mr 13-11-2012

MORNING REPORTNovember 13th 2012

RESIDENT IN CHARGE :Bom/Lum/Rut/Hay/Tir/Ron/Dan

CHIEF : dr. Ton

SUPERVISOR :dr. Bambang Rahardjo, SpOG

dr. Sutrisno, SpOG-Kdr. Samodra Soeparman, SpOG

EMERGENCY ROOM : 3DELIVERY ROOM Physiological Delivery : 3Pathological Delivery

Perabdominam : 1

1

IDENTITY

• Register : 1232787• Mrs. F / 43 y.o./ 6 y.o.e / housewife• Mr. K / 42 y.o./ 6 y.o.e / farmer• Married 1x, 25 years • Address : Ds. Wringin Anom Rt.28 Rw.06

Poncokusumo• Admission : November 13th, 2012 at 09.30 pm

SUBJECTIVEPatient was referred by the name of a general practitioner PHC Tumpang with G3P2002 GA 36-37 weeks with suspect transverse lie + severe preeclampsia

13-11-2012 •At 05.00 am patient felt uterine contraction still stayed at home•At 03.00 pm patient felt uterine contractions more frequent went to Tumpang PHC, examined with BP=180/... + suspect transverse lie patient was suggested referred to RSSA patient and family still discussed•At 05.00 pm patient felt fluid excess from birth canal still looking for vehicle•At 08.00 pm went to RSSA

SUBJECTIVE

• History of hypertension before pregnant (+) since 3 years ago, patient never took any medication

• History of nause (-), vomitting (-), epigastric pain (-), blurred vision (-), headache (-)

• Patient never knew before that her pregnancy was in transverse lie.

SUBJECTIVE

• History of previous delivery:1. At/3300/SptB/Midwife/M/24 y.o/L2. At/2800/SptB/Midwife/F/18 y.o/L3. This pregnancy

• ANC : midwife 2x, last control October 13th 2012

• LMP 23-2-2012 ~ 37-38 weeks ̴� • Contraception: injection every 3 month, stop 1 year

ago

OBJECTIVE• GA : Good, CM• BH : 160 cm BW : 67 kg • BP : 170/100 HR : 88 x/m RR : 20 x/m• Tax : 36,5 ˚C , Trec : 36,7 ˚C• H/N: an -/- ict -/-• Th : c/ S1S2 single, murmur(-)

p/ rh Ξ/Ξ wh Ξ/Ξ • Abd: FH 27 cm, ʘ 102 cm, transverse lie,

FHR : 130 x/m (doppler), EFW: 2754 gr, Uterine contraction 10.3.30/ms

OBJECTIVE

• VT (after SM inj)

– Ø 4 cm, eff 100 %, HI, amniotic membrane (-) clear– Presentation small part of the baby– Denominator difficult to evaluated– Pelvic measurement : wnl

USG

Fetus intrauterine single life, transverse lie right head dorso superior•BPD : 92,7 (37w 5d)•AC : 296 (33w 4d)•FL : 73.2 (37w 3d)•EFW : 2732 gram•AFI : 7,2Placenta implanted at cornual fundal dextra, maturation gr III

CTGNormal•Baseline rate : 130 bpm•Variability: 5-15 bpm•Acc. : (+)•Dec. : (-)

LABORATORY

• CBC : 14.420/ 13,8/ 39,4/ 274.000• RBS : 73• Alb : 3,52• LDH : 586• SGOT/SGPT : 20/20• Ur/Cr : 16/0,55• Na/K/Cl : 135/4,13/114• PPT : 9,6 (10,9)• APTT : 27,4 (26,2)• Urinalysis : protein trace

ASSESSMENT

G3 P2002 Ab000 part 37-38 weeks S/L+ First stage active phase+ Transverse lie right head dorso superior+ Chronic hypertension SIPE+ Secondary old prime+ Age > 35 y.o

PLANNING

PDx: consult cardio and ophtalmology departementPTx: Proposed to terminate by cesarean section cito + Tubectomy Pomeroy Inj SM Full dose, SM 20% bolus iv slowly, SM 40% 10 gram im right-left

buttock continued with SM 40% 5 gram drip in RD5% every 6 hours if contraindication (-)

Preparation for operation:– Prepare blood/ c. Anestesi/ register OR– IVFD RL 1000 cc– Inj ampicillin 1 gram iv (skin test) – Inj metoclopramid 1 amp– Inj ranitidine 1 amp– Tocolitic : kaltrofen supp II perrectal – Informed consent

PMo: VS, complain, uterine contraction, FHR, urine production, patellar reflex, fluid balance/ 6 hours, sign of impending eclampsia

CIEc/ SPV ________________________ Acc dr. BAR, SpOG

OUTCOME

On November 14th, 2012 at 01.15 amFemale baby born

BW 2690 gr/ 46 cm / AS 7-9

TERIMA KASIH

2

IDENTITY

• Register : 11074766• Mrs. W / 22 y.o./ 9 y.o.e / housewife• Mr. A / 22 y.o./ 9 y.o.e / factory labour• Married 1x, 5 bulan • Address : Ds. Pakis Kembar RT 1 / 2 Pakis Malang• Admission : November 2nd, 2012 at 04.00 am

SUBJECTIVE

Patient was referred by a midwife with G1P0Ab0 GA 24-28 wks susp premature fluxus active

1-11-2012 •At 11.00 pm patient felt uterine contraction still stayed at home2-11-2012•At 01.00 am patient felt uterine contraction more frequent accompanied with blood excess from birth canal ± 3 female napkins went to midwife reffered to Saiful Anwar Hospital•History of trauma (-), massage (-), coitus (+)

SUBJECTIVE

• History of previous delivery:1. This pregnancy

• ANC : midwife 2x

• LMP 9-5-2012 ~ 26-28 weeks ̴� • Contraception: (-)

OBJECTIVE

• GA : good, CM• BP : 100/70 HR : 100 x/m RR : 20 x/m• Tax: 36,0 ˚C , Trec : 36,1 ˚C• H/N: an -/- ict -/-• Th : c/ S1S2 single, murmur(-)

p/ rh Ξ/Ξ wh Ξ/Ξ • Abd : FH 19 cm, longitudinal bujur U , EFW : 930

gr, FHR : 160 x/m (doppler), uterine contraction (+) rarely

OBJECTIVE• GE : flux (-), fluor (-)• Insp:

Fluxus (+), clot (+)Fluxus coming out from OUEOUE opened 2 cm, tissue (+)Laseration (-), varises (-)

• VT : didn’t performed

USG

Fetus intrauterine single life, longitudinal lie head below•BPD : 64,5 (26w1d)•AC : 202 (24w2d)•FL : 44.7 (24w5d)•EFW : 802 gram•AFI : 2,1Placenta implanted at corpus anterior spreading covering OUI, maturation gr I

Lab Result• CBC : 20.470/10,4/29,3/249.000 • PPT : 10,3 (11,0)

APTT : 27,7 (25,4)

ASSESSMENT

• G1 P0000 Ab000 gr 26-28 weeks S/L+ Mid trimester bleeding+ Fluxus active

PLANNING

PDx: -PTx: Pro termination with hysterotomi cito Preparation for operation:– Prepare blood/ c. Anestesi/ register OR– IVFD double line – Insert DC– Inj Gentamycin 80 mg iv – Inj metoclopramid 1 amp– Inj ranitidine 1 amp– Tocolitic : Kaltrofen supp II per rectal – Informed consent

PMo: VS, complain, uterine contraction, FHR, flux CIEc/ SPV Acc dr. BAR, SpOG

OUTCOME

On November 2, 2012 at 05.35 ammale baby bornBW gr/ cm /

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