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    Ibu Anemia Pada 36 Minggu

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    ainzahir94
    This document summarizes the antenatal care of a 25-year-old primigravida woman with gestational diabetes mellitus and anemia in pregnancy. Over the course of her prenatal visits, her hemoglobin levels declined requiring intravenous iron supplementation. Non-compliance with oral iron medications was noted. At term, her hemoglobin levels stabilized with counseling on proper medication administration. She delivered at term with no complications.

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    Ibu Anemia Pada 36 Minggu

    Uploaded by

    ainzahir94
    15 views6 pages
    This document summarizes the antenatal care of a 25-year-old primigravida woman with gestational diabetes mellitus and anemia in pregnancy. Over the course of her prenatal visits, her hemoglobin levels declined requiring intravenous iron supplementation. Non-compliance with oral iron medications was noted. At term, her hemoglobin levels stabilized with counseling on proper medication administration. She delivered at term with no complications.

    Original Title

    IBU ANEMIA PADA ±36 MINGGU

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    This document summarizes the antenatal care of a 25-year-old primigravida woman with gestational diabetes mellitus and anemia in pregnancy. Over the course of her prenatal visits, her hemoglobin levels declined requiring intravenous iron supplementation. Non-compliance with oral iron medications was noted. At term, her hemoglobin levels stabilized with counseling on proper medication administration. She delivered at term with no complications.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    15 views6 pages

    Ibu Anemia Pada 36 Minggu

    Uploaded by

    ainzahir94
    This document summarizes the antenatal care of a 25-year-old primigravida woman with gestational diabetes mellitus and anemia in pregnancy. Over the course of her prenatal visits, her hemoglobin levels declined requiring intravenous iron supplementation. Non-compliance with oral iron medications was noted. At term, her hemoglobin levels stabilized with counseling on proper medication administration. She delivered at term with no complications.

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    IBU ANEMIA PADA

    ±36 MINGGU
    KLINIK KESIHATAN SELANDAR
    CASE 1: BOOKING DETAILS
    MOTHER’S DETAIL

    AGE 25

    OCCUPATIONS CLEANER UTC

    PARITY & POA AT BOOKING GRAVIDA: 1 PARA: 0


    POA: 10w3d
    FAMILY HISTORY Mother has DM

    PREMORBID & RISK 1/ primigravida


    FACTORS IDENTIFIED 2/ GDM on diet controlled
    (CODING:RED/GREEN/ 3/ Anemia in pregnancy
    YELLOW) GREEN TAG
    PAST OBSTETRIC/GYNEA./ Nil
    SURGICAL HISTORY
    CURRENT GDM on d/c
    OBS/GYNAE/MEDICAL Anemia in pregnancy
    PROBLEM.
    NOTED (any abnormal of -
    ANC screening/ checkup)
    DATE OF LK 19/7/2022 2/8/2022 16/8/2022 30/8/2022 7/9/2022
    (BOOKING)
    POA 10+3 12+3 14+6 16+4 17+6

    BP/PR/WT/URINE ALB BP 107 / 63 BP 102/56 BP 97/56 BP 99/59


    SUGAR PR 85 PR 90 PR 94 PR 92
    Wt 70.5 Wt 70 Wt 72 Wt 71
    Urine Alb/Sugar : Nil Urine Alb/suga : nil Urine Alb/Sugar : Nil Urine Alb/Sugar : nil

    FBC: Came to rpt scan


    Hb 11.3 11.0 10.5 10.2
    MCH/MCV 27.8/ 79.6 27.8/ 81 27.6/ 81.3 28.1/ 81.3
    Rbc 4.06 3.97 3.79 3.63
    RDW 13.3 13.8 13.6 13.1

    Claim compliant to
    Pt not compliant to zincofer meds
    Not taking much iron
    rich food

    Se. Feritin - - Se Ferritin 47.5


    Atau
    Se. Iron/TIBC
    PBF (sekiranya perlu) - -
    Plan of management 1. T zincofer 1/1 BD 1. Advice on compliancy d/w FMS 1. Increase T
    2. Rpt FBC in 2/52 2. Cont t zincofer 1/1 bd 1.Change to maltofer maltofer 1/1 tds
    3. MGTT 16/52 AND 28/52 3. Rpt fbc 2/52 1/1 bd 2. Advise iron rich
    2.Rpt fbc at 20/52 food
    3.For serum ferritin 3. Rpt FBC and scan
    4.Refer PSP at 20/52
    SERIAL MONITORING

    DATE OF LK 27/9/2022 11/10/2022 14/10-25/10/22 8/11/2022 22/11/22

    POA 20w 22w 26+4 28w


    BP/PR/WT/URINE BP 100/64 BP 100/59 On iv cosmofer
    ALB SUGAR PR 92 PR 113 -uneventful
    Wt 72 Wt 72.8
    Urine Alb/Sugar: nil Urine Alb/Sugar: Nil

    FBC:
    Hb 10.5 10.3 10.8 10.5
    MCH/MCV 28/ 81.1 28.7/ 82.4 29.5/84.5 29.8/83.6
    Rbc 3.73 3.59 3.65 3.52
    RDW 13.2 14.4 14.8 13.8

    Pt took maltofer 1/1 bd Pt took iberet direct after


    Claimed nausea meal
    Brownish stool
    Se. Feritin -
    Atau
    Se. Iron/TIBC
    PBF (sekiranya -
    perlu)
    Plan of d/w fms d/w FMS 1. Cont t iberet 1/1 bd 1. Cont t iberet 1/1 bd
    management 1.Change t iberet 1/1 bd 1. For iv cosmofer 2. Rpt fbc in 2/52 2. Reinforce compliancy
    * sila 2.Rpt FBC 2/52 kiv cosmofer and correct way to take
    tambah
    sebarang
    ujian yang
    berkaitan
    DATE OF LK 6/12/2022 3/1/2023 17/1/2023 9/2/2023

    POA 30+4 34+4 36+5 Post natal d15

    BP/PR/WT/URINE ALB BP 99/69 BP 102/60 BP 90/55


    SUGAR PR 103 PR 99 PR 86
    Wt 75 Wt 75.5 Wt 72.8
    Urine Alb/Sugar: nil Urine Alb/Sugar: nil Urine Alb/Sugar: Nil

    FBC:
    Hb 11.3 10.9 10.8 11.3
    MCH/MCV 29.8/ 84.2 29.5/ 83.9 28.7/ 81.7 28.9/ 86
    Rbc 3.81 3.69 3.77 3.93
    RDW 13.5 12.8 13.1 13.4

    Claim taking iberet 30 Not compliant to iberet


    mins after meals (husband claim not
    taking at all)
    Se. Feritin
    Atau
    Se. Iron/TIBC

    PBF (sekiranya perlu)

    Plan of management Cont t iberet 1/1 bd Cont t iberet 1/1 bd Cont t iberet 1/1 bd
    Advice pt to take Advice on compliancy
    iberet 2h post /pre
    meals
    Rpt fbc at 36/52
    SHORTFALL REMEDIAL ACTION

    Pt issue – not compliant

    Pt taking meds <2h after meals Maybe we can change to t maltofer

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