DUTY REPORT

Thursday, March 30th 2023

Supervisor:
Dr. dr. Khairani Sukatendel, M.Ked(OG), Sp.O.G, Subsp. Obginsos

Residents:
dr. Armin Wijaya
dr. M. Tasnim Dalimunthe
dr. Bella Kurniati Agustin
dr. Mohammad Naufal
dr. Roy Rinaldi Marpaung
dr. Rizdyna Mahvira Adlin

Obstetric and Gynecology Department

Medical Faculty of Universitas Sumatera Utara
Universitas Sumatera Utara General Hospital
2023
New Patient : 2 Patients
1.Mrs. B, 35 y.o, G2P1001
Diagnosis : PASD(PAS 0) + Prev. C-Section 1x + MG + IUP (37-38) wga + Head Presentation + Live Fetus + Anemia (8.9)
Planning : General condition Improvement with transfusion 1 bag PRC
Prepared for C-Section consideration hysterectomy with blood preparation 2 packs of PRC and 2 packs of WB
Monitoring vital sign and fetal well-being
Patient was handled over to fetomaternal team
ICD X : O43.21 · Placenta accreta 
O34. 21 for Maternal care for scar from previous cesarean 
D64.9 Anemia, unspecified
ICD IX : 669.70 Expectative management for PASD (PAS0)

2. Mrs. P, 30 y.o, P1001

Diagnosis : Anemia (6.2) + Susp. Gestational Trophoblastic Neoplasm
Planning : General condition improvement with transfusion 3 packs of PRC
Monitoring Vital sign, Urine output , and vaginal bleeding
USG confirmation after general condition improvement
ICD X : O01.9 Hydatidiform Mole
D64.9 Anemia, unspecified
ICD IX : 99.04 Transfusion of packed Cells
PATIENT 1
Mrs B, 35 y.o, G2P1001, Javanese, Moslem, Senior High School, Housewife, Married once at 30 y.o with Mr.
A, 33 y.o, Javanese, Moslem, Senior High School, Entrepreneur. The patient was came to Adam Malik
Hospital on March 28th 2023 with:

Cc : History of Vaginal Bleeding

E : Experienced by patient 6 hours before admitted to hospital. Frequency of changing pads 2 times.
History of amniotic leakage (-). History of labor contraction (-). History of blood slime (-). History of
abdominal pain (-), History of prior vaginal Bleeding (+) 1 week ago with frequency 2-3x changing pads,
History of vaginal discharge (-). History of fever (-), shortness of breath and cough (-). Defecation and
Micturition within normal limit. The patient was routine patient of Fetomaternal Clinic placenta previa dd
placneta accreta.
History of previous illness :-
History of Medication : -
History of Surgery : C-Section 1x (2020)
History of Contraception: -
History of Menarche : 13 y.o, 2-3x changing pads, 5-7 days, regular, dismenorrhea (-)
LMP : 30/06/2022 (38w 6d)
EDD : 07/04/2023
ANC : Obstetrician 6x, Midwife 2x

History Of Pregnancy :
1. Female, Aterm,2.900 gr, C-Section d/t Obstructed Labor , Obstetrician, Hospital, 2 y.o , Healthy
2. Current Pregnancy
Vital Signs
Cons: CM Anemic : (+)
BP : 115/82 mmHg Icteric : (-)
Pulse : 98 x/min Cyanosis : (-)
RR : 20 x/min Dypsnoe : (-)
Temp : 36.7 C Edema : (-)

General state : Moderate BW : 57 kg

Nutritional state : Normoweight BH : 160 cm
Illness State : Moderate UAC : 26 cm

Generalized Status
• Head : Inferior palpebra conj anemic (-/-), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : Vesiculer (+/+)
Additional sound : wheezing(-)/(-), rhales (-)/(-)
• Extremities : oedema (-/-), swelling on finger joints (-)
• Lymph nodes : no enlargement
MEOWS

Total Score : 1
Obstetric Examination
Abdomen : Asymmetrically enlarged
Fundal Height : 2 fingers below Proc. Xyphoideus (36 cm)
Tension Part : Right
Lower Part : Head
Uterine Contraction : (-)
Fetal Movement : (+)
Fetal Heart Rate : 145 bpm
EFW : (36 – 13) = 23 x 155 gram = 3.565 gram

Vaginal Examination
VT : Not performed
Inspeculo : Stoll cell (+), cleaned with gauze seems not active bleeding (-), F/A (-)
Inspeculo
 TAS
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 USG TAS
March, 30th 2023
• Intrauterine, Live fetus
• FM(+), FHR (+) 133 bpm, regular
- BPD : 9.52cm
- HC : 11.44cm
- AC : 33.25cm
- FL : 7.44cm
- Cereb : 5.52cm
- FHR : 144bpm
- S/D Ratio : 2.00
- EFW : 3.325gr
- Placenta Grade III seems previa with no evidence of accreta and covering the OUI
- Cervical length 1.5 cm

Conclusion:
PASD (PAS 0) + IUP (37-38) wga + Head Presentation + Live Fetus
 CTG
March 30th 2023

Baseline : 125 bpm

Variability : 5 – 25 bpm
Acceleration : (-)
Deceleration : (-)
Contraction : (-)

Conclusion : Category I
 • Hb : 8.9 N: 12 – 16 gr/dL
• Leukocyte : 3.970 N: 4,000 – 11,000 /µL
• Hematocrite : 27.6 N: 36 – 47 /%
• Platelet : 308.000 N: 150,000 – 450,000 /µL
• MCV : 85 N: 81 – 99 fL
• MCH : 27.4 N: 27 – 31 pg
• MCHC : 32.2 N: 31 – 37 g/dL
Laboratory Findings • Neutrofil : 68.80 N: 50.00 – 70.00%
March 31st 2023 • Limfosit : 21.00 N: 20.00 - 40.00%
• Monosit : 8.60 N: 2.00 – 8.00%
• Eosinofil : 1.50 N: 1.00 – 3.00%
• Basofil : 0.10 N: 0.00 – 1.00%
• Neutrophil Abs : 6.57 N: 2.7 – 6.5 103/µL
• Lymphocyte Abs : 2.01 N: 1.5 – 3.7 103/µL
• Monosit Abs : 0.82 N: 0,2-0,4 10^3/l
• Eosinophyl Abs : 0.14 N: 0-0,1 10^3/l
• Basophyl Abs : 0.01 N: 0-0.1 10^3/l
• GDS : 102 N: <200
Diagnosis :
PASD (PAS 0) + Prev. C-Section 1x + MG + IUP (37-38) wga + Head Presentation + Live Fetus + Anemia (8.9)

Therapy :
• O2 via NC 5 Lpm
• IVFD RL 20 dpm
• Inj. Cextriaxone 2gr (Prophilaxis)
• Urine Catheter insertion

Plan :
• General condition improvement in Emergency room  Transfusion 1 pack of PRC
• Prepared for C-Section with blood preparation 2 packs of PRC and 2 packs of WB
• Monitoring vital sign and fetal well-being
• Consult to Anesthesiology Department
• Consult to Perinatology Department
• Patient was handled over to Fetomaternal team

Reported to supervisor on duty Dr. dr. Khairani Sukatendel, M.Ked(OG),Sp.O.G, Subsp. Obginsos  Approved
THANK YOU
PATIENT 2
Mrs. P, 30 yo, P1A1, Javanese, Moeslem, Senior High School, Housewife married to Mr. F, 32 yo, Bataknese,
Moeslem, Senior High School, Enterprenur, youngest child 4 yo. The patient was come to Adam Malik Hospital on
March 31st 2023 at 05.30 a.m with :
Cc : History of vaginal bleeding
E : This has been experienced by patient since 2 months ago, with frequency changing 2 pads/day, stoll cell (+).
History of abdominal pain (+). History of intermenstrual bleeding (-). History of pain on menstrual period (-).
History of prolonged menstruation (-). History of nausea and vomiting (+) within 2 months ago. History of fever,
cough, and shortness of breath (-). History of vaginal discharge (-). History of abdominal massage (-). History of
weight loss (-). History loss of appetite (-). Micturition and Defecation within normal limits. Patient was Referred
from other hospital with Hydatidiform Mole
History of previous illness : Hydatidiform Mole
History of Medication :-
History of Surgery : C-Section 1x (2019) & Curettage (Jan 2023)  No Pathology Anatomy Result
History of Contraception :-
History Of Menstruation : Menarche on 13 yo, regular, 28 days cycle, duration 5-7 Days, Frequency
3-4 pads/day, Dysmenorrhea (-), LMP: 20 November 2022

History of Pregnancy
P1A1
Vital Signs
Cons : Alert Anemic : (+)
BP : 105/70 mmHg Icteric : (-)
Pulse : 81 x/min Cyanosis : (-)
RR : 20 x/min Dypsnoe : (-)
Temp : 36,8 C Edema : (-)

General state : Normal BW : 50 kg

Nutritional state : Moderate BH : 153 cm
Illness State : Moderate BMI : 25,3 kg/m2

Generalized Status
• Head : Inferior palpebra conj anemic (+/+), icteric (-)
• Neck : Within normal limits
• Thorax : Respiratory sound : Vesiculer (+/+)
Additional sound : wheezing(-)/(-), rhales (-)/(-)
• Extremities : Oedema (-/-)
• Lymph nodes : no enlargement
Chest X-Ray

Conclusion: Cor and pulmo within normal limit

Localized State
Abdomen : Laxed, normoperistaltic, palpable uterine bigger than normal size with upper pole 2
fingers below navel and lower pole as level as pubic symphysis, regular surface,
mobile, pain (-)
Vaginal bleeding : (+) spotting

Gynecology Examination
Inspeculo : smooth portio, seen blood cleaned not active bleeding, erosion (-), F/A (-)
RVT : Uterus bigger than normal size with upper pole 2 fingers below navel and lower pole as
level as pubic symphysis, regular surface, mobile, left and right adnexa was not palpable
mass, both parametrium were laxed, Douglas cavity was not protruded, spingter ani was thigt,
ampula recti filled with feces, mucosa recti was smooth, mass (-).
Inspeculo
 USG TVS
March 31st 2023
 USG TVS
March 31st 2023
 USG TVS
March 31st 2023
 USG TVS
March 31st 2023
 USG TVS
March 31st 2023
 USG TVS
March 31st 2023

‐ Bladder was not Filled

‐ Uterus AF bigger than normal with size 135.5 x 90.3 x 75.9 mm
‐ Seen mass snowstorm appearance intrauterine cavity with size 93.1 x 86.9 mm, hypervascularization (+)
‐ Right Ovary with size 18.9 x 11.5 mm
‐ Left Ovary with size 34.5 x 17.4 mm
‐ Free fluid (-)

Conclusion: Susp. Gestational Trophoblastic Neoplasm

 • Hb : 6.2 N: 12 – 16 gr/dL
• Leukocyte : 4.970 N: 4,000 – 11,000 /µL
• Hematocrite : 19.3 N: 36 – 47 /%
• Platelet : 249.000 N: 150,000 – 450,000 /µL
• MCV : 84 N: 81 – 99 fL
• MCH : 27.1 N: 27 – 31 pg
• MCHC : 32.5 N: 31 – 37 g/dL
Laboratory Findings • Neutrofil : 57.90 N: 50.00 – 70.00%
March 31st 2023 • Limfosit : 30.00 N: 20.00 - 40.00%
• Monosit : 9.80 N: 2.00 – 8.00%
• Eosinofil : 1.80 N: 1.00 – 3.00%
• Basofil : 0.50 N: 0.00 – 1.00%
• Neutrophil Abs : 2.30 N: 2.7 – 6.5 103/µL
• Lymphocyte Abs : 1.19 N: 1.5 – 3.7 103/µL
• Monosit Abs : 0.39 N: 0,2-0,4 10^3/l
• Eosinophyl Abs : 0.07 N: 0-0,1 10^3/l
• Basophyl Abs : 0.02 N: 0-0.1 10^3/l
 Laboratory Findings
March 31st 2023
• GDS : 84 N: <200
• Plano Test :Positive
• BHCG Quantitatif : 339.240
Diagnosis :
Anemia (6.2) + Gestational Trophoblastic Neoplasm

Therapy :
• IVFD NaCl 0.9% 20 dpm
• Inj. Tranexamic Acid 500 mg/8 jam

Plan :
• Monitoring Vital Sign, Vaginal Bleeding, and Urine Output
• General condition improvement with transfusion 3 packs of PRC
• USG confirmation after general condition improvement
THANK YOU