Case No.

25
 Name : Mrs. A
Age : 23 years old
MR No. : 97 81 36
Date : Mai 09th, 2017
 Chief Complaint:
A 23 years old patient was admitted to the
Emergency Room of Dr. M. Djamil Central
General Hospital on July 27th, 2016 at 12.00
am refered by Pasaman Private hospital with
diagnosed: decreased Consciousness ec
Eclampsia ante partum in MgSO4 Regiment on
G1P0A0L0 term parturient first stage of active
phase
 Airway : Patent
Breathing : Oksigen with Nasal canule
Circulation : IV line with MgSO4 regiment
Present Illness History
Previously Patient was seizures two times at home and decreased of conciusness after
that. Patient went to Midwife and referred to West Pasaman Private Hospital. At there
Patient was seizure again. From the examination the blood preasure 180/120, patient
got regimen MgSO4, urine catheter inserted and Dexametason inj. And then patient
referred to M Djamil General Hospital.
Headeche (+), Blur vision (-), epigastric pain (-)
Feeling of pain from waist to region which referred to the groin 10 hours ago
Bloody show from the vagina since 10 hours ago
fluid leakage from the vagina (+) since 1 hours ago
There was no massive vaginal bleeding
Amenorrhea since 9 months ago
First date of last menstrual : Forgotten
Estimation date of delivery : difficult to examined
 Fetal movement was felt since 4 months ago
No complain of nausea, vomiting, or vaginal
bleeding neither during early nor late
pregnancy
Prenatal care to midwife three times on 2,3,
and 5 month of pregnancy
No history of hypertension before.
Menstrual history : menarche at 13 years old,
iregular cycle, 5-7 days each cycle with the
amount of 2-3 times pad change/day without
any menstrual pain.
Previous Illness History
There was no previous history of heart, lung, liver, kidney disease, DM,
hypertension and allergy

Family Illness History

There was no history of any hereditary disease, contagious and
phsycological illness in the family.
Occupation, Socioeconomics, Psychiatry, and
Habitual History :
Marital history: once in 2015
History of pregnancy/abortion/delivery: 1/0/0
1. Present
History of family planning: (-)
History of immunization: (-)
History of education : elementary school
History of occupation : (-)
Physical Examination:
General Record:

GA Cons BP HR RR T
Severe GCS 11 180/120 123 28 37

urine : 500 cc/at time (reddish)

patella reflex : +/+ normal
Eyes : conjunctiva wasnt anemic, sclera wasnt icteric
Neck : JVP 5-2 cmH2O, no enlargement of thyroid gland
Chest : Lung and heart within normal limit
 Obstetric Record
Abdomen
Inspection : Abdomen seems enlarged in accordance with term pregnancy,
mid line hyperpigmentation (+), striae gravidarum (+), scars(-)

Palpation :
L1 Uterine fundal was palpable 3 fingers below proc.xiphoideus,
a large nodular mass was palpable
L2 hard and resistance structure was palpated on the left side.
Numerous small, irregular structure were palpated on the right side
L3 hard mass was palpable, fixed
L4 Paralel
UFH: 34cm EBW: 3410 gr ; Uterine contraction : (-)
Percussion : Tympani
Auscultation : FHR 140-145bpm
 Obstetric Record

Genitalia
Inspection : v/u within normal limits, no vaginal
bleeding
Internal examination :
: 5-6cm
Amniotic sac (-), Greenish residue
Head presentation, anterior left occiput, H II-III
USG
 Fetal alive, singleton,intra uterine, head presentation.
Fetal movement activity (-)
Biometrics :
BPD : 94,1 mm
AC : 265 mm
FL : 70,0 mm
EFW : 3345 gr
Placenta was implanted in posterior corpus grade II
Impession : term pregnancy
Fetal alive
CTG
 CTG
Baseline : 140-145
Variability : 2-5
Acelleration : (-)
Deceletarion : (-)
Contraction : (-)
Impression : non reactive
Diagnose :
Decrese Of Consiusness ec Antepartum
Eclampsia in MgSO4 regimen of maintenance
dose from other institution on G1P0A0L0 term
parturient first stage of active phase + Fetal
distress
Fetal alive, singleton, intrauterine, head
presentation, left anterior occiput-HII-III
Management :
Control GA, VS, fluid balance, patellar reflex,FHR
continue MgSO4 regimen
Informed consent
O2 5 l/ nasale
Complete blood count
Antihypertention
Metil dopa 500mg, Nifedipine 10mg
Antibiotics Skin test (Ceftriaxon 1gr)
report to PE team
report to operation room
consult to anestesiologyst and perinatologist
Crossmatch PRC, FFP, Thrombocite
Consult to intensivist for post op care ICU
Consult to high risk consultant: Advice Termination with CS
Plan :
Cyto CS
 cardiology :
A/antepartum eclampsia in G1P0A0L0 term
pregnancy
P/methyldopa 3 x 500 mg if blood presure
>140
oftalmologist :
A/ mild fundus eclampsia has found
P/according to Obsgyn
Neurologist
A/ Antepartum eclampsia
P/according to Obsgyn
At 01.15 pm : TPPCS was performed
A male baby was born by TPPCS with 3400 gram in
weight, 50 cm in height, Apgar score : 3/4.
Placenta was born with a light traction on umibilical
cord, complete, 1 piece. Size was 17 x 15 x 12 cm,
weight 200 gram, length 40 cm.
Bleeding during operation 300 cc
D/ P1A0L1 post TPPCS on indication of antepartum
eclampsia in maintenance dose of MgS04
regiment from other institution + HELLP
sindrome
P/Control GA, VS, FHR, urine, fluid balance, patela ref
Intensive Care Unit
Continue MgSO4 regiment
IVFD RL (Oksitosin 2amp + Metergin 1amp)
Ceftriaxone 2x1 gr
Dexametason 2x2amp
Ranitidine 2x50mg IV
Tranexamic Acid 3x1gr
Vit K 3 x 10 mg
Tramadol 3 x 100mg
Misoprostol 2tab/6hours/rectal
Metil dopa if BP 140mmhg
Transfusion PRC 2unit
Transfusion Trombosit 20 Unit
Transfusion FFP 4 unit
Pronalges supp II (K/P)
Consult Internist
 PARAMETER Laboratory findings Normal Value
Hemoglobin 14,0 gr/dl 9.5-15
Leukosit 33.360/mm3 5.000 16.000
Hematokrit 41 % 37 43
Trombosit 54.000 /mm3 150.000 400.000
APTT 51,1 detik 29,2 39,4
PT 15,5 detik 10 13,6
Ureum darah 35 mg/dl 16,6 48,5
Creatinin darah mg/dl 0,6 1,2
LDH 5142 u/l 0 480

Gula darah sewaktu 112 mg/dL 74 106

Protein total 4,4 mg/dL 67

Albumin 2,6 g/dL 3,5 5,2

Globulin 1,8 g/dL 1,3 2,7

SGOT 697 u/l 0 31

SGPT 166 u/l 0 34

Total bilirubin mg/dL 0,1 1,2

Direk <0,20

Indirek <0,4

Calsium - 8,1 10,4

Natrium 136 Mmol/dL 136 145

Kalium 5,8 Mmol/L 3,5 5,1

Chlorida 111 Mmol/L 97 111

 URINALISA
Protein : +++
Glukosa : (-)
Leukosit : 2-3/LPB
Eritrosit : 200-250/LPB
Silinder : (-)
Kristal : (-)
Epitel : (+), gepeng
Bilirubin : (-)
Urobilinogen : (+)
 Internist :
D/eclampsia post CS
pregnancy in MgSO4 regimen maintenance
Sekunder DIC
HELLP sindrome,
HP Pro 2x1
Join Treatment Whit Hematologis
Join Treatment Whit Kidney & Hipertension
Join Treatment Whit Gastroenterologis
 PARAMETER Laboratory Laboratory Laboratory
findings findings findings
09/05/2017 10/05/2017 10/05/201

Hemoglobin 14 gr/dl 9,8 10,9

Leukosit 33.360/mm3 27.880/mm3 20.390/mm3

Hematokrit 41 % 28 % 32 %
Trombosit 78.000 /mm3 155.000 /mm3 64.000 /mm3

APTT 51,1 detik 48,5

PT 13,4 detik 14,6
Ureum darah 45 mg/dl 43mg/dl 90mg/dl
Creatinin darah 1,3 mg/dl 2,0 mg/dl 2,8 mg/dl
LDH 5142 u/l 3405u/I

Gula darah sewaktu 112 mg/dL 117 mg/dL

Protein total 4,4 mg/dL 4,1 mg/dL

Albumin 2,6 g/dL 2,5 g/dL

Globulin 1,8 g/dL 1,6 g/dL

SGOT 697 u/l 721 u/l

SGPT 116 u/l 391 u/l

Total bilirubin 13,7 mg/dL 7,4 0,1 1,2

Direk 11,4 mg/dl 6,0 <0,20

Indirek 2,0 mg.dl 1,4 <0,4

Calsium 8 mg/dl 7,1 mg/dl 8,2

Natrium 136 Mmol/dL 135 Mmol/L 135

Kalium 5,8 Mmol/L 5,1 Mmol/L 4,6

Chlorida 111 Mmol/L 110 Mmol/L 110

D-Dimer 22630,58 6151,63

 10-05-17 11-05-17 12-05-17
S/ On Anastesion S/ On Anastesion S/ On Anastesion

Physical Examination Physical Examination Physical Examination

Ku: Severe, Kes: On Anastesion, Td:145
/94, Nd: 80
Eye: Conjunctiva was not anemic, Sclera
wasnt icteric
Abd: Wound closed by verban, uterine
contraction goods
Gen: I: V/U within normal limit
Ku: sdg, Kes: On Anastesion, Td: 138/95, Nd:
80
Eye: Conjunctiva was not anemic, Sclera
wasnt icteric
Abd: Wound closed by verban, uterine
contraction goods
Gen: I: V/U within normal limit
Ku: sdg, Kes: On Anastesion, Td: 142/91, Nd:
80
Eye: Conjunctiva was not anemic, Sclera
wasnt icteric
Abd: Wound closed by verban, uterine
contraction goods
Gen: I: V/U within normal limit

A/ P1A0L1 post TPPCS on indication of A/ P1A0L1 post TPPCS on indication of eclamtia A/ P1A0L1 post TPPCS on indication of eclamtia
eclamtia in MgSO4 regimen maintenance in MgSO4 regimen maintenance dose + HELLP in MgSO4 regimen maintenance dose + HELLP
dose + HELLP syndrome NH1 syndrome NH2 syndrome NH3
Airway Compromized Airway Compromized Airway Compromized
Anemia Anemia Anemia
Hipoalbumiemia Hipoalbumiemia Hipoalbumiemia
Cuagulation disorder Cuagulation disorder Cuagulation disorder

P/ Control GA, VS, FHR, urine, fluid P/ Control GA, VS, FHR, urine, fluid P/ Control GA, VS, FHR, urine, fluid
balance, patela ref balance, patela ref balance, patela ref
Check complete blood test + urine + Continue MgSO4 regimen maintenance Ceftriaxone 2x1 gr
hepar, kidney, dose Adalat oros 1x30 mg
Haemostatic Ceftriaxone 2x1 gr Metil dopa 3x500 mg
Continue MgSO4 regimen Adalat oros 1x30 mg Dexametason 2x2amp
maintenance dose Metil dopa 3x500 mg
Transfusion trombocite 20 unit Dexametason 2x2amp
Transfusion PRC 2 unit
Ceftriaxone 2x1 g
Metil dopa 3x500 mg if BP 140mmHg
Dexametason 2x2amp
Thank You