CASE REPORT SESSION

P1A0 TERM LABOR

SECTIO CAESAREA
WITH INDICATION
GLAUCOMA +
ASTHMA + IUD
INSERTION

ANA TACYA HAYUNINGTIAS
12100117103
Counselor:
dr. H. Dadan Susandi, Sp.OG., M.Kes.
Identities

Patient’s Identity Husband’s Identity

– Name : Mrs. P
– Age : 30 years old – Name : Mr. G
– Address : Garut City – Age : 30 years old
– Education : Bachelor
– Address : Garut City
– Job : Entrepreneur
– Medrec
– Education : Diploma
: 843xxx
– Date of Admission : – Job : Regional
February 6th, 2019 Owned Enterprises
– Time of Admission :
1.15 PM
ANAMNESIS
Chief Complaint:
Contractions
 G1P0A0 The patient felt 9 months of pregnancy. The patient
came with irregular non-radiating contractions but still rare since 8
hours before she admitted to the hospital. The patient deny there is
watery vaginal discharge and bloody show come out from the birth
canal. The fetal movement began to be felt since around 4 months
ago until now. Patients have a history of glaucoma and asthma.
 OBSTETRIC HISTORY
Pregnancy Place Helper The way of Mode of Birth Weight Gender Age Status
Pregnancy Delivery

1. This Pregnancy

ADDITIONAL INFORMATION
MARRIAGE
♀ : 1st marriage, 29 years old, Bachelor, Entrepreneur
♂: 1st marriage, 29 years old, Diploma, Regional
Owned Enterprises
MENSTRUAL HISTORY CONTRACEPTION

Last menstrual first day: Forget The patients have never

EDD: - used contraception. Refused
Menarche: 12 years old to use one because they still
Menstruation: Irregular, 28-30 want to have children.
day cycle, 5 days duration,
normal amount with the heaviest
on the 2nd/3rd day, consuming 2-4
pads/day, dysmenorrhea
PRE NATAL CARE PREGNANCY COMPLAINTS
Place : Obstetrician Lower ekstremities oedema (+)
Amount : > 10 times, USG
2 times
Last PNC : 1 week ago
HISTORY OF ILLNESS

History of heart, lung, kidney, liver, thyroid

disease, hypertension before pregnancy, diabetes
mellitus, and epilepsi is denied by the patient.
– The patient had a history of asthma that was known 3 years ago.
This complaint last relapsed 4 months ago and received
nebulisation. Patients do not take any asthma medication routinely
because complaints of asthma are rare.
– History of dust allergy (+), so the patient often using cendo citrol
(corticosteroids) for a long time
– The patient had a history of drug allergy. The drug is analsic and if
the patient take high-dose antibiotics the patient becomes swollen
– The patient had a history of glaucoma 13 years ago. The patient's initial
complaint is a persistent headache, sore eyes, nausea, vomiting, blurred
vision, such as seeing a rainbow around a lamp or light and starting with
red eyes. The patient has done a series of tests, one of them is a field
test. Patients have been diagnosed with Juvenile Glaucoma by
ophthalmologists
– The complaints in the eye that are felt at this time are decreased vision.
The right eye is unable to see, and the left eye has started blurry with 1/4
under the field of vision has begun to darken and there are cylinders ½
– History of eye trauma (-), head trauma (+) was hit by a basketball
throw on the back of the head 13 years ago
– There is no family with a history of glaucoma, DM (-), hypertension (-),
cataracts (-), eye surgery before complaints arise (-), high myopia (-)
– The patient had been operated on 10 years ago and routinely
controlled in cicendo and ophthalmologists at karawang. During
control the patient was given cendo timol for glaucoma
– The patient has been released from medicine since 2 years ago
General Examination

– General Condition : Compos mentis

– Vital Sign:
– Blood Pressure : 120/70 mmHg
– Pulse : 82 x/minute
– Respiratory Rate : 20 x/minute
– Temperature : 36,2 0C

– Anthropometric Measurement:
– Height: 162 cm
– Weight: 68 kg (Pre-pregnancy weight = 56 kg)
 PHYSICAL EXAMINATION

– Skin : Warm, good turgor, no jaundice – Thorax :

– Head : Headache (-), dizziness (-) Cor: S1 S2 pure, regular, murmur (-), gallop (-)
– Eyes : Anemic conjuntiva (-/-), Icteric Sclera (-/-) Pulmo: VBS right=left, ronchi (-/-), wheezing(-/-)
OD OS – Gastrointestinal: convex, soft, tenderness (-)
Blind vision Blurred vision, sore
VOD : 0 eyes, 1/4 under the L1 palpated breech, L2 fetal back on left,
field of vision has
begun to darken L3 cephalic, L4 cephalic prominence
VOS : C 1/2
Liver : no enlargement

– Ears : Pain (-), discharges (-) and hearing loss Spleen : no enlargement
(-) – Extremities: warm, crt < 2 minutes, oedem (-),
– Nose : Discharges (-), sinusitis (-), epistaxis (-) varices (-)

– – Genital: sores (-), itchiness (-)

Mouth & throat : Oral lesions (-) and sore throat (-)
– Neck : Thyroid : no enlargement

Lymph : no enlargement
OBSTETRIC STATUS

External Examination Inspekulo

–Uterine fundal height : 34 cm, according -
to the period of pregnancy 38-39 weeks Fornices Examination
–Abdominal circumference : 96 cm -
–Fetal Weight : 2.970 gram Internal Examination
–Child’s position : Lengthwise, head, 5/5, left- Vulva / Vagina : no abnormalities
fetal back
Portio : thick, soft, medial
–HIS :- OUE : closed
–Fetal heart rate : 142x/ min., regular Amniotic Fluid : intact
Lowest part :-
 DIAGNOSIS

G1P0A0 GRAVIDA 38-39 WEEKS W/

GLAUCOMA + ASTHMA
PLANNING

– R/ Abdominal delivery
– IVFD RL 500cc 20 gtt/minute
– Observe general condition, vital sign, fetal heart rate, uterine contraction, and
progress of labor.
– Hematologic test
– SIO, IC
– Put on DC
– Fasting 6 hours before surgery
– Family planning motivation.
Date
FOLLOW UP
S/ Rare contractions, watery vaginal discharge (-), bloody Eyes: CA -/- SI -/-
7/02/2019 show come out from the birth canal (-) Abd: convex, soft, tenderness-
Uterine fundal height : 34 cm, according to the
06.00
period of pregnancy 38-39 weeks
O/ GC: CM Abdominal circumference : 96 cm
Fetal Weight: 2.970 gram
BP: 120/70 mmHg
Child’s position: Lengthwise, head, 5/5, left-fetal back
P: 76x/m, regullar HIS : -
Fetal heart rate: 145x/m, regular
RR: 20x/m
urination/defecate: +/+
T: Afebris

A/ G1P0A0 gravida 38-39 weeks w/ glaucoma + Asthma

P/ R/ abdominal delivery
IVFD RL 500cc 20 gtt/minute
Observe general condition, vital sign, fetal heart rate, uterine contraction, and progress of labor
SIO, IC
Put on DC
Fasting 6 hours before surgery
Family planning motivation.
 OPERATION REPORT
Name : Mrs. P Medrec : 843XXX Operating hours starts : 09.10
Age : 29 years old Operating hours finish : 10.10
Duration : 60 minutes
ELECTIVE Date: 7-2-2019
Operator : Assistant I : Elis Instrument : Neneng
dr. Rizky S, Sp.OG

Anesthesilogist : Anesthesiologist Assistant : Anesthesi type : Regional

dr. Dhadi , Sp.An Asty

Pre Surgery Diagnosis : Indication:

G1P0A0 gravida 38-39 weeks Glaucoma + asthma
w/ Glaucoma + Asthma
Post Surgery Diagnosis : Operation Name :
P1A0 term labor sectio Sectio caesarea
caesarea with indication
Glaucoma + Asthma +
IUD insertion
Operation Category : Big
Desinfectant: Tissue Excision :
Povidine iodine PA (X)
COMPLETE OPERATION REPORT :
A and antiseptic action is performed on the abdomen and beyond.
a 10 cm pfannenstiel incision was made on the abdominal wall
after the perineum is opened it appears that the front of the uterus does not appear to adhere to the tissue around the
omentum
a concave incision is made in the lower uterine segment, then extended with the helper's finger to the right and left.
at 09.13 WIB a baby boy was born, weighed 3430 grams, body length 47 cm, A / S 7-9
Intramural IU oxytocin 10 was injected, contraction was good
09.16 WIB the placenta was born with a light pull on the umbilical cord
SBR is sewn layer by layer by interlocking with chromic no II thread
the installation of contraception is done in the form of IUD insertion
bleeding treated.
The fascia is sewn with PGA no. 1
the skin is sewn subcutaneously with PGA no. 3
bleeding 300 cc, diuresis 100cc / hour

POST SURGERY INSTRUCTION :

Observation : GC, BP, HR, RR, Temp, Bleeding
Fasting :-
Infuse : RL 500 cc 20 gt
Antibiotic : Cefotaxime 2x1gr IV
Metronidazole 3x500mg IV
Analgetic : Kaltrofen 3x100 mg supp
 FINAL DIAGNOSIS

P1A0 TERM LABOR SECTIO CAESAREA WITH

INDICATION GLAUCOMA + ASTHMA +
IUD INSERTION
 FOLLOW UP
Date S/ Swelling of both eyelids after consuming tramadol Eyes: CA -/- SI -/-
7/2/2019 and kaltrofen drugs suppository before. patients have a Breast milk : -/-
20.08 history of allergies for the consumption of antalgin and Abd: flat, soft, tenderness (+) at lower quadrant of
amoxicillin drugs abdomen
Uterine fundal height : 2 fingers above umbilical
PP day 0
Contractions : good contraction
Baby’s identity O/ GC: CM Lochia : rubra
Surgical wound : closed bandage
(7/2/19 09.13) BP: 110/70 mmHg
urination/defecate: + DC /-
♂, alive P: 89x/m, regullar Contraception : IUD
BW 3430 g RR: 21x/m
BL 47 cm T: Afebris
AS 5-7

A/ P1A0 term labor sectio caesarea with indication Glaucoma + Asthma +

IUD insertion

P/ Observe general condition, vital sign

dr. Bowo Advice:
Dexamethasone extra 1 amp IV
Paracetamol 500 mg post 2 hour dexamethasone ekstra 1 amp
Consultation Ophthalmologists
 FOLLOW UP
Date S/ slight surgical wound pain Eyes: CA -/- SI -/-
8/2/2019 (06.30) swelling of the eyelids begins to improve Breast milk : -/-
PO day I Abd: flat, soft, tenderness (+) at lower quadrant of
Baby’s identity O/ GC: CM abdomen
(7/2/19 09.13) Uterine fundal height : on the umbilical
BP: 110/70 mmHg
Contractions : good contraction
♂, alive
P: 82x/m, regullar Lochia : rubra
BW 3430 gr Surgical wound : closed bandage
RR: 22x/m
BL 47 cm urination/defecate: + DC /-
AS 5-7
T: 36.5 Contraception : IUD

A/ P1A0 term labor sectio caesarea with indication Glaucoma + Asthma +

IUD insertion

P/ Observe general condition, vital sign

Cefotaxime 2x1 gr
Metronidazole 3x 500 mg
Kaltrofen 2x100 mg sup
Aff DC
Breast care
Consultation ophthalmologists
 FOLLOW UP
Date S/ slight surgical wound pain Eyes: CA -/- SI -/-
9/2/2019
swelling of the eyelids (-) Breast milk : +/+
06.00
PO day II Abd: flat, soft, tenderness (+) at lower quadrant
O/ GC: CM of abdomen
Uterine fundal height : 1 finger under umbilical
BP: 120/80 mmHg
Contractions : good contraction
P: 80x/m, regullar Lochia : rubra
Surgical wound : dry
RR: 20x/m
urination/defecate: +/-
T: 36.2 Contraception : IUD

A/ P1A0 term labor sectio caesarea with indication Glaucoma + Asthma +

IUD insertion

P/ Observe general condition, vital sign

Cefadroxil 2x500 mg
Metronidazole 3x 500 mg
Asam Mefenamat 3x500 mg sup
Aff Infuss
Consultation ophthalmologists
ADDITIONAL EXAMINATION

(7/2/19, 15:08) (8/2/19, 13:29)

Hematologic Hematologic

–Hemoglobin –Hemoglobin : 12,0 g/dl

: 12,3 g/dl
–Hematocrit : 38 %
–Hematocrit : 37 %
–Leucocyte : 5.850/mm3
–Leucocyte : 16.040/mm3
–Trombocyte : 156.000/mm3
–Trombocyte : 159.000/mm3
–Eritrocyte : 4,35 million/mm3
–Eritrocyte : 4,36 million/mm3
Immunoserologic
HIV : NON REAKTIF
HBsAg : NON REAKTIF
CASE PROBLEM

GLAUKOMA AND 
ASTHMA IN 
PREGNANCY AND 
LABOR
How is the diagnosis? Is it
right/wrong?
G1P0A0 GRAVIDA 38-39 WEEKS
W/ GLAUCOMA + ASTHMA
– The patient is currently the first pregnancy, and has never had a miscarriage
(G1A0P0)
– The patient claimed to be 9 months pregnant but the patient did not remember
the first day of her last menstruation. From the physical examination it was
found that the patient's TFU was 34 cm, according to the gestational age of 38-
39 weeks. (38-39 weeks)
– . Patients have a history of Glaucoma and Asthma.
OBSTETRIC STATUS

External Examination Inspekulo

–Uterine fundal height : 34 cm, according -
to the period of pregnancy 38-39 weeks Fornices Examination
–Abdominal circumference : 96 cm -
–Fetal Weight : 2.970 gram Internal Examination
–Child’s position : Lengthwise, head, 5/5, left- Vulva / Vagina : no abnormalities
fetal back
Portio : thick, soft, medial
–HIS :- OUE : closed (gravida)
–Fetal heart rate : 142x/ min., regular Amniotic Fluid : intact
Lowest part :-
– The patient had a history of
asthma that was known 3
years ago. This complaint last
relapsed 4 months ago and
received nebulisation.
Patients do not take any
asthma medication routinely
because complaints of
– The complaints in the eye that are felt at this
asthma are rare.
– The patient had a history of glaucoma 13 years
ago. The patient's initial complaint is a
persistent headache, sore eyes, nausea,
vomiting, blurred vision, such as seeing a
rainbow around a lamp or light and starting
with red eyes. The patient has done a series of
tests, one of them is a field test. Patients have
been diagnosed with Juvenile Glaucoma by
ophthalmologists
time are decreased vision. The right eye is
unable to see, and the left eye has started
blurry with 1/4 under the field of vision has
begun to darken and there are cylinders ½
– Initial diagnosis : G1P0A0 GRAVIDA 38-39 WEEKS W/ GLAUCOMA +
ASTHMA
 SC and IUD insertion

– Final diagnosis: P1A0 TERM LABOR SECTIO CAESAREA WITH

INDICATION GLAUCOMA + ASTHMA + IUD INSERTION
 GLAUCOMA IN 
PREGNANCY
(Juvenille Glaucoma)
DEFINITION
THEORIES
Glaucoma is a group
of eye disorders that lead to
progressive damage to the
optic nerve. People with
glaucoma can lose nerve
tissue, resulting in vision
loss.
CASE
The patient complaints
in the eyes that are felt at this
time are decreased vision. The
right eye is unable to see, and
the left eye has started blurry
 Epidemiology
Theories Case
– Glaucoma has been reported to occur in roughly 2-3% of adults over – The patient age is 26 years old.
the age of 40. Few data exist regarding the prevalence of glaucoma – The patient had a history of
prior to the age of 40, particularly in women of childbearing age. glaucoma 13 years ago (17 years
Additionally, women of childbearing age may have glaucoma acquired old). Patients have been diagnosed
early in childhood. Glaucoma is the second-leading cause of blindness with Juvenile Glaucoma by
in the U.S. It most often occurs in people over age 40, although an ophthalmologists
infant (congenital) form of glaucoma exists.
– Juvenile open-angle glaucoma (JOAG) is a subset of primary open-
angle glaucoma (POAG). The two conditions are classified somewhat
arbitrarily by age, with JOAG affecting those who are between 5 and
35 years old and adult-onset POAG affecting those older than 35
years.1 JOAG is, fortunately, a rare condition and is estimated to affect
1 in 50,000 individuals.
 Juvenile Glaucoma
– Frequency in United States
Juvenile glaucoma has an estimated occurrence of 1 per
50,000 persons. It is rare when compared in frequency to
other types of childhood glaucoma.
– Mortality/Morbidity
No risk of mortality exists with juvenile glaucoma. Loss of
vision is possible without early diagnosis and treatment.
– Race
Juvenile glaucoma has been observed in Japanese, French,
French Canadian, Caucasian-American, Asian-American,
Hispanic-American, African-American, Panamanian, German,
English, Irish, Danish, Italian, and Spanish families.
Young black patients with juvenile glaucoma, especially when
myopic, are more susceptible to glaucomatous damage than
are whites. [6]
– Sex
Juvenile glaucoma probably occurs with
equal frequency and severity in males and
females.
– Age
Patients with juvenile glaucoma show no
evidence of congenital or infantile
glaucoma. When candidate children are
monitored carefully in families with a
history of glaucoma, the onset of abnormal
eye pressures occurs in children aged 5-10
years. In sporadic patients or those with no
known family history of juvenile glaucoma,
recognition of this glaucoma has occurred
more often in adolescence or during the
early adult years.
Etiology

– Several genes—including myocilin (MYOC, GLC1A) (CCDS1297.1), optineurin

(OPTN, GLC1E) (CCDS7094.1), and WD repeat domain 36 (GLC1G) (CCDS4102.1)
23—are associated with a monogenic, autosomal dominant trait;

– Following recognition of linkage of the gene for juvenile glaucoma on

chromosome 1 (band 1q21-q31), the gene itself was identified and related to
mutations found in the trabecular meshwork inducible glucocorticoid response
(TIGR) gene in patients with juvenile glaucoma. This gene, now called myocilin,
codes for the glycoprotein myocilin that is found in the trabecular meshwork
and other ocular tissues.
 Risk Factor
Theories Case

Some people have a higher than normal risk of getting glaucoma. •History of dust allergy (+), so the patient
This includes people who: often using cendo citrol (corticosteroids)
for a long time
–Age (> 40 years ago)
–Race •History of eye trauma (-), head trauma
(+) was hit by a basketball throw on the
–Family history of glaucoma back of the head 13 years ago
–Medical conditions (DM, HT, Heart disease) •There is no family with a history of
–Physical injuries to the eye (severe trauma) glaucoma, DM (-), hypertension (-),
cataracts (-), eye surgery before
–Other eye-related risk factors complaints arise (-), high myopia (-)
–Corticosteroid use
–Are farsighted or nearsighted
CLASSIFICATION
Open-Angle Glaucoma
–Open-angle glaucoma, the most common form of
glaucoma, accounting for at least 90% of all glaucoma cases:
–Is caused by the slow clogging of the drainage canals,
resulting in increased eye pressure
–Has a wide and open angle between the iris and cornea
–Develops slowly and is a lifelong condition
–Has symptoms and damage that are not noticed.
–“Open-angle” means that the angle where the iris meets
the cornea is as wide and open as it should be. Open-angle
glaucoma is also called primary or chronic glaucoma. It is the
most common type of glaucoma, affecting about three
million Americans
Angle-Closure Glaucoma
–Angle-closure glaucoma, a less common form of
glaucoma:
–Is caused by blocked drainage canals, resulting in a
sudden rise in intraocular pressure
–Has a closed or narrow angle between the iris and
cornea
–Develops very quickly
–Has symptoms and damage that are usually very
noticeable
–Demands immediate medical attention.
–It is also called acute glaucoma or narrow-angle
glaucoma. Unlike open-angle glaucoma, angle-closure
glaucoma is a result of the angle between the iris and
cornea closing.
 Classification
– Normal-Tension Glaucoma
(NTG)
– Congenital, pediatric, or
juvenile-onset Glaucoma
– Other Types of Glaucoma
Variants of open-angle and angle-closure
glaucoma include:
• Secondary Glaucoma
• Pigmentary Glaucoma
• Pseudoexfoliative Glaucoma
• Traumatic Glaucoma
• Neovascular Glaucoma
• Irido Corneal Endothelial Syndrome (ICE)
• Uveitic Glaucoma
Juvenile Open­Angle Glaucoma

Juvenile open-angle glaucoma (JOAG) is a subset of

primary open-angle glaucoma (POAG). The two conditions
are classified somewhat arbitrarily by age, with JOAG
affecting those who are between 5 and 35 years old and
adult-onset POAG affecting those older than 35 years.
Pathophysiology

– Increased intraocular pressure

(IOP) is caused by impaired outflow
of aqueous humor through the
trabecular meshwork into the
Schlemm canal.
The optic nerve is
made of more
than a million tiny
nerve fibers. It is
like an electric
cable made up of
many small wires.
As these nerve
fibers die, you will
develop blind
spots in your
vision. You may
not notice these
blind spots until
most of your optic
nerve fibers have
died. If all of the
Sign and symptoms

Open-angle glaucoma
–With open-angle glaucoma, there are no warning signs or obvious symptoms in
the early stages. As the disease progresses, blind spots develop in your peripheral
(side) vision.
–Most people with open-angle glaucoma do not notice any change in their vision
until the damage is quite severe. This is why glaucoma is called the “silent thief of
sight.”
Angle-closure glaucoma
–People at risk for angle-closure glaucoma usually show no symptoms before an attack. Some early
symptoms of an attack may include blurred vision, halos, mild headaches or eye pain. People with
these symptoms should be checked by their ophthalmologist as soon as possible. An attack of angle-
closure glaucoma includes the following:
– severe pain in the eye or forehead
– redness of the eye
– decreased vision or blurred vision
– seeing rainbows or halos
– headache
– nausea
– vomiting
– Normal tension glaucoma
People with "normal tension glaucoma" have eye pressure that is within normal
ranges, but show signs of glaucoma, such as blind spots in their field of vision
and optic nerve damage.
– Glaucoma suspects
Some people have no signs of damage but have higher than normal eye
pressure (called ocular hypertension). These patients are considered "glaucoma
suspects" and have a higher risk of eventually developing glaucoma. They
should be carefully monitored by an ophthalmologist.
IOP changes and disease course
–Intraocular pressure typically decreases during pregnancy. In one study of pregnant
women, the mean intraocular pressure of first trimester patients was on average 2 mmHg
higher than that of third trimester patients. Potential mechanisms for this IOP reduction
include greater aqueous outflow facility due to hormonal changes, decreased episcleral
venous pressure from reduction of venous pressure in the upper limbs, and metabolic
acidosis resulting from gestation. Specifically, increased progesterone and relaxin levels may
decrease intraocular pressure and increase the coefficient of facility of aqueous outflow
during the menstrual cycle and pregnancy. However, the extent to which these IOP changes
should be anticipated in women with pre-existing glaucoma is unclear.
 Diagnosis
Theories Case
Glaucoma testing includes:
•Patient history to determine any symptoms the patient is –There is no family with a history of glaucoma,
experiencing and if there are any general health problems and
DM (-), hypertension (-), cataracts (-), eye
family history that may be contributing to the problem.
•Visual acuity measurements to determine if vision is being surgery before complaints arise (-), high
affected. myopia (-)
•Tonometry to measure the pressure inside the eye to detect –The patient has done a series of tests, one of
increased risk factors for glaucoma. them is a field test. Patients have been
•Pachymetry to measure corneal thickness. People with thinner diagnosed with Juvenile Glaucoma by
corneas are at an increased risk of developing glaucoma. ophthalmologists
•Visual field testing, also called perimetry, to check if the field
of vision has been affected by glaucoma.
•Evaluation of the retina of the eye, which may include
photographs or scans of the optic nerve, to monitor any changes
over time.
•Supplemental testing, which may include gonioscopy. Serial
tonometry is another possible test. This procedure acquires
several pressure measurements over time, looking for changes
in the eye pressure throughout the day.
Patient’s History Laboratory Studies
–Juvenile glaucoma are often asymptomatic but in ophthalmological –Mutational analysis of the myocilin gene at
examination, optic nerve abnormalities are noted. Symptoms of visual
chromosomal region 1q21-q31 can be performed.
loss and headache may lead to discovery of the disease.
More than 50% of disease-causing alleles may be
–A family history of glaucoma with occurrence over 2 generations or in a
screened by restriction enzyme analysis.
parent and sibling often is responsible for an early diagnosis of juvenile
glaucoma. Patients are asymptomatic until glaucoma is advanced. Imaging Studies
Physical Examination –Glaucoma assessment - Field testing, fundus
–General physical examination findings are normal. photography, and retinal tomography
–Eye examination Histologic Findings
–Elevated eye pressures - Both eyes –An isolated report by Tawara and Inomata found an
–Myopia is present in 50% of persons with juvenile glaucoma abnormal compact trabecular meshwork in patients
–Optic nerve atrophy or Optic disc damage (cupping) with juvenile glaucoma
–Asymmetry of the optic nerve heads
–Visual field loss
–Slit lamp examination - Normal
–Gonioscopy - Normal, open angles, occasionally prominent uveal
processes
How is the management?
Is it right/wrong?
– The management of the patient is correct.
– The first is to do a section caesarea in the patient because it avoids the
risk of the patient's eyes, but there is no basic theory or research on
the exact mode of delivery for the required glaucoma patients.
– Second, the patient has been observed in general conditions, vital
signs, his, FHR, and the progress of labor.
– Third, patients were placed on an IUD considering patients who were
at risk were having a history of glaucoma and asthma. Patients have
also been given antibiotic home remedies and analgesics
 Medical treatment
The safety of glaucoma medications in pregnancy has been classified by the United States
Food and Drug Administration (FDA) based on evidence available from human and animal studies.
–Category A medications have strong evidence of safety based on human studies.
–Category B medications have varying and /or contradictory human and animal data. For
example, a drug may be graded as Class B if animal studies showed some harm but human
studies indicated safety, or if animal studies showed safety and no human studies were available.
–Category C is used to describe medicines which showed side effects in animal models, or where
inadequate animal and human studies are available.
–Category D medications indicate human studies showing risk to the fetus.
–Category X drugs show strong evidence of birth defects.
 Stages of pregnancy
– First Trimester
– Pre-Conception Brimonidine, a Category B drug, may be the safest
Ideally, a discussion of the option for the first trimester. Other anti glaucoma
treatment plan of a woman’s medications such as beta-blocker, prostaglandins
glaucoma should be initiated and carbonic anhydrase inhibitors should be
before pregnancy begins. In this avoided when possible in first trimester to reduce
way, the adverse effects of potential teratogenic effects or premature abortion.
medications can be prevented Discussions with the patient may include
during the first trimester, when observation off treatment in this critical period.
most organogenesis is occurring. For glaucoma surgery, anesthetics, sedative agents,
and antimetabolites are all possible teratogenic
agents. Therefore, avoiding surgery in first trimester
may decrease the risk of teratogenicity and
spontaneous abortion.
– Second Trimester
In second trimester, brimonidine can be applied and beta-blockers
can be used with regular fetal heart rate and fetal growth
monitoring. If prostaglandin analogues are used, premature labor
symptoms and signs should be described to the patient, and the
medication should be stopped if such symptoms are noted. When
topical or oral carbonic anhydrase inhibitors are used, fetal growth
retardation monitoring may be considered.
Third Trimester
–Brimonidine, beta-blocker, or topical carbonic anhydrase inhibitors, can be used with caution.
Avoidance of prostaglandins may decrease the risk of premature labor, which is particularly
important early in the third trimester. Late in the third trimester, brimonidine should be
discontinued because it can induce central nervous system depression in newborns. Topical
carbonic anhydrase inhibitors may be the optimal choice in this period.
–Glaucoma surgery can be performed with caution in second and third trimester if the
patients have a strong indication for the procedure. However, anesthetics, sedative agents,
and antimetabolites still have potential risk for the fetus. Additionally, uterine displacement
ought to be performed to prevent maternal hypotension that can induce fetal asphyxia.
–Argon laser trabeculoplasty(ALT)or selective laser trabeculoplasty (SLT)is an alternative
glaucoma treatment that can be performed in all trimesters. ALT or SLT may be less effective
for long term IOP control, but may result in short-term IOP control until the end of pregnancy.
– Postpartum
Carbonic anhydrase inhibitors and beta-blockers are certified
by the American Academy of Pediatrics for use during nursing.
However, low doses of these medications should be considered
when used in the breast feeding period. Brimonidine is
contraindicated for use in lactating mothers due to the risk of
central nervous system depression in the newborn.
Case

– Antibiotic : Cefotaxime 2x1gr IV – Surgical : Sectio Caesarea

Metronidazole 3x500mg IV

– Analgetic : Kaltrofen 3x100 mg sup

– For Allergy:

Dexamethasone extra 1 amp IV

Paracetamol 500 mg post 2 hour

dexamethasone ekstra 1 amp
A survey of ophthalmologists and gynecologists regarding termination of pregnancy and choice of delivery
mode in the presence of eye diseases
–C-section delivery for women with glaucoma was recommended by 25% of the gynecologists, and the rest
had no comment, but 84% of the ophthalmologists recommended NVD. Gynecologists seem to recommend C-
section delivery whenever they feel there is a “potential risk” because they consider C-section delivery to be a
more manageable situation than NVD. We may consider abortion or early delivery (C-section) for patients with
advanced or uncontrolled glaucoma who are expected to need multiple anti-glaucoma eye drops or an eye
surgery. Anti-glaucoma medications may interfere with the process of delivery (for instance beta blockers). On
the other hand, it is very difficult to perform glaucoma surgery in a pregnant women in either local or general
anesthesia. Efforts should be made to perform glaucoma surgery prior to pregnancy. These are special and rare
conditions with no clear evidence for the approach in the literature.
Cesarean Section
–Whether to perform a C-section is a question that Dr. Barton has been asked by patients and obstetricians.
“If the patient is tending toward a C-section, then I have no objection from the glaucoma point of view. It is
more difficult if the patient asks if she should have a C-section because of her glaucoma. There is no
evidence to suggest she should; however, one might expect that a lot of pushing and Valsalva-type activity
might compromise an optic nerve if it is already severely damaged, in which case most patients will be
concerned about the risk of visual loss and, in my experience, more likely to ask for a C-section. In reality,
this has only been a serious concern in my practice in patients with severe glaucoma in one or both eyes.”
–A caveat for all deliveries. A major concern for Dr. Katz is ensuring that blood pressure does not drop too
low during delivery. He warned, “With blood loss, or dropping blood pressure, I would be concerned about a
large drop in ocular perfusion pressure. The mom in delivery must be kept hydrated, and in rare instances,
transfused.”
Asthma in pregnancy
Definition

– Asthma is a chronic inflammatory disease of the airways that is characterized by

increased responsiveness of the tracheobronchial tree to multiple stimuli. It is
the most common chronic condition in pregnancy.
Epidemiology
– The prevalence of asthma in the general population is 4-5%. In pregnancy, the
prevalence ranges from 1-4%.
– Asthma-related morbidity and mortality rates in pregnant women are
comparable to those in the general population. The mortality rate from asthma
in the United States is 2.1 persons per 100,000.
 Etiologic Factors in Asthma
– Asthma results from a complex and
poorly defined interaction of genetic
predisposition and environmental
stimulation. The basic mechanism for
nonspecific bronchial
hyperresponsiveness is unknown.
Airway inflammation is the most popular
hypothesis.
Implicated stimuli include the following:
–Allergens, including pollens, house-dust mites, cockroach antigen,
animal dander, molds, and Hymenoptera stings
–Irritants, including cigarette smoke, wood smoke, air pollution, strong
odors, occupational dust, and chemicals
–Medical conditions, including viral upper respiratory tract infections,
sinusitis, esophageal reflux, and Ascaris infestations
–Drugs and chemicals, including aspirin, nonsteroidal anti-
inflammatory drugs, beta blockers, radiocontrast media, and sulfites
–Exercise (see Exercise-Induced Asthma.)
–Cold air
–Menses
–Emotional stress
 Examination Findings

History findings in pregnant and nonpregnant patients may include the

following: General physical examination findings
–Cough may include the following:
–Shortness of breath –Tachypnea
–Chest tightness –Retraction (sternomastoid,
–Noisy breathing abdominal, pectoralis muscles)
–Nocturnal awakenings –Agitation, usually a sign of hypoxia or
–Recurrent episodes of symptom complex respiratory distress
–Exacerbations possibly provoked by nonspecific stimuli –Pulsus paradoxicus (>20 mm Hg)
–Personal or family history of other atopic disease (eg, hay fever, eczema)
– Pulmonary findings are as follows:
– Diffuse wheezes - Long, high-pitched
sounds on expiration and, occasionally, on
inspiration)
– Diffuse rhonchi - Short, high- or low-
pitched squeaks or gurgles on inspiration
and/or expiration
– Bronchovesicular sounds
– Expiratory phase of respiration equal to
or more prominent than inspiratory
phase
– Signs of fatigue and near-
respiratory arrest are as follows:
– Alteration in the level of
consciousness, such as lethargy,
which is a sign of respiratory
acidosis and fatigue
– Abdominal breathing
– Inability to speak in complete
sentences
– Signs of complicated asthma are as follows:
– Equality of breath sounds: Check for equality of breath sounds (pneumonia,
mucous plugs, barotrauma). The amount of wheezing does not always correlate
with the severity of the attack. A silent chest in someone in distress is more
worrisome.
– Jugular venous distension from increased intrathoracic pressure (from a
coexistent pneumothorax)
– Hypotension and tachycardia (think tension pneumothorax)
– Fever, a sign of upper or lower respiratory infections
 Antiasthma Drugs

– Almost all antiasthma drugs are safe to use in pregnancy and during breastfeeding. In fact,
undertreatment of the pregnant patient is a frequent occurrence, because such patients are worried
about medication effects on the fetus.
– Outpatient management of asthma is similar for the pregnant patient as it is for the nonpregnant
patient. Beta-adrenergic agonists remain the mainstay of treating exacerbations and handling mild forms
of asthma. Early research suggests a management algorithm for asthma in pregnancy based on fraction
of exhaled nitric oxide (FE NO) and symptoms significantly reduces asthma exacerbations.
– For moderate-persistent asthma, a beta-adrenergic agonist combined with an inhaled anti-inflammatory
agent or inhaled corticosteroid is recommended for treatment. In severe asthma, oral corticosteroids
and beta agonists are recommended.
– Corticosteroids can be used in the acute and outpatient setting and have been shown to be relatively
safe in pregnancy.
 Outcomes and complications of asthma in
pregnancy
– Although women with mild asthma
are unlikely to have problems,
patients with severe asthma are at
greater risk of deterioration. The
deterioration risk is highest in the
last portion of a pregnancy.
 
– In fact, severe and/or poorly controlled asthma has
been associated with numerous adverse perinatal
outcomes, including the following:
– Preeclampsia
– Pregnancy-induced hypertension
– Uterine hemorrhage
– Preterm labor
– Premature birth
– Congenital anomalies
– Fetal growth restriction
– Low birth weight
– Neonatal hypoglycemia, seizures, tachypnea, and
neonatal intensive care unit (ICU) admission
How is the prognosis of
this case? (Sexual,
Menstruation &
Reproduction)
Quo ad vitam: Dubia Ad bonam, Because after SC, the patient complained of an allergy to
the medication given post-operatively which cause swelling in both eyes but after being
given treatment the patient's condition is stable and good. From follow-up on day 2 vital
signs and surgical wounds were dry, clean and maintained.
Quo ad functionam :
–Reproduction : Dubia ad bonam. Because if the patient’s want to get pregnant again the
patient must prepare his pregnancy first and discuss it with an ophthalmologists
–Sexual & Menstruation : Ad bonam, because the patient can still do the sexual intercourse
normally and experience menstruation as usual.
Quo ad sanationam: Ad malam, because glaucoma damage is permanent—it cannot be
reversed. But medicine and surgery help to stop further damage.
How is the view of the
principle of medical
ethics in these patient?
How is the islamic view
of these case?
THANK YOU