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CLINICAL CONFERENCE

MONDAY, JANUARY 8TH, 2018
Reporting Obstetric Patients from
January 4 th -7 th, 2018

REPORTER :
dr. Ariapriyoga Rheza Mahendra
(4 th SEMESTER)
Program Pendidikan Dokter Spesialis Obstetri dan Ginekologi
Fakultas Kedokteran Universitas Negeri Sebelas Maret
Rumah Sakit Dr. Moewardi Surakarta
2018

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Statement

 I , dr. Ariapriyoga Rheza Mahendra, said that all
the data that I show in this report are fact .

CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY

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Resume:

Total : 9 cases
 Physiological Delivery : - case
 Pathological Delivery : 6 case
 Minor Obstetric : - case
 Mayor Obstetric : 3 cases
 Admitted to Ward : - cases
 Join with Other Departement : - case
 ICU : 1 case
 Death report : 1 case

CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY

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Contraception Recapitulation

 IUD Post Partum : 3 cases from 5 cases
 IUD Post C-Section : 1 case from 2 cases
 Sterilization : 1 patient

CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY

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PATHOLOGICAL DELIVERY
5 Cases

CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY

37 wga dr. G1P0A0. 18 Hours PROM on Primigravide Fullterm Pregnancy Female baby was born. Ms . AS: 7-7-8 CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY . BW 2800 gr. 6 A. Premature Rupture of the Membrane : 4 cases 1.YNT. 18 yo. Fadli (R3) had assisted spontaneous delivery.

2. AS 8-9-10 Ballard score 30 ~ 36 wga CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 7 . 23 y. G1P0A0. 36 wga dr Ine (R3) had assist spontaneus delivery + IUD Insertion 19 hours PROM on primigravide preterm pregnancy Duration of labor 8 hours Female baby was born. Mrs. HST.o. 2350 gram.

CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 8 .

AS : 7-8-9 . Tama (R3) had assisted spontaneous delivery + IUD Insertion 1 day PROM on primigravide fullterm pregnancy Duration of labor 9 hours Female baby was born.3. G1P0A0. 2600 gram. 37 wga dr. 17 yo. Mrs. MEL.

CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 10 .

Riri (R3) had assisted spontaneous delivery + IUD Insertion 18 Hours PROM on Secundigravide fullterm pregnancy Female baby was born. ENW. 29 yo. 2600 gram. 12 4. AS : 7-8-9 . 37 wga dr. G2P1A0. Mrs.

13 5. 29 yo. Anis (R3) had assisted spontaneous delivery 16 Hours PROM on primigravide fullterm pregnancy Male baby was born. Mrs. RRN. AS : 7-8-9 . 39 wga dr. 3300 gram. G1P0A0.

ANH. Partial HELLP syndrome on Primigravide immature pregnancy + hipoalbumin (2. 13 B. maseration (-) CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY . G1P0A0. 25 wga dr. 650 gram. Mrs.Severe Preeclampsia : 1 case 1. 39 yo. Tama (R3) had assisted spontaneus delivery + IUD Insertion IPFD Severe preeclampsia unresponse therapy.7) in a catheter balloon followed by the induction of the first bottle oxytocin Duration of labor 7 hours Female baby was born.

MAJOR OBSTETRIC 3 Cases CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 14 .

Fadli (R3) under permission dr. 37 wga dr. FETAL HYPOXIA : 1 Case 15 1.o. Yoga (R4) supervised by dr. 37 y. G2P1A0. IND. A . Eric Edwin SpOG (K) had performed emergency C-section + IUD Insertion b/i Fetal Hypoxia Dx : Fetal Hypoxia 16 Hours PROM on Secundigravide Fullterm Pregnancy in labor 1st Stage Latent Phase Male baby was born. Mrs. AS :7-8-9 CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY . Lini (R7) assisted by dr. BW : 2900 gr .

CST before resuscitation CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 16 .

CST after resuscitation CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 17 .

SRH. Yoga (R4) supervised by dr Lini (R7) assisted by dr Fadli (R3) under permission dr Eric Edwin SpOG (K) had performed Emergency C-Section + sterilization b/i Breech Presentation Premature Rupture of Membrane not yet in labor Dx : Breech Presentation 16 Hours PROM on Multigravide Fullterm Pregnancy not yet in labor with Gestasional Hypertension Female baby was born. BW : 3000 gr . Mrs. BREECH PRESENTATION( 1 Case) 18 1. 39 wga dr. G3P2A0. AS : 7-8-9 CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY . 37 yo.B.

4 AT 67) + prolonged PT APTT THIS CASE WILL BE DISCUSSED .6). 31 yo dr. resolved hypovolemic shock. early post partum haemorrhage ec post vaginal repair ec vaginal laceration + bisitopenia (HB 4. C. RIZ. Wisnu Prabowo. Mrs. UTERINE ATONIA ( 1 Case) 1.i uterine atony Dx pre OP : Uterine atony. P3A0. prolonged PT APTT Dx post OP : Uterine atony. early post partum haemorrhage ec post vaginal repair ec vaginal laceration + anemia (7. Kus (R6) had perfomed supracervical hysterectomy b. resolved hypovolemic shock. SpOG (K) assisted by dr. Lini (R7) supervised by dr.

ICU 1 Case CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 20 .

31 yo Dx : SIRS.5mg/12 Hr inj furosemid sp 5cc/hr (sp) check for DR3. resolved hypovolemic shock. P3A0. albumin Other therapy ~ Anesthesia. Tranexamat Acid 1 gr / 8 hr in 500cc RL Inj.8 Ur 78) + transamination enzyme elevated (SGOT 2456 SGPT 1723) Tx : Inj. Dycinon 1 amp / 8 hr Inj. post vaginal repair ec early post partum haemorrhage ec vaginal laceration + Trombositopenia (79) + Hypoalbumine (2. pulmonology. Adona 1 amp/8 hr inj metil prednisolon 62. SGOT/SGPT. post supracervical hysterectomy b. ICU 1. Vit K 1 amp / 12 hr Inj.7) + renal insufisiency( Cr 1. RIZ. Ceftriaxone 2 gr/ 24 hr Inf. internal medicine . pulmonary oedem.i uterine atoni. Mrs. Metronidazole 500 mg / 8 hr Inj.

Furosemide 1 amp / 12 hr . Metronidazole 500 mg / 8 hr atonia  Inj. Tranexamic Acid 1 gr / 8 hr  Trombositopenia suspect  Inj. Dycinon 1 amp / 8 hr  Pulmonal oedema  Inj. Vit K 1 amp / 12 hr  Haemoragic shock  Inj. Ceftriaxone 2 gr/ 24 hr hysterectomi b. Omeprazole 40 mg / 12 hr DIC  Inj.Dx Anesthesia : Tx Anesthesia :  Post supracervical  Inj.i uterine  Inf.

 Dx Pulmonology  Tx Pulmonology Pulmonary Oedem .O2 Ventilator .observation of haemodinamic .Furosemid 1 amp/12H ~ anestesiology Dept .

9 %/12 hour elevated  Evaluation for transamination enzym after 3 day treatment .transamination enzyme 0. Dx Interal medicine Dept  SNMC 1 amp in 100 cc NaCl .

5 cc/ hr  T : 36.3 OC .1343 cc mode spontan FiO2 21%  UO : 112. CM  I : 2777 cc VS  urine : 2700 cc  BP : 142 / 92 mmHg  IWL : 720 cc  HR : 78 x/ mnt  Drain : 500 cc  RR : 18 x/ mnt  NGT : 200 cc  SpO2 99 % ventilator  BC : .This morning condition Clinical examination Fluid Balance 24 hours  GC : moderate.

DISCUSSION CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 26 .

31 yo SIRS.8 Ur 78) + transamination enzyme elevated (SGOT 2456 SGPT 1723) CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 27 .7) + renal insufisiency( Cr 1.i uterine atoni. post vaginal repair ec early post partum haemorrhage ec vaginal laceration + Trombositopenia (79) + Hypoalbumine (2. resolved hypovolemic shock. pulmonary oedem. post supracervical hysterectomy b.P3AO.

performed the first misoprostol 25mcg induction tablet per vaginam. there was rupture in the posterior fornic section.00 AM Patient came from policlinic and has planned to get induced misoprostol 25mcg. advice tranferred to RSDM 28 . appeared active bleeding portio direction at 12 and 6 o'clock. 3600gr. there was active bleeding (+). there was active bleeding.15 PM contraction (+). evaluation. suturing by midwife has done.00 PM. 2 hours observation with contraction (+) 00.15 PM has born male baby. 2 cm opening of portio with amniotic skin (+) 07.00 AM evaluation.00 PM Amniotic membrane rupture.paired the vaginal tampons.00 PM evaluation. Chronology (4/1/2018 ) Nirmala Suri Hospital VK: A women G3P2A0. suturing has done 09. 31 yo with postdate pregnancy 41 wga 11. 6 hours evaluation 06. opening 5 cm 08:00 PM complete opening 08. there was still active bleeding . twice every 6 hours 12. evaluation of labor appeared rupture perineum. reported to consultant . performed situational suture with consultant and medication has been given.

complete plasental was born with durante of delivery 6 hours.2 fomahes .Misoprostol 5 tab (00.00 am) .Vitamin K inj (00.2 kolf PRC .3 flabot RL .00) Fluid input : . Therapy was given : . delivered her baby 8 hours before went to Moewardi hospital.00 am) .5 flabot RL ( drip oxytocin + metergin) .00 AM): A women P3A0.00 am) . refered from nirmala suri hospital with information post delivery bleeding. Chronology (5/1/2018 ) VK/Ponek (04.00 am) .00 am) .Cefotaxime inj 1 gr (02. patient was spontan delivery in misoprostol induction 25 mcg.Metronidazole inf 500mg (02. 31 yo.Ketorolac inj 30mg (02. with male 3600 gr.Tranexamat acid (00.1 kolf WB CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 29 .

Astma (-). 8 yo. 3600gr CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 30 . 3100gr spontan • III: male. Allergy (-) • I: male. Cardiac disease (-) Diabetes Mellitus (-). 3000gr. • Prior illness : Hypertension (-). History of spontan Illness & parity • II: female. 6 yo.

tenderness (-).3°C • Eyes CA (+/+) SI (-/-) • Souple. somnolen • BP : 80/60 mmHg • HR : 122 x/’ GC/VS • • RR : 24x/’ T : 36.PHYSICAL EXAMINATION • GC : weak. contraction Abdomen weak • Fundal high 1 finger under umbilical 31 .

PHYSICAL EXAMINATION • Inspection: appeared 4 pieces of ovarian clamp and vaginal tampon that had been released • Inspekulo: calm vulva. blood ( +) 32 . bleeding on left lateral OUE and suture on the posterior Genital vaginal wall (suturing perineum) portio had been sutured entirely. blood (+) out of the OUE. appeared wound that had been sutured on perineum (some stitches appart).

7 .4 Ht 24 AL 19.2 Alb 1.8 APTT 45.70 GDS 107 PT 19.Laboratorium  5/1/2018 ( 05.1 AT 134 AE 2.00 AM) Hb 7.

2) CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 34 .8 45. Early Diagnosis: hypovolemic shock. early post partum haemorrhage ec post vaginal repair ec vaginal laceration. anemia (7.4) + prolonged PT APTT (19.

tenderness.After 1 hour resuscitation • GC : moderate. contraction weak Abdomen • Fundal high 1 finger under umbilical • Not appears active bleeding (+) • Blood came out of the portio (+) Gen 35 . compos mentis • BP : 100/70 mmHg • HR : 92 x/’ GC/VS • RR : 20x/’ • T : 36.3°C • Eyes CA (+/+) SI (-/-) • Souple.

8 45.2) CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY .6) + prolonged PT & APTT (19. 36 Diagnosis: Uterine Atonia. early post partum haemorrhage ec post vaginal repair ec vaginal laceration + anemia (7. resolved hypovolemic shock.

• Atonia procedure • Oxytocin & methergin drip in 500 cc RL • Misoprostol 5 tablets 200mcg each (supp) • Installation of uterine & vagina tampon • Proposed an operative measure. B-Lynch Suture to Hysterectomy Therapy: • Communication. information and education to family • informed consent • Patient transferred to ER operation room • Preparation of Operative action CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 37 .

Abdominal wall was sutured layer by layer until cutis 6.Uterus seen as high as umbilicus. contraction (-) .DURANTE OP Hysterectomy 1.Diagnosed uterine atony . identification and exploration : .Decided to perform supracervical hysterectomy 2. Bleeding control  bleeding (-) 4. After peritoneum parietale was opened. bleeding + 3000 ml . Abdominal cavum washed with normal saline 3. Operation finished.Right and left ovary and fallopian tube in normal range . Abdominal drain was inserted 5.

Total transfussion Durante OP ICU post operation Input : Input :  2 FFP  2 WB  6 PRC  11 FFP  11 TC Output : 3200 cc  13 PRC  Bleeding : 3000 cc  Urine : 200 cc .

89 .00 PM) PT 16.6 Hb 4.5 APTT 25 Ht 15 AL 12.Laboratorium  5/1/2018 ( 06.15 PM)  5/1/2018 ( 09.4 AT 95 AE 1.

Laboratorium  Ro thorax (5/1/2018) :  6/1/2018 ( 12.1 Na/K/Cl/Ca = 130/5.4 Ht 14 AL 11.89 .56 GDS 130 Albumin 2.46 AM)  Pulmonal oedem Hb 4.1 AT 67 AE 1.2/105/0.

3 mmHg  pO2 160.6 mmol/ L  Total CO2 12.20 mmol/ L .5 mmHg  HCO3 11.6 %  Lactat artery 14.455  BE -12.AGD  pH 7.6 mmol/ L  pCO2 16.1 mmol/ L  O2 saturation 99.

9 Na/K/Cl/Ca = APTT 29.Laboratory  7/1/2018 ( 10.08 INR 1.73 Ur 78 PT 18.8/106/1.8 AE 2.1 SGOT 2456 Ht 22 SGPT 11723 AL 12.8 134/3.2 AT 63 Cr 1.730 .16 PM) GDS 112 Hb 7.

11 .2 Cl 106 Ca 1.6 AT 79 AE 3.3 Ht 33 AL 10.95 Na 135 K 3.Laboratory  8/1/2018 ( 4.41 AM) Hb 10.

resolved hypovolemic shock.i uterine atoni. pulmonary oedem. post vaginal repair ec early post partum haemorrhage ec vaginal laceration + Trombositopenia (79) + Hypoalbumine (2.Diagnosis SIRS.8 Ur 78) + transamination enzyme elevated (SGOT 2456 SGPT 1723) CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 45 . post ICU: supracervical hysterectomy b.7) + renal insufisiency( Cr 1.

Discussion: Etiology Uterine Atony for this patient Uterine Atony management for this patient 46 .

POST PARTUM HEMORRHAGE DEFINITION  Blood loss > 500 mL on vaginal delivery  Blood loss > 1000 mL on caesarian section Definisi Fungsional  Potensial blood loss causing hemodynamic instability INCIDENT  approximately 5% from all deliveries .

residual tissue/blood clot Trauma . POST PARTUM HEMORRHAGE Etiology of Postpartum Hemorrhage Tonus . uterine atonia Tissue . laceration. coagulophaty . rupture.inversion Thrombin .

ITP) . mainly if undetected Fetal intrauterine death Plasenta previa Gestational Hipertension with proteinuria Excess tense of the uterine ( gemelli. polihidramnion) Bleeding disorder before pregnancy (ex. POST PARTUM HEMORRHAGE Risk Factors of PPH – Antepartum History of APH or manual plasenta Solusio plasenta.

DIC) . HELLP. POST PARTUM HEMORRHAGE Risk Factors of PPH – Intrapartum Operative Delivery – caesarian section or assisted vaginal delivery Prolonged delivery Precipitous delivery Induced labor or augmentation Chorioamnionitis Shoulder dystocia Acquired coagulophaty (ex.

DIC) . Post partum hemorrhage Risk Factors of PPH – Postpartum Laceration or episiotomy Plasenta retention /abnormal plasenta Uterine rupture Uterine inversion Acquired coagulophaty (ex.

KONFERENSI KLINIK OBSTETRI GINEKOLOGI 52 .

Procedure Therapy MECHANIC MEDICAL THERAPY = OPERATIVE • Massage UTEROTONIC CONSERVATIVE RADICAL • Compression DRUGS internal external • Oxytocin Aorta • Ergometrin • Arterial Hysterectomy • Tamponade • Prostaglandin Ligation WHO Guidelines. 2009 .

 Preliminary treatment of uterine atony was inadequate. birth attendant only performed IV line installation with uterotonic and uterine massage. KONFERENSI KLINIK OBSTETRI GINEKOLOGI 54 . hypovolemic shock grade IV ec early postpartum hemorrhage ec atonia uteri occured. Delayed transfer to an adequate health facility occured.  In the event of pre-referral uterine atony. CASE ANALYSIS  In this patient.

due to massive bleeding. without knowing the source of bleeding  Reporter agreed to do supracervical hysterectomy because accelerate operation time due to deterioting patient condition KONFERENSI KLINIK OBSTETRI GINEKOLOGI 55 . CASE ANALYSIS  In this patient. immediately performed hysterectomy without catheter condom installation.

Social Obstretic 3 Delays Model  Delay in decision to seek care due to poor understanding of complications and risk factors in pregnancy  Delay in reaching care due to distance to health centres and hospitals and availability of transportation  Delay in receiving adequate health care due to poor facilities and lack of medical supplies and Inadequately trained and poorly motivated medical staff KONFERENSI KLINIK OBSTETRI GINEKOLOGI 56 .

CONCLUSION Post partum hemorrhage due to uterine atony can caused blood loss > 40% with risk of hypovolemic shock to maternal mortality if not treated properly KONFERENSI KLINIK OBSTETRI GINEKOLOGI 57 .

Death report  Name/ Parity : Ny. loss of conciousness. eclampsia on secundigravide 7months gestational age  Last Diagnose : Apneu. eclampsia on secundigravide 7 months gestational age  Cause of death : eclampsia  Date admitted to ward : January 7th 2018 / 1.50 PM  Date of death : January 7th 2018 / 2.SGY / G2P1A0  Age : 31 y.05 PM CLINICAL CONFERENCE OBSTETRIC AND GYNECOLOGY 58 .o  First Diagnose : Apneu. loss of consciousness.

KONFERENSI KLINIK OBSTETRI DAN GINEKOLOGI 59 .