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Case Report Wednesday: July, 24 2013: Primigravida + Preterm Labor
Case Report Wednesday: July, 24 2013: Primigravida + Preterm Labor
Case Report Wednesday: July, 24 2013: Primigravida + Preterm Labor
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Wednesday : July, 24 2013
Primigravida + Preterm Labor
Identity
Name : Mrs. S
No. MR : 83 56 15
Feeling of pain from waist to groin intermittent since about 2 hours ago
Bloody show from the vagina was abscent
There is no fluid leakage from the vagina
There is no massive vaginal bleeding
Impression : reactive
USG
Hematocrit 38 % 28.0–40.0
Eritrocyte 4.2Finding
Laboratory /mm3: 2.71-4.43
Crystal - -
Bilirubin - -
Urobilinogen + +
Diagnosis
G1P0A0L0 preterm pregnancy 30-32 weeks + threatened
preterm labor
Fetal alive, singleton, intra uterine, head presentation
Management :
Control of GA, VS, uterine contraction, FHR
Tocolitic : Nifedipine 3x10 mg
Lung maturation : dexamethasone 2x6 mg IV (2 days)
Antibiotic (skin test)
Informed Consent
Contraception counseling
Plan :
Expectative
July, 188h 2013 07.00 am
Anamnestic Feeling of pain from Feeling of pain from Feeling of pain from Feeling of pain from Feeling of pain from
waist to groin (-) waist to groin (-) waist to groin (-) waist to groin (-) waist to groin (-)
Fetal movement (+) Fetal movement (+) Fetal movement (+) Fetal movement (+) Fetal movement (+)
Physical Abd : uterine Abd : uterine Abd : uterine Abd : uterine Abd : uterine
Examination contraction (-) contraction (-) contraction (-) contraction (-) contraction
FHR : 156-166 bpm FHR : 158-168 bpm FHR : 154-164 bpm FHR : 152-162 bpm 1x/15”/weak
Gen : I : V/U normal, Gen : I : V/U normal, Gen : I : V/U normal, Gen : I : V/U normal, FHR : 160-168 bpm
vaginal bleeding (-) vaginal bleeding (-) vaginal bleeding (-) vaginal bleeding (-) Gen : I : V/U normal,
vaginal bleeding (-)
July, 19th 2013 04.00 am
Diagnose G1P0A0L0 preterm parturient 30-32 weeks first stage of active phase
Fetal alive singleton intrauterin head presentation at HI-II
Management Control GA, VS, uterine contraction, FHR
Follow the progress of labor
Diagnose G1P0A0L0 preterm parturient 30-32 weeks firrst stage of active phase
Fetal alive singleton intrauterin head presentation at HIII-IV
Management Control GA, VS, uterine contraction, FHR
Lead to bear down