case report no.

30

Name : Mrs. N (30 years old)

MR No. : 910524
Date

: April 16th 2015

Address : banuaran

Anamnesis :

A 30 years old patient was

admitted to the emergency
Room of Dr. M. Djamil Central
General Hospital on April 16th
2015 at 03.00 am.with chief
complain Feeling of pain from
waist to groin since 3 hour ago

Present Illness History :

Feeling of pain from waist to groin since 3

hour ago
Bloody show from the vagina (+) since 3
hour ago
Fluid leakage from the vagina (-)
No massive vaginal bleeding.
Amenorrhea since 9 months ago.
First date of last menstrual period was
forgotten (midle of july 2014)
Estimation date of delivery cant
determined( late april 2015)
Fetal movement was felt since 5 months

Prenatal care to public health 1 times (at 3

month of pregnancy )
Menstruation History : menarche at 13 years old,
irregular cycle, with the amount of 2-3 times pad
change/day without menstrual pain.
Previous Illness History :
There wasnt previous history of heart, lung,

liver, kidney, DM, hypertension, and alergic

history.
Family Illness History :
There wasnt history of hereditary disease,

contagious and physicological illness in the

family.

Marriage history : once in 2004

History of pregnancy/abortion/delivery : 3/0/2

2005, female, 3000 gr, term pregnancy,SC

oi arrest of decent,at private hospital,alive
2. 2010, male, 3100gr, term pregnancy,SC oi
history of previous cs , at at private
hospital,alive
3. Present pregnancy
.History of family planning : (-)
.History of immunization : (-)
1.

Physical Examination :
GA

Cons BP PR RR
T Body Weight Body
Height
Mdt CMC 110/70 88
22 36,4
50 kg
150 cm
LILA 23 cm, BMI 22,22 ( normoweight )
Eyes
: Conjunctiva wasnt anemic, Sclera
wasnt icteric
Neck
: JVP 5-2 cmH2O, tyroid gland no
enlargement
Chest : H/L normal
Abdoment : OR
Genitalia : OR
Extremity : Edema -/-, Physiological Reflex +/+,

 Obstetric Record

Abdoment

:
I : Enlarge accordance with
term
pregnancy, cicatrix (+)
previous CS
Pfanennsteil
Pa :L1: Uterine fundal was palpable 3 fingers
below proc xyphoideus, A large
soft nodular mass
was palpable
L2 : A hard and resistance structure was
felt on the
left side
Numerous small, irregular were felt on
the right
side

L3 : A round hard mass was

palpated, not fixed
L4 : convergen
Uterine Fundal Height:31 cm
Estimated fetal body weight :
2790 gr
Uterine contraction : 23x/30/m
Pe : Tympani
Au : Peristaltic sound was

Genitalia : I V/U normal

Vagina : 2-3 cm
amnionic sac (+)
head was palpable transver sagitalis
suture at HI-II

Laboratory :
Hb
: 10,3 gr%
Leucocyte : 8000/mm
Hematocrit: 32 %
Trombocyte: 260.000/mm3

Diagnose :
G3P2A0L2 first stage laten phase + twice
previous CS
Fetal alive, singleton, intra uterine, head
presentation transver sagitalis suture at HI-II
Management :
Control GA, VS, FHS, Uterine Contraction
Informed concent
AB (skin test)
Report to OR, anesthesiologist
Plan :
cito CS

At 04.00 am : CCS was perfomed

A male baby was born by CCS with 2800

gram in weight, 48 cm in height, Apgar
score : 7/8. Placenta was born with a light
traction on umibilical cord, complete, 1 piece.
Size was 17 x 17 x 3 cm, weight 500 gram.
Umbilical cord was 60 cm in length with
paracentral insertion.
Bleeding during operation 250 cc
D/
P3A0L3 post CCS on indication twice
Previous CS
Mother Child were good
S/ Observe after operation

Post op laboratory
Laboratory :
Hb
: 11,9 gr%
Leucocyte : 12300/mm
Hematocrit: 37%
Trombocyte: 254.000/mm3

Thank You