Case Report Session

Post-term Pregnancy
Written by : Yetti Aneu Rosdiani 12100116184
Supervisor by : dr. Mutawakkil J Paransa., Sp.OG

Faculty of Medicine
Bandung Islamic University RSUD Syamsudin, SH
September, 2017
 Introduction
The international denition of
prolonged pregnancy, endorsed by
the American College of
Obstetricians and Gynecologists
(2004), is 42 completed weeks (294
days) or more from the rst day of
the last menstrual period.
The incidence between 4% and
14%. The average is about 10%.
Subsequent postterm birth
increased from 10 to 27 percent if
the rst birth was postterm.

Prepregnancy body mass index (BMI)

25 and nulliparity Rate of cesarean delivery for
prior postterm birth, socioeconomic dystocia and fetal distress
class, and age
 Patients Identity
Husbands Identity
Name : Mrs. SH Name : Mr. RA
Date of Birth/ Age : April 4th 1989/28 years old Age : 31 years old
Address : Cisarua 002/002 Kec. Sukaraja Marital Status : Married
Marital Status : Married Education : Senior High
School
Education : Senior High School
Occupation : Wiraswasta
Occupation : House Wife
Date of Visit : September 12th 2017
History Taking
Patient G1P0A0 came to
Patient admitted that
Emergency Room RSUD R.
her pregnancy was 3
Syamsudin refered by Limbangan
week more than doctors
Primary Health Care that she was
expected date.
in 43-44 weeks of pregnancy.

There is no contraction, no
Fetal movement are
fluid, no bloody show felt out
still felt by the mother.
from vagina.
 Past Illness History Family Disease History

History of hypertension : denied History of hypertension : denied

History of kidney disease : denied History of kidney disease : denied
History of diabetes melitus: denied History of diabetes mellitus: denied
History of asthma : denied
History of allergy : denied
History of surgery : denied
Menstruation History
LMP : November10th 2016
Estimated delivery : August 17th 2017
Cycle : regular, 28 day
Duration : 7 day
Menarche : 12 years old
Contraception History
Never use Contraception
Obstetrical History
No Age Sex Gestational Labor Type Birth Live/die
Age Weight
1 This Pregnancy

ANC: Patient did 6x ANC at Midwife and Primary Health Care

Physical Examination
Present Status
General examination : Moderately ill
Consciousness : Composmentis
Vital signs
Blood Pressure : 110/70 mmHg
Pulse Rate : 80x/ minute
Respiration Rate : 20x/ minute
Temperature : 36,3oC
Body Weight : 105 kg
Body Height : 154 cm
BMI : 44,27 (Obesity)
General Examination
Head
Head : Normocephal
Eye : Conjunctiva Anemic (-/-),
Sclera : Icteric (-/-)
Nose : Deformity (-), secrete ()
Ear : Deformity (-), secrete ()
Mouth : Wet oral mucous
Neck
Neck : Lymph node enlargement ()
Cor
COR : regular 1st and 2nd heart sounds, Murmur (-), Gallop ()
Pulmo
Inspection : symmetric chest expansion in breathing
Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, rhonchi -/-, wheezing -/-
Abdomen
Inspection : Concave, Striae gravidarum (+)
Palpation : Soft, Tenderness (-)
Percusion : Tymphanic
Auscultation : Bowel sound (+)
Extremity
Warm, CRT <2 second
 Obstetric examination
Inspection Johnson Formula :
Convex, striae gravidarium (+), linea nigra (+) - Estimated Fetal Weight :
(38-13)x155= 3875 gram
Palpation
Leopold I : Fundal Height 39 cm . Soft and not fully
rounded part was palpated.
Leopold II : Wide and flat part was palpated in the right
side.
Leopold III : Hard and round part was palpated
Leopold IV : Convergent
HIS : (-)
Auscultation
FHR : 142x/m, regular
Gynecological Examination
Vaginal Toucher
Vulvo/ Vagina : No Abnormalities
Portio : thick, soft
Cervical dilatation :-
Amnion sac : not identified
Pelvic

Pelvic examination : normally

 Bishop Score 5.

Factor Score
0 1 2 3
Cervix Dilatation (cm) 0 1-2 3-4 5-6
Cervix Flattening (%) 0-30 40-50 60-70 80
Station -3 -2 -1 atau 0 +1 atau +2
Cervix Consistensy Kaku Medium Soft -
Cervix Position Posterior Center Anterior
Laboratory Examination

Haematology
Hb : 12.9 g/dL MCV : 85 fL
Leucocyte : 12.100/mikroliter MCH : 29 pg
Hematocrite : 37 % MCHC : 35 g/dL
Trombocyte : 297.000 juta/mikroliter
Urinalisis
Color : Yellow Glukosa : Negatif
Protein : Negatif Bilirubin : Negatif
Keton : Negatif Nitrit : Negatif
USG

NST
Baseline: 130 bpm
Variable: Normal
Acceleration: (+) 2 times in
20 minute
Deceleration : (-)
Fetal movement : (+)
His : -
Reactive
WORKING DIAGNOSIS

G1P0A0, 28Th, gravid 43-44 weeks, with

single live intrauterine fetus with cephalic
presentation.
Management

R/ termination of pregnancy
Informed consent
 Failure to drip Patient
VK Report going to SC

Come to VK VT : Portio: ; 09.00, 13.00,

RSUD Syamsudin thick, soft, 14.30
21.30
DJJ :150x/m dilatation 2cm,
His (-), fetal membrane
VT: Portio: ; (+) VT : Portio: ;
VT: Portio: bud, thick, soft,
fetal Hodge 1 thick, soft,
dilatation 1-2cm, dilatation 2-3cm,
membrane(+), fetal membrane Oxytocin drip 5
convergen (+) unite 500 cc RL fetal membrane
Hodge 1 (20-60tpm) (+)
Misoprostol per Misoprostol Hodge 1
forniks 50mcg tab (ke2) 22.30 DJJ 146c/m
14-09-2017,
06.00
Drip Oxytocin
13-09-2017, 20-60tpm
16.30
(14.00)
 Operation Report
On Thursday August 13th 2017 (16.45 WIB operation begin)
Anesthesia Type : Spinal anesthesia
Diagnoses Pre Surgery: G1P0A0 gravid 43-44week with indication failure
induction, with serotinous
Durante operational after the baby was delivered at 16.53 WIB, placenta was
delivered at 17.05 WIB. (Baby : 4540 gram, 54 CM, AS 9/10 )
Operation finished at 17.30 WIB
Diagnoses Post Surgery : P1A0 Post SC indication failure induction
Baby Report

No Time of Birth Sex Weight Length Apgar Score

1 September 13 2017 Boy 4540 gram 54 cm 9/10

16.53
Management Post Op
- Fluid therapy : IVFD RL 20 tpm
- Antibiotic
- Check HB post operation, transfuse if HB <8gr/dL
- Bed rest 10 hours
Final Diagnosis
Mrs. SH, 28 th, P1A0, Post SC with indication
failure induction, with serotinous.
 Follow up 14-16 September
S : Pain on the operation site S : Pain on the operation site was
14 September 17

16 September 17
O: GC : Moderate illness , C : CM decreased
Vital sign : O: GC : Mild illness , C : CM
BP : 100/60 mmHg Vital sign :
HR : 80 bpm BP : 110/60 mmHg
RR : 20 bpm HR : 80 bpm
T : 36,3 C RR : 20 bpm
Fundal height : 1 finger below T : 36,0 C
umbilical. contraction hard Fundal height : 2 finger below umbilical.
Surgical wound gauze covered. contraction hard
Mobilitation : (-) Surgical wound good, no infection sign
Lochea Rubra (+) Mobilitation : (+)
Micturition : attached catether Lochea Rubra (+) minimal
A : Mrs SH 28 yo P1A0 post sectio Micturition : spontaneous
caesarea indication failure induction
with serotinous POD1 A : Mrs SH 28 yo P1A0 post sectio
caesarea indication failure induction with
P: Ceftriaxone 2x1gr, Fetic Supp 2 x1, serotinous POD3
Transfusion if Hb <= 8g/dL, Diet High
Protein , gradual mobilization, Wound P: Patient discharged, control after 1
care week to Poly
Prognosis

Quo ad vitam : ad bonam

Quo ad functionam : ad bonam
Quo ad sanationam : ad bonam
CASE ANALYSIS

1. What is Post Term Pregnancy ?

2. How To Diagnosis Post Term Pregnancy ?
3. How To Manage The Case ?
4. How To Follow Up ?
5. What Are The Complications ?
Post Term Pregnancy
The international denition of prolonged pregnancy,
endorsed by the American College of Obstetricians and
Gynecologists (2004), is 42 completed weeks (294 days) or
more from the rst day of the last menstrual period.

The incidence between 4% and 14%. The average is about

10%.
 Risk Factor Etiology

Prepregnancy body mass index Wrong Date LMP

(BMI) 25 (most common)
Nulliparity. Maternal Factor
Previous post-term pregnancies Placental Factor
Hormonal factors (Placental Hereditary
Sulfatase deficiency, Fetal adrenal Congenital Factor
insuficiency or Hypoplasia), and
Genetic predisposition
Diabetic Mellitus
Theory Post term

Progesteron Oxytocin Cortisol

Influence Theory Theory

Uteri
Hereditary
Inervation
Diagnosis
Management
Fetal Surveilance
 Termination of Pregnancy
1. Misoprostol if Bishop score 5
2. Drip oxytocin 5 IU in Dextose 5% for augmentation delivery
3. Assembly Metrolisa if labor not progressing and fetal death
4. Combination.

Sectio cesarean if failure to pervaginam labor or theres indication of maternal or

fetal to finish labor.
And if the baby was suspected macrosomia, the termination of pregnancy by
Section Caesarean.
Complication
Postpartum hemorrhage,

To Mother
Dystocia, and
Maternal infection
Utery Rupture

Risk of placental

To Fetal
insufficiency due to
placental aging
Fetal risks

Antepartum Intrapartum Following birth

Diminished Fetal hypoxia Pneumonitis,

placental function Labor dysfunction atelektasis,
IUGR Meconium pulmonary
Oligohydroamnion aspiration hypertension
Meconium Brith trauma (big Hypoxia.
size baby and non- Respiratory failure
molding head) Hypoglicemia and
Dysmaturity, polycythemia
macrosomia
Follow up

Diet Mobilization Wound Care

High Protein Gradual Cleaned and

mobilization gauze
dressing once
a day
Reference
Dutta D. DC Duttas Textbook of Obstetrics including Perinatology and Contraception. 8th ed.
New Delhi: Jaypee Brothers Medical Publishers (P) LTD; 2013.
Cunningham F, Leveno K, Bloom S, Spong C, Dashe J, Hoffman B, et al. Williams Obstetrics.
24th ed. New York: McGraw-Hill Companies,Inc; 2014.
Saifuddin A, et al. Ilmu Kebidanan: Sarwono Prawirohardjo. Jakarta: PT Bina Pustaka Sarwono
Prawirohardjo. 2014.
M. Galal1, i. SyMOndS2, H. MuRRay3, F. PetRaGlia4, R. SMitH5 Postterm pregnancy, 2012
Practice Guidelines, ACOG Issues Guidelines on Fetal Macrosomia
Clinical formulas, mothers opinion and ultrasound in predicting birth weight Hospital Municipal
Maternidade-Escola Dr. Mrio de Moraes Altenfelder Silva, So Paulo, Brazil, 2008
Pediatric Obesity Maternal body mass index and post-term birth: a systematic review and meta-
analysis N. Heslehurst, R. Vieira, L. Hayes, L. Crowe, D. Jones, S. Robalino, E. Slack and J.
Rankin, July 2016

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