Case Report

No.

Name : Mrs. M
Age : 37 years old
MR No. : 92 62 62
Date
: March 15th, 2016
A 37 years old patient was admitted to
the Ward Room of Dr. M. Djamil Central
General Hospital on March 15th, 2016
at 02.00 pm reffered from policlinic
with d/ G3P2A0H2 term pregnancy +
previous CS 1x + Ca Cervix

Present Illness History

Feeling of pain from waist region

which referred to the groin was
absent.
Bloody show from the vagina was
absent
Fluid leakage from the vagina was
absent
Massive vaginal bleeding was
absent
Amenorrhea since 9 months ago

Present Illness History

First date of last menstrual : forgetten
Estimation date of delivery : cannot be estimated
Fetal movement was felt since 5 months ago
No complain of nausea, vomiting, or vaginal
bleeding neither during early nor late pregnancy
Prenatal care to midwife 5x and Obstetricians 2x
(at 22 weeks of pregnancy age patient refuged to
chemoterapy, and at term pregnancy mother and
fetal was in good condition)
Menstrual history : menarche at 13 years old,
irregular cycle, once a month, 5-7 days each cycle
with the amount of 2-3 times pad change/day
without any menstrual pain.

There was no previous history of heart, lung, liver,

kidney disease, DM, hypertension and allergy`
Patiet has know as Ca Cervix since 1 years a go with
Pathological (Adenocarcinoma Cervix)

Family Illness History

There was no history of any hereditary disease,

contagious and phsycological illness in the family.

Occupation, Socioeconomics,
Psychiatry, and Habitual
History :

Marital history: once in 2000

History of
pregnancy/abortion/delivery: 3/0/1
1. 2002, male , 2900gr,
spontaneous, midwife, alive
2. 2010, male, 3200gr, c-section oi
protracted labor, ObGy, alive
3. present
History of family planning: (-)
History of immunization: (-)
History of education : High school
History of occupation : house wife

Physical Examination
GA
Cons
BP
HR
RR
T
BW before
BW
BH
BMI
UAC

:
:
:
:
:
:
:
:
:
:
:

Mdt
CMC
120/70
82
21
36,7
40
50 kg
144 cm
19,29
24 cm

Eyes : Conjunctiva was

sub 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 in accordance
with term pregnancy, mid line hyperpigmentation (+),
striae gravidarum (+), cicatrix (-)

Palpation :
L1: Uterine fundal height was 3 fingers below xiphoideus
processus. A large, soft, nodular mass was palpated.
L2: hard and resistance structure was palpated on the
left side. Numerous small, irregular structure were
palpated on the right side
L3 : A hard and round mass was palpated, floating
L4 : not performed
UFH: 40 cm; EBW: 4185 gr; Uterine contraction : (-)
Percussion : Tympani
Auscultation : Peristaltic sound was normal, Fetal heart
sound: 140-150 bpm

Obstetric Record
Genitalia :
Inspection
: V/U within normal limit
Inspeculo :
Vagina : tumor(+) 1/3 proximal of
vaginal wall, iregular, easy to bleeding.
Portio : tumor (+) size 3x3x2 cm,
iregular, easy to bleeding.

Laboratorium
Hb
: 8.8 gr%
Leucocyte : 9.700 /mm

(9,5-15)
(5900-16900)

Ht
: 26 %
(28-40)
Trombocyte : 205.000 /mm3 (146-429.000)

Ongcology-Gynecology Consul
Re evaluated after c-Section
Plan : Chemoteraphy post C-Section after 14 days
puerperrium

 Diagnose :

G3P2A0L2 term pregnancy + previous cs 1x

+ Ca Cervix
Fetal alive, singleton, intrauterine, head
presentation

 Management :

Control GA, VS, FHR, uterine contraction

Antibiotics skin test
Informed consent
Consult to anesthesiologist
` Report to operating room

Plan :

Caesarean Section

March, 16th 2016 -08.15 AM

TPPCS was performed
A female baby was born with TPPCS with , Birth Weight:
4000 gr
Birth Length: 49 cm
APGAR score 8/9.
Placenta was delivered with manual, complete, 1 piece.
Size was 17 x 16 x 2 cm, weight 480 gram, umbilical
cord length 50 cm. Paracentral insertions.
TP was performed.
Blood lose during surgery 250 cc

 Diagnose:
P3A0L3 post TPPCS on indication of Previous CS 1x + Ca
Cervix
Mother baby were in care
Plan:
Post surgery monitoring
Tranfusion 1 PRC

Laboratorium
Hb
: 10.8 gr%
Leucocyte : 9.700 /mm

(9,5-15)
(5900-16900)

Ht
: 32 %
(28-40)
Trombocyte : 202.000 /mm3 (146-429.000)

Thank you