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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


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 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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