Supervisor :

dr. Edihan, Sp. OG

Presented by :
Sendy Perdana / 2011-061-008
Natallia Batuwael / 2011-061-193
Olivia Dharmasanti / 2011-061-197

Department Of Obstetric And Gynecology

Medical Faculty Of Atma Jaya University

Patients and Patients Husband Identity

Name

: Mrs. I
Age : 37 y.o.
Address : Muara Baru,
Penjaringan, Jakarta Utara
Ethnic
: Betawi
Occupation
: Housewife
Education : Elementary
School
MR : 248621
Admitted : January 8th 2013

Name

: Mr. A
Age
: 38 y.o.
Address : Muara Baru,
Penjaringan, Jakarta
Utara
Ethnic
: Betawi
Occupation
: Workers
Education: Junior High
School

History Taking (1)

Chief complain :

Headache since 5 days before hospital admission.

History of present illness:

Five days before admission, she complained

headache, and she came to local health center
for her 7th pregnancy. In examination, her blood
pressure was 160/110mmgHg. She didnt take
any medicine. then patient came to the clinic with
the same complain, during the examination the
blood pressure was 180/110 mmHg, then referred
to the hospital due to increasing blood pressure.
She was planned by the obgyn doctor/physician
to have caesarean section and and the patient
choose strerilization for herself. She denied pain
abdominal, secretion nor blood from vagina.

History Taking (2)

No Blurring of visions, No epigastric pain, No
seizure, No spontaneus bleeding

History taking (3)

The patient had a history of hypertension on the

6th pregnancy.
No history of allergy.
No history of asthma.
No history of Diabetes.
No history of trauma.
No history of operations before.

History
taking
(4)

Antenatal care : five times at health care center with

history of hypertension (patient does not

remember

the exact number)

Menarche : 12 y.o.
Menstrual Cycle: regular, 30 days interval, 7 days

duration , dysmenorrhea Contraception

: oral contraception, early 2011

1st day of last menstrual Period : 1st week on April 2012

(the

patient forgot the exact date)

Estimated date of delivery

: 1st week January 2013

Obstetrical History
Gravida
Married
Time

: G7 P6 A0
: One time for 20 years.

Age of
Pregnancy

Labor
History

Sex

Birth
Weight

1. 1993

9 months

Spontaneous
vaginal
delivery

Female

2900 gr Breast milk

2. 1995

9 months

Spontaneous
vaginal
delivery

Female

3100 gr Breast milk

3. 1997

9 months

Spontaneous
vaginal
delivery

Male

2700 gr Breast milk

4. 2002

9 months

Spontaneous
vaginal
delivery

Male

3000 gr Breast milk

5. 2006

9 months

Spontaneous
vaginal
delivery

Female

3200 gr Breast milk

Spontaneous

Male

6. 2011

Breast
Milk/substitu
te

Status praesens (1)

January 8th 2013 , at.2.00 pm
General condition
Level of Conciousness
Blood Pressure
Pulse
Respiration Rate
Temperature
Body weight
Body height

: appear calm
: conscious
: 190/110 mmHg
: 114 beats/minute
: 24 breaths/minute
: 36,30C
: 62 kgs
: 143,5 cms

Status praesens (2)

Head

: normal shape
Eyes
: ananemic conjungtiva , anicteric
sclera, pupil
3mm/3mm
Ears
: normal shape, no secret
Teeth
: appear normal
Neck
: no lymph nodes enlargement
Thorax
Mammae
Both are symmetric with hyperpigmented
areola

Status praesens (3)

Lung :
Inspection : symmetry
Inspection : apical impulse
respiratory movement
was not inspected
on the both sides
Palpation
: apical impulse
Palpation : fremitus is
palpable
present on the both
Percussion:
symmetric areas
Upper side : ICS III
Percussion : sonor +/+
Left Side
: linea mid
Auscultation
:
clavicularis sinistra
breathing sound
Right Side : linea sternalis
vesicular, no rhonchi
dextra
and wheezing
Auscultation: heart sound I
& II N, murmur (-),gallop (-)

Cor :

Status praesens (4)

Abdomen
Inspection

: striae gravidarum +, linea nigra +

Palpation
: no pain
Percussion
: tympanic in all region
Auscultation : bowel sounds (+)
Extremity
Oedema -/ Physiologic Reflex
Biceps +/+
Triceps +/+

Patella +/+
Achilles +/+

Pathological Reflex -/-

Obstetrical Status (1)

Fundal height
: 35 cms
Fetal birth weight prediction
: 3.720 grams
Fetal Heart Beats
: 144 bpm

His : -

Obstetrical Status (2)

Leopold examination
Leopold I

: feels firm but irregular (botttom)

Leopold II : feels back on the left side
Leopold III : feels hard and round part (head)
Leopold IV : 5/5
Fetal lie : longitudinal

Obstetrical Status (3)

Vaginal Examination:

VT was not performed

CTG

CTGs Result
Fetal Heart Beats:
Baseline : 160 bpm
Acceleration Deceleration -

Uterus contraction:
Contraction: -

Fetal Motion:

1 motion in 20 minutes
observation

Conclusion:

Doubt NST

Laboratory Findings
(January 8th 2013)
Hb: 9,8 g/dl
Ht : 29 %
Leukocyte: 10.500/l
Trombocyte : 168.000/l
Blood type : O/ Rh: +
Bleeding time: 3 minutes
Clotting time: 5 minutes
Blood glucose: 78 mg/dl

Blood Chemistry
SGOT / AST: 24 U/l
SGPT / ALT: 19 U/l
Electrolyte
Sodium: 140 mmol/L
Potassium: 3,8 mmol/L
Calsium: 1,17 mmol/L
Chloride: 114 mmol/L
Renal Function
Urea: 11 mg/dl
Creatinine: 0,6 mg/dl
Carbohydrate
Random Glucose test: 84 mg/dl

Complete Urine
Sediment
Glucose: Leukocyte: 4-8/LPB
Protein: Three (+++)
Eritrocyte: 2-5/LPB
Bilirubin: Epitel: +/LPK
Urobilinogen: normal
Cylinder: -/LPK
Ph: 7,0
Crystal: Density: 1010
Bacteria: Occult blood: Satu (+) Others: Ketone: Nitrite: Leukocyte: Three (+++)

Admitting Diagnosis
Mother :

G7P6A0, 37 y.o., gravid 39-40 weeks, not in labor,

severe pre eclampsia with impending eclampsia.
Fetus : intrauterine, single, alive, head

presentation
Prognosis of mother
Prognosis of fetus

: dubia ad bonam
: dubia ad bonam

Course in The Ward

On admission:
Prepare for Sectio Caesarea

Operation report (1)

Pre-operative diagnosis:
G7P6A0, 37 y.o., gravid 39-40 weeks, not in labor,
severe pre
eclampsia with impending eclampsia.

Post-operative diagnosis:
P7A0, 37 y.o., post partus maturus with caesarean
section with indication severe preeclampsia with
impending eclampsia and post bilateral
fimbriektomy.
Incised tissue: Lower segment of uterus
Operation name: Transperitoneal Profunda Sectio
Caesaria

Operation report (2)

Operation duration = 60 mintutes
Parturition started at 8/01/2013 at 03.25 p.m.

in sectio caesare with indication severe

eclampsia with impending eclampsia and
bilateral fimbriectomy.
Child was born at 8/01/2013 at 03.33 p.m
with APGAR 9/9, body length 43 cms, birth
weight 2990 grams.
Placenta was born at 8/01/2013 at 03.34 p.m.

Operation report (3)

The patient was laid supine and spinal anesthesized.

The A/A action was done, and the sterile linen was
placed.
The operator made a pfannenstiel incision 12 cms.
After the peritoneum being opened, there appeared a
gravid uterus appropriate with aterm gestation.
There werent found any abnormality on both adnexa.
The plica vesica uterine being incised, then the lower
uterus segmen being opened.
At 03.33 p.m, the baby was born. Male sex, 2990
grams on birth weight, body length 43 cms, APGAR
score 9/9 with using vaccum

Operation report (4)

The umbilical cord was clamped and hanged.

The baby handed to perinatology.

Placenta was born at 03.34 p.m, cavum uteri
was cleaned, then the lower segment of
uterus being closed.
After the exploration, the operator carried
bilateral fimbriectomy.
The operation wound was closed layer by
layer.
Operation done at 04.25 p.m

Operation report (5)

Fetal membrane weight is 2990 grams, fetal cord

length at 43 cm
Bilateral Fimbriectomy was done
Post partum mother condition : moderately ill
General condition : moderately ill
BP = 160/90 mmHg, T= 36,7 oC, P = 100
bpm, RR = 24 bpm
Fundus height 2 cm below the level umbilical,
moderate uterine contractions. Total bleeding
400 cc

Post Operation Therapy

Bed Rest for 6 hours
Fasting until bowel sound +, then to drink

gradually
IVFD RL 1500 cc/24 hours + Oxytosin 20 IU, 10 IU,
10 IU in each RL
Ketorolac 3x50 mg IV
Cefotaxim 2x1g IV
Check HB 6 hours post op
Check UO / 4hr and Balance /24 hr
Check blood pressure fluctuation

Laboratory Follow Up
6 hours post operation Hemoglobin: 9,2 gr/dL

Instruction :
Give Ferofort Tab 1 x 1

DATE
2nd Day
09/01/20
13

S O A P
S : pain around operative
wound
+ , Flatus -,
Defecation
O : Appear calm
Fundal height: one finger
below the
umbilicus
Contractions intensity: strong
Bleeding : rubra, 40 cc
A : P7A0, 37 y.o., post partus
maturus with caesarean section
with
indication
severe
eclampsia
with
impending
eclampsia and post bilateral
fimbriectomy.
P : maintenance MgSO4 until 24 hr
amilodipine 1x10 mg

VITAL SIGNS
BP : 150/90 mmHg
P : 108 beats/min
T : 36,2 C
RR : 24 breaths/min
UO : 1.01 cc/kg/hr

DATE

3th Day
19/9/2012

S : Pain around operative

flatus +, defecation -

POD-1

VITAL SIGNS
wound +,

BP
Pulse
O: Appear calm
T
Fundal height : one fingers below the RR
umbilicus
Contractions intensity : strong
Bleeding : rubra, 20 cc
A: P7A0, 37 y.o., post partus maturus with
caesarean section with indication severe
eclampsia with impending eclampsia and
post bilateral fimbriectomy.
P: Change with oral therapy:
Amilodipine 2 x 10 mg p.o
Coamoxiclav 3 x 625 mg p.o
Mefenamic Acid 3 x 500 mg p.o
Gastrul 3 x I p.o

: 170/100 mmHg
: 112 beats/min
: 36,4C
: 22 breaths/min

Final Diagnosis
P7A0, 37 y.o., post partus maturus with

caesarean section with indication severe

preeclampsia with impending eclampsia and
post bilateral fimbriectomy.

Case Analysis
From History Taking and Physical Examination, we

can conclude:
The patient was pregnant
Gestational age 39-40 weeks
She was in first stage of labor on admission
She has risk factor of severe eclampsia with impending
No history of previously sectio caesarea

Case Analysis
The patient was pregnant
Fetal heart beat positive with baseline 144 bpm

Positive diagnostic sign :

Fetal heart tones can be detected as early as 9 to 10

weeks from the last menstrual period (LMP) by

Doppler technology.

Case Analysis
Gestational age 39-40 weeks
Last menstrual period : April 2012 (the patient forgot the

exact date) -> 39-40 weeks

Fundal height 35 cm.

CTG
CTG examination :
Fetal Heart Beats:
Baseline : 160 bpm
Acceleration Deceleration -

Uterus

contraction:
Contraction: -

Fetal Motion:

1 motion in 20 minutes
observation

Conclusion:

Doubt NST

Analysis for CTG

Criteria for Doubt NST
Fetal movement < 2 times in 20 minutes
examination
or accelaration < 10 bpm
Normal Baseline
Criteria for normal baseline
Frequency 120-160 bpm

Case Analysis
In anamnesa we found :
Headache since 5 days before hospital admission
History of hypertension on the 6 th pregnancy

In physical examination we found :

Blood Pressure : 190/110 mmHg
No epigastric pain
Oedema -/-

In laboratory findings,we found :

Proteinuria +++

Case Analysis
Criteria for Severe Pre-eclampsia:
Cyanosis
Microangiopathy hemolysis

Criteria for Impending:

blurry vision
Epigastric pain
Headache

INDICATION SECTIO
CAESAREAN
Maternal
Repeat cesarean delivery
Obstructive lesions in the lower genital tract,

including malignancies, large vulvovaginal

condylomas, obstructive vaginal septa, and
leiomyomas of the lower uterine segment that
interfere with engagement of the fetal head
Narrow pelvic absolute and abnormalities
(stenosis) that preclude engagement or interfere
with descent of the fetal presentation in labor
Placenta previa
Disporpotion of cephalopelvic
Rupture uteri

INDICATION SECTIO
CAESAREAN
Fetal
Breech
Dystocia
Fetal distress

Sectio Caesarean for

Preeclampsia
Indication :
Gestation < 34 weeks
unfavourable cervix,
previous Cesarean section,
bad obstetric history,
fetal distress,
failed induction of labor
intra-uterine growth restriction
(Obinna V Ajuzieogu1, Humphrey Azubuike Ezike. A retrospective study of the
outcome of cesarean section for women with severe pre-eclampsia in a third world
setting. University of Nigeria 2011.5:15-18)

Management of seizures
Seizures are usually self-limiting
MgSO4 is the ANTICONVULSANT of choice

Both in controlling as well as in preventing seizure

IV diazepam is NOT the drug of choice unless MgSO4 is not
available

Protocol
Loading dose of MgSO4 (4gr over 10-15minutes)

8 ml of MgSO4 dilute in 12 ml of NS (20 cc syringe)

Followed by maintenance dose of 1 gr/hour

50 ml (10 ampul) in 500 ml NS @ Hartmanns solution
Give at 21 ml/hour (1gr/hour)
Usually continued for 24 hours after delivery or after

the last convulsion (not 24 hours after starting

MgSO4)

If no IV access, administer MgSO4 through

deep IM route:
Loading dose : IM MgSO4 5gr (10ml) in each

buttock (10gr total) @ IV 4gr over 10-15

minutes
Maintenance : IM MgSO4 5gr every 4 hour
Extremely painful, risk of gluteal abscess
Addition of 1 ml of 1% xylocaine to the solution may
help to reduce the pain at the injection site

Monitoring when on
MgSO4
Hourly monitoring
Patellar Reflexes should be present

Earliest sign if toxicity develops

Respiratory Rate > 12-16 bpm

Urine Output > 30 ml/hour (@100 ml / 4 hour)

Ensure MgSO4 is excreted through the kidneys

MgSO4 does not cause renal impairment / failure

O2 saturation

THANK YOU