Case report

no
IDENTITY
Name : Mrs. AP
Age : 32 years old
MR No. : 906806
Address : Jl. Kubang Panjang,
Dharmasraya
Date : 6th November 2017
 Anamnese
• A 32 years old patient was admitted to the
Ward Room of Dr. M. Djamil Central General
Hospital on November, 6th 2017 at 05.21 pm.
She was referred from Polyclinic Obsetry of
Dr. M. Djamil Central General Hospital with
diagnose G5P4A0H3 term pregnancy +
Gestational Hipertension + once previous CS
 Present Illness History:
• Blurred vision (-), headache (-), epigastric pain (-)
• Feeling of pain from waist to region which
referred to the groin (-)
• Bloody show from the vagina was absent
• Fluid leakage from the vagina was absent
• Massive bleeding from the vagina was absent
• Amenorrhea since 9 months ago.
• First date of last menstrual period was forgotten
• Estimation date of delivery can not be estimated
• Fetal movement was felt since 5 months ago
• No complain of nausea, vomiting, and vaginal
bleeding neither during early pregnancy nor late
pregnancy
• Prenatal care : she controlled her pregnancy at
the midwife 4 times in 4,6,7,8 month of
pregnancy, the blood pressure wasn’t high
before
• Menstruation history: menarche at 13 years old,
irregular cycle, once every month which last for
5 to 7 days each cycle with the amount of 2-3
times pad change/day without menstrual pain
Previous Illness History:
• There was no previous history of heart, lung, liver, kidney,
DM, hypertension and allergy
• On the 4th pregnancy, patient got Severe Preeclamsia at
preterm gestational age and been operated TPPCS.

Family Illness History:

• There was no history of hereditary disease, contagious and
physiological illness in the family
 Occupation, Socioeconomics,
Psychiatry, and Habitual History:
• Marriage history : once in 2008
• History of pregnancy/abortion/delivery: 5/0/3
• 2009, male, 3500 gr , term, Vacuum extraction, hospital.
• 2011, male, 2800 gr, term, spontaneous, hospital.
• 2013, male, 2700 gr, term, forcep , hospital.
• 2015, male, 1600 gr, preterm, CS due to preeclamsia, hospital,
dead.
• Present
• History of family planning : (-)
• History of immunization : (-)
• History of education : junior high school
 Physical Examination:
General Record:
GA Cons BP HR RR T
Mdt CMC 150/90 86 20 37

Body weight :
before pregnancy : 60 kg
present : 72 kg
Body Height : 152 cm
BMI : 25,96
upper arm circumference : 28 cm
• Eyes : Conjunctiva wasn’t anemic, Sclera
wasn’t icteric
• Neck : JVP 5-2 cmH2O, thyroid gland no
enlargement
• Chest : H/L normal
• Abdomen : obstetrical record
• Genitalia : obstetrical record
• Extremity : Edema -/-, Physiological Reflex +/+,
Pathological Reflex -/-
 Obsetric Status
Abdomen :
I : Abdomen seem enlarger to term pregnancy, striae gravidarum (+), cicatrix (+) pfannsteil
Pa :
L1 fundal uterine was palpable at 3 finger below proc.xyphoideus
a large nodular mass was palpated
L2 a hard and resistance structure was felt on the left side,
numerous small part of the baby was felt on the right side
L3 a hard round mass was palpable and it wasn’t fixated
L4 converge

Uterine fundal height : 33 cm EFW : 3100 grams

Uterine contraction : -

Pe : Tympani

Au : Peristaltic sound was normal, FHR :135-145 x/minutes

Genitalia :
Inspection : V/U normal, vaginal bleeding (-)
VT : dilatation of servix was 1 finger
portio thicked 1 cm, posterior, medium
amnion sac was (+),
Head was palpated on HI

• Pelvic Inlet and Outlet : no contracted pelvic

 USG
• Fetal Alive singleton intra uterin head presentation
• Fetus movement was good
• Biometric :
– BPD : 9,21
– AC : 32,85
– FL : 7,04
– HL : 6,41
• EFW : 3045 gr
• AFI : 10,43
• SDAU : 2,48
• Plasenta Implanted at posterior corpus gr II.
• Impresion :
• Term pregnancy , fetal alive head presentation
 HASIL LABOR
Normal value 6 / 11/ 2017 8/11/2017
Hemoglobine 9,5-15,0 9,5 gr/dl 9,7
Leucocyte 5.9–16.9 10.250 /mm3 10.930
Hematocrit 28.0–40.0 28 % 30
Trombocyte 146–429 236.000/mm3 256.000
PT 10,0-13,6 10,7 11,1
APTT 29,2-39,4 42,4 46,9
GDS 0,00-200,00 208 mg/dl 208
HbsAg Non reaktif Non reaktif
Na 136-145 143
K 3,5-5,1 2,7
Cl 97-111 112
Ureum 10,0-50,0 18 12
Creatinin 0,6-1,2 1,1 0,7
 Normal value 6 / 11/ 2017 8/11/2017
Protein total 6,6-8,7 6,5 6,0
albumin 3,8-5,0 3,6 3,3
Globulin 1,3-2,7 2,9 2,7
Bilirubin total 0,3-1,0 0,7 1,2
Bilirubin direct <0,2 0,3 0,3
Bilirubin
<0,60 0,4 0,9
indirect
SGOT <32 24 20
SGPT <31 19 10
LDH 240-480 586 528
magnesium 1,9-2,5
D dimer < 500 1289,75
URINALISIS RESULT REFERENCE VALUE
Protein Negatif -
Glucose Negatif -
Leucocyte 6-7 0-5
Eritrocyte 1-2 0-1
Cylinder Negatif -

Crystal Negatif -

Epitel + gepeng +

Bilirubin Negatif -

Urobilinogen + +
 Diagnose
G5P4A0L3 term pregnancy + Gestational Hypertension + once
previous CS.
Fetal alive singleton intrauterin head presentation
Action :
 Control GA,VS,HIS,FHR,
 ECG
 Informed consent
 Consult anesthesia and OR
 Cross match
 Metil dopa 3x500 mg

Plan
TPPCS
• Internist Consult result :
– I/ G5P4A0H3 term pregnancy + Hipertension
Gestational + mild anemia
• Operation tolerance :
– Cardiovascular : mild – moderate (goldna criteria
class II)
– Pulmo : mild
– Metabolic : mild
– Homeostatic : stable
At 01.00 PM on november 8th 2017 :TPPCS + TP was performed
The first baby was born, a male baby with :
BW : 3100 gr
BH : 47 cm
A/S : 8/9
Placenta was born with mild traction on umbilical cord, complete 1 piece, size
17x17x3 cm, 500 gr in weight, and Umbilical cord was  62 cm in lenght,
paracentral insertion
Tubectomy Pomeroy was performed
Bleeding during operation was ± 250 cc
• Diagnose
– P5A0H4 post SCTPP due to previouse CS + hipertension gestational +
TP oi enough child
• Mother and Child were in care
• Action : Observe after procedure