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8/13/2019 Eklampsi Antepartum Hellp Syndrom + DIC + Icteric
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Case No. 47
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Identity
Name : Mrs. S
Age : 25 years old
MR No. : 83 77 71
Address : South Solok
Date : Augst 11st, 2013
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Anamnesis :
A 25 years old patient was admitted to theDelivery Room of Dr. M. Djamil Central
General Hospital on Augst 11st, 2013 at 02.05
PM, referred from South Solok District
Hospital with D/ G3P2A0L1 preterm
pregnancy + eklampsia
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Present Illness History: (from husband history)
She got her first seizure 8 hours ago while she was athome, she had a headache before. She got seizure forabout 1 minute, whole body, she was conscious afterthat. 30 minutes latter she got the second seizure andthen go to South Solok District Hospital, in emergencyroom, the nurse checked her blood pressure, it was
200/110.In emergency room distric hospital she hadseizure for the third time. She wasnt conscious afterseizure. Than she referred to RSMJ with MgSO4regiment (began with initial dose, and followed with
maintanance dose), and urine catheter reddish color. Headache (+), Epigastric pain (+) but no history of blur
vision
Sign of the labor cant be examined
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Amenorrhea since 7,5 months ago.
First date of LMP: Forgotten, approximately onJanuari 2013 ( from her husband story )
No complain of nausea, vomitting and vaginal
bleeding during early pregnancy.
Prenatal care to a midwife 2 times (at 4th,6th
month of pregnancy). No finding of high blood
pressure during her prenatal care.
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Previous Illness History :
There wasnt previous history of heart, lung, liver, kidney, DM andhypertension and no drugs allergic. No hystory of previous seizurebefore she get pregnant.
Family Illness History :
There wasnt history of hereditary disease, contagious and physicologicalillness in the family
Marriage history : twice, first marriage on 2009, the last on 2012 History of pregnancy/abortion/delivery : 3/ 0 / 2
1. 2010, male, 2800 gr, term, spontaneous, midwife, life
2. 2011, female, 2700 gr, term, spontaneous, midwife, died after 5 monthbirth
3. Present
History of family planning : none
History of immunization : none
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Physical Examination
GA Cons BP PR RR T FHS Urine Protein Urine volume patella rf
Worse Sopor 220/110 106 24 37 + ++ 500 cc +/+ N
Continues of regiment MgSo4 maintanance dose
Eyes : conjunctiva wasnt anemic, sclera icteric +/+
Neck : JVP 5 -2 cmH2O, tyroid gland no enlargement
Chest :
Cor Inspection : Ictus cordis wasnt seemPalpation: Ictus cordis was at ICS V midclavicularis sinistra
Percussion : cor edge was normal
Auscultation : murmur(-)
Pulmo Inspection : simetric in moving and shape
Palpation : left and right fremitus were same
Percussion : sonorAuscultation : vesiculer, Rh-/-, wh-/-
Abdoment : OR
Genitalia : OR
Extremity : Edema +/+, Patellar Reflex / achiles rf +/+ normal, Pathological
Reflex -/-
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Obstetric Record
Abdoment :
I: Enlarge according to preterm pregnancy, median line hiperpigmentation,
striae gravidarum (+), cicatrix (-)
Pa: Uterine fundal was palpable 3 fingers above umbilicus, Ballotement (+)
UFH : 23 cm EFW : 1550 gr Uterine contraction: (-)
Pe : Tympanic
Au : Peristaltic sound normal
FHS : 112-126 x/
Genitalia :
Vaginal Touche 1 finger
Eff 10-20%, portio thick 2,5cm thick, mdt Amnionic sac (+)
Head was palpable HI
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Ultrasonography
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Laboratory (11/8/13 ):
Hb : 14.1 gr/dl 9.515.0
Leucocyte : 21,300/mm3 (5.916.9)x103
Hematocrit : 39 % 28.040.0
Trombocyte : 50,000/mm3 146429 x 103
APTT : 45.7 22.635.0PT : 15.6 9.6
12.9
INR : 1.3 0.801.09
SGOT : 733u/l 432
SGPT : 235u/l 225
Random blood sugar : 115 mg% 74-106
Ureum : 54 mg% 15.0-40.0
Creatinin : 0.9 mg % 0.6-1.2
Kalium : 3,6 mEq/L 3.5-5.1
Chloride : 104 mg/dl 97-111
Natrium : 134 mEq/L 139-145Calcium : 8.7 mg/dL 8.29.7
Albumin : 2,9 g/dL 2.34.2
LDH : 8652u/l
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Urinalysis
Protein : (++) negatif
Glucose : (-) negatif
Leukocytes : 12-15/LPB 0-5
Erythrocyte : >500 0-1
Cylinder : difficult to assessed negatif
Crystal : difficult to assessed negatif
Epithelial : (+) flat (+) flat Bilirubin : (-) negatif
Urobilinogen : (+) positif
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D/ decreased of consciousness at G 3P 2A 0L 1preterm pregnancy 28-30 weeks + antepartum eclampsy under SM regiment maintenancedose from outside + HELLP syndrom
Fetal alive, singleton, intra uterine, head presentation HI
Management :
Control GA, VS, FHS, urine, patella reflex, fluid balance
Continue MgSO4maintainance dose
Informed consent
Consult to (ophthalmologist, internist, neurology, cardiology)
Consult to anesthesiologist and report to Intensive Care Unit
Consult perinatology
Plan: CS
Report to on duty consultantacc report to high risk consultant
report to high risk consultantstabilitation in ICU
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Ophthalmologist result
At present theres no sign of eclamptic fundus onophthalmologic examination, eclamptic fundus KW 1
Therapy according to ObgynCardiology result
Emergency Hypertension
Perdipine drip start from 0.5, until MAP target 118 perhours.
Join treatment with cardiology department
Neurology result
At this time, theres no neurologic focal deficits.
G3P2A0L2 preterm pregnancy + eclampsia antepartum
Therapy according to Obgyn
Plan : Brain CT-Scan
03.00 : Brain CT Scan was performed, impression edem cerebri
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Internist result
Crisis hypertension oi eclampsia
DIC Icterus kolestasis
Advis:
Metildopa 3 x 500 mg Drip perdipine according to cardiologist
Liver Care
UDCA
Therapy according to Obgyn
Plan : Check D-Dimer and HbsAg
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At 03.30 pm arrived in ICU
PE (monitor) :
GA Cons BP PR RR T Sat Urine
Worse Sopor 162/92 108 24(binasal) 37 98% 500cc (reddis color)
Abd/gen: HIS (-), DJJ 130I : v/u normal,
VT : 1 finger. Portio 1,5 cm in thickness, posterior, moderate
amniotic sac (+), head palpable H1
D/ decreased consciousness on G3P2A0L1 preterm pregnancy 28-30 weeks + antepartumeclampsia in MgSO4 regiment maintenance dose from outside + HELLP Syndrome, fetal alive
Th/
Control GA, VS, FHS, urine, patella reflex, fluid balance
Continue MgSO4maintainance dose
Tutofusin Ops
Ceftriaxone inj 2 x 1 gr
Dexamethason 2 x 10mg
Perdipine drip start from 0.5 iu until the MAP 118 in 1 hour
Liver care 3 x 1 tab
UDCA 3 x 1 tab
Cervica rippening with misoprostol 50 mcg
Plan : termination after stabilization
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Laboratory in icu
Hb : 15 g/dl
HT : 42 %
Leuco : 22,200 /mm3Tromb : 25,000 /mm3
HbsAg : -
Calcium : 8,5 mg/dlTotal Prot : 6,2 g/dl
Alb : 2,8 g/dl
Glob : 3,4
SGOT : 659SGPT : 215
U/Cr : 67/0,6
D-Dimer : 3,0 mg/dl
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parameter
pH 7,4
pCO2 33 mmHg
pO2 217 mmHg
Na+ 133 mmol/L
K+ 3,5 mmol/L
Ca++ 0,89 mmol/L
Hct 44 % / 37
Temp-Corrected 36 C / 37
pH(T) 7,41
pCO2(T) 32 mmHgpO2(T) 212 mmHg
Ca++ (7,4) 0,89 mmol/L
HCO3- 20,4 mmol/L
HCO3std 22,2 mmol/L
parameter
TCO2 21,4 mmol/L
BEecf -4,4 mmol/L
BE (B) - 3,6 mmol/L
602c 100 %
THbc 13,6 g/dL
THb 10,2 g/dL
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At 07.30 pm
PE (monitor) :
GA Cons BP PR RR T sat Urine
Worse Sopor 178/101 94 24(binasal) 37 99% 120cc
Abd/gen: HIS +/s/w, DJJ 110-120 x/
VT : 1 finger. Eff 30-40%. Portio 1,5 cm in thickness, posterior, mild
amniotic sac (-)head palpable H1
D/ decreased consciousness on G3P2A0L1 preterm pregnancy 28-30 weeks +
antepartum eclampsia in MgSO4 regiment maintenance dose + HELLP Syndrome
fetal alive
Th/
misoprostol 50 mcg for cervical rippening
Plan : termination
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At 09.30 pm
PE (monitor) :
GA Cons BP PR RR T sat : 100%
Worse Sopor 182/98 90 24(binasal) 37 urine 100cc
Abd/gen: HIS 1-2/20/mdt, DJJ 100-110 x/
VT : 2 finger, eff 40-50%. Portio medial soft
amniotic sac (-) clear residu,
head palpable HI.
D/ decreased consciousness on G3P2A0L1 preterm parturient 28-30 weeks+ antepartum eclampsia in MgSO4 regiment maintenance + HELLPSyndrome, fetal alive
Th/
Acceleration drip
Transfusion 5 unit trombocyte
Plan : termination
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11.30 pm 01.30 am 02.30 am 03.30 am 05.30 am 07.30 am
PE-
BP/PR/RR
(168/88)-
102-
24
(172/92)-
92-
21
(164/94)-
100-
22
(188/101)-
104-
26
(162/92)-
88-
23
(161/84)-
93-
22
Abd
UC/FHS
(+/s/w)
100-115
(+/20/mdt)
70-80
(+/20/mdt)
70-80
02.45 : 62-70
03.00 : 58-60
03.15 : 40
(+/20/mdt)
FHS (-)
(+/35/mdt) (+/50/s)
Gen 2,
eff 60-
70%,
2,
Eff 70-
80%,
2-3
Eff 80-90%,
2-3
Amniotic
sac (-),
head HII-III
3-4
Amniotic
sac (-),
head HII-III
4-5
Amniotic
sac (-),
head HII-III
Th/ Continue
accelerati
on drip
Continue
acceleratio
n drip
Continue
acceleration
drip
Continue
acceleratio
n drip
Trombocyt
e transf 5
unit
F ll U A 12nd 2013
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Follow Up Augst 12nd, 2013
Time PE Abd/Gen Therapy/Plan
09.25 am GA : moderate, Cons :
somnolen, BP : 168/92, PR:
98, RR: 24 (binasal), T : 37,1
HIS : 3-4x/45/s,
I : v/u normal,
VT : head wascrowning opened the
vulva
Th/Continue
P/ vaginal
delivery withkristeller
ekspression
At 09.30 amA male baby was born :
FW : 1200gr
FL : 40 cm
A/S : -/-
Placenta was spontaneous delivered , complete, 14x 12x 2 cm in size,
240 gr in weight, umbilical cords length 40 cm, insertion paracentralis.
Blood loss during operation 50 cc
Diagnosis :
P3A0L1 post partus prematurus spontaneous with kristeller ekspression + antepartum
eclampsia + HELLP Syndrome
Mother were in care, baby death
M/ close monitoring
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11.35 am
a/ fever (-), vaginal bleeding (-), increase consciousness.
PE/
GA Cons BP PR RR T sat : 99%Worse Somnolen 168/92 98 24(binasal) 37 urine : 300 cc
Abd : uterine fundal palpable 3 finger below umbilicus, contraction was good.
Gen : I v/u normal, vaginal bleeding (-)
D/ P3A0L1 post partus prematurus spontaneous with kristeller ekspression +
antepartum eclampsia in SM regiment maintenance dose + HELLP Syndrome
Plan : check routine blood
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August, 12
Gastrohepatology Department
Kolestasis extrahepatal ec ca caput pankreas Ad/ SNMC in D5% drip per 18 hours
UDCA 3x1
livercare 3x1sistenol 3x500 mg
Check hepar function
Hypertension-kidney Department Hypertension stg III
Continue therapy
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August, 13
a/ fever (-), vaginal bleeding (-), increase consciousness.
PE/
GA Cons BP PR RR T sat : 100%
Mdt Somnolen 148/88 88 24(binasal) 37,8 urine : 400cc/3 hours
Abd : uterine fundal palpable 3 finger below umbilicus, contraction was good.
Gen : I v/u normal, vaginal bleeding (-)
D/ P3A0L1 post partus prematurus spontaneous with kristeller ekspression +
antepartum eclampsia in SM regiment maintenance dose + HELLP SyndromeTh/ Control GA, VS, FHS, urine, patella reflex, fluid balance
Tutofusin Ops Omeprazole 1x1
meropenem inj 2 x 1 gr ranitidin 3x1 inj
Systenol 2x500 mg transamin 3x1 inj
Dexamethason 2 x 5 mg dopamed 3x500 mg
SNMC in D5% drip
Liver care 3 x 1 tab
UDCA 3 x 1 tab
Plan : transfusion PRC 2 unit
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August, 13
Gastrohepatology Department
Kolestasis extrahepatal ec ca caput pankreas
Continue therapy
Check hepar function
Hypertension-kidney Department
Increase ureum/creatinin value
Liquid balance
Chech kidney function everyday, beware for the
worsening value.
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parameter August 12 (am/pm) August 13
Hb 10,6 / 10,2 7,5
HT 29 % /29 % 21,2
Leucocyte 23,200/ 28.000 13,300
Trombocyte 32.000 / 32.000 133,000
MCH 30 pg
MCV 86 m3
MCHC 35 g/dL
APTT 43,5 sec 45,1
PT 13,3 sec 12
INR 1,2 INR 1,2
LDH 4.722 1741
Total Protein 5,6 g/dL 4,7
Albumin 2,8 g/dL 2,6
Globulin 2,8 g/dL 2,1
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parameter August 12 August 13
Total Bilirubin 17,01 mg/dL 4,5
Bilirubin Direct 15,3 mg/dL 3,58
Bilirubin Indirect 1,17 mg/dL 0,9
SGOT 134 61
SGPT 229 80
Ureum 89 101
Creatinin 1,4 2
THb 10,6 g/dL
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parameter August 12 August 13
pH 7,44 / 7,49 7,56
pCO2 30 mmHg / 32 31
pO2 162 mmHg / 117 163
Na+ 137 mmol/L / 134 138
K+ 3,5 mmol/L / 3,7 3,6
Ca++ 0,52 mmol/L / 0,85 0,61
Hct 43 % / 37
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parameter August 12 August 13
TCO2 21,3 mmol/L / 25,4 28,8
BEecf -3,8 mmol/L / 1,1 5,6
BE (B) - 2,7 mmol/L / 1,5 5,8
602c 100 % / 99 100
THbc 13,3 g/dL / 11,5
THb 10,2 g/dL
D-dimer 2,4
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August, 14 07.00 am
a/fever (-), vaginal bleeding (-)
PE/GA Cons BP PR RR T sat : 99%
Mdt Somn 152/85 72 24(binasal) 37,8 urine : 300cc/3hours Abd : good contraction, uterine fundal 3 finger above simp
Gen : ppv(-)
D/ P3A0L1 post partus prematurus spontaneous with kristeller ekspression +antepartum eclampsia in SM regiment maintenance dose + HELLP
Syndrome
Th/ Control GA, VS, FHS, urine, patella reflex, fluid balance
Tutofusin Ops Omeprazole 1x1
meropenem inj 2 x 1 gr ranitidin 3x1 inj
Systenol 2x500 mg transamin 3x1 injDexamethason 2 x 5 mg dopamed 3x500 mg
SNMC in D5% drip
Liver care 3 x 1 tab
UDCA 3 x 1 tab
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Thank You