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            It is November 2nd and you are medical a medical student attending obstetrics
outpatient clinic in Puskesmas Serpong. Your next patient is, a 20-year-old house wife,
named Dewi. She complains of nausea and vomiting for the past week. She does not
have fever or diarrhea, but she notices that she has to the toilet more frequently
although there is no pain or burning sensation when she’s urinating. She also says that
she missed her period last month. Her last menstrual period was in September but it
was only spotting for 2 days. She doesn’t remember the date.

            Vital signs: BP 110/80 mmHg, HR 70/min, RR 14/min, T 37.4°C, Ht 165 cm, Wt
52 kg.  Skin and conjunctiva are a normal color and mucus membranes are moist. The
examination of ears, throat, tonsils and cervical lymph nodes is normal. Palpation of
thyroid is normal. She has normal cardiac and respiratory sounds. Abdominal exam
reveals a flat, soft and nontender abdomen with no signs of organomegaly. Auscultation
of bowel sounds is normal. 

1.       Identify Dewi’s presenting complaint and generate a list of hypotheses for it

- Pregnancy

- Hormonal

- Neoplasm

- Baru menggunakan alat kontrasepsi

2.       What further information do you need to know?  

- USG transvagina: looking for pregnancy,

- Hormone blood tests

- Anamnesa

- Terakhir berhubungan seks kapan?

- Menggunakan kontrasepsi ga? kalo iya apa dan rutin apa ga?

- Udah punya anak belom?

- Sebelumnya pernah begini ga?

- Punya riwayat keluarga cancer ga?

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 On further questioning you learn that she started menstruating when she was 14 years old
(Menarche) and after that she has period regularly every 28 – 30 days. Her period usually
lasts for 5 days with normal amount of blood. She’s got married at 18 years old and had been
pregnant twice. She had her first pregnancy right after she got married. She delivered her
first pregnancy prematurely at eight months pregnancy. Her baby had to be put in the
hospital for a week but eventually went home in good condition.  Her second pregnancy was
ten months ago but ended in a spontaneous miscarriage at seven weeks pregnancy.   After
that she uses combined oral contraceptives, but she admits that she sometimes forget to take
the pill regularly.

Her past medical and/or surgical history is negative.  There is no history of blood disorders in
either family.

The pregnancy kit tests positive for hCG antibody in her urine.
*hCG adalah hormon yang diproduksi oleh plasenta saat hamil. Muncul tak lama
setelah embrio menempel pada dinding rahim. Jika sedang hamil, hormon ini
meningkat sangat cepat. Jika memiliki siklus menstruasi 28 hari, dapat mendeteksi
hCG dalam urin pada 12-15 hari setelah ovulasi.

Pelvic exam: inspection of the vulva, vagina and cervix reveals a bluish tinge of the tissues
(Chaddwick’s sign). No blood is noted in the vagina. On inspection, the cervical ostium is
closed. The speculum is removed and the bimanual reveals a nontender soft uterus about the
size of an orange. The cervix is soft. The uterus is anteverted and ante flexed. There is a small
cyst (3 cm) noted on the left ovary. Auscultation (suprapubically) with a Doppler does not
detect a fetal heart rate. (terdengar kalo udah 13 minggu kandungan) 

After knowing the pregnancy test is positive, she’s very upset, because she doesn’t plan to get
pregnant. Dewi asks you “Are you sure I am pregnant? Is this pregnancy test accurate? And
how many weeks my pregnancy is?”

3.       How does this change your idea about Mrs. Dewi

- Normal pregnant

4.       How does a urine pregnancy test work?

Urine pregnancy test is looking for hCG hormone which is produce by placenta

- hCG adalah hormon yang diproduksi oleh plasenta saat hamil. Muncul tak lama
setelah embrio menempel pada dinding rahim. Jika sedang hamil, hormon ini
meningkat sangat cepat. Jika memiliki siklus menstruasi 28 hari, dapat mendeteksi
hCG dalam urin pada 12-15 hari setelah ovulasi.
5.       Address Dewi’s questions.

- Iya bu, saya yakin ini pregnant karena urine pregnant test itu akurasi nya 99% bu,
dan beberapa gejala juga sudah menunjukan adanya kehamilan seperti adanya
Chaddwick’s sign, mual muntah, tidak ada nyeri dan demam. Lalu ibu konsumsi pil KB
nya juga ada bolong-bolong dan kemungkinan kehamilannya masih 6-8 minggu.

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You then consult her to the obstetrician in the Puskesmas. After being examined by the
obstetrician, Dewi comes back to see you again with ultrasound result: “From ultrasound
examination reveal intrauterine gestation with one embryo with crown rump length 2,2
cm, equal to 8 weeks pregnancy. Fetal heart rate 160 beats per minutes.  Ovaries are within
normal limit.” 

Dewi asks “ Is everything all right ? I was told that I am eight weeks pregnant. How that can
be ? I still have period about 2 months ago. And I still take my contraceptive pill until last
week, can the baby be affected by the pill ?” She also says that she got a headache 3 week
ago and took mefenamic acid tablet three times daily for 1 days. She asks you, “Could this be
a problem for my baby ?”

6.       Address Dewi’s concern 

- untuk asam emfenamat itu gapapa bu selama ibu konsumsi saat sedang tidak
menyusui

- kemungkinan ada risk buat abnormal tetapi tenang aja bu, hanya sedikit
kemungkinannya

 
7.       What are the important aspects of first trimester prenatal care?