Residents : Dewi/Fifi/Diah/Rina/Fakhrurrazi/Amru

Obstetric and GynecologyMedical Faculty University of North Sumatera

dr. Pirngadi General Hospital2014

DUTY REPORTSaturday, November, 15th 2014

CONSULTANT dr. Jenius L Tobin,M.Ked(OG), SpOG

REPORTING :

1. SEVERE PREECLAMPSIA WITH IMPENDING ECLAMPSIA + PG + IUP (32-34) WGA +

HEAD PRESENTATION + LIVE FETUS + NOT IN LABOR

No

Description Procedures Outcome /plan

1. Mrs. D, 33 yo, G1P000

Diagnosis : Severe preeclampsia with impending eclampsia + pg + IUP (32-33) wga/USG + head presentation + live fetus + not in labor

- Monitoring vital sign and fetal -heart rate- Stabilization General conditionImmediate Cesarean section

Baby boy was born, BW 1650 gr, 46cm, Anal (+), A/S 4/6

Mother condition is not stabile

1. Mrs. D, 33 yo, G1P0A0, Javanese, Moslem, Senior high school, housewife w/o Mr. M, 34 yo, Bataknese , Moslem, Junior high school, entrepreneur admitted to ER on 15 th November 2014 with: Cc: UnciousnessThis has been experienced since 15th November 2014 on 12.00 PM , history of high blood pressure before pregnancy (+), history of headache (+) . History of nausea (+), Vomit (+), blurr vision (+) since November 15th 2014, epigastric pain (-). History of seizure (-), History of uterine contraction (-), history of leakage of amniotic membrane (-), History of bloody show (-), urination, defecation (+) normal.

Previous medical history : -Previous medication history : -LMP: ?/?/2014EDD : ?/?/2014ANC : midwife 6x

History of Labor :1. This pregnancy

Status Presens Sens : Sopor Anemic : (-)BP : 210/120 mmHg Icteric : (-)HR : 84x/i Cyanotic : (-)RR : 22 x/i Dispnoe : (-)Temp : 36,80C Oedem : (+)pretibial

Protein : (+)4

General State :Head : Conj Palpebra inferior anemic ( -)/(-), sclera icteric

(-)/(-), pupil anisokor, light reflex (-)/(+)Neck : in normal limitThorax : Breathing sound: Vesicular

Additional sound: Wheezing(-)/(-), Rhonki (-)/(-)

Extremity : in normal limit

APR/KPR : (+)/(+)Urine output : 300 cc

Obstetrical state : Abdomen : symetrical enlargedFH : 3 fingers upper umbilical (21 cm)Tension Part : RightLowest Part : Head Movement : (+)Uterine Contraction : (-)FHR : 120 x/i , regulerEBW : 1600– 1800 gram

VE (after SM Therapy) : Closed cervix

Laboratorium report 15/11/2014

Hb : 12,5gr/dl N: 12-14/gr/dl

Leukocyte : 13300/mm3 N: 4000-11000/uLHematocrit : 37,3% N: 36,0-42,0/%Trombocyte : 143.000/mm3 N: 150.000-400.000/uLBGL adr : 115 mg/dl N: < 200 mg/dlAPT : 33,2 C= 33,5 SGOT : 22 N= 0-40SGPT : 11 N= 0-40LDH : 560 N= 240-480 U/IUreum ; 20 N=10-50 mg/dlCreatinin : 0,74 N=0,6-1,2D-dimer : 370 N= < 500 ng/ml

USG TAS

USG TAS• Singleton, Head presentation, live fetus• FM (+), FHR (+), • Placenta Fundal grade II• BPD : 83,5 mm• FL : 60,1 mm• AC : 24,4 mm• Amnion fluid : in normal limit

Concl : IUP (32-33) wga + head presentation + live fetus

Diagnosis: Severe preeclampsia with impending eclampsia + pg + IUP (32-34) wga + Head Presentation + Live fetus + not in labor

Treatment :- O2 2-4 L/i- inj. MgSO4 20% 20cc (4gr) loading dose- IVFD RL + MgSO4 40% 30cc (12 gr) 14 drops /minute- Nifedipine tab 10 mg/ 30 minutes if the blood pressure ≥ 180/110

mmHg, max 120mg/24 hours, maintenance 4x10 mg- Inj Dexamethason 15 mg single dose

Planning : emergency CS

Report to Supv dr. Jenius L Tobing, M.Ked (OG). Sp.OG.K permitted

Born baby boy, 1650gr, 46cm, 4/6, anus (+)

Time sens BP pols RR Temp FHR

18.30 Sopor 210/120 84 x/I 22x/i Afebris 120x/i Nifedipine 10mg

19.00 Sopor 210/120 86x/I 22x/i Afebris 126x/I Nifedipine 10mg

19.30 Sopor 180/100 84x/i 22x/i Afebris 120x/I Nifedipin e 10mg

20.00 Sopor 160/90 87x/i 20x/i Afebris 122x/i CS

FOLLOW UP

C-Section d/t Impending Eclampsia

baby boy was born, BW: 1650 gram, BL: 46 cm, AS: 4/6 , Anus (+)•Mother was laid in operation table, with iv line and urine catheter installed well

•Antiseptic and aseptic procedure was performed, with betadine and alcohol solution

(70%), and covered by sterile fabric except operation field

•Under general anesthesia, Pfannestiel incision was starting from kutis, subcutis

•By inserting the underlying anatomical tweezers, fascia cut left and right, then the

fascia and muscle were separated bluntly

•The peritoneum is clamped with two clamps, then the scissors up and down

•Installed hack blast, uterus gravidarum seem appropriate for gestational age,

identification of lower uterine segment and ligamentum rotundum

• Then cut a concave plica vesicouterina left and right and down towards blast setaside sufficiently

• Furthermore, the low cervical incision in the uterine wall to penetrate

subendometrium concave, then the endometrium penetrated by a blunt

and enlarged in the direction of the incision

• By grasping the head, a baby Boy was born with 1650 gr of weight and

46cm of height, apgar score was 4/6, anus (+)

• The umbilical cord is clamped in two places and cut them. The placenta

was born with the umbilical cord traction and pressure on the fundus, an

impression: complete.

• Both left and right edges of the incision is clamped by the clamp oval

• uterine cavity cleaned of the remnants of the amniotic membranes with opened sterile gauze until there are no membranes or the placenta is left behind. Impression: clean

• Do figure of eight suturing hemostasis at both ends of the laceration of

the uterus with a thread chromic Catgut no.2 wall of the uterus sutured

layer by layer by overhecting locked. Evaluation: there is no bleeding. Do

reperitonealisation

• Abdomen wal is sticth layer by layer

• The operation wound was closed with sterile gauze and hypafix

• Patient's post-operative condition: Good