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CHAPTER I

PREFACE

At pregnancy period, fetus will be protected by amnion fluid that use as


movement space and shield for fetus by harassment from the outside. Besides that,
amnion fluid is use to protect the fetus from infection and stabilizer temperatur
changing. Time by time based on gestation, amnion fluid index wont be same
from time by time at gestation. When pregnancy age at 25 weeks, ussually
amnion fluid index reach 239 ml,

and it will be increase to 984 ml when

pregnany age at 32 weeks.


When amnion fluid more than 2000 ml, its call as polyhidramnion or
hydramnion. Hydramnion make symptoms to pregnancy woman like dispnoe
stertorous breathing), swollen on feet, big and glowing stomach. Another causes
of hydramnion is related to congenital abnormalities (anensefalus, atresia
esofagus, spina bifida, intestinal fistula), placenta abnormalities, diseases at
pregnancy period (diabetes mellitus, gemilli). So amnion fluid had important part
in progrees of pregnancy and birthcild.

CHAPTER II
CASE

SMF ONSTETRY AND GYNECOLOGY


HOSPITAL OF EMBUNG FATIMAH BATAM CITY

Medical Record : 160372


I.

II.

PATIENTS IDENTITY
Name
Age
Gender
Religion
Address
Job
Marital Status
HPHT
Date of entry
Weight
Height

: Mrs. FH
: 44 years old
: Female
: Islam
: Muka Kuning
: Housewife
: Married
: 15 january 2016
: December, 8th 2016
: 55 kg
: 158 cm

ANAMNESIS
Patient come to obstetrics poli with complaint bleeding from vagina after
sexual intercourse since almost 1 month ago. She had much discharges
(leuchorrea) since 6 years ago thats clear and foul-smelly.
MAIN COMPLAINT
Bleeding from vagina after coitus since almost 1 month ago .
HISTORY OF PRESENT ILLNESS
A woman 26 years old by her own self went to obstetrics poli, hospital of
embung fatimah, batam city with complaint bleeding from vagina after
sexual intercourse since almost 1 month ago. She had much discharges
(leuchorrea) since 6 years ago thats clear and foul-smelly. She had checked
herself to clinics but it never get better.

Pregnancy history, patient born her first child: boy, weight : 3000 gr by
normal childborn at clinic on 2011.
PERIODS HISTORY
Patient admited, her first period at 14 years old. Her periods cycles regular
every single month. Periods cycles 28 days, for 3-5 days. LMLP is
November, 25th 2016.
MARITAL HISTORY
Married just once at 2003, she were 27 years old.
PREVIOUS MEDICAL AND OPERATIONS HISTORY
(-)
CONTRACEPTION HISTRORY
(-)
ALERGIC HISTORY
(-)
PREVIOUS ILLNESS HISTORY
(-)
FAMILYS ILLNESS HISTORY
(-)
III.

PRESENT STATUS
GENERAL STATUS
General Condition
Consciousness
Weight
Height
Blood Pressure
Heart Rate
Respirasi Rate
Temperature

: good
: compos mentis
: 55 kg
: 158 cm
: 110/70 mmHg
: 78x/i
: 20x/i
: 36,7 oC

PHYSICAL EXAMINATION
Head
: Conjungtivity : anemis (-)
sclera
: ikterik (-)
Neck
: Lymph gland
: normal
Thyroid gland : normal
Thoraks
: lung : - inspection : simetris

Heart
Abdomen
Ekstremity

Palpation: fokal fremitus dekstra//sinistra

normal
Percussion
: sonor at all lungs path
Auscultation : vesikuler (+/+), rhonki : (-/-),

wheezing (-/-)
: heart sound S1-S2 regular, murmur (-) gallop (-)
: tense looking dan glowing (+), bowel sound (+)
: Edema : -/Varises: -/Akral : warm (+)

IV.

LABORATORIUM
Routine Blood Test
Hb
: 14,8 gr/dl
Leukocytes
: 8.600
Ht
: 42%
Eritrocytes
: 5,5 juta/ul
Trombocytes
: 260 ribu/ul
Blood Group
: O Rh+
HIV
: negatif
HbSAg
: negatif
Blood Glucose : 135 mg/dl

V.

DIAGNOSE
Cervical Polyp
Follow up at ward
Date : December, 8th 2016
S

A
P

blood spot(+), pain (-)


General status : good
consciousness : compos mentis
blood ressure : 110/70 mmHg
heart rate: 78x/i
Respiratory rate: 20x/i
Temperatur : 36,7 C
General Physical Examination: Normal
Gynecology Examination: Blood Spot (+)
Cervical Polyp
IVFD RL 20 tpm
Plan :
Polyp Extirpation December, 9th 2016

Date : December, 9th 2016 (post amniosintesis)

S
O

A
P

blood spot(+), pain (-)


General status : good
consciousness : compos mentis
blood ressure : 120/70 mmHg
heart rate: 80x/i
Respiratory rate: 20x/i
Temperatur : 36,5 C
General Physical Examination: Normal
Gynecology Examination: Blood Spot (+)
Cervical Polyp
IVFD RL 20 tpm
Inj. Cefotaxim 1x1fls
Plan :
Polyp Extirpation December, 9th 2016

SURGERY REPORT
Pre-surgery Diagnose
Cervical Polyp
December, 9th 2016, surgery start at 11.25 and finish at 11.55. Patient on Litotomys

potition. On potition theres polip 3x2 cm. Doing extirpation and then DSL for
remove the polyp. Take the polyp to PA. And surgery done.
Diagnosis Post-operasi
Post Extirpation and DSL of Cervical Polyp
Post Surgery Treatment

IVFD D5% 20tpm


Amoxycilin tab 3x500mg
Mefenamic Acid tab 3x500mg
SF tab 1x1

Date : December, 9th 2016


S
O

Pain post Surgery (+)


General status: good
consciousness : compos mentis
blood ressure: 120/90 mmHg

heart rate : 72x/i


Respiratory rate: 20x/i
T : 36,4 C
General Physical Examination: Normal
A
P

Gynecology Examination: Blood (-)


Post Extirpation and DSL of Cervical Polyp
Observation condition and vital sign of patient
Suggest patient to rest
IVFD D5% 20 tpm
Asam mefenamat tab 3x500mg
Amoxycilin tab 3x500mg
SF tab 1x1

Date : December, 10th 2016


S
O

A
P

(-)
General status: good
consciousness : compos mentis
blood ressure: 130/90 mmHg
heart rate : 83x/i
Respiratory rate: 20x/i
T : 36,7 C
General Physical Examination: Normal
Gynecology Examination: Blood (-)
Post Extirpation and DSL of Cervical Polyp
IVFD D5% 20 tpm
Asam mefenamat tab 3x500mg
Amoxycilin tab 3x500mg
SF tab 1x1

VI.

Patient can go home

RESUME
Patient 44 years old, with cervical polyp. At December 8th 2016, patient
come by her own self to obstetrics poli, hospital of embung fatimah, batam
city with complaint bleeding from vagina after sexual intercourse since
almost 1 month ago. She had much discharges (leuchorrea) since 6 years

ago thats clear and foul-smelly. She had checked herself to clinics but it
never get better. Observation result, general condition : good, blood pressure
= 110/70 mmHg, heart rate= 78x/i, respiratory rate : 20x/i, temperatur =
36,7c,. Gynecology Examination: Blood spot(+).

CHAPTER III
THEORY
1

Definition
The cervix is a tubelike channel that connects the uterus to the vagina. A polyp is a
mass of tissue projecting from a mucous membrane. Cervical polyps are growths that
usually appear on the cervix where it opens into the vagina. Polyps are usually smooth,
soft, cherry-red to reddish-purple or grayish-white. They are considered fragile because it
is common for polyps to bleed when touched. They vary in size and often look like bulbs
on thin stems. Cervical polyps are usually not cancerous (benign) and can occur alone or
in groups. Most polyps are small, about 1 centimeter to 2 centimeters long. Because rare
types of cancerous conditions can look like polyps, all polyps should be removed and
examined for signs of cancer. (Harvard)

There are two types of cervical polyps:

Ectocervical polyps can develop from the outer surface layer cells of the

cervix. They are more common in postmenopausal women.


Endocervical polyps develop from cervical glands inside the cervical
canal. Most cervical polyps are endocervical polyps, and are more
common in premenopausal women (reproductive ages). Endocervical
growths tend to have a longer stalk.

Epidemiology
Polyps are rare, occurring in about one in every 10,000 women. They are more
common in women who have been pregnant more than once. More than 99% of
polyps are benign. The incidence of malignant polyps of the cervix is rare. Less

than 1 in every 200 polyps is malignant. (hers) According to Harvard University,


theyre most common in women in their 40s and 50s whove had more than one
child. Polyps almost never occur in young women before the start of
menstruation. Polyps are also common during pregnancy. This may occur due to

an increase in the hormone estrogen. (healthline)


Etiology
The cause of cervical polyps is not well understood, but they are associated with
inflammation of the cervix. They also may result from an abnormal response to
the female hormone estrogen. (harvard)
Suggested theories include:

Abnormal response to the female hormone estrogen. Estrogen may over


stimulate the growth of cervical tissue. Estrogen levels will be highest
during childbearing years, during any pregnancies, and in the months

leading up to menopause.
Chronic inflammatory disease that irritates the cervix.
Clogged blood vessels in the cervix.

Manifestation
Cervical polyps often cause no symptoms. If symptoms do occur, they may
include:

Heavier bleeding during periods


Bleeding after intercourse
Bleeding after menopause
Bleeding between periods
Vaginal discharge, with a foul smell caused by infection

Diagnosis
Diagnosing cervical polyps is relatively easy because they are usually clearly
visible during a pelvic examination. They appear red or purple fingerlike growths
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with a smooth surface and protrude from the cervical canal.(medline)


Ultrasound examination will show:
Sessile or pedunculated well-circumscribed masses within

the

endocervical canal
may be hypoechoic or echogenic
identifying the stalk attaching to the cervical wall helps differentiate it

from an endometrial polyp


A cervical biopsy will be performed. Most of the time, the biopsy will show cells
that are consistent with a benign polyp. Rarely, there may be abnormal,
precancerous, or cancer cells in a polyp. (medlineplus).

Treatment
The most effective and least invasive way to remove polyps is with a
polypectomy during a pelvic exam. This can be done by gently twisting the polyp
until it is freed. After the polyp is removed, the base is cauterized to stop the
bleeding.
Depending on the size of the polyp, other methods of removal include:

Tying the base of the polyp to minimize bleeding


Electrical current (LEEP) or laser therapy, for large polyps
Traditional surgery to cut off and stitch close the polyp site
Dilation and curettage, scraping the polyp off for heavy or irregular

bleeding, often without knowing the cause of the bleeding.


The removed polyp will be sent to the laboratory to evaluate for signs of cancer.
(bcm)

Differential Diagnosis
For a polypoid lesion within the cervical canal consider:

pedunculated uterine leiomyoma protruding through the cervical canal


endometrial polyp protruding through the cervical canal
blood clot (mimic) (radiopedia)

Complication

10

A small percentage of polyps (between 2 and 15 in every 1,000) are


abnormal and may develop into cancer if left. (nhs)

Prognosis
The outlook is excellent. The vast majority of cervical polyps are not cancerous.
Once removed cervical polyps tend not to grow back on the original site.
However, they can occur in other parts of the cervix. For this reason, a regular
pelvic examination is recommended so that new growths can be spotted and
treated before they cause symptoms. (harvard)

CHAPTER IV
DISCUSSION

There is pregnancy woman, 26 years old with G2P1A0H1 gravid 34 weeks


come to clinic hospital of embung fatimah with complain pain on her stomach for
3 days. From anamnesis we get HPHT on january 15th 2016. At USG examination
at september 6th 2016, we find a fetus, fetus heart (+), gestation age 33-34 weeks,
with amnion fluid index more than normal (AFI>25). Headache (-), pain on
bottom stomach (+), stertorous breathing (+), nausea (-), vomit (-).

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At physcal examination we find general condition is good, consciousness


compos mentis, vital sign stable. By inspection, patient abdoments negative pain.
On Inspeculo, theres polyp.
Result of laboratory is normal. From anamnesis, physical examination,
supportive examination, we can diagnose this patient to Cervical Polyp.
Cervical Polyp
Standing based on:
Anamnesis

Theory
Symptos :

bleeding from vagina after sexual


intercourse since 1 month ago. She had
much discharges (leuchorrea) since 6
years ago thats clear and foul-smelly.

Heavier bleeding during periods


Bleeding after intercourse
Bleeding after menopause
Bleeding between periods
Vaginal discharge, with a foul
smell caused by infection

Supportive Examination
Inspeculo

Management

Theory
Polyp

Explaination

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BAB V
CLOSING

A. CONCLUSION
Mrs. SP 26 years old come to clinic hospital of embung fatimah on
september 6th 2016 at 10 am with complain pain on her stomach for 3
days.
Ay physical and supportive examination, we find abdomen skin looks
strained and glowing, hurt (+), acites (+), and AFI >25 cm based on USG.

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Based on anamnesis, physical examination, and supportive examination,


we standing diagnose G2P1A0H1 gravid 33-34 weeks + polihidromion.
Management for this case is to reduce stertorous breathing and pain by bed
rest and amnionsintesis.
Generally, standing diagnose, rule of management is already suit with
literatur. Prognosis to this case based on diseases history and management
is bonam.
B. SUGGESTION
To make diagnose to patient acurately, we need anamnesis, physical
examination, and supportive examination well, so that we can make suit
and effective management.

BIBLIOGRAPHY

Prawirohardjo, S. Ilmu Kebidanan. Edisi 4. Jakarta: PT Bina Pustaka


Sarwono Prawirohardjo. 2010
Cunningham. Et all. William Obstetric (23nd ed). United States Of America :
the McGraw-Hill Companies. 2010
Amriewibowo.2010. Kelainan Air Ketuban Poihidromion Komplikasi Dan
Penyulit Dalam Kehamilan. Pengantar Kuliah Obstetri Dan Ginekologi
Mochtar R. Sinopsis Obstetry Jilid 2. Jakarta:EGC;2010

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Manuaba IBG, Chandranita IA, Fajar IBG. Pengantar Kuliah Obstetry.


Jakarta;EGC;2007

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