Nama : Hanna Yudit Lamro Silitonga

NIM : 211101065
Kelompok : Enam
Mata Kuliah : Praktikum Kesehatan Reproduksi
Dosen Fasilitator : Dr. Siti Saidah Nasution, S.Kp., M.Kep., Sp.Mat
Topik : High Risk Pregnancy

1) Biodata Pasien

➢ Nama Ibu : Isma

➢ Umur : 31 tahun
➢ Pekerjaan : Ibu rumah tangga
➢ Agama : Islam
➢ Suku : Banjar
➢ Alamat : Kabupaten Langkat
➢ Nama Suami : Luhut Wijaya
➢ Umur : 31 tahun
➢ Pekerjaan : Wirausaha
➢ Agama : Islam
➢ Suku : Batak
➢ Alamat : Kabupaten Langkat
➢ Riwayat Kunjungan ANC :
● ANC >4x
➢ Riwayat Haid :
● HPHT : 09-08-2022
➢ Perkiraan tanggal persalinan : 12-05-2023
➢ Riwayat Obstetri dan Ginekologi :
● Gravida :3
● Partus :2
● Abortus :0
 2) PENENTUAN KEHAMILAN RESIKO TINGGI
Hasil Skor :
❖ Low risk (1-2)
❖ Moderate Risk (3-5)
❖ High risk (≥ 6)

Medical Risk Factors Score Past Obstretrical Factors Score Present Obstretrical Score
Factors

Age less than 16 0 Assisted reproductive 1 Premature rupture of 0

technique (ART) conception membranes (rupture of
membranes before 37
completed weeks)

Age more than 35 0 Abortions (first trimester) 0 Preterm labour pains 0

(contractions of four in 20
minutes or eight in 60
minutes plus progressive
charge in the cervis/cervical
dilatation greater than 1
cm/cervical effacement pf
80 percent of greater)

Parity more than 4 0 Abortions (second trimester) 0 Polyhydramnions (amniotic 0

fluid index on ultrasound is
>24 cm)

Less maternal weight 0 Preterm birth (<37 weeks 0 Intrauterine growth 0

(body mass index <19) gestation) restriction (foetal growth
<10th centile for gestational
age)

More maternal weight 0 Family history of recurrent 0 Rhesus isommunisation 0

(body mass index >28) abortions

Heart disease 0 Recurrent spontaneous 0 Malpresentation at term 0

(symptomatic) New abortions
York heart association
class III-IV

Heart disease New 0 Postpartum haemorrhage 0 Vaginal bleeding (first 0

York heart association trimester)
class I-II

Moderate-severe renal 0 Hypertension/pre eclampsia 0 Vaginal bleeding (second 0

disease (S.creatinine trimester
>1.5 mg/dl)
Chronic renal disease 0 Prolonged labour/difficult 0 Mild anemia (haemoglobin 1
(S.creatinine >3 mg/dl) delivery <10gm%)

Pregestational diabetes 0 Still birth/neonatal death 0 Severe anemia 0

melitus (insulin (haemoglobin <6gm%)
dependent or
noninsuline dependent)

Chronic Hypertension 0 Caesarean delivery 1 Intrahepatic chlestasis of 0

(blood pressure pregnancy
>140/90 mmHg before
pregnancy or diagnosed
before 20 weeks)

Controlled epilepsy (at 0 Foetal anomaly with 0 Minor foetal malformation 0

least 1 year free of heritable genetic cause
seizures before
pregnancy)

Uncontrolled epilepsy 0 Foetal anomaly without 0 Major foetal malformation 0

(recent seizure episode, heritable genetic cause
on multiple
antiepieptic)

Active immunological 0 Radiolodne ablation within 0 Placenta praevia 0

disease like systemic past 6 months
lupus erythematosus,
rheumatoid arthritis,
systemic sclerosis,
vasculitis, etc

Immunological disease 0 Gynaecological disease like 0 Morbid acherent placenta 0

(inactive for past 6 fibroids, synaechiae, ovarian
months) cysts

Tuberculosis or PPD 0 Uterine malformation 0 Gestation hypertension 0

(purified protein (blood pressure >140/90
derivative) >10 mm without proteinuria

Pulmonary disease like 2 Pre-eclampsia (blood 0

asthma, pneumonia, pressure >140/90 mmHg
bronchitis, pulmonary with proteinuria of >300
tuberculosis mg/dl after 20 weeks of
gestation

Smoking 0 Eclampsia (seizures that 0

cannot be attributed to other
causes in a woman with
pre-eclampsia

Moderate alcohol use 2 Oligohydramnions 0

Brain 0 Abnormal umbilical artery 0
tumour/carcinoma doppler

Icterus decreasing 0 Absent or reverse dastolic 0

flows

Icterus increasing 0 Gestational diabetes 0

(abnormal 75 glucose test,
95/180/155)

Chronic disease like 0

HIV

Positive serology for 0

infections

Active bacterial, viral, 0

fungal or protozoal
infection

Urinary tract infections 0

(urinary culture with
>10’ organisms/ml

TOTAL SCORE :
7 (high risk)