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Identity
Name : Mrs B
Age : 26 yo
Date of entrance : Oct 17th 2017
Adress : Lintau
MR : 993632
Chief complaint
A female 26 yo come to emergency room M Djamil Hospital on Oct
17th 2017 at 16.30 PM sent from Batusangkar Hospital with Diagnose
G2P1A0L1 34 – 35 weeks of pregnancy + PEB on Regimen MgSO4
Maintenance dose from other hospital + ALO + IUFD
Primary Survey
• Airway : Patent
• Breathing : O2 by nasal canul 4l/mnt
• Circulation :
BP : 160/100
IVFD RL + MgSO4 Maintenance Dose
• GA : Moderate
• Cons : CMC
• BP : 160/100mmHg
• HR : 105 x /minutes
• RR : 30 x/minutes
• BH: 150 cm
• BW: 65 kg
• Before pregnant : 55kg
• BMI: 23,2 kg/m2 (normoweight)
• Upper arm circumference : 24 cm
• Urine : 200 cc yellow cloudy
• Refleks Patella +/+
• A/Dispneu ec susp ALO on G2P1A0L1 preterm pregnancy 34-35 weeks in
maintenance dose of MgSO4 regimen from other institution + IUFD
fetal die singelton intra uterine head presentation
• P/
• control GS,VS,FHR,Uterine contraction,fluid balance and patellar reflex
• Informed concern
• Continue maintenance dose of MgSO4 regimen
• Metildopa 500 mg (p.o)
• Complete laboratory examination
• EKG,CTG,USG
• Inj .Dexametason 8 mg (i.v)
• Consult to PEB team , perinatologist , anastesi
• Plan stabilisation
Present Illness History:
• Feeling heavy on breath happend since 5 days ago
and happend continuosly. Patient was taken to
primary healthcare and hospitalize for 2 days, feeling
well and patient repatrieted.
• 2 days then, patient feel the same things, and patient
was taken to Sayang Ibu Hospital, Patient was
hospitalized for 2 days and blood pressure was
obtained 170/100mmHg, patient get MgSO4 regiment
initial and maintenance dose, MetilDopa 500mg and
patient sent to M Djamil hospital.
• Headache (-) epigastrium paint (-) blurred vision (-)
• Pelvic pain referred to the groin was (-)
• Bloody show from the vagina was (-)
• Fluid leakage from the vagina was (-)
• Massive bleeding from the vagina was (-).
• Amenorrhea since ± 8 months ago.
• First date of last menstrual was Forgotten
• Estimation date of delivery was difficult to be
predicted
• Fetal movement was felt since 3 months ago, and the
last movement felt since 12 hours ago.
• No complain of nausea, vomitting, and vaginal
bleeding neither during early pregnancy nor late
pregnancy
• Prenatal care : control to primary center once a
month since 3 month of pregnancy,control to
obstetrician 2 times since 6 month and 7 month, she
never had high blood pressure during her pregnancy.
• Menstruation history: menarche at 12 years old,
irregular cycle, 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 allergic
• 20.30 acc OK
D/ : P2A0L1 post CCS oi. PEB in maintenance dose of MgSO4 regimen from
other institition + susp. ALO + IUFD + TP oi medicinalis
mother on ICU – Child were Die
Laboratory Finding
Protein ++++ -
Glucose - -
Cylinder - -
Crystal - -
Bilirubin - -
Urobilinogen + +
Post Surgery Laboratory Finding
No. Parameter Results Normal range
2 Haematokrit 31 37-43
2 Haematokrit 36 37-43