dr.

Viola
LAPORAN DOKTER JAGA
RSUP Prof. Dr. R. D. Kandou Manado
Tgl 28 Oktober 2021 jam 07.00 WITA s/d 29 Oktober 2021 jam 07.00 WITA
Tim Jaga : dr. Wina, dr. Viola, dr. Iriawan, dr. Edwin, dr. Joanna, dr. Jenni,
dr. Hendra, dr. Elisabeth, dr. Irene, dr. Wawan, dr. Rima dr. Kris, dr. Gezta
Konsulen Jaga : dr. Suzanna P. Mongan, Sp.OG(K)-Onk

OBSTETRI : 3 Orang
FISIOLOGI : 1 Orang (sptlbk, aterm, hidup)
PATOLOGI : 2 Orang (1 Laporan Singkat,1 Laporan Panjang)
1. G5P4A0 33 tahun dengan Blighted Ovum
 Kuretase + Pemasangan IUD
GINEKOLOGI : 1 Orang (1 Laporan Panjang)
KB : 2 orang (2 IUD)
KEMATIAN :-

LAPORAN OBSTETRI :
1. G4P3A0 32 Tahun Hamil 37 – 38 Minggu Observasi Inpartu + Bekas SC 3x + Perlengketan à Seksio Sesarea +
IUD Post plasenta (Ny. Paputungan Lilis Dianti 74.95.05)
G4P3A0 32 tahun MRS tanggal 29 Agustus 2021 jam 03.00 WITA datang dengan keluhan nyeri perut jarang-jarang
sejak 2 jam SMRS
Anamnesis :
 Nyeri perut ingin melahirkan (+) sejak 2 jam SMRS
 Pelepasan lendir campur darah (-)
 Pelepasan air dari jalan lahir (-)
 Pergerakan janin masih dirasakan saat MRS
 Riwayat penyakit jantung, hati, ginjal, kencing manis, tekanan darah tinggi: disangkal
 Ibu sudah vaksin Covid-19 dua kali
 HPHT : 10 Februari 2021 TP : 17 November 2021
 PAN : 4x Sp.OG
 Menarche : 14 tahun Menstruasi : 28 hari, teratur 3-5 hari, 2-3 pad / hari
 Menikah : 2x (I : 2005 – 2009, II : 2015 – sekarang)
 KB : implan (2009-2012), Pil (terakhir 2021)
 P1 : 2007 / laki-laki / 4800 gr / SC ai makrosomia / Rumah Sakit Datubinangkang Kotamobagu / Dokter / Sehat
 P2 : 2008 / perempuan / 3600 gr / SC ai Bekas SC / Rumah Sakit Datubinangkang Kotamobagu / Dokter / Sehat
 P3 : 2015 / perempuan / 2600 gr / SC ai Bekas SC / Rumah Sakit Pobundayan Kotamobagu/ Dokter / Sehat

Status praesens :
Keadaan umum : cukup Kesadaran : CM
Tensi : 120/80 mmHg Nadi : 86 x/menit
Respirasi : 20 x/menit Suhu : 36,8 ºC
Konjungtiva : anemis (-) Sklera : ikterik (-)
C/P : dalam batas normal Ekstremitas : edema (-)
TB : 156 cm BB : 65 kg BMI : 26 kg/m2

Status Obstetrik :
TFU : 32 cm Letak janin : letak kepala U punggung kanan
BJJ : 140 – 145 x/mnt His : jarang-jarang
TBBA : 3.255 gram (JT)

Pemeriksaan Dalam :
Portio tebal lunak, arah axial, pembukaan 1 jari, ketuban (+), PP kepala H1

USG :
Janin intra uterin tunggal letak kepala
FM (+), FHM (+)
BPD: 9,19 cm, FL: 7,50 cm, AC:32,59 cm.
EFW: 3200-3300 gram
AFL > 2 cm
Plasenta implantasi di fundus grade II - III
Kesan : Hamil aterm + letak kepala

CTG

Baseline : 145 – 150 kpm

Akselerasi : (+)
Deselerasi : (-)
Variabilitas : 15 – 20 kpm
Gerakan Janin : > 5 x/20 menit
Kesimpulan : Kategori I

Laboratorium :
Hb : 11,9 gr/dl WBC : 12.400/mm3 Platelet : 222.000/mm3
SGOT : 14 U/L SGPT : 5 U/L GDS : 72 mg/dl
Ureum : 8 mg/dl Creatinine : 0,4 mg/dl Natrium : 135 mEq/L
Potassium : 4,1 mEq/L Chlorida : 105,0 mEq/L
Swab Antigen SARS CoV-2 : Negatif

Foto thorax
Dalam batas normal

EKG
Sinus Rhythm, 84x/m

Diagnosis:
G4P3A0 32 tahun hamil 37 – 38 minggu observasi inpartu + bekas SC 3x
Janin intrauterin tunggal hidup letak kepala

Sikap
 R/ SCTP Cito
 Konseling, informed consent
 Crossmatch, sedia darah
 Konseling KB  Sterilisasi Pomeroy, jika terdapat perlengketan dan tidak dapat dilakukan sterilisasi, setuju
IUD post plasenta
  Observasi T,N,R,S, His, BJJ
 Lapor DPJP advis : R/ SCTP Cito
Konseling, Informed Consent
Konseling kontrasepsi  Sterilisasi Pomeroy, jika terdapat perlengketan dan tidak dapat
dilakukan sterilisasi, setuju IUD post plasenta
Obs TNRS, His DJJ

Observasi :
Jam 03.00 – 04.00 : His : jarang-jarang BJJ : 145-150 x/menit
Jam 04.00 – 05.00 : His : jarang-jarang BJJ : 140-145 x/menit
Jam 05.00 – 06.00 : His : jarang-jarang BJJ : 135-140 x/menit

Jam 06.30 : Penderita didorong ke OK cito

Jam 06.55 : Operasi dimulai, dilakukan seksio sesarea
Jam 07.03 : Lahir bayi perempuan, BBL : 3200 gram, PBL : 50 cm, AS : 7 – 9
Eksplorasi lanjut, ditemukan perlengketan antara uterus dengan dinding peritoneum bagian kanan
dan kiri, kedua adneksa tidak dapat tervisualisasi, diputuskan untuk dilakukan pemasangan IUD
Post Plasenta
Jam 08.10 : Operasi selesai

Saat ini kondisi ibu cukup, dirawat di Irina D atas (Hb Post op : 9,4 gr/dL). Bayi rawat gabung dengan ibu.

LAPORAN GINEKOLOGI :

1. P0A2 26 years old with Rupture of Tuba Pars Ampularis Dextra + History of Salpingectomy Sinistra (May
2021) + Anemia (Hb 7,5 gr/dL) Salpingectomy Dextra (Mrs. Mandang Yeska F. Pingkan, MR 74.95.37)
The patient was referred from Hermana Lembean Hospital 0n October 28 th 2021, at 4.00 PM with Ruptured Ectopic
Pregnancy

History taking:
 She felt abdominal pain, radiating to shoulder since 1 day prior to admission
 There was blood through out the vagina since 6 hours prior to admission
 There was history of yellowish and itchy vaginal discharge since 1 year ago and left untreated.
 There was no history of cardiac, pulmonary, liver, renal, hypertension, and diabetic disease
 Swab antigen SARS CoV-2 (October 28th, 2021) in Hermana Lembean Hospital : negative
 She has been Covid-19 vaccinated twice
 Menarche : 13 years old
 Menstruation : 30 days, regular, 3-5 days, 2-3 pads/day
 LMP : September 12th, 2021
 Marriage :-
 Contraception :-
 A1 : May 2021 / History of Laparotomy of Ruptured Ectopic Pregnancy / Hospital in Timika

Present status
General Condition : Fair Conciousness : compos mentis
Blood pressure : 90/60 mmHg Pulse rate : 108 x/minute
Respiration rate : 26 x/minute Temperature : 37.0° C
Conjunctive : anemic + Sclera : icteric -
Heart and lung : within normal limit Hepar/lien : within normal limit
Extremities : oedema -/-
Pregnancy test : (+)

General examination
Abdominal
 Inspection : flat, surgical scar (+)
Palpation : tenderness, pain (+) lower abdominal region, mass (-) muscular defense (+)
Percussion : difficult to evaluate due to pain
Auscultation : difficult to evaluate due to pain

Gynecology Examination
Inspection : fluxus (+), vulva within normal limit
Inspeculo : fluxus (+), vagina within normal limit, portio livide, erotion (-),
closed OUE ostium
VT : fluxus (+), vulva and vagina within normal limit, soft portio, slinger pain (+),
closed OUE ostium
Uterus : difficult to evaluate due to pain
Bilateral A/P : difficult to evaluate due to pain
Douglas Cavity : bulging (+)

USG
Bladder was filled with balloon catheter
The uterine was anteflexi 8,60 cm x 5,22 cm
Endometrial line (+)
Complex mass (+) from right adnexa 5,15 cm x 3,75 cm
Free fluid (+) at cavum douglas, hepato-renal space, spleno-renal space
Conclusion : Ruptured ectopic pregnancy

Laboratory :
Hb : 7.5 gr/dl WBC : 9.700/mm3 Platelet : 132.000/mm3
SGOT : 8 U/L SGPT : 4 U/L Ur : 12 mg/dL
Cr : 0.7 mg/dL RBG : 105 mg/dl
Cl : 109,0 mEq/L K : 3,5 mEq/L Na : 136 mEq/L
Plano test (+) Swab Antigen negatif

ECG
Sinus Tachycardia, HR 108 bpm

Chest X-Ray
Within normal limit

Diagnose
Ruptured Ectopic pregnancy + History of Salpingectomy Sinistra (May 2021) + Anemia (Hb 7,5 gr/dL)

Management
 Haemodyamic Stabilization
 Emergency Laparatomy Exploration
 Counseling, informed consent
 Crossmatch, blood was prepared
 Observation of vital sign
 Consulted to supervisor, advice : Haemodynamic Stabilization
Emergency Laparatomy Exploration
Counseling, informed consent
Observation Vital Sign

At 04.00 – 05.00 PM : TD : 90 / 60 mmHg N : 102 x/m RR 20 x/m T: 36,6C

At 05.00 – 06.00 PM : TD : 90 / 70 mmHg N : 104 x/m RR 18 x/m T: 36,5C

Jam 06.00 PM : The patient was brought to the operating theatre

Jam 06.15 PM : Operation was begun
Laparotomy
The peritoneum was bluish. After the peritoneum was opened there was blood + 1000 cc
Exploration:
The uterine within normal size. Within exploration there was ruptured on right ampullary tube, right ovary was
normal, decided to do right salpingectomy. The embrio was not found. Further exploration, left tube was not found
and left ovary was normal. The tissue was sent for histopathology examination.
She had received 1 bag of PRC transfusion during operation

At 07.30 pm : Operation was finished

The mother is in good condition (Hb : 7,5 gr/dL)