Erry Gumilar Dachlan

Pulmonary edema in preeclampsia: an Indonesian case–control study

Abstract Objective: To analyze risk factors, obstetric outcome and the need for mechanical ventilation in preeclampsia complicated by pulmonary edema. Materials and methods: Case–control study using medical record on preeclampsia complicated by pulmonary edema patients in East Java tertiary referral hospital over 2 years. A simple scoring system was developed to predict the need for mechanical ventilation, using logistic regression. Results: 1106 cases of preeclampsia were admitted, with 62 cases (5.6%) had pulmonary edema. Postpartum (p < .001) and cesarean delivery (p = .001) proportions were higher in the preeclampsia with pulmonary edema group. Of the 62 cases with pulmonary edema, 81% required intensive care admission and 60% needed mechanical ventilation support. Mechanical ventilation used was associated with eclampsia (p = .04), hypertensive crisis (p = .02), lower serum albumin (p = .05) and higher creatinine (p = .01). A simple scoring model developed could predict a 46%–99% probability of need for mechanical ventilation (AUC (ROC): 0.856, 95%CI 0.763–0.95). Conclusions: Pulmonary edema is a common complication of preeclampsia in Indonesian referral hospitals. This severe complication increased maternal and perinatal morbidity and mortality. The developed scoring model in this study can be used as a triage tool to predict the probability of mechanical ventilation use due to this complication.

OS018. Maternal mortality and its mainly possible causepre-eclampsia/eclampsia in developing country (Surabaya-Indonesia as themodel)

INTRODUCTION By slow decrease of Indonesias 2010 highly maternal mortality rate (MMR) as 228/100,000 births mostly estimated to be out reach toward 2014 MDG target achievement of 118/100,000 births, even maternal deaths are notoriously under reported, possibly at least by as much as quarter. The population of Indonesia according to the 2010 national census is 237.6 million, with 58% living on the island of Java, the worlds most populous island since it is only 6% of Indonesia total area. Despite risk approaching strategy and referral method in Indonesia national health system had already been formed but the application has not been optimal yet so that its achievement is still far from destination. OBJECTIVES To study the correlationship between maternal mortality rate and its mainly possible cause pre-eclampsia/eclampsia METHODS Retrospectively study was performed by using data Dr. Soetomo teaching hospital Surabaya and local government of East Java. RESULTS Before the year 2008 the maternal deaths on our hospital Dr. Soetomo Surabaya was depicted very high as approximate 713/100,000 births (range 5.05-10.24 per 100,000 births) or 105 maternal deaths among 14,712 births. Pre-eclampsia/eclampsia was the most possible cause rate of 50-65%. Although at present tend to be improved situation but the year 2008 classic data indicated bad referral system application of severe pre-eclampsia and eclampsia cases that they came lately into our teaching hospitals intensive care unit with approximately 12.6% major complications consist of 50% lung oedema and the remain with placental abruption and cerebral bleeding. In more detailed description of maternal deaths as 29% died on the day 1 of intensive care unit treatment that some cases were death on arrival, 35% on the day 1-3 and >day 3 showed 36% of deaths. Even 40% our preeclampsia/eclampsia dominated ventilator use in hospital ICU due to >60% lung oedema that almost those 70% persist until 3 days (72h) in respiratory machine use. Our Dr. Soetomo hospital Surabaya as the tertiary hospital and referral center as well we observed 210 cases of severely pre-eclampsia which divided into 40 cases of early onset and late onset type as 170 cases by the year 2010. Mainly the characteristic features in early onset type as follow 70% they were reproductive ages (20-35 years old), 60% was 24-32 gestational weeks, 12.5% got complication of Hellp syndrome, 25% with low albumin serum level (<3g%) and had renal failure as 40%. CONCLUSION Despite Indonesia MMR apparently declined over last two decades but it did not slump as expected even it failed to achieve the 2014 MDGs target.

New three-dimensional/four-dimensional volume rendering imaging software for detecting the abnormally invasive placenta

This study aimed to determine the role of three‐dimensional (3D)/four‐dimensional (4D) volume rendering ultrasound (VRU) in the diagnosis of abnormally invasive placenta (AIP).

Serum heme oxygenase 1 (HO-1), soluble FMS like tyrosine kinase (sFlt-1) level, and neonatal outcome in early onset, late onset preeclampsia, and normal pregnancy

ABSTRACT Objective: To compare the level of serum heme oxygenase 1 (HO-1), soluble FMS like tyrosine kinase (sFlt-1), and neonatal outcome in early onset preeclampsia (EO-PE), late onset preeclampsia (LO-PE), and normal pregnancy (NP). Methods: In this prospective observational case control study, HO-1 and sFlt-1 levels were measured in blood samples within 24 h of hospital admission. Preeclampsia cases were divided into two groups based on gestational age at delivery: EO-PE (<34 weeks) and LO-PE (≥34 weeks). A total of 45 patients were involved in this study. Result: Maternal serum level of sFlt-1 was higher in EO-PE than LO-PE and NP groups (mean ± SD; 14.50 ± 17.12 ng/ml vs 5.20 ± 6.69 ng/ml vs 2.72 ± 1.2 ng/ml [p = 0.020]. Maternal serum level of HO-1 was not different between EO-PE, LO-PE, and NP groups (p = 0.681). Birthweights were significantly lower in the EO-PE group compared with the LO-PE and NP groups (1580 ± 536 g vs 2635 ± 578 g vs 3010 ± 371 g [p = 0.000]). The rate of small for gestational age infant (26.7% vs 6.7% vs 0%; p = 0.046) and perinatal death (20% vs 0 vs 0; p = 0.037) was also significantly higher in EO-PE compared to LO-PE and NP. The maternal sFlt-1 level was negatively correlated with birthweight (p = 0.006; CC = −0.445). Conclusion: This study did not find a correlation between maternal HO-1 levels and sFlt-1 levels. Maternal serum sFLt-1 levels in preeclampsia were higher in EO-PE and were associated with a worse perinatal outcome.

Clinical characteristics of acute fatty liver of pregnancy in a tertiary Indonesian hospital

Abstract Acute fatty liver of pregnancy (AFLP) is a rare, often autosomal recessive disorder with a major risk for maternal and perinatal mortality and morbidity. In order to achieve a more favorable outcome, awareness of its clinical signs and symptoms and early recognition are of pivotal importance. Over a 5-year period, 18 patients were diagnosed with AFLP (one twin, 19 babies). The most common sign and symptoms were jaundice, hypoglycemia, nausea and vomiting, encephalopathy, and hypertension. Abnormal laboratory test results included elevated total/conjugated (direct) bilirubin, AST, ALT, PT, APTT, creatinine, leukocyte count, and hypoalbuminemia. Maternal and fetal mortality rate was high: 66.7% resulted in a maternal death and 57.9% in an intrauterine fetal demise (IUFD). The number of complications was found to correlate with maternal death (p = .042). Surviving AFLP patients had ≤3 complications, while patients with >3 complications on presentation had a high risk of maternal death (OR = 5.0; 95% CI: 0.55–45.4). The presence of hypertension significantly increased the risk of maternal death (OR: 24.5; 95% CI: 1.1–542.8; p = .01). The risk of IUFD was primarily related to gestational age at delivery and birth weight. The high rate of jaundice as presenting symptom of AFLP suggests that Indonesian primary maternity care providers may often miss its important earlier signs and symptoms, in particular de novo onset of nausea and vomiting in late pregnancy.

The characteristic of Indonesia’s pre-eclampsia: From obstetric intensive care with ventilator until epidemiologic and its molecular biology profile of pulmonary edema in severe pre-eclampsia

Pulmonary edema is among the least frequently diagnosed criteria for severe pre-eclampsia. A higher incidence of pulmonary edema was noted in older patients, multigravidas, and patients with underlying chronic hypertension that developed prior to delivery. The development of pulmonary edema was also associated with the administration of excess colloid or crystaloid infusion. Two hundreds and thirty millions people occupying Indonesia as tropical and coastal country gave rise the problem of highly maternal mortality rate of 225/100,000 deliveries where pre-eclampsia and eclampsia as most possible cause. Over 5years from the year 2005 through 2009 our 160 eclampsia study observed about significantly correlation between typical estafet referred case and maternal mortality (Odds ratio 19.1 and P=0.065). Specifically those referred eclampsia cases arriving lately to our tertiary hospital, complication of pulmonary edema also apparently became determinant factor to uphold the increased maternal mortality (Odds ratio 6.1 and P=0.083) We found at our teaching hospital Dr. Soetomo Surabaya as referral center along the year 2012, 477 pre-eclampsia-eclampsia cases which complicated by 27 cases of pulmonary from which we apply obstetric intensive care unit for tightly monitoring treatment. The majority use of ventilator were applied on 22 cases (81.4%), that most approximately 16 cases (72%) need 48h under ventilator use and the remaining 6 cases was not untill 5days of extubation. The etiology of pulmonary edema in preeclamptic patients involves multi-factors; abnormal COP-PWCP gradient, increased pulmonary capillary permeability, and left ventricular failure were identified causes. It has been well known that the pathogenesis of pulmonary edema in severe pre-eclampsia-eclampsia initiated by capillary alveolar leakage that leading increased capillary permeability and extravascular fluid oncotic as well as decreased plasma oncotic pressure. In severe pre-eclampsia appear that another circumstance directing its worst state of inhibited angiogenesis related pulmonary edema. The study confirmed that the decreased serum albumin of ⩽3g% and its content of amino acid essentiale acitvate endoplasmic reticulum stress response in which indicated by increasingly produced GRP (Glucose Related-Protein) 78. It may affect the decreased VEGFR and may also be inhibiting angiogenesis and hypoxia as well. At such moment apparently pulmonary edema patient get worsening clinical sign.

OS017. Maternal death risk factor score based on hospital reference pattern and maternal condition of eclamptic woman in Soetomo Hospital, Surabaya, Indonesia

INTRODUCTION Maternal Mortality Rate in Indonesia is still high, around 230/100,000 live birth in 2005. Eclampsia is the second most cause of maternal death (about 13%). We have a very high prevalence of eclampsia in our center (Surabaya) about 1.08% of all delivery. One of our main problem about eclampsia case is multiple referral hospital system, because we do not have many tertiary center for this case. We assumed that high incidence of maternal death because of eclampsia is caused by this factor. OBJECTIVES To evaluate relationship between hospital referral system and maternal condition of eclamptic woman with maternal death event and develope scoring system to predict maternal death event on eclamptic woman. METHODS This is a case control study with retrospective observational analytic design, involve all eclamptic woman whom reffered and admitted to Soetomo hospital (Indonesia) from 1 January 2005 until 31 December 2009. Total eclamptic woman was 160 cases, with 12 maternal death on case group and 148 survive maternal on control group. Research variable includes maternal condition (ages, parity, eclampsia type, complication) and hospital referral pattern (ANC, Magnesium Sulfate, anti-hypertensive drugs, multiple hospital referral, health workers accompanion during patient referral). Primary outcome includes maternal death. RESULTS There is significant association between multiple hospital referral (RO 6.1, P=0.083), maternal age >35 (RO 17.4, P=0.032), lung oedema (RO 19.1, P=0.065), renal failure (RO 98.8, P=0.002), intra cranial hemorrhage (RO 6319.7, P⩽0.0001), Eclampsia type (RO 0.009), on eclamptic women with maternal death. No significant association between parity (RO 0.3 P=0.310), HELLP syndrome (RO 2.2 P=0.478), Magnesium Sulfate given before patient reffered (RO 0.7, P=0.685), ANC quantity (RO 0.9 P=0.844), health workers accompanion during referral (RO 0.9, P=0.901), on eclamptic women with maternal death event. CONCLUSION There are 6 significant variable includes Maternal complication (ICH, renal failure, lung oedema), Maternal ages >35 years, antihypertensive drugs, multiple hospital referral, multiparity, and eclampsia type that can be made a scoring system. We develop scoring system based on risk factor that can be used to predict maternal death event on eclamptic woman.

P26. Comparison serum inhibin A level, placenta inhibin A level and placenta inhibin A expression in severe preeclampsia/eclampsia and normal pregnant women

in the year 2010 where 15 severe pre-eclampsia/eclampsia and 15 normal pregnant blood samples as control were collected. ELISA method was use to make assesment of inhibin A maternal serum and placental levels, for the expression of placental inhibin A, immunohistochemistry method was done in this study as well as the use of statistical analysis. Results: Inhibin A serum levels in both maternal and placental appeared to be significantly increase comparing with normal pregnancy as control as well as its expression in placenta. In severe pre-eclampsia/eclampsia they were found as 17.3 ± 12.9 ng, 18.1 ± 13.5 ng, 20.4 ± 5.2 ng, respectively at the levels of maternal serum, placental and placental expression compared to normal pregnancy as 5.3 ± 1.8 ng (p < 0.05), 6.2 ± 1.6 ng (p < 0.05) and 4.9 ± 1.6 ng (p < 0.05). Conclusion: Inhibin A increase seem in severe preeclampsia/eclampsia.