ZULHERMAN

RAHMI FITRI
DENADA LEONA
AULIA RAHMI
NOVA SURYATI
HIDAYATURAHMI
ULFIA RAHMANITA
FITRA KURNIA
FEBY RAHMA ASTRI

1. Vaginal Bleeding During Pregnancy
2. IUGR
3. Examination in pathological pregnancy

4. The maternal mortality ratio and child
mortality rate
5. Preeclapmsia dan eclampsi
6. Treatment of pathological pregnancy
7. Case referred to pregnancy


1.Bleeding in early pregnancy.
2.Bleeding in late pregnancy ( ante partum
hemorrhage).
3. Examination in pregnancy pathology



Causes
Abortion.
Vesicular mole.
Ectopic pregnancy.
Local lesions cervical polyps cervical
cancer.

It is the termination of pregnancy before 24
weeks, or products of conception weighing
below 500 grams.

The termination is either spontaneous or
induced, before the fetus develops
sufficiently to survive
50%-80% of abortions in the first 12 weeks of pregnanacy result from
Chromosomal anomalies.
Fetal
Chromosomal anomalies.
Diseases of the fertilized ovum.
Hypoxia.

Maternal
Infections e.g. influenza, malaria, syphilis ,HIV.
Disease such as chronic nephritis,TB.
Drug intake during pregnancy.
Rh and ABO incompatibility.
Incompetent cervix.
Uterine malformation.
Aquired uterine defect as uterine fibroid or adhesions
Trauma - criminal interference,
Endocrinal disorder as hypothyrodism , daibetes mellitus

First 8 weeks gestation
Separation of decidua basalies and expulsion of
the ovum
If retained within the uterus, the ovum
becomes surrounded by decidua and blood
clot
8-12 weeks of gestation
Rupture of decidua capsularis and expuslion of
the product of conception
After 12 weeks
Rupture of membranes followed expulsion of
the product of fetus and the placenta
retained in uterus



Spontaneous abortion
Threatened abortion:
Missed abortion
Inevitable abortion
Complete abortion



Hydatidiform mole is a gross malformation
of the trophoblast in which the chorionic
villi proliferate and become avascular.

The exact cause is unknown.
Risk factors are:
Maternal age above 40 years or below 19
years.
Malnutrition
Types
1- partial mole
2- complete mole

pregnancy occurring outside the normal
uterine cavity
Ectopic pregnancy usually occurs 99% of
cases in the uterine tube.

Causes
Impaired tubal ciliary action.
Impaired tubal contractility.
Decreased sperm mobility.
The use of intrauterine contraceptive device.

Antepartum hemorrhage is defined as bleeding
from the genital tract between 28th week of
pregnancy and onset of labor.
Classification
Placenta previa
Abruptio placenta
Extraplacental bleeding (cervical polyp)
placenta is partly or totally implanted over
the lower uterine segment.


No specific cause can be detected for most of
the cases, while the predisposing factors are:
Large placenta
previous uterine scarring
Multipara
Complete central placenta previa
Placenta previa partialis
Placenta previa marginalis
Low lying placenta


bleeding during the last three months of
pregnancy, the first or second stage of labor,
due to premature separation of a normally
implantated placenta


The most important cause is hypertension.
The second most common cause is trauma
deficiencies in vitamins C and K.
Traction on a short umbilical cord.
Sudden reduction of the size of the uterus.


Revealed: almost all the blood expelled
through the cervix.
Concealed: almost all the blood is retained
inside the uterus.
Combined: some blood is retained inside the
uterus and some is expelled through the
cervix.

IUGR: Failure of normal fetal growth caused
by multiple adverse effects on the fetus.
SGA: Infant with wt < 10% ile for GA, or >
2 SDs below mean for GA.

3 - 10 % of all pregnancies.
20 % of stillborns are growth retarded.
30 % of infants with SIDS were IUGR.
1/3 of infants with BW < 2800 gms are growth
retarded and not premature.
9 - 27 % have anatomic and/or genetic
abnormalities.
Perinatal mortality is 8 - 10 times higher for
these fetuses.

Symmetric IUGR: weight,length and head
circumference are all below the 10 th
percentile. (33 % of IUGR Infants)
Asymmetric IUGR: weight is below the 10
th percentile and head circumference and
length are preserved. (55 % of IUGR)
Combined type IUGR: Infant may have
skeletal shortening, some reduction of soft
tissue mass. (12 % of IUGR)

Stage I (Hyperplasia)
- 4 to 20 weeks
- Rapid mitosis
- Increase of DNA content
Stage II (Hyperplasia & Hypertrophy)
- 20 to 28 weeks
- Declining mitosis.
- Increase in cell size.


Stage III ( Hypertrophy)
- 28 to 40 weeks
- Rapid increase in cell size.
- Rapid accumulation of fat, muscle and
connective tissue.
95% of fetal weight gain occurs during last 20
weeks of gestations.


Growth inhibition in stage I:
- Undersized fetus with fewer cells.
- Normal cell size.
Result in symmetric IUGR.
Associated conditions:
- Genetic
- Congenital anomalies
- Intrauterine infections
- Substance abuse
- Cigarette smoking
- Therapeutic irradiation

Growth Inhibition in Stage II/III
-Decrease in cell size and fetal weight
- Less effect on total cell numeric, fetal
length, head circumferance.
Result in asymmetric IUGR.
Associated Conditions:
- Uteroplacental insufficiency.
Combination above associated mixed type IUGR.

1) Fetal factors:
Genetic Factors:
- Race, ethnicity, nationality
- sex ( male weigh 150 -200 gm more than
female )
- parity ( primiparous, weigh less than
subsequent siblings)
-genetic disorders ( Achondroplasia, Russell
- silver syn.)
Chromosomal anomalies:
- Chromosomal deletions
- trisomies 13,18 & 21

Congenital malformations:
examples:Anencephaly, GI atresia, potters
syndrome, and pancreatic
agenesis.
Fetal Cardiovascular anomalies
Congenital Infections:
mainly TORCH infections.
Inborn error of metabolism:
- Transient neonatal diabetes
- Galactosemia
- PKU


Maternal hypoxemia
- Hemoglobinopathies
- High altitudes
Others
- Short stature
- Younger or older age (<15 and >45)
- Low socioeconomic class
- Primiparity
- Grand multiparity
- Low pregnancy weight
- Previous h/o preterm IUGR baby
- Chronic illness ( DM, renal failure,
cyanotic heart
disease etc.)

3) Placental Factors:
Placental insufficiency ( most imp in 3
rd

trimester)
Anatomic problems:
Multiple infarcts
Aberrant cord insertions
Umbilical vascular thrombosis & hemangiomas
Premature placental separation
Small Placenta

Growth parameters: weight, height, HC
Assess GA with Ballard score.
Plotted growth parameters in growth chart


Heads are disproportionately large for their
trunks and extremities
Facial appearance has been likened to that
of a wizened old man.
Long nails.
Scaphoid abdomen


Signs of recent wasting
- soft tissue wasting
- diminished skin fold thickness
- decrease breast tissue
- reduced thigh circumference
Signs of long term growth failure
- Widened skull sutures, large fontanelles
- shortened crown heel length
- delayed development of epiphyses
Comparison to premature infants,IUGR has brain
and heart larger in proportion to the body
weight, in contrast the liver, spleen, adrenals
and thymus are smaller.


Pelvic examination in ectopic
pregnancy

Unilateral or bilateral exquisite tenderness
especially on motion of the cervix
Adnexal mass
Enlarged uterus
Tenderness and painful of the posterior
fornix

Signs of internal hemorrhages which
provoke hypovolemic shock are the more
prominent the more closely fertilized
ovum localized near the uterus

Complete blood count
Positive urinary test fir estimation of
chorionic gonadotropin (hCG) levels
Ultrasonography
Culdocentesis
Curettage of the uterine cavity can also rule
out ectopic pregnancy

Bloody fluid that
does not clot result of hemoperitoneum
resulting from an ectopic pregnancy


Is an abnormal conceptus with loss of
villus vascularity and without an embryo
or fetus.
Most of symptoms are presented thanks to
markedly elevated hCG levels.

Is an abnormal conceptus with loss of villus
vascularity and without an embryo or fetus.
Most of symptoms are presented thanks to
markedly elevated hCG levels.


Vaginal bleeding with molar elements
Preeclampsia
In pelvic exam - uterus larger than expected,
Ovarian enlargement due to bilateral theca
lutein cysts
Ultrasonography snow-storm appearance

Painless bleeding It almost always ceases
spontaneously, unless digital examination or
other trauma occurs.

Ultrasonography has been of enormous
benefit in localizing the placenta.


Careful vaginal examination in labor.

Diagnosis speculum inspection
Management - ligation and suturing of all
ruptures of the vagina, cervix and perineum.
In the case of uterine rupture hysterectomy
should be performed

1. Absence of the signs of placental separation
during 30 minutes.
2. External bleeding in the case of partial
adherence, absence of the bleeding in the
case of total placenta accreta.
3. Manual removal of the placenta confirms
the diagnosis of different types of abnormal
placental adherence.
In the case of partial placental adherence it
stops bleeding, but in the case of placenta
accreta, increta and percrata it increases
bleeding. Attempts at manual removal are
futile. Thats why in these cases manual
removal of the placenta should be stopped
immediately and hysterectomy should be
performed.

THE MATERNAL MORTALITY RATIO

Maternal death is the death of a woman
while pregnant or within 42 days of
termination of pregnancy, irrespective of
the duration and site of the pregnancy,
from any cause related to or aggravated
by the pregnancy or its management but
not from accidental or incidental causes.


The high number of maternal deaths in
some areas of the world reflects
inequities in access to health services,
and highlights the gap between rich and
poor. Almost all maternal deaths (99%)
occur in developing countries. More than
half of these deaths occur in sub-Saharan
Africa and almost one third occur in South
Asia.

The maternal mortality ratio in
developing countries is 240 per 100 000
births versus 16 per 100 000 in developed
countries. There are large disparities
between countries, with few countries
having extremely high maternal mortality
ratios of 1000 or more per 100 000 live
births. There are also large disparities
within countries, between people with
high and low income and between people
living in rural and urban areas.


Women die as a result of complications
during and following pregnancy and
childbirth. Most of these complications
develop during pregnancy. Other
complications may exist before pregnancy
but are worsened during pregnancy.

The major complications that account for
80% of all maternal deaths are:
severe bleeding (mostly bleeding after
childbirth)
high blood pressure during pregnancy
(pre-eclampsia and eclampsia)
infections (usually after childbirth)
unsafe abortion.
The remainder are caused by or
associated with diseases such as malaria,
and AIDS during pregnancy.


The status of child health in Indonesia has
been improving. This is indicated by declining
rates of neonatal, infant, and under-five
mortality.
Under-five mortality declined sharply from 97
per 1,000 live births in 1991 to less than half,
which were 44 in 2007. Infant mortality
rate significantly declined from 68 per 1,000
live births in 1991 to 34 per 1,000 live births in
2007. Over the same period neonatal
mortality rate also declined from 32 per 1,000
live births to 19 per 1,000 live births.



The main cause of under-5 mortality was
neonatal complications (asphyxia, low birth
weight, and neonatal infections), infectious
diseases (primarily diarrhea and pneumonia) as
well as closely related to nutritional problems
(malnutrition).
Other issues were the disparity among provinces
on neonatal mortality, infant mortality and
under-5 mortality are relatively high. This
condition was caused by issues of quality and
access to health services, socio economic and
cultural issues, infrastructure development as
well as the openness of areas to educational
and economic development.



PREECLAMPSIA

The presence of hypertension of at least
140/90 mm Hg recorded on two separate
occasions at least 4 hours apart and in the
presence of at least 300 mg protein in a
24 hours collection of urine arrising de novo
after the 20
th
week gestation in a previously
normotensive women and resolving
completetly by the sixth postpartum week.
Preeclampsia / eclampsia
Chronic hypertension
Chronic hypertension with superimposed
preeclampsia
Gestational or transient hypertension

(Genetic predisposition)
(Abnormal immunological response)
(Deficient trophoplast invasion)
(Hypoperfused placenta)
(Circulating factors)
(Vascular endothelial cell activation)
(Clinical manifestations of the disease)


Incidence
3% of pregnancies.
Epidemiology
More common in primigravid
There is 3-4 fold increase in first degree
relatives of affected women.


Defective trophoplast invasion hypoperfused
placenta release factors (growth factors,
Cytokines) vascular endothelial cell
activation.
Vasospasm hypertension
Endothelial cell damage oedema,
hemoconcentration
Kidneys,glomeruloendotheliosis
proteinuria,reduced uric excretion and oliguria.

Liver,subendothelial fibrin deposition
elevated liver,hemorrhage,infarction,liver
rupture and epigastric pain.
Blood thrombocytopenia,DIC,HELLP
syndrome.
Placental vasospasm placental
infarction,placental abruptio&
uteroplacental perfusion IUGR.
CNS vasospasm&oedema headache,
visual symptons(blurred vision,spots,

Symptoms of preeclampsia
1. Headache
2. May be symptomless
3. Visual symptoms
4. Epigastric and right abdominal pain
Signs of preeclampsia
1. Hypertension
2. Non dependent oedema
3. Brisk reflexes
4. Ankle clonus(more than 3 beats)
5. Fundal height

Investigations
1. Maternal
Urinalysis by dipstick
24 hours urine collection
Full blood count(platelets&haematocrit)
Renal function(uric acid,s.creatinine,urea)
Liver function tests
Coagulation profile
2. Fetal
1. Uss(growth parameters,fetal size,AF)
2. CTG
3. BPP
4. Doppler


Preeclampsia consists of :
A Mild preeclampsia
Diastolic blood pressure 90-95mmhg
minimal proteinurea,normal heamatological
and biochemical parameters,no fetal
compromise.Deliver at term.
B severe preeclampsia (BP>160/110MMHG,
urine protein 5grams 3+ )
Abnormal haematological and biochemical
parameters,abnormal fetal findings
1. Control blood pressure(aim to keep
BP 90-95mmgh )




Complications of preeclampsia:-
ECLAMPSIA
Maternal
CVA
HEELP syndrome
Pulmonary oedema
Adult RDS
Renal failure
Fetal
IUGR
IUFD
Abruptio placenta
Prophylaxis(aspirin,antioxidant)



Eclampsia:-
Is a life threatening complications of
preeclampsia,defined as tonic,clonic
convulsions in a pregnant woman in the
absence of any other neurological or
metabolic causes.It is an obstetric
emergency.
It occurs antenatal,intrapartum,postpartum
(after delivery 24-48hs)





Treatment in the case abortion


Bed rest
Sedative drugs Valeriannae, Persen,Novopaside.
Spasmolitics Papaverini hydrochloride
Analgetics Analgin, Baralgin
Progesterone Utrogestan, Duphastone,
Progesterone
Vitamines vit. E
Surgical uterine curettage

Management:
Medical care:
Correction of:
Anemia
Dehydration
Hyperthyroidism
hypertension

Management:
Surgical care:


Suction curettage (with
oxytocin or prostaglandin
infusion)
Suction curettage (with
oxytocin or prostaglandin
infusion)
The method of choice
The method of choice
Home Management
Decrease activities and promote bed rest
Sedative drugs
Lie in left lateral position
Remain quiet and calm restrict visitors
and phone calls

Dietary modifications
increase protein intake to 70 - 80 g/day
maintain sodium intake
Caffeine avoidance

Weigh daily at the same time

Keep record of fetal movement - kick counts

Check urine for Protein

If symptoms do not get better then the
patient needs to be hospitalized in order to
further evaluate her condition.
Common lab studies:
Renal blood studies -- creatitine, uric acid
Liver studies
DIC profile -- platelets, fibrinogen, FSP, D-
Dimer

ACTION
CNS Depressant, reduces CNS irritability
Calcium channel blocker- inhibits cerebral
neurotransmitter release
ROUTE
IV effect is immediate and lasts 30 min.
IM onset in 1 hour and lasts 3-4 hours

Prior to administration:
Insert a foley catheter with urimeter for
assessment of hourly output

NURSING IMPLICATIONS
1. Monitor respirations > 14-16; < 12 is
critical

2. Assess reflexes for hyporeflexia -- D/C for
hyporeflexia
3. Measure Urinary Output >100cc in 4 hrs.

4. Measure Magnesium levels normal is 1.5-2.5
mg/dl

Have Calcium Gluconate available as antagonist

Check B / P frequently.

Give Antihypertensive Drugs
Hydralzine ( apresoline)
Labetalol
Aldomet
Procardia
Check Hemocrit

* Do NOT want to decrease the B/P too low
or
too rapidly. Best to keep diastolic ~90.
Need to maintain uteroplacental perfusion!



Bed rest in left or right lateral position

Check hourly output -- foley cath with
urimeter

Dipstick for Protein

Weigh daily -- same time, same scale

*Have a history of heart disease, kidney,
diabetes, and epilepsy before pregnancy.

*Having a family history of genetic
disorders
Signs of severe anemia (hemoglobin
<7g/dl)

*History of stillbirth, low birth weight
(LBW), preeclampsia or eclampsia &
sectio Caesar in the previous pregnancy
history.


*The advent of high blood pressure or
proteinuria (protein in the urine)

*Elevated blood glucose (> 200mg/dl)
during pregnancy

*Vaginal bleeding or the appearance of
blotches of blood during pregnancy.

*Severe headaches, blurred vision or
swelling throughout the body.

*Infection during pregnancy.


TERIMA KASIH