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Resident on Duty :
Obstetrical chief: Dr. M. Fauzi Chairul Husna
Gynecological chief: Dr. Arief Krisnadhi
Dr. Chaerannisa Akmelia
Dr. Willyyam Danles
Dr. Riyan Wira Pratama
Dr. Rivai Baharuddin
Dr. Mughan Sukardo
Dr. Wadhit Taubah
D. M. Atthariq Prasetiyo
Dr. Sonia Prima Arisa Putri
1
Duty Report
Wednesday, Desember 5th 2018, 3.30 PM to
Thursday, Desember 6th 2018, 07.00 AM
2
Obstetric Patients
No Identity Diagnosis ICD Procedure ICD
. 10 9
1 Mrs. G4P3A0 33 weeks gestational age O26.9 - VBAC 654.2
KAR/29/UA inlabor 1st stage active phase O14.3 P/ vaginal
with PPROM 4 hours + prior CS O34.21 delivery
1x oi SLF cephalic presentation
Laboratory Hb: 10.8 g/dl, WBC: 24.300/mm3, PLT: 370.000/mm3 Ht: 33%,
examination
Diagnosis G2P1A0 38 weeks gestational age in labor 1st stage active phase with PROM 8 hours + severe preeclampsia +
VBAC 6 = 77% prior CS 1x oi severe preeclampsia SLF cephalic presentation
Management • Stabilization 3 hours
• Observation vital signs ,FHR, and labor
• IVFD RL gtt xx/m
• Nifedipine 10 mg/8 hours PO
• MgSO4 40% according to protocols
• Inj. Ampicillin 1 gr/6 hours IV
• Urinary catheter, monitor I/O
• Consult to Internal medicine Dept, Opthalmology Dept
• P/ Vaginal delivery
Interna dept A : Gestational hypertention
P: Methyldopa 3x250 mg
P :informed consent
Hypertention regulation as OBGYN
Reassesment if was decreasing of visus
Identity Mrs. RUS/31 yo/ RA
Chief complaint Aterm pregnancy with watery discharge
History ± 2 days before admission, patient complain about history of amniotic leakage (+)clear, odor
5.12.18 (-) >3x changing napkins. abdominal contraction(-). history of bloody show (-). history of
(8.49 PM) abdominal massage (-), history of post coital (-), history of leucorrhea (+), history of
abdominal trauma (-), history of toothache (-). history of fever (-). She admitted that her
pregnancy was preterm and and fetal movement (+). Patient went to Moh. Hoesin hospital
Marital status Married 1 time 11 months
Reproduction status Menarche since 13yo, regular cycle 30 days, 7 days, LMP: 22 02 2018
Obstetric history 1. current pregnancy
Past iIlness history -
Physical Examination Vital sign: BP: 120/80mmHg, HR: 82x/m, RR: 20x/m, T: 36.7 oC
Obstetric examination Palpation:
Fundal height 3 fingers below Proc.xyphoideus ( 29 cm), longitudinal lie, left back, W uterine
contraction (-), FHR: 133 x/minute, EFW: 2745 g
Inspeculo
Portio Livide, external uterine ostium closed, fluor (-), fluxus (+) amniotic fluid not active,
Nitrazine test + red blue, erosion/laceration/polyp (-)
VT
Portio soft, posterior, eff 0 %, 0cm of dilatation, breech, above spina ischiadica, amnionic
membrane and denominator cannot be determined yet
Identity Mrs. RUS/31 yo/ RA
US ER (CNN) There’s SLF breech presentation
Fetal biometry:
BPD 8.42 cm AC 28.14 cm EFW 2361g
HC 30.43cm FL 7.25 cm
Placenta at anterior corpus
Amnionic fluid minimal
C/ 40 weeks of gestational age SLF breech presentation + anhydramnios
Diagnosis G1P0A0 40 weeks gestational age not inlabor with PROM 2 days SLF breech presentation +
anhydramnios
Laboratory Hb: 8.7 g/dl, WBC: 13.600/mm3, PLT: 207.000/mm3 Ht: 27%
examination
17
Identity Mrs.ELI/31/RA
US Confirmation - Single life fetus cephalic presentation
- Fetal Biometry: BPD 78.6 mm AC 284 mm EFW: 1993 gr
HC 294.3 mm FL 60.9 mm
- Placenta at anterior corpus extend spreading to OUI
- Amniotic sufficient, SDP 4,25 cm
-C/ 34 weeks gestational age SLF cephalic spresentation + total placenta previa
Lab results Hb 7.1 Leu 26.100 Plt 273.000 Ht 25 HBsAg non reactive, anti HIV non reactive T3 3.53 Free T4 3.06 TSHs 0.0020
Diagnosis G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
uncontrolled + moderate anemia SLF cephalic presentation
Theraphy Expectative management
Obs vital sign, His, FHR, bleeding sign
Nifedipine 10mg/6 h po
Inj. dexamethason 6mg/12 h IV
Assesment interna department
Plan for US confirmation
Assesment interna A/ Asthma attack in pregnancy
department Hypertyroid subklinis
Index wyne 3 P/ Nebu ventolin 1 resp/8 hours
Burch wartoschcy 30 Metylprednison 2x4mg PO
Faal Tyroid examination
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SLF cephalic presentation
P/ expectative management
US confirmation
Consult to internal department
18
Identity Mrs.ELI/31/RA
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SLF cephalic presentation
14.30 P/ Nebulizer with ventolin
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SLF cephalic presentation +fetal distress
15.10 P/ intrauterine resuscitation
Informed consent
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SDF cephalic presentation
15.30 P/ for abdominal termination
Consult to internal and anesthesiology
Internal department A/ impending thyroid storm
Hypertension st II
Anemia
Thyroid heart disease NYHA II
P/ PTU 100mg/8 hours
Digoxin 0.25 mg
Metyldopa 500mg/ 8 hours
Furosemide 40 mg/ 24 hours
Lugolization 8 gtt / 6 hours
Anesthesiology A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
uncontrolled + moderate anemia SDF cephalic presentation
P/ collaboration with internal department
Plan for PRC transfusion
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
4/11/2018 uncontrolled + THD NYHA 2 + moderate anemia SDF cephalic presentation
06.00 P/ observation vital sign. bleeding
Identity Mrs.ELI/31/RA
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
5/11/2018 uncontrolled + THD NYHA 2 + moderate anemia SDF cephalic presentation
06.00 P/ observation vital sign. bleeding
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
5/11/2018 uncontrolled + moderate anemia SDF cephalic presentation
17.10 P/
Follow up A/ G3P2A0 32 weeks gestational age not inlabor with APH ec total placenta previa + asthma attack + H/ Hypertyroid
3/11/2018 uncontrolled + moderate anemia SDF cephalic presentation
15.30 P/ for abdominal termination
Consult to internal and anesthesiology
Operative report Male death baby born BW 2100g BL 40 cm A/S 0 PTAGA
22.00 Placenta delivered completely PW : 400g UL 45 cm Ꝋ 17x18cm
Identity Mrs. LEN/27 yo/ UA
Chief complaint Inlabor with high blood pressure and prior cesarean section
History Patient referred from SpOG with G3P2A0 aterm not inlabor with high blood pressure and
5.12.18 prior cesarian section. patient complain about abdominal contraction(+). Hypertension in
() current pregnancy (-), hypertension before pregnancy (-), hypertension in previous pregnancy
(-), hypertension in family (-), severe headache (-) nausea (-), vomiting (-), epigastric pain (-),
blurry vision (-) history of bloody show (+), history of amniotic leakage (-). history of
abdominal massage (-), history of post coital (-), history of leucorrhea (+), history of
abdominal trauma (-), history of toothache (-). history of fever (-). She admitted that her
pregnancy was preterm and and fetal movement (+). Patient went to Moh. Hoesin hospital
Marital status Married 1 time 4 years
Reproduction status Menarche since 13yo, regular cycle 28 days, 7 days, LMP: forgot
Obstetric history 1. 2014. female. 2300g. CS. Bunda hospital, healthy
2. 2017 female. 2700g CS . Az-Zahra hospital. Healthy
3. current pregnancy
Past iIlness history -
Physical Examination Vital sign: BP: 120/80mmHg, HR: 82x/m, RR: 20x/m, T: 36.7 oC
Obstetric examination Palpation:
Fundal height 3 fingers below Proc.xyphoideus (33 cm), longitudinal lie, right back, head, U
4/5, uterine contraction (2x/10’/20”), FHR: 133 x/minute, EFW: 3100 g.
VT
Portio soft, medial, eff 25%, 2cm of dilatation, cephalic, H I, amnionic membrane and
denominator cannot be determined yet
Identity Mrs. LEN/27 yo/ UA
US (ER) There’s SLF cephalic presentation
Fetal biometry:
BPD 9.37 cm AC 33.63 cm HC 32.56 cm FL 7,2 cm cm
Placenta at fubdus
Amnionic fluid minimal
C/ 38 weeks of gestational age SLF cephalic presentation
Diagnosis G3P2A0 38 weeks gestational age inlabor 1st stage latent phase with PPROM 4 hours + prior
CS 1x oi breech presentation SLF cephalic presentation
Laboratory Hb: 11.5 g/dl, WBC: 9700/mm3, PLT: 311.000/mm3 Ht: 34%
examination
Laboratory Hb: 12.8 g/dl, wbc 10.300/ mm3, trombosit 244.000/mm3, Ht 39%, Proteinuria +2, LDH 309, SgOT 69,
Examination SgPT 40, ureum 17, Cr 0.7
Identity 7. Mrs. RAN /30/UA 7.4.2018 01.00 AM
Diagnosis G1P0A0 37 weeks gestational age inlabor 2nd stage SLF breech Presentation
Therapy • IVFD RL gtt xx/m
• Laboratory examinataion
• Plan for vaginal delivery
• Conduct the labor
Delivery report 06:20 AM : Male life baby, Weight 2500 g, Height 43 cm, A/S 8/9 FTAGA
06:25 PM : complete placenta, PW 380 g, UC 40 cm, Ø 15 x 16 cm
Perform tubectomy
Identity Mrs. FIT/26/UA
Chief complaint preterm pregnancy with vaginal bleeding
5/12/2018
09.00 PM
History 1 hours before admitted patient complain vaginal bleeding, reddish 1x change napkins, h/ amniotic leakage(-).
abdominal contraction regulerly (-), H/ post coital (-) h/ trauma (-) h/ Abdominal massage (-) H/ Leukorrhea (-),
Patient admitted that pregnancy was preterm and fetal movement (+)
US ER (CNN) Uterine small in size and shape, 2.63x1.8 cm in size – post menopause
Both ovarium – post menopause
Liver within normal limit
Right kidney within normal limit
Left kidney : hydronefrosis
Ascites (-)
k/ there is no abnormality in gynecologic
Diagnosis Left humerus neoplasm with malignancy was suspeted
US ER (CNN) Uterus both size and shape within normal limit, 6.94x3.91 cm, endometrial line (+)
Both ovarium within normal limit
Hepar, Lien within normal limit
Right kidney within normal limit
Left kidney = Hydronephrosis
Ascites (+)
k/ there is no abnormal in gynecologic
Diagnosis Ascites ec cirrhosis hepatic was suspected
Moderate anemia
trombocytosis
Management There is no medical treatment from OBGYN department
PASSED AWAY
Identity Mrs. HER /38 y.o/ RA
Nov 22nd 2018 at
10.55 AM
Chief complain Preterm pregnancy with vaginal bleeding and placenta covering birth canal
History 9 hours before admission, patient complain about vaginal bleeding (+) 3 times
changing underpad. patient complained abdominal contraction spreading to waist and
back (+) infrequently. History of amniotic leakage (-) hystory of trauma (-), hystory of
post coital (-), patient referred from Ogan Ilir hospital. Patient admitted that her
pregnancy is preterm and she can still feel the movement of the fetus.
Marital status 1x, 12 years
Reproduction Menarche since 13 yo, irregular cycle, LMP : forgot
status
Obstetric history 1. 2007. female. 2600 g. Midwife. Spontaneus delivery. healthy
2. 2012. female. 4500 g. CS oi hydrocephalus. Moh Hoesin hospital, +
3. 2012. female. 2600 g. CS oi prior CS 1x. Moh Hoesin hospital. healthy
4. This pregnancy
Identity Mrs. HER /38 y.o/ RA
Physical Sens: Compos mentis
examination BP : 110/70 mmHg, P : 100 bpm, T : 36.0 C, RR : 20 bpm BW: 62 kg BH: 150 cm
Insp : portio livide, closed OUE, fluor (-), fluxus (+) non active bleeding, E/L/P (-)
US ER - Single life fetus intrauterine
- Fetal Biometry: BPD 6.70 cm AC 24.86 cm EFW: 1250g
HC 22.53 cm FL 5.05 cm
- Placenta at posterior corpus extended covering OUI
- Amniotic fluid SDP: 0.95 cm
50
RR SpO2%
TD N T Tindakan,
Tgl/jam Sens (x/mnt
(mmHg) (x/mnt) (ºC) cairan,obat-obatan
)
05/12/20 E1M1VT 92/67 72 25 36,40 92/67 Drip dobutamine 1 amp dalam
18 NaCl 0,9% 100cc gtt X/m
15.00
E1M1VT 72/50 68 17 36,20 72/50 Drip dobutamine 1 amp dalam
15.15 NaCl 0,9% 100cc gtt X/m
C/ Pulmonary
edema dd/
pneumonia
Cardiomegaly
25-11-2018
C/Pulmonary Edema
Cardiomegaly
x
x x