CASE REPORT

IMPENDING ECLAMPSIA WITH MICROCEPHALY AND

ENCEPHALOCELE

Supervised by:

M. Arief Solehudin, dr., Sp.OG., M. Kes.

Presented by:

Bhismo Prasetyo

2012730119

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

FACULTY OF MEDICINE UMJ

RSUD SYAMSUDIN SH SUKABUMI

2017

0
 CASE REPORT

Patients Identity
Name : Mrs. E
Age : 43 years old
Nationality : Indonesian
Address : Kp. Pasupaopat 09/03, Ciramutan
Marital status : Married
Occupation : Housewife
Religion : Moslem
Date of admission : February 23rd, 2017
Date of examination : February 25th, 2017

History Taking
Chief Complaint
G4P3A0 gravid 9 months came to the hospital with seizure from 4 hours
ago before hospital admission

History of Present Illness

Patient came to the RSUD R. Syamsudin, SH with complaint of seizure
from 4 hours ago before admission. The patient confirmed that she was pregnant
9 months. Before the seizure patient complaint for dizziness, abdominal
discomfort, and blurred vision. The patient admitted that she was vomited three
times before admission. The patient denied that she has hypertension before
pregnancy, and she admitted hypertension since 7 months of pregnancy and
taking pill from public health but she forgot the name of the pills. The patient
admitted that she was taking vitamin but not regularly.

History of Past Illnesses

History of chronic hypertension : denied
History of kidney disease : denied
History of diabetes mellitus : denied
History of auto immune disease : denied
History of asthma : denied
History of allergy : denied
History of surgery : denied
History of cancer : denied

Familial History
History of hypertension : denied
History of kidney disease : denied
History of diabetes mellitus : denied
History of auto immune disease : denied
1
 History of cancer : denied

Menstruation History
Menarche : 14 years old
Menstrual cycle :regularly every 28-30 days, 5-7 days
duration
Amount of menstrual blood : 2-3 normal pads / day ( 60 cc )
First day of last menstruation : May 17th 2016

Contraception History
History of using contraception pills.

Marital History
Married once

Obstetric History
Birth
No Age Gestational Age Labor History Sex
Weight
1. 25 Aterm Vaginal delivery Boy 3000 g
2. 21 Aterm Vaginal delivery Boy 3000 g
3. 16 Aterm Vaginal delivery Girl 4000 g

Physical Examination
General condition : mildly ill appearance
Consciousness : compos mentis
Blood pressure : 180/100 mmHg
Heart rate : 110 bpm
Respiratory rate : 25x/minute
Temperature : 37,6C
Weight : 60 kg
Height : 150 cm
BMI : 26,67 kg/m2

General Examination
Eyes : anemic conjunctiva -/-, icteric sclera -/-
Mouth : wet oral mucosa membrane
Neck : stiff neck (-)
Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
Lung
Inspection : symmetric chest expansion in breathing
Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, rhonchi -/-, wheezing -/-
Abdomen
Inspection : Flat, mass (-)
Palpation :mass (-), tenderness (+)
Auscultation : bowel sound (+)

2
 Extremities : warm, edema -/-/+/+, CRT < 2 seconds

Obstetric Examination
First day of menstruation: May 17th 2016
Estimation due date: February 22nd 2017
Fundal height: 30 cm
Uterine contraction: (+) 2x/10 minutes
Fetal heart rate: 140x/minute
Leopold I: Buttocks
Leopold II: Right back
Leopold III: Head
Leopold IV: Convergent 5/5

Laboratory

Types Results Units Normal Value

Hematology
Hemoglobin 12.8 g/dL 12 16
Hematocrit 36 % 37-47
Leucocytes 17000 /uL 4000 10000
Platelets 153000 Thousands/uL 150000-450000
Eritrocyte 4.3 Millions/ uL 3.8-5.2
MCV 84 Fl 80-100
MCH 30 Pg 26-34
MCHC 36 g/dL 32-36
Urine
Eritrocyte +++ -
pH 7.0 4,6-8,0
Keton - -
Glucose - -
Protein ++ -
Microbiology exam

Types Results
Microbiology
Sample Urine
Leucocytes 4-6
Eritrocyte 25-30

Working Diagnosis
Mrs. E, 43 years old, G4P3A0, gravid 36-37 weeks with eclampsia

Management
Planning: pervaginam delivery
Nifedipine 3x10mg

3
 Methyldopa 3x50mg
IVFD RL 500cc
MgSO4 20% 4gr loading dose
MgSO4 20% 10gr maintenance dose
O2 4L/m
Termination of pregnancy
Insert uterine catheter
Observation of vital sign
Observation obstetric sign: HIS and FHR

Final Diagnosis
Mrs. E, 43 years old, P4A0, partus maturus spontan with eclampsia,
microcephaly, and cephalocele

Prognosis
Quo ad vitam : dubia
Quo ad functionam : dubia
Quo ad sanationam : dubia