Previous CS

Case No. 61
 Patients ID

Name : Mrs. P
Age : 30 years old
MR : 891417
Time of admission : Oct 17th, 2017
 Anamnesis
A 30 years old patient was admitted to the Delivery Room of Dr.
M. Djamil Central General Hospital on Oct 17th, 2017 at 01.30 am
Pelvic pain to the groin iregularly was felt since 2 hours ago (before
her admission in M Djamil hospital )
 Present Illness History
Previously the patient was known as a SLE patient and get routine theraphy
from internist alergi imunolgy sub departement M Djamil hospital
Pelvic pain to the groin was felt since 2 hours ago (before her admission in M
Djamil hospital )
Bloody show from the vagina since 2 hours ago.
Fluid leakage from the vagina was absent
Massive bleeding from the vagina was absent.
Amenorrhea since 8,5 months ago.
First date of last menstrual period was 2/2/2017.
Estimation date of delivery 9/11/2017.
Fetal movement was felt since 4 months ago.
patient estimated will be control at Oct 26th 2017 to internist dept.
felling fatique from all of the body
No complain of nausea, vomiting, and vaginal bleeding neither during early
pregnancy nor late pregnancy.
Prenatal care to obstetrician once in a month, the pregnancy was well-
controlled.
Menstruation history: menarche at 12 years old, irregular cycle, once a month
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

Patient was diagnosed got Systemyc Lupus Erithematous since 1,5 Years ago
There was no history of lung, liver, renal disease, diabetes mellitus,
hypertension.
Allergic history was denied
The patient was recognized as tachycardia before her third pregnancy, and got
bisoprolol as therapy. As she was going pregnant, the bisoprolol was stoped.

Familial Illness History

There was no history of any hereditary, contagious, or psychiatric dysorder.
Marriage history: married once, at November 2010
Obstetric history : Pregnancy/Abortion/Delivery: 3/0/2
1. In 2011, female, 2500 gr, term, spontaneus delivery, midwife, alive,
2. In 2015, male, 2200 gr, term, SC, Sp. OG, alive,
3. Present
Educational history : senior High School
Occupational history : housewife
History of family planning : (-)
Immunization : (-)
 Physical Examination
GA Cons BP HR RR T BW BH BMI

Mdt CMC 120/80 104 24 36,8 65/75 150 28,88

Eyes : conjunctiva was not anemic, sclera was not icteric

Neck : JVP 5-2 cmH2O, no enlargement of thyroid gland
Thorax : Heart & lung were in normal limit
Abdomen : Obstetric record
Extremity : oedem -/-, Physiological reflex +/+,
Pathologycal reflex -/-
OBSTETRIC RECORD

Abdomen
Inspection : Seems enlarged accordance 8 month pregnancy, cicatrix (+) Pfanensteal
Palpation :
L1 : Uterine fundal was palpated Proc. Xyphoideus umbilical, a large soft noduler mass was
palpated
L2 : The largest resistance was felt on the left side,
Small structures of the fetus were felt in the right side
L3 : A hard, round mass was palpated,floating
L4 : didnt do examination
Fundal height : 28cm EBW : 2325gr gr
Uterine contraction : -
Percussion : thympany
Auscultation : peristaltic sound was normal, FHR : 140-150 bpm

11/2/2017
Genitalia : I : V/U normal, bleeding from vagina(-)
Vaginal Touche
Not perform

11/2/2017
D/:
G3P2A0L2 preterm pregnancy 34-35 minggu + Ppi + SLE
Fetal alive, singleton, intra uterine, head presentation
Management :
Control GA,VS,HIS,FHS
Informed consent
Complete blood count, EG, CTG, USG
IVFD RL 28 tpm
Dexametason inj. 2x2 amp
Nifedipin 3x10mg
Mefenamic acid 3x500mg

Plan : Emergency CS
Laboratory examination
Parameter Result Normal Value
Hemoglobin 8,7g/dl 12,00-14,00
Leukocyte 8940/mm3 5,00-10,00
Hematocryte 28% 37,00-43,00
Erythrocyte 3,990 x 106/mm3 4,00-5,00
Thrombocyte 128.000/mm3 150,00-400,00
PT 10,5 sec 10,0-13,6
APTT 31,5 sec 29,2-39,4
 PARAMETER RESULT REFERENCE VALUE
Calcium 8,2mg/dl 8,6-10,3

Potassium 2,9 mmol/L 3,5-5,1

Sodium 140 mmol/L 139-145

Chlorida 107 mmol/L 97-111

Random blood glucose 94 mg/dl <200,00
Total protein 6,0 g/dl 5,6 6,7
Albumin 3,0 g/dl 2,3 4,2
Globulin 3,0 g/dl 2,5-3,3
LDH 298 u/l < 480
Ureum 13mg/dl 16,6 48,5
Creatinin 0,4 mg/dl 0,6 1,2
 PARAMETER RESULT NORMAL VALUE

Protein total 7,5 g/dl 6,7 7,8

Albumin 3,5 g/dl 3,5 5,2
Globulin 2,9 g/dl 2,5-3,3
SGOT 17 u/l 0,0 31,0
SGPT 7 u/I 0,0-34,0
Ureum 13 mg/dl 21,0 43,00
Creatinin 0,4 mg/dl 0,6 1,2
CTG

11/2/2017
 Baseline : 130 bpm
Variability : 5-10 bpm
Acceleration : (+)
Deceleration : (-)
Fetal Movement : (+)
Contraction : (-)

Impression : reactive CTG

11/2/2017
Internist
A/
SLE
G3P2A0L2 latent preterm 34-34 weeks of pregnancy
P/
metil prednisolon 8-0-0
Lansoprazole 1x 30mg
Osteocal 1x1000mg

11/2/2017
D/:
G3P2A0L2 preterm pregnancy 34-35 weeks + partus prematurus
imminens + previous SC + SLE + moderate anemia
Fetal alive, singleton, intra uterine, head presentation
Management :
Control GA,VS,HIS,FHS
Informed consent
Inj. Dexametason 2x2amp
Mefenamic acid 3x500mg
Nifedipin 3x10mg
KSR 2x1 tab
Joint treatment with internist

Plan : USG FETOMATERNAL

USG
Fetal alive singletone intra uterine head
presentation
Fetal movement was good
Biometri :
BPD : 85,4 mm
FL : 68,7,mm
AC : 301 mm
EFW : 2486gr
AFI : 2,46
SDAU : 1,97
Plasenta incertion in uterine fundal grade 2
impression :
34-35 weeks pregnancy
Severe oligohidramnion

11/2/2017
D/:
G3P2A0L2 preterm pregnancy 34-35 weeks + partus prematurus
imminens + previous SC + SLE + moderate anemia
Fetal alive, singleton, intra uterine, head presentation
Management :
Control GA,VS,HIS,FHS
Informed consent
Inj. Dexametason 2x2amp
Mefenamic acid 3x500mg
Consult internist
Consult anesthesy
Confirmed OK

Plan : elective SC 19/10/17

19th Oct 2017 At 12.30 am
TPPCS was performed
A male baby was born with :
................ gr weight, 50 cm height, APGAR score was 8/9.
The placenta was delivered with a slight traction on the
umbilical cord, complete, 1 piece, 16x17x3 cm size, 500 g
weight, the umbilical cord length was 60 cm, paracentral
insertion.
Pomeroy Tubectomy was performed
Bleeding during surgery was approximately 250 cc

Diagnosis :
P3A0L3 post CS oi. SLE + previous CS + TP oi medicinalis
Mother and baby were in care
THANK YOU
 Follow Up
20-10-2017
Anamnesa demam (-), PPV(-)

Pemeriksaan fisik
Ku : sdg Td: 120/90
Kes: cmc Nd: 82
Mata: konjungtiva tidak anemi
Abd: luka op tertutup perban, TFU 2 jari bawah pusat, kontraksi baik
Gen: I: v/u tenang, PPV (-), Urine 1800 cc/24jam

Diagnosa
P2A0L2 Post CS oi previous cs + SLE + TP oi medicinalis

Plan
IVFD RL 20 tpm
inj ceftriaxone 2x1 gram
inj Asam tranexamat 3x500 mg
inj Vit K 3x1 amp
Pronalgess supp k/p
11/2/2017
11/2/2017
Laboratorium
19-5-2017
PARAMETER HASIL RUJUKAN
Hemoglobin 10,3 9.5-15
Leukosit 11.320 5.000 16.000
Eritrosit 3,2 4,0-4,5 juta
Hematokrit 29 37 43
Trombosit 327.000 150.000 400.000
APTT 24,2 29,2 39,4
PT 10,2 10 13,6