Case No.

55

Identity

Name : Mrs. Y
Age
: 32 years old
MR No.: 95 20 81
Date
: July 27th, 2016

Chief Complaint:
A 32 years old patient was admitted
to the Emergency Room of Dr. M.
Djamil Central General Hospital on
July 27th, 2016 at 14:30 pm referred
by Pasaman Barat private hospital
with diagnosed: G4P3A0H3 33-34
weeks preterm pregnancy +
eclampsia antepartum in
maintenance dose of MgSO4 regimen
+ Gemelli

Present Illness History

Patient seizure three times at 26-07-16 at 00.00 pm, seizure for 3

minutes, mouth closed, eye closed, all body war rigid. Patien was
concious after seizure
Patient refered to puskesmas at 01.00 pm. No seizure at puskesmas
and patient refered to Yarsi hospital without infus and cateter attached
Patien ariveded at Yarsi hospital at 02.30 pm. Regimen MgSo4 was
given. The patient was planed to termination tommorow. Because
perinatology not resdy so the patient refered to RSUP M Djamil wih
regimen MgSO4 and cateter attached
Headeche (+), Blur vision (-), epigastric pain (-)
Bloody show from the vagina was abcent
There was no fluid leakage from the vagina
There was no massive vaginal bleeding
Amenorrhea since 8,5 months ago
First date of last menstrual : midlle September 2015
Estimation date of delivery : -

 Fetal movement was felt since 4 months

ago
No complain of nausea, vomiting, or
vaginal bleeding neither during early nor
late pregnancy
Prenatal care to midwife three time on 2,3
and 7 month of pregnancy.
Menstrual history : menarche at 13 years
old, iregular cycle, which last for 5-7 days
each cycle with the amount of 2-3 times
pad change/day without any menstrual
pain.

Previous Illness History

There was no previous history of heart, lung, liver, kidney
disease, DM, hypertension and allergy

Previous Illness History

There was no history of any hereditary disease, contagious

and psycological illness in the family.

Occupation, Socioeconomics,
Psychiatry, and Habitual History :

Marital history: once in 2007

History of pregnancy/abortion/delivery: 4/0/3
1. 2005, male, 3500 gr, term pregnancy, spontaneus, midwife,
alive.
2. 2008, female, 3500 gr, term pregnancy, spontaneus,
midwife, alive.
3. 2012, female, 3500 gr, term pregnancy, spontaneus,
midwife, alive.
4. Present
History of family planning: (-)
History of immunization: (-)
History of education : Junior High School
History of occupation : (-)

Physical Examination:
General Record:

GA

Cons

BP

HR

RR

Mdt

CMC

160/110

92

20

37

urine
: 350 cc/at time
patella reflex : +/+ normal
protein urine (++)
GCS: 15
Eye : anemic -/-, icteric -/-, isokor 3mm/3mm
Neck : Jvp 5-2 cmH2O
Thorax : H/L within normal limit

Obstetric Record

Abdomen
Inspection :
Abdomen seems enlarged in accordance with term
pregnancy,
mid line hyperpigmentation (+), striae
gravidarum (+)
Palpation :
L1 Uterine fundal 1 finger above proc xyphoideus .
hard and
resistance structure was palpated
L2 two large, soft, nodular mass was palpated. on the left side.
L3

two hard and round mass was palpated on the right side
hard and resistance structure was palpated

L4

not performed

UFH: 39 cm
EBW: Uterine contraction : Percussion : Tympani
Auscultation : Peristaltic sound was normal, Fetal heart sound I: 140150 bpm
Fetal heart sound II: 130-140 bpm

USG I

USG II

 Fetal alive, Gemelly,intra uterine, transver lie, transver

lie
Fetal movement (+), FHM (+)
Biometrics :
Fetal I BPD : 79,8 mm Fetal II BPD: 80,4 mm
AC : 273 mm
AC : 285 mm
FL : 61,1 mm FL : 60,2 mm
EFW : 1832 gr EFW : 1706 gr
Placenta was implanted in fundus grade II-III, lambda
sign (+)
Impession : 32-34 weeks preterm pregnancy
Fetal alive, transverse lie, transverse lie

CTG I

CTG I Interpretation
Baseline : 140 bpm
Variability : 5-15 bpm
Acceleration : (+)
Deceleration : (-)
Fetal movement : (+)
Contraction : (-)
Impression : reactive

CTG II

CTG II Interpretation
Baseline : 140 bpm
Variability : 5-10 bpm
Acceleration : (+)
Deceleration : (-)
Fetal movement : (+)
Contraction : (-)
Impression : reactive

PARAMETER

Laboratory findings

Normal Value

9,9 gr/dl

9.5-15

8.300/mm3

5.000 16.000

31 %

37 43

162.000 /mm3

150.000 400.000

36,0 detik

29,2 39,4

PT

9,4 detik

10 13,6

Ureum darah

6 mg/dl

16,6 48,5

0,5 mg/dl

0,6 1,2

Hemoglobin
Leukosit
Hematokrit
Trombosit
APTT

Creatinin darah

LDH

360 u/l

0 480

Gula darah sewaktu

81 mg/dL

74 106

Protein total

5,3 mg/dL

67

Albumin

2,6 g/dL

3,5 5,2

Globulin

2,7 g/dL

1,3 2,7

SGOT

17 u/l

0 31

SGPT

5 u/l

0 34

Total bilirubin

0,5 mg/dL

0,1 1,2

Direk

0,2

<0,20

Indirek

0,3

<0,4

Calsium

7,3 mg/dL

8,1 10,4

Natrium

137 Mmol/dL

136 145

Kalium

2,6 Mmol/L

3,5 5,1

Chlorida

109 Mmol/L

97 111

URINALISA

Protein
: ++
Glukosa
: (-)
Leukosit : 2-3/LPB
Eritrosit
: 200-250/LPB
Silinder
: (-)
Kristal
: (-)
Epitel
: (+), gepeng
Bilirubin
: (-)
Urobilinogen : (+)

Diagnose :
G4P3A0L3 32-34 weeks preterm
pregnancy + eclampsia antepartum
in maintenance dose of MgSO4
regimen from other institution
Fetal alive, gemelli, intrauterine,
transverse lie - transverse lie

 Management :
Control GA, VS, FHR, urine, fluid balance, patela ref
Informed consent
O2 5 l/ nasale
Continous MgSO4 regimen
Check complete blood test + urine + hepar, kidney,
Haemostatic
Antihypertention
Metil dopa 500mg
Nifedipin 10mg
Antibiotics Skin test (Ceftriaxone 1gr)
Consult to Eclampsia team
Consult to Anestesiologist, Intensivist, Perinatology
Report to Operation Room
Plan :
Stabilisation
Termination

 Heart departement :
D/eclampsia antepartum in G 4P3A0L2 33-34
weeks
preterm pregnancy
HT stage II pada HT chronic
M/methyldopa 3 x 500mg
adalat oros 1x30mg
Eye department :
D/There is no sign of fundus eclampsia
M/according to Obsgyn
Neuro department
D/There is no sign of focal defisit neurologis or sign of
acute stroke
Intensivist
Acc post op to ICU

 Internist departement:
D/antepartum eclampsia in G 4P3A0L3 32
preterm
pregnancy in MgSO4 regimen
Tolerance operation:
Metobolic risk: mild
Pulmoner riak: moderate
Cardiovascular risk: moderate
Hematology risk: moderate
M/consult anestesi
joint treatment with Kidney
Hypertention

At

19.30 pm

: TPPCS was perfomed

A baby I, female baby was born by TPPCS with 1800

gram in weight, 43 cm in height, Apgar score : 8/9.
A baby II, male baby was born by TPPCS with 2000
gram in weight, 44 cm in height, Apgar score : 8/9.
Placenta was born with a light traction on umibilical
cord, complete, 2 piece.
Bleeding during operation 200 cc
D/

P4A0L5 post TPPCS on indication of eclamptia antepartum in

maintenance dose of MgSO4 regimen + Gemelly
Mother Child were in care

July 27th, 2016

09.00 pm at ICU
S/ Headeche (-), Blur vision (-), epigastric pain (-),
Dispnoe (+), Vaginal bleeding (-), fever (-)
Physical Examination :
GA

Cons

BP

PR

RR

Mdt

CMC

150/9
0

80

20

36,7

Eyes
:Conjunctiva was not anemic, Sclera
wasnt icteric
Abdoment: Wound closed by verban, uterine
contraction
goods
Genitalia : I: V/U within normal limit
Diagnoses :
P4A0L5 post TPPCS on indication of eclamptia
antepartum in

maintenance dose of MgSO4

Management :
Control GA, VS, FHR, urine, fluid balance,
patela ref
Continue MgSO4 regimen maintenance dose
Ceftriaxone 2x1 gr
Adalat oros 1x30 mg
Metil dopa 3x500 mg
Pronalgess supp II (k/p)
Other treatment is according intencivist

Laboratory 28-07-16 post SC

PARAMETER

Laboratory findings

Normal Value

9,8 gr/dl

9.5-15

9.300/mm3

5.000 16.000

31 %

37 43

148.000 /mm3

150.000 400.000

31,0 detik

29,2 39,4

PT

9,4 detik

10 13,6

Ureum darah

10 mg/dl

16,6 48,5

Creatinin darah

0,5 mg/dl

0,6 1,2

Hemoglobin
Leukosit
Hematokrit
Trombosit
APTT

LDH

360 u/l

0 480

Gula darah sewaktu

81 mg/dL

74 106

Protein total

5,3 mg/dL

67

Albumin

2,5 g/dL

3,5 5,2

Globulin

2,8 g/dL

1,3 2,7

SGOT

17 u/l

0 31

SGPT

5 u/l

0 34

Total bilirubin

0,5 mg/dL

0,1 1,2

Direk

0,2

<0,20

Indirek

0,3

<0,4

Calsium

7,2 mg/dL

8,1 10,4

Natrium

136 Mmol/dL

136 145

Kalium

2,7 Mmol/L

3,5 5,1

Chlorida

108 Mmol/L

97 111

28-07-16

29-07-16

S/ Headeche (-), Blur vision (-), epigastric

pain (-), Vaginal bleeding (-), fever (-)

S/ Headeche (-), Blur vision (-), epigastric

pain (-), Dispnoe (+), Vaginal bleeding (-),
fever (-)

Physical Examination
GA: Mdrt, Cons: Cmc, BP: 130/90, HR: 80
SpO2: 98%
Eye: Conjunctiva was not anemic, Sclera
wasnt icteric
Abd: Wound closed by verban, uterine
contraction goods
Gen: I: V/U within normal limit

Physical Examination
GA: Mdrt, Cons: Cmc, BP: 130/90, HR: 80
Eye: Conjunctiva was not anemic, Sclera
wasnt icteric
Abd: Wound closed by verban, uterine
contraction goods
Gen: I: V/U within normal limit

A/ P4A0L5 post TPPCS on indication of

eclamptia antepartum in maintenance dose
of MgSO4 regimen + Gemelly NH1 +
hipokalemia
Mother Child were in care

A/ P4A0L5 post TPPCS on indication of

eclamptia antepartum in maintenance dose
of MgSO4 regimen + Gemelly NH2 + post
corection electrolit
Mother Child were in care

P/ Control GA, VS, FHR, urine, fluid

balance, patela ref
Continue MgSO4 regimen maintenance
dose
02 4 l/ Nasal
Ceftriaxone 2x1 gr
Adalat oros 1x30 mg
Metil dopa 3x500 mg
Corection Kcl 50 meq
Acc to move HCU Obstetric

P/ Control GA, VS, FHR, urine, fluid

balance, patela ref
Continue MgSO4 regimen maintenance
dose
Ceftriaxone 2x1 gr
Adalat oros 1x30 mg
Metil dopa 3x500 mg
Antalgin 3x1 tab

Thank You