Case Report

th
Wednesday : July, 24 2013
Primigravida + Preterm Labor
 Identity

Name : Mrs. S

Age : 18 years old

No. MR : 83 56 15

Address : Korong Chaniago Nagari Kasang

Date : July, 17th 2013

Chief Complaint
• A 18 years old patient was admitted to the Obstetric
Emergency Room of Dr. M. Djamil Central General Hospital on
July 17th, 2013 at 07.45 pm, with chief complain feeling of
pain from waist to groin intermittent since about 2 hours ago
 Present illness History

Feeling of pain from waist to groin intermittent since about 2 hours ago
Bloody show from the vagina was abscent
There is no fluid leakage from the vagina
There is no massive vaginal bleeding

Amenorhea since ± 7 ½ months ago

First date of last menstruation period was forgotten

Estimation date of delivery was difficult to examinate

Fetal movement was felt since 2 ½ months ago

No complain of nausea, vomiting and vaginal bleeding neither
during early pregnancy nor late pregnancy

Antenatal care : midwives once in a month since 4th months of

gestational age, there was no complain about her pregnancy during
control, she got vitamin everytime she was control.

Menstrual history : menarche at 13 years old, irregular menstrual

cycle in 3 month before pregnancy its about 1 in 25-35 days, which
last for 5-7 days each cycle with the amount of 2-3 times pad
change/day without menstrual pain
Previous • There wasn’t previous history
Illness of heart, lung, liver, kidney, DM,
Hypertension, and allergy
History :
Family • There wasn’t history of
hereditary disease, contagious
Illness and physicological illness in the
History family
Marriage history : once in 2012
History of pregnancy/abortion/delivery : 1/0/0
1. Present
History of family planning : was absent
History of immunization : was absent
History of education : junior high school
Occupation :
House wife
Physical Examinations

General appearrance : Moderate

Conciousness : Composmentis cooperative
Blood pressure : 120/70 mmHg
Heart rate : 84 x/m
Respiratory rate : 20 x/m
Body Temperature : 36,7⁰C
Body Height : 155 cm
Body Weight : 57 kg
Before pregnant : 50 kg
BMI : 20,83 kg/m2
Nutrisional status : Good
Physical Examinations
Eyes : Conjunctiva wasn’t anemic, Sclera wasn’t icteric
Neck : JVP 5-2 cmH2O, thyroid gland no enlargement
Chest : H/L normal
Abdoment : OR
Genitalia : OR
Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
Obstetrical Record
Abdomen :
I : Enlarge accordance to preterm pregnancy, median line hyperpigmentation (+),
striae gravidarum (+)
Pa : L1 : Uterine fundal was palpable 3 fingers above umbilical
A large nodular mass was palpated
L2 : A hard resistance was felt on the left side.
Numerous small, irregular were felt on the right side
L3 : A hard round mass was palpable and bounce
L4 : Convergen
Uterine Fundal Height : 24 cm
Estimated fetal body weight : 1700 grams
Uterine contraction :
(+)/seldom/weak
Pe : Tympani
Au : Peristaltic sound normal Fetal Heart Sound : 165-
175 bpm
Obstetrical Record

Genitalia : I : V/U normal, vaginal bleeding was abscent

Inspeculo :
Vagina : tumor (-), laceration (-), fluksus (-)
Portio : NP, tumor (-), laceration (-), fluksus (-), OUE was opened 1 cm
CTG

Baseline : 150 bpm

Variability : 5-15 bpm
Acceleration : (+)
Deceleration : (-)

Impression : reactive
USG

Fetal live, singleton, intrauterine head

presentation
Fetal movement activity was good
Biometry :
BPD : 81,1 mm
FL : 60,2 mm
AC : 274 mm
EFW : 1.811 gram
Placenta was implanted at posterior corpus
Gr II-III
I/ Pregnancy 32-33 weeks
Fetal alive
Head presentation
 LABORATORY
Laboratory finding Normal value for 3rd TM

Routine blood testing

Hemoglobine 12,5 gr/dl 9,5-15,0

Leucocyte 10.100/mm3 5.9–16.9

Hematocrit 38 % 28.0–40.0

Eritrocyte 4.2Finding
Laboratory /mm3: 2.71-4.43

Trombocyte 233.000/mm3 146–429

MCV 92 um3 81–99

MCH 30,1 pg 29–32

MCHC 32,8 g/dl 32-36

URINALISIS RESULT REFERENCE VALUE
Protein - -
Glucose - -
Leucocyte 1-2 0-5
Eritrocyte 0-1 0-1
Cylinder - -

Crystal - -

Epitel + flat Flat Epithel

Bilirubin - -

Urobilinogen + +
Diagnosis
G1P0A0L0 preterm pregnancy 30-32 weeks + threatened
preterm labor
Fetal alive, singleton, intra uterine, head presentation
Management :
Control of GA, VS, uterine contraction, FHR
Tocolitic : Nifedipine 3x10 mg
Lung maturation : dexamethasone 2x6 mg IV (2 days)
Antibiotic (skin test)
Informed Consent
Contraception counseling
Plan :
Expectative
 July, 188h 2013 07.00 am

Anamnestic Feeling of pain from waist to groin intermittent (-)

Bloody show from the vagina (-)

Physical Examination Vital sign :

General appearrance : Moderate
Conciousness : Composmentis cooperative
Blood pressure : 120/80 mmHg
Heart rate : 80 x/m
Respiratory rate : 20 x/m
Body Temperature : 37 ⁰C
Abd : uterine contraction (-)
FHR : 156-168 bpm
Gen : I : V/U normal, vaginal bleeding was abscent

Diagnose G1P0A0L0 preterm pregnancy 30-32 weeks + threatened preterm labor

Fetal alive singleton intrauterin head presentation
Management Control GA, VS, uterine contraction, FHR
Lung maturation : Dexamethasone 2x6 mg IV (2 days)
Urine culture and vagina swab
Fetomaternal division USG
Tocolitic
Plan Expectative
 July, 18th 09.00 am 01.00 pm 05.00 pm 09.00 pm 01.00 am
2013

Anamnestic Feeling of pain from Feeling of pain from Feeling of pain from Feeling of pain from Feeling of pain from
waist to groin (-) waist to groin (-) waist to groin (-) waist to groin (-) waist to groin (-)
Fetal movement (+) Fetal movement (+) Fetal movement (+) Fetal movement (+) Fetal movement (+)

Physical Abd : uterine Abd : uterine Abd : uterine Abd : uterine Abd : uterine
Examination contraction (-) contraction (-) contraction (-) contraction (-) contraction
FHR : 156-166 bpm FHR : 158-168 bpm FHR : 154-164 bpm FHR : 152-162 bpm 1x/15”/weak
Gen : I : V/U normal, Gen : I : V/U normal, Gen : I : V/U normal, Gen : I : V/U normal, FHR : 160-168 bpm
vaginal bleeding (-) vaginal bleeding (-) vaginal bleeding (-) vaginal bleeding (-) Gen : I : V/U normal,
vaginal bleeding (-)
 July, 19th 2013 04.00 am

Anamnestic Feeling of pain from waist to groin intermittent (+)

Bloody show from the vagina (+)

Physical Examination Vital sign :

General appearrance : Moderate
Conciousness : Composmentis cooperative
Blood pressure : 120/80 mmHg
Heart rate : 80 x/m
Respiratory rate : 20 x/m
Body Temperature : 37 ⁰C
Abd : uterine contraction 2-3x/25”/moderate
FHR : 156-168 bpm
Gen : I : V/U normal, vaginal bleeding was abscent
Inspeculo :
Vagina : tumor (-), laceration (-), fluksus (-)
Portio : NP, tumor (-), laceration (-), fluksus (-), OUE was opened 3 cm
Diagnose G1P0A0L0 preterm parturient 30-32 weeks first stage of latent phase
Fetal alive singleton intrauterin head presentation at HI-II
Management Control GA, VS, uterine contraction, FHR
Lung maturation : Dexamethasone 2x6 mg IV (2 days)
Tocolitic
Plan Expectative
 July, 19th 2013 07.30 am

Anamnestic Feeling of pain from waist to groin (+)

Bloody show from the vagina (+)
Fetal movement (+)
Physical Examination Vital sign :
General appearrance : Moderate
Conciousness : Composmentis cooperative
Blood pressure : 120/80 mmHg
Heart rate : 85 x/m
Respiratory rate : 20 x/m
Body Temperature : 37 ⁰C
Abd : uterine contraction 3-4x/40”/strong
FHR : 135-145 bpm
Gen : I : V/U normal, vaginal bleeding was abscent
Vaginal Toucher :
Ø 4-5 cm
Amnionic sac (+)
Head palpated at HI-II

Diagnose G1P0A0L0 preterm parturient 30-32 weeks first stage of active phase
Fetal alive singleton intrauterin head presentation at HI-II
Management Control GA, VS, uterine contraction, FHR
Follow the progress of labor

Plan Report to counsulent on duty

Adv  Vaginal delivery
Consult to perinatology
 July, 19th 2013 08.30 am

Anamnestic Feeling of pain and to bear down

Amniotic Fluid spontaneusly leakaged from the vagina
Fetal movement (+)
Physical Examination Vital sign :
General appearrance : Moderate
Conciousness : Composmentis cooperative
Blood pressure : 120/80 mmHg
Heart rate : 80 x/m
Respiratory rate : 20 x/m
Body Temperature : 37 ⁰C
Abd : uterine contraction 3-4x/40”/strong
FHR : 130-140 bpm
Gen : I : V/U normal, vaginal bleeding was abscent
Vaginal Toucher :
Ø complete
Amnionic sac (-), clear residu
Head palpated at HIII-IV

Diagnose G1P0A0L0 preterm parturient 30-32 weeks firrst stage of active phase
Fetal alive singleton intrauterin head presentation at HIII-IV
Management Control GA, VS, uterine contraction, FHR
Lead to bear down

Plan Vaginal delivery

0n 08.45 am
A male baby was born with spontaneously, 1900 grams in weight, 42 cm in lenght,
and Apgar Score 7/8
Placental was born spontaneous, complete, size was 14x14x2 cm, weight
approximately 350 gr.
Umbilical cord was approximately 45 cm in length with paracentral insertion
IUD insertion was performed
Episiotomy wound was sutured and treated
Diagnose :
P1A0L1 post spontaneous preterm delivery + IUD acceptor
Mother was in good condition - child was in care
Management :
Observe fourth stage
Thank you