DUTY REPORT

Wednesday, September 20th 2017, 4 PM to

Tuesday, September 21st 2017, 7 AM
Consultant on Duty :
Dr. Awan Nurtjahyo, SpOG(K)
Resident on Duty :
Obstetrical chief: Dr. Adriansyah Dwi Saputra
Gynecological chief: Dr. Aswin Boy Pratama
Dr. M. Galih Supanji
Dr. Endrianus Jaya Putra
Dr. Rachmad Hidayat
Dr. Fitrah Tindar Atthaariq
Dr. Gita Adelia Sari
Dr. Nur Karimah
Dr. Aria Indrabrata

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Obstetric Patients
No. Identity Diagnosis ICD 10 Procedure ICD 9
1. Mrs. G2P1A0 39 week of gestational age O14.13 Vaginal delivery 642.5
PUJ/29/RA/ADI- with severe preeclampsia SLF
AW cephalic presentation
2. Mrs. G1P0A0 345week of gestational age O15.2 LSCS 669.7
SIT/24/UA/DRI- not inlabor with antepartum
AW eclampsia SDF cephalic presentation
3. Mrs. G4P3A0 24 week of gestational age O14.13 Vaginal Delivery 642.5
ERN/41/RA/GIS- not inlabor with severe preeclampsia
AW + Partial HELLP syndrome SDF
cephalic presentation
4. Mrs. P1A1 post spontaneous delivery 7 O15.2 Medicinalis
NUR/21/UA/GIS- hours (outside) with postpartum
AW eclampsia
Identity 1. Mrs. PUJ/29/RA/ADI-AW
Chief complain Inlabor pregnancy with high blood pressure

History 1 day ago patient complain of abdominal contraction (+), bloody show (+), watery discharged (-.)
20-9-17 History of previous hypertension (-), previous hypertension during pregnancy (+), currently
(11.45 PM) hypertension during pregnancy (+), hypertension in family (+). severe headache (-), blur vision (-
), epigastric pain (-), nausea and vommiting (-). Patient went to midwife then reffered toRSMH
Patient admit aterm pregnancy and fetal movement was felt.

Marital status Married twice

1. 6 years
2. 1 year

Reproduction status Menarche since 13 yo, reguler cycle 28 days, 7 days, LMP 22-12-16

Obstetric history 1. 2009, male, 3400gr, spontaneous delivery, aterm

2. current pregnancy

Past iIlness history -

Physical Examination Vital sign: BP = 160/110 mmHg, Pulse = 88 x/mt, temp = 36.7 C, RR = 18x/mt
GI 6

Obstetrical Palpation: Fundal height 3 fingers below processus xyphoideus (33 cm), longitudinal lie, fetal's
examination back on the left of mother's axis, head as lowest part, 4/5 of head descending , his 2x/10'/35”,
FHR 142x/mt, EFW 3100gr
VT: portio soft, medial, eff 100%, Ø3cm, H I-II, amnion sac +, transverse sagitalis suture as
denominator
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Identity 1. Mrs. PUJ/29/RA/ADI-AW
Lab examination Hb:12.5g/dL, Ht: 36%, WBC: 13.600/mm3, PLT: 354.000/mm3
SGOT/SGPT 14/8 U/L, LDH 402, Ur/Cr 6/0.41 mg/dL

US ER - Single life fetus cephalic presentation

- Fetal Biometry: BPD 9.11cm AC 31.87 cm EFW: 3038 gr
HC 32.41 cm FL 7.34 cm
- Placenta at anterior corpus
- Amnion volume, AFI 1.01, 1.16, 1.4, 2.01 = 6.02 cm
C/ 38 week gestational age SLF cephalic presentation
Diagnosis G2P1A0 39 week of gestational age inlabor first stage laten phase with severe preeclampsia SLF cephalic
presentation
Therapy Stabilization 1-3 hours
Obs vital sign, his, FHR
IVFD RL gtt xx/mt
urinary catherer, monitor input and output
Inj MgSo4~ protocol
Nifedipine 10mg/8h po
internal dept. and opthalmology dept. assesment
Plan for acceleration with oxytocin drip after stabilization
Internal A: hypertension in pregnancy, cor and pulmo compensata
Departement P: advice: methyl dopa 250mg/12 h po
Opthalmology A: no retinopathy and coroidopathy hypertension
Departement P: BP regulation, reconsultation if thre is suddenly decrease of visus,consult to outpation refraction
subdivision

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Identity 1. Mrs. PUJ/29/RA/ADI-AW
21-9-17 G2P1A0 39 week of gestational age inlabor first stage active phase with severe preeclampsia SLF
02.00 AM cephalic presentation
Ø 8cm
IG 4
21-9-17 G2P1A0 39 week of gestational age inlabor second stage with severe preeclampsia SLF cephalic
03.00 AM presentation

P: Conduct the labor

21-9-17 Male life baby was born, BW 3200gr, BL 49cm, A/S 8/9 FTAGA
03.15AM placenta delivered completerly, PW 550gr, UCL 49cm

Lab examination Hb:12.6g/dL, Ht: 36%, WBC: 18.400/mm3, PLT: 421.000/mm3, LDH 381,

Follow Up Patient was stable at ward

22-9-17
06.00AM

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Identity 2. Mrs. SIT/24/UA/DRI-AW
Chief complain Preterm pregnancy with high blood pressure and seizure
History Patient was reffered by Pelabuhan Hospital with diagnosis antepartum eclampsia. Patient
20-09-17 complain of abdominal contraction -. bloody show -, watery discharged -. History of previous
(5.10 PM) hypertension -, previous hypertension during pregnancy +, currently hypertension during
pregnancy +, hypertension in family +. severe headache +, blur vision -, epigastric pain -, nausea
and vomiting -. Patient admit preterm pregnancy and fetal movement was not exist.
Marital status Married once, 1 year
Reproduction status Menarche since 13 yo, reguler cycle 28 days, 7 days, LMP unknown
Obstetric history 1. current pregnancy
Past iIlness history -
Physical Examination Vital sign: BP = 140/100 mmHg, Pulse = 90x/mt, temp = 36.7 C, RR = 18x/mt
GI 3

Obstetrical examination Palpation: Fundal height 1/2 umbilicus - processus xyphoideus, longitudinal lie, fetal's back on
the right of mother's axis, head as lowest part, floating , his -, FHR -
VT: Portio soft, posterior, eff 0%, closed, amnion sac and denominator not assesedable
Lab examination Hb:8.3 g/dL, Ht: 25%, WBC: 18.700/mm3, PLT: 365.000/mm3
SGOT/SGPT 127/48 U/L, LDH 1623, Ur/Cr 76/2.62 mg/dL

US ER - Single death fetus cephalic presentation

- Fetal Biometry: BPD 8.38cm AC 26.4 cm EFW: 1944 g
HC 30.18 cm FL 6.27 cm
- Placenta at anterior corpus
- Amnion volume enough
C/ 35 week gestational age SDF cephalic presentation 7
Identity 2. Mrs. SIT/24/UA/DRI-AW
Diagnosis G1P0A0 35week of gestational age not inlabor with antepartum eclampsia with history of SLE SDF
cephalic presentation
Therapy Stabilization 6hours
Obs vital sign and inlabor sign
IVFD RL gtt xx/mt
urinary catherer, monitor the input and output
Inj MgSo4~ protocol
Nifedipine 10mg/8h po
lab exam
Internal dept. and opthalmology dept. assesment
Plan for abdominal delivery
Internal A: hypertension stage ii in pregnancy, intra uterine infection, DD/ UTI, AKI stage I, SLE
Departement P: valsartan 80mg/24h, amlodipine 5mg/24h
Opthalmology A: no retinopathy and coroidopathy hypertension
Departement P: BP regulation, reconsultation if thre is suddenly decrease of visus,consult to outpation refraction
subdivision
21-9-17 Male death baby was born, BW 1800gr, BL 45cm, grade II masceration
4.00 AM Placenta delivered completerly, PW 300gr, UCL 35cm, 15x15cm

Lab examination Hb:12.0 g/dL, Ht: 37%, WBC: 26.200/mm3, PLT: 67.000/mm3
SGOT/SGPT 103/44 U/L, LDH 2268, Ur/Cr 76/2.7 mg/dL, Ca 7.7

Follow Up D/ P1 post LSCS oi Antepartum eclampsia + Partial HELLP syndrom + AKI stage II + SLE + Hipocalcemia
21-9-17
06.00 AM Patient at ICU ward

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Identity 3. Mrs. ERN/41/RA/GIS-AW
Chief complain Preterm pregnancy with high blood pressure and baby not movement
History Patient was reffered from Ogan Ilir Hospital. History of abdominal contraction -. bloody show -,
20-9-17 watery discharged -. History of previous hypertension -, previous hypertension during pregnancy
(11.57 PM) +, currently hypertension during pregnancy +, hypertension in family -. severe headache -, blur
vision -, epigastric pain -, nausea and vommiting -. Patient went to Ogan Ilir Hospital then
reffered to RSMH. Patient admit aterm pregnancy and fetal movement was not exist.
Marital status Married 1x, 19 years
Reproduction status Menarche since 12 yo, reguler cycle 28 days, 7 days, LMP 17-9-17
Obstetric history 1. 1999, female, 3800gr, midwife, spontaneous delivery, passed away 1 year old
2. 2002, female, 3600gr, midwife, spontaneous delivery
3. 2008, male, 3500gr, midwife, spontaneoud delivery, healthy
4. current pregnancy
Physical Examination Vital sign: BP = 160/100 mmHg, Pulse = 84 x/mt, temp = 36.7 C, RR = 18x/mt
GI 6
Obstetrical Palpation: Fundal height as umbilicus, external ballotement (+), FHR (-), his (-)
examination VT: Portio soft, posterior, eff 0%, Ø1cm, amnion sac and denominator was not assesedable

Lab examination Hb:12.6 g/dL, Ht: 37%, WBC: 10.200/mm3, PLT: 422.000/mm3
SGOT/SGPT 41/24 U/L, LDH 984, Ur/Cr 9/0.78 mg/dL, Proteinuria ++
US ER - Single death fetus intrauterine
- Fetal Biometry: BPD 6.24cm AC 16.48 cm EFW: 614 g
HC 21.9 cm FL 4.33 cm
- Placenta at fundal
- Amnion volume enough
C/ 24 week gestational age SDF intrauterine 11
Identity 3. Mrs. ERN/41/RA/GIS-AW
Diagnosis G4P3A0 24 weeks of gestational agenot inlabor with severe preeclampsia + Partial HELLP syndrome SDF
intrauterine
Therapy Stabilization 1-3 hours
Obs vital sign and inlabor sign
IVFD RL gtt xx/mt
Urinary catherer, monitor the input and output
Inj MgSo4~ protocol
Nifedipine 10mg/8h po
lab exam
Internal dept. and opthalmology dept. assesment
P/ Vaginal delivery
Internal A: hypertension in pregnancy, cor and pulmo compensata
Departement P: advice: methyl dopa 250mg/12 h po

Opthalmology A: no retinopathy and coroidopathy hypertension

Departement P: BP regulation, reconsultation if thre is suddenly decrease of visus,consult to outpation refraction
subdivision
21-9-17 Female death baby was born, BW 750g, BL 34cm
00.30 PM Placenta delivered not completerly

P/ Curretage
Lab exam Hb:12.4 g/dL, Ht: 36%, WBC: 13.200/mm3, PLT: 488.000/mm3, LDH 929,
21-9-17 Patient was curretage with blood and tissue ±250cc
05.00 PM
Follow Up Patient was stable at ward
22-9-17
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06.00 AM
Identity 4. Mrs. NUR/21/UA/SE-AW
Chief complain Post spontaneous delivery with high blood pressure and seizure
History Patient was reffered by Pelabuhan Hospital with diagnosis postpartum eclampsia. About 7 hours
20-09-17 ago patient post spontaneous delivery with male life baby was born BW 2200g, BL 44cm.
(07.10 PM) Placenta was delivered completely. About ± 1 before Patient complain seizure 2 times and
severe headache. History of previous hypertension -, previous hypertension during pregnancy +,
currently hypertension during pregnancy +, hypertension in family +.
Marital status Married once, 1 year 6 month
Reproduction status Menarche since 12 yo, reguler cycle 28 days, 7 days, LMP 07-12-2016
Obstetric history 1. 2016, abortus, curretage
2. 2017, spontaneous, ♂,2200g, healthy
Physical Examination Vital sign: BP = 140/100 mmHg, Pulse = 90x/mt, temp = 36.7 C, RR = 18x/mt
GI 3
Obstetrical examination Palpation: Fundal 2 fingers below umbilicus, good contraction, active bleeding -, Lochia rubra +

Lab examination Hb:11.6 g/dL, Ht: 35%, WBC: 16.800/mm3, PLT: 233.000/mm3
SGOT/SGPT 33/13 U/L, LDH 737, Ur/Cr 16/0.8 mg/dL

Diagnosis P1A1 post spontaneous delivery 7 hours (outside) with postpartum eclampsia
Therapy Stabilization 6hours
Obs vital sign
IVFD RL gtt xx/mt
urinary catherer, monitor the input and output
Inj MgSo4~ protocol
Nifedipine 10mg/8h po
Internal dept. and opthalmology dept. assesment 13
Identity 4. Mrs. NUR/21/UA/SE-AW
Internal A: hypertension stage I in pregnancy
Departement P: methyldopa 500mg/8hours
Opthalmology A: no retinopathy and coroidopathy hypertension
Departement P: BP regulation, reconsultation if thre is suddenly decrease of visus,consult to outpation refraction
subdivision
Follow Up Patient stable at ward
22-9-17
06.00 AM

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Thank You