CASE

• Name : Mrs. M• Age : 41 yo• Address : Lingsar• Admitted: July, 16th 2016• MR : 579556

TIME SUBJECTIVE OBJECTIVE ASSESTMENT PLANNING

16/06/16(18.00)

Patient come to NTB GH referred from Praya GH with G1P0A0H0 A/S/L/IU with Severe Preeclampsia + Hypertiroid + elderly primigravida + Sinus Tachycardia. Patient confessed abdominal pain since 21.00 (15/06/16), Bloody slime (+) since 22.00 (15/06/16), FM (+), water leaked out from her womb (-). PatientPalpitation (+), sweating (-), tremor (-), weakness (-), Defecation and urination in normal range.History of Hypertiroid (+) since 17 yo, HT (+) since 4 year ago, DM (-), asthma (-) allergy (-)History of family (-)

History of medication: PTU and propanolol.History of Allergy: (-)

LMP : 01/09/2015EDD : 06/06/2016GW: 41-42 weeks

ANC history : 8x at PHCLast ANC : 10/06/2016Result : BP 140/70 mmHg, BW: 47kg, UFH: 28 cm, head presentation. USG history : 1x at SPOGLast : 13/03/16Result : G1P0A0 uk. 32 minggu T/H/IU+ hipertiroid + HDK + Primi tua primer

Family planning history :-Plan of family planning: IUD

General status :GC : wellConsciousness : CMBP : 180/110 mmHgPR : 100 bpmRR : 31 rpmT : 36,50C

Local StatusEye : pale (-/-), icteric (-/-), exofthalmus (+)Cor : S1S2 single regular, murmur (-), gallop (-)Pulmo : vesicular (+/+), ronchi (-/-), wheezing (-/-)Abdomen : striae gravidarum (-), scar (-)Extremity : edema (-/-), warm acral (+/+), tremor (-/-)

Obstetrical StatusL1 : breechL2 : back on the right sideL3 : headL4 : 4/5UFH : 31 cmEFW : 3100 gramUC : 2x10’~30”FHR : 11-12-11 (136 bpm)VT : ᴓ 3 cm, eff 25%, amnion (+) head presentation, ↓H1, denominator ROA, not palpable small part & umbilical cord

G1P0A0L0 41-42 weeks S/L/IU head presentation with Cronic Hypertension + Hyperthyroidism + elderly primigravida + inpartu latent phase first stage of labor

DM PlanningDiagnostic• CBC• UL• CTG• HbsAg• ECG• FT4, TSH

Therapy• Observation

progress of labor• Observe mother &

fetal well being• Suggest mother to

eat and drink• Suggest mother to

lay to to the left side.• CIE : CIE mother

and family about planning

• Pro consul interna

DM co to GP, GP co to SPV, advice : • Observation

Progress of labor• Nifedipine 3 x 10

mg

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

Obstetric History:1. Ini

Pelvic ExaminationPromontorium unpalpableSpina ischiadica not prominentOs sacrum convexOs coccygeus mobileArcus pubis > 90

Laboratory (02/05/2016):HB: 13.9 g/dl RBC: 4,86 (10^6/uL)HCT: 41,0 %WBC: 9,17 (10^3/uL)PLT: 293 (10^3/uL)Ureum : 14Cr: 0,6SGOT: 49SGPT: 46HbsAg: non reactive

TIME SUBJECTIVE OBJECTIVE ASSESSMENT PLANNING

16/06/2016 Chronology at Praya GH (16/06/2016)S :Patient referred from Langko PHC with G1P0A0 A/T/H + Hyperthyroid. Patient confess abdominal pain referred to flank since 17.00 (15/06/16). Water leaked out from her womb (-).O :GC : moderateConsciousness : CMBP : 160/100 mmHgPR: 80 bpmRR: 20 tpm

Obstetric statusUFH: 27 cmFHB : 144 bpm

VT : ᴓ 3 cm, eff 50%, amnion (+) head presentation, ↓H II.

A:G1P0A0L0 A/S/L with severe preeclampsia + Hyperthyroid + PTP +synus tachicardy

P:IVFD RL + MgSO4 40% 20 dpmBolus MgSO4 20% 4gr

Time Subject Object Assessment Planning

22.00 Abdominal pain (+++), FM (+)

General statusGC : wellBP : 180/110 mmHgPR: 100 tpmRR: 20 tpmT: 36,5°CUC : 3x10~35”FHB : 11-12-11VT : ᴓ 4 cm, eff 50%, amnion (+) head presentation, ↓H1, denominator ROA, not palpable small part & umbilical cord

Active phase first stage of labor

Observation Progress of labor with WHO partograph

17/06/1602.00

Abdominal pain (++), FM (+)

General statusGC : wellBP : 170/100 mmHgPR: 104 tpmRR: 20 tpmT: 36,5°CUC : 3x10~35”FHB : 12-12-12VT : ᴓ 6 cm, eff 50%, amnion (+) head presentation, ↓H1, denominator ROA, not palpable small part & umbilical cord

Protracted active phase first stage of labor

DM planning:Observation Progress of labor with WHO partograph

DM co to GP, GP co to SPV, SPV advice:Observation, if there is no progress, pro C-section

06.00 Abdominal pain (++), FM (+)

General statusGC : wellBP : 170/90 mmHgPR: 96 tpmRR: 20 tpmT: 36,5°CUC : 3x10~35”FHB : 12-12-12VT : ᴓ 6 cm, eff 50%, amnion (+) head presentation, ↓H1, denominator ROA, not palpable small part & umbilical cord

Arrested active phase first stage of labor

DM Planning:Amniotomy

DM co to GP, GP co to SPV, SPV advice:Pro C section