Morning Report

May, 1st 2015

Supervisor : dr. Agus Thoriq, SpOG
Medical Students :
Gus Indra, Fuji, Melinda, Titin, Zihan, Santya
Cases Resume
Normal labor

Pathologic labor

1. G1P0A0L0 21-22 weeks S/IUFD/IU head presentation with

hypovolemic shock e.c susp. rupture of uteri, and anemia
gravis

Case Report
Name

: Mrs. SS
Age
: 18 yo
Address
: Pelangan, Sekotong
Admitted
: May 1st, 2015 at 16.50
RM
: 559523

Time
01-05-2015
(16.50)

Subjective
Patient reffered from Gerung GH with
hypovolomic shock e.c susp. rupture of
uteri + severe anemia. Patient
confessed abdominal pain since
30/04/2015 at 22.00. Firstly, patient
confessed epigastric pain then spread
to all part of abdomen. Patient had
vomited 5x since before she
confessed abdominal pain. Patient
was weak. Bloody slim (-), water
leaked out from her womb (-). Patient
did not feel fetal movement since
28/04/2015, at night. Patient had gone
to traditional practitioner and got
abdominal massage there
(28/04/2015, 05.00)
History of DM (-), HT (-), asthma (-),
allergy (-)

Objective
General status
GC : poor
GCS: E3V5M4
BP : 60/40 mmHg
PR: 114 tpm
RR: 42 tpm
T: 36,4C
Local status
Eye : an (+/+), ict (-/-)
Pulmo: ves (+/+), rh (-/-), wh
(-/-)
Cor : S1S2 single regular M(-),
G(-)
Abd : distended,
tenderness(+), striae
gravidarum (+), linea nigra (+),
scar (-)
Ext : cool (+/+), edema (-/-)

LMP : 01/12/2014
EDD : 08/09/2015
GW : 21-22 weeks

Obstetric status
Leopold : can not be evaluated

History of ANC : 5x, at posyandu

Last ANC at 29/04/2015
Result BP 110/70, BW 54 kg, GW 21
weeks, UFH 1 finger below umblicus,
head presentation, FHB (+).

UFH: can not be evaluated

EFW : can not be evaluated
UC : FHB : (-)

History of USG : History of family planning: Next family planning: has not decided
Obstetric History:
I. This

VT : (-), head presentation,

OUE closed, active bleeding
(-)

Assessment
G1P0A0L0 21-22
weeks S/IUFD/IU
head presentation
with hypovolemic
shock e.c susp.
rupture of uteri, and
anemia gravis

Planning
DM planning:
Diagnostic planning
- Check CBC
- Use monitor
- Pro transfusion of PRC
Therapeutic planning :
- Pro O2 5 lpm, mask
- Pro doublle IV line RL
infusion
- Pro laparatomy
CIE planning
- CIE mother and family
about result of
examination, diagnostic
planning and therapeutic
planning
- CIE husband and family
to look for blood
transfusion
Obs. mother well being
DM co to GP, GP acc and
advice :
Check CBC
Pro EKG
Use monitor
Pro O2 5 lpm, mask
Pro ouble IV line RL
infusion
Pro drip vascon 0,1 mcg
by syringe pump

Time

Subjective
Chronologist:
(01/05/2015) 09.00
S : Patient with 5 months pregnancy
came to Gerung GH confessed
abdominal pain since 1 day ago.
Patient had gone to traditional
practitioner and got abdominal
masssage there.
O:
General status
GC : poor
GCS: E3V5M6
BP : 60 mmHg per palpation
PR: weak
RR: 20 tpm
Abdomen : defans muscular (+),
tenderness (+).
Obsetrical status :
UFH: did not evaluated
FHB ; VT: (-), OUE closed, blood flek (+)
Lab:
Hb: 5,5 g/dl
A : Hypovolomic shock e.c susp.
rupture of uteri + severe anemia
P:
Urine cathether
IVFD widahes 40 dpm, macro
O2 5 lpm, mask
RL 2000 cc
Drip vascon 5 mcg/KgBB (BW 60 Kg)
Kaltrofen supp per rectal
Inj. Cefoferaxon 1 gr

Objective
Lab:
HB: 2,9 g/dl
RBC: 1,02 M/dl
HCT: 8,4%
WBC: 43,89 K/dl
PLT: 173
MCV : 82,4 fL
MCH : 28,4 pg
MCHC : 34,5 g/dl
HbsAg: non reactive

Assessment

Planning

Time

Subjective

Objective

Assessment

Planning

17.05

GC : poor
GCS: E3V5M4
BP : 80/40 mmHg
PR: 128 tpm
RR: 47 tpm
T: 36,6C
UO: 150 cc

Obs. mother well

being

17.20

GC : poor
GCS: E3V5M4
BP : 100/40 mmHg
PR: 130 tpm
RR: 39 tpm
T: 36,6C
UO: 150 cc

Obs. mother well

being

17.35

GC : poor
GCS: E3V5M4
BP : 100/40 mmHg
PR: 134 tpm
RR: 42 tpm
T: 36,6C
UO: 150 cc

Obs. mother well

being

18.00

GC : poor
GCS: E3V5M4
BP : 100/40 mmHg
PR: 140 tpm
RR: 48 tpm
T: 36,4C
UO: 200 cc

Obs. mother well

being
GP co to SPV,
advice; pro
laparatomy
exploration and tell
dr. Elya Sp.An

GC : poor
GCS: E3V5M4
BP : 100/40 mmHg
PR: 133 tpm
RR: 40 tpm

18.30

Obs. mother well

being
GP co to dr. Elya;
acc laparatomy with
high risk

Time

Subjective

Objective

Assessment

Planning

18.35

Change NaCl infusion with

transfusion of PRC kolf I 40
dpm

19.40

Start laparatomy
exploration

Baby was born (20.05)

dead, male, BW 600 gram
(with placenta), BL 20 cm.

Duplex uterus, rupture one

of uteri.

Histrerektomi in the rupture

uterus.

Obs. general status and

vital sign
Obs. Input and output
dr. Elya, advice: tight
observation, tell family to
look for blood transfusion

21.00

21.30

General status
GC : weak
GCS : E3VxM5
BP : 100/50 mmHg
PR : 127 bpm
RR : 30 tpm
T : 36,40C
UO: 300 cc
Used RL infusion
Used blood transfusion kolf II
Used drip tramadol 30 dpm
Used vascon with syringe pump
General status
GC : weak
GCS : E3VxM5
BP : 100/50 mmHg
PR : 119 bpm
RR : 31 tpm
T : 36,40C
UO: 300 cc

Post laparatomy e.c

RUI

22.00

General status
GC : weak
GCS : E3VxM5
BP : 100/50 mmHg
PR : 126 bpm
RR : 33 tpm
T : 36,50C
UO: 300 cc

22.30

General status
GC : weak
GCS : E3VxM5
BP : 100/50 mmHg
PR : 119 bpm
RR : 37 tpm
T : 36,50C
UO: 300 cc

Kolf II of blood
transfusion finished,
changed to NaCl

23.00

General status
GC : weak
GCS : E3VxM5
BP : 100/50 mmHg
PR : 125 bpm
RR : 40 tpm
T : 36,50C
UO: 500 cc

Start kolf III of blood

transfusion

Time
(02/5/2015)
07.00

Subjective
-

Objective
General status
GC : weak
GCS : E3VxM5
BP : 120/80 mmHg
PR : 119 bpm
RR : 26 tpm
T : 36,40C
UO: 900 cc
Local Status:
Abd: distenstion (-),
tenderness (-), bleeding (-)
Lab:
Hb: 7,8 g/dl

Assessment
1 day post
laparatomy
histerectomy

Planning

Obs. Mother well being

Pro transfusion of PRC
until Hb 10 g/dl
Continue previuos
therapy

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