OBSTETRIC OUTPATIENT

REPORT
Friday, March 01st, 2019
Residents:
Dr. Santa Maria
Dr. Joko Prasanto
Dr.Andry Jullius
Dr. Bagus Hilmawan
Dr. Mughan Sukardo
Dr. Kartika Ikrama Shafirlana
Dr. Siti Chodijah

Supervisor:
Dr. Hj. Fatimah Usman, OBGYN(C)
Recapitulation Obstetric Outpatient
st
Friday, March 01 , 2019
Physiology Patient 0
Pathology Patient 2
Total 2
 Friday March 01th 2019 – Thursday, March 07th 2019

Physiology Pathology Total

Friday, March 01st ,2019 0 2 2

Monday, March25th 2019
Tuesday, March26th 2019
Wednesday, March 27th 2019
Thursday, March 28th 2019
Total
NO. IDENTITY DIAGNOSIS ICD-10 MANAGEMENT ICD-9

1 Mrs. DAR/ 38 G4P2A1 35 weeks gestational O35.1 - CIE V72.62

age not inlabor, SLF Cephalic
Y. O/ RA/KY
presentation + Bilateral
Ventriculomegaly
2 Mrs. SIT/ 28 Y. G3P1P1 37 weeks gestatioal
age, not inlabor, SLF Cephalic
O/ RA/ AR
presentation + Hydrops fetalis
88.78
- Laboratory examination
- US Examination
- Sulphate ferrous 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 housr (oral)
- Plan for elective ceasean section on March
21st 2019
O36.2 - CIE V72.62
88.78
- Laboratory examination
- US Examination
- Sulphate ferrous 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 housr (oral)
- Plan for elective ceasean section
 Identity Mrs. DAR/ 38 Y. O/ RA/KY

Chief complain Preterm pregnancy with fluid accumulation in baby’s head

History Patient came to Fetomaternal Polyclinic to control her pregnancy. History of abdominal contraction (-),
history of bloody show (-), history of amnionic leakage (-).
About three days ago, patient went to Prabumulih Public Hospital to control her pregnancy. Us
examination found that there was an accumulation of fluid in the fetus’s head. Patient was given antiviral
for 10 days. Patient then reffered to RSMH with diagnosis G4P2A1 36 weeks gestational age, SLF Cephalic
presentation with hydrocephalus. Patient admitted if her pregnancy was preterm and baby movement (+)
Marital status 1x, 17years

Reproduction status Menarche 12 years old, regular cycle, lasts 4 days, LMP: June 28th ,2018

Obstetric history 1. 2003, Male, 3500 g, spontaneous delivery, midwife, healthy

2. 2008, Male, 3300 g, spontaneous delivery, midwife, healthy
3. 2018, Abortion, 12 weeks, curettage (+)
4. Current pregnancy
Vital sign Sens: CM BP: 110/80 mmHg Pulse : 88 x/m T: 36,5 oC RR: 20x/m BW 78 kg BH 162 cm

Obstetrical Inspection & Palpation : -

examination Uterine fundal 4 fingers below proc. xyhpoideus (30 cm), longitudinal lie, left back, Head U 5/5, uterine
contraction (-), FHR 150x/m, EFW 2635 g
Laboratory Hb 10,7 g/dL, WBC 11.050/mm3, PLT 220.000/µL, DC 0/1/74/18/7, HbsAg Non reactive, Anti HIV Non
examination reactive,
28-2-2019 TORCH: Toxoplasma IgG 113 reactive, IgM 0,43  non reactive; Rubella IgG 36,30 (reactive), IgM 0,24
(non reactive); CMV IgG 120  reactive, IgM 0,08  non reactive
 Identity Mrs. DAR/ 38 Y. O/ RA/KY

US By Ultrasound:
Dr. Nuswil Bernolian, • SLF Cephalic presentation
OBGYN (C) • Fetal Biometri :
28.2.19  BPD 8,9 cm AC 31,6 cm EFW 2739 gr
 HC 32 cm FL 6,9 cm
• Wide ventricle bilaterally was seen, 2,3 & 2,4 cm
• Placenta at anterior corpus
• Amniotic fluid sufficient
• PIAU 0,72
C/ 35 weeks gestational age SLF Cephalic presentation + Bilateral ventriculomegaly
Diagnosis G4P2A1 35 weeks gestational age, SLF Cephalic presentation with + Bilateral ventriculomegaly

Therapy - CIE
- Sulfate ferrous 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 housr (oral)
- Plan for elective caesarean section
 Identity Mrs. SIT/ 28 Y.O/ RA/ AR

Chief complain Preterm pregnancy with congenital anomaly was suspected

History Patient came to Fetomaternal Polyclinic to control her pregnancy. History of abdominal contraction (-),
history of bloody show (-), history of amnionic leakage (-).
About three days ago, patient went to Muhammadiyah Hospital Palembang to control her pregnancy.
She was told if there was a congenital anomaly in her baby, she was then referred to RSMH.

Marital status 1x, 8 years

Reproduction Menarche 12 years old, regular cycle, lasts 5 days, LMP: forget
status
Obstetric history 1. 2011, Abortion, 6 weeks, curettage
2. 2012, Male, 3800 g, spontaneous delivery, midwife, healthy
3. Current pregnancy

Vital sign Sens: CM BP: 110/80 mmHg Pulse : 88 x/m T: 36,5 oC RR: 20x/m BW 75 kg BH 153 cm

Obstetrical Inspection & Palpation : -

examination Uterine fundal 2 fingers below proc. xyhpoideus (36 cm), longitudinal lie, left back, Head U5/5, uterine
contraction (-), FHR 155x/m, EFW 3565 g
Laboratory Hb 11,2 g/dL, WBC 11.640/mm3, PLT 276.000/µL, DC 0/0/78/12/10, HbsAg Non reactive,
examination TORCH: Toxoplasma IgG 2,8 greyzone, IgM 0,05  non reactive; Rubella IgG 29,30 (reactive), IgM
28-2-2019 0,66 (non reactive); CMV IgG 678,90  reactive, IgM 0,17,  non reactive; HSV I IgG 3,8016
(reactive), IgM 0,57; HSV II IgG 0,1838 (negative), IgM 0,7137 (negative)
 Identity Mrs. SIT/ 28 Y.O/ RA/ AR

US By Ultrasound:
Dr. Peby Maulina • SLF Cephalic presentation
Lestari, OBGYN (C) • Fetal Biometri :
1.3.19  BPD 8,8 cm AC 34,7 cm EFW 3455 gr
 HC 32,8 cm FL 7,2 cm
• Placenta at anterior corpus
• Amniotic fluid a lot 10,5 cm
• Bilateral lungs hypoplasia (+)
• Ascites (+)
• Hydrothorax (+)
• BPP 10
C/ 36 weeks gestational age SLF Cephalic presentation + Hydrops fetalis + BPP 10

Diagnosis G3P1A1 36 weeks gestational age, SLF Cephalic presentation with Hydrops fetalis

Therapy - CIE
- Sulfate ferrous 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 housr (oral)
- Plan for elective caesarean section
THANKYOU