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Obstetric Case Report

1. Ny. Rah/29/Dwi Nugroho was admitted to the hospital at 35 weeks gestation with pre-eclampsia and a diagnosis of threatened preterm labor. 2. She was given magnesium sulfate, nifedipine, and dexamethasone for pre-eclampsia and fetal lung maturity. An ultrasound showed normal fetal growth and amniotic fluid. 3. On May 23rd, due to worsening pre-eclampsia and signs of imminent delivery, she underwent a cesarean section. A live male infant was delivered weighing 2500g with good Apgar scores. The patient recovered well post-operatively.

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Assyifa Anindya
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50 views3 pages

Obstetric Case Report

1. Ny. Rah/29/Dwi Nugroho was admitted to the hospital at 35 weeks gestation with pre-eclampsia and a diagnosis of threatened preterm labor. 2. She was given magnesium sulfate, nifedipine, and dexamethasone for pre-eclampsia and fetal lung maturity. An ultrasound showed normal fetal growth and amniotic fluid. 3. On May 23rd, due to worsening pre-eclampsia and signs of imminent delivery, she underwent a cesarean section. A live male infant was delivered weighing 2500g with good Apgar scores. The patient recovered well post-operatively.

Uploaded by

Assyifa Anindya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd

1

21.05.14
13.10 WIB
TD 160/100mmHg
RR : 20x
N : 104 x
T : 36,7
PL:
TFU 29 cm
His (-), DJJ :
146x/m,
TBJ 2480 g
VT:
Portio lunak,
kuncup
Eff 0%
Ketuban dan
penunjuk belum
dapat dinilai
HI
Proteinuria 4+
IG 7
22.05.14
09.00 WIB

15.00 WIB
TD : 140/80 mmHg
N : 96x/m
RR : 24x/m
T : 36,8 C
DJJ : 142x/m

SSTP a.i Gawat Janin


Ny. RAM/31th/Agustia
G2P1A0 Hamil 35 Minggu Belum Inpartu dengan PEB JTH Preskep
T/ Ekspektatif
Observasi TVI, DJJ
IVFD RL + MgSO4 40% 6gr gtt XX/m
MgSO4 40% 4gr IV bolus perlahan
Dexamethasone 2x6 mg IV
Nifedipine 3 x 10 mg
Cek DR, UR, KD
R/ USG konfirmasi

USG:
Aktivitas dan gerak janin normal
DJJ + Bagian terbawah kepala
Ketuban cukup
Plasenta di fundus
BPD sesuai dengan 35-36 minggu
Kesan : Hamil 35-36 minggu JTH preskep
Pasien pindah ke bangsal
T/ Observasi TVI, DJJ
IVFD RL + MgSO4 40% 6gr gtt XX/m
MgSO4 40% 4gr IV bolus perlahan
Dexamethasone 2x6 mg IV
Nifedipine 3 x 10 mg

23.05.14
08.30 WIB
DJJ I: 104x/m
DJJ II : 106x/m
DJJ III : 106x/m
09.00 WIB

G2P1A0 Hamil 35 Minggu Belum Inpartu dengan PEB dan KPSW 12


jam JTH Preskep + Gawat Janin
R/ Terminasi perabdominam

09.40 WIB

Lahir neonatus hidup. Laki-laki BB 2500 g PB 40 cm A/S 5/7 PT AGA


Lahir plasenta lengkap. BP 450 gram PTP 50 cm 16 x 18 cm

09.50 WIB

Pasien naik OK cito

OBSTETRI
No. Identitas Pasien
Ny. Rah/29/Dwi
1. Nugroho
No. RM: 364922
Datang : 21/05/2014
DM/ G2P1A0 Hamil
35 minggu belum
inpartu dengan PEB
JTHpreskep
D/P2A0 post partum
SSTP a.i gawat janin
neonatus hidup lakilaki BB 2500gr, PB
40 cm A/S 7/8 PT
AGA + PEB

Keadaan
Tgl 22-05-2014
Pukul 15.00 pasien pindah ke bangsal
S: kel : (-)
St.present
TD : 130/90
N : 88
RR : 24
T : 36,5
St.obs :
PL: Tifut 3 jbpx (28cm), memanjang puka,
kepala, u 5/5, His (-), DJJ 146x/mnt, TBJ
2325

Tindakan
Th/
Ekspektatif
Obs TVI, , DJJ
Nifedipin
3x10mg
Evaluasi sesuai
satgas gestosis

HB : 10,5
Lekuosit : 6.500
Trombosit : 384.000
A/ G1P1A0 hamil 35 minggu blm inpartu
dengan PEB jth preskep
Tgl 23-05-2014
Pukul 06.45
S : Keluhan : (-)
St.present
TD : 120/90mmHg N : 80x/mnt
RR : 24x/mnt
T : 36,3 C
St. Obs
TFU 3 jbpx (28cm), memanjang puka,
kepala, u 5/5, His (-), TBJ 2325, DJJ I :
106, DJJ II : 108, DJJ III : 105
A/ G1P0A0 hamil 35 minggu blm inpartu
dengan PEB jth preskep + gawat janin

Th/

O2 5L
Lateroposisi
Lapor residen
R/ Terminasi
perabdominan

Pukul 10.00
Lahir neonatus hidup laki-laki BB 2500gr,
PB 40cm, A/S 7/8 PT AGA
Tgl 24-05-2014
Pukul 06.45
S.Keluhan : (-)
St.present
TD : 120/80 mmHg
N : 76x/m
RR : 20 x/m
T : 36,1 0C
St. Obs
PL: Tifut 2 jbpst, perdarahan aktif (-), lokia
rubra (+), kontraksi baik, luka operasi
tertutup opsite

Th/
RL gtt xx
Vicillin 1amp / 8jam
Ketrolac 1amp /8jam
Asam traneksamat

A/ P1A0 post SSTP hari I ai. Gawat janin


+ PEB
Tgl 26-05-2014
Pukul 06.45
S.Keluhan : (-)
St.present
TD : 120/70 mmHg
N : 80x/m
RR : 24 x/m
T : 36,7 0C
St. Obs
PL: Tifut 3 jbpst, perdarahan aktif (-), lokia
rubra (+), kontraksi baik, luka operasi
tertutup opsite
A/ P1A0 post SSTP hari II ai. Gawat janin
+ PEB

1amp /8jam
Metronidazole /12jam
Gentamicin /12jam
Dopamet 3x250mg

Th/Rawat jalan
Cefadroxil 3x1
Paracetamol 3x1
B.Complex 3x1
Dopamet 3x250mg
Pasien boleh pulang

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