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Case Report

Editha Aldillasari R (4151131493)


Reza Khadafy N (4151131495)

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

Condition when home


Baby Health

: 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

Past Medical and Surgical


History
Toxoplasmosis

Family History
History of stillbirth
Diabetes (-)

Physical Examination
This patient looks clinically well
Temperature

: 36,2 celcius degree

Blood pressure

: 120/80 mmHg

Pulse

: 84 bpm, regular

Respiratory rate : 18 x/m

Obstetric Examination
Symphysiofundal height : 28 cm
Fetal heart

: 169 bpm

Leopold I

: Breech

Leopold II

: Back on the right

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

Direct Bilirubin : 0.25

mg/dl

Indirect Bilirubin : 0.46

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

Amniotic fluid index (AFI) of


5 cm

TABEL HAL

FETAL DISTRESS
FETAL
DISTRES
S

Asphyxi
a

Meconiu
m + FHR
up

DISCUSSION

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