CASE REPORT

Baby N, male, was born at Dr. Soetomo Hospital on January 24th 2017 at 11.40
am by section caesarean, from a 23 years old gravida 1 mother with premature rupture
of membrane, gastroschisis infant, and low birth weight infant estimation in lung
maturation therapy. The baby born with gastroschisis and low birth weight. Right after
birth, he got primary closure of gastroschisis laparotomy operation. History of birth, he
was born with Apgar score 5-8-9, with clear amniotic fluid. The birth weight was 1600
gram, with birth length was 43 cm, with the head circumference at birth was 29 cm.
The Ballard score was 32 weeks and Lubschenco score was P25-75.
Figure 1. The Ballard Score of the patient.
Figure 2. The Lubchenco Score of the patient.
 Figure 3. The Fenton Chart of the patient.

This is the first preagnancy of his mother. She got antenatal care eight times at
private obstetrician during preagnancy. No history of vaginal discharge, and got lung
maturation therapy 1 time. She had no fever with history of preterm rupture of
membrane more than 24 hours with clear amnion fluid.
The physical examination revealed a weak baby with pulse rate was 140
times/minute, regular rhythm, the body temperature was 36,6 0C, and the respiratory
rate was 50 times/minute. From the head and neck examination, there were no
jaundice, no flaring nostrils, and no hemorrhagic manifestation observed. Neither
caput succedaneum nor cephal hematoma were found. The chest was symmetric
chest expansion with no retraction. The heart was normal, no murmur was noted. The
breath sound in the both lungs was vesicular. Neither rales nor wheezing were noted.
The abdomen was abnormal which show intestines protrude through the anterior
abdominal wall. The defect located on lateral umbilical with 2 cm diameter. Ileum
protrudes along ± 100 cm to ascendens colon, and no appearance of appendix. The
extremities were warm. No edema presented on both extremities. The baby had
normal external genitalia, and normal neurological examination. The initial assessment
was as preterm infant, low birth weight (LBW), appropriate for gestational age (AGA),
and gastroschisis.
The initial laboratory examination after birth revealed haemoglobin 17.6 g/dL,
white blood cell count 9.240 /μL, platelet was 753.000/µL, and haematocrit 55.9%. Her
blood glucose was 52 mg/dL, BUN 7 mg/dL, albumin 2.68 g/dL, creatinine serum 0.32
mg/dL, SGOT 102 mg/dL, SGPT 6 mg/dL, Calcium 9.8 mg/dL, APTT 32.2 seconds
(control 26.2), PPT 16.7 seconds (control 10.2).

Figure 3.The babygram of the patient.

Figure 4. The patient.