WEEKLY REPORT

July 30th – August 07th 2015

OBSTETRICS & GYNECOLOGY DEPARTMENT

AIRLANGGA UNIVERSITY HOSPITAL
 Weekly Report Supervisors:

Prof. Dr. Erry Gumillar Dachlan, dr., Sp.OG (K)

Young Doctors:

Ali Akbar Hasan Al buyani

Astry ayunda
Nurul ‘Izzati Binti Abdul Fatah
Aminuddin Aziz
Arina Salsabila

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Number of Deliveries:

10

4 6
Vaginal Abdominal
Deliveries Deliveries
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 LIST OF DELIVERIES (Physiologic)
Patient Mode of Outcome of
Date Diagnosis
ID Delivery Baby
1 23rd
July
Mrs.T/
25 y.o
GIIP1001 40/41weeks SLIU
+ head presentation + post
Spontaneous
delivery + IUD ♂ / 3072 g /
50 cm / AS 8-9
2015 date + oligohidramnion (AFI
/ NA
6.3) + History of cesarian
section+ EFW 3000 g
2 24th Mrs. R/ GIIP1001 36/37 weeks SLIU Spontaneous ♂ / 2800 g / 50
July 37 y.o. + head presentation + delivery cm / AS 8-9 / NA
2015 Partus Prematurus
Imminens + EFW 2500 g
3 25th
July
Mrs. N/
36 y.o.
GIP0000 38/39 weeks SLIU
+ head presentation + latent
Spontaneous
delivery ♂ / 2866 g /
49 cm / AS 8-9
2015 phase + pre eclampsia +
/ NA
obesity gr II + elderly primi +
EFW 3100 g

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 LIST OF DELIVERIES (Physiologic)
Patient Mode of De Outcome
Date Diagnosis
ID livery of Baby
4 27th
July
Mrs.A /
26 y.o
GIP0000 37/38weeks SLIU + Spontaneous
head presentation + PROM < 12 delivery
♀ / 3250
g / 49 cm
2015 hours+ EFW 3000 g
/ AS 8-9 /
NA

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 LIST OF DELIVERIES (Pathologic)
Patient Mode of Outcome
Date Diagnosis
ID Delivery of Baby
1 24th Mrs. S / GIIP1001 40/41 weeks SLIU + SC ♀ / 3316g
July 28 y.o head presentation + history of (Indication: / 51 cm /
2015 cesarian section + youngest history of AS 8-9 /
cesarian
child < 5 y.o. + post date + EFW NA
section + post
3100g date)
2 27th Mrs. ES / GIIP0010 39/40 weeks SLIU + SC
(Indication:
♂/
July 37 y.o Breech presentation + age> 35 2866gr /
2015 y.o + bad obstetric history + total placenta
previa + 49 cm /
total placenta previa + EFW AS 6-8 /
breech
3300 g presentation) NA
3 27th Mrs. SH/ GIIP1001 41/42 weeks SLIU + SC ♀/
July 26 y.o head presentation + post date + (Indication: 3134gr /
2015 history of cesarian section + oligohidramn 50 cm /
oligohidramnion (AFI 6.0) + ion + history AS 8 - 9 /
EFW 3000 g of cesarian NA
section)
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LIST OF DELIVERIES (Pathologic)
Patient Mode of De Outcome
Date Diagnosis
ID livery of Baby
4 27th Mrs. D/ GIVP3003 38/39 weeks SLIU + SC + ♀/
July 35 y.o Head presentation + Sec. elderly Sterilization ( 2829gr /
2015 primi + age > 35 y.o. + scoliosis Indication: 49 cm /
+ LBP + EFW 2500 g scoliosis + AS 8-9 /
LBP) NA
5 28th Mrs. NK/ GIIP1001 39/40 weeks SLIU + SC ♀ / 3554g
July 27 y.o. Head presentation + eclampsia (Indication: / 49cm/
2015 + fetal distress + lung edema + fetal distress AS 3-5-7 /
EFW 3000 g + eclampsia NA
+ lung
edema)
6 29th Mrs. EK/ GIP0000 41/42 weeks SLIU + SC ♂ / 3374g
July 28 y.o. Head presentation + post date + (Indication: / 49cm /
2015 LH  mild contracted pelvic + post date + AS 8-9 /
Oligohidramnion (AFI 6.3) + Oligohidram NA
EFW 3200 g nion)
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LIST OF GYNECOLOGIC PROCEDURE

No. Adm. Date Patient ID Diagnosis Intervention

1. 28th July 2015 Mrs. NK / 27 P2002 + Post Sc + Cito SC

y.o IUD Day 7 + Fetal
Distress + Lung Edem
+ Eclampsia +

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 PATIENT’S IDENTITY

Name : Mrs. NK
Age : 27 y.o
Nation : Javanese / Indonesia
Education : Senior High School
Occupation : House wife
Marital Status: Married
Address : Surabaya
Admitted : 28th July 2015

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 CHIEF COMPLAINT
“Loss of Consciousness ”

She was brought to Emergency department in Airlangga University

Hospital with a chief complaint of loss of consciousness since 30 minutes
before came to the hospital. Before that, the patient had Seizure 2 times
Characterized by stiffening of the hands and tongue biting. Each seizure
lasted for 5 minutes and between the two seizures, the patient was
unconscious. The patient had never experience seizure before.
2 days ago, the patient complained of headache. The patient has
experienced edema of the body during 9 months of pregnancy. The
patient has never experienced dyspneu before. There is no stiffness of
neck.

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 MENSTRUAL HISTORY

Menarche : 11 y.o.
Duration : 10 days
Cycle length : 30 days, regular
Dysmenorhea : +, during period
Last Menstrual Period : 27 – 05 -2014
Amount of Menstrual Blood : As usual ( she used 2 sanitary
napkins a day)

No history of fluor

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 MARITAL STATUS

She has married once, for 8 years. She has 1 children who is 7
years old.

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 OBSTETRIC HISTORY
History of Pregnancy :
1st : 9 month/ Spontaneous delivery /Midwife/ Boy/3600g/7 years old
2nd : This pregnancy

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 FAMILY PLANNING HISTORY

Contraception:
- She used oral contraception for one year after she delivered the first child.
- Currently, she uses IUD (day 9)

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PATIENT’S HISTORY OF DISEASE

- No Hypertension
- No Diabetes
- No Allergic

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 FAMILY’S HISTORY OF DISEASE

- Her mother has Hypertension

-No Diabetes
-No Allergy

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 PHYSICAL EXAMINATION
General Status
Conciousness : loss of conciousness, GCS 1-1-4
Vital Sign :
- BP : 220/130 mmHg - HR : 155 x/minute
- RR : 30 x/minute - Temp : 37 0C
Height : 155 cm
Weight : 90 kg BMI : 37,5

Head and neck : a- / i- / c- / d-

Thorax : symetric, retraction -/-
- Cor : S1, S2 single murmur-, gallop-
- Pulmo: vesikuler/vesikuler, rhonki -/-, wheezing -/-
Abdomen : bowel sound (+) normal, H/L inpalpable
Extremities : Perfusion red dry and warm, CRT < 2”, edema -/-

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 Obstetric Status

UFH : 3 fingers under umbilical

Uterin Contraction : positive
v/v : Fluxus -, Fluor –

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 Additional Examination

HEAD CT SCAN

Conclusion :
- Ischemic lession of cortical-subcortical area of left parietal
lobe. This support eclamptic brain.
- No intracranial hemorrhage.

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 DIAGNOSIS

P2002 + Post Sc + IUD Day 9 + Fetal Distress +

Lung Edem + Eclampsia

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 PLANNING
Diagnosis : - consult Neuro
- consult opthalmology
- consult Cardiology
- EEG

Therapy :
1. Methyldopa 3x250mg
2. Furosemide inj. 1x1ampule
3. Spironolacton 25mg-0-0
4. Diazepam 1 amp i.v (duirng seizure)

Monitoring :
1. Vital sign
2. Complain
3. Bleeding
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TIMELINE

July 27th 2015

9.00 am vaginal bleeding, brownish red, watery
went to midwife. USG and prescribed medicine to
strengthen the uterus
6.00 pm vaginal bleeding, brownish red, watery

July 28th 2015

Vaginal bleeding, brownish red, watery, the amount has increased

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July 29th 2015

12.00 pm Vaginal bleeding with blood clots, abdominal pain

03.00 pm went to emergency room Airlangga University
S: vaginal bleeding with blood clots, abdominal pain
O: BP : 130/80 mmHg - HR : 105 x/minute
RR : 20 x/minute - Temp : 36,5 0C
VT: Vulva/vagina : Fluxus + fluor -
Portio : opened, tissue palpated, shake pain -
Cavum Uteri : Anteflexed, slightly enlarged
Adnexa Parametrium: No palpable mass, no pain
Cavum Douglas : No abnormalities
Inspeculo : Fluxus + Fluor –
portio opened, tissue +
A: GIIIP3003 10/11 weeks + incomplete abortion

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Planning:
Dx: IV Line, laboratorium checked
Tx: Curetage PA
Inj Oxytocin 2 ampules
Inj Cefazolin 2g IV
Mx: Vital Sign
Complain

05.30-06.00 pm
Curettage PA with general anesthesia

07.00 pm
Moved to ward
S: -
O: TD : 120/80 mmHg N:84x/m RR: 20 t: 36,5 C
A: P3013 post curetage
P: Bed Rest
RL 500 cc IV

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THANK YOU