Eklampsi Antepartum Hellp Syndrom + DIC + Icteric

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    Case No. 47

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    Identity

    Name : Mrs. S

    Age : 25 years old

    MR No. : 83 77 71

    Address : South Solok

    Date : Augst 11st, 2013

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    Anamnesis :

    A 25 years old patient was admitted to theDelivery 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

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    Present Illness History: (from husband history)

    She got her first seizure 8 hours ago while she was athome, she had a headache before. She got seizure forabout 1 minute, whole body, she was conscious afterthat. 30 minutes latter she got the second seizure andthen go to South Solok District Hospital, in emergencyroom, the nurse checked her blood pressure, it was

    200/110.In emergency room distric hospital she hadseizure for the third time. She wasnt conscious afterseizure. Than she referred to RSMJ with MgSO4regiment (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

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    Amenorrhea since 7,5 months ago.

    First date of LMP: Forgotten, approximately onJanuari 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.

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    Previous Illness History :

    There wasnt previous history of heart, lung, liver, kidney, DM andhypertension and no drugs allergic. No hystory of previous seizurebefore she get pregnant.

    Family Illness History :

    There wasnt history of hereditary disease, contagious and physicologicalillness 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 monthbirth

    3. Present

    History of family planning : none

    History of immunization : none

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    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 seemPalpation: 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 : sonorAuscultation : vesiculer, Rh-/-, wh-/-

    Abdoment : OR

    Genitalia : OR

    Extremity : Edema +/+, Patellar Reflex / achiles rf +/+ normal, Pathological

    Reflex -/-

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    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

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    Ultrasonography

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    Laboratory (11/8/13 ):

    Hb : 14.1 gr/dl 9.515.0

    Leucocyte : 21,300/mm3 (5.916.9)x103

    Hematocrit : 39 % 28.040.0

    Trombocyte : 50,000/mm3 146429 x 103

    APTT : 45.7 22.635.0PT : 15.6 9.6

    12.9

    INR : 1.3 0.801.09

    SGOT : 733u/l 432

    SGPT : 235u/l 225

    Random blood sugar : 115 mg% 74-106

    Ureum : 54 mg% 15.0-40.0

    Creatinin : 0.9 mg % 0.6-1.2

    Kalium : 3,6 mEq/L 3.5-5.1

    Chloride : 104 mg/dl 97-111

    Natrium : 134 mEq/L 139-145Calcium : 8.7 mg/dL 8.29.7

    Albumin : 2,9 g/dL 2.34.2

    LDH : 8652u/l

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    Urinalysis

    Protein : (++) negatif

    Glucose : (-) negatif

    Leukocytes : 12-15/LPB 0-5

    Erythrocyte : >500 0-1

    Cylinder : difficult to assessed negatif

    Crystal : difficult to assessed negatif

    Epithelial : (+) flat (+) flat Bilirubin : (-) negatif

    Urobilinogen : (+) positif

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    D/ decreased of consciousness at G 3P 2A 0L 1preterm pregnancy 28-30 weeks + antepartum eclampsy under SM regiment maintenancedose from outside + HELLP syndrom

    Fetal alive, singleton, intra uterine, head presentation HI

    Management :

    Control GA, VS, FHS, urine, patella reflex, fluid balance

    Continue MgSO4maintainance 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 consultantacc report to high risk consultant

    report to high risk consultantstabilitation in ICU

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    Ophthalmologist result

    At present theres no sign of eclamptic fundus onophthalmologic examination, eclamptic fundus KW 1

    Therapy according to ObgynCardiology result

    Emergency Hypertension

    Perdipine drip start from 0.5, until MAP target 118 perhours.

    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

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    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

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    At 03.30 pm arrived in ICU

    PE (monitor) :

    GA Cons BP PR RR T Sat Urine

    Worse Sopor 162/92 108 24(binasal) 37 98% 500cc (reddis color)

    Abd/gen: HIS (-), DJJ 130I : 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 + antepartumeclampsia in MgSO4 regiment maintenance dose from outside + HELLP Syndrome, fetal alive

    Th/

    Control GA, VS, FHS, urine, patella reflex, fluid balance

    Continue MgSO4maintainance 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

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    Laboratory in icu

    Hb : 15 g/dl

    HT : 42 %

    Leuco : 22,200 /mm3Tromb : 25,000 /mm3

    HbsAg : -

    Calcium : 8,5 mg/dlTotal Prot : 6,2 g/dl

    Alb : 2,8 g/dl

    Glob : 3,4

    SGOT : 659SGPT : 215

    U/Cr : 67/0,6

    D-Dimer : 3,0 mg/dl

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    parameter

    pH 7,4

    pCO2 33 mmHg

    pO2 217 mmHg

    Na+ 133 mmol/L

    K+ 3,5 mmol/L

    Ca++ 0,89 mmol/L

    Hct 44 % / 37

    Temp-Corrected 36 C / 37

    pH(T) 7,41

    pCO2(T) 32 mmHgpO2(T) 212 mmHg

    Ca++ (7,4) 0,89 mmol/L

    HCO3- 20,4 mmol/L

    HCO3std 22,2 mmol/L

    parameter

    TCO2 21,4 mmol/L

    BEecf -4,4 mmol/L

    BE (B) - 3,6 mmol/L

    602c 100 %

    THbc 13,6 g/dL

    THb 10,2 g/dL

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    At 07.30 pm

    PE (monitor) :

    GA Cons BP PR RR T sat Urine

    Worse Sopor 178/101 94 24(binasal) 37 99% 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

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    At 09.30 pm

    PE (monitor) :

    GA Cons BP PR RR T sat : 100%

    Worse Sopor 182/98 90 24(binasal) 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 + HELLPSyndrome, fetal alive

    Th/

    Acceleration drip

    Transfusion 5 unit trombocyte

    Plan : termination

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    11.30 pm 01.30 am 02.30 am 03.30 am 05.30 am 07.30 am

    PE-

    BP/PR/RR

    (168/88)-

    102-

    24

    (172/92)-

    92-

    21

    (164/94)-

    100-

    22

    (188/101)-

    104-

    26

    (162/92)-

    88-

    23

    (161/84)-

    93-

    22

    Abd

    UC/FHS

    (+/s/w)

    100-115

    (+/20/mdt)

    70-80

    (+/20/mdt)

    70-80

    02.45 : 62-70

    03.00 : 58-60

    03.15 : 40

    (+/20/mdt)

    FHS (-)

    (+/35/mdt) (+/50/s)

    Gen 2,

    eff 60-

    70%,

    2,

    Eff 70-

    80%,

    2-3

    Eff 80-90%,

    2-3

    Amniotic

    sac (-),

    head HII-III

    3-4

    Amniotic

    sac (-),

    head HII-III

    4-5

    Amniotic

    sac (-),

    head HII-III

    Th/ Continue

    accelerati

    on drip

    Continue

    acceleratio

    n drip

    Continue

    acceleration

    drip

    Continue

    acceleratio

    n drip

    Trombocyt

    e transf 5

    unit

    F ll U A 12nd 2013

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    Follow Up Augst 12nd, 2013

    Time PE Abd/Gen Therapy/Plan

    09.25 am GA : moderate, Cons :

    somnolen, BP : 168/92, PR:

    98, RR: 24 (binasal), T : 37,1

    HIS : 3-4x/45/s,

    I : v/u normal,

    VT : head wascrowning opened the

    vulva

    Th/Continue

    P/ vaginal

    delivery withkristeller

    ekspression

    At 09.30 amA 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

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    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

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    August, 12

    Gastrohepatology Department

    Kolestasis extrahepatal ec ca caput pankreas Ad/ SNMC in D5% drip per 18 hours

    UDCA 3x1

    livercare 3x1sistenol 3x500 mg

    Check hepar function

    Hypertension-kidney Department Hypertension stg III

    Continue therapy

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    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 SyndromeTh/ 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

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    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.

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    parameter August 12 (am/pm) August 13

    Hb 10,6 / 10,2 7,5

    HT 29 % /29 % 21,2

    Leucocyte 23,200/ 28.000 13,300

    Trombocyte 32.000 / 32.000 133,000

    MCH 30 pg

    MCV 86 m3

    MCHC 35 g/dL

    APTT 43,5 sec 45,1

    PT 13,3 sec 12

    INR 1,2 INR 1,2

    LDH 4.722 1741

    Total Protein 5,6 g/dL 4,7

    Albumin 2,8 g/dL 2,6

    Globulin 2,8 g/dL 2,1

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    parameter August 12 August 13

    Total Bilirubin 17,01 mg/dL 4,5

    Bilirubin Direct 15,3 mg/dL 3,58

    Bilirubin Indirect 1,17 mg/dL 0,9

    SGOT 134 61

    SGPT 229 80

    Ureum 89 101

    Creatinin 1,4 2

    THb 10,6 g/dL

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    parameter August 12 August 13

    pH 7,44 / 7,49 7,56

    pCO2 30 mmHg / 32 31

    pO2 162 mmHg / 117 163

    Na+ 137 mmol/L / 134 138

    K+ 3,5 mmol/L / 3,7 3,6

    Ca++ 0,52 mmol/L / 0,85 0,61

    Hct 43 % / 37

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    parameter August 12 August 13

    TCO2 21,3 mmol/L / 25,4 28,8

    BEecf -3,8 mmol/L / 1,1 5,6

    BE (B) - 2,7 mmol/L / 1,5 5,8

    602c 100 % / 99 100

    THbc 13,3 g/dL / 11,5

    THb 10,2 g/dL

    D-dimer 2,4

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    August, 14 07.00 am

    a/fever (-), vaginal bleeding (-)

    PE/GA Cons BP PR RR T sat : 99%

    Mdt Somn 152/85 72 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 injDexamethason 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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    Thank You