Patient’s ID

Name : Mrs. J
Age : 41st years old
Address : Batang Anai
MR Number : 65 32 47
Time of admission : July 9th 2017
 Anamnesis
• Female patient 41 years old was admitted to M
Djamil Hospital Padang on July 9th 2017 at 08:00
pm with chief complained blood come through
from vagina 3 hours ago.
 Present Illness History
• Feeling of pain from waist referred to groin area was absent.
• Bloody show from the vagina was absent
• Large amounts of fluid flow through the vagina
• Amenorrhea since 8,5 months ago
• First date of LMP was in October 25th 2016
• Estimated due date in Agustus 2nd 2017
• Fetal movement was felt since 4 months ago
• No complain of nausea, vomiting and vaginal bleeding during
early and late pregnancy
• Prenatal care : to public health center since 4 month
pregnancy
• Menstruation History : menarche at 13 years old, regular
cycle, which last for 5 to 7 days each cycle with the amount of
3-4 times pad change/day without menstrual pain
3
 Present Illness History
• Antenatal care : Midwife every month since 2 month of
pregnancy, never goes to OG doctor.
• This is her fifth pregnancy

4
 Patient History
• Mariage : November 2001
• History of pregnancy/abortion/delivery : 5 / 0 / 4
1. 2002 / Male / 2600 g / Preterm / Spontaneous Delivery / Midwife /
Alive
2. 2004 / Male / 3000 g / Term pregnancy / Spontaneous Delivery /
Midwife / Alive
3. 2007 / Male / 3300 g / Term pregnancy / Spontaneous Delivery /
Midwife / Alive
4. 2011 / Male / 2800 g / Term pregnancy / Spontaneous Delivery /
Midwife / Alive
5. Present
• History of family planning : None
• History of immunization : None
• History of education : Junior high school graduate
• Occupation : House wife

5
• Previous Illness History :
Patient had a history of myomectomy surgery at Ibnu
Sina hospital on July 16th 2016
She had no history of heart, liver, kidney, DM and
hypertension.

• Family Illness History :

There wasn’t history of hereditary disease,
contagious and physicological illness in the
family.
• History of family planning : (-)
• History of immunization : (-)
• History of education : No history of school
• History of occupation : Housewife
• Habit : Alkoholic (-), Smoke (-), Allergic to
drugs (-)
 Physical Examination

GA Cons BP PR RR T BW BH BMI
Md CMC 120 / 80 100 20 37 54 Kg 150 cm 24
normoweight
• General appearance : Moderate
• Conciousness : Compos mentis cooperative
• Eyes : Conjunctiva wasn’t anemic, sclera wasn’t icteric
• Neck : JVP 5-2 cmH20, no enlargement at thyroid glands
• Chest : H/L normal
• Abdoment : OR
• Genitalia : OR
• Extremities : No edema, normal physiological reflex,
no phatological reflex
Obstetric Record

Abdomen
Inspection :
Seemed enlarged in accordance with term pregnancy, Striae
gravidarum (+), cicatrix (-)

Palpation :
Uterine fundal was palpable 4 fingers under proc. Xyphoideus,
nodular mass was palpated
Hard resistance structure felt on the right side, small parts of the
baby was palpated on the left side
A large, hard, round, ballottable mass was palpated

Uterine fundal height : 28cm

Estimated fetal weight : 2.325g
Uterine contraction : Hard to determine
Fetal Heart Sound : 140-150 x/'
Obstetric Record

Genital:
Inspection : V/U seemed normal, Vaginal bleeding (+)
Inspeculo :
• Vagina : Mass (-); Laceration (-), Fluxus (+)
There were blood stool on fornix posterior vagina
• Portio : Multiparous, as big as adult foot thumb
Mass (-); Laceration (-), Fluxus (+)
Blood flowing from OUE
CTG

Baseline: 160 bpm

Acceleration: (+)
Deceleration: (-)
Contraction (-)
Variability: 5-20 bpm
Impression : Reactive CTG
LAB July 12th, 2017

Hb : 9,5 gr% (9,5-15)

Leucocyte : 19.080 /mm ( 5900-16900)
Ht : 30 % (28-40)
Trombocyte : 224.000 /mm3 (146-429.000)
PT : 10,7 (10,0-13,60)
APTT : 37,0 (29,20-39,40)
Diagnosis :
G5P4A0L4 32-33 weeks of parturient pregnancy
+ total of placenta previa
Fetal alive singleton intrauterine

Management :
Control GA, VS, FHS
Expectative
Fetomaternal USG Examination
 09 / 07 / 2017 10 / 07 / 2017
S Fetal movement (+) Fetal movement (+)
Feeling of pain from waist referred to Feeling of pain from waist referred to
groin (-) groin (-)
O VS GC moderate VS GC moderate
Con CMC Con CMC
BP 120/80 mmHg BP 110/70 mmHg
HR 80x/’ HR 93x/’
RR 18x/’ RR 16x/’
Abd HIS (-) Abd HIS (-)
DJJ 160-170 x/’ DJJ 160-1650 x/’
Gen V/U Calm PPV (+) Gen V/U Calm PPV (+)
A G5P4A0L4 32-33 weeks of parturient G5P4A0L4 32-33 weeks of parturient
pregnancy + total of placenta previa pregnancy + total of placenta previa
Fetal alive singleton intrauterine Fetal alive singleton intrauterine
P Control GA, VS, FHS, HIS Control GA, VS, FHS, HIS
IVFD RL 20 tpm IVFD RL 20 tpm
Dexamethasone 2x6 mg (iv) Dexamethasone 2x6 mg (iv)
Mefenamic acid 3x500mg (po) Mefenamic acid 3x500mg (po)
Nifedipine 3x10mg (po) Nifedipine 3x10mg (po)
USG
• Fetal alive, singleton, intrauterine,
head presentation
• Fetal mmovement activity was good
• Biometrics :
BPD : 80 mm FL : 62 mm
AC : 280 mm EFW : 1932 g
• AFI : 33 cm
• Low-lying placenta II-III grades

 Impression :
32-33 weeks of preterm pregnancy
Fetal alive head presentation
 11 / 07 / 2017 12 / 07 / 2017
S Fetal movement (+) Fetal movement (+)
Feeling of pain from waist referred to Feeling of pain from waist referred to
groin (-) groin (-)
O VS GC moderate VS GC moderate
Con CMC Con CMC
BP 120/80 mmHg BP 110/70 mmHg
HR 80x/’ HR 93x/’
RR 18x/’ RR 16x/’
Abd HIS (-) Abd HIS (-)
DJJ 160-170 x/’ DJJ 160-1650 x/’
Gen V/U Calm PPV (+) Gen V/U Calm PPV (+)
A G5P4A0L4 32-33 weeks of parturient G5P4A0L4 32-33 weeks of parturient
pregnancy + total of placenta previa pregnancy + total of placenta previa
Fetal alive singleton intrauterine Fetal alive singleton intrauterine
P Control GA, VS, FHS, HIS Control GA, VS, FHS, HIS
IVFD RL 20 tpm IVFD RL 20 tpm
Dexamethasone 2x6 mg (iv) Dexamethasone 2x6 mg (iv)
Mefenamic acid 3x500mg (po) Mefenamic acid 3x500mg (po)
Nifedipine 3x10mg (po) Nifedipine 3x10mg (po)
 13 / 07 / 2017 04:00 pm

S Feeling of pain from waist referred to groin (+)

Fetal movement (+)
Vaginal bleeding (+)
O VS GC moderate
Con CMC
BP 120/80 mmHg
HR 80x/’
RR 18x/’
Abd HIS (-)
DJJ 160-170 x/’
Gen V/U Calm PPV (+)
A G5P4A0L4 32-33 weeks of parturient pregnancy + total of placenta previa
Fetal alive singleton intrauterine
P Control GA, VS, FHS, HIS
IVFD RL 20 tpm
Dexamethasone 2x6 mg (iv)
Mefenamic acid 3x500mg (po)
Nifedipine 3x10mg (po)
 13 / 07 / 2017 08:00 pm

S Feeling of pain from waist referred to groin (+)

Fetal movement (+)
Vaginal bleeding (+)
O VS GC moderate
Con CMC
BP 120/80 mmHg
HR 132x/’
RR 18x/’
Abd HIS (-)
DJJ 160-170 x/’
Gen V/U Calm PPV (+)
A G5P4A0L4 32-33 weeks of parturient pregnancy + total of placenta previa
Fetal alive singleton intrauterine
P Control GA, VS, FHS, HIS
IVFD RL 20 tpm
Dexamethasone 2x6 mg (iv)
Mefenamic acid 3x500mg (po)
Nifedipine 3x10mg (po)
 14 / 07 / 2017 00:00 am

S Feeling of pain from waist referred to groin (+)

Fetal movement (+)
Vaginal bleeding (+)
O VS GC moderate
Con CMC
BP 120/80 mmHg
HR 132x/’
RR 18x/’
Abd HIS (-)
DJJ 160-170 x/’
Gen V/U Calm PPV (+)
A G5P4A0L4 32-33 weeks of parturient pregnancy + total of placenta previa
Fetal alive singleton intrauterine
P Control GA, VS, FHS, HIS
IVFD RL 20 tpm
Dexamethasone 2x6 mg (iv)
Mefenamic acid 3x500mg (po)
Nifedipine 3x10mg (po)
July 14th 2017 at 01.00 am:
Vaginal obstetric delivery was perfomed. A male baby was born with:
BW: 2500 gr
BH : 46 cm
A/S : 8/9
Placenta was born with slight traction on umbilical cord, weight ± 400 gr, Umbilical cord
± 50 cm, paracentral insertion.
Bleeding during operation ± 150 cc

Diagnosis :
P5A0L5 post vaginal delivery
Baby and mother were in care

S/: observe after procedure

P/:
Control GC, VS, contraction, vaginal bleeding
Injection Ceftriaxone 2x1gr (iv)
Check lab after 6 hours operation
Thank You..