Case Report

PREECLAMPSIA
Composed by: Marion KACZOREK
Reviewed by : Dr. Andrianes B,
Sp.OG(K)

Clinical Rotation of Obstetric and Gynecology Department

Faculty of Medicine Sebelas Maret University (UNS)/DR. Moewardi
Hospital Surakarta
2016

Preface

Background of the case

For example, you tell the resume of the case topic you have
composed to answer the question e.g currently, why does PROM
become a big problem?

Literature Review

Definition
Preeclampsia is defined as the occurrence of
hypertension and significant proteinuria
in a previously healthy woman on or after
the 20th week of gestation

Etiology/Cause
Known risk factors for preeclampsia
include:

Obesity
Nulliparity(never given birth)
Antiphospholipid antibody
syndrome
Diabetes mellitus
Multiple gestation
Kidney disease
Havingdonated a kidney.
Chronic hypertension
Having
Prior history of preeclampsia
subclinicalhypothyroidism
Family history of preeclampsia
orthyroidantibodies
Advanced maternal age (>35years)
Placental abnormalities such as
placental ischemia.

Pathogenesis and Pathopysiology

Normal pregnancy : placenta vascularizes to allow for
blood flow between the mother and fetus.
Abnormal development of the placenta leads to poor
placental perfusion. Characterized by poor trophoblastic
invasion.
It is thought that this results in oxidative stress, hypoxia,
and the release of factors that promote endothelial
dysfunction, inflammation, and other possible reactions.

Diagnostic Criteria
1. Blood pressure 140mm Hg systolic or 90mm Hg
diastolic on two separate readings taken
2. Proteinuria >0.3 grams (300mg)
And for the preeclampsia who is beginning before 20
weeks gestational age, the diagnostic criteria are: an
increase in systolic blood pressure (SBP) of 30mmHg or
an increase in diastolic blood pressure (DBP) of
15mmHg.

Differential Diagnosis

Chronic hypertension
Gestationel hypertension
Epilepsy
Antiphsopholipid antydbody syndrom
Haemolytic uraemic syndrom
Renal

Comprehensive Management
Purpose of therapy/principle therapy?
Therapy which is suitable?
Current therapy?

Complication

Prognosis/Outcome

Patient Status

Patient Identity

Name
: Sri Handayani
Age
: 36
Gender
: Female
Address
: Gedongan RT/RW 4/5 gedongan
Married status
: Maried
Religion
: Muslim
Entrance date (in hospital) : 01/07/16
Medical Record Number: 01344594

Anamnesis
Main Problem : Come by herself for highblood preasure and feel
some contraction
Current History of illness : tell the chronological story of the pat
Past history of illness

Hypertension (-)
Cardiac Sickness (-)
Diabetes Mellitus (-)
Asthma (-)
Allergy (food/drugs) (-)

Anamnesis
Family history of illness

Hypertension (-)
Cardiac Sickness (-)
Diabetes Mellitus (-)
Asthma (-)
Allergy (food/drugs) (-)

Fertility History : good/bad?

Obstetric History :
Outcome of first pregnancy : (for example) Boy, 3500 gram, Spontan, 10 y.o
Outcome of the second pregnancy: etc

Anamnesis
Menstruation History
Menarche
: age y.o
The length of period : 6-10 days
Menstruation cycle : 28 days

Married Status : once, 15 years (the length of married period)

Contraception history
Last menstruation : 8 november 2015

Physical Exam
General Condition : Good
Compos: Mentis ( Glasgow score : 15 )
Nutritional status: Good
Vital Sign

Blood Pressure : 190/100

Pulse : 76
Respiration rate : 44
Temperature : 37,6

Physical Examination

Eye :
No anemia conjunctive , no icteria
Thorax :
Heart :
Lung :
Abdomen :
Inspection : No scare , no skin pb , no inflammation
Palpation : souple , no mass , no ascite ,

Physical
examination
Genicolo:
Inspection :
Uretrea isnt inflammation
Normal wall vagin
Externe orifice is closed , dilatation 0 , effacement 10% , still
posteriori
No blood no discharge
Palpation :
1. High part of the ftus
2. Back of the ftus : on her left
3. Lower part of the ftus : the head
4. Ftus isnt descendu in the pelvis.

Supportive exam
Blood laboratorium (examination date)

Hemoglobin : 12.3 /dL

INR
: 0.94
Hematocrit
: 36 %
Na+
: 135 mmol/L
Eritrosit
: 3.55 x 103/L
K+
: 4.1 mmol/L
Leukosit
: 7.8 x 103/L
Cl: 106 mmol/L
Trombosit : 48.0 x 103/L
Blood Group : B
PT
: 12 detik
HbsAg: Non-Reactive
APTT
: 30.7 detik
Pregnancy Test: Positive

SGOT
: 36 /L
Albumin : 36 mikro/L
SGPT
: 19 /L
Creatinine
: 19 mikro/L
Ureum
: 26 mg/dl
LDH
: 600 u/L
Qualitative Protein : ++++(4)

Supportive Exam
Ultrasonography (examination date):
one fetus IU elongated
head presentation
fetus heartbeat(+) : 145
Placenta insertion in corpus
Enough amnion fluid.
Fetus condition is good.
No major congenital anomaly.
Estimate weight : 1817 gr

Conclusion

G2-P1-A0
Age pregnancy age in weeks : 34
Good obstetric & fertility history
Vital sign : without anomaly except : 190/100
Abdominal examination: normal
Genital Examination: no
Blood laboratorium :
USG examination:

Diagnosis
Several pre-Eclampsia on second pregmancy , Preterm , no active labor

Prognosis
Ad vitam : dubia
Ad sanam: dubia
Ad fungsionam : dubia

Plan/Therapy
To keep the pregmancy :
Kehomilan
Pre-Eclampsia:
O2
Mg 20 % 1gr / min
Nifedipine : 3 X 10 mg if her blood preasure > 160/110
For the baby :
Dexamethasone

Patient Follow Up
Follow the patient condition as written in medical record until the
patient goes home

Merci de votre attention !!