Premature rupture of membrane on Aterm pregnancy

Pembimbing: dr. H.A.Djaenuddin ., Sp.OG

Rustan Efendy/ 07120060086
Kepaniteraan Klinik Ilmu Kebidanan & Kandungan FK UPH / Rumkital Marinir Cilandak Periode 24 Oktober 2011- 31 Desember 2011

PATIENT IDENTITY
No MC Name Age Citizen Religion Occupation Address Name of husband Age Occupation Date of admission : 28.91.97 : Mrs. R : 29 y.o : Indonesia : Moeslim : House wife : Ciganjur : Mr. T : 30 y.o : TNI AL : 28 November 2011

ANAMNESIS (28 November 2011)

Chief complaint Patient complaining about fluids that come out from her vagina since 7 hours before admitted to the hospital

History of present illness

Patient with G1P0A0 38 weeks of gestation , complaining about fluids that comes out from her vagina since 7 hours before admitted to the hospital . Nausea (-). Blood , discharge (-). Trauma (-) , heavy activities (-)

History of HYPERTENSION History of DRUG CONSUMPTION History of OPERATION History of ABORTION

History of HYPERTENSION History of DM History of ASTHMA History of HEART PROBLEM History of ALLERGIC

 Menarche : 12 yrs old Duration : 5-7 days Cycle length : 30 days Amount : 2-3 pads/day Dysmenorrhea :+ 1st day of last menstrual period : March 1st 2011 TP : 8 december 2011

Marriage history Patient was married on 2010. Obstetric history

Patient is pregnant about 38 weeks of gestation and this is the first pregnancy

Contraceptive use history Patient never use any kind of contraceptive

Operation procedure history

Patient never had any operation before.

Social and economic history

Patient is a housewife from a middle economical family. Patient denied alcohol consumption and smoking.

Consciousness Vital Signs Blood Pressure Heart rate Respiratory rate Temperature

: Compos Mentis

: 120/80 mmHg : 72 x/min : 18 x/min : 36,8 C

Hair Head Face Eyes Ears Nose Throat

Mouth teeth Neck Thorax Heart Pulmo Abdomen

Black and thin hair, Evenly distributed Normocephaly Simetric, pale(-), edema (-), kloasma gravidarum (-) CA -/-, SI -/-, pupil round isokor, light refleks +/+ normal. simetric, secret (-), tenderness (-) Symetrical, hyperemis (-), discharge(-) Tonsil T1 - T1, no tonsilo-pharyngeal inflammation
& Pale and dry lips, tongue centrally located, caries (-) normal, enlargement thyroid gland (-), enlargement of lymph nodes (-). Chest movement symmetric and dynamic, retraction(-). Ictus cordis not seen, pure S1S2, regular, murmur (-), gallop (-). Sonor in both lung, fremitus symetric on both side, breath sound vesiculer, rhonki -/- wheezing -/-. Flat, symmetrical upon inspection, soft and non tender

Status Obstetrikus
Abdomen : Inspection : striae gravidarum (-), linea nigra (-) Palpasi : Leopold I: uterine fundus high is 32 cm, round and tender part was palpable , interpretation was lower part of body

(bokong )
Leopold II: a hard part on mothers right side was palpable . head Leopold III : a round and hard part was palpable , interpretation : Leopold IV : part of head has been pass through upper hip (4/5)

Auskultation : DJJ: 142 x/menit, reguler.

Status Obstetrikus
Genitalia:

Inspection : there was no disorder on vulva dan vagina, no sign of tumor/bump , no inflamation and there was fluids that comes out from the vagina.
Vaginal toucher: there was no opening yet.

Supportive examination
Lakmus test: the red colour of lakmus paper turn into blue. Interpretation : membrane water.

CTG

: non-reaktif.

(baseline 145x/m, akselerasi (+), deselerasi (-), fetal movement(-), contraction(-), variabilitas < 6).

Laboratory examination
Hb Ht 10.4 g/dL 30% ( 12-16 g/dL) (37-54%)

Lekosit
Trombosit Clotting time/CT Bleeding time/BT Gol. Darah GDS

8500
209.000 4.5 menit 2 menit B+ 86 mg/dl

(5000-10.000/uL)
(150.000-400.000/uL) (2-6 menit) (1-3 menit )

(< 200 mg/dl)

DIAGNOSIS
Working diagnosis

G1P0A0, 38 week of gestation with premature rupture of membrane

Treatment plan
Treatment plan
Observation on mothers general condition Observation on fetal heart beat and kemajuan persalinan. Patient was planned for secario sectarian operation because there was imposible for induction technique and normal birth deliver based on genitalia examination and CTG.

Rencana Edukasi

Give an explanation to the patient and family about the patient condition. Bed rest. Preparation for operation

PROGNOSIS

Mother Fetal

: dubia ad bonam : dubia ad bonam

Operation report
Operation was done on 29 November 2011 at 10.00 AM until 10.50 AM Patien was on supine potition. Spinal anasthesia was performed. asepsis and antisepsis was done on the operation field,and sterile pad was used. pfanensteill insisi was done on lower segment , around 12cm length . Technique was done on each layer until peritoneum. Peritoneum was opened, there was uterus gravida with intraperitoneum fluid.

 Semilunar insisi was done on lower segment of uterus. Baby was born manually with foot first then body, shoulder and in the end the head. A baby boy with 3200 gr of weight , 47 cm of length , anus +, disorder -, A/S= 8/9. Plasenta was being extracted manually , interpretation : complete , bleeding volume around 100cc. Cavum uteri was cleaned and uterus was being stiched back Bleeding was being cared and abdominal cavity was rinsed with NaCl 0,9%.

Follow Up
30 November 2011 S: pain on operation field. O: general condition : good consciousness : CM TD : 110/70 mmHg, pulse: 78 x/menit, RR: 16 x/menit, temp : 36,50C
eye : konjungtiva anemis -/-, sklera ikterik -/-, light reflex +/+ Cor : S1S2 murni, reguler Pulmo : vesikuler breath sound, wheezing -/-, ronkhi -/Ekstremities : akral hangat, edema (-), sianosis (-)

Stat. Obsterikus : TFU sepusat, uterus contraction (+), pervaginal bleeding (-), ASI (-)

Laboratory result
Hb: 10.9 g/dl Ht: 31 5 Leukosit: 10.500 /ul Trombosit : 182.000/ul

A: P1A0 post SC day-1 P: IVFD RL+Tramadol 20 tpm Cefepime 2x1 gram IV Amoxicillin 3 x 500 mg Tramal supp 2x1 Paracetamol 3 x 500 mg Vitaneuron 2 x 1 tablet

1 Desember 2011 S: Flatus +, pain level was decreased. O: general condition: good consciousness: CM TD : 110/70 mmHg, pulse: 72 x/menit, RR: 18x/menit, temp : 36,50C eye : konjungtiva anemis -/-, sklera ikterik -/-, refleks cahaya +/+ Cor : S1S2 murni, reguler Pulmo: SN vesikuler, wh -/-, rh -/Ekstremitas: akral hangat, edema (-), sianosis (-)

Stat. Obsterikus : TFU 1 jari bawah pusat, uterus contraction (+), pervaginal bleeding (-), ASI (-) A: P1A0 post SC day-2 P: Amoxicillin 3 x 500 mg Paracetamol 3 x 500 mg Vitaneuron 2 x 1 tablet

2 Desember 2011 S: no complain. O: KU: good, consciousness: compos mentis TD : 110/70 mmHg, pulse : 74 x/menit, RR: 18 x/menit, temp: 36,50C Eye : konjungtiva anemis -/-, sklera ikterik -/-, light reflex +/+ Cor : S1S2 murni, reguler Pulmo : SN vesikuler, wh -/-, rh-/Ekstremitas : akral hangat, edema (-), sianosis (-)

Stat. Obsterikus : TFU 1 jari bawah pusat, uterus contraction (+), pervaginal bleeding (-), ASI (+). A: P1A0 post SC day-3 P: patient was discharged from hospital . Amoxicillin 3 x 500 mg Paracetamol 3 x 500 mg Vitaneuron 2 x 1 tablet

Case analysis
Woman 29 years old, G1P0A0 with 38 weeks gestation was complaining there was fluids that comes out from vagina since 7 hours before admitted to hospital. Blood (-), Lendir (-). trauma history (-), heavy activity (-).

Analisa Kasus
HPHT : 1 Maret 2011, using Naegele formula (date HPHT plus 7 dan month minus 3)

birth date guessing base on formula 8 Desember 2011.

Case analysis
vaginal toucher examination :

Inspection : there was no disorder on vulva dan vagina, no sign of tumor/bump , no inflamation and there was fluids that comes out from the vagina.
Vaginal toucher: there was no opening yet.

Case analysis
To make a diagnosis on premature rupture of

membrane , pH examination was done on the fluid

using lakmus paper and will give a changes on the colour from red to blue. Normally, vagina pH on pregnant women was about 4,5; if there was a leakage from the

membrane fluid, then the pH will go around 7,1-7,3

and make the lakmus paper become blue in colour

Case analysis
Based on anamnesis and physical examination

Working diagnosis: premature rupture of membrane on aterm pregnancy of woman with G1P0A0, 38 weeks of gestation

Base on the definition , PROM is a condition of membrane rupture that happened before delivery . If the rupture was before inpartu which is the servix opening on primipara was

Case analysis
Normally after the rupture of membrane , delivery process was next after it

On aterm pregnancy , 90% delivery process happen

in 24 jam after the rupture.

 In this case, firstly the patient was planned for induction and normal deliver was going to be done
Observation in VK
contraction/ his tidak ada CTG non reaktif, which is fetal movement (-), contraction(-), baseline 145x/m, akselerasi (+), deselerasi (-), variabilitas <6.

Induction cancelled pro-Seksio sesarea

TINJAUAN PUSTAKA
Definition
Spontaneous membrane rupture on any week of gestation before delivery process begins (William, 2001). If the rupture was before inpartu which is the servix opening on primipara was less than 3 cm and on multipara was less than 5 cm(Mohtar, 1998). Rupture of membrane before any sign of delivery and one hour after it , delivery process was negative

(Manuaba, 2001).

Tinjauan Pustaka (definisi)

Fluid that comes out from vagina after 22 weeks of gestation and before delivery process and can

happened on preterm gestation before 37 weeks or

even on aterm pregnancy (Saifudin, 2002).

A condition that a membrane rupture before elivery

process begins. (Sarwono Prawiroharjo, 2002).

Insidens In normal condition 8-10% of aterm pregnant women will have this premature rupture of membrane. Mechanism of PROM The rupture of membrane normally because of the uterus contraction and repeated streching Rupture of membrane because that in some part of the membrane there was a changes in biochemical that make the inferior part of membrane become rapuh , not because of all part of the membrane is rapuh.

Tinjauan Pustaka
The membrane was strong in young pregnancy On 3rd trimester, the membrane was eaasily broken

Weeken of the membrane power was related to size

of uterus that enlarged, uterus contraction and fetal movement. On late trimester there was changes in biochemical of the membrane . Rupture of membrane on aterm

pregnancy is physiologically

Tinjauan Pustaka
Taylor dkk. Make a research about the relation of premature rupture of membrane with this condition : hipermotilitas uterus that happened way before the rupture. Disease like pielonefritis, sistitis, servisitis, dan vaginitis was positive along with this hipermotilitas uterus. The membrane was too tipis (membrane disorder) infection (amnionitis atau korioamnionitis) Predisposising factors : multipara, malposisi, disproporsi, cervix incompetent, dan etc. Artifisial PROM (amniotomi), which was done too soon

Tinjauan Pustaka
Complication Complication happened was according to the age of gestation. Thing that can happened : - Maternal infection and neonatal infection - prematur delivery - hipoksia cause by plasenta compresion - Fetal deformity

Tinjauan Pustaka
Diagnosis Inspekulo: fluid from the vagina lakmus test (Nitrazin test) USG