DUTY REPORT

Monday, December 04th 2023

Supervisor:
Dr. dr. M. Oky Prabudi, M.Ked(OG), Sp.OG, Subsp. F.E.R

Residents:
dr. Roni Batara Lubis
dr. Wijitha Varenni
dr. Derissa Khairina Khaidirman
dr. Zulfindra Arifin
dr. Rahmi Permata Sury Lubis

Obstetrics and Gynecology Department

Faculty of Medicine Universitas Sumatera Utara
Prof. dr. CPL General Hospital
2023
NEW PATIENT : 1 PATIENT
1. Mrs. B, 36 y.o, G3P2001
Diagnosis : Anemia (6.0 gr/dL) + PASD (PAS 2) + Previous C-Section 2 times + MG + IUP (36-37) wga
+ Breech Presentation + Live Fetus
Supervisor : Dr. dr. M. Oky Prabudi, M.Ked(OG), Sp.OG, Subsp. F.E.R
Planning : General Condition Improvement
Monitoring vital sign, vaginal bleeding, signs of labor and fetal wellbeing
Blood transfusion 7 packs of PRC (2 packs/day)
Referred to Fetomaternal Consultant (Accreta Team)  USG Confirmation

ICD X : O43.21 Placenta Accreta

D64. 9 for Anemia
Thank You
PATIENT 1
Mrs. B, 36 y.o, G3P2001, Karonese, Moslem, Diploma, Housewife, married to Mr. C, 29 y.o, Karonese,
Moslem, Senior High School, Farmer. The patient was came to Emergency Room of CPL USU Hospital on
December 4th 2023 at 00.39 am with :

Cc : History of Vaginal Bleeding

E : This has been experienced by the patient since 1 day ago before admitted to hospital, with volume
5 - 6 changing pads / day, blood clot (+), history of vaginal bleeding (+) since 1 week ago. History of labor
contraction (-). History of amniotic leakage (-). History of blood slime (-). History of abdominal pain (-),
History of vaginal discharge (-). History of fever, shortness of breath and cough (-). Defecation and
Micturition within normal limit. Patient was referred from other clinic with diagnosis Susp. Placenta Accreta
+ Previous C-Section 2 times.
History of previous illness :-
History of Medication :-
History of Surgery : C-Section 2 times (2012, 2019)
LMP : ?/4/2023
EDD : ?/1/2024
ANC : Midwife 3x, Obstetrician 1x

History Of Pregnancy :
1. Male, Aterm, 4500 gram, C-Section d/t Macrosomia, Obstetrician, Hospital, 2012, healthy.
2. Female, Aterm, 3100 gram, C-Section d/t Previous C-Section 1x, Obstetrician, Hospital, 2019, Deceased.
3. Current Pregnancy.
Vital Signs
Cons : CM Anemic : (+/+)
BP : 143/77 mmHg Icteric : (-)
Pulse : 102 x/min Cyanosis : (-)
RR : 20 x/min Dypsnoe : (-)
Temp : 36,7⁰C Edema : (-)

General state : Moderate BW : 109 kg

Nutritional state : Obese BH : 156 cm
Illness State : Moderate UAC : 40 cm

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
Obstetric Examination
Abdomen : Asymmetrically enlarged
Fundal height : 3 fingers below proc. Xyphoideus (32 cm)
Tension part : Right
Lower part : Breech
Uterine contraction : (-)
FM : (+)
FHR : 135 bpm

Vaginal Examination
Inspeculo: Smooth portio, erosion (-), blood clot (+) cleaned  seems not active bleeding

Vaginal Toucher: Was Not Performed

 CTG
December 04th 2023

Baseline : 150 bpm

Variability : 5-25 bpm
Acceleration : (+)
Deceleration : (-)
Uterine Contraction : (-)

Conclusion : Category 1
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
Ultrasonography Examination
December 4th 2023
 Ultrasonography Examination
December 5th 2023
- Single fetus, Intrauterine, Live Fetus
- FM (+), FHR (+) 158 bpm
- BPD : 91.74 mm
- HC : 328.65 mm PAS Score :
- Loss of clear zone (+)
AC : 323.05 mm
- Lacunae (+)
FL : 71.18 mm
- Uterovesical Hypervascularity (+)
EFW : 2,983 gr
Bladder Wall Interruption/Bridging vessel (+)
- S/D Ratio : 2.17
- Placenta covers entire OUI
- Cervical Length : 2.50 cm

Conclusion:
PASD (PAS 2) + IUP (36-37) wga + Breech Presentation + Live Fetus
 Laboratory Findings
December 5th 2023
• Hb 6.0 N: 12-14 gr/dL
:
• Leukocyte 14.200 N: 4.000-11.000/uL
:
• Hematocrite 18.2 N: 36,0-42,0/%
:
• Platelet 280.000 N: 150.000-400.000/uL
:
• MCV 82.7 N: 82 – 92 fL
:
• MCH 27.3 N: 27 – 33.7 pg
:
• MCHC 33 N: 32 – 36 %
:
• Neutrofil 70.8 N: 50.00 – 70.00%
:
• Limfosit 25.2 N: 20.00 – 40.00%
:
 Laboratory Findings
December, 5th 2023
• PT : 15 C: 15.4”
• APTT : 33.6 C: 34”
• INR : 1.04
• TT : 19.20 C: 21.4”
• HbsAg : Non-Reactive N: Non-Reactive
• Anti HIV : Non-Reactive N: Non-Reactive
Diagnosis:
Anemia (6.0 gr/dL) + PASD (PAS 2) + Previous C-Section 2 times + MG + IUP (36-37) wga + Breech Presentation + Live Fetus

Therapy:
- IVFD RL 1000 ml continue with 20 gtt/I
- O2 NC 4L/i
- Urinary Catheter Insertion
- Hystolan 2x1/2 tab
- Inj. Tranexamic acid 500 mg / 8 hrs

Planning:
General Condition Improvement
Monitoring vital sign, vaginal bleeding, sign of labor and fetal wellbeing
Blood transfusion 7 packs PRC (2 packs/day)
Referred to Fetomaternal Consultant (Accreta Team)  USG Confirmation

Reported to supervisor on duty Dr. dr. M. Oky Prabudi, M.Ked(OG), Sp.OG, Subsp. F.E.R  Approved
 FOLLOW UP
TIME SENS BP HR RR T V/B FHR NOTES
00.00 CM 145/78 mmHg 102 bpm 20 rpm 36,5˚C (-) 135 bpm
01.00 CM 135/89 mmHg 99 bpm 20 rpm 36,5˚C (-) 145 bpm
02.00 CM 125/77 mmHg 98 bpm 20 rpm 36,5˚C (-) 148 bpm
03.00 CM 136/78 mmHg 100 bpm 20 rpm 36,5˚C (-) 131 bpm
04.00 CM 112/77 mmHg 89 bpm 20 rpm 36,5˚C (-) 122 bpm
05.00 CM 133/89 mmHg 81 bpm 20 rpm 36,5˚C (-) 142 bpm
06.00 CM 115/75 mmHg 93 bpm 20 rpm 36,5˚C (-) 139 bpm
07.00 CM 100/70 mmHg 105 bpm 20 rpm 36,5˚C (-) 156 bpm
07.30 CM 95/70 mmHg 117 bpm 22 rpm 36,5˚C (+) 160 bpm Profuse bleeding

08.00 Confused 88/60 mmHg 119 bpm 30 rpm 30,1˚C (+) 175 bpm - Double IV Line
- Bolus Ringer Lactate 2 flash
- Bolus HES 1 flash
- Blood Transfusion 1 pack of PRC
- O2 via NRM 15 L per minutes
- Consult to Anesthesiologist
- Report to Spv Accreta Team
with advice Stabilization of the
patient, blood transfusion
 FOLLOW UP
TIME SENS BP HR RR T V/B FHR NOTES
08.30 Somnolen 78/56 mmHg 132 bpm 33 rpm 27,7˚C (+) 110 bpm
09.00 Comatose undetected not 40 rpm 26,7˚C (+) 50 bpm - Perform CPR 5 cycles
- Epinephrine 7 ampules
palpable - Sulfas Atrophine 2 ampules
09.15 Comatose undetected not 40 rpm 26,7˚C (+) undetected USG: Fetal heart rate not
detected
palpable
09.38 Comatose undetected not undetected 26,7˚C (+) undetected Patient was sentenced
deceased at 09.38 am in
palpable front of patient’s family and
Nurse
Thank You