OBSTETRIC

OUTPATIENT REPORT
Friday, February 1th 2019 – Thursday, February 7th 2019

CHIEF ON DUTY
Dr. Miranni Indah Kosim
Dr. R. A. Kusuma Andini

RESIDENTS ON DUTY
Dr. Inez Wijaya
Dr. Siti Chodijah – Dr. Kartika Ikrama Shafirlana

SUPERVISOR : Dr. Hj. Putri Mirani, OBGYN(C)

Recapitulation Obstetric Outpatient

Fetomaternal Clinic
Physiology : 1 Patients
Pathology : 6 Patients
Family Planning Clinic : 1 Patients
Lactation and Puerpural Clinic : 5 Patients
Total : 13 Patients
 Recapitulation Fetomaternal Clinic
Date Cases TM I TM II TM III

New Old New Old New Old

Patient Patient Patient Patient Patient Patient
Friday, February 1st, 2019 Physiology 0 0 0 0 0 0
Pathology 0 0 0 0 0 0
Monday, February 4th ,2019 Physiology 0 0 0 0 0 0
Pathology 0 0 0 0 0 2
Tuesday, February 5th 2019 Physiology 0 0 0 0 0 0
Pathology 0 0 0 0 0 0
Wednesday, February 6th 2019 Physiology 0 0 0 0 1 0
Pathology 0 0 0 1 0 0
Thursday, February 7th 2019 Physiology 0 0 0 0 0 0
Pathology 0 1 0 0 2 0
TOTAL 0 1 0 1 3 2
 RESUME FETOMATERNAL

No Pathological Cases Total

1 Pregnant with history of hydatidiform mole 1

2 Pregnant with antiphospolypid syndrome 1

3 Pregnant with history of recurrent pregnancy loss 1

4 Pregnant with ovarian carcinoma complete therapy 1

5 Pregnant with syphilis infection 1

6 Pregnant with HIV infection 1

 Friday, February 1th 2019 – Thursday, February 7th 2019

Physiology
Physiology Pathology
Pathology Total
Total

Friday, 02st1,th2018
NovFeb
Friday, 2019 0 0 0
Monday, Nov
Monday, 054thth, 2018
Feb 2019 0 2 2
Tuesday, Nov 06th,
2018
Tuesday, Feb 5th 2019
Wednesday, Nov 07th, 2018
Wednesday, Feb 6th, 2019 1 1 2
Thursday, Nov 08th,
2018
Thursday, Feb 7th, 2019 0 3 3
Total
Total 1 6 7
 RESUME FETOMATERNAL CLINIC

No Date New Cases Old Cases Total

1 Friday, Feb 1th 2019 0 0 0

2 Monday, Feb 4th 2019 0 2 2

3 Tuesday, Feb 5th 2019 0 0 0

4 Wednesday, Feb 6th, 2019 1 1 2

5 Thursday, Feb 7th, 2019 1 2 3

Total 2 5 7
 Months Total

HOSPITAL FAMILY PLANNING CLINIC 2018

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN 19

Counselling 89 69 56 46 46 54 59 92 96 100 43 99 69 687

Contraceptive methode:

- Post placenta & Post partum IUD 25 28 22 23 14 18 12 15 23 37 20 28 38

- LSCS + Tubal ligation 17 7 4 14 3 11 25 8 19 11 13 17 19
- Implant insertion 7 1 1 4 4 1 3 2 4 12 4 4 5
- DMPA/ suntikan 26 20 20 - 17 11 10 37 30 30 - 30 2
- Tubal ligation 4 7 4 3 1 3 2 - - - - - -
- Interval IUD insertion - 1 - 1 1 2 2 15 - - - - -

- IUD insertion after curettage - - - - - 1 - - - - 1 - -

- Pill, Barrier (kondom), Natural family

planning, Withdrawal, Lactational 5 - - - 2 2 - 10 15 5 - 15 -
amenorrhoea method.

Total patient had

Contraceptive
84 64 51 45 41 49 54 87 91 95 38 94 64 639

Removal of IUD - - 1 - - - - -
Removal of Implant - 1 - - - - - 1
IUD expulsion/ekstra uterine 1 1 - - - 1 -
Pregnancy with IUD - - 1 1 - - -

•7
 HOSPITAL LACTATION AND PUERPERAL CLINIC 2018
Months Total
JAN FEB MAR APR MAY JUN JUL AUG SEP OKT NOV DEC JAN
2019

Lactation
and 18 16 18 19 18 17 18 15 18 19 18 16 18 210
puerperal

•8
 RECAPITULATION FAMILY PLANNING CLINIC

Date Cases Contraception

IUD Implant Tubectomy
Friday, February 1st 2019 Post Partum 1 0 0

Post LSCS 0 0 1
Saturday , February 2nd 2019 Post Partum 0 0 0
Post LSCS 0 0 1
Monday, February 4th 2019 Post Partum 1 0 0

Post LSCS 0 0 1

Tuesday, February 5th 2019 Post Partum 0 0 0

Post LSCS 0 0 2
Wednesday, February 6th 2019 Post Partum 1 0 0

Post LSCS 0 0 1
Thursday, February 7th 2019 Post Partum 0 0 0

Post LSCS 0 0 1
TOTAL 3 0 7
 RECAPITULATION LACTATION AND PUERPURAL

Date Total Diagnosis

Post Partum Post LSCS

Friday, February 1st 2019 1 0 1

Monday, February 4th 2019 0 0 0
Tuesday, February 5th 2019 0 0 0
Wednesday, February 6th 2019 1 0 1

Thursday, February 7th 2019 3 0 3

Total 5 0 5
 RESUME FAMILY PLANNING CLINIC

No Date Total

1 Friday, February 1st 2019 0

2 Monday, February 4th 2019 1

3 Tuesday, February 5th 2019 0

4 Wednesday, February 6th 2019 3

5 Thursday, February 7th 2019 0

Total 4
 RESUME LACTATION AND PUERPURAL

No Date Total

1 Friday, February 1st 2019 1

2 Monday, February 4th 2019 0

3 Tuesday, February 5th 2019 0

4 Wednesday, February 6th 2019 1

5 Thursday, February 7th 2019 3

Total 5
FETOMATERNAL
 FETOMATERNAL OUTPATIENT
Friday, February 1th 2019

NO. IDENTITY DIAGNOSIS ICD010 MANAGEMENT ICD09 Phy

No patients to be reported
 FETOMATERNAL OUTPATIENT
Monday, February 4th 2019
NO. IDENTITY DIAGNOSIS ICD010 MANAGEMENT ICD09 Phy
1 Mrs. WEL/ 25 G2P0A1 30 weeks gestational age Z35.1 - CIE 89.0 FU
Y.O/ UA/ FU not inlabor, SLF Cephalic - US Examination 88.78 RNI
Presentation - Ferrous sulfate 300mg/ 24 hours (oral) IZY
- Calcium lactate 500mg/ 8 hours (oral)

2 Mrs. TRI/ 36 G5P1A3 34 weeks gestational O26.2 - CIE 89.0 FU

Y.O/ UA/ FU age not Inlabor, with
Antiphospholipid Syndrome, SLF
Cephalic Presentation
O99.1 - US Examination 88.78 RNI
- Ferrous sulfate 300mg/ 24 hours (oral) IZY
- Joint care with internal department
(Therapy from internal department:
- Oral 
- Methylprednisolone 4mg/ 24
hours,
- Folic acid tab 400 mcg/ 8 hours,
- CaCO3 1 tab/ 24 hours,
- Calcitriol 1 tab/ 24 hours, and
- Aptor® tab 100mg/24 hours)
 FETOMATERNAL OUTPATIENT
Tuesday, February 5th 2019

NO. IDENTITY DIAGNOSIS ICD010 MANAGEMENT ICD09 Phy

-
 FETOMATERNAL OUTPATIENT
Wednesday, February 6th, 2019

NO. IDENTITY DIAGNOSIS ICD010 MANAGEMENT ICD09 Pby

1 Mrs. YOS/ 25 G5P1A3 16 weeks gestational Z35.1 - CIE 89.0 HI

88.78 RNI
Y.O/ UA/ HI age, with prior CS 1x (o.i fetal - US Examination ZIY
distress), SLF Intrauterine - Laboratory examination
- Ferrous sulfate 300mg/ 24 hours (oral)
 FETOMATERNAL OUTPATIENT
Thursday, February 7th, 2019

NO. IDENTITY DIAGNOSIS ICD 10 MANAGEMENT ICD 9 PHY

1 Mrs. SAS/ 27 G1P0A0 8 weeks gestational age Z34.0 - CIE 89.0 RS

RNI
Y.O/ UA/ RS with Ovarian carcinoma stage - US examination V72.62 IZY
O34.9
IIB Complete therapy, SLF - Tumor markers level evaluation
88.78
Intrauterine - Folic acid 400mcg/ 24 hours (oral)

2 Mrs. IND/ 32 G2P1A0 37 weeks gestational Z35 - CIE 89.0 HI

V72.62 RNI
Y.O/ UA/ HI age not Inlabor with prior CS 1x O34.21 - Laboratory examination IZY
88.78
with syphilis infection, SLF O98.1 - Plan for elective caesarean section
Cephalic presentation - Ferrous sulfate 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 hours (oral)

3 Mrs. FEB/ 25 G1P0A0 32 weeks gestational Z34.0 - CIE 89.0 NS

V72.62 RNI
Y.O/ UA/ NS age not Inlabor with HIV O98.7 - US Examination IZY
88.78
Infection, SLF Cephalic - Laboratory examination
presentation - Plan for elective caesarean section
- Ferrous sulfate 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 hours (oral)
FAMILY PLANNING CLINIC
 Family Planning Clinic
Friday, February 1th 2019

Identity Diagnosis ICD010 Management ICD09 PHY

•20
 Family Planning Clinic
Monday, February 4th 2019

Identity Diagnosis ICD-10 Management ICD-

No patient to be reported
 Family Planning Clinic
Tuesday, February 5th 2019

Identity Diagnosis ICD-10 Management IC

No patient to be reported
 Family Planning Clinic
Wednesday, February 6th 2019

Identity Diagnosis ICD-10 Management IC

Mrs. FIT/ 42 yo/ UA/AB P5A0 post Bracht Manuver day 2nd +
IUD insertion
1 History of ROM 7 hours O34.21 V 25
Education
 Family Planning Clinic
Thursday, February 8th 2019

Identity Diagnosis ICD-10 Management ICD-

No patient to be reported
LACTATION AND PUERPURAL
 Lactation puerperal
Friday, February 1th 2019

Identity Diagnosis ICD01 Management ICD09 PHY

0
Mrs. LIN/ P2A2 post LSCS (day 12th) oi gemelli
O34.2 Counseling V25.1
1 25 yo/ + transverse lie-transverse lie+ Post
1 Education 1
RA/ AB IUD insertion

•26
 Lactation Puerperal
Monday, February 4th 2019

No Identity Diagnosis ICD-10 Management ICD-9

No patients to be reported
 Lactation Puerperal
Tuesday, February 5th 2019

No Identity Diagnosis ICD-10 Management ICD-9

No patients to be reported
 Lactation Puerperal
Wednesday, February 6th 2019

Identity Diagnosis ICD-10 Management ICD

P1A0 post LSCS (day 16th ) o.i
Mrs. PEB/30 Counselling
anhydramnios + PPROM 4 days + 034.21 V25
yo/RA/FB Education
intrauterine infection

•29
 Lactation Puerperal
Thursday, February 7th 2019

Identity Diagnosis ICD-10 Management IC

Counselling
P2A0 post LSCS (day 10th ) oi fetal
Mrs. RIA/33 Education
distress + umbilical cord prolapse + 034.21 V
yo/UA/AF Anti hypertension
severe preeclampsia
Drugs
P2A0 post LSCS (day 10th ) oi Prior CS Counselling
Mrs. PUJ/25 1x + Oligohydramnios + Post pomeroy Education
034.21 V
yo/UA/AF tubectomy Anti hypertension
Drugs
P2A0 post LSCS (day 10th ) oi Prior CS
Mrs. WEL/41 Counselling
1x + Oligohydramnios + Post pomeroy 034.21 V
yo/RA/KY Education
tubectomy
•30
THANK YOU
FETOMATERNAL
Friday, February 1th 2019
No patient to be reported
Monday, February 4th 2019
 Identity Mrs. WEL/ 25 y.o/ UA/ FU
Chief complain Preterm pregnancy with history of hydatidiform mole
History Patient came to fetomaternal outpatient clinic to control her pregnancy, history of abdominal
contraction spread to waist and back (-), history of bloody show (-), history of amniotic leakage (-).
Patient admitted that her pregnancy was preterm and fetal movement (+).
History of past medication: Patient experienced curettage at Moh. Hoesin Hospital Palembang on
February 23rd 2018, caused by Hydatidiform mole (826/A/2018: Hydatidiform mole on endometrial
curettage)
Marital status 1x 1 years

Reproduction status Menarche 13 yo, regular 28-day cycle, lasts 4 days, LMP: July 08th, 2018
Obstetric history 1. 2018, hydatidiform mole (10 weeks gestational age), curettage, Moh. Hoesin General Hospital
2. Current pregnancy
Vital sign Sens :CM BP: 120/70 mmHg Pulse : 80 x/m T: 36,6 oC RR: 20 x/m BW 73 kg BH 154 cm
Obstetrical Inspection & Palpation :
examination Palpation: Uterine fundal ½ Umbilical – Processus Xyphoideus (25 cm), longitudinal lie, right back, Head
U 5/5, Abdominal contraction (-), FHR 144x/minute, EFW 1860 g
 Identity Mrs. WEL/ 25 y.o/ UA/ FU

US - SLF Cephalic presentation

Dr. Abarham Martadiansyah, - Fetal Biometry: BPD 7,5 cm HC 27,6 cm AC 26,15 cm FL 5,6 cm EFW 1519 g
SpOG (K)
- Placenta at posterior uterine corpus
04.02.19
- Amnionic fluid sufficient
C/ 30 weeks gestational age SLF, Cephalic presentation

Diagnosis G2P0A1 30 weeks gestational age not inlabor, SLF Cephalic presentation

Therapy CIE
Ferrous sulfate tab 300 mg/ 12 hour (PO)
Calcium lactate tab 500 mg/ 8 hour (PO)
Return control to 1 months
 Β-Hcg Evaluation

Dates Β-Hcg
Level(mIU/mL)
H +7 30.02.2018 40,839

H +21 16.03.2018 87.77

H +28 23.03.2018 27.78

H +35 29.03.2018 14.70

H +42 06.04.2018 6.11

H +49 12.04.2018 4.04

H +56 20.04.2018 2.70

06.06.2018 <1,2

05.07.2018 1,2
 Identity Mrs. TRI/ 36 y.o/ UA/ FU

Chief complain Preterm pregnancy with APS

History Patient come to RSMH Fetomaternal Polyclinic to control preterm pregnancy with history of APS.
History of abdominal contraction spread to waist and back (-), history of bloody show (-), history of
amnionic leakage (-). Patient admitted that her pregnancy was preterm and fetal movement (+).
History of medication: Patient was diagnosed with APS (Antiphospolipid Syndrome) since 2016,
controlled, patient consumed Methylprednisolone 1 x 4 mg, Folic acid tab 3 x 400 mcg, CaCO3 tab 1 x 1
, and Aptor tab 1 x 1 routinely since then.
Marital status 1x, 12 years
Reproduction status Menarche 14 yo, regular cycle, lasts 7 days, LMP: forget
Obstetric history 1. 2007, female, 2700 gr, vaginal delivery, AK Gani Hospital, Healthy
2. 2014, Abortus, 10 weeks gestational age, curettage (+) at AK Gani Hospital
3. 2015, Abortus, 16 weeks gestational age, curettage (+) at AK Gani Hospital
4. 2016, Abortus, 14 weeks gestational age, curettage (+) at AK Gani Hospital
5. Current pregnancy
Vital sign Sens: Compos Mentis BP: 110/80 mmHg Pulse : 84 x/m RR: 20 x/m T: 36,5 oC BW 63 kg BH 155 cm

Obstetrical Inspection & Palpation :

examination Palpation: uterine fundal height 4 fingers below processus xyhpoideus (29 cm), longitudinal lie, left
back, head U 5/5, abdominal contraction (-), FHR 144 bpm, EFW 2480 g
 Identity Mrs. TRI/ 36 y.o/ UA/ FU

Lab Examination Hb 12,8 g/dl; Leu 11400/mm3; Ht 37%; Trombo 226000; Diff.count 0/1/76/18/5
03.12.2018 MCV 92,2 fL; MCH 32 pg; MCHC 35 g/dL; RDW-CV 12,40%; LED 34 mm/hour

PT+INR 14,2; INR 1.06; APTT 34,8’ ; Fibrinogen 434,0 mg/dL; D-dimer 1,29 µg/mL
Fe 65 µg/mL; TIBC 296 µg/mL; Ferritin 53,10 ng/mL

ACA IgG : 12.71

ACA IgM: 16.83
US - SLF Cephalic presentation
Dr. Abarham Martadiansyah, - Fetal Biometry: BPD 8,9 cm HC 31,6 cm AC 29,8 cm FL 6,1 cm EFW 2260 g
SpOG (K)
- Placenta at posterior uterine corpus
05.02.19
- Amnionic fluid sufficient
C/ 34 weeks gestational age SLF Cephalic presentation, no sign of hypoperfusion

Diagnosis G5P1A3 34 weeks gestational age with APS (Antiphospolipid Syndrome), SLF Cephalic presentation
Therapy CIE
Ferrous sulfate tab 300 mg/ 24 hours/ po
Joint care with Internal Department, Therapy:
- Methylprednisolone 4mg/ 24 hours,
- Folic acid tab 400 mcg/ 8 hours,
- CaCO3 1 tab/ 24 hours,
- Calcitriol 1 tab/ 24 hours, and
- Aptor® tab 100mg/24 hours
Tuesday, February 5th 2019
NO PATIENT TO BE REPORTED
Wednesday, February 6th 2019
 Identity Mrs. YOS/34 Y.O/ UA
Chief complain Early pregnancy with prior CS 1x and bad obstetrical history
History Patient came to Fetomaternal Polyclinic to control her pregnancy. History of abdominal
contraction (-), bloody discharge (-), watery discharge (-), nausea (+), vomit (-). Patient
routinely comes to our clinic to control her pregnancy.
History of past illness = Hypertension (+) on the 3rd pregnancy.
Marital status 1x, 4 years

Reproduction Menarche 12 yo, regular cycle, last 7 days, LMP: 12/10/2018

status
Obstetric history 1. 2014, Abortus, 6 weeks gestational age, curettage (+) at YK Madira Hospital
2. 2015, Abortus, 6 weeks gestational age, curettage (-)
3. 2016, male, 1600 gram, caesarean section delivery o.i fetal distress, at RSMH
4. 2018, spontaneous delivery, 20 weeks gestational age, congenital anomali, deceased
5. Current pregnancy

Vital sign Sens: CM BP: 130/80 mmHg Pulse : 88 x/m RR: 20 x/m T: 36,8 oC
BW: 65 kg BH: 156 cm

Obstetrical Inspection & Palpation :

examination Abdomen flat, supple, Fundal height 1 fingers below umbilicus (15cm) , contraction (-), FHR
159x/minute, EFW 310 g, scar (+)
 Identity Mrs. YOS/ 34 Y.O/ UA

Lab Examination Hb 15, WBC 11900, HT 43%, PLT 328.000, MCV 83.6 MCH 29 MCHC 35
07.01.18

Lab Examination TORCH

04.02.18 Toxoplasma Ig G: 0,01 (Non reactive < 1,6; Grey zone 1,6 - < 3,0; Reactive ≥ 3,0)
Toxoplasma Ig M: 0,04 (Non reactive <0,50; Grey zone 0,50 – 0,60; Reactive ≥ 0,6)

Rubella Ig M: 0,17 (Non reactive < 1,20; Grey zone ≥ 1,2 - < 1,6; Reactive ≥ 6,0)

CMV Ig G: 99,8 (Non reactive < 6.00; Reactive ≥ 6,0)

CMV Ig M: 0,25 (Non reactive < 0,85; Grey zone 0,85 - 0,99; Reactive ≥ 1,00)

HSV I Ig G: 0,2785
HSV I Ig M: 1,4380

HSV II Ig G: 0,3495
HSV II Ig M: 0,6231
 Identity Mrs. YOS/ 34 Y.O/ UA
US - SLF intrauterine
Dr. Hj. Putri - Fetal Biometry: BPD 3,5 cm HC 13,2 cm AC 11,2 cm FL 2,4 cm EFW 179 g
Mirani, OBGYN (C) - Placenta at posterior uterine corpus
06.2.19 - Amnionic fluid sufficient,
C/ 16 weeks gestational age, SLF Intrauterine

Diagnosis G5P1A3 16 weeks gestational age, with prior CS 1x (o.i fetal distress), SLF Intrauterine
Therapy CIE
US confirmation
Laboratory Examination
Ferrous sulfate 300mg/ 24 hours (oral)
Thrusday, February 7th 2019
Mrs. SAS/ 25 Y.0/ UA
Chief Complain Early pregnancy with history of ovarian carcinoma

History Patient came to control her pregnancy. History of abdominal contraction (-), breast tense (+), vaginal
bleeding (-). Patient admitted that she didn’t got menstrual cycles since 2 months ago. She admitted that
her pregnancy test was positive.

Marital status 1x, 2 years

Reproduction status Menarche since 12 yo, regular cycle 28 days, for 6 days, LMP : December 12th, 2018
Obstetric history 1. Current pregnancy
Past iIlness history Patient was diagnosed with ovarian carcinoma since 2 years ago.
November 2016, patient was experienced first surgery at Muhammadiyah Hospital
December 2016, patient was experienced surgical staging at RSMH
Pathology anatomy result 4933/A/2016: Carcinoma with clear cell figure on tissue surrond sigmoid colon,
left folicular ovarian cyst, paratubal cyst, hypocelullar peritoneal cytology.
Physical examination BP : 110/70 mmHg, P : 88 x/min, T : 36.7 C, RR : 20 x/min

Obstetrical Palpation : Abdomen flat,symmetric, Fundal height unpalpable, mass (-), tenderness (-).
examination
US Confirmation • SLF Intrauterine was seen
• Biometry : CRL 1.8 cm ~ 8 weeks 4 days gestational age
• Fetal pulse (+)
C/ - 8 weeks gestational age, SLF Intrauterine

Laboratory AFP 2.49 ng/mL

Examination CEA 1.30 ng/mL
(9-1-19) CA 125 37.9 U/mL
Diagnosis G1P0A0 8 weeks gestational age with history of ovarian carcinoma stage II, SLF Intrauterine
Therapy - CIE
- Tumor markers level evaluation (scheduled on April 2019)
- Folic acid 400mcg/ 24 hours (oral)
 Identity Mrs. IND/ 32 Y.O / UA/ HI

Chief complain Aterm pregnancy with syphilis infection

History Patient came to Fetomaternal Polyclinic to control her pregnancy. History of abdominal contraction (-),
history of bloody show (-), history of amnionic leakage (-). Patient admitted that her pregnancy was
aterm and fetal movement (+)
History of medication : Patient went to AK Ghani Hospital on February 1 st ,2019, she was told if her
pregnancy was aterm and she has syphillis infection, patient then reffered to RSMH

Marital status 1x, 7 years

Reproduction Menarche 12 yo, regular cycle, lasts 5 days, LMP: May, 7th ,2018
status
Obstetric history 1. 2013/ Female, 2700 g, LSCS (o.i anhydramnios), at Muhammadiyah Hospital, helthy
2. Current pregnancy
Vital Sign Sens: CM BP: 100/70 mmHg Pulse : 88 x/m T: 36,5 oC RR: 20x/m

Obstetrical Inspection & Palpation :

examination Palpation: Uterine fundal 4 fingers below proc xyphoideous (33 cm), longitudinal lie, right back,
cephalic, U 5/5, uterine contraction (-), FHR 151 bpm, EFW 3100 g

Laboratory Hb 11.2 g/dL, RBC 4.40 x 106 /mm3 WBC 13,700/ mm3, HT 34%, PLT 315.000/µL, MCV/MCH/MCHC
examination 78,2fL/24 pg/ 33 g/dL LED 50 mm/hours, DC 0/2/75/17/6, , HbsAg non reactive, Anti HIV non
(06-02-2019) reactive, VDRL reactive(1/4), TPHA reactive(1/320)
 Identity Mrs. IND/ 32 Y.O / UA/ HI

Diagnosis G2P1A0 37 weeks gestational age not Inlabor with prior CS 1x with syphilis infection, SLF Cephalic
presentation

Therapy - CIE
- Laboratory examination
- Consult to STD Polyclinic
- Plan for elective caesarean section
- Ferrous sulfate 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 hours (oral)
STD Polyclinic (DV) A/ Past syphillis
P/
- no specific therapy was needed at the moment, therapy will be given if VDRL Titer ≥ 1/8
 Mrs. FEB/ 27 Y.0/ UA/ NS
Chief Complain Aterm Pregnancy with HIV Infection
Anamnesis Patient came to Fetomaternal Polyclinic control her pregnancy. History of abdominal contraction spread to
waist and back (-), history of bloody show (-), history of amnionic leakage (-). Patient admitted that her
pregnancy was aterm and fetal movement (+). She was diagnosed with HIV Infection since 2016. She
consumed ARV regullary since then.

Marital status 2x, 1st marriage 2010-2011, 2nd marriage 2018- now

Reproduction History Menarche since 13 yo, regular 28-day cycle, lasts 7 days, LMP: May, 11th 2018
Obstetric status 1. This pregnancy

Physical Examination Vital Signs

Sens: Compos Mentis BP: 110/70 mmHg Pulse : 84 x/m T: 36oC RR: 20 x/m BW 55 kg BH 155 cm

Obstetric Palpation: Uterine fundal 3 fingers below proc xyphoideous (29 cm), longitudinal lie, left back, cephalic, U
Examination 5/5, uterine contraction (-), FHR 141 bpm, EFW 2170 g

Lab examination Hb: 12,8 g/dL, WBC: 9300/mm3, HT 37 % PLT: 312.000/mm3, MCV 83,9 MCH 29 MCHC 35 HBsAg non
(04-10-2018) reactive, CD4 Absolut 373, CD 4% 12,6, CD8 Absolut 1,769, CD8% 60,79, Rasio CD4:CD8 0,21
 Mrs. FEB/ 27 Y.0/ UA/ NS
US Examination - SLF cephalic presentation
- Fetal Biometry
BPD 8,4 cm HC 30,8 cm AC: 28,3 cm FL : 6,6 cm EFW 2146 g
- Placenta an anterior corpus
- Amniotic fluid sufficient
C/ 32 weeks gestational age SLF cephalic presentation
Diagnosis G1P0A0 32 weeks gestational age not Inlabor with HIV Infection, SLF Cephalic presentation
Therapy CIE
- CIE
- US Examination
- Laboratory examination
- Plan for elective caesarean section
- Ferrous sulfate 300mg/ 24 hours (oral)
- Calcium lactate 500mg/ 8 hours (oral)
Family Planning Clinic

67
Identity Mrs. FIT/ 42 yo/ UA/NS

Chief complaint Contraception Counselling

History Patient spontaneous delivery on February 5th 2019. Female life baby was born
with BW: 2900g, BL: 31 cm, healthy. Patient was aterm pregnancy in labor first
stage latent phase with breech presentation
Obstetric history P5A0
Obstetrical Palpation: Uterine fundus 2 fingers below umbilicus, contraction was good,
examination tenderness (-), Lochia (+) rubra,

Diagnosis P5A0 post LSCS day 16th oi anhydramnios + PROM 4 days

Laboratory exam Hb: 13.1, Ht: 38, WBC: 21.700, Plt: 2252.000

Management IUD insertion

Lactation-puerperal
 Identity Mrs. LIN/ 43 yo / UA/ AB
Chief complaint Post operative counselling
History Patient with preterm pregnancy (24 weeks) had LSCS on January 20th 2019 05.25 PM (JPO)
with IUD insertion. 2 Male baby was born, 1500-1900 g, BL: 40-42 cm, A/S 8/9 being treated
on NICU
Marital Status 1x, 6 years
Obstetric history 1. 2013, abortion, 12 weeks of pregnancy, curettage on Kayu Agung Hospital
2. 2015, abortion, 9 weeks of pregnancy, curettage on Kayu Agung Hospital
3. 2016, male, 2700 g, full term, spontaneous delivery, Bari hospital, healthy
4. 2019, male-male, preterm, 1500-1900 g, CS oi gemelli transverse lie-transverse lie, MH
hospital, NICU
Obstetrical BP: 128/86 mmHg, HR: 100 bpm
examination Palpation: Uterine fundus not palpable, tenderness (-), free fluid sign (-), Lochia (+) serosa
Diagnosis P2A2 post LSCS (day 12th) oi gemelli + transverse lie-transverse lie+ Post IUD insertion
Management Counseling
Education
Identity Mrs. PEB/30 yo/RA/FB
Chief Complaint Counselling post operation.
History Patient had LSCS on January 23rd 2019 Female life baby was born with BW: 1400
g, BL: 38 cm, A/S 3/5/7 PTAGA. Patient was preterm pregnancy (30 weeks)
with PPROM and intrauterine infection. abdominal pain (-), vaginal bleeding (-),
breast feeding (-).
Obstetric History P1A0
Obstetrical Palpation:
Examination Uterine fundus not palpable, tenderness (-), free fluid sign (-), lochia (+) alba,
pfannensteil scar (+), redness (-), open wound (-)
Diagnose P1A0 post LSCS (day 16th ) o.i anhydramnios + PPROM 4 days + intrauterine
infection
Management Counseling
Identity Mrs. RIA/33 yo/UA/AF

Chief Complaint Counselling post operation.

History Patient had LSCS on January 27th 2019 Male live baby born, BW 2900g BL 48
cm AS 1/0 FTAGA. Patient was aterm pregnancy (38 weeks) with severe
preeclampsia and fetal distress and umbilical cord prolapse. abdominal pain (-),
vaginal bleeding (-), breast feeding (-).
Obstetric History P2A0
Obstetrical Palpation:
Examination Uterine fundus not palpable, tenderness (-), free fluid sign (-), lochia (+) alba,
pfannensteil scar (+), redness (-), open wound (-)
Diagnose P2A0 post LSCS (day 10th ) oi fetal distress + umbilical cord prolapse + severe
preeclampsia
Management Counseling
Education
Anti hypertension Drugs
Identity Mrs. PUJ/25 yo/UA/AF
Chief Complaint Counselling post operation.
History Patient had LSCS on January 28th 2019 male life baby was born with BW: 2650g,
BL: 47 cm, A/S 8/9 FTAGA. Patient was aterm pregnancy (39 weeks) with
severe preeclampsia and inertia uteri . abdominal pain (-), vaginal bleeding (-),
breast feeding (-).
Obstetric History P2A0
Obstetrical Palpation:
Examination Uterine fundus not palpable, tenderness (-), free fluid sign (-), lochia (+) alba,
pfannensteil scar (+), redness (-), open wound (-)
Diagnose P2A0 post LSCS (day 10th ) o.i severe preeclampsia with inertia uteri
Management Counseling
Education
Identity Mrs. WEL/41 yo/RA/KY
Chief Complaint Counselling post operation.
History Patient had LSCS on January 27th 2019 Female life baby was born, BW 2600g,
BL 46 cm, A/S 8/9 FTAGA. Patient was aterm pregnancy (38 weeks) with prior
CS 1 x with oligohydramnios and post pomeroy tubectomy . abdominal pain (-),
vaginal bleeding (-), breast feeding (-).
Obstetric History P2A0
Obstetrical Palpation:
Examination Uterine fundus not palpable, tenderness (-), free fluid sign (-), lochia (+) alba,
pfannensteil scar (+), redness (-), open wound (-)
Diagnose P2A0 post LSCS (day 10th ) oi Prior CS 1x + Oligohydramnios + Post pomeroy
tubectomy
Management Counseling
Education
Anti hypertension Drugs
Thank You