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CASE REPORT NO.

Identity : Husbands Identity :


Name : Mrs. S Name : Mr. M
Age : 31 years old Age : 37 years old
MR No. : 00.97.18.34 Address : Kerinci
Address : Kerinci Education : Senior High School
Admisssion date : Sept 18th, 2018 Occupation : Trader
Education : Junior High School
Occupation : Housewife
(Anamnese)
A 31 years old patient was admitted to the Emergency
Room of Dr. M. Djamil Central General Hospital on Sept
18th 2018 at 13.15 pm, referred from Policlinic
Fetomaternal RSUP DR M Djamil Padang With D/
G3P2A0L2 37-38 weeks of term pregnancy + SLE + severe
preeclampsia

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presentation.
Present Illness History:
• Previously, the patient came to the Fetomaternal Policlinic to control her
pregnancy. When control, the blood pressure was 160/100 mmHg, the
patient also in term pregnancy, then patient was referred to Emergency
room of M Djamil General Hospital
• Headache (+) Blurry vision (-) and epigastric pain (+)
• 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 9 months ago
• First date of last menstrual : forget
• Estimation date of delivery : cant identified
• Fetal movement was felt since 5 months ago
• No complain of nausea, vomitting, and vaginal bleeding
neither during early pregnancy nor late pregnancy
• Prenatal care : control to obstetrician every month since 2
month of pregnancy, she had no high of blood pressure every
control.
• Menstruation history : menarche at 12 years old, regular cycle,
which last for 5 to 7 days each cycle with the amount of 2-3
times pad change/day without menstrual pain
• A light fever (-), mialgia (-), arthralgia (-)
Previous Illness History:
• There was no previous history of heart, lung, liver, kidney, DM,
hypertension and allergic
• Patient was diagnosed with SLE since 1 year ago and got threatment from
internist and got metilprednisolon 1x8mg, As. Folat 1x1 tab, osteocal 1x1
tab, ranitidin 2x1 tab

Family Illness History:


• There was no history of hereditary disease, contagious and psychological
illness in the family
Occupation, Socioeconomics,
Psychiatry, and Habitual History:

• Marriage history: once in 2006


• History of pregnancy/abortion/delivery: 3/0/2
• 1. 2007/female/4000 gr/term pregnancy/spontan delivery/midwife/alive
• 2. 2012/male/4500 gr/term pregnancy/spontan delivery/midwife/alive
• 3. Present
• History of family planning: (-)
• History of immunization: (-)
General Record:
GA Cons BP HR RR T Patellar rf
Mdt CMC 150/100 84 18 36,7 ° +/+ N
• BH : 152 cm
• BW : 68 kg
• BMI : 23,5 kg/m2 (normoweight)
• Upper arm circumference : 26 cm
• Eyes : conjunctiva wasn’t anemic, sclera wasn’t icteric
• Face : Butterfly Rush (+)
• Neck : JVP 5-2 cmH2O, there was no thyroid gland enlargement
• Chest : H/L normal
• Extremity : Edema -/-, patellar reflex +/+, pathologic reflex -/-
• Urine : 200cc/light yellow
Abdoment :
I : Enlarge accordance to term pregnancy, hyperpigmentated of median line was (+),
striae gravidarum (+) sicatrix (-)
Pa:
L1 : uterine fundal was palpated 3 finger below xyphoid processus
a round, soft and big mass was palpated
L2 : a hard resistace felt on the left side, a small parts felt on the right side
L3 : a hard, round and fixated mass was palpated
L4 : convergen
Uterine fundal height : 29 cm Estimated fetal weight : 2480gr
Uterine contraction : -
Au: FHR : 145-149x/’
Genitalia : I: V/U normal, vaginal bleeding (-)
CTG
IMPRESSION
• Baseline : 140x/I
• Variability : 5-10x/I
• Acceleration : (-)
• Deceleration : (-)
• Contraction : (-)
• Fetal Movement : (+)
• Impression : Categori II
USG
USG
• Fetal alive,singleton,intrauterine,head presentation
• Fetal movement activity was good
• Biometri
• BPD : 91,2 mm AC : 305,4 mm
• FL : 72,4 mm
• EFW : 2768 gr
• Plasenta was implanted on posterior corpus grade II-III
• Impression : 37 - 38 weeks of term pregnancy according to fetal biometry
Fetal alive
head presentation
Laboratory Finding (18/09/2018)

Laboratory finding Normal value for 3rd TM


Routine blood testing
Hemoglobine gr/dl 9,5-15,0
Leucocyte /mm3 5.9–16.9
Hematocrite % 28.0–40.0
Trombocyte .000/mm3 146–429
PT 9-12
APTT 32-41

D-Dimmer <500

Ureum mg/dl 10,0-50,0

Creatinin mg/dl 0,6-1,2


PARAMETER RESULT REFERENCE
LDH u/l < 480
Random blood glucose 119 mg/dL < 200
Total protein 6,7 mg/dL 6–7
Albumin 3,8 g/dL 3,5 – 5,2
Globulin 2,9 g/dL 1,3 - 2,7
Total bilirubin 0,8 mg/dL 0,1 – 1,2
Bilirubin direct 0,3 mg/dL < 0,2
Bilirubin indirect 0,5 mg/dL < 0,6
SGOT 32 u/l < 31
SGPT 23 u/l < 34
Calsium 8,5 mg/dl 8,1 – 10,4
Natrium 135 mmol/L 136 - 145
Kalium 4,7 mmol/L 3,5 – 5,1
Chloride serum 101 mmol/L 97 – 111
HBsAg rapid Non reaktif
URINALYSIS RESULT REFERENCE VALUE

Protein ++ -

Glucose - -

Leucocyte 2-4 0-5

Eritrocyte 0-1 0-1

Cylinder - -

Crystal - -

Epitel - -

Bilirubin - -

Urobilinogen + +
• Opthalmologist consult result :
• There was mild sign of fundus eclampsia ODS
• P/ observation, threatment up to obstetric departement
• Cardiologist consult result :
• Severe preeclampsia on term pregnancy + SLE
• Methyldopa 3x250 mg po bila TD > 150/90
• Join treatment
• Internist consult result :
• SLE on threatment with lupus nephritis
• Severe preeclampsia on G2P1A0L1 37-38 weeks of term pregnancy + once
previous CS
• Low cardiovascular risk
• Low pulmonal risk
• Low metabolic risk & stabil haemostasis
• Methyldopa 3x500 mg p.o
• Consult to anesthesiologyst
• Join treatment
Diagnose
G2P1A0L1 37-38 weeks of term pregnancy + severe
preeclampsia on maintenance dose of MgSO4 regiment
from other institution + once previous CS
Fetal alive singleton intra uterine head presentation

Management :
 Control GA, VS, FHR, fluid balance, patellar reflex,
impending sign
 Informed consent
 Continue maintenance dose of MgSO4 regiment
 Inj.Ceftriaxon 2 x 1 gr
 Metildopa 3x500 mg
 Consult perinatology
 Report to OR and anesthesiologist

Plan : CS +TP
03/07/2018 (At 08.00 AM : TPPCS was performed)
A female baby was born with 2900 gr weight, 49 cm height and A/S : 8/9
Placenta was born by mild traction on umbilical cord, 1 piece, complete. Size
was 17x15x2,5 cm, weight approximately 500 gr. Umbilical cord was
approximately 50 cm in length with paracentral insertion.
Pomeroy tubectomy was performed
Blood loss during operation  200 cc
D/ : P2A0L2 post TPPCS oi severe preeclampsia on maintenance dose of MgSO4
regiment from other institution + once previous CS + pomeroy tubectomy oi
enough child
Both Mother – Child were in care
A/ : Control GA, Vital sign, uterine Contraction, Vaginal bleeding, fluid balance
 Continue maintenance dose of MgSO4 regiment
 Drip Oxytosine 2 amp in 500 cc RL 20 drops/minutes
 Inj.Ceftriaxon 2 x 1 gr iv
 Pronalgess supp 2 per rectal
 Post Op lab check
Post op laboratorium (4/07/2018)

Laboratory finding Normal value for 3rd TM


Routine blood testing
Hemoglobine 14,1 gr/dl 9,5-15,0
Leucocyte 27.230/mm3 5.9–16.9
Hematocrit 43 % 28.0–40.0
Trombocyte 360.000/mm3 146–429
PT 9,9 9-12
APTT 34,0 32-41

D-Dimmer 598,4 <500


THANK YOU