DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Emergency Room Report

Wednesday, September 25th 2019

Resident on Duty:

Dr. Bagus Hilmawan

Chief on Duty:

Dr. Venny Melinda

Doctor in charge :

Dr. H. Iskandar Zulqarnain, SpOG(K)

Supervisor :

Dr. dr. H. Heriyadi Manan, SpOG (K), MARS

 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

PATIENT RECAPITULATION

EMERGENCY ROOM

DATE OBSTETRICS GYNECOLOGY TOTAL

Friday, Sep 20th 1 1 2

2019

Monday, Sep 23th 1 0 1

2019

Tuesday, Sep 24th 4 2 6

2019

Wednesday, Sep - - -
25th 2019

Thursday, Sep 26th - - -

2019

6 3 9
Total
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG
REKAPITULATION BASED ON DIAGNOSIS EMERGENCY ROOM
REPORT

Diagnosis ICD 10 Procedure ICD 9 Number

of Cases
Preterm with PPROM 4 O42.113  LSCS 74 1
hours + severe preeclampsia O14.13
+ prior CS 1x interdelivery O34.21
15 months + Gestational DM O24.41
+ Hepatitis B infection + O32.1
SLF breech presentation + Q77.4
Chondroplasia
Aterm pregnancy with O42.10  Labor induction 73.01 1
PROM 12 hours + Moderate D64.9  Vaginal delivery 650
anemia + Oligohydramnios O41.03
Ovarian cancer stage IIIC C56.9  Medicinalis 99.2 1
post suboptimal debulking T81.31
with burst abdomen + R77.0
Hypoalbuminemia + Mild D64.9
anemia
Early pregnancy with O20.0  Medicinalis 99.2 1
threatened abortion with A15.0  Assessment 89
dyspneu cb lung tuberculosis J45 Internal Medicine 793.6
was suspected + Asthma  US confirmation
attack
Aterm pregnancy with O42.10  Labor induction 73.01 1
PROM 2 hours  Vaginal delivery 650
Preterm with severe O14.13  Assessment 89 1
preeclampsia + prior CS 1x O34.21 Internal Medicine 74
(oi Eklampsia) + Controlled O77.9 Dept &
SLE + moderate anemia SLF Opthalmology
cephalic presentation + fetal Dept
distress  LSCS
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

No Date Identification Diagnosis ICD 10 Management / ICD 9

Procedure
1 25/09 Mrs. ISP/ 32 G2P1A0 35 weeks O42.113  Assessment 89
/2019 Y.O/1139396/ gestational age not O14.13 Internal 74
RA/ HIL- in labor with O34.21 Medicine Dept
VNY/ PB PPROM 4 hours + O24.41 &
severe O32.1 Opthalmology
preeclampsia + Q77.4 Dept
prior CS 1x  LSCS
interdelivery 15
months +
Gestational DM +
Hepatiti B
infection SLF
breech presentation
+ Chondroplasia
2 25/09 Mrs. FIT/ 26 G1P0A0 38 weeks O42.10  Labor 73.01
/2019 Y.O/1141742/ gestational age not D64.9 induction 650
UA/ HIL- in labor with O41.03  Vaginal
VNY/ FU PROM 12 hours + delivery
Moderate anemia
SLF cephalic
presentation +
Oligohydramnios
3 25/09 Mrs. NIN/ 53 Ovarian cancer C56.9  Medicinalis 99.2
/2019 Y.O/1126089/ stage IIIC post T81.31
RA/ HIL- suboptimal R77.0
VNY/ AT debulking with D64.9
burst abdomen +
Hypoalbuminemia
+ Mild anemia
4 25/09 Mrs. NUR/ 31 G3P2A0 16 weeks O20.0  Medicinalis 99.2
/2019 Y.O/ gestational age A15.0  Assessment 89
1141852/ UA/ with threatened J45 Internal 793.6
HIL-VNY/ abortion with Medicine
HE dyspneu cb lung  US
tuberculosis was confirmation
suspected +
Asthma attack SLF
intrauterine
5 25/09 Mrs. SHE/31 G1P0A0 40 weeks O42.10  Labor 73.01
/2019 Y.O/ 339383/ gestational age induction 650
UA/ HIL- inlabor first stage  Vaginal
VNY/ AF latent phase with delivery
PROM 2 hours
SLF cephalic
presentation
6 25/09 Mrs. Mrs. G2P1A0 32 weeks O14.13  Assessment 89
/2019 SIT/ 27 Y.O/ gestational age not O34.21 Internal 74
1025042/ UA/ in labor with O77.9 Medicine Dept
HIL-VNY/ severe &
NS preeclampsia + Opthalmology
prior CS 1x (oi Dept
Eklampsia) +  LSCS
Controlled SLE +
moderate anemia
SLF cephalic
presentation +
Fetal distress
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

Identity 1. Mrs. ISP/ 32 Y.O/ 1139396/ RA/ HIL-VNY/ PB

Chief Preterm pregnancy with amniotic leakage, hypertension, Hepatitis
Complaint B and congenital fetal abnormalities
History of About 4 hours before admission patient complained amniotic
Present leakage, 1x changing pad, clear, odor (-), history of abdominal
Illness contraction (-), history of vaginal bleeding (-).
History of leuchorrea (-), history of skin disease (-), history tooth
24-09-2019 ache (+), history of abdominal trauma (-), history of take medicine
08.22 AM and herbs (-).
History of hypertension before pregnancy (-), history of
hypertension in prior pregnancy (+), history of epigastic pain (-),
history of headache (-), history of nausea (-), history of vomitus(-
), history of blurry vision (-).
Patient admitted that her pregnancy was preterm and she still can
feel the fetals movement.
Past illness 09-09-2019:
history Patient referred from Pagaralam to Fetomaternal clinic at Moh.
Hoesin hospital and has an elective cesarean section schedule 09-
10-2019.

Other Marital Status : 1x, 10 years

Histories Reproduction Status : menarche 13 yo, regular cycle 28 days, for
7 days, LMP : 13-01-2019
Obstetric History :
1. June 2018, female, 1300 g, preterm, CS o.i severe preeclampsia,
died when baby was 2 days old
2. Current pregnancy
General BP : 160/90 mmHg, P : 88 x/min, RR : 20 x/min, T : 36.5 C,
Physical BW: 81 kg, BH: 158 cm, BMI 32.4
Examination Head: normocephali, pallor conjunctival (-/-), scleral icterus (-/-)
 Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-)
Thorax: Heart: I-II HR N, regular, murmur (-), gallop (-)
Lungs: vesicular (+/+) N, ronkhi (-/-), wheezing (-/-)
Extremity : edema (-)
Obstetrical Inspection and palpation :
Examination Abdomen : fundal height ½ umbilical - proc. Xyphoideus (31 cm),
(HIL) longitudinal lie, right back, breech, W, contraction (-), FHR 150
bpm, EFW 2995 g

Inspeculo :
Portio livide, OUE closed, fluor (-), fluxus (+), clear, odor (-),
didn’t active, Nitrazine test (+), erosion (-), laceration (-), polyp (-
)

VT :
Portio was soft, posterior, eff 0%, dilatation (-), breech, upper
spina Ischiadica, amniotic membrane and denominator difficult to
assessed.

Gestosis Index : 4
Laboratory 24.09.2019
Examination Hb 11.6 g/dL, RBC : 4.39 x 106/ mm3, WBC 8880; Ht : 35% , PLT
328.000, MCV : 79.3, MCH: 26, MCHC : 33, DC: 0/0/72/23/5,
SGOT 36 U/L, SGPT 38 U/L, Albumin 3.1 g/dL, LDH 248 U/L,
BSS 148 mg/dL, Ur/Cr 15/0.61 mg/dL, Uric acid 7.1mg/dL, CRP
21, Ca 8.5 mg/dL, Mg 1.60 mg/dL, Na 142 mEq/L,K 4.4 mEq/L.

Urin: pH 6.0, protein (+2), glucose (-), keton (+1), blood (-),
Leucocytes esterase/LEA (-), epitel (-), leucocytes 0-1,
erythrocytes 0-1, silinder granuler (-), mucous (-).

09-09-2019
HbsAg Reactive, Anti HIV Non-reactive, TPHA non-reactive,
VDRL Non-reactive
US - SLF breech presentation
Examination - Fetal biometry :
09.09.19 BPD : 8.35 cm FL : 5.15 cm
(AB) HC : 10.80 cm AC : 28.34 cm EFW : 1514 gr
 TCD : 4.16 cm
Bone size: Radius 4.55 cm, Ulna 5.19 cm, TIB 5.18 cm,
right FL 4.40 cm, left FL 4.17 cm
- There wasn’t other congenital abnormalities, heart difficult
to evaluation.
- There Femur length was short in sized with bowing and
imperfect ossification.
- Placenta at uterine fundal
- Amniotic fluid sufficient
C/ 33 weeks gestational age, SLF breech presentation with the
baby has defects in both femurs + thick segment of the lower
uterus was 1-2 mm
 ER US - SLF breech presentation
24.09.19 - Fetal biometry :
(VNY) BPD : 8.72 cm FL : 4.49 cm
HC : 30.97 cm AC : 31.35 cm EFW : 1958 gr
TCD : 4.64 cm = 34 w 4 d
- Placenta at uterine fundal
- Amniotic fluid sufficient
C/ 34 weeks gestational age, SLF breech presentation
 Diagnosis G2P1A0 35 weeks gestational age not in labor with PPROM 4
hours + severe preeclampsia + prior CS 1x interdelivery 15
months + Gestational DM +Hepatitis B infection SLF breech
presentation + Chondroplasia
Management  Vital sign, abdominal contraction, FHR Observation
 Laboratory examination (complete blood count, liver function,
renal function, blood sugar, electrolyte, hemostatic function
test)
 Stabilization
 Nifedipin 10 mg/ 8 hours PO
 Urinary catheter
 MgSO4 ~ protocol
 Assessment Internal Medicine Dept & Opthalmology Dept
 Report to doctor incharge: DR. Dr. Peby Maulina, SpOG(K):
Suggestion to LSCS after stabilization
 Assessment A/ Hypertension in pregnancy
Internal P/ Metildopa 250 mg/8 hours
Medicine Dept Less salt diet
Another therapy appropriate Obgyn
Assessment A/ There are currently no signs of hypertensive choroidopathy and
Opthalmology retinopathy
Dept P/ Therapy appropriate Obgyn
Operating 03.30 PM : Pfannensteil incision
report 03.35 PM : male life baby was born, WB 2000 g, BL 43 cm, A/S
03.30 – 04.10 3/5/7 PTAGA
PM 03.38 PM : complete placenta was delivered, weight 380 g, UCL
40 cm, Ø 15x16 cm
Lubchenco

Ballard

Recent P2A0 post LSCS oi severe preeclampsia + PPROM 4 hours +

diagnosis prior CS 1x interdelivery 15 months + Gestational DM + breech
presentation
 Recent Patient was stable in ward
condition

Identity 2. Mrs. FIT/ 26 Y.O/ 1141742/ UA/ HIL-VNY/ FU

Chief Aterm pregnancy with amniotic leakage
Complaint
History of About 12 hours before admission patient complained amniotic
Present leakage, 2-3x changing pads, clear, odor (-), history of abdominal
Illness contraction (-), history of vaginal bleeding (-).
History of leuchorrea (-), history of fever (-), history of skin
24-09-2019 disease (-), history tooth ache (-), history of abdominal trauma (-),
08.45 AM history of take medicine and herbs (-).
Patient admitted that her pregnancy was aterm and she still can
feel the fetals movement.
Past illness Routine ANC at OB/GYN
history
Other Marital Status : 1x, 1 year
Histories Reproduction Status : menarche 13 yo, regular cycle 28 days, for
5 days, LMP : 06-01-2019
Obstetric History :
1. Current pregnancy
General BP : 100/70 mmHg, P : 80 x/min, RR : 20 x/min, T : 36.5 C,
Physical BW: 57 kg, BH: 156 cm
Examination Head: normocephali, pallor conjunctival (-/-), scleral icterus (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-)
Thorax: Heart: I-II HR N, regular, murmur (-), gallop (-)
Lungs: vesicular (+/+) N, ronkhi (-/-), wheezing (-/-)
Extremity : edema (-)
Obstetrical Inspection and palpation :
Examination Abdomen : fundal height 3 fingers below proc. Xyphoideus (32
(HIL) cm), longitudinal lie, right back, head,U 5/5, contraction (-), FHR
141 bpm, EFW 2948 g
 Inspeculo :
Portio livide, OUE closed, fluor (-), fluxus (+), amniotic fluid,
didn’t active, clear, odor (-), Lakmus test (+), erosion (-),
laceration (-), polyp (-)

VT :
Portio was soft, posterior, eff 25%, dilatation (-), head, HI,
amniotic membrane and denominator difficult to assessed.

Bishop Score : 3
Laboratory Hb 8.5 g/dL, RBC : 3.76 x 106/ mm3, WBC 14670; Ht : 28% , PLT
Examination 270.000, MCV : 73.1, MCH: 23, MCHC : 31, DC: 0/0/82/10/8,
24.09.2019 SGOT 36 U/L, Ferritin 1.90, Serum iron 27, TIBC 474, CRP < 5,
HbsAg Non-reactive, Anti HIV Non-reactive, TPHA non-reactive,
VDRL Non-reactive

Urin: pH 6.0, protein (-), glucose (-), keton (+2), blood (-),
Leucocytes esterase/LEA (+3), epitel (-), leucocytes 8-11,
erythrocytes 0-1, silinder granuler (-), mucous (-).
ER US - SLF cephalic presentation
24.09.19 - Fetal biometry :
(DRI) BPD : 9.20 cm FL : 7.24 cm
HC : 33.20 cm AC : 33.82 cm EFW : 3238 gr
- Placenta at posterior corpus of uterine
1 1.2
- Amniotic fluid was decreased AFI = 1.4 1
= 4.6

C/ 38 weeks gestational age, SLF cephalic presentation

 Diagnosis G1P0A0 38 weeks gestational age not in labor with PROM 12
hours + moderate anemia SLF cephalic presentation +
Oligohydramnios
Management  Vital sign, abdominal contraction, FHR Observation
 Laboratory examination (complete blood count, CRP, complete
urin, LEA)
 IVFD RL xx drops/min
 Report to doctor incharge: Dr. Hj. Fatimah Usman, SpOG(K)
suggestion: Labor induction using Misoprostol 25 mcg/ 6 hours
 Vaginal delivery
Identity 3. Mrs. NIN/ 53 Y.O/1126089/ RA/ HIL-VNY/ AT
Chief complain Surgery wound was bleeding
History Since 6 hours before admissions patient complained bleeding from
surgery wound, pain (-). 19-09-2019 patient D/ Ovarian cancer
24-09-2019 stage IIIC post suboptimal debulking + adhesiolysis (only biopsy
00.35 PM because tumor was fragile).
History of abdominal enlargement (-), history of fever (-), history
of nausea & vomiting (-), history of pus out from surgery wound (-
), history of decreased appetite (+) and lost weight (+), urinate and
defecate in normal limit. Patient went to emergency room Moh.
Hoesin hospital.
Past Illness 19-09-2019 patient D/ Ovarian cancer stage IIIC post suboptimal
debulking + adhesiolysis (biopsy)
Marital status 1x, 22 years
Reproduction Menopause since 17 years ago
status
Obstetrical P2A1
status
Physical BP : 100/60 mmHg, P : 80 x/min, T : 36.2 C, RR : 20 x/min,
examination weight 45 kg, height 150 cm.
Head: normocephaly, pale conjunctiva (-/-) Sclera icteric (-/-)
Neck: JVP (5-2)cmH2O, lymph enlargement (-)
Heart: Sound I-II clearly, regular, murmur (-) gallop (-)
Lung: Vesicular (+), Rh (-/-), Wh (-/-)
Extremities: pretibial edema (-)
Gynecology Inspection: There was Mediana incision, pus (-), blood (-), defect
Examination (+) edge of the incision, sized 3x15 cm
(HIL) External examination of Abdomen :
convex, symmetric, uterine fundal height difficult to assessed,
mass (+) 18x20 cm, immobile, upper border was 3 fingers above
umbilical, right border was right LMC, left border was left LMC,
lower border was symphysis, tenderness (+), free fluid sign (-).
Genitalia :
Inspeculo : portio wasn’t livide, ostium uterine external was
closed, fluor (-), fluxus (-), erosion (-)/ laseration (-), polyp (-)
VT : portio was firm, pushed anteriorly, ostium uterine external
was closed, uterine corpus ~ normal, Douglas pouch didn’t
 protrude, both of AP were tense and palpable mass sized 18x20 cm,
immobile.
RT : Anal sphincter was good, smooth mucous, ampula recty was
empty, uterine corpus ~ normal, both of AP were tense and
palpable mass sized 18x20 cm, immobile.

US ER - Uterine difficult to identification.

(VNY) - There was solid mass with cystic part, multiloculare, sept
24.09.2019 (+),sized 15x15x13 cm, increased of vascularization possibilty
mass malignancy of adnexa was suspected (solid ovarian
neoplasm with cystic part malignancy was suspected) 
Ovarian cancer post sub-optimal debulking
- Liver in normal limit.
- There was right hydronephrosis
- Left kidney in normal limit.
- Ascites (-)
C/ Solid ovarian neoplasm with cystic part malignancy was
suspected  Ovarian cancer post sub-optimal debulking
Laboratory Hb 9.9 g/dL, RBC : 3.31 x 106/mm3, WBC 16.470/mm3; Ht :30%
Examination , PLT 643.000/µL, MCV : 90.3 fL, MCH: 30 pg, MCHC : 33 g/dL,
24.09.2019 DC:0/1/73/19/7, Albumin 3.0 g/dL, BSS 68 mg/dL, Ur/Cr 47/0.70
mg/dL, Ca 7.7 mg/dL, Na 135 mEq/L, K 5.1 mEq/L
Diagnosis Ovarian cancer stage IIIC post suboptimal debulking with burst
abdomen + Hypoalbuminemia + Mild anemia
Treatment  Vital sign Observation
 Laboratory examination (complete blood count, albumin, renal
function, blood sugar, electrolyte)
 IVFD RL xx drops/min
 Report to doctor in charge Suggestion:
 Cultur: secretory out from surgery wound
 Ceftriaxone inj 1 g/ 12 hours IV
 Metronidazol 500 mg/ 8 hours IV
 Surgical wound care

Identity 4. Mrs. NUR/ 31 Y.O/ 1141852/ UA/ HIL-VNY/ HE

Chief Early pregnancy with vaginal bleeding, cough and dyspneu.
Complaint
History of Since 6 days before admissions patinet complained vaginal
Present bleeding, fresh red, 10x changing pads. History of nausea (-),
Illness history of vomitus (-), history of tense breast (+), history of vaginal
bleeding (-), history of abdominal trauma (-), history of post coital
24-09-2019 bleeding (-), history of leuchorrea (-), history of taking drugs or
02.30 PM
 herbs (-). Patient admitted early pregnancy with late menstruation
4 months.

Past illness History hospitalized with D/ Threatened abortion with lung

history tuberculosis was suspected with dyspneu. Patient got Ceftriaxone
3 x1, Maltofer and MgSO4.
History of DM (-), history of Hypertension (-), History of Asthma
(-)
Other Marital Status : 1x, 8 years
Histories Reproduction Status : menarche 13 yo, regular cycle 28 days, for
7 days, LMP : forgot
Obstetric History :
1.2012, female, 3000 g, spontaneous delivery, Midwife, healthy
2.2014, male, 2800 g, spontaneous delivery, Moh. Hoesin hospital,
healthy
3.Current pregnancy
General BP : 120/80 mmHg, P : 88 x/min, RR : 26 x/min, T : 36.4 C,
Physical Head: normocephali, pallor conjunctival (-/-), scleral icterus (+/+)
Examination Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-), struma
diffusa (+)
Thorax: Heart: I-II HR N, regular, murmur (+), gallop (+)
Lungs: vesicular (+/+) N, ronkhi (+/+), wheezing (+/+)
Extremity : edema (-)
Index wayne : 17
Obstetrical Inspection and palpation :
Examination Abdomen : Fundal height 3 fingers above symphysis, external
(HIL) ballotement (+), contraction (-), FHR 180 bpm/min
Inspeculo: portio was livide, OUE closed, fluor (-), fluxus (-),
erosion (-), laceration (-) and polyp (-)
Laboratory Hb 9.1 g/dL, RBC : 3.69 x 106/ mm3, WBC 10.570; Ht : 27% ,
Examination PLT 283.000, MCV : 73, MCH: 25, MCHC : 34, DC: 0/1/66/23/8,
24.09.2019 SGOT 30 U/L, SGPT 18 U/L, HbsAg Non-reactive, Anti HIV
Non-reactive, TPHA Non-reactive, VDRL Non-reactive
US - SLF intrauterine
Examination - Fetal biometry :
24.09.19 BPD : 3.09 cm FL : 1.67 cm
(VNY) HC : 11.37 cm AC : 10.47 cm EFW : 131.08 gr
- Placenta at posterior corpus of uterine spread & covered internal
ostium uterine.
- Amniotic fluid suficent was sufficient, SDP 2.1 cm
C/ 16 weeks gestational age SLF intrauterine
 Diagnosis G3P2A0 16 weeks gestational age with threatened abortion with
dyspneu cb lung tuberculosis was suspected + Asthma attack SLF
intrauterine
Management  Vital sign, fetal heart rate, abdominal contraction, bleeding
Observation
 O2 4L/min
 Laboratory examination (complete blood count, complete
urine, genexpert)
 Salbutamol
 Assessment Internal Medicine
 US confirmation
Assessment A/ CHF cb Thyroid Heart Disease
Internal Hypertension in pregnancy
Medicine Hyperthyroid
CAP was suspected
P/ Echocardography
Metildopa 500 mg/ 12 hours PO
Ceftriaxone 1 g/ 12 hours IV
N-Acetyl cystein 1 tab/ 8 hours PO
Check fT4, TSH
Furosemide 40 mg/ 24 hours IV
PTU 100 mg/ 8 hours PO

Identity 5. Mrs. SHE/31 Y.O/ 339383/ UA/ HIL-VNY/ AF

Chief Aterm pregnancy with amniotic leakage
Complaint
History of About 2 hours before admission patient complained amniotic
Present leakage, clear, odor (-), history of abdominal contraction (-),
Illness history of vaginal bleeding (-).
History of leuchorrea (+) odor (-) ithcy (-), history of fever (-),
24-09-2019 history of skin disease (-), history tooth ache (-), history of
01.30 PM abdominal trauma (-), history of take medicine and herbs (-).
Patient admitted that her pregnancy was aterm and she still can
feel the fetals movement.
Past illness DM (-), Hypertension (-)
history
Other Marital Status : 1x, 1 year
Histories Reproduction Status : menarche 13 yo, regular cycle 28 days, for
5 days, LMP : 18-12-2018
Obstetric History :
1. Current pregnancy
General BP : 110/70 mmHg, P : 84 x/min, RR : 20 x/min, T : 36.2 C,
Physical BW: 74 kg, BH: 163 cm
Examination Head: normocephali, pallor conjunctival (-/-), scleral icterus (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-)
Thorax: Heart: I-II HR N, regular, murmur (-), gallop (-)
Lungs: vesicular (+/+) N, ronkhi (-/-), wheezing (-/-)
Extremity : edema (-)
Obstetrical Inspection and palpation :
Examination Abdomen : fundal height 3 fingers below proc. Xyphoideus (34
(HIL) cm), longitudinal lie, left back, head,U 4/5, contraction (+)
2x/10’/25”, FHR 141 bpm, EFW 3255 g

Inspeculo :
Portio livide, OUE opened, fluor (+), fluxus (+), amniotic fluid,
didn’t active, clear, odor (-), Nitrazine test (+), erosion (-),
laceration (-), polyp (-)

VT :
Portio was soft, posterior, eff 100%, dilatation 1 cm, head, HI,
amniotic membrane (-), clear, odor (-) and denominator was
transverse sagittal suture.
Laboratory Hb 10.8 g/dL, RBC : 4.78 x 106/ mm3, WBC 11.810; Ht : 35% ,
Examination PLT 403.000, MCV : 73.6, MCH: 23, MCHC : 31, DC:
24.09.2019 0/6/66/20/8.
ER US - SLF cephalic presentation
24.09.19 - Fetal biometry :
(VNY) BPD : 9.15 cm FL : 7.27 cm
HC : 32.92 cm AC : 33.55 cm EFW : 3186 gr
TCD 5.54 = 38 w 3 d
- Placenta at posterior corpus of uterine
 - Amniotic fluid was sufficient
C/ 39 weeks gestational age, SLF cephalic presentation

Diagnosis G1P0A0 40 weeks gestational age inlabor first stage latent phase
with PROM 2 hours SLF cephalic presentation
Management  Vital sign, abdominal contraction, FHR Observation
 Laboratory examination (complete blood count, complete urin)
 IVFD RL xx drops/min
 Ampicillin inj 1 g/ 6 hours IV
 Report to doctor incharge: Dr. H. Amir Fauzi, SpOG(K), PhD
suggestion: Labor induction using Oxytocyn 5 IU
 Vaginal delivery

Identity 6. Mrs. SIT/ 27 Y.O/ 1025042/ UA/ HIL-VNY/ NS

Chief Preterm pregnancy with SLE
Complaint
History of Patient was diagnosed SLE and got regular treatment. History
Present malar rash (-), history of joint pain (-).History of abdominal
Illness contraction (-),amniotic leakage (-), history of vaginal bleeding/
bloody show (-).
24-09-2019 History of hypertension before pregnancy (-), history of
00.00 PM hypertension in prior pregnancy (+), history of epigastic pain (-),
history of headache (-), history of nausea (-), history of vomitus(-
), history of blurry vision (-).
Patient admitted that her pregnancy was preterm and she still can
feel the fetals movement.
Past illness Diagnosed SLE since 2016 and routine got medicine :
history Metilprednisolon 8 mg, Reboquine, Aspilet, Hemibion

Other Marital Status : 1x, 3 years

Histories Reproduction Status : menarche 13 yo, regular cycle 28 days, for
7 days, LMP : 06-02-2019
Obstetric History :
1.2017, male, 2300 g, preterm, CS o.i Eklampsia, died when baby
was 2 days old
2.Current pregnancy
 General BP : 140/90 mmHg, P : 86 x/min, RR : 20 x/min, T : 36.7 C,
Physical BW: 53 kg, BH: 160 cm
Examination Head: normocephali, pallor conjunctival (-/-), scleral icterus (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-)
Thorax: Heart: I-II HR N, regular, murmur (-), gallop (-)
Lungs: vesicular (+/+) N, ronkhi (-/-), wheezing (-/-)
Extremity : edema (-)
Obstetrical Inspection and palpation :
Examination Abdomen : fundal height ½ umbilical - proc. Xyphoideus (26 cm),
(HIL) longitudinal lie, right back, head, U, 5/5, contraction (-), FHR 153
bpm, EFW 2068 g

Inspeculo :
Portio livide, OUE closed, fluor (-), fluxus (-), erosion (-),
laceration (-), polyp (-)

VT :
Portio was soft, posterior, eff 0%, dilatation (-), head, HI, amniotic
membrane and denominator difficult to assessed.

Gestosis Index : 3
Laboratory Hb 7.3 g/dL, RBC : 2.39 x 106/ mm3, WBC 7490; Ht : 22% , PLT
Examination 194.000, MCV : 93.3, MCH: 31, MCHC : 33, DC: 0/0/78/15/7,
24.09.2019 SGOT 23 U/L, SGPT 13 U/L, Albumin 2.0 g/dL, LDH 383 U/L,
BSS 91 mg/dL, Ur/Cr 39/0.80 mg/dL, Uric acid 7.0mg/dL, Ca 6.6
mg/dL, Mg 2.30 mg/dL, Na 140 mEq/L, K 5.1 mEq/L.

Urin: pH 6.0, protein (+2), glucose (-), keton (+1), blood (+2),
Leucocytes esterase/LEA (+), epitel (-), leucocytes 20-25,
erythrocytes 15-20, silinder granuler (+4), mucous (+1).
US - SLF cephalic presentation
Examination - Fetal biometry :
24.09.19 BPD : 8.16 cm FL : 6.38 cm
(NS) HC : 28.6 cm AC : 27.72 cm EFW : 1922 gr
- Placenta at anterior corpus of uterine
- Amniotic fluid sufficient
C/ 32 weeks gestational age, SLF cephalic presentation
 Diagnosis G2P1A0 32 weeks gestational age not in labor with severe
preeclampsia + prior CS 1x (oi Eklampsia) + Controlled SLE +
moderate anemia SLF cephalic presentation
Management  Vital sign, abdominal contraction, FHR Observation
 Laboratory examination (complete blood count, liver function,
renal function, blood sugar, electrolyte, hemostatic function
test)
 Stabilization
 Nifedipin 10 mg/ 8 hours PO
 Urinary catheter
 MgSO4 ~ protocol
 Dexamethasone 12 mg/ 24 hours IM
 Assessment Internal Medicine Dept & Opthalmology Dept
 Expectative management
Assessment A/ SLE + G2P1 32 weeks gestational age with severe preeclampsia
Internal P/ Continued SLE medicine
Medicine Dept Another therapy appropriate Obgyn
Assessment A/ There are currently no signs of hypertensive choroidopathy and
Opthalmology retinopathy
Dept P/ Therapy appropriate Obgyn
Follow up S/ Preterm pregnancy with hypertension + Fetal distress
09.25 PM O/ BP : 140/90 mmHg, P : 84 x/min, RR : 20 x/min, T : 36.3 C
Abdomen : fundal height ½ umbilical - proc. Xyphoideus (26
cm), longitudinal lie, right back, head, U, 5/5, contraction (-),
FHR I : 113 bpm, FHR II : 109 bpm, FHR III : 106 bpm EFW
2068 g
 A/ G2P1A0 32 weeks gestational age not in labor with severe
preeclampsia + prior CS 1x (oi Eklampsia) + Controlled SLE
+ moderate anemia SLF cephalic presentation + fetal distress
P/ Intrauterine resuscitation
O2
P/ LSCS
Assessment Anesthesiology Dept

Operating 09.55 PM : Pfannensteil incision

report 10.05 PM : male life baby was born, WB 1600 g, BL 42 cm, A/S
09.55 – 11.00 8/9 PTAGA
PM 10.08 PM : complete placenta was delivered, weight 360 g, UCL
38 cm, Ø 16x19 cm
Lubchenco

Ballard
 Recent P2A0 post LSCS oi fetal distress with severe preeclampsia + prior
diagnosis CS + SLE controlled

Recent Patient was stable in ward

condition