome
causing maternal death
Thank you
ralat
LABORATORY FINDINGS (Dec 7th, 2008)
Hb
Lekocyte
Hct
Thrombocyte
PT/aPTT
AST/ALT
Ureum/Creatinin
Blood Sugar
Na/K
: 11.3 gr %
: 10.900/mm3
: 35 %
: 183.000/mm3
: 13.6/47.3 seconds
: 23/16 U/L
: 179/4.56 mg/dL
: 113 mg/dL
: 140/2.9 mEq/L
Case Presentation I
Monday, March 16th, 2009
Moderator :
dr. Dina Erasvina
Resource Person :
dr. Ahmad Yogi Pramatirta, SpOG, MKes.