peb pprom.pptx

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Case No. 65



Name : Mrs. R

Age : 21 yrsAddress : Kuranji, Padang

MR No. : 93 04 21

Admission date : Desem!er 3rd, 201"

Patient’s ID



• A 2# years o$d %atient admitted to t&e 'mergeny

Room o( Dr. M. Djami$ )enera$ *os%ita$ Padang on

Desem!er 3rd, 201" 11."" am, +it& &ie(

om%$ain since 6 hours ago fuidleakage rom the vagina

Anamnesis



•

Preious$y %atient +as oming to R-P Dr. Mdami$ Padang (or $oo/at &is (ami$i, in R-P M.Dami$ t&ere are fuid leakage romthe vagina t&en %ation +ent to de$$iery room M.Djami$. n

de$iery room (ound !$ood %ressure +s &ig& 1#0130 Patient t&en

re(erred to M.Djami$ entra$ *os%ita$ +it& i $ine Mg-54 maintenanedose and urine at&eter atta&ed• Any om%$ain o( &eada&e, !$urred ision, or e%igastri %ain +as

a!sent•

Fluid leakage rom the vagina since 6 hours ago• Pain (rom +aist region +&i& re(erred to t&e groin +as a!sent• 6$oody s&o+ (rom t&e agina +as a!sent• 7&ere +as no massie agina$ !$eeding• Amenorr&ea sine 8 9 mont&s !e(ore

Present Illness!istor"



irst date o( $ast menstrua$ %eriod 21"2013

'stimation date o( de$iery 2;22014

eta$ moement +as (e$t sine 8 4 mont&s !e(ore

No om%$ain o( nausea, omit, or agina$ !$eeding

during ear$y or $ate %regnany

Prenata$ are to mid+i(e in %rimary &ea$t& are eerymont& sine 2nd mont& %regnany. <ast ontro$ 2 +ee/s

ago. -&e said t&e %regnany +as +e$$ and t&ere +as no

&y%ertension. Menstrua$ &istory : menar&e at 13 years o$d, regu$ar

y$e in t&ree mont& !e(ore %regnany +it& t&e amount

o( 23 times %ad &angeday +it&out any menstrua$ %ain



Previous Illness

!istor"• 7&ere +as no &istory o( &y%ertension, ardia, $ung,

$ier, or rena$ dia!etes me$$itus disease nor a$$ergy

• No &istory o( any ontagious, or %sy&o$ogia$disorder in t&e (ami$y

Famil" Illness!istor"



• Marita$ -tatus : married in 2012• 5!stetris -tatus :

Pregnany De$iery A!ortion : 2 1 0

1. 2004, inom%$it a!ortion, uretage

2. Present•. *istory o( ami$y P$anning : •. mmuni=ation :



Ph"sical #$amination)en on 6P *R RR 7 > urine

Moderate M 1#0100 92 20 3#? 300 at t&e time

Pate$$a re($e@ : N

6* 6B 6M A

14; ";43 19,C3 2C

'yes : onjuntia +as not anemi, s$era +as not iteriNe/ : EP "2 m*25, no en$argement o( t&yroid g$and

7&ora@ : *eart <ung F +it&in norma$ $imit

'@tremity : edema , %ate$$ar re($e@ n



Obstetrics Records

Abdomen

•

ns%etion : en$arged aording to %reterm %regnany, mid$ine&y%er %igmentation , iatri@ • Pa$%ation :

– <1 : uterine (unda$ +as %a$%ated 4 (ingers !e$o+ %ro.

@y%&oideusA large sot nodular mass %as &al&a'le

– <2 : $argest resistane struture +as %a$%ated at $e(t

Numerous sma$$, irregu$ar struture +ere %a$%ated on t&erig&t

side – <3 : a &ard round mass +as %a$%ated not (i@ated – <4 : onergent

*: 2# mG '6B: 23;0 gr( uterine ontration :



• Perussion : tym%ani• Ausu$tation : norma$ %erista$ti sound, *R : 1401"0

!%m

)enita$• ns%etion : u$a and uret&ra F +it&in norma$ $imit

•

agina$ e@amination• ∅ no di$atation

• Portio +as t&i/ 1," m, %osterior, medium

• '((aement 2030 H

• Amnioti sa +as di((iu$t to e@amine

• *ead %a$%ated, *

Pe$i sore 1



n$et Pe$i :

• Promontory +as not rea&a!$e

•

nnominate $ine +as %a$%ated 1313• -arum !one : onae

• Pe$i side +a$$ : straig&t

• s&iadi s%ine : not %rotruded

• oygeus !one : moea!$e

• Ar o( %u!i : I90°

5ut$et Pe$i :

• nter tu!erous distane ou$d !e %assed t&roug& !y norma$adu$t (ist I 10," m

m%ression : no ontrated %e$i



)*+



)ltrasound

• Fetal alive singleton intrauterinehead &resentation

• Fetal movement %as good

• ,iometric - ,PD 65 mm #F/ 0122gr

AC 033 mm

F4 662 mm

• Placental im&lanted at anterior

cor&us gr IIIII



Laboratory FindingParameter Result Normal Value Unit

Haemoglobin 9,4 12.00-14.00 g/dl

Leuo!te 129.000 ".#0-1#.90 10$/mm$

%ritro!te 4,& 4.00-".00 10#/'l

()rombo!te 10&.000 1"0.00-400.00 10$/mm$

Hematorit $& $&.00-4$.00 *

P( 9,2 10-1$,# se

+P(( $$,& 29,2-$9,4 se

Parameter R%UL( Normal Value Unit

Protein - g/dl

Urinalisa



Parameter Result Normal Value Unit

LH "00 40 u/l

Potassium 3 $."-".1 mmol/L

odium 1$# 1$9-14" mmol/L

Random lood 5luose 2 200.00 mg/dL

(otal Protein ",9 #.0-&. g/dL

+lbumin $,# $."-".2 g/dL

5lobulin 2,$ 0.00-0.00 g/dL

56( 19 0.00-$1.00 u/L

5P( 14 0.00-$4.00 u/LUreum 9 1".00-40.00 mg/dL

7reatinine 1,$ 0.#0-1.20 mg/dL

8%R 1,1&4,29 0," g/dl



Diagnosis :

• )2P0A1<0 %reterm %regnany 343C +ee/s

-eere Pree$am%sia on regimen Mg-54maintenane dose (rom ot&er intitution

PPR5M

• eta$ a$ie, sing$eton, intrauterine, &ead%resentation, *



Management :

• ontro$$ing genera$ ondition, ita$ sign, ($uid !a$ane,

%ate$$ar re($e@, *R• n(ormed onsent

• Maintenane dose o( Mg-54 regimen• ')• a$$ Pree$am%sia 7eam : 5%&t&a$mo$ogy,

ardio$ogy, and agina$ De%artment• onsu$e %erinato$ogy

P$an : 7ermination



6:)t)almolog! e:artment

• m%ression :

– Mi$d e$am%sia (undus +as (ound

– 7&era%y :

• Aording to 5!)yn De%t

7ardiolog! e:artment

• m%ression :

– -eere Pree$am%sia in )2P0A1<0 %reterm %regnany

3434 +ee/s

– Adie :

• Met&y$do%a 3@"00 mg



nterne De%artment

• m%ression :

– -eere Pree$am%sia in )2P0A1<0 %reterm

%regnany 3434 +ee/s

– Adie :

• Met&y$do%a 3@"00 mg



At 0C.30 %m :

• 7PP- +as %er(ormed• A ma$e !a!y +as !orn +it& 2300 g in +eig&t, 44 m in

$engt&, AP)AR sore 3C• P$aentas +as de$iered +it& mi$d tration on

um!i$ia$ ord, a %iee, 1C @ 1" @ 2," m in si=e, 4"0

g in +eig&t, um!i$ia$ ord $engt& +as "0 m,

%araentra$is insertion.• 6$ood $ose during surgery : 8 2"0



Diagnosis :

• P1A1<1 %ost 7PP- on indiation o( -eere

Pree$am%sia PPR5M• Mot&er and !a!y +ere in are



hank 7ou

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