PREVIOUS CS + PROM

Case No. 41

PATIENTS ID
Name
: Mrs. A
Age
: 33 years old
Address
: Tunggul Hitam
MR No.
: 84 11 41
Admission date : September 8th, 2013

ANAMNESIS
A 32 years old patient admitted to General
Hospital of Dr. M. Djamil Padang on
September 8th, 2013 at 11:30 am, with chief
complain fluid leakage from the vagina since
11 hours ago

PRESENT ILLNESS HISTORY

Fluid leakage from the vagina since 11 hours ago, smelly odor, clear,
wetting 1 pieces of sarong
Feeling of pain from waist region which referred to the groin was absent

Bloody show from the vagina was absent

There was no massive vaginal bleeding
Amenorrhea since 9 months before

First date of last menstrual period : 2-12-2012

Estimation date of delivery : 9-9-2013
Fetal movement was felt since 5 months ago.
No complain of nausea, vomiting and vaginal bleeding neither during
early pregnancy nor late pregnancy.
Prenatal care to midwife in Tunggul Hitam once a month, since 3 month
pregnancy age, never had a complain during pregnancy
Menstruation History : menarche at 13 years old, regular cycle, once a
28 days which last for 5 to 7 days, each 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 allergic reaction to the drugs.
Family Illness History
There wasnt history of hereditary disease, contagious and
physicological illness in the family.
Marital status : married once in 2010
Obstetrics status : pregnancy / abortion / delivery : 2 / 0 / 1
1. In 2011, male, 3500 gr, term pregnancy, CS o.i PROM,
at private hospital , with Doctor, wound healing is in 7
days, a live
2. Present pregnancy
History of family planning : (-)
Immunization : (-)
Educational background : High School graduated
Occupation : housewife

PHYSICAL EXAMINATION
GA Cons BP
PR RR T
Mdt CMC 120/80
80x 20x 37
Body Height
: 150 cm
Present Body weght
: 60 kg
Before Pregnancy Body Weight
: 50 kg
BMI
: 22.2 kg/m2
Upper Arm Circumferrence
: 24 cm

PHYSICAL EXAMINATION
Eyes : Conjunctiva wasnt anemic, Sclera wasnt icteric
Neck : JVP 5-2 cmH2O,
thyroid gland no enlargement
Chest
Abdomen

: H/L normal

Genitalia
Extremity

: OR (obstetric record)

: OR (obstetric record)
: Edema -/-,

Physiological Reflex +/+,

Pathological Reflex -/-

Abdomen
Inspection : enlarged due to a term pregnancy, median line
hyperpigmentation, cicatrix (+) previous CS with pfannenstiel
incision
Palpation :
L1 : uterine fundal was palpated 3 fingers below proccesus xyphoideus,
a soft, large noduler mass was palpated
L2 : hard and resistance structure was felt on the left side,
numerous small and irregular structures were felt in the right side
L3 : a hard round mass was palpated, fixated
L4 : convergen
Uterine fundal height : 38 cm, EBW : 3875 g, uterine contraction : (-)

Percussion : tympani
Auscultation : normal peristaltic sound,
FHR : 140-152 bpm

Genitalia : I : V/U normal, Vaginal bleeding (-)

Inspeculo :
Vagina :
tumor (-), laceration (-), fluxus (+), there was a clear fluid accumulating in
posterior fornix, Nitrazine Test (+)
Portio :
NP, size equal to adult thumb, tumor (-), laceration (-), fluxus (-), OUE was
closed
Vaginal examination :
1 finger tight
Portio 1,5 cm in thickness, posterior, moderate
Effacement 30-40%
Amniotic sac (-), residu was clear
Head was palpated at HI

Pelvic Inlet
Promontory couldnt be reached
Inominate line was palpable 1/3 1/3
Sacrum bone concave
Pelvic side wall straight
Ischiadic spine not protruded
Coccygeus bone moveable
Arc of pubic > 90

Pelvic Outlet
Inter tuberous distance could be passed through by normal adult fist
(>10.5 cm)

Impression Internal and External pelvimetry : adequate pelvic

ULTRASOUND

ULTRASOUND
Fetal alive, singleton, intrauterine, head presentation
Fetal movement was limited
Biometrics :
BPD

: 94.8 mm

AC

: 349 mm

FL

: 78.0 mm

EFW

: 3714 gr

Placenta was implanted in posterior corpus, grade II-III

Impression : term pregnancy
fetal alive

CARDIOGRAPH

CARDIOGRAPH
Interpretation :
Baseline

: 145 bpm

Variability

: 5-15 bpm

Acceleration

: (+)

Deseleration

: (-)

Contraction

: (-)

Impression : Reactive CTG

LABORATORY FINDING
Laboratory finding

Normal value for 3rd TM

Routine blood testing

Hemoglobine

12,5 gr/dl

9,5-15,0

Leucocyte

19.500/mm3

5.916.9

Hematocrit

38 %

28.040.0

Trombocyte

193.000/mm3

146429

10,5

10,0-13,6

29

29,2-39,4

PT
APTT

URINALYSIS

Protein
Glucose
Leukocytes
Erythrocyte
Cylinder
Crystal
Epithelial
Bilirubin
Urobilinogen

: (+)
: (-)
: 1-2
: 0-1
: (-)
: (-)
: (+) flat
: (-)
: (+)

Diagnosis :
G2P1A0L1 term pregnancy + Previous CS + PROM
Fetal alive, singleton, intra uterine, head presentation, H I
Management :
Control GA, VS, FHS, uterine contraction.
Routine blood examination
Antibiotic skin test
Informed consent
Consult to an anesthesiologist
Report to Operating theatre
Planning : Caesarean Section

At 02:30 pm : TPPCS was performed

A female baby was born by TPPCS, with :
4100 grams in body weight, 53 cm in height, APGAR score
8/9
Placenta was born with little pulling on the umbilical cord,
complete, 1 piece, 18x17x3 cm in size, 550 g in weight, the
umbilical cord was 60 cm, with paracentral insertion.
IUD was inserted
Estimated blood lose during operation 250 cc
Diagnosis :
P2A0L2 post TPPCS on indication of Previous CS + PROM
Mother and child were in care
Management :
Post surgery observation

THANK YOU