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Case No.

CASE REPORT
IDENTITY
• Name : Mrs.F • Husband name : Mr. D
• Age : 41 yo • Age : 43 yo
• Address: Sungai Penuh • Address : Sungai Penuh
• MR : 01 00 22 46 • Occupation : Labour
• Occupation : housewife • History of education : junior high
Age
• History of education : junior high school
school
Identity

A 41 years old patient was admitted to the Emergency Room


of Dr. M. Djamil Central General Hospital on Dec 28th, 2017
at 22:00 pm referred from Kerinci general hospital with
diagnose: G9P4A4L2 34-35 weeks of preterm pregnancy +
severe preeklampsia
GA Cons. BP PR RR T Saturation
Severe CM 170/110 120x/1’ 34x/1’ 37OC 92%

• Airway : Free airway


• Breathing : O2 4lt/minute via canule nasal 
10lt/minute via NRM
• Circulation :
– Line 1: Reg MgS04 maintenance dose
D/ Observation of dispneu ec ?? on G9P4A4L2 34-35
weeks of preterm pregnancy + severe preeclampsia
on maintenance dose of MgSO4 regiment from
other institution
P/
Control GA, VS, Σ urine, fluid balance, patela reflex
Continue MgSO4 regimen maintenance dose
Informed consent
Check complete blood test + urine + hepar, kidney, Haemostatic Urine : 300cc at time
Antihypertention  Metil dopa 500mg
USG, CTG, ECG Protein urine: +++ (burn)
report to preeclampsia team (CARDIOLOGIST, INTERNIST, OPTHALMOLOGYST) Patela Reflex: +/+ normal
Present Illness History
• Previously patient was came to Kerinci general hospital
with chief complain hard to breathing since 2 hours ago. In
the hospital the patient was examine, and found the blood
pressure was 180/110mmHg. Then patient was diagnose
with severe preeclampsia. The patient was given the
loading dose of MgSO4 regiment and continued by
maintenance dose. Patient also was given the
antihypertensiojn therapy with metildopa 500 mg in dose.
Patient was planning to termination of pregnancy, but
because of the anestesiologyst doctor was not available so
the patient was referred to RSMJ with MgSO4 regiment and
urinary catheter inserted.
• No history of blurred vision, headache or epigastrial pain.
Present Illness History
 Feeling hard to breathing since 2 hours ago, and patient
was prefer in sitting position rather on supine position.
 Feeling of pain from waist to region which referred to
the groin was abcent
 Bloody show from the vagina was abcent
 fluid leakage from the vagina was abcent
 Amenorrhea since ± 8,5 months ago
• Last menstrual period was forgotten
• Estimated date of delivery hard to estimated
• Prenatal care to midwife was twice in this
pregnancy, in 1 and 3 month of pregnancy
Previous Illness History
• There was no previous history of heart, lung, liver, kidney disease, DM,
hypertension and allergy

Family Illness History


• There was no history of any hereditary disease, contagious and
phsycological illness in the family.
Occupation, Socioeconomics, Psychiatry, and
Habitual History :
 Marital history: once in 2000
 History of pregnancy/abortion/delivery: 9/4/4
1. 2001 ♀, term, 3200 gr, spontaneous delivery, midwife
2. 2003, ♀, term, 3000 gr, spontaneous delivery, midwife,
3. 2005, abortus, curettage, doctor, hospital
4. 2006, abortus, curettage, doctor, hospital
5. 2006, ♀, term, 3000 gr, spontaneous delivery, midwife,death at 2 years
old
6. 2010, abortus, curettage, doctor, hospital
7. 2011, abortus, curettage, doctor, hospital
8. 2016, ♀, term, 3000 gr, spontaneous delivery, midwife,death at 2 months
9. Current pregnancy
 History of family planning: (-)
 History of immunization: (-)
Physical Examination:
General Record:

GA Cons BP HR RR T Sat
Severe CM 160/110 110 28 37 98%

Eyes : conjunctiva wasnt anemic, sclera wasn’t icteric


• Neck : JVP 5-2 cmH2O, no enlargement of thyroid gland
• Cor : within normal limit
• Pulmo : bronkovesikuler, ronkhi (+),wheezing (-)
• Weight before pregnancy : 55
• Weight after pregnancy :65
• Height :150
• BMI: 24,4 (normoweight)
• Arms circumferences : 24
Obstetric Record
• Abdomen
Inspection : Abdomen seems enlarged in accordance with 34-35 weeks of preterm
pregnancy, mid line hyperpigmentation (+), striae gravidarum (+), sicatricks (-)
Palpation :
L1 : uterine fundal wa palpated 4 finger below proccesus xyphoideus,round mass was
palpated
L2 : Hard and resistance structure was felt on right side,numerous small and irregular
structure were felt in the left side
L3 : a soft,large noduler mass was palpated
L4 : -
The abdomen was firm
Uterian fundal was palpable 3 fingers below proc. Xyphoideus,
Leopold was difficult to examined.
Uterian contraction can’t be predicted
UFH: 29 cm EBW: 2480gr
Contraction : (-)
Fetal heart sound: 150-153
Obstetric Record

Genitalia
Inspection : v/u within normal limits, vaginal bleeding (-)
USG
• Fetal alive, singleton, intra uterine, head presentation.
• Fetal movement (+)
• Biometrics :
BPD : 86,8mm
AC : 308 mm
FL : 66 mm
EFW : 2410 gr
• Placenta was implanted in fundus grade II
• Impession : 34-35 weeks preterm pregnancy
Fetal alive, head presentation
Laboratory
Parameter Result Reference Value
SGOT 17 4 – 32 u/l

Parameter Result Reference SGPT 6 2 – 25 u/l


Value
Random blood 128 74-106 mg%
Hb 11,5 12 – 15 g/dL sugar
Ht 33 40 – 48 % Ureum 18 15-40 mg%

Leucocyte 16.490 5,9 - 16,9.103 /mm3


Creatinin 0,8 0.4 – 0.9 mg%
Trombocyte 235.000 146 - 429.103 /mm3
aPTT 32,2 22.6 – 35.0 Sec Kalium 4,2 3.3 – 5.1 mEq/L

PT 12,8 9.6 – 12.9 Sec Chloride 110 97 – 109 mg/dl

D-Dimer 2760,8 <50 mg/dl Natrium 134 130 – 148 mEq/L

mg/dL Calcium 8,3 8.2 – 9.7 mg/dl


Total 0,5 0,1 – 1,2
bilirubin Protein total 7,0 5.6 – 6.7 g/dL

Direk 0,2 <0,20 mg/dl Globulin 2,5 1,3-2,7 g/dl

mg/dl Albumin 3,5 3.8 – 5.0 g/dL


Indirek 0,3 <0,4
LDH 876 240– 480 u/l
Urinalysis

Parameters Result Normal limit


Protein +++ -
Glucose - -
Leukocytes 2-3 0-5
Erythrocytes 0-1 0-1
Cylinder - -
Crystal - -
Epitel Flat + + (flat)
Bilirubin - -
Uroblinogen + +
Consultation Result

Ophthalmologists Internist Cardiology


• There’s mild eclampsia Severe preeclampsia + PPCM • Dyspneu ec PPCM
fundus appearance suspected suspected
• Therapy according to Obgyn advice : Operation tolerance : • Methyldopa
Cardiovasculer risk : moderate to 3x500mg PO
severe • Lasix 80 mg iv
Metabolic risk : mild • Echo on stable
condition
Pulmonal risk : mild
Hemostatic risk : mild
Diagnose :
• Observation of dispneu ec PPCM suspected
on G9P4A4L2 34-35 weeks of preterm
pregnancy + severe preeclampsia on
maintenance dose of MgSO4 regiment from
other institution

• Fetal alive, singleton, intrauterine ,head


presentation
Management :
Control GA, VS, Σ urine, fluid balance, patela reflex
Continue MgSO4 regimen maintenance dose
Informed consent
Antibiotics Skin test (Ceftriaxon 1gr)
Preparation of ICU
report to operation room
consult to anestesiologyst
Crossmatch PRC 2
Plan :
 Cyto CS
At 23.30 pm : TPPCS was perfomed
A female baby was born by TPPCS with 2200 gram in
weight, 42 cm in height, Apgar score : 5/7,
Placenta was born with a light traction on umibilical
cord, complete, 1 piece. Size was 17 x 15 x 2 cm, weight
 400 gram, length 50 cm.
Bleeding during operation  350 cc

D/ P5A4L3 post TPPCS on indication Observation of dispneu


ec PPCM suspected + Severe Preeclampsia on SM regimen
Maintainance dose from other institution

Management : observe after procedure


P/ Post op in Intensive Care Unit
Control GA, VS, FHR, Σ urine, fluid balance,
patella reflex
Continue MgSO4 regimen maintenance dose
Ceftriaxone 2x1 gr
Misoprostol 2tab/6hours/rectal
Metil dopa if BP ≥ 150 mmHg
Pronalges supp II (if needed)
Thank You