Supervisor :
dr. Melvin NG Barus, M.Ked(OG), Sp.OG
CC : abdominal contraction
Experienced by the patient since 4 hours ago, and getting more frequent.
History of bloody show (+), since 8 hours ago. History of amniotic fluid
leakage (-). History of hypertension before (-). History of blurred vision (-).
Headache (-). Nausea (-), vomiting (-). Micturition and defecation within
normal limit. This patient was referred from other hospital with diagnose
severe PE + PG + IUP (aterm) + head presentation + alive fetus
History of Pregnancy
1. Current Pregnancy
Present State
Cons : Alert Anemic : (-)
BP : 180/100 mmHg Icteric : (-)
HR : 74 times/min Cyanotic : (-)
RR : 20 times/min Dispnoe : (-)
Temp : 36,7 C Oedem : (-)
Localized state
Head : Anemic palpebra Conjuctiva (-), icteric (-)
Neck : Lymph node enlargement (-)
Cor : S1 > S2, additional sound : (-)
Thorax : Respiratory sound : Vesicular
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
Genitalia : no abnormality
Superior Ext : normal
Inferior Ext : Oedem : (-)/(-)
Obtetrical State
Conclusion:
IUP (36-37) wga + head presentation + alive fetus
LABORATORY FINDINGS on September, 14th ,2017
Hb : 10,3 N: 12-14 gr/dl
Ht : 31 N: 36-42 gr/dl
Leukocyte : 14.300 N:4000-11000/mm3
Platelet : 279.000 N:150000-400000/mm3
adRandom glucose : 64 N : < 200
Ureum : 101 N : > 50 mg/dl
Creatinin : 3,51 N : 0,6-1,2 mg/dl
Natrium : 129 N :135-155
Kalium : 4,2 N : 3.6-5.5
Cloride : 99 N : 96-106
HBsAg : Reactive N : non reactive
Anti HIV : non reactive N : non reactive
Diagnosis : PE with severe features + AKI stadium failure +
Hepatitis B + PG + IUP (36-37) wga + head presentation + alive
fetus
Therapy :
- IVFD RL 20 dpm
- Inj. Cefazoline 2 gr profilaxis
Plan:
- C-section immediately
THANK YOU
PATIENT 2
Mrs. I, 26 y.o, G3P2A0, Bataknese, moslem, Primary school, housewife,
married to Mr. M, 26 y.o, Javanesse, Moslem, Senior high school,
fisherman.
CC : labor contraction
Experienced by the patient since 1 day ago, and getting more frequent.
History of bloody show (+), since 10 hours ago. History of amniotic fluid
leakage (-). Micturition and defecation within normal limit.
Localized state
Head : Anemic palpebra Conjuctiva (-), icteric (-)
Neck : Lymph node enlargement (-)
Cor : S1 > S2, additional sound : (-)
Thorax : Respiratory sound : Vesicular
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
Genitalia : no abnormality
Superior Ext : normal
Inferior Ext : Oedem : (-)/(-)
Obtetrical State
Vaginal exam : cervix axial, dilatation 1 cm, eff 80%, floating breech,
amniotic membrane (+) protruded
Gloves : slime (+), blood (+)
USG TAS
USG TAS
USG TAS
USG TAS
USG TAS
Singleton pregnancy, breech presentation, alive fetus
FHR (+), FM (+)
BPD : 8,15 cm
HC : 28,37 cm
AC : 26,27 cm
FL : 6,24 cm
EFW : 1771 gr
Placenta fundal grade II
Conclusion:
IUP (30-31) wga + breech presentation + alive fetus
LABORATORY FINDINGS on September, 14th ,2017
Hb : 10,6 N: 12-14 gr/dl
Ht : 33 N: 36-42 gr/dl
Leukocyte : 12.310 N:4000-11000/mm3
Platelet : 224.000 N:150000-400000/mm3
adRandom glucose : 85 N : < 200
Ureum : 28 N : > 50 mg/dl
Creatinin : 0,31 N : 0,6-1,2 mg/dl
Natrium : 137 N :135-155
Kalium : 3,6 N : 3.6-5.5
Cloride : 106 N : 96-106
HBsAg : N : non reactive
Anti HIV : N : non reactive
Diagnosis : preterm labor + MG + IUP (30-31) wga + breech
presentation + alive fetus
Therapy :
- IVFD RL 20 dpm
- Inj. Dexamethasone 6 mg/12 hours
- Nifedipine 20 mg (mitral dose) 4x10 mg maintenence
Plan:
- Expectative care
THANK YOU