2. Mother’s history
Name :NFMZ
Age : 32
G4P3
Bld group : O +ve
VDRL & HIV : non reactive
Occupation : Teacher at XXXX
PAST OBS HX : Uneventful
Summary of Visits
Booking done at 8/52 POA @ GP X
4 Antenatal check ups at GP X
First visit to KK Desarhu @ 31/52 POA
Visit to KK 3 times
Visit to MO 2 times
H/o hospital admission x 3 ( 1 referred from GP X, 2 REFERRED BY
KK DR)
3. 1ST BOOKING@ GP X (& subsequent
follow ups)
Date
POA
BP
W=k
g
Alb
SFH
30/7
8w3d
106/65
94
-
-
18w6
d
119/74
98
N
18
23/11
25w
98/60
100
N
24
3/1
30w4
d
150/60
110
+++
30
Ix :
FBC - hb 10.8
mch 26
Blood Group : O+ve
HIV : Non reactive
Hb
Remarks
-
10.8
Fh
US : S
CRL
12mm
7w6d
Follow
date
Show
n
Request MGTT
Show
n
MGTT 4.5/4.6
Referal to GH
STAT
4. First Admission To GOV HOSP (3/1/2014 5/1/2014)
Referred from GP X
Patient admitted for 2 days.
Dx as Late Onset of PIH with UTI
Plan :
EOD BP at nearest KK 2/52
TCA ANC in 2/52 (22nd January 2014)
To complete Unasyn 375 mg BD for 2/52
Not for anti hypertensive medication
5. First Booking At KK DR
At 6/1/2014 at 30/52 POA
ANC : Late PIH in pregnancy not on RX
Previous ANC claimed uneventful
During examination , no fresh complain noted
edema both
legs
BP 150/100 repeated 160/100 Urine Albumin 3+
S/T Specialist O+G on call
For T. Nifedifine 10mg TDS
For Admission STAT
6. 2nd Admission to Hospital (6/1/2014
– 7/1/2014)
Diagnosis upon discharge as PIH
Plan Upon Discharge
EOD BP at KK 2/52
NOT for medication
7. 2nd Visit to MO in KK DR (after
discharged from ward)
10 January 2014
BP noted 1)140/100
2)140/90
Otherwise patient asymptomatic
Urine Alb : NIL
S/T Specialist O+G on call
Plan :
- Start on T. Labetolol 100mg TDS
- Cont EOD BP 2/52
- For PE Profile
- TCA ANC at given date (22/1/2014)
8. Summary Of F/u at KK DR
Date
POA
Weigh
t
BP
6/1/14
30w
106.5
10/1/14
31w5d
12/1/14
32w
SFH
Hb
Remarks
150/10 3+
0
160/110
30cm
10.6
ADMITTED til 7th
Jan
140/10
0
140/90
-
31cm
-
Started on
T.Labetolol
100mg TDS
30cm
-
HomeVisit
(Sunday)
2nd BP on L
Lateral
140/90
120/80
Alb
NIL
9. 13th Jan 2014( POA 32 w 1 day)
Pt went to work as usual , no symptom of labor , FM good.
At 11am, pt felt severe backpain and noted trickling of per vaginal
bleed by12pm
Ambulance called from workplace(Sekolah XX) at her school and pt was
sent to Hosp at 1230pm , strong contraction felt and was sent to Labour
room straight
BP was 156/116 and urine alb 2+ , patient was transferred to OICW
Ultrasound done : Fetal heart not detected
Induced at 2pm and delivered at 4.06pm
Baby girl delivered 1.7kg 0’ 0” no resuscitation done
?Baby passed away at 1606pm at OICW , HTJ
MOTHER was discharged on 17th January 2014
COD : Fresh still birth secondary to abruptio placenta complicated with
primary PPH, severe pre eclampsia
10. Discharged on 17th January 2014
Plan Upon Discharge :
1. EOD BP and review HB level
postpartum
Postnatally
Patient plan to insert IUCD (not yet)
Hb level 10.0
BP MONITORING – 120-130/80-90 , Not on
medication since delivery
Patient recuperating well.
