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DUTY REPORT

Friday, June 22nd 2018

Supervisor :
dr. Edy Ardiansyah, M.Ked(OG), SpOG.K

Residents :
1. dr. Devi Meliana Syam
2. dr. Dyah Nurvita
3. dr. Widya Nelvi Pandia
4. dr. Alfiani Sari R. Cy
5. dr. Ivan Christian Pasaribu
6. dr. Dwi Fenny Amir

Department of Obstetric and Gynecology


Medical Faculty University of Sumatera Utara
H. Adam Malik General Hospital
2018
NEW PATIENT : 5 PATIENTS
1. Mrs. R, 29 yo, G2P1A0

Diagnose : Placenta Previa Totalis + Prev SC 1x + SG + IUP (39-


40) wga + Breech Presentation + Alive fetus + In Labour
Planning : Immediate C-Section
Born baby girl at 02.00 am, BW 3290 gr, BL 49 cm, A/S 8/9, anus (+)

2. Mrs. U, 26 yo, G1P0A0

Diagnose : PE with Severe Feature + PG + IUP (37-38) wga + Head


Presentation + Alive Fetus
Planning : Immediate C-Section
Born baby boy at 12.00 am, BW 2900gr, BL 46 cm, A/S 8/9, anus (+)
3. Mrs. N, 39 yo, G5P2A2

Diagnose : Prev SC 2x + MG + IUP (37-38) wga + Head


Presentation + Alive Fetus + In Labour
Planning : Immediate C-Section
Born baby boy at 07.30 am, BW 3080 gr, BL 48 cm, A/S 8/9, anus
(+)

4. Mrs. M, 24 yo, G1P0A0

Diagnose : Ectopic Pregnancy


Planning : Immediate Laparotomy
5. Mrs. M, 39 yo, G3P2A0

Diagnose : Placenta Previa susp. accreta + Prev SC 2x + MG


+ IUP (36-37) wga + Head Presentation +
Alive Fetus
Planning : Immediate C-Section
Born baby girl at 11.20 am, BW 2710 gr, BL 49 cm, A/S 8/9,
anus (+)
Patient 1
Mrs. R. 29 y.o, G2P1001, Javanese, Moeslem, Senior high school,
housewife, married to Mr. W, 35 y.o, Javanese, Moeslem, Senior High
School, Farmer. The patient was admitted to Adam Malik General
Hospital on 22nd of June 2018, at 07.30 pm with:

Cc : Vaginal Bleeding
E : This has been experienced by the patient since 3 days ago
(19/06/2018). And worsened since yesterday, frequency 3-4
times changing pads/day. History of labor contraction (-). History
of amniotic fluid leackage (-). Patient was refered from other
hospital with diagnose placenta previa totalis + prev SC
1x. Micturition and defecation was no abnormality.
History of previous illness :-
History of Medication :-
History of surgery : C-Section (2015)

LMP : ??/10/2017
EDD : ??/07/2018
ANC : Obstetrician 3 times, midwife 5 times

Obstetric History :

1. Baby Girl, aterm, 3200 gr, C-section, Obstetrician, Hospital, 2 y.o,


Healthy

2. Current Pregnancy
Vital Signs
Cons : Alert Anemic : (-)
BP : 130/80 mmHg Icteric : (-)
Pulse : 82x/i Cyanosis : (-)
RR : 16x/i Dypsnoe : (-)
Temp : 36,5°C Edema : (-)
General state : Moderate
Nutritional state : Normal
Illness State : Moderate

Generelized Status :
• Head : Inferior palpebra conj anemic (-), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rales (-)/(-)
Obstetrical State
• Abdomen : Asimetrically enlarged
• Fundal Height : 3 fingers below process xhypoid, 34 cm
• Tension part : Left
• Lower part : Head
• Fetal movement : (+)
• Fetal Heartrate : 142x/i, reguler
• Uterine Contraction : 2x20”/10’

Gynecological State
Inspeculo : Seen blood at the OUE, cleaned out and no active
bleeding
VT : Not performed
Hands Glove : Not performed
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
- Single fetus, Intra Uterine, Head presentation, alive
fetus
- Fetal movement (+), Fetal heart rate (+) 140 bpm,
reguler
- BPD : 9,87 cm
- HC : 34,88 cm
- AC : 35,37 cm
- FL : 7,51 mm
- EFW : 3793 gr
- Placenta :
Conclusion : IUP (39-40) wga + Head presentation + alive
fetus + Placenta Previa totalis
CTG
Laboratory Findings
June, 22nd 2018 at 08.00 pm

• Hb : 8,1 N: 12-14 gr/dL


• Leukocyte : 10.640 N: 4.000-11.000/uL
• Hematocrite: 25 N: 36,0-42,0/%
• MCV : 87 N : 81-99
• MCH : 28,7 N : 27-31
• MCHC : 33.1 N : 31-37
• Platelet : 243.000 N: 150.000-400.000/uL
• BUN :6 N: 7-19 mg/dl
• Ureum : 13 N: 10-50 mg/dl
• Creatinin : 0,46 N: 0.6-1.2 mg/dl
Laboratory Findings
June, 22nd 2018 at 08.00 pm
• KGD ad : 110 N: <200
• Natrium : 132 N: 136-155 mmol/dl
• Kalium : 3,4 N: 3.5-5.5 mmol/dl
• Chlorida : 106 N: 95-103mmol/dl
• HbsAg : Non Reactive N: Non Reactive
• HIV : Non Reactive N: Non Reactive
DECISION POINT
• Previous C-section 1 times
– 2 years ago
• Placenta Previa Totalis
• In labor
• Diagnosis :
Placenta Previa totalis + Prev C- Section 1x + SG + IUP (39-
40) wga + Breech presentation + Alive Fetus + In Labour

• Therapy :
IVFD RL 20 gtt/i
Inj. Cefazoline 2 gr IV (skin-test)

• Plan :
Immediate C- Section
Consult to Anasthesiology
Consult to Perinatology

Report to supervisor on duty dr. M. Edy Ardiansyah, M.Ked (OG),


SpOG(K) approved
Thank You
Report of C-Section d/t Placenta Previa Totalis + Prev C-section 1 time
Born a baby girl at 02.00 am, BW 3290 gr, BL 49 cm, A/S 8/9, anus (+)
• The patient was laid on the operating table, with IV line and urinary
catheter inserted.
• Antiseptic and aseptic procedures were performed using povidone iodine
on the abdomen, and then draped leaving the surgical field exposed.
• Under Spinal anesthesia, a pfanennsteil incision was made on the
previous incision, through to the underlying layer of fascia. The fascia was
incised and extended laterally using scissor. Superior aspect of the fascia
was elevated using Kocher, and the underlying rectus muscles were
dissected.
• Peritoneum was identified. The peritoneum was elevated using clamp and
entered using Metzenbaum scissor with care for the underlying organ, and
extended superiorly and anteriorly with careful visualization of the
bladder.
• Evaluationthere was severe adhesion between muscle, peritoneum and
vesicouterine fold.
• The lower uterine segment was identified. A low cervical incision in the
uterus performed until subendometrium layer. Endometrium penetrated
and widened bluntly.
• By luxating the head, born baby girl at 02.00 am, BW 3290 gr, BL 49 cm, A/S
8/9, anus (+). The umbilical cord was clamped in two places and cut in
between. The placenta was born with fundal pressure and traction on the
umbilical cord.
• Uterine cavity was cleaned with gauze.
• Uterus was sutured by continuous interlocking stitches in two layer.
• Abdominal cavity was cleaned from blood and stoll cell.
• Peritoneum was sutured continuously, muscle approximation using simple
suture and fascial closure using continous suture.
• Subcutaneous layer was sutured with simple suture and cutis was sutured
with subcuticuler suture.
• Surgical wound was closed with sofratulle, sterile gauze and hypafix.
• Mother was not stable after the operation and was monitored closely at
HCU.
• Estimated blood loss ± 4000 cc.
Therapy:
• IVFD RL + Oxytocin 10IU 20 drops / minute
• Inj. Ceftriaxone 1 gram / 12 hours
• Inj. Ketorolac 30 mg / 8 hours
• Inj. Ranitidin 50 mg/ 8 hours

Plan :
• Check CBC 6 hours post transfusion
• Monitoring vital sign, uterine contraction and vaginal bleeding
Patient 2
Mrs. U. 26 y.o, G1P0000, Javanese, Moslem, Senior high School,
housewife, married to Mr. A, 27 y.o, Javanese, Moslem, Senior High
School, Entrepreneur. The patient was admitted to Adam Malik
General Hospital on 23rd of June 2018, at 00.45 a.m with:

Cc : High Blood Pressure


E : This has been experienced by the patient since 1 month ago.
History of hypertension before pregnancy (-). Headache (-),
Vomitus (-), Epigastric Pain (-), Blurred Vision (+). History of labor
contraction (-). History of amniotic fluid leakage (-). History of
vaginal bleeding (-). Patient was refered from other hospital
with diagnose Preeclampsia with severe feature + IUP (37-
38) wga. Micturition and defecation was no abnormality.
History of Previous illness : Hypertension
History of Medication : nifedipine, cal 95, flumizin
History of Surgery :-
LMP : ?/09/2017
EDD : ?/06/2018
ANC : Obstetrician 2 times, Midwife 7 times

Obstetric History :

1. Current Pregnancy
Vital Signs
Cons : Alert Anemic : (-)
BP : 180/110 mmHg Icteric : (-)
Pulse : 80x/i Cyanosis : (-)
RR : 20x/i Dypsnoe : (-)
Temp : 36,5°C Edema : (-)
General state : Moderate
Nutritional state : Normal
Illness State : Moderate

Generelized Status :
• Head : Inferior palpebra conj anemic (-), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rales (-)/(-)
Obstetrical State
• Abdomen : Asimetrically enlarged
• Fundal Height : 3 fingers below process xhypoid, 35 cm
• Tension part : Right
• Lower part : Head
• Fetal movement : (+)
• Fetal Heartrate : 135x/i, reguler
• Uterine Contraction : (-)

Gynecological State
Inspeculo :
VT : Not performed
Hands Glove : Not performed
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
- Single fetus, Intra Uterine, Head presentation, alive
fetus
- Fetal movement (+), Fetal heart rate (+) 140 bpm,
reguler
- BPD : 9,39 cm
- HC : 32,33 cm
- AC : 32,90 cm
- FL : 6,94 mm
- EFW : 3059 gr
- Placenta : Corpus anterior grade II
Conclusion : IUP (37-38) wga + Head presentation + alive
fetus + Placenta Previa totalis
Laboratory Findings
June, 23rd 2018 at 02.00 am

• Hb : 12,5 N: 12-14 gr/dL


• Leukocyte : 12.840 N: 4.000-11.000/uL
• Hematocrite: 38 N: 36,0-42,0/%
• MCV : 75 N : 81-99
• MCH : 25 N : 27-31
• MCHC : 33.3 N : 31-37
• Platelet : 369.000 N: 150.000-400.000/uL
• Fibrinogen : 259 N: 150 – 400 mg/dL
• D-Dimer : 502 N: < 500 ng/dL
Laboratory Findings
June, 23rd 2018 at 02.00 am
• BUN :5 N: 7-19 mg/dl
• Ureum : 68 N: 10-50 mg/dl
• Creatinin : 1,8 N: 0.6-1.2 mg/dl
• KGD ad : 103 N: <200
• Natrium : 132 N: 136-155 mmol/dl
• Kalium : 3,7 N: 3.5-5.5 mmol/dl
• Chlorida : 94 N: 95-103mmol/dl
• HbsAg : Non Reactive N: Non Reactive
• HIV : Non Reactive N: Non Reactive
Laboratory Findings
June, 23rd 2018 at 02.00 am
• Urinalysis
– Color : Cloudy yellow N: Yellow
– Glucose : Negative N: Negative
– Bilirubin : Negative N: Negative
– Keton : Negative N: Negative
– Specific gravity: 1.015 N: 1.005 – 1.030
– pH : 7.0 N: 5 – 8
– Protein : Postive 3 N: Negative
– Nitrit : Negative N: Negative
– Leukocyte : Positive N: Negative
– Blood : Positive N: Negative
• Diagnosis :
Preeclampsia with severe feature + PG + IUP (37 - 38) wga + Head
Presentation + Alive Fetus

• Therapy :
IVFD RL 20 gtt/i
Inj. Cefazoline 2 gr IV (skin-test)
MgSO4 20% bolus
Ringer Lactate + MgSO4 14 dpm

• Plan :
Immediate C- Section
Consult to Anasthesiology
Consult to Perinatology

Report to supervisor on duty dr. Edy Ardiansyah, M.Ked (OG), SpOG(K) 


Approved
FOLLOW UP
Time Blood Pressure Heart Rate Respiratory Uterine FHR
Rate Contraction

01.00 am 180/110 86 22 - 140


02.00 am 180/100 86 20 - 140
03.00 am 170/100 90 20 - 134
04.00 am 160/100 90 30 - 130
05.00 am 160/110 92 22 - 132
06.00 am 170/100 92 20 - 132
07.00 am 170/100 90 20 - 142
08.00 am 160/100 90 20 - 140
09.00 am 160/100 88 20 - 145
10.00 am 160/100 95 22 - 138
11.00 am 160/100 100 20 - 142
Thank You
Report of C-Section d/t Preeclampsia with severe feature
Born a Male baby with BW 2900 gr, BL 46 cm, AS 8/9, anus (+)

• The patient was laid on the operating table, with IV line and urinary
catheter inserted.
• Antiseptic and aseptic procedures were performed using povidone iodine
on the abdomen, and then draped leaving the surgical field exposed.
• Under Spinal anesthesia, a pfanennsteil incision was made on the
previous incision, through to the underlying layer of fascia. The fascia was
incised and extended laterally using scissor. Superior aspect of the fascia
was elevated using Kocher, and the underlying rectus muscles were
dissected.
• Peritoneum was identified. The peritoneum was elevated using clamp and
entered using Metzenbaum scissor with care for the underlying organ, and
extended superiorly and anteriorly with careful visualization of the
bladder.
• Evaluationthere was no adhesion.
• The lower uterine segment was identified. A low cervical incision in the
uterus performed until subendometrium layer. Endometrium penetrated
and widened bluntly.
• By luxating the head, a male baby, BW 2900 gr, BL 46 cm, A/S 8/9, anus (+)
was born. The umbilical cord was clamped in two places and cut in
between. The placenta was born with fundal pressure and traction on the
umbilical cord.
• Uterine cavity was cleaned with gauze.
• Uterus was sutured by continuous interlocking stitches in two layer.
• Abdominal cavity was cleaned from blood and stoll cell.
• Peritoneum sutured continuously, muscle approximation using simple
suture and fascial closure using continous suture.
• Subcutaneous layer was sutured with simple suture and cutis was sutured
with subcuticuler suture.
• Surgical wound was closed with sofratulle, sterile gauze and hypafix.
• Mother was stable the after the operation.
• Estimated blood loss ± 200 cc.
Therapy:
• IVFD RL + Oxytocin 10 IU 20 drops / minute
• IVFD RL + MgSO4 40 %  1 gr / hours
• Inj. Ceftriaxone 1 gram / 12 hours
• Inj. Ketorolac 30 mg / 8 hours
• Inj. Ranitidin 50 mg/ 12 hours

Plan :
• Check CBC 2 hours post operation.
• Monitoring vital sign, uterine contraction, vaginal bleeding, sign
and symptom of post partum eclampsia.
Patient 3
Mrs. N. 39 y.o, G5P2022, Bataknese, Moeslem, Senior high School,
Housewife, married to Mr. M, 38 y.o, Bataknese, Moeslem, Senior High
School, Enterpreneur. The patient was admitted to Adam Malik
General Hospital on 23rd of June 2018, at 00.50 a.m with:

Cc : Labor Contraction
E : This has been experienced by the patient since 8 p.m. History of
blood slime (-). History of amniotic fluid leackage (-). Micturition
and Defecation was no abnormality.
History of previous illness :-
History of Medication :-
History of Operation : C-Section 2 times, curettage 2 times

LMP : ?/09/2017
EDD : ?/06/2018
ANC : Obstetrician 3 times, midwife 6 times

Obstetric History :
1. Baby Girl, aterm, 3000 gr, C-section d/t CPD, Obstetrician, Hospital, 8 y.o,
Healthy
2. Baby boy, aterm, 3500 gr, C-section d/t prev. sc 1x, Obstetrician, Hospital, 2 y.o,
Healthy
3. Abortus
4. Abortus
5. Current Pregnancy
Vital Signs
Cons : Alert Anemic : (-)
BP : 130/70 mmHg Icteric : (-)
Pulse : 88x/i Cyanosis : (-)
RR : 20x/i Dypsnoe : (-)
Temp : 36,7°C Edema : (-)
General state : Moderate
Nutritional state : Normal
Illness State : Moderate

Generelized Status :
• Head : Inferior palpebra conj anemic (-), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rales (-)/(-)
Obstetrical State
• Abdomen : Asimetrically enlarged
• Fundal Height : 2 fingers below process xhypoid, 30 cm
• Tension part : Right
• Lower part : Head
• Fetal movement : (+)
• Fetal Heartrate : 138x/i, reguler
• Uterine Contraction : 2x10’’/10’

Gynecological State
Inspeculo : Smooth portio, erosion (-)
VT : Cervix sacral, ɸ 1cm, eff 60%, Head H-I, minor fontanelle ?,
Amniotic membrane (+).
Hands Glove : Blood Slime (+) amniotic Fluid (-)
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
- Single fetus, Intra Uterine, Head presentation, alive fetus
- Fetal movement (+), Fetal heart rate (+) 140 bpm, reguler
- BPD : 9,19 cm
- HC : 32,56 cm
- AC : 33,06 cm
- FL : 7,26 mm
- EFW : 3153 gr
- Placenta : Fundal posterior grade II

Conclusion : IUP (37-38) wga + Head presentation + alive


fetus
Laboratory Findings
June, 23rd 2018 at 03.00 am

• Hb : 10,4 N: 12-14 gr/dL


• Leukocyte : 7.730 N: 4.000-11.000/uL
• Hematocrite: 32 N: 36,0-42,0/%
• MCV : 85 N : 81-99
• MCH : 27,2 N : 27-31
• MCHC : 32,2 N : 31-37
• Platelet : 260.000 N: 150.000-400.000/uL
• BUN :4 N: 7-19 mg/dl
• Ureum :9 N: 10-50 mg/dl
• Creatinin : 0,55 N: 0.6-1.2 mg/dl
Laboratory Findings
June, 23rd 2018 at 03.00 am
• KGD ad : 140 N: <200
• Natrium : 140 N: 136-155 mmol/dl
• Kalium : 3,0 N: 3.5-5.5 mmol/dl
• Chlorida : 102 N: 95-103mmol/dl
• HbsAg : Non Reactive N: Non Reactive
• HIV : Non Reactive N: Non Reactive
DECISSION POINT
• Previous C-section 2 times
– 8 years ago
– 2 years ago
• In Labour
• Diagnosis :
Prev C- Section 2x + MG + IUP (37-38) wga + Head
presentation + Alive Fetus + In labour

• Therapy :
IVFD RL 20 gtt/i
Inj. Cefazoline 2 gr IV

• Plan :
Immediate C- Section
Consult to Anasthesiology
Consult to Perinatology

Report to supervisor on duty dr. Edy Ardiansyah, M.Ked(OG), SpOG (K)


approved
Therapy:
• IVFD RL + Oxytocin 10IU 20 drops / minute
• Inj. Ceftriaxone 1 gram / 12 hours
• Inj. Ketorolac 30 mg / 8 hours
• Inj. Ranitidin 50 mg/ 8 hours

Plan :
• Check CBC 2 hours post operation
• Monitoring vital sign, uterine contraction and vaginal bleeding
Thank You
Report of C-Section d/t Prev C-section 2 times
Born baby boy at 7.30 am , BW 3080 gr, BL 48 cm, A/S 8/9, anus (+)
• The patient was laid on the operating table, with IV line and urinary
catheter inserted.
• Antiseptic and aseptic procedures were performed using povidone iodine
on the abdomen, and then draped leaving the surgical field exposed.
• Under Spinal anesthesia, a pfanennsteil incision was made on the
previous incision, through to the underlying layer of fascia. The fascia was
incised and extended laterally using scissor. Superior aspect of the fascia
was elevated using Kocher, and the underlying rectus muscles were
dissected.
• Peritoneum was identified. The peritoneum was elevated using clamp and
entered using Metzenbaum scissor with care for the underlying organ, and
extended superiorly and anteriorly with careful visualization of the
bladder.
• Evaluationthere was no adhesion.
• The lower uterine segment was identified. A low cervical incision in the
uterus performed until subendometrium layer. Endometrium penetrated
and widened bluntly.
• By luxating the head, a male baby, BW 3080 gr, BL 48 cm, A/S 8/9, anus (+)
was born. The umbilical cord was clamped in two places and cut in
between. The placenta was born with fundal pressure and traction on the
umbilical cord.
• Uterine cavity was cleaned with gauze.
• Uterus was sutured by continuous interlocking stitches in two layer.
• Abdominal cavity was cleaned from blood and stoll cell.
• Peritoneum sutured continuously, muscle approximation using simple
suture and fascial closure using continous suture.
• Subcutaneous layer was sutured with simple suture and cutis was sutured
with subcuticuler suture.
• Surgical wound was closed with sofratulle, sterile gauze and hypafix.
• Mother was stable the after the operation.
• Estimated blood loss ± 250 cc.
PATIENT 4
Mrs. M, 24 y.o, G1P000, Bataknese, Christian, Senior high school,
Housewife, married to Mr. M, 30 y.o, christian, Moeslim, Bachelor, Police,
admitted to Adam Malik Hospital on June, 23rd 2018, at 08.00 a.m.

CC: Abdominal Pain


E : This has been experienced by the patient since 1 day ago. The
abdominal pain was felt on all region. History of spotting has been
experienced since 1 weeks ago, volume 2-3 times changing pads. History
of trauma (-), history of abdominal massage (-), Micturation and
defecation within normal limit.
History of previous illness :-
History of Medication :-
LMP : ?-?-2018
EDD :?
ANC :?

Obstetric History :
1. Abortus
2. Current pregnancy
Vital Sign :

Cons : Compos Mentis Anemic : -


BP : 110/60 mmHg Icteric : -
Pulse : 80 bpm Cyanosis: -
RR : 20 x/i Dyspnoe: -
Temp : 36.2 °C Oedem : -/-
VAS : 5-6

General Condition : Moderate


Nutrition Condition : Underweight ( BW: 40kg ; BL:156 cm  BMI=16 )
Disease Condition : Moderate
Localized St :
Head : Conj Palpebra inferior pale (-), icteric (-)
Neck : No abnormalities
Thorax : Respiratory sound : Vesiculer
Additional sound : Wheezing(-)/(-), Rhales (-)/(-)
Abdominal : Soepel, Lax (+), peristaltic (+)
Tenderness (+) on lower abdomen, mass (-)
Genitalia : Vaginal bleeding(+)
Gynecology state :
Inspeculo : Smooth portio, erotion (-), mass (-), blood
clot (+), lividae (+), F/A (-)
VT : Closed Cervix, cervical motion tenderness, cavum
douglas was protruded (+)
Gloves : Blood (+)
USG TAS
USG TAS
USG TAS
• Bladder was fully filled
• Uterine AF, Size : 5,35 x 8,85 x 4,40 cm, uterine cavity was empty
• Right adnexa : seen hypo and hyperechoic mass , size : 5,34 x 4,9 cm
• Left adnexa : Normal
• Free fluid (+)

Conclusion : Ruptured Ectopic Pregnancy


LABORATORY FINDINGS on 23/06/2018 at 01.00
a.m
Hb : 8,7 gr/dl N: 12-16/gr/dl
Leucocyte : 14.380 /mm3 N: 4000-11000/uL
Hematocrite : 25% N: 36,0-47,0/%
Platelet : 323.000/mm3 N: 150.000-400.000/uL
Ad random BGL : 90 mg/dl N: < 200 mg/dl
BUN : 12 mg/dl
Ureum : 26 mg/dl N : 15-40 mg/dl
Creatinin : 0,66 mg/dl N : 0,6-1,1 mg/dl
Natrium : 134 N : 135-155
Kalium : 4,1 N : 3.6-5.5
Cloride : 106 N : 96-106
Decision Point
1. Acute Abdomen
2. Cervical motion tenderness
3. Pregnancy Test (+)
4. Anemia
Diagnosis :
Ruptured Ectopic Pregnancy

Therapy :
• IVFD RL  20 dpm
• Inj. Cefazoline  2 gr /iv

Planning :
Immediate Exploration Laparotomy

Report to supervisor dr. Edy Ardiansyah, M.Ked(OG), Sp.OG


Approved
Thank You
Post Laparotomy Exploration + Salphingooverectomy sinistra d/t Ruptured
ectopic pregnancy

• The patient was positioned on the operating table in supine position


under general anesthesia with intravenous and catheter indwelled
properly
• Aseptic and antiseptic protocol was performed using povidone iodine
10% and 70% alcohol in the abdominal wall. The abdomen was then
covered with sterile cloth except the operating field
• Perform midline incision from 1 finger below umbilical untill symphisis
pubis. Incision was from cutis, to subcutis and fascia
• By inserting the underlying anatomical tweezers, fascia was cut to
leftside and right side. Muscle is bluntly separated.
• Peritoneum was clamped, lifted, and then cut cranially, and caudally.
Stol cell and bleeding was seen throughout the whole operation field
volume ± 500cc. Suctioning was performed as abdominal cavity was
filled with blood clott and blood.
• Identify the uterus was normal size, right fallopian tube was ruptured
at fimbria, however the ovarium was normal. Left fallopian tube and
ovarium was normal limit. Salphyngectomy dexstra was done.
• Evaluate right salphyng and ovarium, the bleeding was controlled.
• Cavum abdomen was cleaned using aquabidest,there was no source of
bleeding
• Cavum abdomen was closed respectively.
• Abdominal cavity was sewed layer by layer.
• Patient’s condition post surgery was stable.

Therapy
IVFD RL 20 dpm
Ceftriaxone inj 1gr/12 hours
Ketorolac 30mg/ 8 hours
Ranitidine 50 mg / 12 hours
Traneksamat 500 mg/8 hours

Plan: Monitorig vital sign and vaginal bleeding


Check CBC post operation
Patient 5
Mrs. M. 39 y.o, G3P2002, Javanese, Moeslem, Senior high school,
housewife, married to Mr. W, 35 y.o, Javanese, Moeslem, Senior High
School, Farmer. The patient was admitted to Adam Malik General
Hospital on 23nd of June 2018, at 05.30 am with:

Cc : Vaginal Bleeding
E : This has been experienced by the patient since 1 day ago
(22/06/2018). And worsened since this morning, frequency 2-3
times changing pads/day. History of labor contraction (-). History
of amniotic fluid leackage (-). Patient was from this hospital
(Adam malik general hospital) with diagnose placenta
previa totalis + prev SC 2x. Micturition and defecation was no
abnormality.
History of previous illness :-
History of Medication :-
History of surgery : C-Section (2010), (2016)

LMP : 01/10/2017
EDD : 08/07/2018
ANC : Obstetrician 1 times, midwife 5 times

Obstetric History :
1. Baby Boy, aterm, 3200 gr, C-section, Obstetrician, Hospital, 8 y.o,
Healthy
2. Baby Boy, aterm, 3200 gr, C-section, Obstetrician, Hospital, 2 y.o,
Healthy
3. Current Pregnancy
Vital Signs
Cons : Alert Anemic : (-)
BP : 130/80 mmHg Icteric : (-)
Pulse : 82x/i Cyanosis : (-)
RR : 16x/i Dypsnoe : (-)
Temp : 36,5°C Edema : (-)
General state : Moderate
Nutritional state : Normal
Illness State : Moderate

Generelized Status :
• Head : Inferior palpebra conj anemic (-), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : vesiculer
Additional sound : wheezing(-)/(-), rales (-)/(-)
Obstetrical State
• Abdomen : Asimetrically enlarged
• Fundal Height : 3 fingers below process xhypoid, 34 cm
• Tension part : Left
• Lower part : Head
• Fetal movement : (+)
• Fetal Heartrate : 144x/i, reguler
• Uterine Contraction : 2x20”/10’

Gynecological State
Inspeculo : Not performed
VT : Not performed
Hands Glove : Not performed
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
USG-TAS
- Single fetus, Intra Uterine, Head presentation, alive
fetus
- Fetal movement (+), Fetal heart rate (+) 144 bpm,
reguler
- BPD : 8,69 cm
- HC : 32,85 cm
- AC : 33,74 cm
- FL : 7,33 cm
- EFW : 3217 gr
- Placenta : corpus anterior grade II
Conclusion : IUP (36-37) wga + Head presentation + alive
fetus + Placenta Previa totalis
Laboratory Findings
June, 22nd 2018 at 08.00 am

• Hb : 10,7 N: 12-14 gr/dL


• Leukocyte : 13.520 N: 4.000-11.000/uL
• Hematocrite: 33 N: 36,0-42,0/%
• MCV : 87 N : 81-99
• MCH : 28,7 N : 27-31
• MCHC : 33.1 N : 31-37
• Platelet : 239.000 N: 150.000-400.000/uL
• BUN :5 N: 7-19 mg/dl
• Ureum : 11 N: 10-50 mg/dl
• Creatinin : 0,52 N: 0.6-1.2 mg/dl
Laboratory Findings
June, 22nd 2018 at 08.00 am
• KGD ad : 79 N: <200
• Natrium : 131 N: 136-155 mmol/dl
• Kalium : 4,0 N: 3.5-5.5 mmol/dl
• Chlorida : 104 N: 95-103mmol/dl
• HbsAg : Non Reactive N: Non Reactive
• HIV : Non Reactive N: Non Reactive
Laboratory Findings
June, 23nd 2018 at 06.00 am

• Hb : 8,1 N: 12-14 gr/dL


• Leukocyte : 20.640 N: 4.000-11.000/uL
• Hematocrite: 25 N: 36,0-42,0/%
• MCV : 82 N : 81-99
• MCH : 27,7 N : 27-31
• MCHC : 33.1 N : 31-37
• Platelet : 210.000 N: 150.000-400.000/uL
DECISION POINT
• Previous C-section 2 times
– 8 years ago
– 2 years ago
• Placenta Previa Totalis
• Previous Bleeding
• Diagnosis :
Placenta Previa totalis + Prev C- Section 2x + SG + IUP (36-37) wga + Head
presentation + Alive Fetus

• Therapy :
IVFD RL 20 gtt/i
Inj. Cefazoline 2 gr IV (skin-test)

• Plan :
Immediate C- Section
Consult to Anasthesiology
Consult to Perinatology

Report to supervisor on duty dr. M. Edy Ardiansyah, M.Ked (OG),


SpOG(K) approved
Thank You
Report of C-Section d/t Placenta Previa Totalis + Prev C-section 2 time
Born a baby girl at 11.20 am, BW 2710 gr, BL 49 cm, A/S 8/9, anus (+)
• The patient was laid on the operating table, with IV line and urinary
catheter inserted.
• Antiseptic and aseptic procedures were performed using povidone iodine
on the abdomen, and then draped leaving the surgical field exposed.
• Under Spinal anesthesia, a pfanennsteil incision was made on the
previous incision, through to the underlying layer of fascia. The fascia was
incised and extended laterally using scissor. Superior aspect of the fascia
was elevated using Kocher, and the underlying rectus muscles were
dissected.
• Peritoneum was identified. The peritoneum was elevated using clamp and
entered using Metzenbaum scissor with care for the underlying organ, and
extended superiorly and anteriorly with careful visualization of the
bladder.
• Evaluationthere was severe adhesion between muscle, peritoneum and
vesicouterine fold.
• The lower uterine segment was identified. A low cervical incision in the
uterus performed until subendometrium layer. Endometrium penetrated
and widened bluntly.
• By luxating the head, born baby girl at 11.20 am, BW 2710 gr, BL 47 cm, A/S
8/9, anus (+). The umbilical cord was clamped in two places and cut in
between. The placenta was born with fundal pressure and traction on the
umbilical cord.
• Uterine cavity was cleaned with gauze.
• Uterus was sutured by continuous interlocking stitches in two layer.
• Abdominal cavity was cleaned from blood and stoll cell.
• Peritoneum was sutured continuously, muscle approximation using simple
suture and fascial closure using continous suture.
• Subcutaneous layer was sutured with simple suture and cutis was sutured
with subcuticuler suture.
• Surgical wound was closed with sofratulle, sterile gauze and hypafix.
• Mother was stable after the operation Estimated blood loss ± 500 cc.
THANK YOU