Case Report n0 31

IDENTITY
Name

: Mrs. A
Age : 26 years old
MR No. : 91 05 25
Date : april 16th, 2015
Address : Raden Saleh, Padang
A 26 years old patient was admitted to the
Emergency Room of Dr. M. Djamil Central
General Hospital on april 16th, 2015 at 03.51
am with chief complain pain from waist
region which referred to the groin was felt
since 8 hours ago

Present Illness History

Pain from waist region which referred to the

groin was felt since 8 hours ago

Bloody show from the vagina was (+) since 8
hours ago
There was no fluid leakage from the vagina
There was no massive vaginal bleeding
Amenorrhea since 9 months ago

Present Illness History

First date of last menstrual period was forgotten
Estimation date of delivery was hard to

determine
Fetal movement was felt since 4 months ago
No complain of nausea, vomiting, or vaginal
bleeding neither during early nor late pregnancy
Prenatal care to midwife, 2 times (2 and 8
months of pregnancy) , said the pregnancy was
normal
Menstrual history : menarche at 11 years old,
irregular cycle with the amount of 2-3 times pad
change/day without any menstrual pain.

Previous Illness History

There was no previous history of heart, liver,

kidney disease, DM, hypertension and allergy

Family Illness History

There was no history of any hereditary
disease, contagious and psychological illness
in the family.

Occupation, Socioeconomics, Psychiatry, and Habitual

History:

Marital history: once in 2014

History of

pregnancy/abortion/delivery: 1/0/0
Present pregnancy

History of family planning: (-)

History of immunization: (-)

Occupation, Socioeconomics, Psychiatry, and Habitual

History:

History of education: Senior High

School
History of Employment: Housewife
History of Habitual : smoking (-),
alcohol (-), drug abuse
(-)

Physical Examination
GA

: Mdt
Cons : CMC
BP: 120/80
HR : 86
RR : 20
T : 37
BW : 43 kg
BH : 143 cm
BMI : 21,03
UAC : 25,8 cm

Eyes : Conjunctiva wasnt anemic, Sclera

wasnt icteric

Neck : JVP 5-2 cmH2O, no enlargement of

tyroid gland

Chest : H/L within normal limit

Extremity : Edema -/-, Physiological Reflex

+/+, Pathological Reflex -/-

Obstetric Record
Abdomen

Inspection : Abdomen seems enlarged

according to term pregnancy, mid line
hyperpigmentation (+), striae gravidarum (+),
cicatrix (-)
Palpation
L1: Uterine fundal height was 2 fingers below
xiphoideus processus. A large, soft, nodular
mass was palpated.

Obstetric Record
L2: hard and resistance structure was
palpated on the right side. Numerous
small, irregular structure were palpated
on the left side
L3 : A hard and round mass was palpated,
floating
L4 : not performed
UFH: 32 cm; EBW: 2945 gr;
Uterine contraction : 2-3x/30 / Moderate
Osborn test : (+)

Percussion : Tympani
Auscultation : FHR: 140-145 bps

Obstetric Record
Inspection : V/U within normal

limit
Internal examination
2-3 cm
Amniotic sac was (+)
Head palpated, floating

Pelvic Inlet:
Promontory was reachable (CD:9

cm; CV:7,5 cm)

All of Innominate line was
palpated
Sacrum bone : concave
Pelvic side wall : straight
Ischiadic spine : not protruded
Coccygeus bone : moveable
Arc of pubic : >90

Outlet Pelvic :
Inter tuberous distance couldnt be passed
through by normal adult fist (< 10,5 cm)
Impression: contracted pelvic primary cs

Laboratory Evaluation
Haemoglobin : 12,0 gr%
Leukocyte

: 20.200/mm3
Hematocrit
: 38 %
Thrombocyte : 227,000/mm3

 Diagnose:

G1P0A0L0 term Parturient first stage laten

phase + Contracted Pelvic Primary CS
Fetal alive, singleton, intrauterine, head
presentation, floating
Management:

Control GA, VS, FHR, uterine contraction

IVFD : maintenance RL
antibiotics
Informed consent
Consult to anesthesiologist
report to OR
Plan : CS

04.50 pm
TPPCS was performed
A male baby was born with TPPCS with Birth

Weight: 2900 gr, Birth Length: 49 cm, APGAR

score 7/8.
Placenta was delivered with a mild traction
on umbilical cord, complete, 1 piece. Size
was 17 x 16 x 2,5 cm, weight 520 gram,
umbilical cord length 60 cm. Paracentral
insertions. IUD was inserted
Blood loss during surgery 250 cc

Diagnosis :
P1A0L1 post TPPCS on indication contracted

pelvic primary CS
Mother & child were in care

Management :
Post surgery observation

Thank you

Post op laboratory
Haemoglobin : 11,7 gr%
Leukocyte

: 23.500/mm3
Hematocrit
: 36 %
Thrombocyte : 238,000/mm3