CASE REPORT

Friday, 19th Ma7 2017

IDENTITY
Name : Mrs. F
Age : 35 years old
MR No. : 97 40 57
Address : Muara Labuh
 ANAMNESIS

A 35 years old patient was admitted to the

Delivery Room of Achmad Muchtar Hospital
on May, 18th 2017 at 21.00 pm. referred from
private hospital with diagnosed G1P0A0L0
term pregnancy 38-39 weeks + Severe
Preeclampsia + Obesity
 Present Illness History:
Previously, Patinet was control to Selaguri Private Hospital,
From the examination the blood preasure 150/110 and
protein urine ++, And then patient referred to M Djamil
General Hospital.
Blurred vision (-), headache (-), epigastric pain (-)
Feeling of pain from waist to region which referred to the
groin (-)
Bloody show from the vagina (-)
Fluid leakage from the vagina was absent
Massive bleeding from the vagina was absent
Amenorrhea since 9 months ago.
First date of last menstrual period Sep 2th 2016
Estimation date of delivery June 9th 2017
Fetal movement was felt since 4 months ago
 No complain of nausea, vomiting, and vaginal
bleeding neither during early pregnancy nor
late pregnancy
Prenatal care : she controlled her pregnancy
at the Obstetricians every month of
pregnancy, the blood pressure wasnt high
before
Menstruation history: menarche at 13 years old,
1x in 28 days for the last 3 months, once every
month which last for 5 to 7 days each cycle
with the amount of 2-3 times pad change/day
without menstrual pain
Previous Illness History:
There was no previous history of heart, lung, liver, kidney, DM,
hypertension and allergy

Family Illness History:

There was no history of hereditary disease, contagious and
physiological illness in the family
 Occupation, Socioeconomics, Psychiatry,
and Habitual History:
Marriage history : once in 2015
History of pregnancy/abortion/delivery: 1/0/0

Present
History of family planning : (-)
History of immunization : (-)
History of education : Senior high school
 Physical Examination:
General Record:
GA Cons BP HR RR T
Mdt CMC 180/100 87 20 36,5

urine : 50cc/at time

patella reflex : +/+ normal
protein urine (+2) burn

Diagnose :
G1P0A0L0 preterm pregnancy + severe
preeclampsia
Action:
SM regiment in initial dose

21.10 pm : start SM regiment initial dose

21.15 pm : finish SM regiment initial dose
Physical Examination:
General Record: GA Cons BP HR RR T
Mdt CMC 180/100 84 20 36,5

Body weight :
before pregnancy : 65 kg
present : 75 kg
Body Height : 162 cm
BMI : 24,76
upper arm circumference : 28 cm
 Eyes : Conjunctiva wasnt anemic, Sclera wasnt
icteric
Neck : JVP 5-2 cmH2O, thyroid gland no
enlargement
Chest : H/L normal
Abdomen : obstetrical record
Genitalia : obstetrical record
Extremity : Edema +/+, Physiological Reflex +/+,
Pathological Reflex -/-
Abdomen :
I : Abdomen seem enlarger to term pregnancy, striae gravidarum (+),
cicatrix (-)
Pa :
L1 fundal uterine was palpable at 3 finger below proc.xyphoideus
a large nodular mass was palpated
L2 a hard and resistance structure was felt on the left side,
numerous small part of the baby was felt on the right side
L3 a hard round mass was palpable and fixated
L4 paralel

Uterine fundal height : 31 cm EFW : 2945 grams

Uterine contraction : (-)

Pe : Tympani

Au : Peristaltic sound was normal, FHR :132-146 x/minutes

Genitalia :
Inspection : V/U normal, vaginal bleeding (-)
VT : No dilatation Cervix, Portio medial, Firm,
amnionic sac (+)
Head was palpated on HI
Internal Pelvimetry :
Promontorium couldnt be reached
Linea inominata palpable 1/3-1/3
Pelvic wall straight
Os. Sacrum convecs
Spina ischiadica was not prominent
Os coccygeus was mobile
Arcus pubis > 90

External Pelvimetry :
DIT could be passed by one adult fist > 10.5 cm

Impression Internal and External pelvimetry : adequate pelvic

 Laboratory Finding

Laboratory finding Normal value for 3rd TM

Routine blood testing
Hemoglobine 12,1 gr/dl 9,5-15,0
Leucocyte 12.040/mm3 5.916.9
Hematocrit 36 % 28.040.0
Trombocyte 247.000/mm3 146429
PT 10,5 10,0-13,6
APTT 31,9 29,2-39,4
GDS 95 mg/dl 0,00-200,00
 PARAMETER RESULT REFERENCE VALUE
Calcium 10,1 mg/dl 8,6-10,3
Potassium 3,6 mmol/L 3,5-5,1
Sodium 135 mmol/L 139-145
Chlorida 108 mmol/L 97-111
Total protein 6,4 g/dl 0,00-0,00
Albumin 3,7 g/dl 3,5-5,2
Globulin 2,7 g/dl 0,00-0,00
LDH 371 u/l < 480
Ureum 14 mg/dl 16,6 48,5
Creatinin 0,7 mg/dl 0,6 1,2
SGOT 17 mg/dl 00 31
SGPT 15 u/l 00 34
URINALISIS RESULT REFERENCE VALUE
Protein ++ -
Glucose - -
Leucocyte 1-2 0-5
Eritrocyte 0-1 0-1
Cylinder - -

Crystal - -

Epitel + flat Flat Epithel

Bilirubin - -

Urobilinogen + +
 Fetal alive, singleton,intra uterine, head presentation.
Fetal movement activity (+)
Biometrics :
BPD : 89,1 mm
AC : 334 mm
FL : 70,3 mm
EFW: 3096 gr
Placenta was implanted in posterior corpus grade II
Impession : term pregnancy 38-39 weeks
Fetal alive
CTG
CTG

Baseline : 130-140
Variability : 5-15
Acelleration : (+)
Deceletarion : (-)
Contraction : (-)
Impression : reactive
Diagnose
G1P0A0L0 term pregnancy 38-39 weeks + severe
preeclampsia maintainnance dose of SM
Fetal alive singleton intrauterin head presentation
Action :
Control GA,VS,HIS,FHR, urin,Rf Patella, body fluid
balance
Continue SM regiment in maintenance dose
ECG
Report to team of preeclampsia (cardiologist, and
internist,
Informed consent
Plan :
CS
 cardiologist Consult result :
I/ G1P0A0L0 term pregnancy + severe preeclampsia in SM regiment
maintenance dose
A/ Metildopa 3 x 250mg if BP 150/90
a/ joint treatment

Internist Consult result :

I/ severe preeclampsia in SM regiment maintenance dose
G1P0A0L0 term pregnancy
A/ Metildopa 3x500 mg
a/ joint treatment

oftalmologist :
A/ Patient refuse to funduscopic examition
P/according to Obsgyn
At 01.00 am : TPPCS was performed
A female baby was born by TPPCS with 3400
gram in
weight, 50 cm in height, Apgar score : 8/9.
Placenta was born with a light traction on
umibilical
cord, complete, 1 piece. Size was 17 x 15 x 12
cm, weight 500 gram, length 40 cm.
Bleeding during operation 300 cc
D/ P1A0L1 post TPPCS on indication of severe
preeclampsia in maintenance dose of MgS04
regiment
THANK YOU