case report hellp syndrome

8/11/2019 Case Report Hellp Syndrome

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MORNING REPORT


2/15

Anamnesis

Hospital date : September 19th, 2014

Name : Mrs. H Name : Mr. Q

Age : 24 years old Age : 25years old

Religion : Moslem Religion : Moslem

Last Education : S1 Last Education :

Senior High School

Occupation : Housewife Occupation :

Tribe : Bugis Tribe : Bugis

Address : Sidodamai Address : Sidodamai


3/15

Anamnesis

Chief Complaint:

Abdominal contraction came and releaved, and bloodslymcame out from her womb.

Present Illness:

Patient reffered by Midwife from PT. Khaleda with chiefcomplain are abdominal contraction came and releaved since14 hours before. Mother confessed bloodslym came out fromher womb. Patient was diagnosed as G1P0A0gravid

38-39 weeks, latent phase

1ststage of labor + susp.

Gemelli / Makrosomia ?


4/15

AnamnesisHistory of Past Illness: -

Antenatal Care:

- Patient routinely come to the Midwife for the check up every month.

Last check up is on last week.- Patient never do examination by USG.

- There is no complain during this pregnancy.

History of Menstruation :

Menarche since 13 years old, cycle of menstruation is 7 days LMP : 20122013

EDD : 279 - 2014


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Anamnesis

Marriage History : -

Patients was married since 1 years ago and

once

Contraceptional History: -


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Obstretic History

1. 2014 Now pregnancy


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Physical Examination

Height/Weight : 149 cm / 80 kg

Consciusness : Composmentis

Vital Sign:

BP : 130/90 mmHg

PR : 80 bpm T : 36C

RR : 20 bpm


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Physical Examination

Head : Normochepaly

Eye : Anemis (-/-), icteric (-/-)

Thorax

Cor : S1 S2 single reguler

Pulmo : vesiculer, rhonki (-/-), wheezing (-/-)

Abdomen : scar (-), striae (+), linea nigra (+)

Ekstremity : edema (-/-), warm acral (+/+)


9/15

Obstetric State

Linea nigra (+), striaealbicans (+)

PalpationLeopold I : UFH : 35 cm, breechLeopold II : back on the right side

Leopold III : head

Leopold IV : 4/5

VT3 cm, amnion (+), headpalpable H1

FHB I: 129 bpm, FHB II: 134 bpm; UC 2 x 10 duration 25-30

Inspection


10/15

Laboratory Finding

Hb : 10,2 g/dl

WBC : 10.000/mm3

HCT : 32,6 %

PLT : 277.000/mm3

BT : 3

CT : 9

GDS : 88 mg/dl

Ur : 20,3 mg/dl

Cr : 0,5 mg/dl HBsAg : Non Reaktif

112 : Non Reaktif


11/15

Diagnosis

G1P0A0 gravid 38-39 weeks, Single/Life/Intra

Uterine, head presentation, latent phase 1st

stage of labor


12/15

TIME OBSERV TION

20.38 Receive a new patients from ER, anamnesis and physical examination :- BP : 180/120 mmHg- PR : 88 bpm- RR : 20 bpm- T : 36,5C (per axiller)

Leopold I : UFH : 35 cm, breech

Leopold II : back on the right side

Leopold III : head

Leopold IV : 4/5VT : 3 cm, amnion (+), head palpable H1FHB I: 129 bpm, FHB II: 134x/m; UC 2 x 10 duration25-30G1P0A0 gravid 38-39 weeks, S/L/IU, head presentation, latent phase 1

ststage of labor

21.00 Consult to dr. Sp.OG:

Observation the FHB and UC

03.00 FHB I: 140 bpm; FHB II: 146 bpmUC : 3 x 10 duration 30-45

06.00 VT 10 cm, amnion (+), head palpable H1

Consult to dr Sp.OG:- Amniotomy


13/15

TIME OBSERV TION

08.10 Amniotomy: green amnion

08.35 VT 10 cm, amnion (-), head palpable H II+bloodslym (+)

FHB I: 130 bpm, FHB II: 135 bpm; UC 3 x 10 x 40

08.40 Consult to dr. Sp.OG:- Drip oxytocin 5 IU in RL 20 increase 4 dpm/15 minutes, maximumuntil 40 dpm

- Evaluation and reconsul in 1 hours

08.45 Drip oxytocin 5 IU in RL 20 dpm

FHB I: 130 bpm, FHB: 135 bpm; UC 3 x 10 x 20-25

09.00 Drip oxytocin 5 IU in RL 24 dpmFHB I: 136 bpm, FHB: 146 bpm; UC 3 x 10 x 20-30

09.15 Drip oxytocin 5 IU in RL 28 dpmFHB I: 138 bpm, FHB: 144 bpm; UC 3 x 10 x 30-35

09.30 Drip oxytocin 5 IU in RL 32 dpmFHB I: 112 bpm, FHB II: 102 bpm; UC 4 x 10 x 30-35

09.45 Drip oxytocin 5 IU in RL 36 dpmFHB I: 120 bpm, FHB II: 112 bpm; UC 4 x 10 x 30-45

10.00 Drip oxytocin 5 IU in RL 40 dpm

FHB: 121 bpm; UC 4 x 10 x 35-45


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TIME OBSERV TION

10.10 Consult to dr. Sp.OG:- Tappering on oxytocin 40 dpm and reconsul

10.46 The baby born spontaneusly, Male, A/S 7/8 Anus (+), CongenitalDefect (-), Weight 3200 gr, Height 51 cm, green amnion, placenta

born completely, episiotomy on perineum, hecting (+)

TimeBlood

PreassurePR UFH

Uterus

Contraction

Vesica

UrinariaBleeding

11.00 110 / 70 88 At the navel

level

Good Empty 30 cc

11.15 110 / 70 82 At the navel

level

Good Empty 20 cc

11.30 110 / 80 88 At the navel

level

Good Empty 10 cc

11.45 110 / 70 80 At the navel Good Em t 5 cc

Post Partum Observation


15/15

THANK YOU

case report hellp syndrome

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