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Mrs. Herawati, 43, 01106574, Impending Eclampsia, LCSC + TP - RV
Mrs. Herawati, 43, 01106574, Impending Eclampsia, LCSC + TP - RV
IDENTITY
Patient Husband
Name : Mrs. H Name : Mr. R
Age : 43 years old Age : 46 years old
MR : 01 10 65 74 Education : S1
Education : S1 Occupation : Enterpreuner
Occupation : Civil cervant Address : Payakumbuh
Address : Payakumbuh
Admision date : 01/06/2021
Mrs. H, 43 years old, 01 10 65 74
Admission Origin Preparation for surgery Diagnose Plan
date
Date : Origin from : Consult to Cardiologist • G3P2A0L2 31-32 weeks of Emergency CS
01/06/2021 PONEK A/ Emergency hypertension on preterm pregnancy +
impending eclampsia on G3P2A0L2 impending eclampsia on
Referred from : 31-32 weeks of preterm pregnancy
P/ maintenance dose of
Time : Adnaan WD General Hospital MgSO4 regimen from other
04.30 Nicardipin drip start 0,5
mcg/kgBW/hour institution
Diagnose : BP target systolic < 165 or diastolic < • Fetal alive, singleton,
G3P2A0L2 31-32 weeks of 105 intra uterine, head
DPJP : preterm pregnancy + Metyldopa 3x500 mg if BP >140/90
MS presentation
impending eclampsia on
Consult to Internist
Risti : maintenance dose of MgSO4 cardiovaskuler risk : Lee Revise score
HJS regimen 0,9 %
Pulmonal risk: mild
Metabolik risk: mild-moderate
Hemostatikc function: stable
Consult to Perinatologist
Agree to accompany during delivery
Impression :
• 30-32 weeks of preterm pregnancy
• Fetal alive, singleton, intra uterine, head presentation
CTG
Baseline : 145
Variability : 5-20
Acceleration : (+)
Deseleration : (-)
Fetal movement : (+)
Contraction : (-)
Impression : First category
ECG
ECG : sinus rythm
QRS rate : 98 bpm
P wave : normal
PR interval : 0,16 s
QRS duration: 0,06 s
ST-T changes : (-)
LVH : (-)
RVH : (-)
Cardiologist Consult
A/ Emergency hypertension on impending eclampsia on
G3P2A0L2 31-32 weeks of preterm pregnancy
P/
Nicardipin drip start 0,5 mcg/kgBW/hour
BP target systolic < 165 or diastolic < 105
Metyldopa 3x500 mg if BP >140/90
Internist Consult
A/ G3P2A0L2 31-32 weeks of preterm pregnancy + impending
eclampsia on maintenance dose of MgSO4 regimen from other
institution
P/
cardiovaskuler risk : Lee Revise score 0,9 %
Pulmonal risk: mild
Metabolik risk: mild-moderate
Hemostatikc function: stable
Risti Consult
A/ G3P2A0L2 31-32 weeks of preterm pregnancy + impending
eclampsia on maintenance dose of MgSO4 regimen from other
institution
P/
Agree with the assessment
Termination perabdominam
Perinatology Consult
Agree to accompany during delivery
Operation report
• Patient on supine position under spinal anaesthesia
• Antiseptic and septic procedure was performed
• Pfanenstiel incission was performed
• Layer by layer was opened until peritoneal
• Gravid uterine was seen
• Low uterine incicion was performed
• By delivery head extraction a female baby was born, BW : 1185
gram, BL : 35 cm, A/S 6/8
• Placenta was born with mild traction size size 16x14x5 cm, 200
gr
• Uterine closed 2x
• Pomeroy tubectomy was performed
• Abdomen closed layer by layer
• Bleeding during operation 250 cc
DOCUMENTATION
KURVA LUBCHENCO
BALLARD SCORE (Total 20 32 weeks)
Follow Up 2 hours post op