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Identity
Name Sex Age Religion Race Address : Mrs Y : : 34 y.o : Islam : Jawa : Teluk Jambe
Anamnesis (18
th
RPS
Menstrual History
First day of LMP Estimated Due Date Gestational Age Menarche Menstrual Cycle Duration Volume Dismenore :: 22-01-2014 (ANC) : 40 wks : 15 thn : regular : 4 days : 2 pads/day : (-)
Family History
HTN (-) , DM(-), asthma (-), Heart Failure (-)
Marital Status
Married once at 14 y.o
Contraceptive History
Contraceptive Injection (every 3mo)
Physical Examination
General Examination Appearance : Tampak sakit ringan Kesadaran : Compos mentis
Vital Sign Blood Pressure Pulse Temperature Respiratory : 130 / 80 mmHg : 84 x /mins, regular : 36,20 C : 18 x /menit
Head Eyes Nose Mouth Neck Thorax Mammae Cor Pulmo Abdomen Ekstrimities
: Normocephali. : Pupil bulat isokor, CA -/-, SI -/: Normosepta, NCH -/-, sekret -/: Karies -, mukosa intak. : KGB tidak teraba membesar, Tiroid tidak teraba.
: Simetris, hiperpigmentasi pada kedua areola, retraksi putting -/: Bunyi jantung I-II regular, murmur -, gallop : Suara nafas vesikuler, rhonki -/-, wheezing -/: membesar sesuai usia kehamilan, striae gravidarum (+) : akral hangat +/+, edema -/-
Obstetrics Examination
I. II. INSPECTION : Distention (+) PALPATION (4 manouvers of Leopold) 1. Examination of uterine fundus Symphysio- fundal height(35cm) 2. Fetal back (right side) 3. Presenting part : vertex 4. Engagement of presenting part (4/5)
Vaginal Examination
Vulva & vagina Tenang Cervix-dilatation 6cm ,effacement (thin), position (axial) & consistency (soften) Presenting part : Vertex
Hodge : I-II
Membranes (+) Liquor (-)
Pemeriksaan penunjang
Hematologi 18 Januari 2014 Hb : 10,8 Ht : 32,8% Leukosit : 26, 270 Trombosit :299.000 HBsAg : nonreaktif Blood type/ rhesus : B/ + Bleeding time : 2 mins Clotting time GDS mg/dl : 11 mins : 100
USG
BPD FL HC AC EFW ICA : 95,2 mm : 76,4 mm : 324 mm : 351,8 mm : 3712gram :9
Resume
Wanita, 29 tahun, G2P1A0 hamil 39-40 minggu,HPHT : 0904-2013, TP: 16-01-2014 dirujuk bidan dengan keluhan ketuban pecah sejak 1 hari SMRS, mengaku hamil 9 bulan, keluhan keluar air-air sejak 18 jam SMRS. berwarna bening, amis, banyak, tidak disertai lendir bercampur darah. keluar tiba-tiba saat pasien bangun dari tempat tidur untuk kekamar mandi. Keputihan sejak 3 hari SMRS.tidak banyak, putih, gatal. mules-mules hilang timbul sejak 18 SMRS. tidak bertambah kuat. Pasien masih merasakan gerakan janin. Riwayat terbentur/ trauma, demam dan nyeri saat BAK disangkal. Pasien berobat ke bidan terdekat dikatakan oleh bidan ketuban pasien sudah pecah. Kemudian pasien di rujuk ke RSUD Karawang.
Diagnosis
PK1 aktif pada G3P2A0 hamil 38-39minggu, JPKTH
Therapy
Observasi tanda tanda vital, HIS, DJJ dan kemajuan persalinan. Observasi tanda tanda infeksi intrauterin, infeksi intrapartum, maupun tanda tanda gawat janin.
Terapi medikamentosa ;
Ceftriaxone 2 x 1 gram IV bolus Rencana Persalinan Per Vaginam
Prognosis
Mother : dubia ad bonam
Follow up (1)
1100hrs : Fully dilated Active phase 1120hrs : Lahir bayi perempuan, BBL 3400, PBL 50cm, A/S 5/7, ketuban jernih, jumlah cukup, cacat (-), anus (+), mekonium (+), posisi lahir kepala 1130hrs : Dilakukan PTT. Plasenta lahir spontan lengkap dengan berat 500gr, ukuran 12x12x1,5cm. Dilakukan masasefundus, kontraksi lemah dengan perdarahan aktif 700cc injeksi metergin 1 ampul iv, oksitosin 20iu/500RL, misoprostol 1000mcg dan KBI selama 2 menit perdarahan aktif pervaginam (+) KBI lagi, persiapkan tampon kondom A : HPP ec Atonia Uteri
Planning : Survey
A : Free B : Spontaneous C : BP 100/60mmhg, pulse 110x/m D : -IVFD 2 line, loading1000cc -calcium gluconas 1 ampul IV -D40% II -drip oksitosin 40 IU/500cc + metergin 1 ampul dengan metergin 1 ampul IM Observasi keadaan umum, TTV, kontraksi, perdarahan Pasang monitor Cek DPL cito Pasang tampon kondom kateteri intravakum dengan isi 500cc Asam traneksamat 1000 mg IV
Follow up (2)
S : Pusing (-), perdarahan aktif (-), O : KU baik, CM Tanda Vital : TD : 110/700mmHg RR : 20x/m N : 88x/m S : 36,4 C Status generalis : dbn Status obstetrikus : TFU sepusat , kontraksi baik, I: v/u tenang, perdarahan aktif (-) Lochia rubra (+) Terpasang DC, terpasang kondom kateter 500cc, tampon bola intravaginal A : Riwayat HPP pada P3 post partus spontan
P : Observasi TTV, kontraksi, perdarahan Diet TKTP Mobilisasi aktif Rawat ruangan Th/ - As. Traneksamat 3 x 500mg IV - Keluarkan kondom kateter 250cc, tersisa 250cc untuk dikeluarkan pada jam 1230
- Cefadroxil 3 x 500mg p.o.
Analisa kasus
Introduction
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality. All women who carry a pregnancy beyond 20 weeks gestation are at risk for PPH and its sequelae. Although maternal mortality rates have declined greatly in the developed world, PPH remains a leading cause of maternal mortality elsewhere.
Definition of PPH
PPH is defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 mL following cesarean delivery. A loss of these amounts within 24 hours of delivery is termed early or primary PPH, whereas such losses are termed late or secondary PPH if they occur 24 hours after delivery.
Major causes
Uterine atony (90%) lacerations of the genital tract(6%) retained placenta(3%-4%) coagulation defects (blood dyscrasia)
Systemic factors: nervous drugs(magnesium sulfate,sedative) abnormal labor(prolonged,precipitous) History of previous PPH Preeclampsia, abnormal placentation,
pathology
Contraction constricting the spiral arteries preventing the excessive bleeding from the placenta implantation site the uterine atony give rise to PPH when no contraction occur
Surgical methods
If massage and agents are unsuccessful: Ligation of the uterine arteries ligation of the hypogastric arteries selective arterial embolization hysterectomy taking into account the degree of hemorrhage,the overall status of patient,her future childbearing desires
management
Vaginal examination soon after delivery
repair: cervical laceration >2cm in length and be actively bleeding laceration of vaginal and perineum
causes: adherence of placenta (previous cesarean delivery,prior uterine curettage) succenturiate placenta placenta accreta (into the decidua) placenta increta(into the myometrium) placenta pericreta(through the myometrium to the peritoneal)
Record: pulse blood pressure maternal heart rate central venous pressure urine output
Lab tests: Hb, BT(bleeding time), CT( clotting time), platelets count fibrinogen prothrombin time and patial thromboplastin time FDP womens group and cross-matching
Treatment: the key is correcting the coagulation defect resuscitation must be started as soon as possible infusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusion blood transfusion is essential infusion of platelets, fresh frozen plasma, FDP , clotting factors,
Potential complications of PPH: Postpartum infection Anemia Transfusion hepatitis, Sheehans syndrome Ashermans syndrome