preeklampsia ringan

Case ReportName: Mrs. ARM: 049790Age: 18 years oldAddress: Jonggat, Lombok TengahAdmitted: August 1st 2012 at 22.30

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING01/08/201222.30Patient referred from Lingsar PHC with G1P0A0L0 41 weeks S/L/IU head presentation, mother & fetal condition well with latent phase 1st stage of labor & mild preeclampsia. Patient confessed water came out from her womb since 02.00 (01-08-2012) and abdominal pain since 19.00 (01/08/2012), bloody slim (+), FM (+).No history of DM, HT, asthma.

LMP : 20/10/2011EDD : 27/07/2012

History of ANC : > 4x at PHCLast ANC : 30/07/2012History of USG : never

History of family planning : (-)Next family planning : Injection 3 months

Obstetrical History :ThisGeneral Status :GC : wellBP : 140/100 mmHgPR : 96 bpmRR : 24 bpm T : 37,2OCEye : anemis (-/-), icteric (-/-)Cor : S1S2 single regular, murmur (-), gallop (-).Pulmo : vesicular (+/+), wheezing (-/-),ronkhi (-/-).Abdomen : scar (-), striae gravidarum (+), linea nigra (+).Extremity : edema (-/-), warm acral (+/+).

Obstetrical Status :L1 : breechL2 : back on the left sideL3 : headL4 : 4/5UFH : 33 cm EFW : 3410 gramUC : 3x/10~40FHB : 12-12-12 (144 bpm)VT : 5 cm, effacement 50%, amnion (-) clear, head palpable HI, denom LOA, impalpable small part and umbilical cord.G1P0A0L0 40-41 weeks S/L/IU with active phase 1st stage of labor + history rupture of membrane + mild preeclampsia.Observation mother & fetal well being.Observation progress of labor with partografDM co to GP, advice : observation progress of labor.

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNINGChronologist (01/08/2012)20.45S : Patient confessed water came out from her womb since 13.30 (01-08-12).O : GC : wellBP : 140/90 mmHgPR : 88 bpmRR : 20 bpm T : 38OCHead presentation, back on the right side, 4/5.UFH : 34 cm EFW : 3565 gramsUC : 3x10~35FHB : (+) 11-11-11 (132 x/min)Edema (-/-)Proteinuria +1VT : 3 cm, eff 50%, amnion (-), head palpable, HI, denominator unclear, impalpable small part / umbilical cord.A : G1P0A0L0 41 weeks S/L/IU head presentation, mother & fetal condition well with latent phase 1st stage of labor and mild preeclampsia.P : Injection Ampicilin 1 g/IV (21.30)Infuse RL 28 tpm Refer to NTB GHPelvic Evaluation :Spina ischiadica not prominentOs coccygeus mobileArcus pubis > 90o

Lab Examination : HGB : 11,5 g/dl HCT : 35,3 % RBC : 3,95 M/uL WBC : 10,05 K/uLPLT : 275 K/uLHbSAg : (-)Protein urine : +2

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING02/08/201202.00Abdominal pain came more frequentlyMother wants to bearing downGC : wellBP : 140/90 mmHgPR : 88 bpmRR : 20 bpm T : 36,8OCUC : 4 x 10 ~ 40FHB : 12-13-13 (152 bpm)Teknus perjol vulka2nd stage of labor with mild preeclampsiaObservation mother & fetal well being.Conduct mother to bearing down.Head baby was born (02.15)Check umbilical cord entanglement : (+) tight.Turtle sign (+) shoulder dystocia.Cut the umbilical cordMc Robert manueverBaby was born (02.20) after 5 minutes :Female, 3500 gram, 51 cm, AS 3-5, anus (+), anomaly congenital (-).Do neonatal resuscitationPlacenta was born spontan, complete. Bleeding 150 cc.Rupture perineum grade II04.20Patient confessed delivery wound painGC : wellBP : 120/80 mmHgPR : 96 bpmRR : 20 bpm T : 37,5OCUC : (+) wellUFH : at umbilicusLochea rubra : (+)2 hours post partumObserved mother & baby well beingSuggest mother to rest, eat and drink, medication.

TIMESUBJECTIVEOBJECTIVEASSESSMENTPLANNING02/08/201207.00Delivery wound painGC : wellBP : 120/90 mmHgPR : 100 bpmRR : 20 bpm T : 37,4OCUC : (+) wellUFH : at umbilicusLochea rubra : (+)

Baby in NICU :Infuse D10% 20 tpmO2 1 lpmGC : wellPR : 136 bpmRR : 32 bpmT : 37,0OCOne day post partum Observed mother & baby well beingSuggest mother to mobilisation, eat and drink, medication.Breast feeding

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