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Case Presentation
Supervisor :
dr. Edihan, SpOG
Presented by :
Anthony Gunawan / 2010-061-136
Andika / 2011-061-159
Felicia Dewi / 2011-061-160
Department Of Obstetric And Gynecology
Medical Faculty Of Atmajaya University
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Patients Identity
Name : Mrs. y
Age : 27 yo
Marital status : married
Address : Kapuk Muara, Jakarta Nationality : Indonesian
Ethnic : Javanese
Occupation : House Wife
Graduated from : Senior High school Date of Admission : November 26th 2012
Date of Examination : November 26th 2012
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History Taking (1)
Chief complain :
Refered to Atmajaya hospital from PKC
Penjaringan due to fetal distress and premature
rupture of membrane.
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History Taking (2)
History of present illness:
On 26/11/2012 about 4 hours before admitted to the
hospital, patient felt abdominal contraction. She
felt it sometimes (1 -2x/hour,10 - 20, moderatepain) and radiating to back. She also felt mucous
and blood passed from her vagina, so she went to
puskesmas. About 2 hours before admitted to the
hospital, patient felt large amount of fluid passed
from her vagina. The fluid was watery and
greenish. After that patient was refered to the
hospital.
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History taking (3)
No trauma history.
No history of allergy
No history of seizure.
No history of taking herb during pregnancy No history of abdominal massage
No history of smoking cigarette
No systemic or hereditary disease
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History taking (4) ANC
9 times at puskesmas Menstruation History
Menarche: 13 years old Regular cycle, 28 days interval, 7 days duration, no
dysmenorrhea
First day of last menstrual period: March 1th
2012 Estimated date of delivery : December 6th 2012
Fetal movements :first felt by the patient at 3 month ofpregnancy
Marriage:1st marriage,4 years.
Contraception : -
Problems during pregnancy : -
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Obstetrical HistoryNo Date Gestationa
l age
Delivery Result
Sex BW Breastmilk
Explanation
1. This
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Status praesens (1)
November 26th 2012 , at.07.30
General condition : mildly ill
Level of Conciousness : compos mentis
Blood Pressure : 120/80 mmHg
Pulse : 80 beats/minute
Respiration Rate : 20 x/minute
Temperature : 36,4
0
C Body weight : 58 kg
Body height : 162 cm
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Status praesens (2)
Head : normocephalus Eyes : ananemic conjungtiva,
anicteric sclera
Mouth : wet oral mucosa
Chest:
Heart : Regular 1st and 2nd heart sound, murmur(-), gallop (-)
Lungs: Vesicular breath sounds, rales -/-,
wheeze -/- Breast: hyperpigmented areola +/+, nipple
retraction -/-, no breast milk
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Status praesens (3)
Abdomen
Inspection : convex, striae gravidarum +,linea nigra +
Palpation : supple, no pain Percussion : timpani
Auscultation : bowel sounds (+) 4times/minutes
ExtremityOedema -/-, acral warm, CRT < 2 seconds,
Physiologic Reflex +/+
Pathological Reflex -/-
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Obstetrical status
Leopold examination Leopold I : feel firm but irreguler (buttock) fundal
height 31 cm
Leopold II : feel back on the left side
Leopold III : feel hard and round part (head)
Leopold IV : 4/5 Expected birth weight : 2790 grams
Fetal lie : longitudinal
Fetus heart beat: 144 beats per minute
His : 2 x/10 minute, 18-20 second, moderate Vaginal toucher : v/v normal, cervix dilatation 2
cm, effacement 25%; amnion sac -, headpresentation , denominator cant be
determined, Hodge 1
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CTG
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CTG Report
Time : November 26th, 2012 (07.30) Position : supine
GA : 38-39 weeks
BP0 : 120/90 mmHg BP15 : 120/80 mmHg
VT :, v/v normal, retrflexion, cervixdilatation 2 cm, effacement 25%; amnion sac -, head presentation , denominator cant bedetermined, Hodge 1
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CTG Report
Baseline frequency 150 bpm, normalvariability
accelaration (+) 5x/20 minutes
Variable deceleration (+) 2x/20 minutes
Uterine contraction (+), frequency
3x/20minutes, base tone 20 mmHg,
amplitudo 40 mmHg, duration 15 seconds,relaxation (+).
No fetal movement.
Suspicious CST
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Laboratory findings
(November 26th 2012)
Hb : 11,9 g/dl
Ht : 34 %
Leukocyte : 10.800/l Trombocyte : 290.000/l
Blood type : O/ Rh +
Bleeding time : 2 minutes Clotting time : 4 minutes
Blood glucose : 99 mg/dl
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Admitting Diagnosis
Mother :
G1P0A0, 27 yo, gestational age 38-39 weeksby last menstrual period, inpartu, 1st stage
of labor in laten phase with prematurerupture of membranes.
Fetus :
single intrauterine fetus, alive, with head
presentation with fetal distress.
Prognosis of mother : bonam
Prognosis of fetus : dubia
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Analysis
From History Taking and Physical Examination, wecan conclude:
The patient was pregnant
Gestational age 38-39 weeks She was in first stage of labor on admission
Her amniotic membrane was ruptured with watery
green meconium in amniotic fluid
Single, intrauterine fetus, with fetal distress
No history of previously sectio caesarea
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The patient was pregnant
In this patient we find:
Fetal heart rate: 144bpm
Fetal movements are first felt by the
patient: 3 month
USG was performed at 12 october2012 and demonstrated fetal head.
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. Fetal movements are first felt by the
patient at approximately 16 to 18
weeks
USG will demonstrate an intrauterine
gestational sac at 5 to 6 weeks and a
fetal pole with movement and cardiac
activity at 6 to 8 weeks.
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She was in labor on admission
In this patient we find:
Mother feel abdominal contraction,she felt it became more stronger andlonger contraction.
There was a bloodyshow
VT : v/v normal, retro portio, cervix
dilatation 2 cm, effacement 25%;amnion sac -, green amniotic fluid,head presentation , denominatorcant be determined, Hodge 1
In the literature, sign of true labor
Contractions come at regular intervalsand get closer together as time goeson. (Contractions last about 30 to 70seconds.)
Contractions continue, despite
moving or changing positions. Contractions steadily increase in
strength.
Contractions usually start in the lowerback and move to the front of theabdomen.
Bloody show from vagina usually
appear before labor. Dilatation and depletion of cervix
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Her amniotic membrane was ruptured
In this patient we find:
In anamnesa, we found patienthas history of watery greenishfluid 2 hours before admission.
VT :amnion sac -
In the literature, rupture membrane : report a large gush of fluid with continued
leakage, leaving little doubt as to itssource.
Confirmation of rupture of membranes(ROM) :
-Physical examination : speculum exam.
-Laboratory testing : vaginal pH and ferntesting.
-Ultrasound : to evaluate amniotic fluidvolume if the status of the membranes isstill uncertain after physical and laboratorytesting.
-If the status of the membranes stillremains uncertain after the above
evaluations, a strip of nitrazine paper maybe placed on a perineal pad and the patientre-evaluated after ambulating for a periodof time. The patient should be questionedregarding the color of the liquid todetermine the presence of blood ormeconium.
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NST
Left lateral recumbent position
The record is should last 20 minutes
The baseline fetal heart rate should be withinin normal range (120 160 bpm)
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Reactive NST
Reactive NST include at least 2 acceleration fromthe baseline of at least 15 bpm for at least 15
seconds within 20 minutes testing period
The recording should continue for another 20
minutes
If the fetal heart rate tracing reminds non-reactive
after 40 minutes of testing contraction stress
test or a biophysical profile.
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CST
Caution should be used when using the
contraction stress test prior to 37 weeks
gestation in patient at risk for preterm labour
After a twenty minute NST is perform first
Uterine contractions are induced using
exogenous IV oxytocin or nipple stimulation
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CST
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CTG Analysis
Baseline frequency 150bpm, normal variability
Variable deceleration (+)
2x/20 minutes
Uterine contraction (+),frequency 3x/20minutes,
base tone 20 mmHg,
amplitudo 40 mmHg,
duration 15 seconds,
relaxation (+)
Suspicious CST
In the literature,
suspicious CST:
Presence of intermittent
late deceleration
Variable deceleration
Or an abnormal baseline
heart rate (160bpm).
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INDICATION SECTIO CAESAREAN
Maternal Repeat cesarean delivery
Obstructive lesions in the lower genital tract, includingmalignancies, large vulvovaginal condylomas,
obstructive vaginal septa, and leiomyomas of thelower uterine segment that interfere withengagement 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
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INDICATION SECTIO CAESAREAN
Fetal
Breech
Dystocia
Fetal distress
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Pre medication before Sectio
Caesarea
On admission
Prepare for SectioCaesarea
Position : left lateralpotition
O2 2 L / minute vianasal canule
IVFD RL 20drip/minute
Cefotaxime 2 g IV
Primperan 10 mgIV
In the literature,
premedication:
Repositioning of patient to the
lateral position
Discontinuation of uterinestimulants and correction of
uterine hyperstimulation
Correction of maternal
hypotensionDiscontinuing oxytocin serve to
improve uteroplacental perfusion
Monitoring of fetal heart
Administration of oxygen to
mother
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Operation Report
Preoperative Diagnosis : G1P0A0, 27 yo, gestational age 38-39 weeks by last
menstrual period, inpartu, 1st stage of labor in latenphase with premature rupture of membranes, singleintrauterine fetus, alive, with head presentation with
fetal distress. Postoperative Diagnosis :
- Mother: P1A0, 27 y.o, post partus maturus with SC dueto fetal distress and cystectomy due to dermoid cyst
sinistra.- Baby: female, term neonate, 39-40 weeks according to
NBS, APGAR 8/9, body length 47 cms, birth weight2570 grams.
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Operation report (2)
Operation duration = 1 hour 28 minute
Type of procedure: transperitoneal profunda C-section
Type of anesthesia: spinal anesthesia block,L3-L4
Parturiton started at 26/11/2012 at 09.42 a.m.in sectio caesare with indication fetal distress.
Female child was born at 26/11/2012 at 09.50p.m. with APGAR 8/9, body length 47 cms,birth weight 2570 grams.
Placenta was born at 26/11/2012 at 09.51 a.m.
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Operation report (3)
Fetal membrane weight is 660 grams,
complete cotyledon, calcification -,
hematoma -, insertio paracentral, fetal
cord length at 57 cms.
When examining the left adnexa, we
found dermoid cyst in the left ovary
It was decided to perform cystectomy
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Management of Ovarian cyst
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Dermoid Cyst / Mature Cyst Neoplasm
Germ cell Ovarian Cyst Neoplasm
Contain endodermal, mesodermal, and
ectodermal, with predominanly ectodermal
Dermoid Cyst
60% of Benign Ovarian Neoplasm
95% occur in women 15-50 years old
Rokistansky Protuberance / Dermoid plug
Local growth that protrude into cyst cavity
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Diagnosis of Dermoid Cyst
Ultrasonography, with characteristic:
Rokistansky Protuberance
Line and dots
Fat fluid / hair fluid
Tip of Iceberg
Treatment:
Definite treatmentSurgical excision
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Dermoid Cyst in Pregnancy
Treatment based on USG result Cyst > 10 cm Resection
Cyst 6- 10 cmEvaluate with USG doppler or MRI
If there are malignancy tendency
considered resectionMost of the functional cyst will mostly regress in this
period.
Other indication of resection:
Simptomatic Rapidly growing
Suspected ruptured / torsion
May cause obstruction in labor
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