Name: Mrs.

S
Age: 35 yo
Address: Sekarbela
Admitted: July 2nd, 2012 at 23.00
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02/07/ Patient reffered from General status: G3P2A0L2 35 Obs mother & fetal
2012 Narmada PHC with G3P2A0L2 GC: moderate weeks S/L/IU well being
23.00 35-26 weeks S/L/IU head GCS:E4V5M6 with latent DM co GP: pro
presentation with susp BP: 180/140 mmHg phase 1st of obsevation
severe preeclampsi. Patient PR: 100 bpm labor severe progrsive of labor,
confesed headache since RR: 24 T: 36,5 preeclampsia + advice:
06.00 ( 2/7/12) blured vision Eye : palor (-), icteric (-) impending - Continued therapy
since 07.00 ( 2/7/12) and Thorax : eclamsia + MgS04 40% 4 g
nausea. Abdominal pain (-), Cor : S1S2 single reguler HELLP bolus 10 cc, and
history rupture of membrane (murmur -), (gallop -) syndrome drip MgSo4 40% 6
(-) Bloody slim (-), FM (+). Pulmo : vesikuler (+/+), g
No history of DM, HT, wheezing (-/-), - Nifedipine 3x1
asthma. Ronkhi (-/-).
Abdomen : scar (-), striae (+),
LMP: 30/10/2011 linea nigra (+)
EDD: 6/08/2012 Extremity : edema (-/-), warm
acral (+/+)
History of ANC: >4x at
Posyandu & PHC. Obstetrical status:
Last ANC: 04/06/2012Result: L1: breech
normal L2: back on the left side
History of USG: - L3: head
L4: 5/5
History of family planning: UFH: 26 cm
Injection 3 months EFW: 2170 g
Next family planning: UC: 4x10-20
Injection 3 months FHB: 11-12-13 (144 x/min)
VT: 3 cm, eff 25%, amnion
Obstetrical history: (+), head palpable HI,
I. ,aterm, spontan,TBA, denominator unclear impalpable
13 yo, L small part / umbilical cord.
II. , aterm, spontan, midwive, 8
yo, L
III. this
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Lab:
HB: 13,9 g/dl
RBC: 4,67 M/dl
WBC: 10,43 K/dl
PLT: 188
HbSAg: (-)
Protein urine : +2
SC: 0,9
Ureum : 23
Uric acid: 3,8
SGOT : 281
SGPT : 333
Albumin 3,2
2/07/2 Patient come to Narmada PHC with 8
012 month pregnancy confessed tension
headache since this morning. Blured
vision (+), epigastric pain (-). Patien
wes cheked her blood presure at
polindes and she get 2 tablet of
captopril from midwive.
LMP: 30/10/2011
EDD: 6/08/2012

Obstetrical history:
I. ,aterm, spontan,TBA, 13 yo, L
II. , aterm, spontan, midwive, 8 yo, L
III. This
O:
GC: moderate
GCS:E4V5M6
BP: 190/140 mmHg
PR: 72 bpm
RR: 20 T: 35,8
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Obstetrical status:
L1: breech
L2: back on the left side
L3: head
L4: 4/5
UFH: 30 cm
EFW: 2945 g
UC: -
FHB: 12-12-12 (144 x/min)
VT: not done
Proteinuria: +++

G3P2A0L2 35 weeks S/L/IU

with susp severe
preeclampsia

Advise GP:
Insert DC (21.30)
MgS04 40% 4 g bolus (22.00)
Drip MgSo4 40% 6 g

Nifedipine 10 mg
TIM SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING
E
3/07 - GC: moderate G3P2A0L2 35 Co to GP:
/201 GCS:E4V5M6 weeks S/L/IU methyldopa 1
2 BP: 200/130 mmHg with latent tablet
03.0 PR: 88 bpm phase 1st of
0 RR: 24 T: 36,5 labor severe
UC: 2x10-20 preeclampsia +
FHB: 144 bpm impending
VT: 3 cm, eff 25%, amnion eclamsia +
(+), head palpable HI, HELLP
denominator unclear impalpable syndrome
small part / umbilical cord.

Mother want to bearing down

Doranteknusperjolvulka Observ. Mother and
04.2 fetal well being
5 G3P2A0L2 35 Conduct mother to
weeks S/L/IU bearing down
with 2nd stage of
labor, severe
preeclampsia +
impending Baby was born,
eclamsia + male, AS 7-9, 2250
HELLP gram, 49 cm, Ballard
04.3 syndrome score: 34 (37-38
0 weeks) Anus (+),
congenital anomaly
(-)
Placenta was born
spontaneous,
complete, bleeding
250cc
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06.30 Patien confessed headache GC: moderate 4th stage of CIE to feed and
and nause GCS:E4V5M6 labor drunk
BP: 160/120 mmHg
PR: 86 bpm
RR: 24 T: 36,5
UFH: 2 finger bellow the
umbilicus
UC: + good
Lochea: rubra + 45 cc
UO: 700 cc

Baby in NICU
PR:144
RR: 46
T: 36,4
09.30 Patien convultion
GC: bad Eclampsia MgS04 40% 4 g
GCS:E3V3M6 Puerperium bolus 10 cc
BP: 200/160 mmHg O2 set
PR: 104 bpm Co to SPV:
RR: 24 T: 36,5 MgS04 40% 2 g
UFH: 2 finger bellow the bolus 10 cc
umbilicus If bad condition
UC: + good reffered to ICU
10.00
Co. to dr. Sp.
Anesthesi
12.00 Patien convultion again O2 masker 7Lpm

GC: bad Co. to SPV:

GCS:E3V3M6 IV Inj. Diazepam 1
BP: 240/170 mmHg amp
PR: 128 bpm Co.to dr. Sp.
RR: 32 T: 36,5 Anesthesi
UFH: 2 finger bellow the Reffered to ICU
umbilicus
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12.30 - Consiousnes:somnolen
BP: 190/140 mmHg
PR: 130 bpm
RR: 32 T: 36,9
UO: -
14.00 - Consiousnes:somnolen
BP: 180/130 mmHg
PR: 101 bpm
RR: 32 T: 36,1
UO: -
16.00 - Consiousnes:somnolen
BP: 160/120 mmHg
PR: 136 bpm
RR: 27 T: 36,6
UO: -
18.00 - Consiousnes:somnolen
BP: 180/140 mmHg
PR: 130 bpm
RR: 32 T: 36,9
UO: 10 cc
20.00 - Consiousnes:somnolen
BP: 200/140 mmHg
PR: 130 bpm
RR: 32 T: 36,9
UO: 10 cc
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23.30 - Consiousnes:somnolen
GCS:
BP: 170/130 mmHg
PR: 114 bpm
RR: 32 T: 36,9
UO: 10 cc
04/06/ convultion Consiousnes:somnolen IV Inj. Diazepam 1
2012 GCS: amp
01.30 BP: 160/130 mmHg
PR: 120 bpm
RR: 24 T: 36,9
UO: 20 cc
06.00 - Consiousnes:somnolen
GCS:
BP: 180/130 mmHg
PR: 130 bpm
RR: 32 T: 36,6
UO: 50
09.00 -