EMERGENCY ROOM REPORT

Friday, July 12th 2019

Friday, July 05th – Thursday, July 11th 2019

Chief on duty :
Dr. Fitrah Tindar Atthaariq

Supervisor :
Dr. H. Iskandar Zulqarnain, OBGYN(C)
 Recapitulation Emergency Room
Friday, July 05th – Thursday, July 11th 2019
Obstetrics Physiology 0 Patient
Patient
Pathology 6 Patient
Patient
Gynecology 2 Patients

Total Patient 8 Patients

 RECAPITULATION
Friday, July 05th – Thursday, July 11th 2019

DATE OBSTETRICS GYNECOLOGY TOTAL

Friday, Jun 05th 2019 1 1 2

Monday, Jul 08th 2019 2 0 2

Tuesday, Jul 09th 2019 2 0 2

Wednesday, Jul 10th 2019 1 1 2

Thursday, Jul 11st 2019

Total 6 2
 RECAPITULATION
Friday, July 05th – Thursday, July 11th 2019

Procedural AMOUNT %

Vaginal Delivery 1

LSCS 2
Medicinalis 5
Laceration repair
TOTAL
 EMERGENCY ROOM REPORT
Friday, July 05th – Thursday, July 11th 2019
OBSTETRICS
NO IDENTITY DIAGNOSIS ICD 10 TREATMENT ICD 9 LAST DIAGNOSIS CONDITION RES/
CON
G1P0A0 37 weeks gestational age in MUG
• Vital sign observation, FHR
Mrs. JUN / labor with history of circlage + primary P1A0 post LSCS oi FTA
1. O42.2 • Lab examination 669.7 discharge
863829 / 34 YO infertile 7 years SLF cephalic anhydramnios AW
• LSCS
presentation
G3P2A0 38 weeks gestational age in MUG
Mrs. NUR / 38 labor active phase with severe P3A0 post spontaneous FTA
2. O42.2 • Spontaneus delivery 669.7 discharge
YO / 1130153 preeclampsia + prior CS 2x SLF delivery AB
cephalic presentation
G1P0A0 36 weeks gestational MUG
G1P0A0 36 weeks gestational age not
• Vital sign observation, FHR age not in labor with FTA
Mrs. RAM / 26 in labor with threatened preterm labor Stable in
3. O60.00 • Bedrest Z74.01 threatened preterm labor SLF FU
YO / 1126399 SLF cephalic presentation – cephalic ward
• Medicinalis cephalic presentation –
presentation
cephalic presentation
G2P1A0 36 weeks gestational ARM
G2P1A0 36 weeks gestational age not in • Expectactive management age not in labor with prior CS FTA
labor with prior CS 1x (o.i multiple O60.10 • Observation of Vital sign, 642.7 1x (o.i multiple congenital AB
Mrs. NEN / 31 Stable in
4. congenital anomaly) SLF cephalic O14.13 uterine contraction, FHR 650 anomaly) SLF cephalic
YO / UA / AB ward
presentation + multiple congenital O34.21 • Lung Maturation 669.5 presentation + multiple
anomaly + hydramnios • P/ US Confirmation congenital anomaly +
hydramnios
G1P0A0 42 weks gestational age not in ARM
P1A0 post LSCS o.i
Mrs. DIA / 37 labor SLF cephalic presentation with Stable in FTA
5. O60.0 • LSCS 74.1 anhydramnios
YO / RA / PB anhydramnios + umbilical cord ward PB
strangulation 1x
 EMERGENCY ROOM REPORT
Friday, July 05th – Thursday, July 11th 2019
OBSTETRICS
NO IDENTITY DIAGNOSIS ICD 10 TREATMENT ICD 9 LAST DIAGNOSIS CONDITION RES/
CON
• Expectactive management G1P0A0 33 weeks gestational ARM
G1P0A0 33 weeks gestational age not • Observation of Vital sign, age not in labor with severe FTA
in labor with severe preeclampsia SLF O60.10 uterine contraction, FHR 642.7
Mrs. PRA / 38 preeclampsia SLF cephalic Stable in AB
6 cephalic presentation with baby tend O14.13 • Lung Maturation 650
YO / UA / AB • Anticonvulsant 669.5 presentation with baby ward
to be small + multiple congenital O34.2
• Antihypertension tend to be small + multiple
anomalies
congenital anomalies
 EMERGENCY ROOM REPORT
Friday, July 05th – Thursday, July 11th 2019
GYNECOLOGY
NO IDENTITY DIAGNOSIS ICD 10 PROCEDURE ICD 9 LAST DIAGNOSIS CONDITION RES/
CON
• Vital sign observation G1P0A0 6 weeks gestatinal discharge MUG
Mrs. HER / G1P0A0 6 weeks gestational age with FTA
1 O02.1 • Medicinalis Z74.01 age with history of
836821 / 30 YO threatened abortion RS
• Bed rest threatened abortion
• Expectactive management G4P0A3 9 weeks gestational Stable in ARM
• Observation of Vital sign, age with abortus imminens ward FTA
Bleeding + recurrent pregnancy loss HI
G4P0A3 9 weeks gestational age with • Bed Rest SLF intrauterine
642.7
Mrs. DAH / 32 O09.91 • Cygest supp 400 mcg/24
2 abortus imminens + recurrent 650
YO / UA / HI Z86.2 hours
pregnancy loss SLF intrauterine 669.5
• Folic acid 400 mcg/24 hours
• Consult to internal
departement
• US Confirmation
OBSTETRICS
Identity Mrs. JUN/ 34 yo/ UA/ AW July 5th 2019 03.30 PM
Chief complaint Inlabor Aterm pregnancy , post circlage
History 3 hours before admitted to Moh Hoesin hospital, patient complained her abdominal contraction spreading to waist and back regularly (+)
history of bloody show (+), history of amniotic leakage (+) , history of leucorrhea (-), history of toothache (-), history of post-coital (-), history
of drugs (-), history of trauma(-), history of fever (-).
She admitted that her pregnancy was aterm and can feel fetal movement
Marital status 1x, 7 years
Reproduction status Menarche since 12 yo, irregular cycle, last 5 days, LMP: 1.10.18
Obstetric history 1. Current pregnancy
Past iIlness history History of cerclage on March 2019 at RSMH
Physical Examination BP: 120/70mmHg, Pulse : 80 x/m, T: 36.2oC, RR: 20 x/m, BW: 67kg, BH: 152cm
Obstetrical Palpation: Uterine fundal height was 3 fingers below proc xyphoideous (32cm), longitudinal lie, left fetal spine, head, U 4/5, contraction
examination 2x/10’/25’’, FHR: 156bpm, EFW 2945g
Inspeculo: portio was livide, OUE with cerclage, fluor (+), fluxus (+) not active amniotic fluid (-), clear, smelly (-) nitrazine test (+), E/L/P (-)
VT: Portio soft, anterior, eff 100 %, Ꝋ 1 cm, head, HI, amniotic membrane (-), clear, smelly (-) and denominator transvere sagitalis suture
US ER (FTA) - SLF cephalic presentation
- BPD: 9.63cm HC: 32.67cm AC: 33.59 cm FL: 7.31cm TCD : 5,3 ~ 37W5D. EFW: 3269g
- Placenta on posterior uterine corpus
- Amnionic fluid minimal
- C/ 37 weeks gestational age SLF cephalic presentation + anhydramnios
Diagnose G1P0A0 37 weeks gestational age inlabor 1st stage latent phase with PROM 8 hour + post cerclage SLF cephalic presentation + anhydramnios

Therapy •Observation of vital signs, contraction, FHR

•Laboratory examination
•Plan for cerclage removing
Identity Mrs. JUN/ 34 yo/ UA/ AW
Diagnose G1P0A0 37 weeks gestational age inlabor 1st stage latent phase with PROM 8 hour + post cerclage SLF cephalic presentation +
anhydramnios
Therapy •Observation of vital signs, contraction, FHR
•Laboratory examination
•Plan for cerclage removing
Follow Up A/ G1P0A0 37 weeks gestational age inlabor 1st stage latent phase with PROM 8 hour + post cerclage SLF cephalic presentation +
04.00 PM anhydramnios
P/ Plan for abdominal delivery
Laboratory Hb: 11.7 g/dL, WBC: 11.550/mm3, PLT: 237.000/mm3
examination
Intraoperative 05.15 PM Removing the cerclage
05.28 PM Male live baby was born with BW 2900g, BL 49cm, A/S 9/10 FTAGA
05.30 PM Placenta was delivered compeletely with PW 510g, UCL 49cm, Ꝋ 18x19cm
Follow Up A/ P1A0 post SSTP o.i Anhydramnion
BP: 120/80mmHg P/ Observation of vital signs, contraction
IVFD RL+ oxytocin 20 IU xx drops/minute
Ceftriaxone 1 gr/12 hour
Ketorolac 30 mg/ 8 hour
Tranexamic acid 500mg/8 hour
Laboratory Hb: 11.2 g/dL, WBC: 23.860/mm3, PLT: 257.000/mm3
examination
Post op
Recent condition Stable in ward
 Identity Mrs. NUR / 38 YO / 1130153 / AB
09:30 AM Aterm inlabor with prior CS 2x and hypertension
Chief complain
History 5 hours before admission, patient complained bloody show (+), abdominal contraction (+), amniotic leakage (-). History of : hypertension
before pregnancy (-), hypertension prior pregnancy (-), hypertension in this pregnancy (-), family had hypertension (-), blur vision (-),
epigstrial pain (-), nausea vomit (-), headache (-). Patient admitted that her pregnancy was aterm and she has felt fetal movement.
Marital status 1x, 6 years
Reproduction status Menarche 14 years old, regular menstrual cycles 28 days, for 5 days, LMP : 15/10/18
Obstetric history 1. 2014, aterm, male, 2500 g, CS oi total placenta previa,Myria Hosipital, healthy
2. 2016, aterm, male, 2800 g, CS oi total placenta previa, Bunda Hospital, healthy
3. This pregnancy
Physical examination BP : 160/110 mmHg, P : 88 x/min, T : 36.5 C, RR : 20 x/min, Height 150 cm, Weight 65 kg, IG 7
Obstetrical Inspection & Palpation : Fundal height was 3 fingers below proc. Xypoideus (25 cm), left longitudinal lie, head, U 4/5, His 2x/10’/25”, FHR:
examination 130 x/m, EFW : 2015 g
VT: Portio was soft, posterior, eff 75%, ⌀ 5cm, head, HII, amniotic membrane (+) and denominator transversal` sagittal suture
Lab Examination Hb: 12.0, wbc 13.600, trombosit 272.000, Ht 37, SGOT 30, SGPT 5, LDH 512, UR 13, CR 0,30, Proteinuria +3
Diagnosis G3P2A0 38 weeks gestational age inlabor 1st stage active phase with severe preeclampsia + prior CS 2x SLF cephalic presentation
US ER (FTA) - Single life fetus cephalic presentation
- Fetal Biometry: BPD 8,0 cm AC 26.02 cm EFW 1781 g
HC 32.97 cm FL 6.40 cm
- Placenta at anterior corpus
- Amniotic fluid insuficient, SP :1,81 cm
C/ 32 weeks gestational age SLF cephalic presentation with IUGR was suspected + oligohydramnios
Therapy • IVFD RL gtt xx/m
• Stablitation 1-3 hours
• Inj MgSo4 ~ protocol
• Nifedipine 10 mg/8 hours PO
• P/ LSCS
 Identity Mrs. NUR / 38 YO / 1130153 / AB

Follow up Inspection: Uterine fundus height 4 fingers below proc xypoideus (24 cm) , longitudinal lie, left back, head presentation U 5/5 uterine
07/07/2019 contraction (4/10/40), FHR 136x/minute,
12.30 PM VT : Portio Soft, anterior, Eff 100 % , ∅ 10 cm, head, Hodge III+, amniotic membran (-) and denominator Left anterior occiput
BP:140/100 mmHg G3P2A0 38 weeks gestational age inlabor 2nd swith severe preeclampsia +prior CS 2xcephalic presentation
Pulse:86 x/minute Obs vital sign,FHR
RR: 21 x/minute Plan for vaginal delivery
T: 36.5oC
IG 5
Delivery Report 12:50 PM : Male life baby, Weight 2100 g, Height 44 cm, A/S 5/7 FTSGA
06-07-2019 12:55 PM : complete placenta, PW 450 g, UC 45 cm, Ø 17 x 18 cm
Recent Diagnose P3A0 post spontaneous delivery with severe preeclampsia + prior CS 2x
Identity Mrs. RAM / 26 YO / 1126399 FU
Chief complaint Preterm pregnancy with threatened preterm labor
History ± 1 day before admission, patient complained of contraction (+) still rarely, history of amniotic leakage (-), H/ bloody show (-), H/ trauma (-),
07.07.19 H/ abdominal massage (-), H/ leucorrhea (+), H/ post coital (-), H/ tootache (-). She admitted that her pregnancy was preterm and fetal
(10.30 AM) movement (+).
Marital status 1x, 1 years
Reproduction status Menarche since 14 yo, regular cycle 28 days, 7 days, LMP: 11/10/2019
Obstetric history 1. Current pregnancy
Physical Examination BP:120/80 mmHg Pulse: 88 x/minute RR: 20 x/minute T: 36.5oC
Obstetrical Inspection: Uterine fundus 2 finger bellow proc. xypoideous (39 cm), longitudinal lie – longitudinal lie,cephalic presentation – cephalic
Examination presentation, U 5/5, uterine contraction 1x/10’/10”, FHR 1 150 x/mnt FHR 2 142 x/mnt
Inspeculo: portio livide, OUE closed, flour (+), whitish color, fluxus (-), E/L/P (-)
US CONFIRMATION - TLF life fetus cephalic presentation – cephalic presentation
(AB) - Fetal Biometry A: BPD 8,41 cm AC 28.0 cm EFW 2064 g
HC 30.26 cm FL 6.94 cm
- Fetal Biometry A: BPD 8,73 cm AC 30.62 cm EFW 2311 g
HC 29.65cm FL 6.38 cm
- Placenta at anterior corpus
- Cervical length 1.20 cm
- Amniotic fluid suficient
C/ 36 weeks gestational age TLF cephalic presentation – cephalic presentation (USG serial)
Cervical length 1.20 cm
Lab examination Hb: 11.5, PLT: 276.800, WBC: 8.860, Ht: 33%, CRP kuantatif 10
Diagnosis G1P0A0 36 weeks gestational age not in labor with threatened preterm labor SLF cephalic presentation – cephalic presentation
Therapy • Conservative management
• Observation of vital signs, contraction, FHR
• Laboratory examination
• IVFD RL xx drops/minute
 Identity Mrs. NEN / 31 YO / UA / AB
11.00 AM Preterm pregnancy with multiple congenital anomaly
Chief complain
History Patient was referred from OBGYN with diagnosis : G2P1A0 37 weeks gestational age not in labor with prior CS 1x (o.i multiple congenital
anomaly) SLF cephalic presentation multiple congenital anomaly. History of abdominal contraction (-). history of bloody show (-). History of
amniotic leakage (-). History of fever (-), history of leucorrhea (-), history of trauma (-), history of toothache (-).
Patient admitted her pregnancy was aterm and fetal movement (+).
Marital status 1x, 4 year
Reproduction status Menarche since 14 yo, regular cycle 28 days, for 5 days, LMP : October 23rd 2018
Obstetric history 1. 2017, male, CS o.i congenital anomaly healthy 21 days and then death
Physical examination BP : 120/70 mmHg, P : 82 x/min, T : 36.9 C, RR : 20 x/min, Weight : 67 kg, Height : 153 cm
Obstetrical Palpation : Fundal height was in 3 fingers below proc. xyphoideus (31 cm), leff longitudinal lie, head, U 5/5, His (-), FHR: 140x/m, EFW :
examination 2790 g
VT: Portio was soft, posterior, eff 0%, Ø closed OUE, head, floating, amniotic membrane and denominator can not be assessed yet
US ER (FTA) - Single life fetus cephalic presentation
- Fetal Biometry: BPD 9.19 cm AC 35.09 cm
HC 32.68 cm FL 5,32 cm EFW : 2872 g
- Short femur : 5,32 cm
- Placenta at anterior corpus of the uterine
- Amniotic fluid lots, AFI 6,14 7,17 = 25,92 cm
5,75 6,87
C/ 36 weeks gestational age SLF cephalic presentation + hydramnios
Laboratory Hb: 10,01 g/dl, wbc 8500/ mm3, trombosit 223.000/mm3, Ht 32%, toxoplasma ig G 0.10, toxoplasma ig m 0.04, rubella ig G 15.70, rubella
examination ig M 0.19, CMV ig G 220.40, CMV ig M 0.12
Diagnosis G2P1A0 36 weeks gestational age not in labor with prior CS 1x (o.i multiple congenital anomaly) SLF cephalic presentation + multiple
congenital anomaly + hydramnios
Identity Mrs. NEN / 31 YO / UA / AB
Therapy • Expectactive management
• Observation of Vital sign, uterine contraction, FHR
• Lung Maturation
• P/ US Confirmation
Follow up • Stable in ward
 Identity Mrs. DIA / 37 YO / RA / PB
11.50 AM Posterm pregnancy
Chief complain
History Patient was referred from makarti jaya public health with diagnosis : G1P0A0 42 weks gestational age not in labor SLF cephalic presentation
with anhydramnios. History of abdominal contraction (-). history of bloody show (-). History of amniotic leakage (-). History of fever (-),
history of leucorrhea (-), history of trauma (-), history of toothache (-).
Patient admitted her pregnancy was posterm and fetal movement (+).
Marital status 1x, 1 year
Reproduction status Menarche since 12 yo, regular cycle 28 days, for 7 days, LMP : September 18th 2018
Obstetric history 1. This pregnancy
Physical examination BP : 110/80 mmHg, P : 80 x/min, T : 36.8 C, RR : 22 x/min, Weight : 84 kg, Height : 158 cm
Obstetrical Palpation : Fundal height was in 3 fingers below proc. xyphoideus (36 cm), leff longitudinal lie, head, U 5/5, His (-), FHR: 142x/m, EFW : 3565
examination g
VT: Portio was soft, posterior, eff 0 %, Ø closed OUE, head floating, amniotic membrane and denominator can not be assessed yet
Bishop score 2
US ER (FTA) - Single life fetus cephalic presentation
- Fetal Biometry: BPD 9.79 cm AC 33.64 cm
HC 34.47 cm FL 8.08 cm EFW : 3667 g
- Placenta at anterior corpus of the uterine
- Amniotic fluid decreased, AFI 0.0 0.00
= 0.00 cm
0.0 0.0

C/ 40 weeks gestational age SLF cephalic presentation + Anhydramnios

Laboratory Hb: 13.1 g/dl, wbc : 12.500/ mm3, trombosit : 248.000/mm3, Ht : 39 %, PT : 12.4, APTT : 29.3, BSS : 60, Proteinuria : (+) 1
examination
Diagnose G1P0A0 42 weks gestational age not in labor SLF cephalic presentation with anhydramnios + umbilical cord strangulation 1x
Therapy • LSCS
 Identity Mrs. DIA / 37 YO / RA / PB
Follow up S : Posterm Pregnancy
O : BP : 190/110 mmHg, P : 80 x/min, T : 36.8 C, RR : 22 x/min, Weight : 84 kg, Height : 158 cm
Palpation : Fundal height was in 3 fingers below proc. xyphoideus (36 cm), leff longitudinal lie, head, U 5/5, His (-), FHR: 142x/m,
EFW : 3565 g
VT: Portio was soft, posterior, eff 0 %, Ø closed OUE, head floating, amniotic membrane and denominator can not be assessed yet
A : G1P0A0 42 weks gestational age not in labor SLF cephalic presentation with severe preeclampsia + anhydramnios + umbilical cord
strangulation 1x
P : LSCS

Operating report At 06.12 PM male life baby was born, BW 3700 g, BL 50 cm A/S 7/8 FTAGA.
At 06.17 PM placenta was delivered completely, PW 600 g, UCL 49 cm, diameter 20x21 cm
Recent diagnose P1A0 post LSCS o.i anhydramnios
Follow up Stable in ward
 Identity Mrs. PRA / 38 YO / UA / AB
10-07-2019 at 02.00 Preterm pregnancy with hypertension and multiple congenital anomaly
PM
Chief complain
History Patient was referred from polyclinic fetomaternal obgyn mohammad hoesin hospital with diagnosis :G1P0A0 33 weeks gestational age not in
labor with severe preeclampsia SLF cephalic presentation with baby tend to be small + multiple congenital anomaly (HLHS).History of :
hypertension before pregnancy (-), hypertension in this pregnancy (+), family had hypertension (-), blur vision (-), epigstrial pain (-), nausea
vomit (-), headache (- History of abdominal contraction (-). history of bloody show (-). History of amniotic leakage (-). History of fever (-),
history of leucorrhea (-), history of trauma (-), history of toothache (-).
Patient admitted her pregnancy was preterm and fetal movement (+).
Marital status 1x, 2 years
Reproduction status Menarche since 16 yo, regular cycle 28 days, for 5 days, LMP : Desember 15th 2018
Obstetric history 1. Current pregnancy
Physical examination BP : 160/100 mmHg, P : 82 x/min, T : 36.9 C, RR : 20 x/min, Weight : 58 kg, Height : 150 cm
Obstetrical Palpation : Fundal height was in 4 fingers below proc. xyphoideus (28 cm), left longitudinal lie, head, U 5/5, His (-), FHR: 143x/m, EFW :
examination 2325 g
Laboratory Hb: 11,0 g/dL, WBC: 13.580/mm3, PLT: 276.000/mm3, Proteinuria (-)
examination HBsAg (Non reactive), Anti HIV (Non reactive), TPHA (Non reactive), VDRL (Non reactive)
 Identity Mrs. PRA / 38 YO / UA / AB
US Confirmation • SLF cephalic presentation
(10.07.2019) • Fetal biometry
Dr. Abarham BPD: 7.85 cm AC: 26.63 cm EFW: 1641 g
Martadiansyah, SpOG HC: 29.81 cm FL: 5.73 cm. CD : 4.0 ~ 32 W 1 D
(K) • Head structure : Ventriculomegaly
• Thorax Structure : Aortic stenosis, TR valv (+) N
• Abdominal Structure : within normal limit
• PI : 0.79, PI MCA : 1.94, CPR>1
• DV A Wave (+) N
• Amniotic Fluid : sufficient AFI (8.46 cm)
• Placenta implantation at anterior corpus
C/ 33 weeks gestational age SLF Cephalic presentation
Fetus tends to be small
There is multiple anatomical anomaly, (HLHS)
Diagnosis G1P0A0 33 weeks gestational age not in labor with severe preeclampsia SLF cephalic presentation with baby tend to be small + multiple
congenital anomaly (HLHS)
Therapy • Expectactive management
• Observation of Vital sign, uterine contraction, FHR
• Lung Maturation
• Anticonvulsant
• Antihypertension
Internal departement A : Gestational hypertension
P : Methyldopa tablet 250 mg/8 hours
Follow up • Stable in ward
GYNECOLOGY
 Identity Mrs. HER / 836821 / 30 YO / RS
Chief complaint Vaginal bleeding
History 2 days before admission, patient complained vaginal bleeding but only spotting, history tissue discharge such as chicken liver (-), history
tissue discharge such as fish eye (-), abdominal contraction (-), nausea vomitting (-), history breast tense (+), history of trauma (-), post coital
(-).
Marital status 1x, 5 mounth
Reproduction status Menarche 13 yo, regular cycles 28 days, for 5 days, LMP : 24-05-2019
Obstetric history 1. This pregnancy.
Physical examination BP : 130/70 mmHg, P : 88 x/min, T : 36.0 C, RR : 20 x/min, Weight 58 kg, Height 158 cm
Gynecology Inspection & Palpation :
examination Abdomen flat,symmetric,no tense, Fundal height unpalpable, mass (-), tenderness (-),free fluid sign (-).
Inspeculo : Livide portio, OUE closed, fluor (-), fluxus (+) blood not active, E/L/P (-)
VT : Soft portio, OUE closed, CUT  normal, right & left AP no tense, no bulging of cavum Douglas
US ER (FTA) GS (+) intrauterine  6 weeks
Yolk sac (+)
C/ 6 weeks gestational age intrauterine
Laboratory examination Hb: 12,83 g/dl, wbc 9.300/ mm3, trombosit 315.000/mm3, Ht 39%, PT test (+)
Diagnosis G1P0A0 6 weeks gestational age with threatened abortion
Therapy Obs Vital sign & bleeding
Progesteron 400 ug/24 hours supp
Folic acid 400 mcg/24 hours
Bed rest
P/ US confirmation
 Identity Mrs. DAH / 32 YO / UA / HI
02.30 PM Early pregnancy with spotting
Chief complaint
History 3 hours before admission, patient complained vaginal bleeding but only spotting, history tissue discharge such as chicken liver (-), history
tissue discharge such as fish eye (-), abdominal contraction (-), nausea vomitting (-), history breast tense (+), history of trauma (-), post
coital (-).
Marital status 1x, 10 years
Reproduction status Menarche since 14 yo, irregular, LMP : may 5th 2019
Obstetric history 1. 2009, miscarriage, 5 month of pregnancy, not curatage.
2. 2017, miscarriage, 6 month of pregnancy, curratage, Mohammad Hoesin Hospital.
3. 2018, miscarriage, 6 month of pregnancy, curratage, Charitas Hospital.
4. Current pregnancy
Physical examination BP : 100/60 mmHg, P : 78 x/min, RR : 20 x/min, T : 36.3 C, BW: 70 kg, BH: 163 cm
Gynecology Inspection & Palpation :
examination Simetris, flat, mass (-),supple (+), fundal heigh not palpable, sign of free fluid (-), tenderness (-).
Inspeculo :
Portio livide, OUE closed, fluor (+) yellowish white, fluxus (+) blood not active, E/L/P (-)
US ER (FTA) • Gestasional sac (+)
(10.07.2019) • CRL : 1,89 cm ~ 8W3D
• Yolk sac (+) 0.5 cm
• FHR : 172 x/m
• C/ 8 weeks gestational age, intrauterine
Diagnosis G4P0A3 9 weeks gestational age with abortus imminens + recurrent pregnancy loss SLF intrauterine
Therapy • Expectactive management
• Observation of Vital sign, Bleeding
• Bed Rest
• Cygest supp 400 mcg/24 hours
• Folic acid 400 mcg/24 hours