A PROSPECTIVE SURVEY OF APPROPRIATENESS OF PAIN PHARMACOTHERAPY MANAGEMENT IN POST-CESAREAN SECTION PATIENTS IN CIPTO MANGUNKUSUMO HOSPITAL

Objective: In this study, we sought to assess the pattern of analgesic usage, adequacy of pain management, side effects, and analgesic drug interactionsin the post-emergency cesarean surgery setting.Methods: This was a prospective observational study of 80 patients who underwent emergency cesarean surgery at the Obstetrics and GynecologyDepartment of the Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo (RSUPN-CM) between July 2015 and January 2016. Adequacy of painmanagement during the first 3 post-operative days was assessed using Pain Management Index. Relation between pain intensity during activities andrest with patient characteristic was assessed using Chi-squared test and Fischer’s exact test.Results: Nineteen patients (8.7%) were prescribed two types of nonsteroid anti-inflammatory drugs concomitantly, and 41.8% received inappropriateanalgesics at a lower frequency. Most patients experienced pain with numerical rating scale score >3 in the first 24 h post-surgery: 59 patients(73.75%) experienced pain during activities and 7 patients (8.75%) during rest.Conclusion: Post-emergency cesarean surgery pain management at RSUPN-CM was not optimal. Most patients did not receive adequate painmanagement in the first 24 h post-surgery

Long-term Outcome of Severe Preeclampsia Cases: Cross – Sectional Study: Keluaran Jangka Panjang Kasus Preeklamsia Berat: Studi Potong Lintang

Objectives: To investigate the long term outcome of severe preeclampsia mother by clinically and laboratory, and the long  term outcome of the baby that she delivered. Method: This is a cross sectional study was conducted at Obstetrics Outpatient Clinic Dr. Cipto Mangunkusumo General Hospital (Cipto Mangunkusumo NCGH) on January–June 2017, of patients with previous severe preeclampsia that gave birth in Cipto Mangunkusumo NCGHon January 2014 – December 2016, and was descriptively analyze using SPSS Statistics 24. Results: One hundred and twenty seven patients were studied, divided into 3 groups of post – delivery time which were 6 months, 12 months, and 24 months. The 6 months’ group, mean of blood pressure were 147/92 mmHg (SD 38/SD 39), BMI 29 kg/m2 (SD 6), CRP level 16.6 mg/l (0.3 – 42.60) and urine protein dipstick 1 (0 – 3). The 12 months’ group, mean of blood pressure were 112/88 mmHg (SD 12/SD 24), BMI 21s kg/m2 (SD 7), CRP level 12.7 mg/l (3.4 – 15.2) and urine protein dipstick 0 (0 – 3). The 24 months’ group, mean blood pressure 154/95 mmHg (SD 45/SD 62), BMI 28.83 kg/m2, CRP level 14,2 mg/l (SD 8.54) and urine protein dipstick 0 (0 – 3). Meanwhile, the long – term outcome of babies that 68% baby were born with preterm condition and mean birth weight were 1943 grams (SD 1245), the 5th minute Apgar score >7 were 63.78%, and only 44.88% baby had normal growth development. Conclusion: The long – term outcome patients with previous severe preeclampsia are blood pressure, BMI, and CRP level still high, and negative urine protein level until 2 years of post – delivery. The long – term outcome of the babies that delivered were on preterm condition and low birth weight, with less than 50% had normal growth and development. Keywords: c–reactive protein, growth and development, proteinuria, post–delivery, severe preeclampsia.   Abstrak Tujuan: Untuk mengetahui keluaran jangka panjang pada pasien ibu PEB dari sudut klinis dan laboratoris, serta keluaran jangka panjang bayi yang dilahirkan. Metode: Penelitian ini menggunakan desain potong lintang terhadap pasien riwayat PEB yang pernah melahirkan di RSUPN Dr. Cipto Mangunkusumo pada bulan Januari 2014–Desember 2016. Subjek diminta datang ke Poli Obstetri RSUPN Dr. Cipto Mangunkusumo pada Januari–Juni 2017 untuk dilakukan pemeriksaan klinis dan laboratoris (CRP dan protein urin), serta dilakukan analisa deskriptif menggunakan SPSS Statistik 24.   Hasil: Sebanyak 127 pasien yang diteliti terbagi dalam 3 kelompok yaitu pasien riwayat PEB pasca persalinan 6 bulan (kelompok I), 12 bulan (kelompok II), dan 24 bulan (kelompok III). Kelompok I didapatkan rerata tekanan darah (TD) 147/92 mmHg (SD 38/SD 39), IMT 29 kg/m2 (SD 6), kadar CRP 16,6 mg/l (0,3 – 42,60) dan protein urin 1 (0 – 3). Kelompok II didapatkan rerata tekanan darah (TD) 112/88 mmHg (SD 12/SD 24), IMT 21 kg/m2 (SD 7), kadar CRP 12,7 mg/l (3,4 – 15,2) dan protein urin 0 (0 – 3). Kelompok III rerata TD 154/95 mmHg (SD 45/SD 62), IMT 28,83 kg/m2, dengan rerata kadar CRP 14,2 mg/l (SD 8,54) dan protein urin 0 (0 – 3). Sedangkan keluaran jangka panjang bayi yang dilahirkan bahwa 68% lahir dengan kondisi preterm dengan rerata berat lahir 1.943 gram (SD 1.245), nilai Apgar menit ke-5 >7 63,78%, dan hanya 44,88% tumbuh – kembang bayi normal. Kesimpulan: Gambaran keluaran jangka panjang pasien riwayat PEB didapatkan tekanan darah, IMT dan kadar CRP masih tinggi, serta protein urin urin negatif setelah 2 tahun pascapersalinan. Keluaran jangka panjang bayi yang dilahirkan mayoritas kondisi preterm dan berat lahir rendah, dengan kurang dari 50% bayi tumbuh – kembang normal. Kata kunci: c– reactive protein, preeklamsia berat, proteinuria, pascapersalinan, tumbuh kembang bayi

Can we predict birth asphyxia of neonates born from PPROM women?

Background: To develop a simple and accurate method of predicting birth asphyxia of neonates born from preterm premature rupture of membranes (PPROM) women utilizing clinical parameters that are generally available before delivery in the practical setting.Methods: A retrospective cohort was conducted at single tertiary hospital in Jakarta between January and December 2013. Subjects were PPROM women with singleton live pregnancy who had their delivery on 24 to 34 weeks of gestational age (GA). Primary outcome was birth asphyxia defined by 5th minutes APGAR score 12,450/mm3 (OR=3.6, 95%CI 1.11-11.63), (Final AUC=0.82 (95%CI 0.74-0.89). Clinical chorioamnitis, severe preeclampsia, mode of delivery, PPROM-admission duration was not associated with birth asphyxia.Conclusions: A prediction model to predict BA among PPROM women at 24-34 weeks GA was developed consisted of GA at PPROM and maternal leukocyte counts at patient’s admission

Genetics of Endometrial Cancers

Endometrial cancers exhibit a different mechanism of tumorigenesis and progression depending on histopathological and clinical types. The most frequently altered gene in estrogen-dependent endometrioid endometrial carcinoma tumors is PTEN. Microsatellite instability is another important genetic event in this type of tumor. In contrast, p53 mutations or Her2/neu overexpression are more frequent in non-endometrioid tumors. On the other hand, it is possible that the clear cell type may arise from a unique pathway which appears similar to the ovarian clear cell carcinoma. K-ras mutations are detected in approximately 15%–30% of endometrioid carcinomas, are unrelated to the existence of endometrial hyperplasia. A β-catenin mutation was detected in about 20% of endometrioid carcinomas, but is rare in serous carcinoma. Telomere shortening is another important type of genomic instability observed in endometrial cancer. Only non-endometrioid endometrial carcinoma tumors were significantly associated with critical telomere shortening in the adjacent morphologically normal epithelium. Lynch syndrome, which is an autosomal dominantly inherited disorder of cancer susceptibility and is characterized by a MSH2/MSH6 protein complex deficiency, is associated with the development of non-endometrioid carcinomas

Trans-arterial embolization of acquired uterine arteriovenous malformation after Cesarean section: A case series

Background: Acquired uterine arteriovenous malformation (AVM) is a rare condition due to traumatic episodes in cesarean section. The patient can suffer from life-threatening hemorrhage or recurrent vaginal bleeding. Establishing this diagnosis is difficult, often misdiagnosed due to lack of information and number of cases. Trans-Arterial Embolization (TAE) procedure is rarely performed in our center. All of the cases were found with history of massive bleeding and diagnosed lately after recurrent bleeding history. Even though promising, one of our cases failed to be managed with TAE. It is important to diagnose early symptoms of AVM in order to prevent the life-threatening event. Case presentation: In this case series, four cases of AVMs after cesarean procedures will be reviewed. One could be diagnosed in less than a month but the other three took several months. The symptom of vaginal bleeding might occur a few weeks after the procedure is done, and most patients need transfusion and hospitalization. Three out of four patients were initially sent to the hospital in order to recover from shock condition, and one patient was sent for a diagnostic procedure. AVMs diagnostic was established with ultrasound with or without angiography. Three of our cases were succeeded by performing TAE procedure without further severe vaginal bleeding. One case failed to be treated with embolization and had to proceed with hysterectomy. Conclusion: AVM should be considered early-on in patient with abnormal uterine bleeding and history of cesarean section. Embolization is still the first-choice treatment of AVMs, otherwise, definitive treatment is hysterectomy in a patient without fertility need, or impossible to perform TAE. Key words: Trans-arterial embolization, Acquired uterine arteriovenous malformation, Cesarean section

ANALYSIS OF OXIDATIVE STRESS MARKERS MALONDIALDEHYDE, GLUTATHIONE, NITRIC OXIDE, AND PRORENIN LEVEL IN PREECLAMPSIA PLACENTAL TISSUES

 Objective: Preeclampsia was a syndrome of hypertension proteinuria in pregnant women. In failure of pseudo vasculogenesis, there is persistency of endothelial and smooth muscle cell of vessel wall in spiral artery. Spiral artery could not be emphasis and lead to relative hypoxia, and oxidative stress in placental tissues. Endothelial cell has property to produce nitric oxide (NO) that can dilated vessel. Placenta also produces prorenin, to maintain vascular wall tonicity. Therefore, we want to uncover the property of placenta is there any capacity of prorenin, is that prorenin could overcome the NO level, or is there any depression of NO production, and any oxidative stress.Methods: This observational study was used case–control design. We search preeclampsia cases during September-December 2015. We used preeclampsia placentas from early and late onset. We collect preeclampsia placentas from Cipto Mangunkusumo and normal placentas from Budi Kemuliaan Hospital. We used 30 preeclampsia placentas and 30 normal placentas. Markers measured were NO and prorenin. NO was measured using colorimetric assay kit (K262-200/ BioVision), and prorenin was measured using human prorenin enzyme-linked immunosorbent assay kit (ab157525/ Abcam). Glutathione (GSH) was measured using Ellman method and malondialdehyde (MDA) using Wills method.Results: Prorenin concentration between normal and preeclampsia placenta was analyzed using Mann–Whitney and show that there had no significant difference between preeclampsia and normal placentas (p=0.23). Besides, NO data analyzed using independent t-test show significant differences between preeclampsia and normal placentas (p=0.001). The difference between normal and preeclampsia GSH concentration was not significant (p=0.757), besides the difference between normal and preeclampsia MDA concentration was significant (p=0.000).Conclusion: NO concentration in preeclampsia placenta was increase, higher than normal placenta. There was no effect of preeclampsia on prorenin concentration and GSH. There was marked decrease of MDA in preeclampsia placentas

Clinical potential for noninvasive prenatal diagnosis through detection of fetal cells in maternal blood

Summary Fetal cells circulate in maternal blood and are considered a suitable means by which to detect fetal genetic and chromosomal abnormalities. This approach has the advantage of being noninvasive. Since the early 1990s, nucleated erythrocytes (NRBCs) have been considered good target cells for a number of techniques, including fluorescence-activated cell sorting and magnetic cell sorting, using antibodies such as anti-transferrin receptor and anti-?-hemoglobin antibodies, followed by analysis with fluorescence in situ hybridization or polymerase chain reaction. In the late 1990s, the National Institute of Child Health and Human Development Fetal Cell Isolation Study assessed the reliability of noninvasive prenatal diagnosis of fetal aneuploidy using NRBCs isolated from maternal circulation. This study revealed the limitations of NRBC separation using antibodies specific for NRBC antigens. A more recent study has demonstrated the efficiency and success of recovery of NRBCs using a galactose-specific lectin, based on the observation that erythroid precursor cells have a large quantity of galactose molecules on their cell surface. Thus, recent advances in this field enhance the feasibility of this diagnostic method. This review article focuses on various methods of detection of fetal cells within the maternal circulation, as well as the status of previous and current studies and the prospective view for noninvasive prenatal diagnosis using fetal cells from the maternal circulation

CORRELATION OF (PRO)RENIN RECEPTOR AND VASCULAR ENDOTHELIAL GROWTH FACTOR EXPRESSION LEVEL IN THIRD TRIMESTER OF PREECLAMPSIA PLACENTAS

Objective: This cross-sectional study was designed to correlate the expression of mRNA and protein of (pro)renin receptor ([P]RR) and vascular endothelial growth factor (VEGF) gene in preeclampsia placentas.Methods: We used 34 placenta tissues of normal pregnancy and 34 preeclampsia placenta tissues. Real-time polymerase chain reaction was used to measure relative expression of VEGF and (P)RR mRNAs, and protein concentration was measured using Sandwich ELISA technique.Results: VEGF mRNA relative expression of preeclampsia placenta was 2.83 times higher than the normal placenta (p=0.02). (P)RR mRNA relative expression on preeclampsia placenta was 1.7 times higher than the normal one (p=0.039). Expression of protein (P)RR and VEGF was lower on preeclampsia shown by p<0.05, R=0.441. From this research, it was considered that low protein of (P)RR and VEGF contributes to preeclampsia.Conclusion: There was a correlation between (P)RR and VEGF. It considers that there is any involvement of (P)RR on angiogenesis through VEGF expression in preeclampsia placenta