Name Age MR No Date
: Isdarti : 42 Years old : 28 93 47 : October 18th 2
Anamnesis A 42 Years old !atie"t #as admitted to the Deli$er% Room o& Dr' M' D(amil )e"tral *e"eral +os!ital o" October 18th 2 2 at #ith chie& com!lai" ,l-id [Link] &rom the $agi"a si"ce 12 ho-rs ago
Present Illness History :
,l-id [Link] &rom the $agi"a si"ce 12 ho-rs ago #atered 1 !ice o& saro"g / clear a"d smell% 0aist !ai" re&ered to groi" #as abse"t 1lood% sho# &rom the $agi"a #as abse"t No massi$e $agi"al bleedi"g' +eadache #as !rese"t/ bl-red $isio"/ a"d e!igastric !ai" #as abse"t Ame"orrhea si"ce 9 mo"ths ago ,irst date o& last me"str-al !eriod cold"2t be recalled estimatio" date o& deli$er% ca"2t !redicted ,etal mo$eme"t #as &elt si"ce 3 mo"ths ago' No com!lai" o& "a-sea/ $omiti"g a"d $agi"al bleedi"g/ "either d-ri"g earl% !reg"a"c% "or late !reg"a"c% 4re"atal )are to a mid#i&e reg-larl%' Me"str-atio" +istor% : me"arche at 13 %ears old/ reg-lar c%cle/ e$er% 28 da%s #hich last &or 3 to 7 da%s each c%cle #ith the amo-"t o& 253 times !ad cha"ge 6da% #itho-t me"str-al !ai"'
Previous illness history 7i"ce 2 %ears ago ."o#" ha$e h%!erte"sio"/ co"trole to !-[Link] reg-larl%/ +istor% o& heart/ l-"g/ li$er/ a"d .id"e% desease #as abse"t Family illness history No im!orta"ce Marriage histor% : O"ce at 198 +istor% o& !reg"a"c%6Abortio"6Deli$er% : 46163 1' 198 / abortio"/ 3 mo"th/ !er&ormed c-rretage at M D(amil +os!ital 2' 1982/ male/ 32 gr/ term/ s!o"ta"/ mid#i&e /ali$e 3' 1988/ male 32 gr/ term/ s!o"ta"/ mid#i&e/ death/ a&ter deli$ered 4' 1997/ &emale/ 2 gr/ !reterm/ Ais%ah +os!ital/ )7 oi !lace"ta !re$ia/ ali$e 3' 4rese"t
)o"trace!tio" histor% : I9D/ released beca-se o& h%!erte"sio" Imm-"i:atio" histor% : ;; t#ice d-ri"g !reg"a"c% Physical Examination *e"eral a!!eara"ce )o"scio-s"es 1lood !ress-re 4-lse Rate Res!iratio" rate ;em!erat-re ,etal +eart rate 9ri"e 4rotei" : Moderate : )om!osme"tis coo!erati$e : 22 611 mm+g : 92<6m : 24<6m : 37 ) : 12 =11512 : >>
Diagnosed: *3 43 A1 A2 term !reg"a"c% > 4re$io-s )7 > 7e$ere !reeclam!sia 7-!er Im!osed ,etal ali$e/ i"tra -teri"e Attitude 0ard Isolatio" room I"isial dose Mg7O4 regime" )o"trole *A/ 14/ 4R/RR/ ;em!/ 9ri"e/ 4atelar re&le< ?ie lateral le&t side 4la" Mg7O4 regime" mai"te"a"ce dose 1egi" Mg7O4 regime" I"itial dose ,i"ished Mg7O4 regime" I"itial dose *e"eral a!!eara"ce )o"scio-s"es 1lood !ress-re 4-lse Rate Res!iratio" rate ;em!erat-re ,etal +eart rate 9ri"e 4rotei" 4atelar re&le< @%es : Moderate : )om!osme"tis coo!erati$e : 18 611 mm+g : 88<6m : 24<6m : 37 ) : 12 =11512 6 11512511 : >> : >6>
: )o"(-"cti$a "ot a"emic / 7clera "ot icteric
Nec. )hest Abdome"t *e"italia @<tremit%
: AB4 352 cm +2O / ;%roid "ot e"large : +6? Normal : OR : OR : @dema >6> / 4h%siological Re&le< >6> / 4athological Re&le< 565
Obstetric Record ,ace 1reast Abdome" I"s!ectio" : )hloasma gra$idar-m #as !ositi$e : 1oth e"large/ areola6"i!!les h%!er!igme"tatio" / )olostr-m C>D : : @"larged to lateral side medial li"e h%!er!igme"tatio"/ striae gra$idar-m C>D/ cicatri< C5D : ;he &-"d-s #as !al!ated 2 &i"ger belo# <i!hoid cartilage 4al!ated large "od-lar mass 4al!ated ro-"d hard mass : 4al!ated the great resiste"ce at the le&t side a"d the right side : 4al!ated large "od-lar mass 4al!ated ro-"d hard mass : ;he lo#est !art o& the &etal bod% has e"ter the !el$ic i"let
4al!atio" : ?eo!old I ?eo!old II ?eo!old III ?eo!old IB
9teri"e ,-"dal +eigh : 42 cm @stimated &etal bod% #eigh : 4493 gr 9teri"e )o"tractio" : C5D 4erc-sio" : ;%m!a"i
A-sc-ltatio" : ,etal +eart 7o-"d : 144<6m *e"italia I : :B-l$a69rethra "ormal B; : )er$ical dilatatio" 1 &i"ger 4ortio thic. 1 E cm/ !oterior/ so&t Am"io"ic sac #as "egati&/ small amo-"t resid-e 4al!able head at +I
No 4el$ic co"tractio"
Laboratory: +b ?[Link]%te ;romboc%te +ematocrit );
: : : : :
11/9grF 93 2 7 34 42 : 117
1; : 223 G Ra"dom 1lood gl-cose 9re-m : 21 9ric acid : 8/7 7*O; : 38 7*4; : 18
Diagnosed: *3 43 A1 A2 term !reg"a"c% > 4re$io-s )7 > 7e$ere !reeclam!sia 7-!er Im!osed &i"ished Mg7O4 regime" i"itial dose >4RM ,etal ali$e/ si"gleto"/ i"tra -teri"e/ head !rese"tatio" +I Attitude: Mg7O4 regime" mai"te"a"ce dose )o"trole *A/ 14/ 4R/RR/ ;em!/ 9ri"e/ 4atelar re&le</ &-id bala"ce )hec. r-ti"e blood e<am/ li$er !hisiolog%/ .id"e% !hisiolog%/ haemostatic !hisiolog% @)* )o"s-lt i"ter"is/ o!htalmologhist 4re!ared 1lood 3 cc ?ie le&t lateral side Plan )esarea" sectio" Optalmologhist consult result ;his time a!eared moderate &-"dal eclam!sia Internis consult result Aterm !reg"a"c% > 7e$ere !reeclam!sia s-!er im!osed
)esarea" 7ectio" 4er&ormed October 18 th 2 2 i" a!gar score
;he &irst bab% #as bor" b% ;44)7 gram i" #eight/ cm i" le"gth/
;he seco"d bab% #as bor" b% &oot e<tractio" gram i" #eight/ cm i" le"gth/ i" a!gar score @<!loratio" !er&ormed/ &o-"d 2 chorio" a"d 2 am"io"
;he !lace"ta #as bor" ma"-all%/ o"e !iece/ com!letel% the si:e #as 22<2 <3cm 7 gr i" #eight/ ;he -mbilical cord #as 3 cm i" le"gth/ i"sertio" !arace"trall% 1leedi"g d-ri"g o!eratio" >65 33 cc Diagnosed 4ara 3 Abortio" 1Ali$e 3 !ost ;44)7 o" !re$io-s )7 > se$ere !reeclam!sia > 4ROM 1ab% i" good co"ditio" Mother #as"2t co"scio-s %et Management Obser$e !ost O!eratio"