Case Report

Case ReportEditha Aldillasari R (4151131493)Reza Khadafy N (4151131495)Name: Mrs. PNRoom : V/VIMedical Record : 029925Sex : FemaleAge: 35 th Religion : Islam Address : Bandung Barat

From : Emergency UnitCo-Ass Check : 24 April 20134Condition when home : Mother and Baby Health

Presentation of the HistoryA 39 year old pregnant woman (G5P1A3) gravida aterm 39-41 weeks gestation She came because she gave referral from medical specialties obstetrics and gynecologyShe has no complaint or presents history of abdominal cramping, vaginal bleeding, painful contraction, and leakage of fluid.

Current PregnancyLast menstrual period: 22nd April 2014 Regular cycle menses : 28 dayContraception: combined oral contraceptive pill Estimated date of delivery: 29th January 2015 Baby birth weight prediction: 2500 gramObstetrical Historyfull term normal spontaneous vaginal delivery at term in 2002.First abortion in 2003Second abortion in 2004Third abortion in 2005

Gynecological HistoryMenarche : 13 years oldPast Medical and Surgical HistoryToxoplasmosis Family HistoryHistory of stillbirth Diabetes (-)

Physical ExaminationThis patient looks clinically well Temperature : 36,2 celcius degreeBlood pressure : 120/80 mmHgPulse : 84 bpm, regularRespiratory rate : 18 x/mObstetric ExaminationSymphysiofundal height : 28 cmFetal heart : 169 bpmLeopold I: BreechLeopold II: Back on the rightLeopold III: Head The head isnt engaged

HematologyHemoglobin : 11.7 g/dlLeucocyte: 7.0 103/LErythrocyte: 3.80 106 /LThrombocyte: 157 103/LMCV: 88.4 fLMCH: 30.8 pgMCHC: 34.8 g/dl

Liver FunctionTotal Bilirubin: 0.71 mg/dlDirect Bilirubin: 0.25 mg/dlIndirect Bilirubin: 0.46 mg/dlUreum: 11mg/dlUrea N: 5.30mg/dlCreatinin: 0.50mg/dlLFG : 126 ml/menit/1.73m2Diagnostic Pre OperationG5P1A3 gravida aterm 39-41 weeks + Fetal distress + Oligohydramnios + Intra Uterine Growth Retardation (IUGR)

Treatment Caesarean SectionFollow UpAS : 3-5Meconium (+)Plasenta: Smaller than normalLiterature ReviewIUGRa condition of the birthweight below 10th percentile of the recommended gender-specific birthweight for gestational age reference curves OligohydramniosAmniotic fluid index (AFI) of 5 cmTABEL HALFETAL DISTRESSDISCUSSION