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Culture Documents
Name
: Mrs. PN
Room
: V/VI
Medical Record
: 029925
Sex : Female
Age : 35 th
Religion
: Islam
Address
: Bandung Barat
From
Unit
Co-Ass Check
: Emergency
: 24 April 20134
: Mother and
Presentation of the
History
A 39 year old pregnant woman
(G5P1A3) gravida aterm 39-41 weeks
gestation
She came because she gave referral
from medical specialties obstetrics and
gynecology
She has no complaint or presents
history of abdominal cramping, vaginal
bleeding, painful contraction, and
leakage of fluid.
Current Pregnancy
Last menstrual period: 22nd April 2014
Regular cycle menses : 28 day
Contraception: combined oral
contraceptive pill
Estimated date of delivery: 29th January
2015
Baby birth weight prediction: 2500
gram
Obstetrical History
full term normal spontaneous vaginal
delivery at term in 2002.
First abortion in 2003
Second abortion in 2004
Third abortion in 2005
Gynecological History
Menarche : 13 years old
Family History
History of stillbirth
Diabetes (-)
Physical Examination
This patient looks clinically well
Temperature
Blood pressure
: 120/80 mmHg
Pulse
: 84 bpm, regular
Obstetric Examination
Symphysiofundal height : 28 cm
Fetal heart
: 169 bpm
Leopold I
: Breech
Leopold II
Leopold III
: Head
The head isnt engaged
Hematology
Hemoglobin : 11.7
Leucocyte
g/dl
: 7.0 103/L
Erythrocyte : 3.80
106 /L
Thrombocyte: 157
103/L
MCV : 88.4
fL
MCH : 30.8
pg
MCHC
: 34.8
g/dl
Liver Function
Total Bilirubin
: 0.71
mg/dl
mg/dl
mg/dl
Ureum : 11 mg/dl
Urea N : 5.30
Creatinin
LFG
mg/dl
: 0.50
mg/dl
: 126 ml/menit/1.73m2
Diagnostic Pre
Operation
G5P1A3 gravida aterm 39-41 weeks +
Fetal distress + Oligohydramnios + Intra
Uterine Growth Retardation (IUGR)
Treatment
Caesarean Section
Follow Up
AS : 3-5
Meconium (+)
Plasenta: Smaller than normal
Literature Review
IUGR
Oligohydramni
os
Fetal Distress
IUGR
a
condition
of
the
birthweight
below
10th
percentile
of
the
recommended
genderspecific
birthweight
for
gestational age reference
curves
IUGR
Symetrical
Assymetri
cal
Genetic
Genetic
Maternal
Maternal and
and
Fetal
Fetal
Hormones
Hormones
Maternal
Maternal
Vascular
Vascular
Disease
Disease
Placental
Placental
factors
factors
Congenital
Congenital
Anomalies
Anomalies
Etiolog
y
Environment
Environment
al Toxin
Toxin
al
Inadequate
Inadequate
Maternal
Maternal
Nutrition
Nutrition
Infection
Infection
Multiple
Multiple
Gestation
Gestation
Diagnosis
Physical
Examination
USG
Oligohydramnios
TABEL HAL
FETAL DISTRESS
FETAL
DISTRES
S
Asphyxi
a
Meconiu
m + FHR
up
DISCUSSION