CASE REPORT NO.

Identity Patient Spouse

Name Mrs. G Mr. S
Age 16 Years Old 20 Years Old
MR. No. 01.02.47.74
Address Padang Padang
Education Elementary School Elementary School
Occupation Housewife Trader
Admission Date August 15th, 2018
 Anamnesis
A 16 years old patient was admitted to the Emergency
Room of Dr. M. Djamil Central General Hospital on
August 15th 2018 at 10.30 pm, referred from Yarsi
district hospital have been diagnosed with G3P2A0L2
34-35 weeks of preterm pregnancy + impending
eclampsia on maintenance dose of MgS04 regimen
from other institution

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presentation.
 Primary Survey
A : Patent
B : RR 28 x/minutes, spontaneous. Nasal canule 3 l/minutes.
Sat. O2 98%
C : BP 160/100 mmHg, HR : 100 x/minutes,
IVFD RL + MgSO4 maintenance dose (right hand) from other
institution
Urine catheter 150 cc, bright yellowish

Abd : FHR (+) 150-160 x/minutes

GA Consciousness BP HR RR T
Moderate CMC 160/100 100 18 37,3
A : G1P0A0L0 34-35 weeks of preterm pregnancy + impending eclampsia
on maintenance dose of MgS04 regimen from other institution
Fetal alive singleton intrauterine

P:
- Kontrol GA, VS, FHR, fluid balance, patella reflex
- O2 nasal cannula 3 l/minutes
- Informed consent
- USG, CTG, ECG, Laboratorium check + urinalisa
- Consult to Internist, Cardiologist, Ophthalmologist, Perinatology, Anesthesiologist.
Present Illness History:
• Previously patient came to Yarsi Hospital experiencing severe headache
since 3 hours before. Patient was referred to Dr. M. Djamil Central General
Hospital. There was found tha the blood pressure was 210/110 mmHg, with
protein urine was +2 (dipstick). She was given methyldopa 500 mg and
MgSO4 regimen, and then referred to M Djamil hospital with IV line and
urinary catheter inserted.
• Headache (+) Blurry vision (+) and epigastric pain (-)
• Pelvic pain referred to the groin was (-)
• Fluid leakage from the vagina was (-)
• Massive bleeding from the vagina was (-).
• Amenorrhea since 8,5 months ago.
• First date of last menstrual was forgotten
• Estimation date of delivery difficult to determine
• Fetal movement was felt since 4 months ago
• No complain of nausea, vomiting, and vaginal bleeding during
early pregnancy
• Prenatal care : to midwife every month of pregnancy, she goes
to obstetrician, and blood pressure never been found high
during examination
• 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
Previous Illness History:
• There was no previous history of heart, lung, liver, kidney, DM,
hypertension and allergic

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 2017

• History of pregnancy/abortion/delivery: 1/0/0
1. Present
• History of family planning: (-)
• History of immunization : (-)
Physical Examination:
General Record:
GA Cons BP HR RR T Patellar rf
Mdt CMC 160/100 100 18 37,3 ° +/+ N

• Eyes : conjunctiva wasn’t anemic, sclera wasn’t icteric

• Neck : JVP 5-2 cmH2O, there was no thyroid gland enlargement
• Chest : H/L normal
• Extremity : Edema -/-, patellar reflex +/+, pathologic reflex -/-
• BH : 150 cm BW : 60 kg
• BMI : 23,4 kg/m2 (normoweight)
• Upper arm circumference : 26 cm
Abdoment :
I : Enlarge accordance to preterm pregnancy 34-35 week, hyperpigmentated of
median line was (+), striae gravidarum (+) cicatrix (-)
Pa:
L1 : uterine fundal was palpated between xyphoid process and
umbilicus, a soft, large nodular mass was palpated
L2 : a hard and resistance structure was felt on the right side,
small part of fetus was palpable on the left side
L3 : a round, unfixated hard mass was palpated
L4 : Not Performed
Uterine fundal height : 27 cm Estimated fetal weight : 2170 gr
Uterine contraction :-
Pe: Tympani
Au: Peristaltic sound was normal, FHR : 156-162x/1’
Genitalia : I: V/U normal, vaginal bleeding (-)
CTG

IMPRESSION
Baseline : 150 x/I
Variability : 5-15 x/I
Acceleration : (+)
Deceleration : (+)
Contraction : (-)
Fetal Movement : (+)
Impression : Category l
USG
• Fetal alive, singleton, intrauterine, head presentation
• Fetal movement (+)
• Biometric
• BPD : 85,8mm AC:282 mm
• FL : 67,1 mm. SDP : 27,4 mm
• EFW : 2166 gr
• Placenta was implanted on posterior corpus grade II-III
• Impression : 34 - 35 weeks of preterm pregnancy
Fetal alive
head presentation
 Laboratory Finding (15/08/2018)

Laboratory finding Normal value for 3rd TM

Routine blood testing
Hemoglobine 12.2 gr/dl 9,5-15,0
Leucocyte 12.160/mm3 5.9–16.9
Hematocrit 38% 28.0–40.0
Thrombocyte 235.000/mm3 146–429
PT (C:10,7) 13 9-12
APTT (C:38,3) 38,9 32-41
 PARAMETER RESULT REFERENCE VALUE
Calcium 9,1 mg/dl 8,1-10,3
Potassium 3,3 mmol/L 3,5-5,1
Sodium 137 mmol/L 139-145
Chlorida 110 mmol/L 97-111
Total protein 6,4 g/dl 5,6 – 8,7
Albumin 3,5 g/dl 3,8 – 5,0
Globulin 2,9 g/dl 2,5-3,3
Bilirubin Total 0,4 mg/dl 0,3-1,0
Bilirubin Direct 0,1 mg/dl <0,20
Bilirubin Indirect 0,3 mg/dl <0,60
Ureum 10 mg/dl 16,6 – 48,5
Creatinin 0.5 mg/dl 0,6 – 1,2
SGOT 17 mg/dl <32
SGPT 12 mg/dl <31
URINALISIS RESULT REFERENCE VALUE

Protein + -

Glucose - -

Leucocyte 0-1 0-5

Erythrocyte 0-1 0-1

Cylinder - -

Crystal - -

Epithel (+) -

Bilirubin - -

Urobilinogen + +
Consult
• Internist :
D/ G1P0A0L0 gravis preterm + impending eclampsia
Th/
Methyldopa 3 x 500 mg
Surgical tolerance :
Cardiovascular : Mild Goldman Class I
Pulmonary : Moderate
Metabolic : Moderate
Homeostatic : Stable

• Cardiologist :
D/ G1P0A0L0 gravis preterm + impending eclampsia
Th/ Methyldopa 3X250mg (if TD >140/90)
join care with cardiolog
Surgical tolerance :
Cardiovascular : Mild Goldman Class II
• Opthalmologist :
D/ There was not a sign of fundal eclampsia
 Diagnosis
G1P0A0L0 34-35 weeks of preterm pregnancy + impending eclampsia
on maintenance dose of MgSO4 regimen from other institution
Fetal alive singleton intra uterine head presentation
Action :
 Control GA, VS, UC, FHR, fluid balance, patellar reflex, RR
 Informed consent
 Continued maintenance doses of MgSO4 regimen
 Cross match 2 units of PRC
 Cefotaxime Injection 2x1 gr (iv)
 Metildopa 3x500 mg po
 Dexametason 2amp (IV)
 Consult anesthesiologist and perinatology
 Report to operating room

Plan : Caesarean Section

15/08/2018; At 11.30 PM : TPPCS
A male baby was born with
weight : 2200 gr
length : 40 cm
A/S : 5/7
Placenta was born by mild traction on umbilical cord, 1 piece, complete. Size 15x14x2
cm, weight 440 gr. Umbilical cord 50 cm in length with paracentral insertion.
Blood loss during operation  200 cc
A/ : P1A0L1 post TPPCS due to impending eclampsia
Both Mother – Child were in care
P/ : Control GA, VS, uterine Contraction, VB, fluid balance
• Continue maintenance dose of MgSO4 regimen
• Oxytocine drip 20 IU in 500 cc RL 20 drops/minutes
• Cefotaxime inj. 2 x 1 gr (IV)
• Pronalges supp. II (K/P)
• Methydopa 3 x 500 mg (PO)
• Post Op lab check
THANK YOU