Case No 58

Identity
Name : Mrs D
Age : 32 years old
Occupation : Housewife
MR : 766945
Admission Date : August 17th 2017
Chief Complaint
A 32 years old patient was admitted to the
Emergency Room of Dr.M.Djamil Central
Hospital on August 17th 2017 at 20.00, with a
chief complaint bleeding from vagina since 4
hours ago.
History of Present Illness
Bleeding from the vagina since 4 hours ago, wetting 5 piece of
underwear, dark red colored, and abdominal pain was negative
Meat-like tissue came out from the vagina was (+)
Eyes fish bubbles like tissue out from the vagina was (-)
Ammenorrhea since 3 mounth ago
First date of last menstrual period : 1 Juny 2017
This is the 7rd pregnancies
History of fever (-),trauma (-), and flour albus was (+)
No complain of miction or defecation disturbance
Menstruation history: Menarche at 13 years old, regular cycle,
once every 1 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:
There was no previous history of heart, lung, liver,
kidney, DM, hypertension and drug allergy.
Family Illness History:
There was no history of hereditary disease, contagious
and physiological illness in the family.
Occupation, Socioeconomics, Psychiatry, and Habitual History:
Marriage history: once in 2004
History of pregnancy/abortion/delivery: 7/0/6
1. 2005, female, 2900 gram, at term pregnancy, spontaneous labor, midwife,
alive
2. 2007, female, 3000 gram, at term pregnancy, spontaneous labor, midwife,
alive
3. 2010, male , 3200 gram, at term pregnancy, spontaneuos labor, midwife,
alive.
4. 2012, female, 3300 gram, at term pregnancy, spontaneous labor, midwife,
alive
5. 2014, female, 3400 gram, at term pregnancy, spontaneous labor, midwife,
alive
6. 2016, male , 3300 gram, preterm pregnancy, spontaneuos labor, midwife,
alive.
7. Present
 History of family planning :-
History of education : Junior high school
History of Occupation : Housewife
History of Habit : Smoke (-), Alcohol
(-), Drugs (-)
Physical Examination :

GA Cons BP HR RR T
Mdt CMC 110/70 110 24 36,7

BW before pregnancy : 50 kg
BH : 150 cm
BMI : 22,2 kg/m2 (Normoweight)
Upper arm circumference : 24 cm

Eyes :Conjunctiva wasnt anemic, Sclera wasnt icteric

Neck :JVP 5-2 cmH2O, tyroid gland no enlargement
Chest :H/L normal
Abdoment :OR
Genitalia :OR
Extremity :Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
 Obstetrical record
Abdomen:
I : Enlargement not seen
Pa : Uterine fundal palpated 1 fingers above SOP,
Abdominal tenderness (-), rebound tenderness (-),
Defans Muscular (-)
Pe : Tympani
Au : Peristaltic sound was normal
Genitalia

Inspection : v/u normal, Vaginal bleeding (+)

Inspeculo
Vagina : Tumor (-), laceration (-), fluxus (+), there was
blood red dark color at posterior fornix
Portio : MP, size equal to an adult toe, laceration (-), fluxus (+)
small amount of lood came out from cervical canal
, OUE was opened 2 cm
Bimanual VT
Vagina : tumor (-)
Portio : MP, size equal to an adult toe, cervical motion pain (-),
OUE was opened 2 cm
CUT : AF, size equal to duck egg, tumor (-)
AP : soft right left
CD : not protruded
Laboratorium Routine

PARAMETER RESULT NORMAL LIMIT

Hemoglobin 10.4 9,5-15
Leukosit 23.700 5.900 16.900
Hematokrit 270.000 28 40
Trombosit 28 146.000 429.000
PT 12,1 9,7-12,4
APTT 34,3 28,2-38,2
Diagnose:
G7P6A0L6 10-12 weeks of pregnancy + incomplete abortion
Management :
Control GA, VS, Vaginal bleeding
Informed consent
Antibiotics with skin test
Consult to anaesthetiologist
Report to OR

Plan :
Curettage
(21.45)
Curretage in narcose was performed
Curettage were systematically & carefully performed by
curette spoon no 8, 6, 3
50 gr conception tissue were retained
Blood loss 50 cc

Diagnose:
P6A1L6 Post curretage on indication incomplete abortion

Plan:
Monitoring post operative
 Th/
- IVFD RL + drip oxytosin : metergin = 1:1 20 gtt/mnt
- Urine Catheter 24hrs
- Cefixime 200mg 2x1 tab
- Mefenamic Acid 500mg 3x1 tab
- Vitamin C 50mg 2x1 tab
- SF 1x1 tab
THANK YOU