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 .

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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

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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

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PATHOLOGICAL DELIVERY
5 Cases

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A. Premature Rupture of the Membrane : 4 cases
1. Ms .YNT, G1P0A0, 18 yo, 37 wga
dr. Fadli (R3) had assisted spontaneous delivery, 18 Hours
PROM on Primigravide Fullterm Pregnancy

Female baby was born, BW 2800 gr, AS: 7-7-8

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2. Mrs. HST, G1P0A0, 23 y.o, 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, 2350 gram, AS 8-9-10
Ballard score 30 ~ 36 wga

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3. Mrs. MEL, G1P0A0, 17 yo, 37 wga
dr. Tama (R3) had assisted spontaneous delivery + IUD
Insertion 1 day PROM on primigravide fullterm
pregnancy

Duration of labor 9 hours

Female baby was born, 2600 gram, AS : 7-8-9
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4. Mrs. ENW, G2P1A0, 29 yo, 37 wga

dr. Riri (R3) had assisted spontaneous delivery + IUD
Insertion 18 Hours PROM on Secundigravide fullterm
pregnancy

Female baby was born, 2600 gram, AS : 7-8-9

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5. Mrs. RRN, G1P0A0, 29 yo, 39 wga

dr. Anis (R3) had assisted spontaneous delivery 16 Hours
PROM on primigravide fullterm pregnancy

Male baby was born, 3300 gram, AS : 7-8-9

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B.Severe Preeclampsia : 1 case
1. Mrs. ANH, G1P0A0, 39 yo, 25 wga
dr. Tama (R3) had assisted spontaneus delivery + IUD Insertion
IPFD Severe preeclampsia unresponse therapy, Partial HELLP
syndrome on Primigravide immature pregnancy + hipoalbumin
(2,7) in a catheter balloon followed by the induction of the first
bottle oxytocin

Duration of labor 7 hours

Female baby was born, 650 gram, maseration (-)

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MAJOR OBSTETRIC
3 Cases

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 A . FETAL HYPOXIA : 1 Case 15

1. Mrs. IND, G2P1A0, 37 y.o, 37 wga

dr. Yoga (R4) supervised by dr. Lini (R7) assisted by dr.
Fadli (R3) under permission dr. 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, BW : 2900 gr , AS :7-8-9

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CST before resuscitation

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CST after resuscitation

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B. BREECH PRESENTATION( 1 Case) 18

1. Mrs. SRH, G3P2A0, 37 yo, 39 wga

dr. 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 , AS : 7-8-9

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 C. UTERINE ATONIA ( 1 Case)

1. Mrs. RIZ, P3A0, 31 yo

dr. Lini (R7) supervised by dr. Wisnu Prabowo, SpOG (K) assisted by dr.
Kus (R6) had perfomed supracervical hysterectomy b.i uterine atony

Dx pre OP : Uterine atony, resolved hypovolemic shock, early post

partum haemorrhage ec post vaginal repair ec vaginal
laceration + anemia (7,6), prolonged PT APTT
Dx post OP : Uterine atony, resolved hypovolemic shock, early post
partum haemorrhage ec post vaginal repair ec vaginal
laceration + bisitopenia (HB 4,4 AT 67) + prolonged PT
APTT

THIS CASE WILL BE DISCUSSED

 ICU
1 Case

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 ICU
1. Mrs. RIZ, P3A0, 31 yo
Dx : SIRS, pulmonary oedem, post supracervical hysterectomy b.i uterine
atoni, resolved hypovolemic shock, post vaginal repair ec early post partum
haemorrhage ec vaginal laceration + Trombositopenia (79) + Hypoalbumine
(2,7) + renal insufisiency( Cr 1,8 Ur 78) + transamination enzyme elevated
(SGOT 2456 SGPT 1723)
Tx : Inj. Ceftriaxone 2 gr/ 24 hr
Inf. Metronidazole 500 mg / 8 hr
Inj. Vit K 1 amp / 12 hr
Inj. Dycinon 1 amp / 8 hr
Inj. Tranexamat Acid 1 gr / 8 hr in 500cc RL
Inj. Adona 1 amp/8 hr
inj metil prednisolon 62,5mg/12 Hr
inj furosemid sp 5cc/hr (sp)
check for DR3, SGOT/SGPT, albumin
Other therapy ~ Anesthesia, pulmonology, internal medicine
Dx Anesthesia : Tx Anesthesia :
 Post supracervical  Inj. Ceftriaxone 2 gr/ 24 hr
hysterectomi b.i uterine  Inf. Metronidazole 500 mg / 8 hr
atonia  Inj. Vit K 1 amp / 12 hr
 Haemoragic shock
 Inj. Dycinon 1 amp / 8 hr
 Pulmonal oedema
 Inj. Tranexamic Acid 1 gr / 8 hr
 Trombositopenia suspect
 Inj. Omeprazole 40 mg / 12 hr
DIC
 Inj. Furosemide 1 amp / 12 hr
 Dx Pulmonology  Tx Pulmonology
Pulmonary Oedem - O2 Ventilator
- Furosemid 1 amp/12H
~ anestesiology Dept
- observation of
haemodinamic
 Dx Interal medicine Dept  SNMC 1 amp in 100 cc NaCl
- transamination enzyme 0,9 %/12 hour
elevated  Evaluation for
transamination enzym
after 3 day treatment
This morning condition

Clinical examination Fluid Balance 24 hours

 GC : moderate, 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 : - 1343 cc
mode spontan FiO2 21%  UO : 112,5 cc/ hr
 T : 36,3 OC
DISCUSSION

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P3AO, 31 yo

SIRS, pulmonary oedem, post supracervical hysterectomy b.i

uterine atoni, resolved hypovolemic shock, post vaginal
repair ec early post partum haemorrhage ec vaginal
laceration + Trombositopenia (79) + Hypoalbumine (2,7) +
renal insufisiency( Cr 1,8 Ur 78) + transamination enzyme
elevated (SGOT 2456 SGPT 1723)

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 Chronology (4/1/2018 )
Nirmala Suri Hospital VK:
A women G3P2A0, 31 yo with postdate pregnancy 41 wga
11.00 AM Patient came from policlinic and has planned to get induced
misoprostol 25mcg, twice every 6 hours
12.00 PM, performed the first misoprostol 25mcg induction tablet per
vaginam, 6 hours evaluation
06.00 PM evaluation, 2 cm opening of portio with amniotic skin (+)
07.00 PM Amniotic membrane rupture, opening 5 cm
08:00 PM complete opening
08.15 PM has born male baby, 3600gr, evaluation of labor appeared rupture
perineum, suturing has done
09.15 PM contraction (+), appeared active bleeding portio direction at 12 and
6 o'clock, suturing by midwife has done, evaluation, there was active
bleeding, reported to consultant ,paired the vaginal tampons, 2 hours
observation with contraction (+)
00.00 AM evaluation, there was active bleeding (+), there was rupture in the
posterior fornic section, performed situational suture with consultant and
medication has been given, there was still active bleeding , advice tranferred
to RSDM 28
 Chronology (5/1/2018 )
VK/Ponek (04.00 AM):
A women P3A0, 31 yo, refered from nirmala suri hospital with information
post delivery bleeding, patient was spontan delivery in misoprostol induction
25 mcg, delivered her baby 8 hours before went to Moewardi hospital, with
male 3600 gr, complete plasental was born with durante of delivery 6 hours.
Therapy was given :
- Cefotaxime inj 1 gr (02.00 am)
- Metronidazole inf 500mg (02.00 am)
- Ketorolac inj 30mg (02.00 am)
- Tranexamat acid (00.00 am)
- Vitamin K inj (00.00 am)
- Misoprostol 5 tab (00.00)
Fluid input :
- 5 flabot RL ( drip oxytocin + metergin)
- 3 flabot RL
- 2 fomahes
- 2 kolf PRC
- 1 kolf WB
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 • Prior illness : Hypertension (-),
Cardiac disease (-) Diabetes
Mellitus (-), Astma (-), Allergy (-)

• I: male, 8 yo, 3000gr,

History of spontan
Illness & parity • II: female, 6 yo, 3100gr
spontan
• III: male, 3600gr

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PHYSICAL EXAMINATION
• GC : weak, somnolen
• BP : 80/60 mmHg
• HR : 122 x/’
GC/VS •
•
RR : 24x/’
T : 36,3°C
• Eyes CA (+/+) SI (-/-)

• Souple, tenderness (-), contraction

Abdomen weak
• Fundal high 1 finger under umbilical

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PHYSICAL EXAMINATION

• Inspection: appeared 4
pieces of ovarian clamp and
vaginal tampon that had
been released
• Inspekulo: calm vulva,
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), blood ( +)

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Laboratorium
 5/1/2018 ( 05.00 AM)
Hb 7,4
Ht 24
AL 19,1
AT 134
AE 2,70
GDS 107
PT 19,8
APTT 45,2
Alb 1,7
 Early
Diagnosis: hypovolemic shock, early
post partum haemorrhage
ec post vaginal repair ec
vaginal laceration, anemia
(7,4) + prolonged PT APTT
(19,8 45,2)

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After 1 hour resuscitation

• GC : moderate, compos mentis

• BP : 100/70 mmHg
• HR : 92 x/’
GC/VS • RR : 20x/’
• T : 36,3°C
• Eyes CA (+/+) SI (-/-)

• Souple, tenderness, contraction weak

Abdomen • Fundal high 1 finger under umbilical

• Not appears active bleeding (+)

• Blood came out of the portio (+)
Gen

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Diagnosis: Uterine Atonia, resolved

hypovolemic shock, early
post partum haemorrhage
ec post vaginal repair ec
vaginal laceration +
anemia (7,6) + prolonged
PT & APTT (19,8 45,2)

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 • 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

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DURANTE OP Hysterectomy
1. After peritoneum parietale was opened, identification
and exploration :
- Uterus seen as high as umbilicus, contraction (-)
- Right and left ovary and fallopian tube in normal range
- Diagnosed uterine atony
- Decided to perform supracervical hysterectomy
2. Abdominal cavum washed with normal saline
3. Bleeding control  bleeding (-)
4. Abdominal drain was inserted
5. Abdominal wall was sutured layer by layer until cutis
6. Operation finished, bleeding + 3000 ml
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
Laboratorium
 5/1/2018 ( 06.15 PM)  5/1/2018 ( 09.00 PM)
PT 16,6 Hb 4,5
APTT 25 Ht 15
AL 12,4
AT 95
AE 1,89
Laboratorium
 Ro thorax (5/1/2018) :  6/1/2018 ( 12.46 AM)
 Pulmonal oedem Hb 4,4
Ht 14
AL 11,1
AT 67
AE 1,56
GDS 130
Albumin 2,1
Na/K/Cl/Ca = 130/5,2/105/0,89
AGD

 pH 7,455
 BE -12,6 mmol/ L
 pCO2 16,3 mmHg
 pO2 160,5 mmHg
 HCO3 11,6 mmol/ L
 Total CO2 12,1 mmol/ L
 O2 saturation 99,6 %
 Lactat artery 14,20 mmol/ L
Laboratory

 7/1/2018 ( 10.16 PM) GDS 112

Hb 7,1
SGOT 2456
Ht 22
SGPT 11723
AL 12,2
AT 63 Cr 1,8
AE 2,73 Ur 78
PT 18,9 Na/K/Cl/Ca =
APTT 29,8 134/3,8/106/1,08
INR 1.730
Laboratory

 8/1/2018 ( 4.41 AM)

Hb 10,3
Ht 33
AL 10,6
AT 79
AE 3,95
Na 135
K 3,2
Cl 106
Ca 1,11
Diagnosis SIRS, pulmonary oedem, post
ICU: supracervical hysterectomy b.i uterine
atoni, resolved hypovolemic shock,
post vaginal repair ec early post
partum haemorrhage ec vaginal
laceration + Trombositopenia (79) +
Hypoalbumine (2,7) + renal
insufisiency( Cr 1,8 Ur 78) +
transamination enzyme elevated
(SGOT 2456 SGPT 1723)

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Discussion:

Etiology Uterine Atony for

this patient

Uterine Atony
management for this
patient
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 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
 POST PARTUM
HEMORRHAGE

Etiology of Postpartum Hemorrhage

Tonus - uterine atonia
Tissue - residual tissue/blood clot
Trauma - laceration, rupture,inversion
Thrombin - coagulophaty
 POST PARTUM
HEMORRHAGE

Risk Factors of PPH – Antepartum

History of APH or manual plasenta
Solusio plasenta, mainly if undetected
Fetal intrauterine death
Plasenta previa
Gestational Hipertension with proteinuria
Excess tense of the uterine ( gemelli, polihidramnion)
Bleeding disorder before pregnancy (ex. ITP)
 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. HELLP, DIC)
 Post partum hemorrhage

Risk Factors of PPH – Postpartum

Laceration or episiotomy
Plasenta retention /abnormal plasenta
Uterine rupture
Uterine inversion
Acquired coagulophaty (ex. DIC)
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 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

 CASE ANALYSIS

 In this patient, hypovolemic shock grade IV ec

early postpartum hemorrhage ec atonia uteri
occured. Delayed transfer to an adequate
health facility occured.
 Preliminary treatment of uterine atony was
inadequate.
 In the event of pre-referral uterine atony,
birth attendant only performed IV line
installation with uterotonic and uterine
massage.
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 CASE ANALYSIS
 In this patient, immediately performed
hysterectomy without catheter condom
installation, 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

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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

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 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

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Death report

 Name/ Parity : Ny.SGY / G2P1A0

 Age : 31 y.o
 First Diagnose : Apneu, loss of
conciousness, eclampsia on secundigravide 7months
gestational age
 Last Diagnose : Apneu, loss of consciousness,
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 / 2.05 PM
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