Morning Report 11 June 2023 - PPROM PREEKLAMPSIA.pptx

morning report

1. Morning Report Sunday , June 1 1 th , 2023 Reported on Monday, May 12 th , 2023

2. PATIENT IDENTITY Name : Mrs. M Age : 3 5 years old Date of Birth : 0 2 - 01- 198 8 Address : Semarang Admission : S unday , 1 1 th June 2023 Occupation : Housewife Unit : Obstetri

3. PROBLEMS NO Active Problems DATE No Passive Problem DATE 1. G 2 P 1 A0 3 5 years old, with 40 weeks and 2 days of pregnancy 1 1 /06/2023 2. Single live intrauterine fetus, cephalic presentation, fetal back on the left side, engaged 3. Second stage of labour 4. Premature Rupture of Membrane 10 hours ago 5 Severe P reeclampsia 6. Class II Obesity (BMI 36.2 kg/m 2 )

4. Clinical History Date / Hour : June 1 1 th, 2023 / 1 9.52 WIB Chief complaint : Early leakage of amniotic fluid History of Present Illness: A 3 5 years old female with 40 weeks and 2 days of pregnancy was referred from RSUD Sunan Kalijaga to RSUP dr. Kariadi Emergency Room with a chief complaint of preterm rupture of the membrane and continuous leakage of the clear amniotic fluid for the past 10 hours. Additionally, the patient was also diagnosed with severe preeclampsia since 26 weeks of gestation and oedema of the portio during the labour process. She was given MgSO4 intravenously and ceftriaxone before the referral. She experienced strong contractions and presence of bloody mucus. The fetal movement was active. She denied any symptoms like headaches, nausea, vomiting, blurred vision or epigastric pain. The patient had been regularly taking iron (Fe), calcium, vitamin B6, B12 prior to admission. Patient had no history of leucorrhea, abdominal trauma, post coitus, fever, cough, cold, and sore throat. Patient had no history of travelling in the past 2 weeks and had no contact with COVID-19 confirmed patient.

5. Referral Letter

6. COVID-19 Status Result : Unrelated to COVID-19

7. Maternal and Child Handbook

8. Maternal and Child Handbook

9. Maternal and Child Handbook

10. Maternal and Child Handbook

11. Obstetric History : G 2 P 1 A0 No Gender Method of Delivery Gestational age Birth Weight Birth Attendant Child’s current age Complications 1. Male Vacuum delivery weeks 36 00 gr Sp.OG 8 years old Prolonged Labour 2 . C urrent pregnancy History of Menstruation : LMP: 2 nd September 2022 EDD: 9 th June 2023 History of Marriage : 1x ~ 10 years History of ANC : Sp.OG 3x, Midwife > 3 x History of Contraception : Denied History of Past Illness : HT(+) since this pregnancy , Asthma (-), DM (-), cardiac diseases (-), allergy (-) History of Family Illness : Asthma (-), HT (-), DM (-), cardiac diseases (-), allergy (-) History of Allergy : Denied History of Surgery : Denied Socioeconomic condition : Payment were covered by BPJS NON PBI

12. Physical Examination Date/ Hour : June 1 1 , 2023/ 1 9 . 52 WIB General Status Current condition : Good Consciousness : Compos mentis, GCS E4M6V5 BP : 1 50 / 10 0 mmHg HR : 94 bpm, regular RR : 20x/min Temperature : 36,5 o C SpO2 : 99% room air BW : 95 kg BW before pregnancy : 87 kg Height : 155 cm BMI : 36 . 2 kg/m 2 (Class II Obesity ) Internal Condition Head : Facial edema (-), Mesocephal Mouth : Cyanosis (-), Paleness (-) Eyes : Anemic conjunctiva (-/-), Icteric sclera (-/-) Nose : Discharge (-/-) Ear : Discharge (-/-) Skin : Turgor (<2”) Lymph Node : Enlargement (-)

13. Heart Inspection : Ictus cordis was not visible Palpation : Ictus cordis was palpable on SIC V 2 cm lateral LMCS, strong lift (-), thrill (-) Percussion : Heart configuration was within normal limit Auskultasi : Pure I-II heart sound, murmur (-), gallop (-) Lungs Inspection : Chest wall movement was symmetrical during static and dynamic Palpation : Stem fremitus felt symmetrically along both sides of the chest Percussion : Sonour all right and left lung fields Auscultation : Vesicular base sound (+/ +), ronchi (-/-), wheezing (-/-) Abdomen Inspection : Bulging longitudinally Auscultation : Bowel sound (+) Normal Palpation : Pain (-) Extremities : Edema Hypothermic acral - - - - - - - -

14. Obstetric Status Leopold I - IV : single live intrauterine fetus, cephalic presentation, fetal back on the left side, engaged Fundal Height : 3 2 cm ~ 3255 gr His : 3- 4' ( 35 ") Vaginal Discharge : bloody mucous Fetal Heart Rate : 153 bpm, regular VT : Complete cervical dilatation, amniotic sac ( - ), lowest fetal part at Hodge III+

15. USG RSUD SUNAN KALIJAGA 08 /06/2023 Single live intrauterine fetus, cephalic presentation, fetal back on the left side, FM (+) FHM (+) FHR (+) 1 46 BPM AVG/EFW BPD : 9.2 cm ~ 37w3d AC : 33.5 c m ~ 3 7 w 4 d EFW : 3206 gr Placenta implanted on the fundus, expanding to the corpus posterior, doesn`t reach the lower segment, grade I, calcification (+) Liq. amnii clear, SDP 2.91 cm Umbilicalis Doppler Ri: 0,71 (between 5-50th percentile) Pi: 1,24 (between 5-50th percentile)

16. USG RSUD SUNAN KALIJAGA 08/06/2023

17. USG RSUD SUNAN KALIJAGA 08/06/2023

18. Laboratory RSU D Sunan Kalijaga Demak (1 1 /06/2023) Inspection Result 1 1 /0 6 /2023 Unit Reference Haematology Haemoglobin 11. 6 g/dL 11.7-15.5 Haematocrit 26 . 7 % 32-62 Leucocytes 1 2 . 5 10^3/uL 3.6-11 Thrombocytes 311 10^3/Ul 150-400 Erythrocytes 4. 28 10^6/uL 4.4-5.9 Neutrofil 90.4 % 50 - 70 Limfosit 7.1 % 25 - 40 Monosit 2.2 % 2-8 Eosinofil 0.1 % 2-4 Basofil 0.2 % - 1

19. Laboratory RSU D Sunan Kalijaga Demak (1 1 /06/2023) Inspection Result 1 1 /0 6 /2023 Unit Reference Haematology MCH 27.1 pg 26-34 MCHC 31.6 % 22-36 MCV 85.7 fL 80-100 RDW 17.6 % 1 1.5 - 14.5 MPV 10.6 fL 6 . 6 - 10.0 PDW 11.3 fL 10.0-18.0 HFLC 0.1 Gol. Darah A INR 1 .0 detik APTT 40 .2 detik 28.4-44.6 PT 13 .0 detik 11.7-15.1

20. Laboratory RSU D Sunan Kalijaga Demak (1 1 /06/2023) Inspection Result 1 1 /0 6 /2023 Unit Reference Haematology Calcium 9.08 mg/dL 8.1 - 10.4 Ureum 19.6 mg/dL 0 - 40 Creatinine 0.5 mg/dL 0.5 - 1.2 SGOT 29 U/L <37 SGPT 17 U/L 9 - 43 Magnesium 1.9 mg/dL 1.9 - 2.5

21. Laboratory RSUD Sunan Kalijaga Demak (11/06/2023) Inspection Result 11/06 /2023 Unit Reference Secretion-Excretion Complete Urine + Analyzer Color Yellow - Yellow Clarity Clear - Clear pH 6 - Negative Protein +1 - Negative Glucose +1 - Negative

22. Laboratory RSUD Sunan Kalijaga Demak (11/06/2023) Inspection Result 18/05/2023 Unit Reference SARS-CoV-2 Antigen Negative Negative Reduction +1 Negative Blood glucose stick 161 mg/dL 70-115 HBsAg Non-reactive Non-reactive

23. Laboratory RSU D Sunan Kalijaga Demak (1 1 /06/2023) Inspection Result 1 1 /0 6 /2023 Unit Reference Electrolyte Na 139,66 mEq /L 135- 1 4 5 K 4 mEq/L 3. 5 - 5.3 Cl 107,7 mEq/L 100-106

24. DIAGNOSIS G 2 P 1 A0 3 5 years old, with 40 weeks and 2 days of pregnancy Single live intrauterine fetus, cephalic presentation, fetal back on the left side, engaged Second stage of labour Premature Rupture of Membrane 10 hours ago Severe Preeclampsia Obese

25. PLAN IpDx S : - O : - IpTx Leading to push when the mother felt adequate contraction Planned vaginal delivery with assisted second stage using vacuum extraction Empty the bladder Consultation with perinatology IVFD RL 20gtt IVSP MgSO4 1gr/hour maintenance PO : Nifedipine 10mg/ 8hour Dopamet 500mg/ 8hour Erythromycin 500mg/ 6hour IpMx Monitoring of 9 and signs of impending preeclampsia Ip Ex Provide an explanation to the patient and family regarding the patient's diagnosis Provide an explanation and informed consent to the patient and family regarding the action to be taken Provide an explanation to the patient and family regarding signs of labour and report to doctors/nurses on duty if it was found

26. PARTOGRAPH

27. Delivery Report Date/Hour Follow Up Uterine contraction FHR Information 1 1 /06/2023 20.35 GC : good, composmentis BP: 1 40 / 95 mmHg HR : 88 x/min, reguler T : 36.5 C Spo2 : 98% on NK 3lpm S : after delivery O : Internal Status : Anemic Conjungtiva (-/-), Icteric Sclera (-/-) Heart, lungs, and abdomen within normal values Obstetric Status : Fundal Height : 2 fingers below the umbilicus, adequate contraction Breastmilk -/- PPV : lochea rubra Urination : (-) Defecation : (-) Female Baby Born at 19.56, weight 3600 gr, length 51cm, AS 8/9/10 grade 2 perineal laceration, subcuticular suture was performed A : P2A0 35 years old Post vacuum extraction ec severe preeclampsia Post perineal repair ec grade 2 perineal laceration Severe preeclampsia Obesity

28. Delivery Report Date/Hour Follow Up Uterine contraction FHR Information 1 1 /06/2023 20.35 GC : good, composmentis BP: 1 40 / 95 mmHg HR : 88 x/min, reguler T : 36.5 C Spo2 : 98% on NK 3lpm P : VK 3rd class IVFD RL 20gtt + oxytocin 10IU IVSP MgSO4 1gr/hour maintenance until 24 hour post partum DC PO : Nifedipin 10mg/ 8hour Dopamet 500mg/ 8hour Erythromycin 500mg/ 6hour Vit BC/C/SF 1tab/ 12hour Vit A 200.000 IU/ 24hour for 2 days Observe condition, vital sign, PPV, Fundal height, Breastmilk, Urination, Defecation

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