case obsgyn kista

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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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