Identity Mrs.

AST/29/UA
Chief complaint Preterm pregnancy with high blood pressure + amniotic leakage and headache
History ± 12 hours before admission, patient complained of amniotic leakage, 2x
23.12.18 changes pads, clear, odor (-). History of abdominal massage (-). History of
(06.00 AM) abdominal trauma (-). History of traditional drugs consumption (-), history of
leucorrhea (-), post coital (-), History of toothache (-). History of fever (-).
regular abdominal contraction (-). History of history of bloody show (-). History
of high blood pressure before pregnancy (-), history of high blood pressure in
previous pregnancies (+), history of high blood pressure in current pregnancy
(+). Headache (+), nausea and vomiting (-), epigastric pain (+), blurred vision (-).
Patient admitted her pregnacy was preterm and fetal movement (+).
Marital status Married 1x, 10 years
Reproduction status Menarche since 12 yo, regular 28-day cycle, lasts 5-7 days, LMP: forgot
Obstetric history 1. 2009, male, 2300 g, preterm spontaneous, midwife, healthy
2. 2014, male, 3100 g, spontaneous, midwife, healthy
3. 2016, male, 2700 g, spontaneous, midwife, healthy
4. Current pregnancy

Past iIlness history -

Physical BP: 230/140 mmHg Pulse : 102 x/m T: 36.5oC RR: 20 x/m. H: 165 cm. BW: 86
Examination kg
Obstetrical Palpation: Uterine fundus was 3 fingers upper umbilical (24 cm), longitudinal lie,
examination head, U 5/5, uterine contraction(-), FHR 144 bpm, EFW: 1705 g
Identity Mrs. AST/29/UA
US ER - SLF cephalic presentation
- BPD: 7.2 cm. HC: 28. cm. AC: 25.96 cm. FL: 5.95 cm. EFW: 1666 g
- Placenta on anterior uterine corpus
- Amnionic fluid , SDP: 1.33 cm
C/ 30 weeks gestational age SLF cephalic presentation +
oligohydramanios
Lab Examination Hb: 14.0, LEU 16.600, PLT 164.000, HT: 40 TOT BIL/ BIL I/ BIL II:
1.00/0.20/0.80 , SGOT/PT/LDH/ALB 263/166/1027/3.6, Ur/Cr/UA
13/0.6/4.8, Na/K/Ca/Mg 144/4.0/9/1.8 CRP: non reactive (<5)
Diagnosis G4P3A0 30 weeks gestational age not inlabor with impending eclampsia
+ partial HELLP syndrome + PPROM 12 hours SLF cephalic presentation
Treatment - Stabilization 1-3 hours
- Observation of vital signs, FHR, inlabor signs
- IVFD RL xx drops/minute
- Dwelling catheterization
- Inj. MgSO4 40% ~ protocol IM
- Dexamethasone 12 mg/ 24 hours IM
- Nifedipine 10 mg/8 hours PO
- Consult Internal Medicine Department and Ophthalmology
Department
- Plan for LSCS
Identity Mrs. AST/29/UA
Internal A:
P:

Ophthalmology A:
P:

09.25 PM Female life baby was born BW: 1350 g, BL: 38 cm, A/S : 6/7 PTAGA
Placenta was delivery completely PW : 400 g, UC : 35 cm, 13x14 cm
Identity Mrs. FEB/19/RA
Chief complaint erm pregnancy with seizure and high blood pressure
History Patient come to RSMH seizure 3 times at home about 5 minutes, after seizure
13.12.18 patient not conscious. h/ abdominal contraction that spread to the waist (-)
(06.00 AM) regularly, h/ bloody show (-), h/ amniotic leakage (-), hypertension in this
pregnancy (+), hypertension before pregnancy (-), hypertension in family (-),
severe headache (-), nausea vomit (-) blurry vision (-), epigastric pain (-)

Marital status Married 1x, 1 year

Reproduction status Menarche since 13 yo, regular , lasts 5 days, LMP: forgot
Obstetric history 1. Current pregnancy

Past iIlness history -

Physical GCS: e2m3vT, BP: 220/130 mmHg, P: 137 x/m; R: 39 x/m, T: 36,7⁰C
Examination
Obstetrical Palpation: Uterine fundus was ½ umbilical to xiphoideus proc ( 28 cm )
examination longitudinal lie, head, U 5/5, uterine contraction(-), FHR 170 bpm,
EFW: 2325 g
GI: 9 VT: portio soft, posterior, OUE closed, cephalic, HI, amniotic membrane and
denominator cant assess
Urine dip ++
Identity Mrs. FEB/19/UA
US ER - SLF cephalic presentation
- BPD: 8.98 cm. HC: 30.50 cm. AC: 31.61 cm. FL: 6.05 cm. EFW: 2379
g
- Placenta on anterior uterine corpus
- Amnionic fluid , SDP: 2.10 cm
C/ 34 weeks gestational age SLF cephalic presentation
Lab Examination Hb: 11.1, LEU 24.600, PLT 429.000, HT: 40 TOT BIL/ BIL I/ BIL II:
0.60/0.40/0.20 , SGOT/PT/LDH/ALB 50/21/489/2.6, Ur/Cr/UA
13/0.74/13.2, Na/K/Ca/Mg 145/2.5/8/4, Fib/ D-dimer: 666/ 9.46
Diagnosis G1P0A0 34 weeks gestational age not inlabor with antepartum
eclampsia SLF cephalic presentation
Treatment - Stabilization 1-3 hours
- Observation of vital signs, FHR, inlabor signs
- IVFD RL xx drops/minute
- Dwelling catheterization
- Inj. MgSO4 40% ~ protocol IM
- Dexamethasone 12 mg/ 24 hours IM
- Consult Internal Neurology, Internal Medicine Department and
Ophthalmology Department
- Plan for abdominal delivery after stabilization
Identity Mrs. FEB/19/UA
Internal A:
P:

Ophthalmology A:
P:

11.50 AM Female life baby was born BW: 2800 g, BL: 47 cm, A/S : 6/7 PTLGA
Placenta was delivery completely PW : 700 g, UC : 31 cm, 20x17 cm
Identity Mrs. NUR/34/UA
Chief complaint In labor aterm pregnancy with amniotic leakage
History ± 12 hours before admission, patient complained of amniotic leakage, 2x
23.12.18 changes pads, clear, odor (-), regular abdominal contraction (-). History of
(06.00 AM) history of bloody show (-),History of abdominal massage (-). History of
abdominal trauma (-). History of traditional drugs consumption (-), history of
leucorrhea (-), post coital (-), History of toothache (-). History of fever (-).
Patient admitted her pregnacy was aterm and fetal movement (+).
Marital status Married 2x
1. 10 years
2. 3 years
Reproduction status Menarche since 14 yo, regular 28-day cycle, lasts 5-7 days, LMP: 1/4/2018
Obstetric history 1. 2002, female, 2800 g, spontaneous, midwife, healthy
2. 2005, male, 2400 g, spontaneous, midwife, healthy
3. Current pregnancy
Past iIlness history -
Physical BP: 130/90 mmHg Pulse : 96 x/m T: 36.5oC RR: 20 x/m. H: 155 cm. BW: 67 kg
Examination
Obstetrical Palpation: Uterine fundus was 3 fingers below xiphoideus proc (32 cm),
examination longitudinal lie, head, U 4/5, uterine contraction 2x/ 10’/ 30”, FHR
148 bpm, EFW: 3100 g
GI: 9 Inspeculo : Portio Livide, OUE opened, fluor (-), Fluxus (+) amnioticfluid (+)
not active, Nitrazine test + red blue
Identity Mrs. NUR/34/UA
US ER - SLF cephalic presentation
- BPD: 8.88 cm. HC: 32.65 cm. AC: 33.98 cm. FL: 6.91 cm. EFW: 3144
g
- Placenta on anterior uterine corpus
- Amnionic fluid , SDP: 1.2 cm
C/ 37 weeks gestational age SLF cephalic presentation +
oligohydramanios
Lab Examination Hb: 12.3, LEU 9.700, PLT 297.000, HT: 35 CRP: non reactive (<5), LEA :
(-)

Diagnosis G3P2A0 37 weeks gestational age inlabor 1st stage laten phase with
PROM 12 hours SLF cephalic presentation
Treatment - Observation of vital signs, FHR
- IVFD RL xx drops/minute
- Laboratory examination
- Evaluation with WHO partograph
- Oxytocin 5 IU ( definitive drops )
- Plan for vaginal delivery
Identity Mrs. NUR/34/UA
10.35 AM Female life baby was born BW: 3000 g, BL: 47 cm, A/S : 8/9 FTAGA
Placenta was delivery completely PW : 500 g, UC : 45 cm, 17x18 cm