Case No

IDENTITY
Patient Husband
Name : Mrs. A Name : Mr. A
Age : 41 years old Age : 44 years old
Education : Senior High School Education : Senior High School
Occupation : Housewife Occupation : Entrepeneur
Address : Sijunjung Address : Sijunjung
MR : 01 11 60 10
Admision date : 13-10-2021
 Mrs. A, 41 th, MR 01 11 60 10
Admission
Date Origin Posts Preparation operation Diagnosis Action

07/10/2021 Origin : PONEK Consultation In PONEK: - G3P2A0H2 35-36 weeks of GA stabilization

12.10 pm preterm pregnancy + previous (expectative)
Referred from : covid team consultation CS 2x + placenta previa totalis Maturation of lungs
DPJP : - Sijunjung Hospital Currently the patient does not meet the suspect accreta + moderate Elective CS
criteria for covid 19
VB,HAR care in green zone anemia
Diagnosis:
G3P2A0H2 35-36 weeks of preterm Consult to Perinatology
Agree to assist delivery and perform
pregnancy + placenta previa totalis + resuscitation according to baby condition at
previous CS 2x birth

Internist Consult
A/
moderate anemia ec acute bleeding
HAP ec placenta previa totalis +
hypoalbumin

currently to perform procedures under

general anesthesia with the risk of surgery:
cardiovaCSular : lee revised CSore very low
risk 0.4%
pulmonary: light
Metabolic: light
hemostasis: stable
PRC transfusion 2 units per day, target Hb >=
10 g/d
care with HOM
 Data Clinical Inspection Physical Inspection Support
Patient was referred from Sijunjung Hospital with diagnosis GA Cons BP HR RR T SpO2 ultrasound
G3P2A0H2 35-36 weeks of preterm pregnancy + placenta previa Mdt CM 110/80 80 26 36,7 99% with nasal Gravid 35-36 weeks according to
totalis + previous CS 2x biometry
• Feeling of Pelvic pain referred to the groin (-) TB : 155cm placenta implant anterior expand
• Bloody show from the vagina (-) BB before pregnant : 63 kg cover up OUI
• Fluid leakage from the vagina (-) BB after pregnant : 73 kg
• Massive bleeding from vagina (-) BMI : 21.66 kg/m2 (normoweight) CTG category 1
•history of trauma (-) LILA : 25 cm
•child motion felt since 8 months ago Lab 07/10/2021
•Hpht 5-02-2021 TP 12-11-2021 Eye : conjunctiva anemic +/+, CSlera jaundice -/- Hb : 9.0
•Patient ANC History to Midwife 6x age2, 3, 4, 5, 6, 7 months of Abdomen: Leuko : 17,430
pregnancy. Controlto SpOG 2x, age pregnancy 8.9 month. I : Tlook bulge as pregnancy preterm, hyperpigmented Trombo : 379,000
•Menarch history at age 13 years old, menstrual cycle 28-30 linea median, strie gravidarum (+), cigarrik (+) Ht :28
days, duration 4-5 days, tamponade change 2-3 times a day, no pfannenstiel Count type 0/0/81/14/5/-
pain during menstruation . The menstruation cycle regular in Q: Alb 3.1
last 3 months LI: palpable fundus 4 fingers below the xiphoid proc, Glo 3.6
•History of contraveption : (-) palpable large nodular soft mass Pt 9.8
•cough (-) fever (-) shortness of breath (-) travel history and LII : Tetouch prisoner biggest on the right and palpable apt 21.0
contact with COVID-19 patients for the last 14 days (-) prisoner smallest on the left Sgot 15
•Previous illness history : There were no DM, hypertension, LIII: palpable hard, unfixed mass Sgpt 8
heart,liver, kidney disease LIV : No done Ur 4
TFU : 31 TBJ 2790 gr cm His (-) Cr 0.5
•His Pregnancy/abortion/partum3/0/2 FHR : 140-155x/I HbsAg nr
•1. 2011/3000 grams/Male/CS/Sp.OG/alive HIV nr
•2. 2015/3100 gram/Male/CS/ Sp. OG/ alive genitals Na 137
•3. Now I : V/U calm, PPV (+) K 3.8
VT : no done Cl 109
 Date Diagnose Outcome
/operation
13/10/2021 Pre Op : Baby female was born by CCS + Fimbrectomy total at
G3P2A0H2 35-36 weeks of preterm pregnancy + previous CS 2x + placenta previa 12.15
Operation: totalis suspect accreta + moderate anemia BW : 2550 gram
BL : 47 cm
12.10 Fetal alive, single intrauterine head presentation presentation A/S : 8/9
DPJP : Plan : the placenta was born with a slight pull, complete,
HB,HAR GA Repair (Expectative) dichorion diamniotic, 600 gram in weight.
Elective CS
Post Op :
Instrucions : P3A0L3 Post CCS oi placenta previa totalis suspect
accreta + previous CS 2x + moderate anemia
•Control GA, VS, PPV, FHR, inpartu sign improvement
•Informed consent Mother and baby were in care
•IVFD RL 28 dpm
•inj. Dexamethasone 2 x 6 mg (2x24 hours) Instructions :
•inj. Transamin 3 x 500 mg •Control GA, VS, PPV
•inj. Vitamin K 3 x 10 mg •IVFD RL + oxytocin 10 IUs: meter 0.2 mg 28 tpm
•Mefenamic acid 3 x 500 mg •inj. Ceftriaxon 2 x 1 g iv
•Crossmatch 4 units of PRC, Transfusion 2 units/day to Hb >= 10 g/dl •Pronalgess supp II if needed
•PRC transfusion 4 units
•20% albumin transfusion •Lab check 6 hours post op
•CTG/6 hours
Proses
G3P2A0H2 35-36 weeks of preterm pregnancy + previous CS 2x + placenta
previa totalis suspect accreta + moderate anemia --> General improvement -->
CCS + Fimbrectomy bilateral
Admission letter
ultrasound
 USG PONEK
• Single live intrauterine fetus, longitudinal position cephalic presentation
• Good fetal movement
• Biometrics :
BPD : 8.92 cm EFW : 2831 grams
AC : 31.59 cm FHR : 132 bpm
FL : 7.13 cm SDAU : 2.26
AFI : 7.23 cm

• Placenta embedded in the anterior body extends to cover the OUI, maturation grade II-III
• Halozone (-) bridging vessel (+) placental buldging (-) bladder wall interruption (-)

Impression :
Gravid 35-36 weeks according to biometry
Fetus alive single intrauterine, head presentation
Placenta previa totalist susp acreta
Baseline : 145 bpm
Variability : 5-15 bpm
Acceleration :(+)
Deceleration :(-)
Fetal movement :(+)
Contractions : (-)
Impression : Category I
Laboratory
Consult Anethesiologist
ASA II
Agree to operate
Covid team consul
• Currently the patient does not
meet the criteria for covid 19
• care in the green zone
• therapy according to obstetrician
Internist Consult
A/
• moderate anemia ec acute bleeding
• HAP ec placenta previa totalis + hypoalbumin

currently to perform procedures under general anesthesia with the

risk of surgery:
cardiovaCSular : lee revised CSore very low risk 0.4%
pulmonary: light
Metabolic: light
hemostasis: stable
PRC transfusion 2 units per day, target Hb >= 10 g/d
care with HOM
Consult to Perinatology
• Agree to assist delivery and
perform resuscitation according
to baby condition at birth
Accreta consult

Agree to join op
Follow up 08/10/2021, at 07.30
Historyis child movement (+) ppv (-)
Vital Signs MY: currently
TD: 110/80
ND: 88 x/i
NF : 20x/i
T : 36.7

Obstetric Examination Abd : his (-) FHR 140-150 x/m

Gene : I : v/u calm, PPV (-)

Diagnosisis G3P2A0H2 35-36 weeks of preterm pregnancy + previous CS 2x + placenta previa totalis suspect accreta + moderate
anemia

Attitude Control GA, VS, PPV, FHR

Therapy Control GA, VS, PPV, FHR,inpartu sign
Informed consent
IVFD RL 28 dpm
inj. Dexamethasone 2 x 6 mg (2x24 hours)
inj. Transamine 3 x 500 mg
inj. Vitamin K 3 x 10 mg
Sour mefenamate 3 x 500 mg
Transfusion PRC 2 units
CTG/6 hours
Follow up 09/10/2021, at 07.30
Historyis child movement (+) ppv (-)
Vital Signs MY: currently
TD: 120/80
ND: 88 x/i
NF : 20x/i
T : 36.7

Inspection Abd : his (-) FHR 147-155 x/m

Gene : I : v/u calm, PPV (-)

Hb: 9.0
albumin : 3.1

Diagnosisis G3P2A0H2 35-36 weeks of preterm pregnancy + previous CS 2x + placenta previa totalis suspect accreta + moderate
anemia

Attitude Control GA, VS, PPV, FHR

Therapy Control GA, VS, PPV, FHR,inpartu sign
Informed consent
IVFD RL 28 dpm
inj. Transamine 3 x 500 mg
inj. Vitamin K 3 x 10 mg
Sour mefenamate 3 x 500 mg
PRC Transfusion 1 for it
CTG/6 hours
Follow up 10/10/2021, at 07.30
Historyis child movement (+) ppv (-)
Vital Signs MY: currently
TD: 120/80
ND: 88 x/i
NF : 20x/i
T : 36.7

Inspection Abd : his (-) FHR 147-155 x/m

Gene : I : v/u calm, PPV (-)

Hb: 9.7
albumin : 3.1

Diagnosisis G3P2A0H2 35-36 weeks of preterm pregnancy + previous CS 2x + placenta previa totalis suspect accreta + moderate
anemia in repair

Attitude Control GA, VS, PPV, FHR

Therapy Control GA, VS, PPV, FHR,inpartu sign
Informed consent
IVFD RL 28 dpm
inj. Transamine 3 x 500 mg
inj. Vitamin K 3 x 10 mg
Sour mefenamate 3 x 500 mg
PRC Transfusion 1 for it
CTG/6 hours
Follow up 11/10/2021, at 07.30
Historyis child movement (+) ppv (-)
Vital Signs MY: currently
TD: 110/80
ND: 84 x/i
NF : 20x/i
T : 36.7

Inspection Abd : his (-) FHR 147-155 x/m

Gene : I : v/u calm, PPV (-)

Hb: 11,1
albumin : 3.0

Diagnosisis G3P2A0H2 35-36 weeks of preterm pregnancy + previous CS 2x + placenta previa totalis suspect accreta + moderate
anemia in repair

Attitude Control GA, VS, PPV, FHR

Therapy Control GA, VS, PPV, FHR,inpartu sign
Informed consent
IVFD RL 28 dpm
inj. Transamine 3 x 500 mg
inj. Vitamin K 3 x 10 mg
Sour mefenamate 3 x 500 mg
CTG/6 hours
Follow up 12/10/2021, at 07.30
Historyis child movement (+) ppv (-)
Vital Signs MY: currently
TD: 110/70
ND: 80 x/i
NF : 20x/i
T : 36.7

Inspection Abd : his (-) FHR 147-155 x/m

Gene : I : v/u calm, PPV (-)

Hb: 11.2
albumin : 3.0

Diagnosisis G3P2A0H2 35-36 weeks of preterm pregnancy + previous CS 2x + placenta previa totalis suspect accreta + moderate
anemia in repair

Attitude Control GA, VS, PPV, FHR

Therapy Control GA, VS, PPV, FHR,inpartu sign
Informed consent
IVFD RL 28 dpm
inj. Transamine 3 x 500 mg
inj. Vitamin K 3 x 10 mg
Sour mefenamate 3 x 500 mg
CTG/6 hours
Plan CS tomorrow
Operation report
• Patient on supine position under spinal
anaesthesia
• Antiseptic and septic procedure was performed
• Installed duk sterile
• Done incision abdomen by line median, abdomen
di open until penetrate peritoneum, incision
abdomen 2 cm from symphysis 1 cm from
umbilicus
• Look omentum stick with intestines, done adhesion
• Done incision uterus by corporal, female baby , BB
2550 gram, PB 47 cm, W/S 8/9
• Double layer closure then performed,
fimbriektomy bilateral was performed
• Abdomen was closed layer by layer
• Skin closed by subcuticular closure
• Bleeding during operation approximately 250 cc
Photo baby
 Follow Up 2 hours Post op

S Post operative pain (+) Vaginal bleeding (-) P • Control GA, VS, UC, VB
• IVFD RL + oxytocin 10 IU + methylergometrine 0.2
mg  28 gtt
• Ceftriaxone inj 2 x 1 gram IV
• Pronalges supp II if needed
O GA Cons BP HR RR T • Post operative laboratory check
Mdt CM 110/70 81 20 36,6C

Abd : Operation wound closed by verband. Uterine fundal palpated 2 fingers

below umbilical, uterine contraction was good
Genitalia : V/U normal, Vaginal bleeding (-)

A P3A0L3 Post CCS oi placenta previa totalis suspect accreta + previous CS 2x +

moderate anemia improvement
Mother and baby were in care
curve luvchenko
BALLARDS CSORE: 30. 36 Weeks
Laboratory post OP
Thank you