[Chief Complaint]
Pregnancy in 39th week with pregnancy induced hypertension and/or
pre-eclampsia
[Past History]
1. systemic disease: pre-eclampsia
2. previous Op history: kidney transplantation (donor), July 2004
3. drug or food allergy & previous pregnant history: negative
[Present Pregnancy History and Menstrual History]
G1P0
Menarche: 12-year-old MC Interval/Duration: 30/7
LMP: 18 January 2005 EDC: 25 October 2005
Prenatal condition: pregnancy induced hypertension, preeclampsia
[Present Illness]
A 29-year-old woman, G1P0 is pregnant for 39 weeks. Because of high blood
pressure and regular uterine contraction, she was admitted for NSD. Elevated
blood pressure () and proteinuria (?300 mg/dL) was noted at 37th week.
[Physical Examination]
Consciousness: alert & oriented; clear
Vital sign: TPR 36.2/88/19, BP 160/100 mmHg
HEENT: grossly normal, conjunctiva: not pale, sclera: anicteric; pupils:
isocoric, light reflex: +/+; throat: not injected
Neck: supple, no LAP, no JVE, no goiter;
Chest: symmetric expansion, breathing sound: clear
Heart: regular heart beat; no audible murmur;
Abdomen: ovoid, bowel sound: normoactive
Extremities: freely movable, no cyanosis, no edema, no petechiae
[Obstetrical Findings]
OS: close
Station: high
Effacement: poor
Presentation: vertex
Rupture of membrane: negative
Uterine contraction: +
Vaginal bleeding: negative
[Sonography]
BPD:9 cm AC:33.6 cm FL:6.94 cm EBW:3080 gm
Placenta: post. wall grade II~III
[Laboratory Data]
18 October 2005 Tuesday 03:00 AM
WBC 8.98K/μL, Hb: 10.2 g/dL PT 10.2 sec, (INR: 0.86); aPTT 31.0
BUN 22.7; Cre 1.3
[Impression]
Pregnancy at 39th gestational week with PIH, preeclampsia
[Management]
Admission routine, preparation for NSD
Adalat 1# if BP > 160/110 mmHg prn SL
Apresoline (10 mg) 2# q6h PO
Ulex 1# q6h PO
[Clinical course]
Patient came to NTUH ER at 11:31 pm of 10/17 (Monday) and was then sent to
the delivery room. At that time, there was no cervical dilatation and
station was high. Blood pressure was around 160/100 mmHg, and proteinuria
was ?300 mg/dL. Four hours later, cervical dilatation was 4cm and station
was 0 cm. After another four hours, cervical dilatation was full and station
was +1. (Please refer to the partogram). CS was performed at 12:00 noon of
10/18 (12 hours after transfer to delivery room) because station remained at
0~+1 at second stage of labor for 2hr 20min (failure of descent). Post-op
vital signs and urine output were stable. She was discharged 5 days later.
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