Case Reports

Bhayangkara Hospital
May 26th – May 29th, 2019
Brando Ellioth Tayo

No Dated Patient Detail of Patient Treatment Recommenda

tion
1 26/05/2019 Mrs.M/23 Pre Treatment Diagnosis: - Spontaneous Vertex Delivery -Exclusive Breast
/yo/G1P0 G1P0A0 40 weeks of Gestational Age First Stage of Labor - Repair of Perineal Laceration Feeding for 6
A0/ Latent Phase months
LMP:19- -Vaginal Hygiene
08- Post Treatment Diagnosis: -Family Planning :
2018/RM Term Delivery + Second degree perineal laceration for Hormonal
280331 Progestin
Outcome: Male, BW3300 gr, BL 49cm, APGAR score 8/10
2 27/04/20 Mrs.M/35 Pre Treatment Diagnosis : - Spontaneous Vertex Delivery -Exclusive Breast
yo/G4P3A G4P3A0 38 weeks 5 days of Gestational Age First Stage of Feeding for 6
0/ Labor Active Phase months
LMP:29- -Vaginal Hygiene
08- Post Treatment Diagnosis : -Family Planning
2018/RM: Term Delivery for IUD Insertion
325478
Outcome: Female, BW 3000 gr, BL 47cm, APGAR score 8/10
3 27/05/2019 Mrs.N/22 Pre Treatment Diagnosis : - Spontaneous Vertex Delivery -Vaginal hygiene
yo/G4P2A G4P2A1 39 weeks 1 day of Gestational Age First Stage of -Family Planning
1/ Labor active phase for IUD Insertion
LMP:25-
12- Post Treatment Diagnosis :
2018/RM: Term Delivery
317469
Outcome: Male, BW 2900 gr, BL 48 cm, APGAR score 8/10
4 28/05/2019 Mrs.S/33 G3P2A0 -Exclusive Breast
yo/G3P2A - Spontaneous Vertex Delivery Feeding for 6
0/ Pre Treatment Diagnosis : months
LMP:13- G3P2A0 41 weeks 1 day of Gestational Age First Stage of -Vaginal Hygiene
08- Labor Active Phase -Family Planning
2018/RM: for IUD Insertion
324645 Post Treatment Diagnosis :
Term Delivery

Outcome: Female, BW 3100 gr, BL 49 cm, APGAR score 8/10

5 28/05/2019 Mrs.S/ Pre Treatment Diagnosis : - Spontaneous Vertex Delivery -Exclusive Breast
yo/G3P2A Feeding for 6
0/ 1st C-section on july 2008 due to breech presentation months
LMP:23- -Vaginal Hygiene
08- G3P2A0 39 weeks 5 days of Gestational Age First Stage of -Family Planning
2018/RM: Labor Active Phase + 1 previous C-section for IUD Insertion
318118
Post Treatment Diagnosis :
Term Delivery + VBAC

Outcome: Male, BW2800 gr, BL 47cm, APGAR score 8/10

6 29/05/2018 Mrs.N/21 Pre Treatment Diagnosis : - Spontaneous Vertex Delivery -Exclusive Breast
yo/G1P0A G1P0A0 40 weeks 1 days of Gestational Age Second Stage of - Repair of Perineal Laceration Feeding for 6
0/ Labor months
LMP:21- -Vaginal Hygiene
08- Post Treatment Diagnosis : -Family Planning
2018/RM: Term Delivery + Second degree perineal laceration for Hormonal
251118 Progestin
Outcome: Female, BW 3400gr, BL 48 cm, APGAR score 8/10
7 27/05/2019 Mrs.H/29 G2P1A0 - Curettage - Observation of
yo/G2P1A general condition,
0/ Vaginal Bleeding (+) vital sign, vaginal
LMP:10- bleeding
ECO / ICO : Dilated/Dilated
03-
2019/RM: Urine Pregnancy test (+) -Family Planning
214791 for Hormonal
Pre-Op Diagnosis : Progestin

Incomplete Abortion

P0st-Op Diagnosis :

Incomplete Abortion
8 28/05/2019 Mrs.S/21 G1P0A0 - Dilatation - Observation of
yo/G1P0A - Curettage
Vaginal Bleeding (+) general condition,
0/
LMP:19- vital sign, vaginal
ECO / ICO : Dilated/Dilated
03-
bleeding
2019/RM: Urine Pregnancy test (+)
238537
Pre-Op Diagnosis : - Family Planning
for Hormonal
Blighted Ovum
Progestin
Post –Op Diagnosis :

Blighted Ovum
9 29/05/2019 Mrs.A/31 G3P2A0 - Lower Segment Caesarean Section - - Exclusive
yo/G3P2A Breastfeeding
1/ 1st C-Section in March 2018 due to Fetal Distress - IUD Insertion for 6 months
LMP: 25- - Control for
08- Pre op Diagnosis : G3P2A0 39 weeks 4 days of Gestational operation
2018/RM: Age First stage of labor Latent Phase + 1 previous C-Sections suture
266644 + IUD Acceptor Candidate - Control for IUD
position
Post op Diagnosis : 1 previous C-Sections + Term Delivery + - Subsequent
IUD Acceptor delivery should
be at least
Neonatal outcome: Female, 3200gr, 48cm, A/S:8/10 more than 18
months

10 29/05/2019 Mrs.N/36 G2P1A0 - O2 8 Liters/minute - Exclusive

yo/G2P1A - 4 gr MgSo4 40% in NaCl 100 ml 73 Breastfeeding
0/ BP : 200/100 drops/minute intravena for 6 months
LMP: Protein urine : + 3 - 6 gr MgSo4 40% in 500 cc RL 28 - Control for
01-09- drops/minute until 24 hours post operation
2018 /RM: Pre-Operative Diagnosis : delivery suture
327041 G2P1A0 38 weeks 4 days of Gestational Age + Severe - Nifedipin 10 mg / 8 hours / oral - Control for IUD
- Lower Segment Transverse Caesarean position
Preeclampsia + IUD Acceptor Candidate Section - Control for the
Post-Operative Diagnosis : - IUD Insertion blood pressure
until
Severe Preeclampsia + Term Delivery + IUD Acceptor 12 weeks

Outcome: male, BW: 2300 gr, BL 43 cm, APGAR score 8/10 - Subsequent
delivery should
be at least
more than 18
months
11. 28/05/2019 Mrs.N/30 G4P3A0 - Lower Segment Transverse Caesarean - Exclusive
yo/G4P3A Section Breastfeeding
0/ 1st C-Section in April 2013 due to Fetal Distress - Bilateral Tubectomy Pomeroys for 6 months
LMP: Modification - Control for
27-08- 2nd C-Section in July 2014 due to 1 previous C-Section operation
2018 /RM: suture
346721 3rd C-Section in Mei 2016 due to 2 previous C-Section

Pre op Diagnosis : G4P3A0 39 weeks 1 day of Gestational

Age + 3 previous C-Sections + Female Sterilization
Candidate

Post op Diagnosis : Term Delivery + 3 previous C-Sections +

Bicornuate Uterine+ Female Sterilization Acceptor

Neonatal outcome: Male, 3000gr, 47cm, A/S:8/10

 Total
Vaginal Delivery 6
Dilatation & Curettage 2
Low transverse Caesarean Section 3
Hysterectomy Sub Total/Total -
Conservative -
 Miscarriage Total

Incomplete 1

Missed Abortion -

Mortality/ Nearmiss Total Blighted Ovum 1

Maternal -
Perinatal -

Family Planning

Natural : - Hormonal Combination : - Female sterilization : 1

Barrier : - Hormonal Progestin :- IUD :2

Known By

Makassar,29/05/2019
 (Consulent) (Chief of Resident)

( dr. Suzana S. Pakasi, Sp.OG(K) ) (dr. Haerianty) (dr. Ricky Eko Januar S.)