Case Final Arpol

CHAPTER I
CASE REPORT
Patients Identity:
Name
: Mrs. W
Date of Birth/ Age
: February 6th, 1996/ 18 years old
Ethnic
: Javanese
Nationality
: Indonesian
Address
: Kebon Kelapa RT 005/RW 02 Kecamatan Kamal, Kelurahan Kali Deres,

West Jakarta
Graduate from
: Senior High School
Marital status
: Married
Occupation
: Housewife
Religion
: Moslem
Date of admission
: June 2nd, 2014
Chief complaint:
Fifteen hours prior to admission, patient complained of vaginal bleeding and lower abdominal
pain.
History of Present Illness:
Nine days prior to admission, 7 months into the pregnancy, patient complained of painless
vaginal bleeding with no history of trauma. Patient was quickly rushed to the clinic. In the clinic,
USG was performed on the patient. Based on patients confession, the result of the USG was the
placenta was implanted on the lower segment of the uterus. Patient then referred to Atma Jaya
Hospital. In Atma jaya Hospital, the patient was hospitalized for 5 days and was given
Sangobion 2x1 caps, Duvadilan 3x1 tab, and had blood transfusion 4 bags of blood. Total
blood loss for that day was equal to 3 diapers ( 2,000 cc ). Bleeding only happened in the first
day, and didnt reccur while patient was hospitalized.
Fifteen hours prior to admission, patient complained of painless vaginal bleeding that
happened intermittently. Bleeding started when patient was lying down on the bed and no history
of trauma prior to bleeding.
History of Past Illness:
No history of hypertension
No history of diabetes mellitus
No history of allergy
No history of heart disease
No history of liver disease
No history of kidney disease
No history of epilepsy
No history of hematological disease
No history of asthma
No history of trauma
No history of operative procedures
No history of traditional remedies consumption during pregnancy
No history of abdominal massage
No history of hereditary disease
Contraception History:
No contraception method is used.
Antenatal Care:
5 times in public health center
Menstruation History:
Menarche
Menstrual cycles
: 13 years
: regular cycles, 30 days interval, 7 days duration,
dysmenorrhea
First day of last menstrual period : September 10th, 2013
Marriage History:
Married 1 times, for 11 months.
Gestational History:
First day of last menstrual period : September 10th, 2013

Estimated date of birth
: June 17th, 2014
Result
Year
Gestational
History
Age
Childbirth
of
Sex
Birth
Weight
Breast
Milk/Breast Milk Information
Substitute
this pregnancy
Physical Examination:
General condition
: looks well
Level of consciousness : compos mentis
Vital signs
:
o Blood pressure : 110/70 mmHg
o Heart rate
: 100 x/minute
o Respiration rate: 24 x/minute
o Temperature : 36.5 C
Body Weight
: 65 kilograms
Body Height
: 155 centimeters
General Examination:
Eyes
: anemic conjunctiva -/-, icteric sclera -/Mouth
: wet oral mucous membrane
Thorax
:
o Heart
: regular 1st and 2nd heart sounds, murmur (-), gallop (-)
o Lung
: vesicular breath sounds +/+, rhonchi -/-, wheezing -/o Mammae : areola hyperpigmentation +/+, nipple retraction -/Abdomen
:
o Inspection : convex, linea nigra (+), striae gravidarum (+)
o Palpation
: supple, pain on palpation (+)
o Percussion : not performed
o Auscultation : bowel sounds (+), 4x/minute
Extremities : warm in palpate, CRT < 2 seconds, oedema -/-, physiologic reflexes
+/+/+/+, pathologic reflexes -/-
Obstetric Examination:
Antenatal care: 5 times in public health center

First day of last menstrual period: 10th September 2013
Estimated date of birth: 17th June 2014
Fundal height: 31 centimeters
Estimated fetal weight: 2790 grams
His: absent
Fetal heart rate: 140x/minute
Cardiotocography (CTG):
o Baseline: 135 x/minute
o Variability: normal
o Acceleration: present, 6 times in 20 minutes
o Descelaration: absent
o Fetal movement: 5 times in 20 minutes
o His: absent
o Conclusion: reactive non stress test
Obstetric Status:
Leopold examination :
o I : Breech
o II : Fetal back is at the right side, and fetal extremities is at the left side
o III : Fetal head
o IV : Descendent 5/5
Vaginal toucher
: not performed
Speculum examination :
o Vulva/vagina : normal
o Erosion
:o Fluxus
:+
o Stool cell
:+
o Tissue
:-
Laboratory Examination:
June 2th, 2014 17.29
Examination
HEMATOLOGY
Complete Blood Count
Hemoglobin
Hematocrite
Leucocyte
Value
Unit
Normal Range
Note
12
g/dl
12-16
Norma
37-47
l
Norma
4-10
l
Norma
140-400
l
Norma
37
17,000
Thrombocyte
202,00
Blood type
0
O/Rh +
June 2th, 2014 22.11

Examination
HEMATOLOGY
%
%
/L
Value Unit
Normal Range
Note
Bleeding time
Clotting time
3
5
minutes
minutes
1-3
Norma
3-6
l
Norma
l
BLOOD CHEMISTRY
Glucose
Blood glucose
116
mg/dl
60-140
Norma
l
Admitting Diagnosis:
G1P0A0, 18 years old, gravid 33-34 weeks based on USG, not in a labor, with antepartum
hemorrhage caused by placenta previa and single, alive, intrauterine fetus with head presentation.
Therapy
18.10
Inpatient and bed rest
Duvadilan drip 2 ampules in 500 cc Ringer Lactate, 15 drops per minute

Hemobion 1x1 tablet P.O.
Informed consent to the patient, if bleeding recurrs, cesarean section will be performed.
21.15
Due to recurrence of the bleeding, pro cesarean section CITO
22.45
Patient was given spinal anesthetic
22.50
Operation was engaged.
22.55
Male baby was born with birth weight of 2570 gram, birth length of 44,5 centimeters, and
APGAR score of 8/9.
22.56
The placenta was born. The weight of the placenta was 525 gram, with a size of 18 x 21 x
2 cm, the length of the umbilical cord was 44 centimeters, marginal insertion, complete
cotyledon, complete membrane, stool cell (+), hematoma (-), calcification (-), with total
blood loss of 70 cc.
23.33
Operation was finished with total post operation blood lost was approximately 775 cc.
Final Diagnosis:
P1A0, 18 years old, post aterm labor by cesarean section due to placenta previa.
Post Surgery Treatment:
IVFD KaEn Mg 3 : RL = 2:1

Syntocinon 2 ampules
Cefotaxime 3x1 gram IV
Tramadol 3x1 ampule drip
Kaltrofen supp 2x1 supp
Laboratory Examination Post Operation (June 3rd, 2014):

June 3rd, 2014 06.28
Examination
HEMATOLOGY
Hemoglobin
Value Unit
Normal Range
Note
11.8*
12-16
Decreas
g/dl
e
Follow up
June 3rd, 2014 (05.00 a.m)
S : abdominal pain post operation (+), flatus (-), defecate (-)
O:
General condition
: looks well
Vital signs
:
o Heart rate
: 96 x/minute
Physical examination
Eyes
Thorax
:
o Heart
o Lung
: vesicular breath sounds +/+, rhonchi -/-, wheezing -/o Mammae : areola hyperpigmentation +/+, nipple retraction -/-,-/-, breast milk +/+
Abdomen
:
o Inspection : convex, linea nigra (+), striae gravidarum (+), wound was closed
using 12x15 cm gauze.
o Palpation
o Percussion : tympanic in all quadrants
Puerperium
Mobilization : inactive
Fundal height : 2 centimeters below umbilicus, contraction strong
Lochia
:rubra, 30 cc
Suture
: leakage (-)
Laboratory Examination
June 3rd, 2014 06.28
Examination
HEMATOLOGY
Hemoglobin
Value Unit
Normal Range
Note
11.8*
12-16
Decreas
g/dl
e
A : P1A0, 18 years old, post aterm labor by cesarean section due to placenta previa, post
operation day 1.
P:
Remove infusion and catheter 24 hours post operation

Oral medication :
Cefadroxil 3 x 500mg
Mefinal 3 x 500mg
Methergin 3 x 0.125mg
June 4th, 2014 (05.00 a.m)

S : abdominal pain post operation (+), flatus (+), defecate (-)
O:
General condition
: looks well
Vital signs
:
o Heart rate
: 80 x/minute
Eyes
Thorax
:
o Heart
o Lung
Abdomen
:
o Inspection : convex, linea nigra (+), striae gravidarum (+), wound was closed
using 12x15 cm gauze.
o Palpation
Puerperium
Mobilization : inactive
Lochia
Suture
:rubra, 30 cc
: leakage (-)
operation day 2.
P:
Oral medication :
Cefadroxil 3 x 500mg
Mefinal 3 x 500mg
Methergin 3 x 0.125mg
Moloco B12 3x1 tablet
Change the bandage tomorrow
June 5th, 2014 (05.00 a.m)

S : abdominal pain post operation (+), flatus (+),urinate (+), defecate (+)
O:
General condition
: looks well
Vital signs
:
o Heart rate
: 80 x/minute
Eyes
Thorax
:
o Heart
o Lung
Abdomen
:
o Inspection : convex, linea nigra (+), striae gravidarum (+)
o Palpation
: supple, pain on palpation (-)
Extremities
: warm in palpate, CRT < 2 seconds, oedema -/-, physiologic reflexes

Puerperium
Mobilization : active
Lochia
: rubra, 5 cc
Suture
: leakage (-)
operation day 3.
P :
The patient was permitted to discharge, with:

o Cefadroxil 3 x 500mg per oral
o Mefinal 3 x 500mg per oral
o Methergin 3 x 0.125mg per oral
CHAPTER II
THEORY
Definiton
Placenta Previa is the term used in which the placenta is attached on the lower
portion of the uterus.
Classification
-
Total Placenta previa

o
Marginal placenta previa

o
the edge of placenta os is at the margin of internal os
Partial placenta previa

o
the internal os is covered completely
placenta partialy cover the internal os
Low-lying placenta
o
the placenta is implanted at te lower uterine but not reach the cervical
os
Vasa previa
o
the fetal vessel course through the membranes and present at the
cervical os.
Risk factor
-
Multiparity
Large placenta
Hydrops Fetalis
Decidua vascularization defect
Endometrium scarring because of surgery
Clinical Manifestasion
Painless, causeless, recurrent hemorrhage is the characteristic clinical finding which
is ussualy appear at the end of second semester or after. If the placenta is located
over the cervical os, the dilatation can cause tearing of the placenta and it cause
the bleeding.
Diagnosis
-
History Taking
Inspeculo
to check wether the blood comes from the uterine ostium or the cervix or the
vagina.
Radiology
Radiology testing is used to determine the location of the placenta. Two
radiology modality that can be used is :
Ultrasonographic
the most accurate and simple method. False positive result can be
result of the bladder, so the patient should emptying the bladder
before it done.
The ultrasonographic testing divided into transabdominal and
transvaginal approach. According to studies, transvaginal approach is
the modality of choice for placenta previa diagnostic.
o
-
MRI
Digital Examination of the vagina is absolutely contraindicated

unless placenta previa has been excluded.
Treatment
The treatment principle in placenta previa can be dividided into two : active and
conservative
The conservative treatment can be done if the gestational age is below 37 weeks
and the condition of the mother is in good shape such as good haemoglobin serum
level.
The active management is indicated if the fetus is mature enough, or the fetus is in
stillbirth condition, and the bleeding is uncontrolled. In that case, caesarean section
surgery is necessary.
Some literature said that if the margin of the placenta and the cervical os is above 2
cm, then normal delivery can be done. Otherwise, ceasarean section is a must.
Prognosis
With a good care, the maternal mortality should be low or absent.
CHAPTER III
CASE ANALYSIS
Definition
Theory
Placenta
that
Case
implanted Placenta cover the internal os
over/near the internal cervical completely

os completely (total placenta
Risk Factors
previa)
Age : <19 or >35 years
old
Multiparity
Prior cesarean delivery
Smoked
Unexplained
elevated
screening
maternal
Clinical Manifestation
levels
serum
of
alpha-
fetoprotein
Painless vaginal bleeding
Causeless
vaginal
bleeding
Bleeding happens for the
Age: 18 years old

Primiparity
Patient
painless
vaginal bleeding
Bleeding
happened
without
first time at the end of
trauma.
second semester.
Recurrent hemorrhage
happened
has
history
Bleeding
when
Diagnosis
Physical examination:
patient
was lying down.

7
months
into
pregnancy,
of
the
bleeding
happened first time

Bleeding reccured 9 days
later.
Physical examination:
Vaginal toucher is never
Vaginal toucher was not
permissible
performed
Ultrasonography:
Ultrasonography:
Based on patients confession,
Transabdominal
placenta the result of ultrasound on the
sonography:
clinic was the placenta was

covering the cervix
Transvaginal sonography: implanted on the lower
placenta is lying between segment of uterus.
cervix and fetal head
Transperineal sonography
Magnetic Resonance Imaging:

was not performed
Management
Magnetic Resonance Imaging

For preterm and non persistent PRE-OPERATION:
active
bleeding
observation,
conserve
close 18.10
the
pregnancy
Bed rest
Duvadilan 2 ampules in
500 cc Ringer Laktat, 15
For near term and not bleeding

caesarean section
drops per minute

Hemobion 1x1
P.O.
Informed consent to the
tablet
patient, if there is a
recurrence
bleeding,
section
of
the
cesarean
will
be
performed.
21.15
Due to recurrence of the
bleeding, pro cesarean section
CITO
DAFTAR PUSTAKA
1. Cunningham, F. Gary., Leveno, Kenneth J., Bloom, Steven L., et all. Williams Obstetrics
23rd edition. McGraw Hill. 2010.
2.

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CHAPTER I

Date of Birth/ Age

: February 6th, 1996/ 18 years old

: Kebon Kelapa RT 005/RW 02 Kecamatan Kamal, Kelurahan Kali Deres,

: Senior High School

: June 2nd, 2014

First day of last menstrual period : September 10th, 2013

Antenatal care: 5 times in public health center

June 2th, 2014 22.11

Inpatient and bed rest

Duvadilan drip 2 ampules in 500 cc Ringer Lactate, 15 drops per minute

Due to recurrence of the bleeding, pro cesarean section CITO

Patient was given spinal anesthetic

Operation was engaged.

IVFD KaEn Mg 3 : RL = 2:1

Laboratory Examination Post Operation (June 3rd, 2014):

Remove infusion and catheter 24 hours post operation

June 4th, 2014 (05.00 a.m)

June 5th, 2014 (05.00 a.m)

: warm in palpate, CRT < 2 seconds, oedema -/-, physiologic reflexes

The patient was permitted to discharge, with:

Total Placenta previa

Marginal placenta previa

the edge of placenta os is at the margin of internal os

Partial placenta previa

the internal os is covered completely

placenta partialy cover the internal os

Decidua vascularization defect

Endometrium scarring because of surgery

Digital Examination of the vagina is absolutely contraindicated

over/near the internal cervical completely

Age: 18 years old

first time at the end of

was lying down.

happened first time

Vaginal toucher is never

Vaginal toucher was not

Based on patients confession,

placenta the result of ultrasound on the

clinic was the placenta was

Magnetic Resonance Imaging:

Magnetic Resonance Imaging

For near term and not bleeding

drops per minute

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