Mrs. Adis, 17 years old pregnant woman G1P0A0, 38 weeks pregnancy was brought by her
husband to the RSUD Pali due to convulsion 3 hours ago about+2 minute. She has been
complaining of headache, epigastric pain, committing, and visual blurring for the last 2 days.
According to her husband, on her last ANC, the midwife found that her blood pressure was high
and advice to deliver the baby in the hospital.
Upon admission,
Obstetric examination
Outer examination : fundal height 33 cm, cephalic presentation, contraction 4x/10’/40’’, FHR :
120X/MIN, EFW : 3100 gr
Vaginal toucher : Portio was tender, effacement 100%, dilatation 7 cm, vertex presentation,
amniotic fluid (+), HII, transverse UUK
Lab : Hb 10,2gr/dl, PLT : 132.000/mm3, WBC 12.600/mm3, and she had 4+ protein on urine,
cylinder (-)
I. Klarifikasi Istilah
a. Convulsion : kontraksi involunter atau serangkaian kontraksi otot-otot volunteer
b. ANC : antenatal care, pemeriksaan kehamilan yang dilakukan oleh dokter atau bidan
untuk mengoptimalkan kesehatan mental dan fisik dari ibu hamil
c. Cephalic presentation : presentasi bagian apapun dari kepala janin dalam pesalinan
termasuk vertex, dahi, atau muka
d. Pretibial oedema : pengumpulan cairan secara abnormal di ruang interseluler pada
region pretibia
e. Portio : bagian serviks uteri yang menonjol ke dalam vagina
f. Vertex presentation : presentasi di mana vertex kepala janin adalah bagian yang
dipresentasikan
g. Effacement : sebutan untuk serviks yang selama persalinan sangat berubah sehingga
hanya tersisa ostium eksterna yang tipis
h. Vaginal toucher : suatu tindakan untuk menilai pembukaan, penipisan serviks,
penurunan bagian terbawah janin. Ketuban, keadaan panggul, dan kelainan pada jalan
lahir.
i. HII : bidang yang sejajar dengan bidang Hodge 1 terletak setinggi bagian bawah
simfisis
j. Transverse UUK : ubun-ubun kecil melintang
k. Amniotic fluid : cairan pada membrane extraembrional yang mengelilingi janin
l. EFW : perkiraan berat janin yang ditemukan pada pemeriksaan USG dan atau
merasakan abdomen ibu
II. Identifikasi Masalah
1. Mrs. Adis, 17 years old pregnant woman G1P0A0, 38 weeks pregnancy was brought
by her husband to the RSUD Pali due to convulsion 3 hours ago about+2 minute.
(vvv)
2. She has been complaining of headache, epigastric pain, committing, and visual
blurring for the last 2 days. (vv)
3. According to her husband, on her last ANC, the midwife found that her blood
pressure was high and advice to deliver the baby in the hospital. (vv)
4. In the examination findings : (v)
Upon admission,
Height 163 cm, weight 76 kg
Sense : decrease of consciousness, GCS 13
BP 200/100 mmHg, HR :123x/min. RR 28x/min
Pretibial edema
5. Obstetric examination (v)
Outer examination : fundal height 33 cm, cephalic presentation, contraction 4x/10’/40’’,
FHR :120X/MIN, EFW : 3100 gr
Vaginal toucher : Portio was tender, effacement 100%, dilatation 7 cm, vertex
presentation, amniotic fluid (+), HII, transverse UUK
6. Lab : Hb 10,2gr/dl, PLT : 132.000/mm3, WBC 12.600/mm3, and she had 4+ protein
on urine, cylinder (-) (v)
6. Lab : Hb 10,2gr/dl, PLT : 132.000/mm3, WBC 12.600/mm3, and she had 4+ protein
on urine, cylinder (-)
a. Apa interpretasi pemeriksaan lab ? soni, mutia
b. Bagaimana mekanisme abnormal pemeriksaan lab ? soni, mutia
Hipotesis : Ny. Adis, 17 tahun G1,P0A0, dengan usia kehamilan 38 minggu diduga mengalami
eklampsia.
Learning Issue