Patient 1

Sri Anita Anggraini / 26 yo / G2P1A0

Dx : Prev C- Section + SG + IUP (36-37) wga + Live Fetus
Plan: ANC 4 weeks later
Ms. S, 26 yo, G2P1A0, Javanese, Moslem, Senior High School, Student,
married Mr. F, 38 yo, Bataknese, Moslem, Bachelor, Enterpreneur. This
patient came to Fetomaternal outpatient Clinic USU General Hosp with

Cc : Ante-Natal Care

E : History of labor contraction (-). History of amniotic fluid leakage (-).

History of labor contraction (-). Micturition and defecation are within
normal limits. The patient was referred from other Hospital with Dx: Prev
C- Section 1x + SG + IUP (36-37) wga + Live Fetus
• History Previous illness :-
• History Previous medication :-
• History of Surgery : C-section 1 time(2015)
• LMP : ?/7/2019
• EDD : ?/3/2020
• ANC : OBGYN 2x

History of Pregnancy
1. Male, aterm, 3200gr, C-Section, Obstetrician, Hospital, Healthy
2. Current pregnancy
Vital Sign
Sens : CM
BP : 110/80 mmHg
HR : 80 x/min
RR : 18 x/min
Temp : 36,4OC
General condition : Good Upper arm circumferrence : 25,5 cm
Nutrition state : Good BW: 80 kg BH: 170 BMI: 27.7
Illness condition : Good
Generalized State :
Head : Pale palpebra conjuctiva inferior (-), icteric sclera (-)
Neck : Lymph node enlargement (-), thyroid gland enlargement (-)
Cor : Within no abnormality
Thorax : Respiratory sound : Vesicular (+/+)
Additional sound : Rales (-/-), Wheezing (-/-)
Genitalia externa : Within no abnormality
Superior Ext : Within no abnormality
Inferior Ext : Pretibial oedem : (-/-)
Obstetrical State

Abdomen : Asymmetrically enlarged

Fundal Height :
Tension part :
Lowest part :
Fetal Movement : (-)
Uterine Contraction : (-)
Fetal Heart Rate : (+) 140x/min, regular

Gynecological State
• Vaginal examination : not performed
• Gloves : not performed
• Inspeculo : not performed.
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‒ Single Fetus, intrauterine, live fetus
‒ Fetal movement (+), Fetal Heart Rate (+) 140 bpm,
regular
‒ BPD : 122,3 mm
‒ HC : 441,7 mm
‒ AC : 336,6 mm
‒ FL : 35,4mm
‒ Placenta anterior grade II
‒EFW : 409 gr
‒ S/D ratio : 2.45

Conclusion: IUP (36w5d) wga + head presentation + live

fetus + Holoproenchepaly + Multiple Congenital Anomaly
Diagnosis :
Prev C- Section 1x + SG + IUP (36-37) wga + Live Fetus

Plan :
ANC 4 weeks later
THANK YOU
Patient 2
Resapita Br Sembiring/ 29 yo / G3P2A0
Dx : PG+ MG + IUP (36-37) wga + Head Presentation + Live Fetus
Plan:
ANC
Ms. R, 29 yo, G1P0A0, Bataknese, Christian, 3rd Diploma, Housewife,
married to Mr. N, 30 yo, Bataknese, Christian, Enterpreneur. This patient
came to Fetomaternal outpatient Clinic USU General Hospital with

Cc : Antenatal Care

E : History of blood slime (-). History of labor contraction (-). History of

amniotic fluid leakage (-). Vaginal discharge (+) odorless, Micturition and
defecation are within normal limits.
• History Previous illness :-
• History Previous medication :-
• History of Surgery :-
• LMP : 5/2/2019
• EDD : ?/11/2019
• ANC : OBGYN 3x

History of Pregnancy
1. Current pregnancy
Vital Sign
Sens : CM
BP : 110/70 mmHg
HR : 86 x/min
RR : 18 x/min
Temp : 36,5OC
General condition : Good Upper arm circumferrence : 24,5 cm
Nutrition state : Good
Illness condition : Moderate
Generalized State :
Head : Pale palpebra conjuctiva inferior (-), icteric sclera (-)
Neck : Lymph node enlargement (-), thyroid gland enlargement (-)
Cor : Within no abnormality
Thorax : Respiratory sound : Vesicular (+/+)
Additional sound : Rales (-/-), Wheezing (-/-)
Genitalia externa : Within no abnormality
Superior Ext : Within no abnormality
Inferior Ext : Pretibial oedem : (-/-)
Obstetrical State

Abdomen : Asymmetrically enlarged

Fundal Height : 3 fingers below xiphoid process (35 cm)
Tension part :
Lowest part :
Fetal Movement : (+)
Uterine Contraction : (-)
Fetal Heart Rate : (+) 140x/min, regular

Gynecological State
• Vaginal examination : not performed
• Gloves : not performed
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‒ Single Fetus, intrauterine, live fetus
‒ Fetal movement (+), Fetal Heart Rate (+) 140 bpm, regular
‒ BPD : 90,9 mm
‒ HC : 323,9 mm
‒ AC : 330,1 mm
‒ FL : 70,7mm
‒ Placenta anterior covered all OUI  PAS 2
‒EFW : 3012 gr

Conclusion:
Diagnosis :
PG+ MG + IUP (36-37) wga + Head Presentation + Live Fetus

Plan :
ANC
THANK YOU
PATIENT 3
Erlina/ 27 yo / G3P2A0
Dx : MG + IUP (31-32) wga + Head Presentation + live fetus

Plan:
ANC 1 month later
Ms. E, 27 yo, G3P2A0, Javanesse, Moslem, Senior High School,
Housewife, married to Mr. W, 30 yo Javanesse, Moslem, Senior High
School, Enterpreneur. This patient came to Fetomaternal outpatient
Clinic USU General Hosp with

Cc : Antenatal Care

E : History of blood slime (-). History of labor contraction (-). History of

amniotic fluid leakage (-). Vaginal discharge (-), Micturition and
defecation are within normal limits.
• History Previous illness :-
• History Previous medication :-
• History of Surgery :-
• LMP : ?/1/2019
• EDD : ?/10/2019
• ANC : OBGYN 3x

History of Pregnancy
1. 2013, Male, 3600 grams, aterm, SVD, healthy
2. 2016, Female, 3100gr, aterm, SVD, Healthy
3. Current pregnancy
Vital Sign
Sens : CM
BP : 110/80 mmHg
HR : 86 x/min
RR : 18 x/min
Temp : 36,5OC
General condition : Good Upper arm circumferrence : 26,5 cm
Nutrition state : Good BW: 85 kg BH: 158 cm
Illness condition : Moderate
Generalized State :
Head : Pale palpebra conjuctiva inferior (-), icteric sclera (-)
Neck : Lymph node enlargement (-), thyroid gland enlargement (-)
Cor : Within no abnormality
Thorax : Respiratory sound : Vesicular (+/+)
Additional sound : Rales (-/-), Wheezing (-/-)
Genitalia externa : Within no abnormality
Superior Ext : Within no abnormality
Inferior Ext : Pretibial oedem : (-/-)
Obstetrical State

Abdomen : Asymmetrically enlarged

Fundal Height :
Tension part :
Lowest part :
Fetal Movement : (+)
Uterine Contraction : (-)
Fetal Heart Rate : (+) 142x/min, regular

Gynecological State
• Vaginal examination : not performed
• Gloves : not performed
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‒ Single Fetus, intrauterine, live fetus
‒ Fetal movement (+), Fetal Heart Rate (+) 140 bpm, regular
‒ BPD : 79.0 mm
‒ HC : 297,5 mm
‒ AC : 284,7 mm
‒ FL : 60,2 mm
‒EFW : 1921 gr

Conclusion: IUP (31-32) wga + Head Presentation presentation +

live fetus
Diagnosis :
MG + IUP (31-32) wga + Head Presentation + live fetus
Plan :
ANC 1 month later
THANK YOU