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Residents :
Dewi/Fif/Diah/Rina/Fakhrurrazi/Amru
REPORTING :
1. SEVERE PREECLAMPSIA WITH IMPENDING ECLAMPSIA + PG
+ IUP (32-34) WGA + HEAD PRESENTATION + LIVE FETUS + NOT
IN LABOR
N
o
Description
1.
Procedures
- Monitoring vital sign
and fetal -heart rate
- Stabilization General
condition
Immediate Cesarean
section
Outcome
/plan
Baby boy was
born, BW
1650 gr,
46cm, Anal
(+), A/S 4/6
Mother
condition is
not stabile
1. Mrs. D, 33 yo, G1P0A0, Javanese, Moslem, Senior high school, housewife w/o Mr.
M, 34 yo, Bataknese , Moslem, Junior high school, entrepreneur admitted to ER
on 15 th November 2014 with:
Cc:
Unciousness
This has been experienced since 15th November 2014 on 12.00 PM , history of
high blood pressure before pregnancy (+), history of headache (+) . History
of nausea (+), Vomit (+), blurr vision (+) since November 15th 2014,
epigastric pain (-). History of seizure (-), History of uterine contraction (-),
history of leakage of amniotic membrane (-), History of bloody show (-),
urination, defecation (+) normal.
Previous medical history
:Previous medication history : LMP
: ?/?/2014
EDD
: ?/?/2014
ANC
: midwife 6x
History of Labor :
1. This pregnancy
Status Presens
Sens
: Sopor
Anemic
BP
: 210/120 mmHg Icteric
HR
: 84x/i
Cyanotic
: (-)
RR
: 22 x/i
Dispnoe
Temp
: 36,80C
Oedem
(+)pretibial
Protein
: (-)
: (-)
: (-)
:
: (+)4
General State :
Head : Conj Palpebra inferior anemic ( -)/(-),
sclera icteric
(-)/(-), pupil anisokor,
light reflex (-)/(+)
Neck : in normal limit
Thorax
: Breathing sound: Vesicular
Additional sound: Wheezing(-)/(-),
Rhonki (-)/(-)
Extremity : in normal limit
Obstetrical state :
Abdomen : symetrical enlarged
FH
: 3 fngers upper umbilical
(21 cm)
Tension Part
: Right
Lowest Part
: Head
Movement : (+)
Uterine Contraction : (-)
FHR
: 120 x/i , reguler
EBW
: 1600 1800 gram
: 12,5gr/dl
: 13300/mm3
: 37,3%
: 143.000/mm3
: 115 mg/dl
: 33,2
: 22
: 11
: 560
; 20
: 0,74
: 370
N: 12-14/gr/dl
N: 4000-11000/uL
N: 36,0-42,0/%
N: 150.000-400.000/uL
N: < 200 mg/dl
C= 33,5
N= 0-40
N= 0-40
N= 240-480 U/I
N=10-50 mg/dl
N=0,6-1,2
N= < 500 ng/ml
USG TAS
USG TAS
Diagnosis: Severe preeclampsia with impending eclampsia + pg + IUP (3234) wga + Head Presentation + Live fetus + not in labor
Treatment :
- O2 2-4 L/i
- inj. MgSO4 20% 20cc (4gr) loading dose
- IVFD RL + MgSO4 40% 30cc (12 gr) 14 drops /minute
Nifedipine tab 10 mg/ 30 minutes if the blood pressure 180/110
mmHg, max 120mg/24 hours, maintenance 4x10 mg
Inj Dexamethason 15 mg single dose
Planning
: emergency CS
FOLLOW UP
Time
sens
BP
pols
RR
Temp
FHR
18.30
Sopor
210/12 84 x/I
0
22x/i Afebris
120x
/i
Nifedipine
10mg
19.00
Sopor
210/12 86x/I
0
22x/i Afebris
126x
/I
Nifedipine
10mg
19.30
Sopor
180/10 84x/i
0
22x/i Afebris
120x
/I
Nifedipin
e 10mg
20.00
Sopor
160/90 87x/i
20x/i Afebris
122x
/i
CS
Evaluation:
there
is
no
bleeding.
Do
reperitonealisation