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Case No.

Identity
• Name : Mrs. S
• Age : 33 years old
• MR No. : 996942
• Date : November, 6th 2017

2
Chief Complain

A 33 years old patient admitted to the emergency


room of M Djamil General Hospital on November,
6th 2017 at 15.50 pm referred from private
hospital with diagnosis : G5P4A0L3 30-31 weeks
of preterm pregnancy + olygohidramnion + susp
IUGR
• Previously patient felt less frequently fetal movement
since six days ago. She then go to primary health care
and she referred to Rizki Bunda Private hospital.
Fromthe examination found that the amnion was
decrease an she was treated there for six days. After
that, the patient was discharged and recommended for
control to polyclinic at M.Djamil hospital.
• The pateint come late to the polyclinic, so she check
the pregnancy to the emergency room. In the
emergency room found that the fetal heart movement
was absent from ultrasound.
Present illness History
• Feeling of pain from waist region moving down to
the groin (-)
• Bloody show from the vagina (-)
• Fluid leakage from the vagina (-)
• No massive bleeding from vagina
• Amenorrhea since ± 7,5 months ago
• First date of last menstrual period was forgot
• Estimation date of delivery was hard to determine
• Fetal movement was felt since 3,5 months ago
• No complain of nausea, vomitting and vaginal
bleeding neither during early pregnancy nor late
pregnancy.
• Prenatal care to a midwife since 2 month of
gestational age every monthon 2,6 and 7 months
of pregnancy
• Menstrual history : menarche at 11 years old,
irregular cycle, once a month with the amount of
2-3 times pad change/day without menstrual
pain.
Previous Illness History
There wasn’t any previous history of heart, lung, liver, kidney,
DM, Hypertension, and allergy

Family Illness History


There wasn’t any history of hereditary disease, contagious
and psychological illness in the family
Patient History
• Marriage History : Once in 2002
• History of pregnancy/abortion/delivery : 5 / 0 / 4
1. 2003, male, 3000 gram, term pregnancy, spontaneous, hospital, dead on
1 week
2. 2005, male, 3000 gram, term pregnancy, spontaneous, hospital, alive
3. 2008, male, 3000 gram, term pregnancy, spontaneous, hospital, alive
4. 2011, female, 2200gram, postterm pregnancy, spontaneous, hospital,
alive
5. Present

• History of family planning : Implant after first child, till 5 months,


and then change with condom
• History of immunization : none
• History of education : Elementary school
• Occupation : House wife
Physical Examinations
• General appearrance : Moderate
• Conciousness : Composmentis cooperative
• Body Height : 150 cm
• Body Weight : 45 kg (Before pregnant : 50 kg, BMI : 22,2 kg/m2)
 normo weight
• Nutrisional status : Good
• Blood pressure : 110/70 mmHg
• Heart rate : 84 x/menit
• Respiration rate : 20 x/menit
• Body Temperature : 37⁰C
General Examination
• Eyes : Conjunctiva wasn’t anemic, sclera wasn’t icteric
• Neck : JVP 5-2 cmH2O, thyroid gland no enlargement
• Chest : H/L normal
• Abdomen : OR
• Genitalia : OR
• Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
Obstetrical Record
• Abdomen :
I : Enlarge equal to preterm pregnancy, cicatrix (-) Striae gravidarum (+)
Pa :L1 : Uterine fundal was palpable in the middle of umbilicus and processus
xyphoideus. Large nodular mass was palpated
L2 : A hard and resistance structure was felt on the right side.
Small parts of the baby were felt on the left side
L3 : A round hard mass was palpated, fixated
L4 : Divergent
Uterine Fundal Height : 25 cm
Estimated fetal body weight : 1860 gr
Uterine contraction : -
Pe : Tympani
Au : Peristaltic sound was normal Fetal Heart Sound : -

• Genitalia : I : V/U normal, bleeding from vagina(-)


PARAMETER RESULT NORMAL VALUE
Hemoglobin 11,5 gr/dL 12–16.0
Leucocyte 11.310/mm3 5.9–16.9 x 103
Hematocrit 34 % 28.0–40.0
Trombocyte 355.000/mm3 146–429 x 103
APTT 31,5 sec 22.6–35.0
PT 10,3 sec 9.6–12.9
HbSAg rapid test Non raective Non raective
HIV rapid test Non raective Non raective
Natrium 141 Mmol/L 136-145

Kalsium 3,6 Mmol/L 3,5-5,1

Clorida 108 Mmol/L 97-111

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Ultrasound
Ultrasound
• Fetal alive, singleton, head presentation
• Fetal Biometry :
BPD : 73,0 mm
AC : 244 mm
FL : 57,7 mm
EFW : 1402 gr
AFI : 1,5
Placenta implanted at posterior corpus gr II-III

Impression : 30-31 weeks of pregnancy


Fetal dead
• Diagnosis
– G5P4A0L3 30-31 weeks of preterm pregnancy + IUFD + Oligohidramnion