Case ReportMrs.M, 22 yo, from NarmadaHospitalization on 01/06/2012, 14.10

G1P0A0L0 P/S/L/IU with Eclampsia

TimeSubjectObjectAssessmentPlanningChronologist (01/06/2012, in Narmada PHC):S: Patient pregnant 9 months, came to PHC confessed seizure 2x in home, nausea & vomiting (+), and seizure again 1x at PHC (13.00, 01/06/2012).O:GC: moderateBP: 140/100 PR: 58x/min RR 26x/min T: 37,5cFHR : 11-12-11 (136x/min)

A: G1P0A0L1 S/L/IU with eclampsia.

P: - Infuse RL - Bolus MgsSo4 40% 4 g (13.00) - Dryp MgSO4 40% 6 gram (13.30) - Referred to NTB GHLab:Hb = 13,9g/dlRbc = 4,67Leu = 9,59Plt = 132Hct = 41,1%HbSAg = (-)Protein urine : +2GDS: 104SC: 0,7Ureum : 18Uric acid: 7,6SGOT : 42SGPT : 20

TimeSubjectObjectAssessmentPlanning16.00(at VK Teratai)

16.30

20.00

22.30

02/06/1204.30-

-

Dizziness (+)

-

-General statusBP : 170/100 mmHgPR: 90 tpmRR: 24 tpmT: 36,5C

-

General statusGC: wellBP : 150/100 mmHgPR: 88 tpmRR: 24 tpmT: 36,5CUO: 35 cc/hour

Obstetrical statusUC : -FHB : 12.12.13 (148x/minute)

-

--

-

-

-

-Give Nifedipine 1 tab (16.00).

Insertion Misoprostol 25 mcg pervaginam (1st)

Insertion Misoprostol 25 mcg pervaginam (2nd)

Insertion Misoprostol 25 mcg/6 h, pervaginam (3rd)

TimeSubjectObjectAssessmentPlanning06.30

10.30

15.00

16.00

16.50

17.00-

-

-

-

-

-General StatusGC; wellBP: 140/100 mmHgPR: 88 tpmRR: 20 tpmT: 36,5C

Obstetrical StatusUC : +, seldomFHB : 11.12.11 (136/minute)

-

-

General StatusBP: 170/100 mmHgPR: 92 tpmRR: 24 tpmT: 36,5C

-

General StatusBP: 140/80 PR: 80 tpmRR: 22 tpm T: 36,3C-

-

-

-

-

-

Insertion Misoprostol 25 mcg pervaginam (4th)

DM co SPV, advice observation.

DM co SPV, by phone, but no response.Nifedipine 10 mg oral.

DM co SPV, advice: - Rise up the dose of Misoprostol until 50 mcg/6 h, pervaginam. - CIE family.

Insertion Misoprostol 50 mcg pervaginam (1st)

TimeSubjectObjectAssessmentPlanning18.00

19.00

20.00-

-

-General StatusBP: 140/110 mmHgPR: 88x/minuteRR: 22x/minuteT: 36,4C

Obstetrical StatusUC : 2x10 ~ 20FHB : 12.13.12 (148x/minute)

General StatusBP: 150/100 mmHgPR: 120x/minuteRR: 28x/minuteT: 37,2C

Obstetrical StatusUC : 2x10 ~ 20FHB : 11.12.12 (140x/minute)

General StatusBP: 150/100 mmHgPR: 120x/minuteRR: 20x/minuteT: 37,6C

Obstetrical StatusUC : 1x10 ~ 20FHB : 13.12.12 (148x/minute)

G1P0A0L0 P/S/L/IU with eclampsia.

SPV advice CS at 22.00Prepare to CS- CIE family- Skin test, (-), inj. Ampicilline 2 gIV

TimeSubjectObjectAssessmentPlanning23.00

18.00

-

GC : wellBP : 150100 mmHgPR : 98 bpmRR : 28 tpmTemp : 37,2CUC : + UFH : 2 finger below umbilicusActive bleeding : -

Baby in NICU: PR: 140 x/mnt RR: 44x/mntT: 36,5C

2 hours post CS

CS began

Amnion fluid: clear

Baby was born (23.05). Female. 2250 g. AS 7-9. Anus (+). Congenital anomaly (-).

Placenta was born. Manually. Complete. 300gram.

Bleeding 300cc

CIE mother to bed rest.

TimeSubjectObjectAssessmentPlanning03/06/1208.00-

GC : wellBP : 150100 mmHgPR : 118 bpmRR : 22 tpmTemp :37,3 CUC : + UFH : 2 finger below umbilicusActive bleeding : -

Baby in NICU:PR: 148 x/mntRR: 48 x/mntT: 36,3 C1 day post CS- CIE mother to bed rest total.