Case Report

Name Age Address Admitted : : : : Mrs. B 38 years old Tanjung Karang April, 25th 2013 at 10.00

TIME 25/04/2 013 10.00

SUBJECTIVE Patient referred from tanjung karang PHC with G4P3A0H3 31-32 wks/S/L/IU head presentation with preeclamsia berat. Patient came to NTB GH obstetric polyclinic confessed 8 months pregnant and complaining epigastric pain since 3 days ago. Patient confessed no abdominal pain, water come out from womb (-), Bloody slim (-) FM (+). No history of DM, HT, asthma. LMP : 12-9-2012 EDD: 19-6-2013 History of ANC : 7x at PHC Last ANC : 25/04/2013 History of USG : 1x Result : fetal S/L/IU head presentation, BPD 33 wk, AC 36 wk, FL 34 wk, EFW 2372, amnion fluid enough. History of family planning : 3 months injection Next family planning : tubectomy Obstetrical History : I. Aterm, spontan, TBA, life, 25 yo II. Aterm, spontan, TBA, life, 13 yo III.Aterm, spontan, doctor,, 3800 g, life, 7 yo IV.this

OBJECTIVE General Status : GC : well BP : 190/110 mmHg PR : 100 bpm RR : 20 bpm T : 37OC Eye : anemis (-), icteric (-) Cor : S1S2 single regular, murmur (-), gallop (-). Pulmo : vesicular (+/+), wheezing (-/-), ronkhi (-/-). Abdomen : scar (-), striae gravidarum (+), linea nigra (+). Upper Extremity : edema (-/-), warm acral (+/+). Lower Extremity : edema (-/-), warm acral (+/+). Obstetrical Status : L1 : breech L2 : back on the right side L3 : head L4 : 5/5 UFH : 28 cm EFW :2480 g UC : FHB : 12-11-12 (140 bpm) VT :Lab : Hb : 15,0 ureum: 16 WBC: 13,0 cr: 0,4 PLT: 132 SGOT: 33 HCT : 21 SGPT: 59 GDS:124 protein urine : +3

ASSESSMENT G4P3A0L3 32-33 wk S/L/IU head presentation with severe preeclamsia.

PLANNING Check CBC, HbSAg Obs mother & fetal well being DM con. To SPV pro conservative therapy SPV agree Advice : drip MGSO4 40% 6 grams/6 h Nifedipin 3x10 mg

TIME 01.00

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

TIME 24/04/ 2013 10.30 -

SUBJECTIVE

OBJECTIVE GC : well BP : 120/70 mmHg PR : 82 bpm RR : 20 bpm T : 37OC UC : FHB : 12-12-13 (148 bpm) GC : well BP : 120/70 mmHg PR : 82 bpm RR : 20 bpm T : 37OC UC : FHB : 11-12-11 (136 bpm) GC : well BP : 120/70 mmHg PR : 82 bpm RR : 20 bpm T : 37OC UC : FHB : 11-12-11 (136 bpm)

ASSESSMENT G2P1A0L1 42-43 wk S/L/IU head presentation with good mother and fetal wellbeing + anemia hipochromic microcitic

PLANNING Begin drip oxytocin flash I series I at 8 dpm

16.30

Drip oxy flash I finish switch to flash II

20.30

G2P1A0L1 42-43 wk S/L/IU head presentation with good mother and fetal wellbeing + anemia hipochromic microcitic + failed drip oxytocin series I

Drip oxy flash II finish Break 24 hours Observation mother and fetal wellbeing in melati

TIME 26/04/ 2013 09.00

SUBJECTIVE Patient tranfer back to VK

OBJECTIVE GC : well BP : 120/70 mmHg PR : 82 bpm RR : 20 bpm T : 37OC UC : FHB : 12-12-12 (144 bpm)

ASSESSMENT G2P1A0L1 42-43 wk S/L/IU head presentation with good mother and fetal wellbeing + anemia hipochromic microcitic + failed drip oxytocin series I

PLANNING Obsevation mother and fetal wellbeing DM co. SPV

TIME 05.15

SUBJECTIVE

OBJECTIVE GC: well BP: 100/70 mmHg PR: 84 Bpm RR: 24 rpm T: 37,0 OC UC: 3x10-40 FHB: 148 bpm VT: 6 cm, eff 50% amnion (+), head H I,impalpable small part and umbilical cord. Lab: Hb: 12,6 WBC: 9.74 HbsAg (-)

ASSESSMENT G1P0A0L0 38-39 wk S/L/IU head presentation with prolonged active phase I stage of labor

PLANNING DM co to GP propose amniotomi and rehidradion GP co to SPVSPV agree.

RBC: 4,06 PLT:146

05.30

- Rehidration - Amniotomy

07.00

GC: well BP: 110/70 mmHg PR: 88 Bpm RR: 24 rpm T: 37,0 OC UC: 3x10-40 FHB: 14 bpm

G1P0A0L0 38-39 wk S/L/IU head presentation with prolonged active phase I stage of labor