Case No.

56
 Identity

Name : Mrs. A
Age : 23 years old
MR No.: 97 81 36
Date : Mai 09th, 2017
 Chief Complaint:
A 23 years old patient was admitted
to the Emergency Room of Dr. M.
Djamil Central General Hospital on
July 27th, 2016 at 17:00 pm refered
by Private hospital with diagnosed:
loss of Consciousness ec Eclampsia
ante partum at G1P0A0L0 term
parturient stage I active phase +
HELLP sindrome
Present Illness History
Patient was seizures two time at midwife clinic, patient refered to
Pvite Hospital West Pasaman, at West Pasaman Privete Hospital
Patient was seizure once, on examination the blood preasure 180/120,
patient got regimen MgSO4 initial dose, and maintenance dose,
Catheter dan Inj Dexametason 2 amp and patient was refered to M
Djamil Hospital. The patient came to M Djamil hospital with MgS04
regimen and catheter.
Headeche (-), Blur vision (-), epigastric pain (-)
Feeling of pain from waist to region which referred to the groin 10
hours ago
Bloody show from the vagina was abcent 10 hours ago
fluid leakage from the vagina (+) since 1 hous ago
There was no massive vaginal bleeding
Amenorrhea since 9 months ago
First date of last menstrual : Forget
Estimation date of delivery : difficult to examined
 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 times on
2,3, and 5 month of pregnancy.
Menstrual history : menarche at 13
years old, iregular cycle, 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

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 2011
History of pregnancy/abortion/delivery: 1/0/0
1. Present
History of family planning: (-)
History of immunization: (-)
History of education : elementary school
History of occupation : (-)
Physical Examination:
General Record:
GA Cons BP HR RR T
Severe GCS 11 150/120 123 32 37

urine : 500 cc/at time

patella reflex : +/+ normal
Eyes : conjunctiva wasnt anemic, sclera wasnt
icteric
Neck : JVP 5-2 cmH2O, no enlargement of thyroid
gland
Chest : Lung and heart within normal limit
 Obstetric Record

Abdomen
Inspection : Abdomen seems enlarged in accordance with term
pregnancy, mid line hyperpigmentation (+), striae
gravidarum (+), sicatricks (-)
Palpation :
L1 Uterine fundal was palpable 3 fingers below proc.xiphoideus,
a large nodular mass was palpable
L2 hard and resistance structure was palpated on the left side.
Numerous small, irregular structure were palpated on the right
side
L3 hard mass was palpable, fixed
L4 Convergen
UFH: 34cm cm; EBW: 3410 gr ; Uterine contraction : 2-3X/35/M
Percussion : Tympani
Auscultation : Peristaltic sound was normal, Fetal heart sound: 103-
112
 Obstetric Record

Genitalia
Inspection : v/u within normal limits, no vaginal
bleeding
Internal examination :
: 5-6cm
Amniotic sac (-), Greenish residue
Head presentation, anterior left occiput, H II-III
USG
 Fetal alive, singleton,intra uterine, head
presentation.
Fetal movement (+)
Biometrics :
BPD : 94,1 mm
AC : 265 mm
FL : 70,0 mm
EFW: 1454 gr
Placenta was implanted in posterior corpus grade II
Impession : 3-34 weeks term pregnancy
Fetal alive, head presentation
 PARAMETER Laboratory findings Normal Value
Hemoglobin 13,0 gr/dl 9.5-15
Leukosit 11.760/mm3 5.000 16.000
Hematokrit 38 % 37 43
Trombosit 50.000 /mm3 150.000 400.000
APTT 51,1 detik 29,2 39,4
PT 13,4 detik 10 13,6
Ureum darah 51 mg/dl 16,6 48,5
Creatinin darah 0,8 mg/dl 0,6 1,2
LDH 1735 u/l 0 480

Gula darah sewaktu 135 mg/dL 74 106

Protein total 5,8 mg/dL 67

Albumin 2,7 g/dL 3,5 5,2

Globulin 3,1 g/dL 1,3 2,7

SGOT 47 u/l 0 31

SGPT 46 u/l 0 34
Total bilirubin 0,8 mg/dL 0,1 1,2

Direk 0,2 <0,20

Indirek 0,6 <0,4

Calsium - 8,1 10,4

Natrium 132 Mmol/dL 136 145

Kalium 4,2 Mmol/L 3,5 5,1

Chlorida 106 Mmol/L 97 111

URINALISA
Protein : +++
Glukosa : (-)
Leukosit : 2-3/LPB
Eritrosit : 200-250/LPB
Silinder : (-)
Kristal : (-)
Epitel : (+), gepeng
Bilirubin : (-)
Urobilinogen : (+)
Diagnose :
Degres Of Consiusnes ec Eclampsia
nter partum in MgSO4 regimen
maintenance from other institution
at G1P0A0L0 term parturient stage I
active phase + Fetal distress
Fetal alive, singleton, intrauterine,
head presentation HII-III left anterior
occiput.
Management :
Control GA, VS, urine, fluid balance, patela ref
continue MgSO4 regimen maintenance dose
Informed consent
O2 5 l/ nasale
Continous MgSO4 regimen
Check complete blood test + urine + hepar, kidney, Haemostatic
Informed consent
Antihypertention
Metil dopa 500mg
Antibiotics Skin test (Ceftriaxon 1gr)
report to PE team
report to operation room
consult to anestesiologyst
Crossmatch PRC, FFP, Thrombocite
Plan :
Stabilisation
CS
 cardiology :
D/severe preeclampsia in G2P1A0L1 32 weeks
pregnancy
M/methyldopa 3 x 500 mg if blood presure
>160
oftalmologist :
D/ mild fundus eclampsia has found
M/according to Obsgyn
Neurologis
D/ Eklampsi aterpartum
M/ M/according to Obsgyn
 Internist :
D/severe preeclampsia in G2P1A0L1 32 term
pregnancy in MgSO4 regimen maintenance
HELLP sindrome, IUFD
Tolerance operation:
Metobolic risk: mild
Pulmoner riak: mild
Cardiovasculer: mild
Hematologic: mild-moderate
M/Consult anestesi
Transfusion Trombosit 10 unit
Thrombocite level must be > 50.000
Methyldopa 3 x 500 mg
Joint treatment with Kidney Hypertention department
and HOM
At 13.15 pm : TPPCS was perfomed
At 22.05 pm :
A male baby was born by TPPCS with 3400 gram in
weight, 50 cm in height, Apgar score : 2/0.
Placenta was born with a light traction on umibilical
cord, complete, 1 piece. Size was 17 x 15 x 12 cm,
weight 200 gram, length 40 cm.
Bleeding during operation 250 cc
D/ P1A0L1 post TPPCS on indication of eclamtia
antepartum in MgSO4 regimen maintenance dose
+ HELLP sindrome
P/Control GA, VS, FHR, urine, fluid balance, patela ref
Intensive Care Unit
Continue MgSO4 regimen maintenance dose
Ceftriaxone 2x1 gr
Dexametason 2x2amp
Misoprostol 2tab/6hours/rectal
Metil dopa if BP 140mmhg
Transfusion PRC 2unit
Transfusion Trombosit 20 Unit
Transfusion FFP 2 unit
Pronalges supp II (K/P)
Consult Internist
Mai 10th, 2017
01.00 am at HCU obstetric
S/ Headeche (-), Blur vision (-), epigastric pain (-),
Dispnoe (+), Vaginal bleeding (-), fever (-)
Physical Examination :
GA Cons BP PR RR T
Mdt CMC 150/9 80 20 36,7
0
Eyes :Conjunctiva was not anemic, Sclera
wasnt icteric
Abdoment: Wound closed by verban, uterine
contraction goods
Genitalia : I: V/U within normal limit
Diagnoses :
P2A0L1 post TPPCS on indication of severe
preeclamtia in MgSO4 regimen maintenance
dose + HELLP sindrome + IUFD + previous cs
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
Dexametason 2x2amp
Pronalgess supp II (k/p)
Hb post op, post transfusion thrombocite

PARAMETER Laboratory findings Normal Value

Hemoglobin 8,3 gr/dl 9.5-15
Leukosit 22.600/mm3 5.000 16.000
Hematokrit 25 % 37 43
Trombosit 77.000 /mm3 150.000 400.000
APTT 34,7 detik 29,2 39,4
PT 9,5 detik 10 13,6
 28-07-16
S/ Headeche (-), Blur vision (-), epigastric
pain (-), Vaginal bleeding (-), fever (-)
Physical Examination
Ku: sdg, Kes: Cmc, Td: 130/90, Nd: 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/ P2A0L1 post TPPCS on indication of severe
preeclamtia in MgSO4 regimen maintenance
dose + HELLP sindrome + IUFD + previous
cs
P/ Control GA, VS, FHR, urine, fluid
balance, patela ref
Check complete blood test + urine +
hepar, kidney,
Haemostatic
Continue MgSO4 regimen maintenance
dose
Transfusion trombocite 10 unit
Transfusion PRC 2 unit
Ceftriaxone 2x1 gr
Adalat oros 1x30 mg
Metil dopa 3x500 mg
Dexametason 2x2amp
29-07-16
S/ Headeche (-), Blur vision (-), epigastric
pain (-), Vaginal bleeding (-), fever (-)
Physical Examination
Ku: sdg, Kes: Cmc, Td: 130/90, Nd: 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/ P2A0L1 post TPPCS on indication of severe
preeclamtia in MgSO4 regimen maintenance
dose + HELLP sindrome + IUFD + previous
cs + anemia NH2
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
Dexametason 2x2amp
Thank You