Professional Documents
Culture Documents
Preeclampsia: Case Report
Preeclampsia: Case Report
Preeclampsia: Case Report
PREECLAMPSIA
Composed by: Marion KACZOREK
Reviewed by : Dr. Andrianes B,
Sp.OG(K)
Preface
Literature Review
Definition
Preeclampsia is defined as the occurrence of
hypertension and significant proteinuria
in a previously healthy woman on or after
the 20th week of gestation
Etiology/Cause
Known risk factors for preeclampsia
include:
Obesity
Nulliparity(never given birth)
Antiphospholipid antibody
syndrome
Diabetes mellitus
Multiple gestation
Kidney disease
Havingdonated a kidney.
Chronic hypertension
Having
Prior history of preeclampsia
subclinicalhypothyroidism
Family history of preeclampsia
orthyroidantibodies
Advanced maternal age (>35years)
Placental abnormalities such as
placental ischemia.
Diagnostic Criteria
1. Blood pressure 140mm Hg systolic or 90mm Hg
diastolic on two separate readings taken
2. Proteinuria >0.3 grams (300mg)
And for the preeclampsia who is beginning before 20
weeks gestational age, the diagnostic criteria are: an
increase in systolic blood pressure (SBP) of 30mmHg or
an increase in diastolic blood pressure (DBP) of
15mmHg.
Differential Diagnosis
Chronic hypertension
Gestationel hypertension
Epilepsy
Antiphsopholipid antydbody syndrom
Haemolytic uraemic syndrom
Renal
Comprehensive Management
Purpose of therapy/principle therapy?
Therapy which is suitable?
Current therapy?
Complication
Prognosis/Outcome
Patient Status
Patient Identity
Name
: Sri Handayani
Age
: 36
Gender
: Female
Address
: Gedongan RT/RW 4/5 gedongan
Married status
: Maried
Religion
: Muslim
Entrance date (in hospital) : 01/07/16
Medical Record Number: 01344594
Anamnesis
Main Problem : Come by herself for highblood preasure and feel
some contraction
Current History of illness : tell the chronological story of the pat
Past history of illness
Hypertension (-)
Cardiac Sickness (-)
Diabetes Mellitus (-)
Asthma (-)
Allergy (food/drugs) (-)
Anamnesis
Family history of illness
Hypertension (-)
Cardiac Sickness (-)
Diabetes Mellitus (-)
Asthma (-)
Allergy (food/drugs) (-)
Anamnesis
Menstruation History
Menarche
: age y.o
The length of period : 6-10 days
Menstruation cycle : 28 days
Physical Exam
General Condition : Good
Compos: Mentis ( Glasgow score : 15 )
Nutritional status: Good
Vital Sign
Physical Examination
Eye :
No anemia conjunctive , no icteria
Thorax :
Heart :
Lung :
Abdomen :
Inspection : No scare , no skin pb , no inflammation
Palpation : souple , no mass , no ascite ,
Physical
examination
Genicolo:
Inspection :
Uretrea isnt inflammation
Normal wall vagin
Externe orifice is closed , dilatation 0 , effacement 10% , still
posteriori
No blood no discharge
Palpation :
1. High part of the ftus
2. Back of the ftus : on her left
3. Lower part of the ftus : the head
4. Ftus isnt descendu in the pelvis.
Supportive exam
Blood laboratorium (examination date)
SGOT
: 36 /L
Albumin : 36 mikro/L
SGPT
: 19 /L
Creatinine
: 19 mikro/L
Ureum
: 26 mg/dl
LDH
: 600 u/L
Qualitative Protein : ++++(4)
Supportive Exam
Ultrasonography (examination date):
one fetus IU elongated
head presentation
fetus heartbeat(+) : 145
Placenta insertion in corpus
Enough amnion fluid.
Fetus condition is good.
No major congenital anomaly.
Estimate weight : 1817 gr
Conclusion
G2-P1-A0
Age pregnancy age in weeks : 34
Good obstetric & fertility history
Vital sign : without anomaly except : 190/100
Abdominal examination: normal
Genital Examination: no
Blood laboratorium :
USG examination:
Diagnosis
Several pre-Eclampsia on second pregmancy , Preterm , no active labor
Prognosis
Ad vitam : dubia
Ad sanam: dubia
Ad fungsionam : dubia
Plan/Therapy
To keep the pregmancy :
Kehomilan
Pre-Eclampsia:
O2
Mg 20 % 1gr / min
Nifedipine : 3 X 10 mg if her blood preasure > 160/110
For the baby :
Dexamethasone
Patient Follow Up
Follow the patient condition as written in medical record until the
patient goes home