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A CASE REPORT

Supervisor:
dr. Arie A. Polim, Sp. OG, K-FER

Presented by:
Samuel Hendratno (2012-061-165)
Yulendy (2012-061-167)
Winny Nuradi (2013-061-056)
Dian Daniella (2013-061-061)

Department of Obstetrics and Gynecology


Medical Faculty of Atma Jaya Catholic University
2014

Patients Identity:
Name
: Mrs. W
Date of Birth/ Age: 6th February 1996/ 18 years old
Ethnic
: Javanese
Nationality
: Indonesian
Address
: Kebon Kelapa RT 005/RW 02 Kecamatan Kamal,
Kelurahan Kali Deres, West Jakarta
Graduate from
: Senior High School
Marital status
: Married
Occupation
: Housewife
Religion
: Moslem
Date of admission
: 2nd June 2014
Chief complaint:
Fifteen hours prior to admission, patient complained of vaginal
bleeding and lower abdominal pain.
History of Present Illness:
One month prior to admission, 7 months into the pregnancy, patient
complained of painless vaginal bleeding. Patient quickly rushed to
the clinic. In the clinic, USG was performed on the patient. The result
of the USG was the placenta was implanted on the lower segment of
the uterus. Patient then referred to the Atma Jaya Hospital.
Nine days prior to admission, patient was hospitalized to Atma Jaya
Hospital and was given Duvadilan, Sangobion, had blood transfusion
4 bags of blood, and pregnancy was concerved.
Fifteen hours prior to admission, patient complained of painless
vaginal bleeding that happened intermittenly. Patient also
complained of lower abdominal pain.
all day long. Total blood loss equals to 3 diapers per day.
1 bulan SMRS, Pada usia kehamilam 7 bulan, pasien mengeluh
terdapat darah segar mengalir sepanjang hari. Jumlah darah
mencapai 3 pampers per harinya. Pasien tidak mengeluh
terdapatnya nyeri saat terjadi perdarahan. Pasien segera pergi ke
klinik dekat rumah, dan dilakukan USG, didapatkan hasil plasenta
terletak di bawah. Pasien kemudian dirujuk ke RS Cengkareng, dari
RS cengkareng pasien dirujuk lagi ke rumah sakit atma jaya.
15 jam SMRS, pasien keluar darah banyak, warna merah segar, dan
terdapat bekuan. Pasien tidak merasakan sakit saat darah keluar,
tidak merasa, namun, setelah keluar, pasien merasakan sakit pada
perut bagian bawah
History of Past Illness:
No history of diabetes mellitus
No history of allergy
No history of heart disease

No
No
No
No
No
No

history
history
history
history
history
history

of
of
of
of
of
of

asthma
trauma
operative procedures
taking herbs during pregnancy
abdominal massage
hereditary disease

Contraception History
No contraception method is used
Antenatal care
Mestruation history
Gestational History
Physical Examination
General Examination
Obstetric Examination
Obstetric Status
Laboratory Examination
Admitting Diagnosis
Therapy
Final Diagnosis
Post Labor Treatment
Laboratory Examination Post Operation
Follow Up
S:
O:

General condition
Awareness
Vital Sign
o Blood pressure
o Heart rate
o Respiratory Rate
o Temperature
Urine Output
Balance
Eye

Thorax
o Cor
o Pulmo
Inspection
Percussion
Auscultation
o Mammae
Abdomen
o Inspection
o Palpation
o Auscultation
Extremity
o Extremities
o Edema
o Physiological reflex
o Patological reflex
Nifas examination
o Mobilitation
o Fundus Height
o Lochia
o Suture

A:
P:

PLASENTA PREVIA