OBSTETRIC INPATIENT REPORT

Friday, February 17th 2017 Thursday, February 23th 2017

Chief on duty :
Dr. Robby Prawira Sulbahri

Supervisor :
Dr. H. Nuswil Bernolian. OBGYN (C)
Physiological Patients : 4 Patients
Pathological Patients : 15 Patients
Total : 19 Patients

PROCEDURE AMOUNT %
LSCS 6 40
Spontaneous delivery 5 33,3
Spontaneous Bracht 1 6,6
Conservative 2 13,3
Management
Expectative 1 6,6
Management

TOTAL 15 100
 RECAPITULATION OBSTETRIC PATIENT Friday, February 17 th 2017
Thursday, February 23th 2017
No. DIAGNOSIS AMOUN % PROCEDURE AMOUN %
T T
1. Anhydramnios 2 13, LSCS 2 13,
3 3
2. Placenta preave 1 6,6 Expectative 1 6,6

Spontaneous 2
3. PROM 2 13,3 13,3
delivery
4. Preterm Pregnancy 1 6,6 Spontaneous delivery 1 6,6

5. Severe Preeclampsia 2 13,3 Spontaneous Delivery 2 13,3

6. Fetal Distress 3 20 LSCS 3 20

7. Treatened Preterm Labor 2 13,3 Conservative 2 13,3
8. CPD 1 6,6 LSCS 1 6,6
9. Impending Eclampsia 1 6,6 Spontaneous Delivery 1 6,6
TOTAL 15 100 TOTAL 15 100
 OBSTETRIC PATIENT IN WARD Friday, February 17th 2017
Thursday, February 23th 2017
DATE DIAGNOSIS AMOUN % PROCEDURE AMOUN %
T T
Anhydramnios 1 9 LSCS 1 9
17-02- Placenta preave 1 9 Expectative 1 9
2017
PROM 1 9 Spontaneous Delivery 1 9
PROM 1 9 Spontaneous Delivery 1 9
Preterm pregnancy 1 9 Spontaneous Delivery 1 9
18-02-
2017
Severe Preeclampsia 2 18,1 Spontaneous Delivery 2 18,1
19-02-
2017 Fetal distress 1 9 LSCS 1 9

20-02- Fetal distress 1 LSCS 1

2017 9 9

21-02- Treatened Preterm 1 9 Conservative 1 9

2017 Labor
22-02- Anhydramnios 1 9 LSCS 1 9
2017
TOTAL 11 100 TOTAL 11 100
Obstetric Patient in Ward Report Friday,
February 17th
th 2017
Identitiy Diagnosis ICD 10 Proced ICD Present Physici
ure 9 status an

1. Mrs. P1A0 post LSCS cb O14.1 LSCS 082 Dischar JPO

WEL/27/ RA anhydramnios with severe 3 ge
preeclampsia + history of +
ROM 12 hours O41.8
9+
O42.0
13
2. Mrs. G2P1A0 31 weeks Dischar DAN
LEN/38/ UA gestational age with APH O44.3 Expecta ge
c.b. marginal placental 3+ tive
praeve + prior CS 1x + Z98.8 manag
mild anemia SLF cephalic 9+ ement
presentation O99.0
3. Mrs. P3A0 post spontaneous 042 + Sponta 650 Dischar DAN
Mei /25/ UA delivery with history of O99.0 neous ge
ROM 14 hours Deliver
y
 Obstetric Patient in Ward Report
Saturday,
NO Identity
February
Diagnosis
18 th 2017
th
ICD Procedure ICD Prese Physi
10 9 nt cian
Statu
s
1. Mrs. P1A0 post spontaneous O42. Spontaneo 650 discha DRI
MUT/22/ UA delivery with history of ROM 10 us delivery rge
20 hours
2. Mrs. P2A1 post spontaneous O60 Spontaneo 644 discha DRI
ROY/34/UA preterm delivery us preterm .2 rge
delivery
Obstetric Patient in Ward Report Sunday
February 19th
th 2017
N Identity Diagnosis ICD Procedu ICD Prese Physi
o 10 re 9 nt cian
statu
s
1. Mrs. P3A0 post spontaneous Discha SIY
SUS/35/UA delivery with severe Spontaneo rged
O90. Z38.
preeclampsia us delivery
3 00
Tubectomy

2. Mrs. P2A0 post LSCS cb fetal Discha ALH

SIT/28/UA distress O76 LSCS 082 rged

3. Mrs. P3A0 post spontaneous dischar SIY

ASP/38/UA delivery with severe Spontaneo ged
O14. Z38.
preeclampsia us delivery
1 00
Tubectomy
Obstetric Patient in Ward Report
Monday February 20th 2017
No Identity Diagnosis ICD Procedure IC Prese Physic
. 10 D9 nt ian
status
1 Mrs. P2A0 post LSCS cb fetal 080. LSCS 08 dischar JPO
KAR/ 31/UA distress 0 2 ge
076.
3
Obstetric Patient in Ward Report
Tuesday February 21st 2017
N Identity Diagnosis ICD Procedur IC Prese Physic
o. 10 e D nt ian
9 status
1 Mrs. G3P2A0 31 weeks Z3A. Conservative Stable in DRI
SRI/28/UA gestational with 30+ management ward
threatened preterm 641.
labor SLF cephalic 03
presentation
Obstetric Patient in Ward Report
Wednesday February 22nd 2017
N Identity Diagnosis ICD Proce ICD Prese Physic
o. 10 dure 9 nt ian
status
1. Mrs. P1A1 post LSCS cb. LSCS 082 Stable in ROB
ADE/ 26/ UA anhydramnios O42 + IUD ward
O41.0
 DELIVERY ROOM
Friday, February 17th 2017 Thursday, February 23th 2017
DATE DIAGNOSIS AMOU % PROCEDURE AMOUN %
NT T

17-02-17 Fetal Distress 1 25 LSCS 1 25

20-02-17 Treatened Preterm Labor 1 25 Conservative 1 25

21-02-17 CPD 1 25 LSCS 1 25

22-02-17 Impending Eclampsia 1 25 Spontaeous 1 25

Delivery

TOTAL 4 100% TOTAL 4 100%

Delivery Room Report Friday
February 17th 2017
No Identity Diagnosis ICD Procedur ICD Presen Physici
. 10 e 9 t an
status

1. Mrs. P1A0 post LSCS cb fetal O76 LSCS 082 dischar ALH
WAH/21/UA distress + Anhydramnios ge
Delivery Room Report
Monday February 20th 2017
No Identity Diagnosis ICD Procedure ICD Presen Physi
10 9 t cian
status

1. Mrs. G1P0A0 30 weeks of Conservative Stable DRI

PIT/17/U gestational with threatened O47. cerclage In ward
A 0
preterm labour SLF breech
presentation
Delivery Room Report
Tuesday, February 21st 2017
No Identity Diagnosis ICD Procedure ICD Present Physic
10 9 status ian

1. Mrs. P1A0 post LSCS cb CPD O42. - LSCS 669 Stable in ALH
FIR/30/UA 02 ward
O62.
0

Delivery Room Report
Wednesday, February 22nd
nd 2017

No Identity Diagnosis ICD 10 Procedure ICD Present Physic

9 status ian

1. Mrs. P6A0 Post Spontaneous Spontaneo 651 Stable in SIY

KAR/40/RA delivery with impending O36.4 us delivery ward
O15.9 Tubectomy
eclampsia + partial
O14.2
HELLP Syndrome

Obstetric Patients in
Ward
 B
Identity Mrs. WEL/ 27 y.o/ RA A
C
Hospitalized : 17-01-2017, 07.30 PM K
Chief complaint Inlabor with hypertension, preterm pregnancy, & amnion leakage
History + 2 hours before admited to the hospital, patient complain about
contraction (+). Bloody show (+) amnion leakage (+). Patient go to
midwife and said that she is in inlabor stase with hypertension so
patient refered to Ogan Ilir hospital. Because of operation room was
not complete, patient refered again to RSMH.
History of hypertension in this pregnancy (+) history of hypertension
in family (-) nausea& vomitting (-), cephalgia (-), epigastric pain (-).
Patient says that she has preterm pregnancy & baby was active
Marital status 1x, 9 month
Reproduction Menarche since 15 yo, regular cycle 30 days, 5 days.
status LMP : 21.05.2017
Obstetric history 1. This pregnancy
Past iIlness (-)
history
Vital Sign BP 170/110 Pulse : 84x/m T: 36.5 RR: 20x/m
Obstetrical Palpation:
examination Fundal height 4 finger below proc. Xypoideus (24 cm),
IG 6 longitudinal, right back, head, 4/5, contractions 2x/10/25,
FHR: 145x/m, EFW : 2945 g
VT: Portio was soft, posterior, eff 100%, 3 cm, head, HI-II, amnion
(+)& denominator transverse sutura sagitalis
 B
A
C
K
Identity Mrs. WEL/ 27 y. o/ RA
US ER (NSR) SLF cephalic presentation
Fetal biometri:
BPD 8.42 cm AC 22.20 cm EFW1669 gram
HC 28.69 cm FL 5.89 cm
Placenta at fundus
Minimal amnion, AFI: 0.34
C/ 34 weeks gestational age SLF cephalic presentation +
anhydramnios
Laboratorium Hb 11.1 g/dL
WBC 13.200
Trombocyte 171.000
LDH 511
SGOT/ SGPT 21/ 7
Proteinuria (++)
Diagnosis G1P0A0 34 weeks gestational age inlabor 1st stage latent
phase with severe preeclampsia + PPROM 12 hours SLF
cephalic presentation + anhydramnios
 B
Identity Mrs. WEL/ 27 y. o/ RA A
C
Management Stabilisation 1-3 hours K

Vital sign, FHR, contraction observation

IVFD RL xx drops/ minute
Laboratorium examination
Consult to Internal Departement, Opthalmology Departement
Catheter urine
Inj. MgSo4 protocol
Nifedipine 10 mg/ 8 hours per oral
Inj. Ceftriaxone 1 gram/ 12 hours IV
Inj. Dexamethasone 12 mg IV
Plan for abdominal delivery
10.30PM
Vital Sign BP 160/90 Pulse : 82x/m T: 36.5 RR: 20x/m
IG 5
18.02.2017
00.10 AM Male life baby was born BW 1700 gram BL 43 cm A/S 8/9 PTAGA
Laboratorium Hb 9.9 g/dL WBC 15.700 Ht 30% Trombocyte 180.000 LDH 524
21-02-17 P1A0 post LSCS o.i. anhydramnion +severe preeclampsia
P/ cefadroxil 500mg/12 hours PO
Paracetamol 500mg/8 hours PO
Metyldopa 250mg/8 hours PO
Patient was discharged
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A
20 C
K

Photo Bayi
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A
21 C
K
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A
23 C
K
 B
A
24 C
K

Balad skor
 B
A
Identity Mrs. LEN/38 y. o/ UA C
K
Hospitalized : 17-02-17, 11.30 PM
Chief complaint Preterm pregnancy with bleeding from vagina
History + 3 hours before admited to the hospital, patient complain about
bleeding from vagina. 1x changes pad. History of contraction (+),
History of amnion leakage (-). Patient has been also in RSMH 1
month ago at RSMH with the same main complain. (January 2017).
Patient says that she has preterm pregnancy and fetal movement
was active.
Marital status 1x, 15 years
Reproduction Menarche since 15 yo, regular cycle 28 days, 7 days.
status LMP : 15.08.2016
Obstetric history 1. 2002, female, preterm, 2400 gram, LSCS, Pusri Hospital, healthy
2. This pregnancy
Past iIlness H/ admitted at RSMH, January 2017 with APH c.b marginal placental
history praeve
Vital Sign BP 120/80 Pulse : 84x/m T: 36.5 RR: 20x/m
Obstetrical Palpation:
examination Fundal height 2 finger below proc. Xypoideus (24 cm),
longitudinal, rightback, head, 4/5, contractions (-) FHR:
IT 3 145x/m
Inspeculo: Portio was livide, closed OUE, fluor (-), fluxus (+)
bleeding not active
 B
A
C
Identity Mrs. LEN/38 y. o/ UA K

US ER (NSR) SLF cephalic presentation

Fetal biometri:
BPD 8.16 cm AC 25.96 cm EFW1669 gram
HC 28.48 cm FL 6.27 cm
Placenta at corpus posterior, spread until OUI border margin
Enough amniotic fluid, SP 2.1 cm
C/ 31 weeks gestational age SLF cephalic presentation + marginal
placenta prave
Laboratorium Hb 9.1 g/dL
RBC 3.290.000
WBC 10.400
Ht 28%
Trombocyte 344.000
Diagnosis G2P1A0 31 weeks gestational age with APH c.b. marginal
placental praeve + priot CS 1x+ mild anemia SLF cephalic
presentation
Management Observation of vital sign, bleeding, contraction, FHR
Expectative management
IVFD RL 20 drops/ minute
Laboratorium examination
Inj. Dexamethason 6 mg/ 12 hours IV (had been done at
RSMH 23 January 2017
Nifedipine 10 mg/ 6 hours per oral
 B
A
C
K

US confirmation C/ 34 weeks gestational age SLF cephalic presentation + cervical

20-02-2017 length 2,32 + placenta prevea marginalis

21-02-2017 G2P1A0 31 weeks gestational age with APH c.b. marginal

placental praeve + priot CS 1x+ mild anemia SLF cephalic
presentation
P/Nifedipine 10 mg/ 6 hours per oral

Patient was discharged

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A
C
K

US
 B
Identity Mrs. MEI/25/RA A
C
Hospitalized : 17-02-17, 10.00 AM K
Chief complaint Aterm pregnancy and amniotic leakage (+)
History + 12 hours before admited to the hospital patient complain about
amniotic leakage (+) clear, odor (-) 2x changes pad. contraction (+)
bloody show (+). History of trauma (-) leukorea (+) postcoital (-)
Patient stated that she has aterm pregnancy with fetal movement
(+)
Marital status 1x, 1 years
Reproduction Menarche since 12 yo, regular cycle 28 days, 5 days.
status LMP : forget
Obstetric history 1. 2011, female, 2900 g, aterm, spontaneous delivery, midwife
2. 2016, female, 3100 g, spontaneous delivery,midwife
3. This pregnancy
Past iIlness (-)
history
Vital Sign BP 110/70 Pulse : 78 x/m T: 36.4 RR: 18x/m
Obstetrical Palpation:
examination Fundal height was 3 finger below proc. Xypoideus (32 cm),
right back, head, contractions 2/10/15, FHR 136x/m, EFW
2700 g
VT:
Portio was soft, medial, eff 75 %, 3 cm, head, HI-II, amniotic
membrane (-) clear, smell(-), sagital suture transverse
 B
Identity Mrs. MEI /25/RA A
C
Laboratorium Hb 12.7 g/dL K
exam WBC 9.100
Trombocyte 334.000

G3P2A0 38 weeks gestational age inlabor first stage latent phase

Diagnosis
with PROM 12 hours + mild anemia SLF cephalic presentation
Therapy Observation of vital sign, FHR
Laboratorium examination
IVFD RL gtt xx drops/ minute
Inj. Ampicilin 1 g/ 6 hours IV
P/ vaginal delivery
Labor acceleration with oxitocin drip
Evaluate with Partograph WHO
17-02-17 G3P2A0 38 weeks gestational age inlabor first stage active phase
11.00 AM with history of ROM 13 hours SLF cephalic presentation
4 cm
Therapy P/ vaginal delivery
Evaluate with Partograph WHO
17-02-17 G3P2A0 38 weeks gestational age inlabor 2nd stage with history of
04.25 PM ROM 18 hours SLF cephalic presentation

Therapy Conduct the labor

Identity Mrs. MEI /25/RA
17-02-17 Male life baby was born spontaneously, BW 2800 g, BL 47 cm, A/S
04.30 PM 8/9 FTAGA

Lab Hb 10.2 g/dL B

A
WBC 11.100 C
Trombocyte 310.000 K

18-02-17 P3A0 post spontaneous delivery with history of ROM 18 hours

06.00 PM
P/ cefadroxil 500mg/ 12 hours PO
Mefenamic acid 500 mg/ 8 hours PO
Neurodec tab / hours PO
Patient was discharged
 B
A
32 C
K

partograf
 B
Identity Mrs. MUT/22 yo/ UA A
C
Chief complain Hospitalized at 18-2-2017 at 06.30 PM K
Fullterm pregnancy with amniotic leakage
History 12 hours before admission, patient complained amniotic leakage, amount 2x
change napkin, clear, smelly (-), abdominal contraction (+) but rare, bloddy
show (-), history of : trauma (-), leucorrhea (+), post coital (+) 1 day ago,
toothache (-), skin infection (-), traditional herbal drink (-), traditional massage
(-), trauma (-).
Patient admit that her pregnancy is aterm and she can still feel the movement
of the fetus
Marital status 1x, 3 years
Reproduction Menarche since 12 yo, regular cycle 28 days, for 7 days, LMP : 15/05/2016
status
Obstetric 1. This pregnancy
history
Physical BP : 130/80 mmHg, P : 80 x/min, T : 36.0 C, RR : 20 x/min, Weight 63 kg, Height 158 cm
examination
Obstetrical Inspection & Palpation :
examination Fundal height was in 3 finger below proc. Xypoideus (30 cm), longitudinal lie,
left back, head, U 5/5, His 1x/10/10, FHR: 155x/m, EFW : 2635 g
Inspeculo : Portio livide, OUE closed, fluor (+), fluxus (+) amniotic fluid but
didnt active, Lacmus test (+) red blue, E/L/P (-)
VT: Portio was soft, posterior, eff 0%, closed, head, HI, amniotic leakage,
clear, smelly(-), and denominator cant be assessed
US ER (FEB) - Single life fetus cephalic presentation
- Fetal Biometry: BPD 9.1 cm AC 31,5 cm
HC 31,1 cm FL 7.61 cm EFW : 2624 g
- Placenta at anterior corpus of the uterine
- Amniotic fluid was normal, AFI 0.97 3.76 = 12.14 cm
3.58 3.84
 B
A
Laboratory Hb: 10.4g/dl, wbc 7.700/ mm3, trombosit 206.000/mm3, CRP qualitative : C
K
examination positif, CRP Quantitative : 9, LEA : Positif +
Diagnosis G1P0A0 39 weeks gestational age not inlabor with PROM 12 hours SLF cephalic
presentation
Therapy Observed vital sign, inlabor sign, FHR
IVFD RL gtt XX/ m
Induction with oxytocin drip
Ampicillin inj 1gr/6 hours IV
P/ Evaluate with WHO partograph modified
P / vaginal delivery
20:30 PM G1P0A0 39 weeks gestational age inlabor 1st stage laten phase with PROM 16
Diagnosis hours SLF cephalic presentation
22:30 AM G1P0A0 39 weeks gestational age inlabor 1st stage active phase with PROM 18
Diagnosis hours SLF cephalic presentation
02: 25 AM G1P0A0 39 weeks gestational age inlabor 2nd stage with history of ROM 20
Diagnosis hours SLF vertex presentation
Delivery report 02:35 AM : Male life baby, Weight 2500 g, Height 47 cm, A/S 8/9 FTAGA
02:45 PM : complete placenta, PW 450 g, UC 50 cm, 17 x 18 cm
Laboratory Hb: 10.6 g/dl, wbc 18.000/ mm3, trombosit 222.000/mm3,
examination
(post-partum)
20-02-2017 P1A0 post spontaneous delivery with history of PROM 12 hours
P/ cefadroxil 500mg/ 12 hours PO
Mefenamic acid 500 mg/ 8 hours PO
Neurodec tab / hours PO

Patient was discharged

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C
K
PARTOGRAPH
 Identity Mrs. ROY/ 34yo/ UA B
A
C
Chief complain Hospitalized at 19-2-2017 at 12.30 AM K
preterm pregnancy with death fetus

History 8 hours before admission, patient complained abdominal contraction (+),

bloddy show (+), history of amniotic ruptured (+) 1 hour ago : trauma (-),
leucorrhea (+), post coital (+) 3 days ago, toothache (-), skin infection (-),
traditional massage (+), trauma (-). then patient come to Hermina
hospital and reffered to RSMH.
Patient admit that her pregnancy is preterm and she can not still feel the
movement of the fetus
Marital status 1x, 5 years
Reproduction Menarche since 12 yo, regular cycle 28 days, for 7 days, LMP : 05/08/2016
status
Obstetric 1. 2012, aterm, midwife, girl, 3900 g, healthy
history 2. 2014, abortio, RSMH, not curettage
3. This pregnancy

Physical BP : 130/80 mmHg, P : 80 x/min, T : 36.0 C, RR : 20 x/min, Weight 78

examination kg, Height 155 cm

Obstetrical Inspection & Palpation :

examination Fundal height was in 2 fingers above umbilicus (19 cm), horizontal lie,
right back, head infront of introitus vagina, contraction 4x/10/40, FHR: -
VT: head in front of introitus vagina
Identity Mrs. ROY/ 34yo/ UA B
A
C
Diagnosis G3P1A1 26 weeks gestational age inlabor 2nd stage SDF K
intrauterine
Laboratory Hb: 12.7 g/dl, wbc 13.900/ mm3, trombosit
Examinatio 419.000/mm3, Ht 41%, PT : 14.2, APTT : 29.9,
n Fibrinogen : 401, D-Dimer: 2.55
Manageme conduct the labor
nt
12:45 AM Female death baby was born, BW 800 g, BL 38 cm with
maseration grade II
Laboratory Hb: 11.3 g/dl, wbc 16.000/ mm3, trombosit 406.000/mm3
Examinatio
n
20-02- P1A1 post spontaneous delivery
2017 P/ cefadroxil 500mg/ 12 hours PO
Mefenamic acid 500 mg/ 8 hours PO
Bromocripite tab / hours PO
Patient was discharged
B
A
C
K
B
A
C
K
 Identity Mrs. SUS/35 yo/UA B
A
C
Chief Hospitalized at 18-2-2017 at 11.30 PM K
complain Aterm inlabor with high blood pressure
History 12 hours before admission, patient was abdominal contraction often and
harder (+), bloody show (+), amniotic leakaged (-). 3 days ago, patient
controlled to midwife dan said that she had pregnancy with high blood
pressure and referred to RSMH. History hypertension before pregnancy (-),
blur vision (-), epigstrial pain (-), nausea vomit (-).
Patient admit that her pregnancy is aterm and she can still feel the
movement of the fetus
Marital 1x, 18 years
status
Reproduction Menarche since 13 yo, regular cycle 28 days, for 5 days. LMP : forget
status
Obstetric 1. 1999, aterm, spontaneous, midwife, male, 3200 g, healthy
history 2. 2003, aterm, spontaneous, midwife, female, 3200 g, healthy
3. This pregnancy
Physical BP : 170/100 mmHg, P : 122 x/min, T : 36.5 C, RR : 18 x/min, Weight 82
examination kg, Height 155 cm
Interna C/ Cor and pulmo functional compensated
department Hypertension stage II
P/ Methyldopa 3x250 mg PO
Ophtalmolog C/ There are no sign of retinopathy and choroidopathy hypertension
y Department P/ Recontrol if suddenly decrease of visus
Obstetrical Inspection & Palpation :
examination Fundal height was 3 finger below proc. Xypoideus (33 cm), longitudinal lie,
IG 6 right back, U4/5, head, His 2x/10/20, FHR: 148x/m, EFW : 3255 g
VT: Portio was soft, medial, eff 100%, 3cm, head, HI, amniotic
membrane (+), and denominator transverse sagittal suture
 B
A
C
US ER (FEB) - Single life fetus cephalic presentation K
- Fetal Biometry: BPD 9.0 cm AC 35,05 cm
HC 33,79 cm FL 7.3 cm EFW :
3106 g
- Placenta at anterior corpus of the uterine
- Amniotic fluid was normal, SP 5.9 cm
C/ 37 weeks gestational age SLF cephalic presentation
Laboratory Hb: 11.8 g/dl, wbc 20.400/ mm3, trombosit 315.000/mm3,
Examination SGOT/SGPT: 27/12, Ur /Cr : 15/0.55, Mg : 1.68, Proteinuria (+), LDH
482, Uric acid 5,30
Diagnosis G3P2A0 37 weeks gestational age inlabor 1st stage latent phase with
severe preeclampsia SLF cephalic presentation
Therapy Stabilization 2 hours Consult Internal & Opthalmology
IVFD RL gtt xx/m Department
Catheterization Evaluation with gestosis task
MgSO4 protocol IM Vaginal delivery
Nifedipine 10 mg/8 hours PO Tubectomy counseling
Acceleration with oxytocin drip after
stabilization
Identity Mrs. SUS/35 yo/UA B
A
42 C
12.10 AM Replied from Internal Medicine Department:
K
A/ Stage II hypertension
Heart and lungs are functionally compensated
P/ Methyldopa 3 x 500 mg

Replied from Ophtalmology Department:

A/ No sign of hypertensive choroidopathy and retinopathy
P/ Re-consult when sudden loss of visions occur

19-2-17 D/ G3P2A0 37 weeks gestational age in labor 1st stage latent phase
02.00 AM with severe preeclampsia SLF cephalic presentation
3 cm
Management Observed vital sign, FHR, Nifedipine tab 10 mg/8 hours PO
contraction Acceleration with oxytocin drip
IG 4 Urinary cathetherization, monitor Evaluate according to Gestosis
BP 150/90 mmHg I/O Task Force
MgSO4 inj ~ protocol Plan for vaginal delivery

04.00 AM D/ G3P2A0 37 weeks gestational age in labor 1st stage active phase
4 cm with severe preeclampsia SLF cephalic presentation
Identity Mrs. SUS/35 yo/UA
08.00 AM 43 in labor 2nd with severe preeclampsia SLF cephalic
D/ G3P2A0 37 weeks gestational age
IG 4 presentation
BP 140/90 mmHg
B
Management P/ Conduct the labor A
C
08.15 AM Female life baby was born with BW 2900 g, BL 49 cm, AS 8/9 FTAGA K
08.20 AM Placenta was delivered completely. PW 480 g, UCL 50 cm, 18 x 19 cm

Laboratory Hb: 12.7 g/dl, wbc 13.700/ mm3, trombosit 405.000/mm3, Mg : 2,91, Na/K: 139/4.0 LDH
Examination 352,

Follow up D/ P3A0 post spontaneous delivery with severe preeclampsia

23-02-2017 P/ Cefadroxil 500mg / 12 hours PO
Paracetamol 500mg/ 8 hours PO
Neurodec tab/ 24 hours PO
Metyldopa 250mg/8 hours PO
Patient was discharge
Identity Mrs. SIT/28 yo/UA B
A
Patient history Hospitalized at 19/2/17, 11.30 PM 44 C
K
Preterm pregnancy with contraction & fetal distress
6 hours before admission, patient was abdominal contraction often and harder (+), bloody
show (-), amniotic leakaged (-). Patient come to RSMH.
Patient admit that her pregnancy is preterm and she can still feel the movement of the
fetus
Physical examination Physical exam: UFH 4 fingers below px (29 cm), longitudinal lie, back at right, head, U 5/5,
FHR 117 x/m contraction 1X/10/10, FHR 117 x/m, EFW 2480 g
FHR 120 x/m Vaginal toucher: soft portio, posterior, eff 0%, no dilation, head, amniotic membrane and
FHR 118 x/m denominator was not able to determined yet
Laboratory Hb: 8.6 g/dl, LEA (-)
examination WBC: 4.900/mm3 Proteinuria (-)
Plt: 212.000/mm3 Bakteriuria (-)
CRP Qualitative (-)
CRP Quantitative <5
US ER (FCH) - Single life fetus cephalic presentation
-Fetal Biometry BPD: 8.7 cm AC 31.7 cm
HC: 29.1 cm FL: 8.8 Cm
-Placenta at anterior corpus of the uterine
- Amnion fluid was enough, SP = 2.4 cm
C/ 35 weeks gestational age SLF cephalic presentation
Diagnosis D/ G2P1A0 35 weeks gestational agenot inlabor + moderate anemia SLF cephalic presentation +
fetal distress

Management Observed vital sign, FHR, inlabor sign

Intrauterine rescucitation
Lateroposition
O2 4L/m
Laboratorium examination (DR, KD, UR)
IVFD RL gtt XX/m
Ceftriaxone inj 1 g/12 hours IV
Plan for LSCS
Identity Mrs. SIT/28 yo/UA B
A
45
20-02-17 Male life baby was born with BW 3000 g, BL 48 cm, AS 8/9 PTAGA KC
01.25 AM
01.28 AM Placenta was delivered completely. PW 490 g, UCL 50 cm, 18 x 19
cm
23-02-2017 D/ P2A0 post LSCS cb fetal distress
P/ cefadroxil 500mg/ 12 hours PO
Mefenamic acid 500 mg/ 8 hours PO
Neurodec tab / hours PO

Patient was discharged

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A
46 C
K
47

X X X
B
A
C
K
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A
48 C
K
Identity Mrs. ASP/38 yo/UA B
A
49 C
Patient history Hospitalized at 19/2/17, 11.40 PM K
D/ G3P2A0 39 weeks gestational age in labor 1st stage active phase
with severe preeclampsia SLF cephalic presentation

Physical Physical exam: UFH 3 fingers below processus xiphoideus (34 cm),
examination longitudinal lie, back at right, head, U 3/5, contraction 4X/1035, FHR 150
IG 5 x/m, EFW 3255 g
BP 160/100 Vaginal toucher: soft portio, anterior, eff 100%, 7 cm, head, HI, amniotic
mmHg membrane (-), anterior right small fontanelle

Laboratory Hb: 11.4 g/dl,

examination WBC: 27.200/mm3
Plt:2645.000/mm3
SGOT/SGPT: 27/12,
Proteinuria (+), LDH 322,
Management Observed vital sign, FHR, Consult to Ophtalmology and
contraction Internal Medicine Department
Stabilization 1 hour Evaluate ~ Gestosis Task
Laboratorium examination (DR, Force
KD, UR) Plan for vaginal delivery
Urinary cathetherization, (terminate 2nd stage with
monitor I/O action)
IVFD RL gtt XX/m Conseling Tubectomy
MgSO4 inj ~ protocol
Nifedipine tab 10 mg/8 hours PO
Identity Mrs. ASP/38 yo/UA B
A
12.10 AM Replied from Internal Medicine50
Department: C
K
A/ Stage II hypertension
Heart and lungs are functionally compensated
P/ Methyldopa 3 x 250 mg

Replied from Ophtalmology Department:

A/ Refraction anomaly was suspected
No sign of hypertensive choroidopathy and retinopathy
P/ Consult to Eye Policlinic at Refraction Subdivision for the best vision
correction
Re-consult when sudden loss of visions occur
02.30 AM D/ / G3P2A0 39 weeks gestational age in labor 2nd stage with severe
IG 4
BP 140/90 mmHg
preeclampsia SLF cephalic presentation
Management P/ Conduct the labor
02.50 AM Female life baby was born with BW 3200 g, BL 46 cm, AS 8/9 FTAGA
02.55 AM Placenta was delivered completely. PW 510 g, UCL 48 cm, 18 x 19 cm
Laboratory Hb: 10.6 g/dl, WBC:20.200/mm3 Plt:285.000/mm3 LDH=386
examination
P3A0 post spontaneous delivery with severe preeclampsia + pomeroy
tubectomy
P/ cefadroxil 500mg/ 12 hours PO
Paracetamol 500 mg/ 8 hours PO
Neurodec tab / hours PO
Metyl dopa 250mg/8 hours PO
Patient was discharged
Identity Mrs.KAR/ 30 yo/UA
B
A
51 C
K
Chief Hospitalied at 20-2-17 07.50 AM
complain inlabor aterm pregnancy
History 12 hours before come to hospital patient complain regular
contraction (+) , amniotic discharge (-), bloody show (+),
Patient realized that she has aterm gestational of age and
fetal movement (+).
Marital status 1x, 10 years
Reproduction Menarche since 13 yo, regular cycle 28 days, 5 days,
status LMP 6 mei 2016
Obstetric 1. 2008, Male, 3100 gram, midwife, spontaneus delivery,
history healthy
2. This pregnancy
Obstetrical Inspection : Fundal height 3 finger below proc
examination xypoideus (32 cm), longitudinal, left back, head, U 4/5,
BP:110/70 contraction (2x/10/25), FHR 131x/m, EFW 2935 gr
mmHg VT : portio soft, medial, eff 100%, 3 cm, HI-II, head,
Pulse: 85x/m amniotic membran(+) denominator right oociput
RR: 20x/m transverse
T: 36,5 C
 B
Identit Mrs.KAR/ 30 yo/UA 52 A
C
y K

US ER - Single life fetus cephalic presentation

- Fetal Biometry: BPD 9,13 cm AC 31,77 cm EFW 3063 g
HC 32,19 cm FL 7,4 cm
- Placenta at anterior corpus of uterus
- Amniotic fluid was enough AFI: 7,65 cm
C/ 37weeks gestational age SLF cephalic presentation

Diagnosis G2P1A0 41 weeks gestational age inlabor 1st stage latent phase
SLF cephalic presentation
Lab Hb 9,5/ WBC 17,1/ PLT 310/ crp kualitatif positif, crp kuantitatif 93 LEA
negatif

Therapy IVFD RL gtt xx/m

Laboratory examination
Inj Ampicilin 1g/ 6 hours IV
plan for vaginal delivery
Evaluation with WHO parthograph modification
 B
Identity Mrs.KAR/ 30 yo/UA
53
A
C
K
Follow Up
20-2-17 D/ G2P1A0 41 weeks gestational age inlabor 1st stage latent
09.30 AM phase SLF cephalic presentation
3 cm -P/ vaginal delivery

-D/ G2P1A0 41 weeks gestational age inlabor 1st stage

01.00 AM
3 cm latent phase with febris observation SLF cephalic
T: 39,5 C presentation
His -P/ Vaginal delivery
2x/10/25 - Inj Ampicilin 1g/ 6 hours IV
PCT tab 500mg/8 hours
IVFD RL xxx drops/m

03.00 PM -D/ / G2P1A0 41 weeks gestational age inlabor 1st stage

4 cm active phase with febris observation SLF cephalic
FHR: 170x presentation
-P/ Vaginal delivery
Lateropotition
O2 5 ltr.menit

Consult to Consultant in charge:acceleration with oxytocin

drips
 B
Identity Mrs.KAR/ 30 yo/UA
54
A
C
K
10.05 PM -D/ G2P1A0 41 weeks gestational age inlabor 1st stage active phase
7 cm with febris observation SLF cephalic presentation +fetal distress
FHR: 102x/m Consult to Consultant in charge
FHR: 112x/m -P/ Plan for abdominal termination
FHR : 107x/m

00.32 AM -male life baby was born with BW 3000 gram, BL 48 cm, A/S 7/8
FTAGA
Lab Hb 8,5/ WBC 20.000 / HT 29%/ PLT 286

23-02-2017 D/P2A0 post LSCS cb fetal distress and febris intrapartum

P/ cefadroxil 500mg/ 12 hours PO
Mefenamic acid 500 mg/ 8 hours PO
Neurodec tab / hours PO

Patient was discharged

 B
A
Identity Mrs. SRI/28 yo/UA C
K
Chief Hospitalized at 22-2-2017 at 02.15PM
complain Preterm pregnancy with vaginal bleeding
History 3 hours before admission, patient was got vaginal bleeding ,2
times changing of pad,,abdominal contraction often and harder
(-), amniotic leakaged (-). .trauma (-), post coital bleeding (-)
Patient admit that her pregnancy is aterm and she can still feel
the movement of the fetus
Marital 1x, 7years
status
Reproductio Menarche since 13 yo, regular cycle 28 days, for 5 days. LMP :
n status forget
Obstetric 1. 2005, aterm, spontaneous, midwife, male, 3200 g, healthy
history 2. 2012 aterm, spontaneous, midwife, male, 3500 g, healthy
3. This pregnancy
Physical BP : 120/80 mmHg, P : 82 x/min, T : 36.5 C, RR : 18 x/min,
examinatio Weight 60 kg, Height 155 cm
n
Obstetrical Inspection & Palpation :
examinatio Fundal height was 2 finger below proc. Xypoideus (26 cm),
n longitudinal lie, left back, U5/5, head, His 1x/10/20, FHR:
148x/m, EFW : 1700 g
Inspeculo: portio livide,OUE closed, fluor (-), fluxus (+) ,blood not
active, E/L/P(-)
VT: did not do it
 B
A
Mrs. SRI/28 yo/UA C
K

US ER (RFD - Single life fetus cephalic presentation

- Fetal Biometry: BPD 7,67 cm AC 25,64 cm
HC 26,96 cm FL 6,25 cm EFW :
1769 g
- Placenta at anterior corpus of the uterine spread out until cover
all off OUI
- Amniotic fluid was normal, SP 3,8 cm
C/ 30 weeks gestational age SLF cephalic presentation + total
placentae previa
Laboratory Hb: 10,7 g/dl, wbc 10,4/ mm3, trombosit 199.000/mm3,
Examination diffcount: 0/4/70/19/7
22-02-2017
03:39AM
Diagnosis G3P2A0 30 weeks gestational age not inlabor with ante partum
hemorrhage due to total placental preve +mild anemia SLF
cephalic presentation
Therapy Observation vital sign
Lab examination
IVFD xx gtt/mnt
Dexamethasone 6 mg /12
hour
Nifedipin 10 mg /8 hour
US (AK) 31 weeks gestational age SLF cephalic presentation
 B
A
Mrs. SRI/28 yo/UA C
K

Diagnosis G3P2A0 31 weeks gestational with threatened preterm labor SLF

cephalic presentation
23-03-2017 Observation vital sign
IVFD xx gtt/mnt
Dexamethasone 6 mg /12
hour
Patient was stable in ward
 B
Identity Mrs. ADE/26/UA A
C
Hospitalized : 22-02-17, 04.12 PM K
Chief complaint Preterm pregnancy with watery discharge
History Patient came to emergency room with wathery discharge since 2 days
ago. Discharge was clear, odor (-). contraction (-). History of bloody show
(-). Patient go to Ar-Rasyid hospital and admitted with therapy inj.
Dexamethasone 12 mg/ 24 hours IV (2 days) patient refered to RSMH
History of leukorrhea (+) History of fever (-) History of taking
drugs/traditionalmedicine (-) History of trauma (-) History of toothache
(+)
Patient stated that she has preterm pregnancy & fetal movement was
(+)
Marital status 1x, 10 months
Reproduction Menarche since 13 yo, reguler cycle 28 days, 7 days, LMP forget
status
Obstetric history 1. 2016, abortus,
2. This pregnancy
Past iIlness history (-)
Obstetrical Vital Sign :
examination Sens : CM P : 84 x/m Height : 150 cm
BP : 120/80 mmHg R : 20 x/m Weight : 56 kg
Palpation :
Fundal height 3 fingers bellow processus xiphoideus,
longitudinal, cephalic, 5/5 contraction (-) FHR 150 x/m
Insp : portio livide, OUE closed, fluor (+) fluxus (+) amniotic
discharge not active, lacmus test (+) red -> blue, e/l/p (-)
VT : cervix soft, posterior, eff 50% no dilatation, amnion and
 B
A
60 C
Identity Mrs. ADE/26/UA K

Lab examination Hb:10.3 g/dl, WBC 11.100 /mm3, Ht :33% , Plt 345.000/mm3 CRP
17-02-2017 qual (-) CRP quant <5 LEA (-) Urine epithelial cells (+)
ER US C/ 30 weeks gestational age SLF cephalic presentation +
oligohydramnion
Diagnosis G2P0A1 30 weeks of gestational age not inlabor with PPROM 2 days
SLF cephalic presentation + any

Therapy Conservative management

Assess vital signs, FHR
IVFD RL gtt XX/m
Inj Ampicillin 1g/12 hours IV
P/US Confirmation
US (PM) -Single life fetus cephalic presentation
- Fetal Biometry: BPD 8,07 cm AC 24,56 cm
HC 28,55 cm FL 6,14 cm EFW :
1616g
- Placenta at anterior corpus
- Amniotic fluid was decrease, AFI=1 cm
C/33 weeks gestational age SLF cephalic presentation +
Anhydramnios + baby tends to be small for gestational age
Therapy P/Abdominal Delivery
10.35 AM Male life baby was born with BW 1450 gram, BL 39 cm, A/S 8/9
PTAGA
B
A
C
K
Delivery Room Report
 B
Identity Mrs. WAH/21/UA A
C
Hospitalized : 17-02-17, 05.52 AM K
Chief complaint Preterm pregnancy with watery discharge
History Patient came to emergency room with wathery discharge since 1
day ago. Discharge was clear, odor (-). contraction (-). History of
bloody show (-). History of leukorrhea (-) History of fever (-) History
of taking drugs/traditionalmedicine (-) History of trauma (-) History
of toothache (+)
Marital status 1x, 10 months
Reproduction Menarche since 12 yo, reguler cycle 28 days, 5 days, LMP 3/7/2016
status
Obstetric history 1. This pregnancy
Past iIlness (-)
history
Obstetrical Vital Sign :
examination Sens : CM P : 90 x/m Height : 163 cm
BP : 120/80 mmHg R : 20 x/m Weight : 91 kg
Palpation :
Fundal height 3 fingers bellow processus xiphoideus,
longitudinal, cephalic, 5/5 contraction (-) FHR 150 x/m
Insp : cervix livide, OUE closed, fluor (-) fluxus (-) amniotic
discharge not active, lacmus test (+) red -> blue, e/l/p (-)
VT : cervix soft, posterior, eff 50% no dilatation, amnion and
denominator cant be determined
Identity Mrs. WAH/21/UA
Lab examination 68 Ht :36% , Plt 412.000/mm3 CRP qual (-) CRP
Hb:11.3 g/dl, WBC 12.800 /mm3,
17-02-2017 quant <5 LEA (-) Urine epithelial cells (++) Urine luekocyte 8-10/FOV Urine
bacteria (++)
ER US 34 weeks gestational age SLF cephalic presentation + oligohydramnion
Diagnosis G1P0A0 35 weeks of gestational age not inlabor with PPROM 1 day SLF
cephalic presentation + oligohydramnion

Therapy Conservative
Assess vital signs, FHR, labor signs
IVFD RL gtt XX/m
Inj Ampicillin 1g/12 hours IV
Inj Dexamethasone 12 mg/12 hours IV B
P/US Confirmation A
C
US Confirmation 35 weeks gestational age SLF cephalic presentation + anhydramnion
K
+ BPP 6
P:
Assess vital signs, FHR, labor signs
IVFD RL gtt XX/m
Inj Ampicillin 1g/12 hours IV
Inj Dexamethasone 12 mg/12 hours IV
Report to Consultant in charge : Dr. Hj Hartati,SpOG(K)
Advice : Fetal lung maturation
Consult to fetomaternal
subdivision
Consult to Fetomaternal subdivision : Dr. H. Nuswil
Bernolian,SpOG(K)
Advice : Strict monitoring
 B
A
69 C
K
Identity Mrs. WAH/21/UA B
A
70 C
Follow Up S: - K
(17/02/2017) O : St. Present : BP 110/70 Pulse : 82x/m T: 36.5 RR: 20x/m
01.00 PM Palpation :
Fundal height 3 fingers bellow processus xiphoideus, longitudinal, cephalic,
5/5 contraction (-) FHR I 172 x/m FHR II 177x/m FHR III178 x/m

A: G1P0A0 35 weeks of gestational age not inlabor with PPROM 1 day SLF
cephalic presentation + anhydramnion + non reassuring fetal status + low
biophysical profile + fetal tachycardia

P:
Assess vital signs, FHR, labor signs
IVFD RL gtt XX/m
Inj Ceftriaxone 1g/12 hours IV
Inj Dexamethasone 12 mg/12 hours IV
Intrauterine resuscitation : lateroposition
O2 5-7 l/m
P/ Abdominal termination
Report to Consultant in charge : Dr. Hj Hartati,SpOG(K)
Agree to terminate abdominally
02.25 PM Female life baby was born with BW 2500 g, BL 46 cm, AS 8/9
PTAGA
02.28 PM
Placenta was delivered completely. PW 420 g, UCL 41cm,
16 x 197cm
Identity Mrs. WAH/21/UA B
A
71 C
Lab examination Hb:10.7 g/dl, WBC 14.900 /mm3, Ht :32% , Plt 365.000/mm3 K
18-02-2017

20-02-2017 D/P2A0 post LSCS cb fetal distress and anhydramnios

P/ cefadroxil 500mg/ 12 hours PO
Mefenamic acid 500 mg/ 8 hours PO
Neurodec tab / hours PO
Patient was discharge
 B
A
72 C
K
 B
Identity Mrs. PIT/17/UA A
C
Hospitalized : 19-02-17, 22.30 PM K
Chief complaint Preterm pregnancy with contraction
History Patient came to emergency room with preterm pregnancy
contraction. History of bloody show (-) History of watery discharge
(-). History of flour albus (-) History of post coital (-).

Marital status 1x, 10 mounth

Reproduction Menarche since 12 yo, reguler cycle 28 days, 5 days, LMP 23/7/2016
status
Obstetric history 1. This pregnancy
Past iIlness (-)
history
Obstetrical Vital Sign :
examination Sens : CM P : 82 x/m Height : 152 cm
BP : 120/80 mmHg R : 20 x/m Weight : 51 kg
Palpation :
TI 5 Fundal height 2 fingers above umbilicus (21cm), longitudinal, right
back, breech , hodge I, contraction 2x/10/15 FHR: 128 x/m, EFW :
1510 g
VT : cervix soft, posterior, eff 25% dilatation 2 cm, breech, amnion
(+)
Identity Mrs. PIT/17/UA B
A
C
Lab examination Hb: 8,1 g/dl, WBC 16.300 /mm3, Ht : 26% , Plt 349.000/mm3 K
19-02-2017
USG IRD - SLF breech presentation
- BPD : 78 mm, HC : 283 mm, AC : 252 mm, FL : 51 mm, EFW :
1345 g
- Plcentae at anterior corpus
- Amnionitic fluid Sp : 3,3 cm
Conclution : 30 weeks gestational age SLF breech presentation
G1P0A0 30 weeks of gestational with threatened preterm labour SLF
breech presentation

Therapy Konservatif
Observasi TVI, his, tanda-tanda inpartu
IVFD RL gtt xx/menit
Nifedipine 10mg/6jam
Dexametasone 12 mg/24 jam IV
R/ USG konfirmasi
Identity Mrs. PIT/17/UA B
A
C
US confirmation - SLF breech presentation K
20-02-2017 - Fetal Biometri
BPD : 7,82 cm, AC : 25,28 cm
HC : 28,35 cm, FL : 5,17 cm, EFW : 1345 g
- Plcentae at anterior corpus
- Amnionitic fluid Sp : 3,1 cm
- Cervical length 1,06 cm
Conclution : 30 weeks gestational age SLF breech presentation +
cervical length 1,06 cm
P/ cerclage
20-02-2017 Cerclage at emergency operating room.
14.15 PM
22-02-2017 G1P0A0 30 weeks of gestational with threatened preterm
labour SLF breech presentation + Post cerclage
P/ Nifedifine 10mg/8hours

Patient was discharge

 B
A
76 C
K
 B
A
Identity Mrs. FIR/30/UA C
K
Hospitalized : 12-02-21, 10.00 AM
Chief complaint Aterm pregnancy with Watery discharge
History Patient came to emergency room with history of amniotic fluid seeping
since 14 haours ago, as much as 2 wet panties/day, clear, smell(-) .
History of uterine contraction (+), history of bloody show (+).Fluor
albus (+), trauma (-), massage on abdomen(-), post coital (-), tooth or
skin infection(-), fever(-), consuming medications or potions(-), preterm
pregnancy, fetal movement (+)
Marital status 1x, 1 years
Reproduction Menarche since 13 yo, reguler cycle 28 days, 5 days, LMP24/5/2016
status
Obstetric history 1. This pregnancy
Past iIlness history (-)
Vital Sign BP 120/80 Pulse : 88x/m T: 36.5 RR: 20x/m
Obstetrical Palpation :
examination Fundal height 1 fingers below proc. xyphoideus (40 cm),
longitudinal lie, right back, head, 5/5, contractions 1x/10/25,
FHR 142x/m EFW 4185g
Insp:
Portio livide, closed external os, fluor(-), fluxus(+) amniotic
fluid not active, e/l/p (-), (+) lacmus test redblue
VT:
Portio was soft, posterior, eff 0%, no dilatation, head, H I,
amniotic membrane and denominator could not be determined
yet
 B
A
Identity Mrs. FIR/30/UA C
K
Lab Hb: 9.7 g/dl, WBC 7200/ mm3, Ht : 30% , Plt 324.000 /mm3,
examination DC: 0/1/67/24/2, CRP qualitative: negative CRP quantitative:5
21-02-2017 LEA: negative

Diagnosis G1P0A0 39 weeks gestational age not inlabor with PROM 14

hours + CPD was suspected SLF cephalic presentation+
oligohydramnion

Therapy Assess vital signs, FHR,

Laboratorium
IVFD RL gtt xx/m
Ampicillin 1g/6 hours IV
 B
Identity Mrs.FIR/30/UA A
C
US confirmation c/ 39 weeks gestational age SLF cephalic presentation + K
Dr. H. Amir Fauzi, oligohydramnion
SpOG(K) Advice : LSCS
11.40 AM

Follow Up At 15.40 AM male life baby was born, BW 4600 g, BL 56 cm A/S 8/9
(21/02/2017) FTAGA
15.35 PM
At 15.45 PM placenta was delivered completely, PW 750 g, UCL 57 cm,
LSCS diameter 21x22 cm
At 16.00 PM the operation was completed

Lab Hb:8,8 g/dl, WBC 13.700 /mm3, Ht :28% , Plt 367.000/mm3

examination
23/02/2017 P1A0 post LSCS on indication CPD
P/ cefadroxil 500mg/ 12 hours PO
Mefenamic acid 500 mg/ 8 hours PO
Neurodec tab / hours PO
 B
A
C
K

BSS: 106 gr/dL

 B
Identity Mrs. KAR/40/RA A
C
Hospitalized : 21-02-17, 12.35AM K
Chief Preterm pregnancy with high blood pressure and no fetal movement
complaint
History Since 1 day before admitted to the hospital, patient doesnt feel fetal movement.
Contraction (-) History of watery discharge (-) History of bloody show (-) History of
high blood pressure in this pregnancy (+) History of high blood pressure before
pregnancy (+) history of high blood in prior pregnancy (-) history of high blood
pressure in the family (-) History of headache (-) History of blurred vision (+)
History of epigastric pain (+) nausea and vomiting (-)

Marital status 1x, 10 years

Reproduction Menarche since 12 yo, reguler cycle 28 days, 5 days, LMP 8/6/2016
status

Obstetric 1. 2003,male, 3600g, midwife, spontaneous delivery, healthy

history 2. 2004, male, 3600g, midwife, spontaneous delivery, healthy
3. 2007, female, 3600g,midwife,spontaneous delivery,healthy
4. 2010, male,4800g,midwife,spontaneous delivery,healthy
5. 2012,male,1900g, midwife,spontaneous delivery,healthy
6. This pregnancy

Obstetrical Vital Sign :

examination Sens : CM P : 98 x/m Height : 152 cm
BP : 200/120 mmHg R : 22 x/m Weight : 50 kg
Palpation :
GI : 9 Fundal height at umbilicus, ballotement eksterna (+),contraction (-) FHR
(-) x/m
VT : cervix soft, posterior, eff 0% dilatation 1 cm, amnion and
denominator cant be measured
Identity Mrs. KAR/40/RA B
A
C
Lab examination Hb:11.3 g/dl, WBC 15.600 /mm3, Ht :33% , Plt 60.000/mm3 Albumin
K
21-02-2017 2,6 LDH 1424 Uremic Acid 6,9
Interna department C/ Cor and pulmo functional compensated
Hypertension stage II
P/ Methyldopa 3x250 mg PO
Ophtalmology C/ There are no sign of retinopathy and choroidopathy hypertension
Department P/ Recontrol if suddenly decrease of visus

Diagnosis G6P5A0 24 weeks of gestational age not inlabor with impending

eclampsia + partial HELLP syndrome SDF intrauterine

Therapy Stabilitation 1-3 hours

Obs vital signs
IVFD RL gtt xx/m
Lab examination
Urine catheter
Inj MgSO4 40% 4g/6 hours IM
Inj Dexametasone 10mg/8 hours IV
Nifedipine 10 mg / 6 hours
Consult Internal dept, and eye dept.
P/ Vaginal delivery
P/ Tubectomy
After stabilitation -> Induction with oxytocin 10 IU gtt x/m& ballon
catheter
 B
Identity Mrs. KAR/40/RA A
Follow Up C
S: Headache(+) epigastric pain (+) K
(21/02/2017) O : St. Present : BP 160/80 Pulse : 80x/m T: 36.5 RR: 20x/m
18.30 pm Palpation :
Fundal height at umbilicus, ballotement eksterna (+),contraction (-) FHR (-
x/m
VT : cervix soft, posterior, eff 0% dilatation 1 cm, amnion and denominato
cant be measured

A: G6P5A0 24 weeks of gestational age not inlabor with impending eclampsia

+ partial HELLP syndrome SDF intrauterine

P:
Assess vital signs, FHR, labor signs
Augmentation with oxytocin 10 IU gtt X/m + ballon catheter
Inj MgSO4 40% 4g/6 hours IM
Nifedipine 10 mg / 6 hours
Inj Dexametasone 10mg/8 hours IV
P/ Vaginal Delivery
Follow Up A: G6P5A0 28 weeks of gestational age inlabor first stage latent phase wit
(22/02/2017) impending eclampsia + partial HELLP syndrome SDF intrauterine
07.00 am
11.00 am G6P5A0 28 weeks of gestational age inlabor first stage active phase with
impending eclampsia + partial HELLP syndrome SDF intrauterine
14.10 am G6P5A0 24 weeks of gestational age inlabor second stage with
impending eclampsia + partial HELLP syndrome SDF intrauterine
P/ Conduct to labor
Identity Mrs. KAR/40/RA B
A
84 C
Follow Up Male death neonatus BW : 1100 g BL : 38cm maseration grade II K
(22/02/2017) Hb:10.2 g/dl, WBC 19.500 /mm3, LDH 974
14.25 am

23/02/2017 P6A0 post spontaneous delivery with imending eclampsia + partial

HELLP Syndrome
P:
Assess vital signs,
IVFD RL+ oxytocin 20 IU gtt xx/m
Inj. Dexametasone 10mg/8hours PO
Cefadroxil 500m/12 hours
Paracetamol 500 mg/ 8 hours
Neurodex 1x1 tab PO
Methyldopa 500 mg / 8 hours PO
Plan to tubectomy (24/02/2017)
 B
A
85 C
K
 B
A
86 C
K