Case No.

47

Identity
Name Age MR No. Address Date : Mrs. S : 25 years old : 83 77 71 : South Solok : Augst 11st, 2013

Anamnesis : A 25 years old patient was admitted to the Delivery Room of Dr. M. Djamil Central General Hospital on Augst 11st, 2013 at 02.05 PM, referred from South Solok District Hospital with D/ G3P2A0L1 preterm pregnancy + eklampsia

Present Illness History: (from husband history)

She got her first seizure 8 hours ago while she was at home, she had a headache before. She got seizure for about 1 minute, whole body, she was conscious after that. 30 minutes latter she got the second seizure and then go to South Solok District Hospital, in emergency room, the nurse checked her blood pressure, it was 200/110.In emergency room distric hospital she had seizure for the third time. She wasnt conscious after seizure. Than she referred to RSMJ with MgSO4 regiment (began with initial dose, and followed with maintanance dose), and urine catheter reddish color. Headache (+), Epigastric pain (+) but no history of blur vision Sign of the labor cant be examined

 Amenorrhea since 7,5 months ago. First date of LMP: Forgotten, approximately on Januari 2013 ( from her husband story ) No complain of nausea, vomitting and vaginal bleeding during early pregnancy. Prenatal care to a midwife 2 times (at 4th,6th month of pregnancy). No finding of high blood pressure during her prenatal care.

Previous Illness History : There wasnt previous history of heart, lung, liver, kidney, DM and hypertension and no drugs allergic. No hystory of previous seizure before she get pregnant. Family Illness History : There wasnt history of hereditary disease, contagious and physicological illness in the family Marriage history : twice, first marriage on 2009, the last on 2012 History of pregnancy/abortion/delivery : 3/ 0 / 2 1. 2010, male, 2800 gr, term, spontaneous, midwife, life 2. 2011, female, 2700 gr, term, spontaneous, midwife, died after 5 month birth 3. Present History of family planning : none History of immunization : none

Physical Examination
GA Cons BP PR RR T FHS Urine Protein Urine volume patella rf Worse Sopor 220/110 106 24 37 + ++ 500 cc +/+ N Continues of regiment MgSo4 maintanance dose Eyes : conjunctiva wasnt anemic, sclera icteric +/+ Neck : JVP 5 -2 cmH2O, tyroid gland no enlargement Chest : Cor Inspection : Ictus cordis wasnt seem Palpation: Ictus cordis was at ICS V midclavicularis sinistra Percussion : cor edge was normal Auscultation : murmur(-) Pulmo Inspection : simetric in moving and shape Palpation : left and right fremitus were same Percussion : sonor Auscultation : vesiculer, Rh-/-, wh-/ Abdoment : OR Genitalia : OR Extremity : Edema +/+, Patellar Reflex / achiles rf +/+ normal, Pathological Reflex -/-

Obstetric Record Abdoment : I: Enlarge according to preterm pregnancy, median line hiperpigmentation, striae gravidarum (+), cicatrix (-) Pa: Uterine fundal was palpable 3 fingers above umbilicus, Ballotement (+) UFH : 23 cm EFW : 1550 gr Uterine contraction: (-) Pe : Tympanic Au : Peristaltic sound normal FHS : 112-126 x/

Genitalia :
Vaginal Touche 1 finger Eff 10-20%, portio thick 2,5cm thick, mdt
Amnionic sac (+) Head was palpable HI

Ultrasonography

Hb Leucocyte Hematocrit Trombocyte APTT PT 12.9 INR SGOT SGPT Random blood sugar Ureum Creatinin Kalium Chloride Natrium Calcium Albumin LDH Bilirubin I Bilirubin II Total bilirubin

Laboratory (11/8/13 ): : 14.1 gr/dl 9.515.0 : 21,300 /mm3 (5.916.9)x103 : 39 % 28.040.0 : 50,000/mm3 146429 x 103 : 45.7 22.635.0 : 15.6 9.6 : 1.3 : 733 u/l : 235 u/l : 115 mg% : 54 mg% : 0.9 mg % : 3,6 mEq/L : 104 mg/dl : 134 mEq/L : 8.7 mg/dL : 2,9 g/dL : 8652 u/l : 10,61 : 3,63 : 14,24 0.801.09 432 225 74-106 15.0-40.0 0.6-1.2 3.5-5.1 97-111 139-145 8.29.7 2.34.2 <480 0.10.5 00.1 0.11.1

MCV MCH MCHC Protein Total Globulin

: 85 um3 : 30,9 pg : 36,4 g/dL : 6 g/dL : 3,1 g/dL

Urinalysis
Protein Glucose Leukocytes Erythrocyte Cylinder Crystal Epithelial Bilirubin Urobilinogen : : : : : : : : : (++) (-) 12-15/LPB >500 difficult to assessed difficult to assessed (+) flat (-) (+) negatif negatif 0-5 0-1 negatif negatif (+) flat negatif positif

D/ decreased of consciousness at G 3P 2 A 0 L 1 preterm pregnancy 2830 weeks + antepartum eclampsy under SM regiment maintenance dose from outside + HELLP syndrom Fetal alive, singleton, intra uterine, head presentation HI Management : Control GA, VS, FHS, urine, patella reflex, fluid balance Continue MgSO4 maintainance dose Informed consent Consult to (ophthalmologist, internist, neurology, cardiology) Consult to anesthesiologist and report to Intensive Care Unit Consult perinatology

Plan: CS Report to on duty consultant acc report to high risk consultant report to high risk consultant stabilitation in ICU

Ophthalmologist result At present theres no sign of eclamptic fundus on ophthalmologic examination, eclamptic fundus KW 1 Therapy according to Obgyn Cardiology result Emergency Hypertension Perdipine drip start from 0.5, until MAP target 118 per hours. Join treatment with cardiology department Neurology result At this time, theres no neurologic focal deficits. G3P2A0L2 preterm pregnancy + eclampsia antepartum Therapy according to Obgyn Plan : Brain CT-Scan 03.00 : Brain CT Scan was performed, impression edem cerebri

Internist result Crisis hypertension oi eclampsia DIC Icterus kolestasis Advis: Metildopa 3 x 500 mg Drip perdipine according to cardiologist Liver Care UDCA Therapy according to Obgyn Plan : Check D-Dimer and HbsAg

At 03.30 pm arrived in ICU PE (monitor) : GA Cons BP PR Worse Sopor 162/92 108

RR 24(binasal)

T 37

Sat 98%

Urine 500cc (reddis color)

Abd/gen: HIS (-), DJJ 130 I : v/u normal, VT : 1 finger. Portio 1,5 cm in thickness, posterior, moderate amniotic sac (+), head palpable H1 D/ decreased consciousness on G3P2A0L1 preterm pregnancy 28-30 weeks + antepartum eclampsia in MgSO4 regiment maintenance dose from outside + HELLP Syndrome, fetal alive Th/ Control GA, VS, FHS, urine, patella reflex, fluid balance Continue MgSO4 maintainance dose Tutofusin Ops Ceftriaxone inj 2 x 1 gr Dexamethason 2 x 10mg Perdipine drip start from 0.5 iu until the MAP 118 in 1 hour Liver care 3 x 1 tab UDCA 3 x 1 tab Cervica rippening with misoprostol 50 mcg Plan : termination after stabilization

Laboratory in icu Hb : 15 g/dl HT : 42 % Leuco : 22,200 /mm3 Tromb : 25,000 /mm3 HbsAg :Calcium : 8,5 mg/dl Total Prot : 6,2 g/dl Alb : 2,8 g/dl Glob : 3,4 SGOT : 659 SGPT : 215 U/Cr : 67/0,6 D-Dimer : 3,0 mg/dl

parameter
pH pCO2 pO2 7,4 33 mmHg 217 mmHg

parameter
TCO2 BEecf BE (B) 21,4 mmol/L -4,4 mmol/L - 3,6 mmol/L

Na+
K+ Ca++ Hct

133 mmol/L
3,5 mmol/L 0,89 mmol/L 44 % / 37

602c
THbc THb

100 %
13,6 g/dL 10,2 g/dL

Temp-Corrected
pH(T) pCO2(T) pO2(T)

36 C / 37
7,41 32 mmHg 212 mmHg

Ca++ (7,4)
HCO3HCO3std

0,89 mmol/L
20,4 mmol/L 22,2 mmol/L

At 07.30 pm PE (monitor) : GA Cons BP Worse Sopor 178/101

PR 94

RR 24(binasal)

T sat 37 99%

Urine 120cc

Abd/gen: HIS +/s/w, DJJ 110-120 x/ VT : 1 finger. Eff 30-40%. Portio 1,5 cm in thickness, posterior, mild amniotic sac (-)head palpable H1 D/ decreased consciousness on G3P2A0L1 preterm pregnancy 28-30 weeks + antepartum eclampsia in MgSO4 regiment maintenance dose + HELLP Syndrome fetal alive Th/ misoprostol 50 mcg for cervical rippening Plan : termination

At 09.30 pm PE (monitor) : GA Cons BP Worse Sopor 182/98

PR 90

RR 24(binasal)

T sat : 100% 37 urine 100cc

Abd/gen: HIS 1-2/20/mdt, DJJ 100-110 x/ VT : 2 finger, eff 40-50%. Portio medial soft amniotic sac (-) clear residu, head palpable HI.
D/ decreased consciousness on G3P2A0L1 preterm parturient 28-30 weeks + antepartum eclampsia in MgSO4 regiment maintenance + HELLP Syndrome, fetal alive

Th/ Acceleration drip Transfusion 5 unit trombocyte Plan : termination

11.30 pm

01.30 am

02.30 am

03.30 am

05.30 am

07.30 am

PEBP/PR/RR Abd UC/FHS

(168/88)10224 (+/s/w) 100-115

(172/92)9221

(164/94)10022

(188/101)10426

(162/92)8823

(161/84)9322

(+/20/mdt) (+/20/mdt) 70-80 70-80 02.45 : 62-70 03.00 : 58-60 03.15 : 40 2, Eff 7080%, 2-3 Eff 80-90%,

(+/20/mdt) (+/35/mdt) (+/50/s) FHS (-)

Gen

2, eff 6070%,

2-3 Amniotic sac (-), head HII-III Continue acceleratio n drip Trombocyt e transf 5 unit

3-4 Amniotic sac (-), head HII-III

4-5 Amniotic sac (-), head HII-III

Th/

Continue accelerati on drip

Continue Continue acceleratio acceleration n drip drip

Follow Up Augst 12nd, 2013

Time 09.25 am PE GA : moderate, Cons : somnolen, BP : 168/92, PR: 98, RR: 24 (binasal), T : 37,1 Abd/Gen HIS : 3-4x/45/s, I : v/u normal, VT : head was crowning opened the vulva Therapy/Plan Th/Continue P/ vaginal delivery with kristeller ekspression

At 09.30 am A male baby was born : FW : 1200gr FL : 40 cm A/S : -/Placenta was spontaneous delivered , complete, 14x 12x 2 cm in size, 240 gr in weight, umbilical cords length 40 cm, insertion paracentralis. Blood loss during operation 50 cc

Diagnosis : P3A0L1 post partus prematurus spontaneous with kristeller ekspression + antepartum eclampsia + HELLP Syndrome Mother were in care, baby death M/ close monitoring

11.35 am a/ fever (-), vaginal bleeding (-), increase consciousness. PE/ GA Cons BP PR RR T sat : 99% Worse Somnolen 168/92 98 24(binasal) 37 urine : 300 cc Abd : uterine fundal palpable 3 finger below umbilicus, contraction was good. Gen : I v/u normal, vaginal bleeding (-) D/ P3A0L1 post partus prematurus spontaneous with kristeller ekspression + antepartum eclampsia in SM regiment maintenance dose + HELLP Syndrome Plan : check routine blood

August, 12 Gastrohepatology Department Kolestasis extrahepatal ec ca caput pankreas Ad/ SNMC in D5% drip per 18 hours UDCA 3x1 livercare 3x1 sistenol 3x500 mg Check hepar function Hypertension-kidney Department Hypertension stg III Continue therapy

August, 13 a/ fever (-), vaginal bleeding (-), increase consciousness. PE/ GA Cons BP PR RR T sat : 100% Mdt Somnolen 148/88 88 24(binasal) 37,8 urine : 400cc/3 hours Abd : uterine fundal palpable 3 finger below umbilicus, contraction was good. Gen : I v/u normal, vaginal bleeding (-) D/ P3A0L1 post partus prematurus spontaneous with kristeller ekspression + antepartum eclampsia in SM regiment maintenance dose + HELLP Syndrome Th/ Control GA, VS, FHS, urine, patella reflex, fluid balance Tutofusin Ops Omeprazole 1x1 meropenem inj 2 x 1 gr ranitidin 3x1 inj Systenol 2x500 mg transamin 3x1 inj Dexamethason 2 x 5 mg dopamed 3x500 mg SNMC in D5% drip Liver care 3 x 1 tab UDCA 3 x 1 tab Plan : transfusion PRC 2 unit

August, 13 Gastrohepatology Department Kolestasis extrahepatal ec ca caput pankreas Continue therapy Check hepar function Hypertension-kidney Department Increase ureum/creatinin value Liquid balance Chech kidney function everyday, beware for the worsening value.

parameter Hb HT Leucocyte Trombocyte MCH MCV MCHC APTT PT INR LDH Total Protein Albumin Globulin

August 12 (am/pm) 10,6 / 10,2 29 % /29 % 23,200/ 28.000 32.000 / 32.000 30 pg 86 m3 35 g/dL 43,5 sec 13,3 sec 1,2 INR 4.722 5,6 g/dL 2,8 g/dL 2,8 g/dL

August 13 7,5 21,2 13,300 133,000

45,1 12 1,2 1741 4,7 2,6 2,1

parameter
Total Bilirubin Bilirubin Direct Bilirubin Indirect

August 12
17,01 mg/dL 15,3 mg/dL 1,17 mg/dL

August 13
4,5 3,58 0,9

SGOT
SGPT Ureum Creatinin

134
229 89 1,4

61
80 101 2

THb

10,6 g/dL

parameter
pH pCO2 pO2

August 12
7,44 / 7,49 30 mmHg / 32 162 mmHg / 117

August 13
7,56 31 163

Na+
K+ Ca++ Hct

137 mmol/L / 134

3,5 mmol/L / 3,7 0,52 mmol/L / 0,85 43 % / 37

138
3,6 0,61 <15

Temp-Corrected
pH(T) pCO2(T) pO2(T)

36,6 C / 37
7,45 29 mmHg 160 mmHg

37,5
7,55 32 166

Ca++ (7,4)
HCO3HCO3std

0,53 mmol/L
20,4 mmol/L 22,9 mmol/L

0,65
27,8 29,5

parameter
TCO2 BEecf BE (B)

August 12
21,3 mmol/L / 25,4 -3,8 mmol/L / 1,1 - 2,7 mmol/L / 1,5

August 13
28,8 5,6 5,8

602c
THbc THb D-dimer

100 % / 99
13,3 g/dL / 11,5 10,2 g/dL

100

2,4

August, 14 07.00 am a/fever (-), vaginal bleeding (-) PE/

GA Cons Mdt Somn BP 152/85 PR 72 RR T sat : 99% 24(binasal) 37,8 urine : 300cc/3hours

Abd : good contraction, uterine fundal 3 finger above simp Gen : ppv(-) D/ P3A0L1 post partus prematurus spontaneous with kristeller ekspression + antepartum eclampsia in SM regiment maintenance dose + HELLP Syndrome
Th/ Control GA, VS, FHS, urine, patella reflex, fluid balance Tutofusin Ops Omeprazole 1x1 meropenem inj 2 x 1 gr ranitidin 3x1 inj Systenol 2x500 mg transamin 3x1 inj Dexamethason 2 x 5 mg dopamed 3x500 mg SNMC in D5% drip Liver care 3 x 1 tab UDCA 3 x 1 tab

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