panik jaga 15 nov 2014
DESCRIPTION
PANIK Jaga 15 Nov 2014TRANSCRIPT
Residents : Dewi/Fifi/Diah/Rina/Fakhrurrazi/Amru
Obstetric and GynecologyMedical Faculty University of North Sumatera
dr. Pirngadi General Hospital2014
DUTY REPORTSaturday, November, 15th 2014
CONSULTANT dr. Jenius L Tobin,M.Ked(OG), SpOG
REPORTING :
1. SEVERE PREECLAMPSIA WITH IMPENDING ECLAMPSIA + PG + IUP (32-34) WGA +
HEAD PRESENTATION + LIVE FETUS + NOT IN LABOR
No
Description Procedures Outcome /plan
1. Mrs. D, 33 yo, G1P000
Diagnosis : Severe preeclampsia with impending eclampsia + pg + IUP (32-33) wga/USG + head presentation + live fetus + not in labor
- Monitoring vital sign and fetal -heart rate- Stabilization General conditionImmediate Cesarean section
Baby boy was born, BW 1650 gr, 46cm, Anal (+), A/S 4/6
Mother condition is not stabile
1. Mrs. D, 33 yo, G1P0A0, Javanese, Moslem, Senior high school, housewife w/o Mr. M, 34 yo, Bataknese , Moslem, Junior high school, entrepreneur admitted to ER on 15 th November 2014 with: Cc: UnciousnessThis has been experienced since 15th November 2014 on 12.00 PM , history of high blood pressure before pregnancy (+), history of headache (+) . History of nausea (+), Vomit (+), blurr vision (+) since November 15th 2014, epigastric pain (-). History of seizure (-), History of uterine contraction (-), history of leakage of amniotic membrane (-), History of bloody show (-), urination, defecation (+) normal.
Previous medical history : -Previous medication history : -LMP: ?/?/2014EDD : ?/?/2014ANC : midwife 6x
History of Labor :1. This pregnancy
Status Presens Sens : Sopor Anemic : (-)BP : 210/120 mmHg Icteric : (-)HR : 84x/i Cyanotic : (-)RR : 22 x/i Dispnoe : (-)Temp : 36,80C Oedem : (+)pretibial
Protein : (+)4
General State :Head : Conj Palpebra inferior anemic ( -)/(-), sclera icteric
(-)/(-), pupil anisokor, light reflex (-)/(+)Neck : in normal limitThorax : Breathing sound: Vesicular
Additional sound: Wheezing(-)/(-), Rhonki (-)/(-)
Extremity : in normal limit
APR/KPR : (+)/(+)Urine output : 300 cc
Obstetrical state : Abdomen : symetrical enlargedFH : 3 fingers upper umbilical (21 cm)Tension Part : RightLowest Part : Head Movement : (+)Uterine Contraction : (-)FHR : 120 x/i , regulerEBW : 1600– 1800 gram
VE (after SM Therapy) : Closed cervix
Laboratorium report 15/11/2014
Hb : 12,5gr/dl N: 12-14/gr/dl
Leukocyte : 13300/mm3 N: 4000-11000/uLHematocrit : 37,3% N: 36,0-42,0/%Trombocyte : 143.000/mm3 N: 150.000-400.000/uLBGL adr : 115 mg/dl N: < 200 mg/dlAPT : 33,2 C= 33,5 SGOT : 22 N= 0-40SGPT : 11 N= 0-40LDH : 560 N= 240-480 U/IUreum ; 20 N=10-50 mg/dlCreatinin : 0,74 N=0,6-1,2D-dimer : 370 N= < 500 ng/ml
USG TAS
USG TAS• Singleton, Head presentation, live fetus• FM (+), FHR (+), • Placenta Fundal grade II• BPD : 83,5 mm• FL : 60,1 mm• AC : 24,4 mm• Amnion fluid : in normal limit
Concl : IUP (32-33) wga + head presentation + live fetus
Diagnosis: Severe preeclampsia with impending eclampsia + pg + IUP (32-34) wga + Head Presentation + Live fetus + not in labor
Treatment :- O2 2-4 L/i- inj. MgSO4 20% 20cc (4gr) loading dose- IVFD RL + MgSO4 40% 30cc (12 gr) 14 drops /minute- Nifedipine tab 10 mg/ 30 minutes if the blood pressure ≥ 180/110
mmHg, max 120mg/24 hours, maintenance 4x10 mg- Inj Dexamethason 15 mg single dose
Planning : emergency CS
Report to Supv dr. Jenius L Tobing, M.Ked (OG). Sp.OG.K permitted
Born baby boy, 1650gr, 46cm, 4/6, anus (+)
Time sens BP pols RR Temp FHR
18.30 Sopor 210/120 84 x/I 22x/i Afebris 120x/i Nifedipine 10mg
19.00 Sopor 210/120 86x/I 22x/i Afebris 126x/I Nifedipine 10mg
19.30 Sopor 180/100 84x/i 22x/i Afebris 120x/I Nifedipin e 10mg
20.00 Sopor 160/90 87x/i 20x/i Afebris 122x/i CS
FOLLOW UP
C-Section d/t Impending Eclampsia
baby boy was born, BW: 1650 gram, BL: 46 cm, AS: 4/6 , Anus (+)•Mother was laid in operation table, with iv line and urine catheter installed well
•Antiseptic and aseptic procedure was performed, with betadine and alcohol solution
(70%), and covered by sterile fabric except operation field
•Under general anesthesia, Pfannestiel incision was starting from kutis, subcutis
•By inserting the underlying anatomical tweezers, fascia cut left and right, then the
fascia and muscle were separated bluntly
•The peritoneum is clamped with two clamps, then the scissors up and down
•Installed hack blast, uterus gravidarum seem appropriate for gestational age,
identification of lower uterine segment and ligamentum rotundum
• Then cut a concave plica vesicouterina left and right and down towards blast setaside sufficiently
• Furthermore, the low cervical incision in the uterine wall to penetrate
subendometrium concave, then the endometrium penetrated by a blunt
and enlarged in the direction of the incision
• By grasping the head, a baby Boy was born with 1650 gr of weight and
46cm of height, apgar score was 4/6, anus (+)
• The umbilical cord is clamped in two places and cut them. The placenta
was born with the umbilical cord traction and pressure on the fundus, an
impression: complete.
• Both left and right edges of the incision is clamped by the clamp oval
• uterine cavity cleaned of the remnants of the amniotic membranes with opened sterile gauze until there are no membranes or the placenta is left behind. Impression: clean
• Do figure of eight suturing hemostasis at both ends of the laceration of
the uterus with a thread chromic Catgut no.2 wall of the uterus sutured
layer by layer by overhecting locked. Evaluation: there is no bleeding. Do
reperitonealisation
• Abdomen wal is sticth layer by layer
• The operation wound was closed with sterile gauze and hypafix
• Patient's post-operative condition: Good