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Case Report No
Case Report No
Case Report No
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presentation.
Present Illness History:
• Previously, the patient came to the Fetomaternal Policlinic to control her
pregnancy. When control, the blood pressure was 160/100 mmHg, the
patient also in term pregnancy, then patient was referred to Emergency
room of M Djamil General Hospital
• Headache (+) Blurry vision (-) and epigastric pain (+)
• Pelvic pain referred to the groin was (-)
• Bloody show from the vagina was (-)
• Fluid leakage from the vagina was (-)
• Massive bleeding from the vagina was (-)
• Amenorrhea since 9 months ago
• First date of last menstrual : forget
• Estimation date of delivery : cant identified
• Fetal movement was felt since 5 months ago
• No complain of nausea, vomitting, and vaginal bleeding
neither during early pregnancy nor late pregnancy
• Prenatal care : control to obstetrician every month since 2
month of pregnancy, she had no high of blood pressure every
control.
• Menstruation history : menarche at 12 years old, regular cycle,
which last for 5 to 7 days each cycle with the amount of 2-3
times pad change/day without menstrual pain
• A light fever (-), mialgia (-), arthralgia (-)
Previous Illness History:
• There was no previous history of heart, lung, liver, kidney, DM,
hypertension and allergic
• Patient was diagnosed with SLE since 1 year ago and got threatment from
internist and got metilprednisolon 1x8mg, As. Folat 1x1 tab, osteocal 1x1
tab, ranitidin 2x1 tab
D-Dimmer <500
Protein ++ -
Glucose - -
Cylinder - -
Crystal - -
Epitel - -
Bilirubin - -
Urobilinogen + +
• Opthalmologist consult result :
• There was mild sign of fundus eclampsia ODS
• P/ observation, threatment up to obstetric departement
• Cardiologist consult result :
• Severe preeclampsia on term pregnancy + SLE
• Methyldopa 3x250 mg po bila TD > 150/90
• Join treatment
• Internist consult result :
• SLE on threatment with lupus nephritis
• Severe preeclampsia on G2P1A0L1 37-38 weeks of term pregnancy + once
previous CS
• Low cardiovascular risk
• Low pulmonal risk
• Low metabolic risk & stabil haemostasis
• Methyldopa 3x500 mg p.o
• Consult to anesthesiologyst
• Join treatment
Diagnose
G2P1A0L1 37-38 weeks of term pregnancy + severe
preeclampsia on maintenance dose of MgSO4 regiment
from other institution + once previous CS
Fetal alive singleton intra uterine head presentation
Management :
Control GA, VS, FHR, fluid balance, patellar reflex,
impending sign
Informed consent
Continue maintenance dose of MgSO4 regiment
Inj.Ceftriaxon 2 x 1 gr
Metildopa 3x500 mg
Consult perinatology
Report to OR and anesthesiologist
Plan : CS +TP
03/07/2018 (At 08.00 AM : TPPCS was performed)
A female baby was born with 2900 gr weight, 49 cm height and A/S : 8/9
Placenta was born by mild traction on umbilical cord, 1 piece, complete. Size
was 17x15x2,5 cm, weight approximately 500 gr. Umbilical cord was
approximately 50 cm in length with paracentral insertion.
Pomeroy tubectomy was performed
Blood loss during operation 200 cc
D/ : P2A0L2 post TPPCS oi severe preeclampsia on maintenance dose of MgSO4
regiment from other institution + once previous CS + pomeroy tubectomy oi
enough child
Both Mother – Child were in care
A/ : Control GA, Vital sign, uterine Contraction, Vaginal bleeding, fluid balance
Continue maintenance dose of MgSO4 regiment
Drip Oxytosine 2 amp in 500 cc RL 20 drops/minutes
Inj.Ceftriaxon 2 x 1 gr iv
Pronalgess supp 2 per rectal
Post Op lab check
Post op laboratorium (4/07/2018)