No.

CASE REPORT
 IDENTITY

 Name : Mrs. B
 Age : 24 years old
 MR No. : 99 99 88
 Date : February 28th, 2018
 Adress : Talang Jaya, Sungai Buluah, Padang
Pariaman
Anamnesis :
A 34 years old patient was admitted to the Ward Room
of Dr. M. Djamil Central General Hospital on February
27th, 2018 at 16.30 a.m refered from polyclinic obstetry
with diagnosed G4P2A1L2 39-40 weeks of term
pregnancy + HbsAg (+)
Present Illness History :

 Feeling of pain from waist region which referred to

the groin (-)
 Bloody show from the vagina (-)
 No massive vaginal bleeding.
 Amenorrhea since 9 months ago.
 First date of last menstrual period on May 25th, 2017
Estimation date of delivery on March 01st, 2018
 Fetal movement was felt since 5 months ago.
 No complain of nausea, vomitting and vaginal
bleeding neither during early pregnancy nor late
pregnancy.
 Prenatal care to public health care , 4x on 3,4,6 and 8
month of pregnancy, patient was known with HbsAg
(+) since 3 month of pregnancy
 Menstruation History : menarche at 13 years old,
irregular cycle, once a month which last for 5 to 7
days each cycle with the amount of 2-3 times pad
change/day without menstrual pain.
Previous Illness History :
There wasn’t previous history of heart, lung, liver, kidney,
DM, hypertension and drugs allergic.

Family Illness History :

 There wasn’t history of hereditary disease, contagious and
physicological illness in the family.

Marriage history : once in 2005

History of pregnancy/abortion/delivery : 2/0/1
1. 2005, male, 3500 gr, term, spontanous, midwife, life
2. 2008, IUFD, on 7 months pregnancy
3. 2009, Female, 3600 gr, term, spontanous, midwife, life
4. Present

History of family planning : (+) since 2009-December 2016

History of immunization : (-)
History of formal education: Junior High School
History of Habitually : Cigarrete (-), alcohol (-), drugs (-)
Physical Examination :
 GA : Moderate
 Considered : CMC
 Blood Pressure : 120/80 MmHg
 Pulsase rate : 80x /’
 Respirasi Rate : 20x/’
 Temperature : 36,8 °C

 Body Weight : 55 Kg Body Height : 155 cm

 Body Weight (after pregnancy) : 65 kg
 Circumference upper arm: 24 cm BMI : 22,7 kg/m2

 Eyes : Conjunctiva wasn’t anemic, Sclera wasn’t icteric

 Neck : JVP 5-2 cmH2O, tyroid gland no enlargement
 Chest : H/L normal
 Abdoment: OR
 Genitalia : OR
 Extremity : Edema -/-, Physiological Reflex +/+,
Pathological Reflex -/-

Obstetric Record :
 Abdoment :
I : Enlarge according to term pregnancy, median
line hyperpigmentation, striae gravidarum (+),
Cicatrix (-)
 Palpation :
L1: Uterine fundal height was palpable 3 fingers
below xiphoideus processus. A large, soft,
nodular mass was palpable.
L2: Greatest resistance was palpable on the right
side. Numerous small, irregular structure were
felt on the left side
L3 : A round hard mass was palpable, fixated
L4 : convergent
Uterine Fundal Height : 33 cm – EFW : 3200 gr
Uterine contraction : (-)
 Au : FHR : 140-150/1’ regularly

Genitalia : I : V/U normal, vaginal bleeding (-)

No. Parameter Result Normal Range

1 Haemoglobine 11,5/dl 12.-14

2 Haematocryte 36 % 37-43

3. Leucocyte 6.380 /mm3 5-10

4. Trombocyte 294.000/mm3 150.000-400.000

5. PT 10,4 second 11,8

6. APTT 34,3 second 33,3

7. HbSAg Reactive Non-reactive

8. Anti-HIV Non-reactive Non-reactive

 USG Interpretation

 Fetal live, singleton, intrauterine head presentation

 Fetal movement activity was good
 Biometry :
BPD : 95,4 mm FL : 66,3 mm
AC : 353,3 mm EFW : 3394 gr
SDP : 3,16 cm
 Placenta was implanted at corpus frontside Gr II-III
 I/ Term pregnancy 39-40 weeks
Fetal alive singleton, intrauterine head
presentation
CTG
CTG
 Baseline : 130
 Variability : 5-15
 Acceleration : (+)
 Deseleration : (–)
 Fetal Movement: (+)
 Contraction : (-)
 Impression : CTG category I
Diagnose :
G4P2A1L2 term pregnancy + HbsAg (+)
Fetal alive, singleton, intra uterine, head presentation
Management :
 Control GA, VS, FHS
 Informed consent
 Examine routine Blood test, PT, APTT, HbSAg, Anti HIV
 Antibiotic : Inj. Ceftriaxone 1 g IV (skin test)
 Consult to operation room and
anesthesiologist,perinatology

Plan :
 Elective Caesarean Section
 28/02/2018 At 18.30 : TPPCS was perfomed

A male baby was born by TPPCS with 3100 gram in

weight, 50 cm in height, Apgar score : 8/9.
Placenta was born with a light traction on umibilical
cord, complete, 1 piece. Size was 17 x 15 x 3 cm, weight
 500 gram, Length of umbilical cord : 50 cm,
paracentral insertion

Bleeding during operation  250 cc

 D/ P3A1L3 post TPPCS on indication of HbsAg (+)

Mother – Child were in care
 P/ Control GA, VS, Vaginal Bleeding, uterine
contraction
 IVFD RL + Drip Oxytocin : Metergine = 1:1 20 tpm
 Inj. Ceftriaxone 2x1 g IV
 Pronalges supp 2 (if needed)
 Check routine blood test post op
 01/03/2018
S Pain (+), Fever (-), vaginal bleeding (-
) (-)
O VS GC moderate
Con CMC
BP 120/80 mmHg
HR 80x/’
RR 20x/’
Abd Surgical wound covered with
bandage
FUT 2 finger under umbilical.
Acute abdomen sign (-)
Gen V/U Calm, PPV (-)
A P3A1L3 post TPPCS on indication of
HbsAg (+) Puerpureal Day II
Mother – Child were in care
02/03/2018
Pain (+), Fever (-), vaginal bleeding
VS GC moderate
Con CMC
BP 110/70 mmHg
HR 84x/’
RR 20x/’
Abd Surgical wound covered with
bandage
FUT 2 finger under umbilical.
Acute abdomen sign (-)
Gen V/U Calm, PPV (-)
P3A1L3 post TPPCS on indication of
HbsAg (+) Puerpureal Day III
Mother – Child were in care

P Control GA, VS, FHS, HIS Control GA, VS, FHS, HIS
IVFD RL 20 tpm IVFD RL 20 tpm
Ceftriaxone 2x1gr Cefixime 2x200 mg (po)
Paracetamol 3x500mg (po) Paracetamol 3x500mg (po)
SF 2x300 mg (po) SF 2x300 mg (po)