Vous êtes sur la page 1sur 16

DUTY REPORT

Monday, May 8th 2016


Supervisor :
dr. Letta Sari Lintang, M.Ked (OG), Sp. OG.K.
dr. Sarah Dina, M.Ked(OG), Sp.OG.K
Resident :
2.
3.
4.
5.

1. dr. Titi Amalia


dr. Wardi S. Marpaung
dr. Fachrurrozi
dr. M.Iqsan
dr. Khairul

Department of Obstetrics and Gynecology


Medical Faculty University of North Sumatera
Adam Malik General Hospital
2016

New patient
Prior patient

:
:

1 patient
- patient

1. Ms.L, 21 y.o, G2P1A0


Dx: Fetal distress + Eclampsia + SG+ IUP (30 32 w)
+ Live
Fetus
Plan :
- Caesarean section Immediatelly
- Consult to Department of Anesthesia, Pediatric,
Interna and Neurology
Confirmed to Supv. dr. Letta Sari Lintang,M.Ked(OG),
Sp.OG.K Approved
On Sunday, May 8th 2016 at 03.00pm, with Caesarean
Section, Born baby boy, BW 1900 gram, BH 39 cm,
AS: 0/2, Anus (+)

Mrs. L, 21 y.o, G2P1A0, Bataknese, Christian, Junior High


School, farmer, married to Mr. S, farmer, admitted to Adam
Malik General Hospital on Sunday, May 8th 2016 at 02.00 pm,
with
CC

: Unconsciousness (alloanamnese)

E
: Experienced by patient since 8th May 2016 at 10.30
am. History of seizure (+), twice, first at home and followed
with unconsciousness and the second one when arrived at
Adam Malik General Hospital for 2 minutes. History of
hypertension disease (-), History of Gestational Hypertension in
previous pregnancy (-), History of Gestational Hypertension in
this pregnancy (?), History of epigastric pain (?), headache (?),
nausea and vomitus (?), blurred vision (?). Patient was referred
from Amanda Hospital, Berastagi, with diagnose Eclampsia +
unconsciousness + lung edema + Second gravide + live fetus.
Patient was managed by anesthesiologist first to improved
generalized state with ETT attached

Previous illness
: Previous medical history
: MgSO4 20% 10 ml (4 gr)
Loading
MgSO4 40% 40 ml (12 gr) 14
gtt/I
Inj. Dexametasone 15 mg
Last Menstrual Periode
: ? August 2015
Estimated Due Date : ? May2016
ANC
:?
Obstetric History :
1.Death
2.Current pregnancy

Vital Sign
Cons : Somnolence
BP
Pulse
RR
Temp

:
:
:
:

Anemic

: (-)

160/110 mmHg Icteric


: (-)
100 x/i
Cyanosis
: (-)
14 x/i
Dypsnoe
: (-)
36,5C
Edema
: (- )

Localized state :
Head : Eye : Conjuctiva palpebra anemia(-)/(-),
Sclera : icteric (-)/(-)
Neck : Limph node enlargement (-)
Cor
: S1 = S2, additional sound (-)
Thorax

: Respiratory sound
Additional sound
Ronchi (+)/(+)

: Vesicular
: Wheezing(-)/(-),

Obstetrical state
Abdomen

: Symetrically enlarged

Fundal Height

: 2 fingers upper navel

Lowest Part

: Head

Uterine contraction

: (-)

Fetal movement

: (+)

Fetal Heart Rate

: (+) 178 bpm

LABORATORY FINDINGS on May 8th 2016 :


Hb
Leukocyte
Hematocrit
Platelet
A.R. Glucose

: 38.410
: 41,0
: 446.000
: 129.00

N : 12-14 gr/dl
N : 4000-11000 /mm
N : 36,0 - 42,0 %
N :150.000-400.000/mm3
N : < 200 mg/dL

Albumin

: 2,9

N : 3.5 - 5.0 mg/dL

APTT
PT
Trombin Time
INR

: 12,60

: 42,50
: 13,5
: 15.5

C = 33,8 S
C = 14,0 S
C = 17,3

: 0.97

Ureum
Creatinin: 0,72
BUN

: 19,00

Natrium
Kalium
Cloride

: 137
: 3,2
: 107

:9

N : > 50 mg/dl
N : 0,6-1,2 mg/dl
N : 7 - 19
N :135-155
N : 3.6-5.5
N : 96-106

pH
pCO2
pO2
HCO3
CO2
Total
BE
O2 Saturation

: 7,230
: 20
: 186,0
: 8,4
: 9,0
: - 17,1
: 99,0

N : 7,35- 7,45
N : 38 - 42
N : 85 - 100
N : 22- 26
N : 19 25
N : (-2) (+2)
N : 95 - 100

USG TAS

USG TAS
Single Fetus, alive
Fetal Heart rate (+), Fetal Movement (+)
BPD
: 88 mm
AC
: 258,9 mm
FL
: 57,1 mm
AFI
: 9 cm
Placenta
: Corpus anterior, grade II
Conclusion

: IUP (30 31) weeks + life fetus

Dx: Fetal distress + Eclampsia + SG+ IUP (30 32 w) +


Live Fetus
Management:
IVFD RL + MgSO4 40% (30 cc) 14 gtt/i
Inj. Cefazoline 2 gr skin test
Nifedipin tablet 3x 10 mg
Plan :

- Cesarean section Immediatelly


- Consult to pediatric, interna, neuorology and
anesthesia
departement
Confirmed to dr. Letta Sari Lintang, M.Ked(OG), Sp.OG.K
approved
On Sunday, May 8th 2016 at 03.00pm, with Caesarean

C-Section report d/t Eclampsia + Fetal distress


Born baby boy, BW 1900 gram, BH 39 cm, AS:
0/2, Anus (+)
Mother was laid on operation table, with iv line, urine catheter
and ETT installed well
Antiseptic and aseptic procedure was performed, with betadine
and alcohol solution (70%), and covered by sterile fabric except
operation field
Under General anesthetic, pfannenstiel incision was made until
fascia revealed
Fascia was cut from middle to left and right

Muscle was opened bluntly


Peritoneum was cut from middle upward and downward
Gravida uterine was seen, locating the low servical region
Vesicouterine plica cut concavely to the left and right side,set aside
to the vesica urinary site.
Uterine was cut concavely and widen bluntly
Found feculent amniotic fluid
With grabbing the head, Born baby boy, BW 1900 gram, BH 39 cm,
AS: 0/2, Anus (+)
Umbilical cord was withered

cut and placenta was taken out

completely
Uterine cavity was cleaned with sterile gauss
Uterine was hecting with hemostatic suture figure of eight,
continuously interlocking, overhectingn and reperitonealization

Dx

: Post C-Section d/t eclampsia + fetal distress

Th/
-

IVFD RL + Oxytocin 10-10-5-5 20 gtt/i


IVFD RL + MgSO4 40% (30 cc) 12 gr 14 gtt/i
Inj. Cefazoline 1 gr/ 12 h
Inj. Gentamycin 80 mg/12 h
Drips Metronidazole 500 mg/8 h
Inj. Ketorolac 30 mg/ 8 h
Misoprostol Tab 2 Tab/rectal/8 h

R/
-

Observe 4th period


Check complete blood count post surgery

THANK YOU