N Identity Analysis Diagnosis Procedure

o
1. Mrs. YUL/ 30 27.11.2020; 05.00 AM  G3P2A0 37 weeks  Laboratory
YO/ 1190671/ Patient has watery discharge gestational age not in examination
BANGKA since 10 hours ago for 2x labor  Antibiotic
BELITUNG/ changing pad. History of  PROM 12 hours  US
DID-IAN/ AB
abdominal contraction (-),  Single life fetus Confirmatio
Full term
bloody show (-). Patient had cephalic presentation n
pregnancy
leucorrhea, white color, itchy  Oligohydramnios  Induction of
with watery
(-), fishy odor (-).  IUGR Asymmetrical labor
discharge
 Mayor multiple (misoprostol
Physical examination congenital anomaly 25 mcq
Normal vital sign was suspected vaginally / 6
Abdomen hours)
Uterine fundal height in 3 ICD 10  Vaginal
fingers below xyphoid process Z3A.37 : 37 weeks delivery
(27 cm), longitudinal lie, left gestation age
fetal spine, cephalic, contraction O42.1 : Premature ICD 9
(-), FHR 140x/minute, EFW rupture of membrane V72.62 :
2170 gram Q89.7 : Multiple laboratory
Speculum examination congenital examination
Livid portion, opened OUE, malformations 99.2 : Injection o
fluor (+) white colour, fluxus O36.5: Maternal care for r infusion of othe
(+), didn’t active amniotic fluid, other known or r therapeutic
E/L/P (-), nitrazine test (+) suspected poor fetal 73.4 :
Vaginal toucher growth Medical inductio
Soft portion, posterior, n of labor
effacement 0%, dilatation 0 cm, O41.0: Oligohydramnios 88.78 :
cephalic, amniotic and US examination
denominator can’t be assess yet Recent diagnosis: for gravid
 P3A0 post women
Supporting examination spontaneous delivery 650 :
US evaluation (dr. Abarham  History Rupture of vaginal delivery
Martadiansyah, SpOG (K) Membrane 2 days
- Single life fetus cephalic  IUGR Outcomes
presentation  Multiple congenital 00.30 AM Life
- Fetal biometric
anomaly neonates was
BPD 8.11 cm. AC 27,51
cm
(tanatophoric born, male,
HC 29,33 cm. FL 3,77 dysplasia + weight 1700
cm brachycephaly) gram, length 35
EFW 1427 gram cm, HC 30 cm
PiUmb 0,93 PiMCA A/S 1/3/5/6 FT
0,72. CRP < 1,0 SGA
- Batik sign (+) ~ (with
brachycephali tanatophoric
- There was lung
dysplasia +
hypoplasia; TC/AC 0,83
brachycephaly)
 - There was abnormal
ossification in lower
extremity and dysplasia Recent
tanatophoric ~ condition
osteogenesis imperfecta
Stable in ward
- Amniotic fluid has
The baby was
decreased, AFI 4,58 cm ~
oligohydramnios passed away 8
- Placenta in anterior corpus hours after born
of uterine with diagnosed
- Cervix length, 3,03 cm RDS + Multiple
congenital
C/ anomaly.
37 weeks gestational, single life
fetus cephalic presentation
IUGR Asymmetrical
Mayor multiple congenital anomaly

Laboratory result
Hb 11 g/dL RBC 4,00 x
106/mm3 WBC 12,01x103/mm3
Ht 30% PLT 230x103/uL Diff.
count 0/0/81/12/7
HbsAg Non Reactive HIV Non
Reactive VDRL TPHA Non
Reactive

Thanatophoric dysplasia (TD) is a short-limb skeletal dysplasia that is usually lethal in the perinatal
period. TD is divided into subtypes:
 TD type I is characterized by micromelia with bowed femurs and, uncommonly, the presence
of craniosynostosis of varying severity.
 TD type II is characterized by micromelia with straight femurs and uniform presence of
moderate-to- severe craniosynostosis with cloverleaf skull deformity.
Diagnosis :
Established in a proband with characteristic clinical and/or radiologic features and/or a heterozygous pa
thogenic variant in FGFR3 identified on molecular genetic testing.

Management :
Pregnancy management ;
When TD is diagnosed prenatally, treatment goals are to avoid potential pregnancy complications in
cluding prematurity, polyhydramnios, malpresentation, and delivery complications from macroc
ephaly and/or a flexed and rigid neck; cephalocentesis and cesarean section may be considered to av
oid maternal complications.

OBSTETRIC PATIENT
Identity Mrs. YUL/ 30 YO/ 1190671/ BANGKA BELITUNG/ DID-IAN/ AB
Chief complain Full term with watery discharged
Recent illness Patient has watery discharge since 10 hours ago for 2x changing pad.
history History of abdominal contraction (-), bloody show (-). Patient had
27.09.2020 leucorrhea, white color, itchy (-), fishy odor (-). Patient didn’t had fever,
05.00 AM sore throat, cough, loss of sense. History of trauma (-), history of consume
traditional medicine (-).
Patient admitted had full term pregnancy and fetal movement still can be
felt
Family illness (-)
history
Past Illness Patient routinely done antenatal care with midwife
History
Marital status Married 1x for 8 years
Reproduction Menarche at 14 years old, regular, cycle of 28 days, for 5 days, LMP :
status March 12th 2020
Obstetric 1. 2013, male, aterm, 3000 g, spontaneous delivery, midwife, healthy
history 2. 2016, male, aterm, 3600 g, spontaneous delivery, midwife, healthy
3. Current pregnancy
Physical BP 120/80 mmHg, Pulse : 125 x/minute, T: 37oC, RR: 32x/minute
Examination BW 76 kg BH 158 cm
Head: normocephalic, pale conjunctiva (-/-), icteric sclera (-/-),
Neck : JVP (5-2)cm H2O, there is no lymph nodes enlargement
Thorax:
Cor: Heart sound I-II within normal, murmur (-), gallop (-)
Lungs: Vesicular (+/+) within normal, rales (-), wheezing (-/-)
Extremities: Pretibial edema (-/-)
Obstetrical Abdomen
examination Uterine fundal height in 3 fingers below xyphoid process (27 cm),
longitudinal lie, left fetal spine, cephalic, contraction (-), FHR 140x/minute,
EFW 2170 gram
Speculum examination
Livid portion, opened OUE, fluor (+) white color, fluxus (+), didn’t active
amniotic fluid, E/L/P (-), nitrazine test (+)
Vaginal toucher
Soft portion, posterior, effacement 0%, dilatation 0 cm, cephalic, amniotic
and denominator can’t be assess yet
US examination - Single life fetus cephalic presentation
27.11.2020 - Fetal biometric
Dr. H. Abarham BPD 8.11 cm. AC 27,51 cm
Martadiansyah, HC 29,33 cm. FL 3,77 cm
OB/GYN ( C) EFW 1427 gram
PiUmb 0,93 PiMCA 0,72. CRP < 1,0
- Batik sign (+) ~ brachycephali
- There was lung hypoplasia; TC/AC 0,83
- There was abnormal ossification in lower extremity and dysplasia tanatophtoric ~
osteogenesis imperfecta
- Amniotic fluid has decreased, AFI 4,58 cm ~ severe oligohydramnios
- Placenta in anterior corpus of uterine
- Cervix length, 3,03 cm

C/
37 weeks gestational, single life fetus cephalic presentation
IUGR Asymmetrical
Mayor multiple congenital anomaly
Laboratory Hb 9,6 g/dL RBC 4,00 x 106/mm3 WBC 15,01x103/mm3 Ht 30% PLT
examination 230x103/uL Diff. count 0/0/81/12/7
27.11.2020 HBsAg non reactive; TPHA non reactive; VDRL non reactive; Anti HIV
non reactive
Diagnosis  G3P2A0 37 weeks gestational age not in labor
 PROM 12 hours
 Single life fetus cephalic presentation
 Multiple congenital anomaly was suspected

Management  Observation of vital sign, contraction and FHR

 Laboratory examination
 US examination
 Ampicilin 1 g/ 6 hours (IV)
 Gentamisin 80 mg/ 12 hours (IV)
 Plan for vaginal delivery
Follow up S/ Full term pregnancy with watery discharge
27.11.2020
07.00 PM O/
Sensorium compos mentis, BP 120/80 mmHg, Pulse 92x/minute; RR
20x/minute, T 36,5oC

Abdomen
Uterine fundal height in 3 fingers below xyphoid process (27 cm),
longitudinal lie, left fetal spine, cephalic, contraction (-), FHR 140x/minute,
Speculum examination
Livid portion, opened OUE, fluor (+) white color, fluxus (+), didn’t active
 amniotic fluid, E/L/P (-), nitrazine test (+)
Vaginal toucher
Soft portion, posterior, effacement 0%, dilatation 0 cm, cephalic, amniotic
and denominator can’t be assess yet

A/
G3P2A0 37 weeks gestational age not in labor
PROM 20 hours
Single life fetus cephalic presentation
Multiple mayor congenital anomaly was suspected
IUGR
Oligohydramnios

 P/ Observation of vital sign, contraction and FHR

 Ampicilin 1 g/ 6 hours (IV)
 Gentamisin 80 mg/ 12 hours (IV)
 Plan for vaginal delivery
 Misoprostol 25mcg/6 hours (PV) I

Follow up S/ Full term pregnancy with watery discharge

28.11.2020
01.00 AM O/
Sensorium compos mentis, BP 120/80 mmHg, Pulse 92x/minute; RR
20x/minute, T 36,5oC

Abdomen
Uterine fundal height in 3 fingers below xyphoid process (27 cm),
longitudinal lie, left fetal spine, cephalic, contraction (-), FHR 140x/minute,
Speculum examination
Livid portion, opened OUE, fluor (+) white color, fluxus (+), didn’t active
amniotic fluid, E/L/P (-), nitrazine test (+)
Vaginal toucher
Soft portion, posterior, effacement 0%, dilatation 0 cm, cephalic, amniotic
and denominator can’t be assess yet

A/
G3P2A0 37 weeks gestational age not in labor
PROM 20 hours
Single life fetus cephalic presentation
 Multiple mayor congenital anomaly was suspected
IUGR
Oligohydramnios

 P/ Observation of vital sign, contraction and FHR

 Ampicilin 1 g/ 6 hours (IV)
 Gentamisin 80 mg/ 12 hours (IV)
 Plan for vaginal delivery
 Misoprostol 25mcg/6 hours (PV) II

Follow up S/ Full term pregnancy with watery discharge

28.11.2020
07.00 AM O/
Sensorium compos mentis, BP 120/80 mmHg, Pulse 92x/minute; RR
20x/minute, T 36,5oC

Abdomen
Uterine fundal height in 3 fingers below xyphoid process (27 cm),
longitudinal lie, left fetal spine, cephalic, contraction (-), FHR 140x/minute,
EFW 2170 gram
Vaginal toucher
Soft portion, posterior, effacement 0%, dilatation 0 cm, cephalic, amniotic
and denominator can’t be assess yet

A/
G3P2A0 37 weeks gestational age not in labor
PROM 20 hours
Single life fetus cephalic presentation
Multiple mayor congenital anomaly was suspected
IUGR
Oligohydramnios

P/ Observation of vital sign, contraction and FHR

 Ampicilin 1 g/ 6 hours (IV)
 Gentamisin 80 mg/ 12 hours (IV)
 Plan for vaginal delivery
 Misoprostol 25mcg/6 hours (PV) III
Follow up S/ Full term pregnancy with watery discharge
28.11.2020
01.00 PM O/
Sensorium compos mentis, BP 120/80 mmHg, Pulse 92x/minute; RR
20x/minute, T 36,5oC

Abdomen
Uterine fundal height in 3 fingers below xyphoid process (27 cm),
longitudinal lie, left fetal spine, cephalic, contraction (-), FHR 140x/minute,
EFW 2170 gram
Vaginal toucher
Soft portion, posterior, effacement 0%, dilatation 0 cm, cephalic, amniotic
and denominator can’t be assess yet

A/
G3P2A0 37 weeks gestational age not in labor
PROM 20 hours
Single life fetus cephalic presentation
Multiple mayor congenital anomaly was suspected
IUGR
Oligohydramnios

 P/ Observation of vital sign, contraction and FHR

 Ampicilin 1 g/ 6 hours (IV)
 Gentamisin 80 mg/ 12 hours (IV)
 Plan for vaginal delivery
 Misoprostol 25mcg/6 hours (PV)IV

Follow up S/ Full term pregnancy with watery discharge

28.11.2020
7.00 PM O/
Sensorium compos mentis, BP 120/80 mmHg, Pulse 92x/minute; RR
20x/minute, T 36,5oC

Abdomen
Uterine fundal height in 3 fingers below xyphoid process (27 cm),
longitudinal lie, left fetal spine, cephalic, contraction (-), FHR 178x/minute,
EFW 2170 gram
Vaginal toucher
Soft portion, anterior, dilatation 3 cm, effacement 75%, cephalic, HI,
amniotic (-), denominator : can’t be asses yet
 A/
G3P2A0 37 weeks gestational age in labor first stage latent phase
PROM 20 hours
Single life fetus cephalic presentation
Multiple mayor congenital anomaly was suspected
IUGR
Oligohydramnios

 P/ Observation of vital sign, contraction and FHR

 Ampicilin 1 g/ 6 hours (IV)
 Gentamisin 80 mg/ 12 hours (IV)
 Plan for vaginal delivery
 Intrauterine resuscitation
Follow up S/ Full term pregnancy with watery discharge
28.11.2020
10.00 PM O/
Sensorium compos mentis, BP 120/80 mmHg, Pulse 92x/minute; RR
20x/minute, T 36,5oC

Abdomen
Uterine fundal height in 3 fingers below xyphoid process (27 cm),
longitudinal lie, left fetal spine, cephalic, contraction (-), FHR 158x/minute,
EFW 2170 gram
Vaginal toucher
Portion not palpable ,Full dilatation, cephalic, Hodge IV, amniotic (-) greeni
sh, thick, odor (-), denominator left occipito posterior

A/
G3P2A0 37 weeks gestational age in labor second stage
PROM 20 hours
Single life fetus cephalic presentation
Multiple mayor congenital anomaly was suspected
IUGR
Oligohydramnios

P/
Plan for vaginal delivery

Labour report 00.30 AM Life neonates was born, male, weight 1700 gram, length 35 cm,
27.11.2020 HC 30 cm A/S 1/3/5/6 PT SGA
00.35 AM Placenta was delivered completely, weight 310 gram, umbilical
cord length 32 cm, diameter 14x15 cm
Recent P3A0 post spontaneous delivery with history of Rom 2 days + mayor
Diagnosis congenital anomaly + oligohydramnios
Modified WHO
Partograph
Ballard
Lubchenco