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DUTY REPORT

Saturday, November, 15th 2014


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

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

Obstetric and Gynecology


Medical Faculty University of North Sumatera
dr. Pirngadi General Hospital
2014

REPORTING :
1. SEVERE PREECLAMPSIA WITH IMPENDING ECLAMPSIA + PG
+ IUP (32-34) WGA + HEAD PRESENTATION + LIVE FETUS + NOT
IN LABOR

N
o

Description

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

Procedures
- Monitoring vital sign
and fetal -heart rate
- Stabilization General
condition
Immediate Cesarean
section

Outcome
/plan
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:
Unciousness
This 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
: ?/?/2014
EDD
: ?/?/2014
ANC
: 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 limit
Thorax
: Breathing sound: Vesicular
Additional sound: Wheezing(-)/(-),
Rhonki (-)/(-)
Extremity : in normal limit

Obstetrical state :
Abdomen : symetrical enlarged
FH
: 3 fngers upper umbilical
(21 cm)
Tension Part
: Right
Lowest Part
: Head
Movement : (+)
Uterine Contraction : (-)
FHR
: 120 x/i , reguler
EBW
: 1600 1800 gram

VE (after SM Therapy) : Closed cervix

Laboratorium report 15/11/2014


Hb
Leukocyte
Hematocrit
Trombocyte
BGL adr
APT
SGOT
SGPT
LDH
Ureum
Creatinin
D-dimer

: 12,5gr/dl
: 13300/mm3
: 37,3%
: 143.000/mm3
: 115 mg/dl
: 33,2
: 22
: 11
: 560
; 20
: 0,74
: 370

N: 12-14/gr/dl
N: 4000-11000/uL
N: 36,0-42,0/%
N: 150.000-400.000/uL
N: < 200 mg/dl
C= 33,5
N= 0-40
N= 0-40
N= 240-480 U/I
N=10-50 mg/dl
N=0,6-1,2
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 (3234) 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 (+)

FOLLOW UP

Time

sens

BP

pols

RR

Temp

FHR

18.30

Sopor

210/12 84 x/I
0

22x/i Afebris

120x
/i

Nifedipine
10mg

19.00

Sopor

210/12 86x/I
0

22x/i Afebris

126x
/I

Nifedipine
10mg

19.30

Sopor

180/10 84x/i
0

22x/i Afebris

120x
/I

Nifedipin
e 10mg

20.00

Sopor

160/90 87x/i

20x/i Afebris

122x
/i

CS

C-Section d/t Impending Eclampsia


baby boy was born, BW: 1650 gram, BL: 46 cm, AS:
4/6 ,table,
Anuswith
(+) iv line and urine catheter
Mother was laid in operation
installed well
Antiseptic and aseptic procedure was performed, with betadine and
alcohol solution (70%), and covered by sterile fabric except operation
feld
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

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 fgure 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


hypafx

Patient's post-operative condition: Good