MR Obgyn - Severe Preeclampsia

7/30/2019 MR Obgyn - Severe Preeclampsia

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OBSTETRIC AND GYNECOLOGYDEPARTMENT

Sakinah Ward D-17


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www.themegallery.com

Patient ID

Name : Ny.L

Age : 35 years old

Address : P RT3 RW1 LA

Occupation : Midwife


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ANAMNESIS

Chief complaint : Headache

History of present illness : A 35-year-old woman (gravida 2 para 1) was entered

the emergency room at 32 gestational weeks on May 3, 2013, with

headache. It happened since 3 p.m (4 hours before admitted). She also

vomitted one time. Before that, she often control in midwifery once and she

told the blood pressure within normal limit. Her blood pressure (BP) was

found to be increased since this morning. The blood pressure was 180/ 100

mmHg and then she got nifedipin 10 mg around 8 am and the midwifery

took her to doctors clinic and she could go home. But she felt dizziness and

vomitted at 3 pm and then the midwifery took her to RSML. Seizure (-),

visual disturbance (-), edema (-).


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History of past illness : hypertension for 3 years

before pregnant

Allergy : -

Medication : furosemide before pregnant, she took it

when the BP get increase

Gynecology History : discharge and itchy (+) before

her second pregnant and it disappeared after

pregnant. Never get treatment


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Obstetric history :

First pregnancy, boy, 13 years old, spontaneous labor

with vacuum because of prolonged second phase, BW:3600 gram

Second pregnancy.

The first day of last menstrual period : cant remember.

USG Gestation week : 32-34 weeks


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PHYSICAL EXAMINATION

General Appearance : Good GCS:456

Vital Signs :

BP : 253/ 146 mmHg

HR : 113 x/min

RR : 22 x/min

T :36,7 C


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- Head/ neck : a/i/c/d -/-/-/-

jugular pressure increase (-)

tumor (-)

- Thorax :

- Pulmo : Symetric, sonor/sonor, ves/ves ronchi

-/- wheezing -/-

- Heart : S1S2 single, murmur -/- gallop -/-


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Abdominal Exam

Inspection:

Shape of the uterus: longitudinal line

Contour of the abdomen: Umbilicus may become

everted

Skin changes: Stretch marks (+)


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Abdominal Exam

Palpation: by Leopold maneuver

L1 : Fundus : Soft consistency breech

Fundus length : 27 cm

L 2 : Firm, flat and linear fetal spine fetal back is

in the right. HR : 163x/minutes

L 3 : The head mobility.

L 4 : -

Auscultation : Abdomen sound (+)


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Extremity : Oedem (-)

VT :

Not be evaluated


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Lab

Diffcount 0/0/74/23/3

Hct 33,4 %

Hb 11,5 mg/dl

LED 65/83 Leu 8.100

Trombosit 256.000

HBs-Ag negative Bleeding time 200

Clothing time 900


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NST


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CLUE AND CUE

Women 35 years old

Headache, Vomit

BP : 253/ 146 mmHg HR : 113 x/min

Gestation week : 32-34 weeks

Proteinuria : +3


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PROBLEM LIST

Hypertension in pregnancy

Fetal distress


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Diagnosis

- G2P1001A000 + severe pre-eclampsia

- Intra uterine fetal distress


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Planning Diagnosis

NST


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Planning Therapy

Observation pro SC

O2 nasal 2 lpm

Nifedipine 10 mg orally

IVFD RD 5% 1 ml/kg/hour

MgSO4 40 % 4 g loading for 5-10 minutes

Maintenance 1 g/hour

24 hours


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Planning Monitoring

Vital sign mother and fetus

Urine production

Subjective complaint


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Planning Education

Inform the patient that she needs to be

observe and sometimes can be terminated

for her pregnancy

Bedrest


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GOD BLESS US

Thank You!

Documents

MR Obgyn - Severe Preeclampsia