Lapsus

CHAPTER I
CASE REPORT
3.1. Patient Identity

Patient
Name : Mrs. N
Date of Birth : January 24th, 1996
Age : 23 years old
Occupation : Housewife
Last Education : Senior High School
Religion : Islam
Address : Jl. Pintu Besi RT 03 RW 001
Medical Record Number : 60-62-31
Date of Hospitalized : July 2nd, 2019
Husband
Name : Mr. H
Age : 26 years old
Job : Entrepreneur
Last Education : Senior High School
Religion : Islam
Address : Jl. Pintu Besi RT 03 RW 001
3.2. Anamnesis
` Based on anamnesis with patient on July 2nd, 2019.
A. Chief Complaint
The patient with full term gestation present painful contractions 10
hours before hospitalized. Bloody show (+)
1
B. History of Present Illness
The patient with full term gestation come to PONEK
Muhammadiyah Hospital with chief complaint a painful contractions that
spread to frank 10 hours before hospitalized. The pain progressively
stronger and frequent. Bloody show (+). History rupture of membrane (-)
The patient still feel the fetal movement.
C. History of Menstruation
Menarche : 14 years old
Menstrual Cycle : 28 days
Menstrual Duration : 7 days
Menstrual Complaints : None
Last Menstrual Period : September 29th, 2018
Estimated date of Delivery : July 6th, 2019
D. History of Marriage
Marriage Status : 1x
Marriage duration : 1 year
Marriage at Age : 22 years old
E. History of Contraception
Patient never use any contraceptions.
F. History of Ante Natal Care

2x, at 1st trimester and 3rd trimester
G. History of Labor
1) This pregnancy.
H. History of Previous Illness

Asthma (-) Hypertension (-) Diabetes Mellitus (-) Heart Disease (-)
Epilepsy (-) Medicine allergy (-) Food allergy (-).
2
I. History of Family Illness
Asthma (-) Hypertension (-) Diabetes Mellitus (-) Heart Disease (-)
Epilepsy (-) Medicine allergy (-) Food allergy (-).
3.3. Examination
A. General Status
General conditions : Well
Sensorium : Compos mentis
Height : 154 cm
Weight : 65 kg
Blood Pressure : 130/90 mmHg
Heart Rate : 80 x/minute
Respiration rate : 22 x/minute
Temperature : 36,5°C
Physical Examination
Head : Normocephaly
Eye : Conjunctiva anemia (-/-), sclera icteric (-/-) periorbital

edema (-/-)
Neck : Lymph Gland Enlargement (-) Thyroid Gland

Enlargement (+)
Thorax : Inspection : symmetric

Palpation : stem fremitus (+/+)
Percussion: sonor in both lungs
Auscultation : vesicular (+/+) ronki (-/-) wheezing (-
/-)
Cor : S1 and S2 heart sound (+/+) normal, regular. murmur
(-) gallop (-)
Abdomen : Inspection: Striae gravidarum (-) Linea nigra (-)
Auscultation : Bowel sounds (+) normal
3
Percussion : thmpani
Palpation : No enlargement on hepar and spleen
Genitalia : Discharge (-)
Extremity : Acral coldness (-/-) Edema (-/-)
B. Obstetric Status
External Examination
 Inspection : Enlargement of abdomen, Striae gravidarum (-),
Linea nigra (-)
 Leopold I : Fundal height: 32 cm. Soft consistency / Indefinite
outline: Breech
 Leopold II : On the right hand feel firm and smooth: Back. On
the left hand feel small irregularities and protusions: Extremities.
 Leopold III : Hard, round, well defined: Head
 Leopold IV : both hand convergent.
 FHR : 134x/minute
Internal Examination
 Consistency : Soft
 Position : Posterior
 Cervix dilatation : 2cm
 Cervix effacement : 25%
 Presenting part : Head
 Position of presenting part : Right occipito-anterior
 Fetal station : Hodge I
 Membranes : (+)
4
3.4. Investigations Pre-Operations
Blood Investigations (July 2nd, 2019 at 02:15 PM)
Hematology Result Normal Range
Haemoglobin 11,9 12-16 g/dl
Hematocrit 34,1 37,0-47,0 %
Thrombocyte 294.000 150.000 – 440.000/ul
Leucocytes 13.300 4.200-11.000 /ul
White blood cell
Basophils 0,2 0 – 1%
Eosinophils 0,2 1 – 3%
Neutrophils 77,0 40 – 60%
Lymphocytes 18,2 20 – 50%
Monocyte 4,4 2 – 8%
Blood types
ABO A
Rhesus +
Clinical Chemistry Investigations (July 2nd, 2019 at 02:15 PM)

Investigations Result Normal Range
Blood sugar level 94 70-140 mg/dL
5
Urine Investigations (July 2nd, 2019 at 02:15 PM)
Macroscopy
Color Light Yellow Yellow
Transparency Turbid Clear
pH 6,5 4,5-7,5
Protein Negative Negative
Glucose Negative Negative
Microscopy
Nitrit Negative Negative
Keton Negative Negative
Bilirubin Negative Negative
Urobilinogen Negative Negative
Sediment
Epitel 21 1-15
Leucocytes 5-7 <5
Erythrocyte 25-30 <3
Cylinder Negative
Crystal Negative
Bacteria Negative
Others Negative Negative
3.5 Diagnose
G1P0A0 pregnant full-term inpartu latent phase 1st stage of labor singleton
with cephalic presentation.
3.6 Treatment
- Observation the general conditions, maternal vital sign and fetal heart
rate.
- IVFD Ringer Lactate gtt 20x/m
- Laboratory investigations (Blood, chemical chemistry and urine)
- Observation the progress of labor
6
3.7 Follow Up Pre-Operations
Date Follow Up
Tuesday, July 2nd, 2019 S/ The patient transffered to VK from PONEK with a
At 12.30 PM chief complaint painful contractions that get progressively
stronger and frequent. Bloody show (+)
O/
Respiration rate: 21 x/minute
Temprature : 36,0°C
FHR : 125x/m
A/ G1P0A0 pregnant full-term inpartu latent phase 1st

stage of labor singleton with cephalic presentation.
P/
- Observation the general conditions, maternal vital
sign and fetal heart rate.
- Observation the progress of labor
Tuesday, July 2nd, 2019 S/ Painful contractions that get progressively stronger and
At 1.30 PM frequent and decrease the fetal movement.
O/
7
FHR : 1. 120x/m
2. 115x/m
3. 118x/m
A/ G1P0A0 pregnant full-term inpartu latent phase 1st

stage of labor singleton with cephalic presentation with
fetal distress.
P/
- Observation the general conditions, maternal vital
sign and fetal heart rate.
- Nasal Cannule Oxygen 5L
- Reposition to left side
- Planned to Cesarean Delivery
3.8 Operations report

Operations date : Tuesday, July 2nd, 2019
Time : 05:00 PM
 Operation started at 05:00 PM
 Spinal anesthesia with bupivacaine
 Neonatal outcomes : Female with 3130 grams birth weight, 50 cm
birth length. Apgar score 8/9 (At 05.10 PM)
 Placenta delivered at 05:11 PM
 Operation finished at 06:00 PM
Post operation diagnose: P1A0 post SC due to fetal distress
8
3.9 Follow Up Post-Operations
Date Follow Up
Tuesday, July 2nd, 2019 S/ Patient transferred from OK to Siti Walidah. Patient
At 06:00 PM complained nausea.
O/
A/ P1A0 post SC due to fetal distress
P/
- Observation the general conditions, vital sign,
contraction and bleeding
- Suggest to mobilization
- IVFD RL + 2 amp oxytocin gtt 20x/m (24 hours)
- Check haemoglobin post operations
- Cateter for 24 hours
- Suggest to eat and drink
- Alinamin F 3x25 tab
- Ceftriaxone 3x1 gr (iv)
- Metronidazole 3x500 mg (iv)
- Tranexamic acid 3x250 mg (iv)
- Vitamin C 2x1 tab
- Pronalges sup 4x100 mg
Tuesday, July 2nd, 2019 S/ Patient suffer sudden convulsion in both arms lasting
At 06:20 PM for 20 seconds and it was followed by loss of
consciousness.
9
O/
P/
- MgSO4 40% 4gr administered IM into each buttock (6
hours)
- Laboratory investigations (Blood, Sodium, Potassium,
Ureum, Creatinine, SGOT, SGPT)
Tuesday, July 2nd, 2019 S/ Patient complained nausea and dizziness.

At 08:35 PM
O/
P/
- Patient transferred to ICU (Intensive Care Unit)
- Oxygen 3L
- Dopamet 3x250 mg if the blood pressure higher than
150
- Ondansentron 3x4 mg
10
3.10 Investigations Post-operations
Blood Investigations (July 2nd, 2019 at 09:25 PM)
Hematology Result Normal Range
Haemoglobin 12,9 12-16 g/dl
Hematocrit 36,7 37,0-47,0 %
Thrombocyte 292.000 150.000 – 440.000/ul
Leucocytes 25.800 4.200-11.000 /ul
White blood cell
Basophils 0,0 0 – 1%
Eosinophils 0,0 1 – 3%
Neutrophils 94,4 40 – 60%
Lymphocytes 4,3 20 – 50%
Monocyte 1,3 2 – 8%
Clinical Chemistry Investigations (July 2nd, 2019 at 09:25 PM)

SGOT 34 0 – 35 U/L
SGPT 15 0 – 35 U/L
Ureum 10 10 – 50 mg/dL
Creatinine 0,5 0,60 – 1,50 mg/dL
Sodium 140 135 – 148 mEq/L
Potassium 3,7 3,5 – 5,5 mEq/L
11
3.11 Follow up (cont)
Wednesday, July 3rd, 2019 S/ Patient complained pain of a surgical wound

At 08:00 AM
O/
P/
- Patient transferred to Siti Walidah
- Alinamin F 3x25 tab
- Ceftriaxone 3x1 gr (iv)
- Metronidazole 3x500 mg (iv)
- Tranexamic acid 3x250 mg (iv)
- Vitamin C 2x1 tab
- Pronalges sup 4x100 mg
- Ondansentron 3x4 mg
Wednesday, July 3rd, 2019 S/ Patient complained pain of a surgical wound

At 02:00 PM
O/
12
P/
- The family refuse the injection medication ->injection
stop -> change to oral medication.
- Oral medication:
Cefixime 3x100 mg
Mefenamic acid 3x500 mg
Metronidazole 3x500 mg
Wednesday, July 4th, 2019 S/ Patient complained pain of a surgical wound

At 07:00 PM
O/
P/
- Aff Infus
- Aff Cateter
- Asi on Demand
13
- Oral medication:
Cefixime 3x100 mg
Wednesday, July 5th, 2019 S/ -

At 07:00 PM
O/
P/
- Asi on Demand
- Planned to outpatient treatment
- Oral medication:
Cefixime 3x100 mg
14
CHAPTER II
DISCUSSION
1. How to diagnose on this case?

This case reported a patient 23 years old that come to PONEK
Muhammadiyah Hospital at July 2nd, 2019 and diagnosed as G1P0A0
pregnant full-term inpartu latent phase 1st stage of labor singleton with
cephalic presentation.
Based on anamnesis the patient come to PONEK Muhammadiyah
Hospital with chief complaint a painful contractions that spread to frank 10
hours before hospitalized. The pain progressively stronger and frequent.
Bloody show (+). History rupture of membrane (-) The patient still feel the
fetal movement. The fetal heart rate was 125x/minutes.
But after the patient transferred to VK patient feel the decreasing of
the fetal movement. The fetal rate was 120x/minutes, 10 minutes after that
the fetal rate was 115x/m and the other 10 minutes the fetal rate was
118x/minutes. This condition was diagnosed as fetal distress.
Based on theory, fetal distress is defined as progressive fetal hypoxia
and/or acidemia secondary to inadequate fetal oxygenation, is a term that is
used to indicate changes in fetal heart patterns, reduced fetal movement,
fetal growth restriction, and presence of meconium stained fluid.1 Fetal
status is usually assessed by calculating the fetal heart rate (FHR) and
examine the possibility of meconium in the amniotic fluid.2
For the purposes of clinical need to set criteria for what is meant by
fetal distress. Fetal distress is diagnosed when the fetal heart rate higher than
160x/minutes or lower than 100x/minutes, irregular heartbeat, or discharge
of meconium which came out in early labor.2
On this case we can found that the patient feel the fetal movement
decreasing and also the fetal heart rate found lower than 100x/minutes
which is 118x/minutes on the last calculations. Furthermore on labor the
amniotic fluid found as a green viscous fluid. So the diagnose of this case is
precise.
15
2. What is the etiology of this case?
There’s a lot of possibilities that can caused fetal distress such as: low
oxygen carried by red blood cell as seen on severe anemia, acute bleeding
on plasenta previa or solutio plasenta, the obstructed utero-placental blood
flow, the dysfunction of placenta, malformations of cardiovascular system
and intrauterine infections.3 Among all the possibilities above, one
approach to etiology of this case is intrauterine infections. On this case the
patient leucocyte quite higher >11.000. So we can assume the patient
suffer an intrauterine infections.
3. How fetal distress can happened in this case?

The possible causes of fetal distress on this case is intrauterine
infections. Infection has been hypothesized to result from bacterial
trafficking from the lower genital tract into the uterus. Whether bacteria
traffic from the vagina into the uterus routinely during pregnancy or only
under special conditions is unknown.4 Pro-inflammatory cytokines and
chemokines, small immunologic proteins, likely play a central role in the
pathogenesis of infection-associated fetal distress.5 Bacterial products
stimulate the production of cytokines from many different placental tissues
including chorioamnion, decidua and trophoblast cells. Cytokines
stimulate prostaglandin production that can causes bacterial placental
infection. The infection of placenta will cause insufficient supply of
oxygen to fetal, anaerobic glycolysis occurs which leads to accumulation
of lactic acid and pyruvic acid (metabolic acidosis) due to metabolic
acidosis H+ ions get stimulated and it depresses node of fetal heart which
causes irregular fetal heart rate.3
Meconium passage in utero has been attributed to a fetal response
to intrauterine stress and is often associated with fetal hypoxia, asphyxia,
and acidosis. Hypoxia causes increased gastrointestinal peristalsis and
relaxed anal sphincter tone. Transient compression of the umbilical cord or
fetal head also causes a vagal response, which can result in meconium
passage.
16
4. Why this patient suffered a convulsions and unconciousness?
We discuss the possible etiologic factors for seizures after delivery or
spinal anesthesia, on previous research Convulsions induced by local
anesthetics have been reported twice in cases of epidural anesthesia using
0.75% bupivacaine. The convulsions on this case may happened because
of the epidural anesthesia. We could consider that the local anesthetics
directly affected the cerebral cortex thereby triggering the convulsion.
Dyes injected into the subarachnoid space of the lumbar region travel
slowly towards the head and find their way into the intracranial space, so if
any medication administered into the subarachnoid space is retained in the
body due to any reason, it can travel in the cerebrospinal fluid and reach
the cerebral cortex.6 Systemic toxicity induced by local anesthesia is
directly related to the plasma concentration of the medication, and this is
decided by the amount administered, absorptivity, tissue distribution rate,
and metabolism and excretion rates, and can also be influenced by the
patient’s age, cardiovascular status and liver function. Symptoms of
central nervous system toxicity associated with local anesthetics are
dizziness and lightheadedness, difficulty focusing, tinnitus, drowsiness,
disorientation, shivering, muscle twitching, and tremors originating in the
face and limbs. If it progresses, it can lead to unconsciousness and
generalized seizures accompanied by respiratory arrest. But the amount of
the local anesthetic in spinal anesthesia is too small to cause systemic
toxicity, and we have taken into consideration all the physiological
circumstances during delivery and pregnancy.
First, the possible cause of unconsciousness was considered to be
hypoglycemia, but the blood sugar level measured before the convulsive
episode was 94 mg/dl, and the patient did not have underlying disease such
as gestational diabetes.
Second, we could assume that the patient might be very frightened
not only about anesthesia and delivery, but may also be feeling isolated in
an unfamiliar surrounding. While awakening in the operating room, she
could have faced many auditory and visual stimuli. These psychological
17
factors may also interact with many other causes of seizures.
Third, we could consider that the patient hyperventilated during
spinal anesthesia for cesarean section due to nervousness, which led to
decrease in carbon dioxide and cerebral blood flow leading to convulsions
Fourth, convulsions caused by drop in blood flow can occur due to
supine hypotensive syndrome and low blood pressure post-spinal
anesthesia is frequently seen in gravidas, but stable blood pressure was
maintained throughout the surgery in this case.
Fifth, we could suspect several types of brain damage that can
cause convulsions such as cerebral hemorrhage. Kim et al.7 experienced
intracerebral hemorrhage after vesicolitholapaxy under spinal anesthesia,
and Yildrim et al.8 reported a case where subdural hemorrhage presented
with headaches, high blood pressure and generalized seizures after spinal
anesthesia in a gravida. However, in our case, we have no evidence that
this patient has brain damage, so the cerebral causes can be excluded.
In this case, the factors which caused the convulsions could not be
identified precisely, but it can be considered that the physiological and
anatomical changes due to pregnancy increased the level of the anesthetic,
while at the same time, increased blood absorptivity of the anesthetic,
direct effect of the local anesthetic on the cerebral cortex, and anxiety or
fear during the perioperative period were all responsible for the convulsive
episode.
5. Is the management of labor in this case adequate?

In this case, the patient received appropriate treatment by first
carried out observations of fetal heart rate (FHR), general condition, vital
signs and Ringer lactate IV line for fluid maintenance.
And because FHR remains bradycardia in this case, the fetus must
be delivered as soon as possible, which will be by caesarean section in
most cases. While preparing for caesarean section, fetal resuscitation must
be performed with a reposition to full left lateral. This occur even if
maternal systemic blood pressure is normal because of relief of
unappreciated aortic compression.3 Fetal oxygen saturation has been
18
correlated with this improvement. In this case the caesarean section is not
performed immediately due to permission issues of the family. But while
waiting for the permission of the family, fetal resuscitation and reposition
have been performed so the management of the fetal distress in this case
still adequate. At the end, the family give the permission to do caesarean
section.
Caesarea section is an artificial labor where the fetus is born through
an incision in the abdominal wall and the wall of the uterus on the
condition of the uterus intact as well as fetal weight above 500 grams.
Indications performed Cesarean section, namely: an indication of the
mother (Dystosia, a tumor which can lead to obstruction, placenta previa,
uterine rupture), an indication of fetal (malpresentation and malposition,
fetal distress) and an indication of the maternal-fetal (Gemelli, history of
cesarean section). In this case, an indication performed Cesarean section is
due to fetal distress.
19
CHAPTER III
CONCLUSIONS
3.1 Conclusions
1. Fetal distress is defined as progressive fetal hypoxia and/or
acidemia secondary to inadequate fetal oxygenation, is a term that
is used to indicate changes in fetal heart patterns, reduced fetal
movement, fetal growth restriction, and presence of meconium
stained fluid.
2. Based on anamnesis, The patient feel the fetal movement
decreasing and also the fetal heart rate found lower than
100x/minutes which is 118x/minutes on the last calculations.
Furthermore on labor the amniotic fluid found as a green viscous
fluid. So the diagnose of this case is precise.
3. In this case the caesarean section is not performed immediately due
to permission issues of the family. But while waiting for the
permission of the family, fetal resuscitation and reposition have
been performed so the management of the fetal distress in this case
still adequate.
20
REFERENCES
1. Parer J.T., Livingston E.G. What is fetal distress? Am J Obstet

Gynecol. 1990;162:1421–1425. Discussion 5–7
2. Wijayanegara Hidayat. Fetal distress in labor; In: Obstetrics Sarwono
Prawirohardjo, Chapter 46, Issue 4, PT. Bina Library Sarwono
Prawirohardjo, Jakarta; 2016
3. Pashte, Sayali. Diagnosis And Management Of Fetal Distress: A Review
Based On Modern Concept And Ancient Ayurvedic Granthas. European
Journal of Biomedical and Pharmaceutical Sciences. 2016. 3. 560-562.
4. Egli GE, Newton M. The transport of carbon particles in the human female
reproductive tract. Fertil Steril. 1961 Mar-Apr;12:151–155.
5. Guleria I, Pollard JW. The trophoblast is a component of the innate
immune system during pregnancy. Nat Med. 2000 May;6(5):589–593
6. Dumitru AP, Garcia ER, Berkhart SE, Potter JK. Convulsive seizure
following spinal anesthesia for cesarean section: possible etiologic factors.
Anesth Analg 1962; 41: 422-8.
7. Kim EJ, Chang IY. Intracerebral hemorrhage after vesicolitholapaxy
under spinal anesthesia: A case report. Korean J Anestheisol 2006; 51:
379-82.
8. Yildirim GB, Colakoglu S, Atakan TY, Büyükkirli H. Intracranial
subdural hematoma after spinal anesthesia. Int J Obstet Anesth 2005; 14:
159-62.
21

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CHAPTER I

3.1. Patient Identity

F. History of Ante Natal Care

H. History of Previous Illness

Eye : Conjunctiva anemia (-/-), sclera icteric (-/-) periorbital

Neck : Lymph Gland Enlargement (-) Thyroid Gland

Thorax : Inspection : symmetric

Genitalia : Discharge (-)

Extremity : Acral coldness (-/-) Edema (-/-)

Haemoglobin 11,9 12-16 g/dl

Hematocrit 34,1 37,0-47,0 %

Thrombocyte 294.000 150.000 – 440.000/ul

Leucocytes 13.300 4.200-11.000 /ul

White blood cell

Neutrophils 77,0 40 – 60%

Lymphocytes 18,2 20 – 50%

Clinical Chemistry Investigations (July 2nd, 2019 at 02:15 PM)

Blood sugar level 94 70-140 mg/dL

Transparency Turbid Clear

A/ G1P0A0 pregnant full-term inpartu latent phase 1st

A/ G1P0A0 pregnant full-term inpartu latent phase 1st

3.8 Operations report

A/ P1A0 post SC due to fetal distress

A/ P1A0 post SC due to fetal distress

Tuesday, July 2nd, 2019 S/ Patient complained nausea and dizziness.

A/ P1A0 post SC due to fetal distress

Haemoglobin 12,9 12-16 g/dl

Hematocrit 36,7 37,0-47,0 %

Thrombocyte 292.000 150.000 – 440.000/ul

Leucocytes 25.800 4.200-11.000 /ul

White blood cell

Neutrophils 94,4 40 – 60%

Lymphocytes 4,3 20 – 50%

Clinical Chemistry Investigations (July 2nd, 2019 at 09:25 PM)

Wednesday, July 3rd, 2019 S/ Patient complained pain of a surgical wound

A/ P1A0 post SC due to fetal distress

Wednesday, July 3rd, 2019 S/ Patient complained pain of a surgical wound

Wednesday, July 4th, 2019 S/ Patient complained pain of a surgical wound

Wednesday, July 5th, 2019 S/ -

A/ P1A0 post SC due to fetal distress

1. How to diagnose on this case?

3. How fetal distress can happened in this case?

5. Is the management of labor in this case adequate?

1. Parer J.T., Livingston E.G. What is fetal distress? Am J Obstet

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