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CHAPTER II

Identity Patien

2.1

2.2

Identity
Name

: Mrs. N

Age

: 35 years old

Nationality

: Indonesian

Address

: kp.Tegal Sereh RT04/RW08

Education

: Elementary School

Marital Status

: Marrried

Occupation

: Housewife

Religion

: Moeslem

Date of Admision

: 17-07-1981

Anamnesis
Chief Complaint

: Placenta has not been born since 2 hour ago

Additional complaints:
Patients complain of the placenta has not been out since 2 hours. Complaint accompanied
by a feeling of heartburn and vagina bleeding. Patients experienced vagina bleeding
continuously .The volume of the bleeding more than 500 cc (3 times a diaper
change).Patients feel heartburn is increasing. 4 hours ago patient partus maturus with
vagina delivery helper by paraji, in home of the patient.The baby The placenta has not
come out half an hour,the patient was referred to a midwife. Midwives can not handle,
the patient referred to the RS Syamsudin. During the trip the patient is not treated.. After
arrifing to the RS Syamsudin the patients complain of the same as before.

2.3 History of Past Ilness :


-

History of hypertension
History of diabetes mellitus
History of trauma
History of surgery

: denied
: denied
: denied
: 5 years ago SC

2.4 Family History


-

History of hypertension
History of diabetes mellitus
History of allergy
History of astma
History of genetic disorder

: denied
: denied
: denied
: denied
: denied

2.5 Habitual History


-

History of smoking
History of drug comsumtif
History of alcohol comsumtif

: denied
: denied
: denied

2.6 Mensruation History


Menarche

: 13 years old

Menstrual cycle

:30 days, regularly,with duration 5-7 days,dysmenorrhea (-)

First day of last menstrual

: 3-1-2016

2.7 Marital History


Married once, last for 20years
Contraception History

Denied

2.8 Gestational History


N
O
1

Date

2002

2001

Gestational
Age
9 mounth

9 mounth
3

2011
9 mounth

2016
9 mounth

Labor History

Helper

Sex

Spontaneous
Vaginal
Delivery
Spontaneous
Vaginal
Delivery
Sectio Cesaria
a/I PPT

Paraji

Spontaneous
Vaginal
Delivery

Life

Birth
weight
3000

Paraji

3200

Life

Doctor
RS
Sekarwang
i
Paraji

forget

Life

3000

Life

2.9 Antenatal Care


Examination

: 3-4 times at midwife

History of Hipertantion

: denied

History of Anemia

: denied

History of sexual trsmited disease

: denied

History of tetanus toxoid immunization

: denied

Life

2.10 Physical Examination

General condition

: moderatelt ill appearance

Level of consciousness

: Compos mentis

Vital sign

(11-10-2016) EK

Blood pressure

: 90/60 mmHg

Heart rate

: 130 x/minutes

Respiration rate

: 20x/minutes

Temperature

: [37 Celcius]

SaO2

: 99 %

Weight

: 53 Kg

Height

: 155 cm

BMI

: 22,08 Kg/2 (Normoweight)

General Exanimation
Eyes

: icteric sclera (-), anemic conjunctiva (+/+)

Mouth

: wet mucosa oral, no signs of inflamation

Thorax
Heart

: cardiomegaly (-), regular heartbeat, murmur (-), gallop (-)

Lung

: simetric, vesicular breath sounds +/+, rhonchi -/-, wheezing -/-

Mammae

: areola hyperpigmentation +/+, nipple retraction -/-, ASI +/+

Abdomen
Inspection

: convex, striae gravidarum (-), linea nigra (-)

Palpation

: pain (-), mass(-), tenderness (-)

Percussion

: timpanic of all abdomen

Auscultation : bowel sounds (+), 8 times / minutes

Extremities

CRT >2 seconds, upper extremities physiologic reflex ++/++, bottom extremities
physiologic reflex ++/++, patologic reflex -/-/-/2. 11 Obstetric Examination
1. Inspection

: look flat, striae gravidarum (+), linea nigra (+), visible cord 20cm
in front of the vagina clamped with forceps.

2. Palpation

: Palpable TFU fingers equal the navel,


consistency of uterus : strong, tenderness (+)

Vagina Toucher :
vulva looks umbilical cord baste
Vaginal palpable umbilical cord
Dilatation : 2-3 cm

2. 12 Work Up Examination (11-10-2016) EK


o

Hb

: 4,9 g/dL

Ht

: 15,7%

Leukosit

: 14.300 cell/l

Eritrosit

: 1,2 million cell/l

Index erythrocyte

MCV : 92 fL

MCH : 32 fl

MCHC: 35 pg

Anti HIV quantitative

: Non Reactive

2.13 Admitting Diagnosis


Mrs. N 35 years old P4A0 partus maturus with vaginal delivery (outside) post partum
bleeding e.c retensio placenta+ anemia severe + Syok Hemoragik

2.14 Therapy At Admission


Diagnostic Plan:
Observation of vital signs, general condition, vaginal bleeding and amount of urine.
Treatment plan:
(Repair Shock)
Oxygen 3 liters / min with oxygen cannula
IVFD 2 line: left hand: liquid Ringer Lactate 500 cc / drip
Right hand: NaCl 0.9% 20 drops / minute + Plan 2 kolf Whole Blood transfusion
Install a urinary catheter
-

Check : Hb post transfusion

(shock resolve) : pro manual placenta


2.15

Prognosis
-

Quo ad vitam
Quo ad functionam
Quo ad sanctionam

: dubia
: dubia
: dubia

2.16 Follow Up
Tuesday (11-10-2016) VK
Date S

11Patient
10complaint
2016 abour
dizziness

General condition
:
moderatelt ill appearance
Level of consciousness
: Compos mentis

Mrs. N 35 years
old P4A0 partus
maturus
with
vaginal delivery
(outside)
post
manual
plasenta(at 09.45
AM) a/i post
partum bleeding
e.c
retentio
plasenta + anemia
moderate+post
shock hemoragic

- IVFD 2 line
Left : RL(5)
Right : RL
Cefotaxime 2 x
1 gr IV
Metronidazole 3
x 500 mg IV
Tranfusi 2 labu
PRC
- Drip oxytosin : 20 iu /
500 cc cairan
Lasix IV
Observation of
vital sign
Check : Hb post
tranfusi

Kateter (+),
defecation (-)

Diuresis : +
Bloody: below 200 cc
Hb post transfution 2
labu : 6,2 mg/dl
Eyes
: CA +/+
Abdomen
I: convex
P: pain
(-),
tenderness
(-)
P
:A
:Palpable TFU 1 fingers
below the navel,
consistency of uterus :
strong, tenderness (-)
Lokia : Rubra
Mobilitation :
Gradually

Tanggal

Jam

N
x/m
120

RR

S / SpO2

08.00

TD
mmHg
70/30 mmHg

30

36,7 / 99

08.15

70/40 mmHg

120

22

36,8 /100

08.30

80/60 mmHg

110

19

36,8 /100

08.45

90/60 mmHg

104

20

36,8 /100

09.00

100/60 mmHg

100

18

36,8 /100

09.15

100/60 mmHg

95

20

36,8 /100

09.45

110/70 mmHg

90

22

36,8 /100

10.00

120/70 mmHg

96

18

36,8 /100

10.30

110/70 mmHg

96

20

36,8 /100

11.00

120/70 mmHg

100

20

36,8 /100

14.00

120/80 mmHg

90

20

36,8 /100

15.00

120/80 mmHg

88

20

36,8 /100

16.00

110/70 mmHg

88

18

36,8 /100

17.00

110/80 mmHg

90

20

36,8 /100

18.00

110/70 mmHg

80

18

36,8 /100

19.00

110/80 mmHg

90

20

36,8 /100

20.00

120/80 mmHg

88

20

36,8 /100

11-10-2016

21.00

120/80 mmHg

80

18

36,8 /100

Follow Up
Wednesday(12-10 2016) VK

S
no complaint ,kateter

O
General condition:

A
Mrs. N 35 years old

P
IVFD 1 line

(+) Defecation (-)

moderatelt ill

P4A0 partus maturus

Right : RL

appearance

with vaginal delivery

(outside) post

1 gr IV

consciousness :

manual plasenta a.i.

Compos mentis

post partum bleeding

x 500 mg IV

Vital sign

e.c retention plasenta

TD: 120/80 mmHg

+ moderate anemia +

PRC

HR: 80x/minutes

post syok Hemoragik

Level of

Cefotaxime 2 x
Metronidazole 3
Tranfusi 1 labu
Observation of

RR: 20x/minutes

vital sign

Temperatur: [36,8

Celcius]

tranfusi

SaO2 : 100 %
Hb post transfution 1
labu : 7,1 mg/dl
Eyes

: CA -/-

Abdomen
I

: convex

: pain (-),

tenderness (-)

Check : Hb post

:-

:-

Palpable TFU 2
fingers below the
navel,
consistency of
uterus : strong,
tenderness (-)
Lokia

Rubra
Mobilitation
Active

Follow Up
Thursday (13-10 2016) MP
S
no complaint ,

O
General condition:

A
Mrs. N 35 years old

P
- IVFD 1 line Right :

kateter(-)

moderatelt ill

P4A0 partus maturus

RL

Urnation (+),

appearance

with vaginal delivery

Defecation (+)

Level of

(outside) post

1 gr IV

consciousness :

manual placenta a/i

Compos mentis

post partum bledding

x 500 mg IV

Vital sign

e.c retensio plasenta

TD: 120/80 mmHg


HR: 80x/minutes
RR: 20x/minutes
Temperatur: [36,8
Celcius]
SaO2 : 100 %
Hb post transfution 1
labu : 8,1 mg/dl
Eyes
: CA -/Abdomen

: convex
P

: pain (-),

tenderness (-)
P

:-

: bowel sounds

Cefotaxime 2 x
Metronidazole 3
Observation of

vital sign

(+), 8 times / minutes


Palpable TFU 2
fingers below the
navel,
consistency of
uterus : strong,
tenderness (-)
Lokia

Rubra
Mobilitation

Active
2. 16 Final Diagnosis
Mrs. N 35 years old P4A0 post partus maturus with vaginal delivery (outside) post
manual placenta a/i post partum bledding e.c retensio placenta

CHAPTER III
CASE ANALYSIS

Patients Ny. N age of 35 years referred to the hospital with the main complaints of
the placenta has not been born. Based on the results of anamnesis, physical examination,
and investigations, in patients diagnosed P4A0, 35 years, post partus maturus with
vaginal delivery (outside) post manual placenta a/i post partum bleeding e.c retensio
placenta + severe Anemia + Syok Hemoragic
1.
2.
3.

Whetrer the diagnosis made correctly ?


Whetrer the management of this patient correct ?
What are the risk factor that can be lead to retentio placenta in this patient ?

1.
Wherer the diagnosis made correctly ?
Anamnesis
Theory
Case
- The placenta has not been born 30 minutes - Babies born spontaneously and after 30
after the baby is born.

minutes, the placenta is not born

Postpartum hemorrhage

- There area postpartum hemorrhage more than

- Bleeding

more than 500 mL in normal 500 cc.

vaginal birth after birth


- Bleeding causing clinical symptoms such as - When you arrive at the hospital, the patient's
dizziness, syncope, hypotension, tachycardia or blood pressure: 90/60 mmHg
oliguri
- Classification: primer : when it occurs within
24 hours postlabor
- Secondary : if more than 24 hours postpartum

- This bleeding including primary postpartum


hemorrhage (<24 hours)

The history is based on the patient referred with complaints of difficulty in passing
pasenta after more than 30 minutes a baby was born, the placenta that support the
diagnosis retentio placenta. Based on the amount of bleeding that occurs in these patients
amounted to more than 500 CC so that it can be diagnosed as vaginal bleeding after
childbirth (postpartum) and are included in the primary classification because of a <24
hours postpartum.
The cause of postpartum hemorrhage :
Contraction

Trauma

retained

Clotting factor

placenta/retention
-

placenta
-

Normal

Normal

Strong

Normal

Strong

Abnormal

Atonia Uteri
Weak
(Tone)
Laceration of the Strong
birth canal
(Trauma)
Retained
placenta

retentio
(TISSUE)
Coagulation
Disorder
(Trombin)
In patients found:
- Contractions uterus
: Strong
- Lacerations of the perineum rupture : Denied
- The rest of the placenta / retained placenta was not born : account after 30 minutes the
baby was born. Ultrasound confirmation is required to determine the rest of the placenta.
- Clotting factors
:are not checked

Obstetric Examination
Symptom
Consistensi Uterus

Case
-

Strong

Involusion Uteri

1 fingers below the navel

Bleeding

More than 500 cc

visible cord 20 cm in front of the


vagina clamped with forceps.

Opened

Founds sign shock in the patient

Umbilical cord

Ostium Uteri
Symptom Shock

Based on the physical examination that has been done, get some signs that support
the diagnosis of retentio placenta consistensi uterus is strong, involution uteri is 1 finger
below the navel, vaginal bleeding more than 500 cc, umbilical cord is visible 20 cm in
frint of the vagina. The findings on physical examination is consistent with existing
theory and lead to the kind of retention plasenta, but to ensure do not necessary anatomic
pathology examination. One of the frequent complications include shock of hemoragic
due to bleeding, in this patient was found signs of shock.

Examination

Theory

Case

Routine blood tests will usually show signs of

Routine blood in patients:

anemia such as low hemoglobin levels.

Hb: 4,9 g / dl : severe anemia

Ultrasound

The placenta is not separated from the uterine

To determine the type of retained placenta

wall may be due to:

anatomical pathology examination is required

a. Less powerful contractions to release the

is taken from the placenta uterus / results

placenta (placenta adhesive)

curette myometrium

b. The placenta is firmly attached to the uterine


wall and therefore penetrate the villi decidua
korialis until myometrium-up under the
peritoneum (placenta accreta-perkreta)
Investigations were performed on these patients is routine blood laboratory tests,
ultrasound and pathology anatomy. From the results of routine blood tests, showed the presence
of anemia in these patients with a hemoglobin level of 4,9 g / dl. In this case ultrasound
examination and anatomical pathology not performed.

2.

Whetrer the management of this patient correct ?

Management

Theory

Case

Management kala 3

Outside

1. Management of physiological / wait

Oxygen 5 liters / min with oxygen cannula

Awaiting

signs

placenta

separated IVFD 20 IU of oxytocin in 500 CC RL

spontaneously.

liquid drip 20 drops / minute

2. Active management of the third stage

Installing urinary catheter to empty urinary

Giving uterotonic prior to delivery of the vesica


placenta.

Stretching controlled cord.

Pro manual placenta

If there is still bleeding continues, can we

Massage uterus after delivery of the suspect the existence of retained placenta : pro
placenta.

curettage with general condition was good.

manual Placenta
curettage
Menagemnet
Theory
1. Repair

Case
KU (infusion, oxygen, control 1. Use O2, IVFD RL accelerated

bleeding, blood transfusion).

2. Do external compression (massage of the

2. Search etiology. The most common cause is uterus).


an atonic.

3. Giving uterotonic (oxytocin IV drip).

3. Massage uterus and administration of 4. Do the exploration of the birth canal.


uterotonic.
4.

If

unsuccessful,

5. Do checks in looked panhandle and


perform

bimanual palpable cord, thick lower portion, the opening

compression.

of 2-3 cm.

5. If unsuccessful laparotomy and uterine 6. Suspect retentio placenta confirmed by


artery ligation and hypogastric.

ultrasound.

6. If no unsuccessful: hysterectomy.

7. Check Hb 6.7 g / dl transfusion 2

7. Exploration lacerations of the birth canal. If pumpkins.


there is to do sewing.
8. Exploration intrauterine, if the placenta has
not been born, was born with a pull cord
manually.
9. When the suspect placenta accreta, do a

hysterectomy,
10. If the suspect retained placenta, digitally
remove or curettage.
11. When there is suspicion of a blood clotting
disorder patient : consul Internist.

3.What are the risk factor that can be lead to retentio placenta in this patient ?
Adhesions are abnormal placental decidua formation occurs when disturbed.
Circumstances related include implantation in the lower uterine segment, above the scar tissue
sesareaatau section or other uterine incision after kuretasu uterus. In his review of the 622 cases
were collected between the years 1969 1945dan, fox (1972) noted the following characteristics:
a. Placenta previa in the identification of a third pregnancy affected.
b. A quarter of the patients had undergone cesarean section.
c. Nearly a quarter of almost underwent curettage.
d. A quarter is gravida 6 or more.
Mothers with pregnancies of more than 3 times or included multigravida have a higher
risk of postpartum hemorrhage compared with mothers who belonged primigravida (pregnant the
first time). This is because in multigravida, reproductive function decline and thus the likelihood
of postpartum hemorrhage becomes larger. (According to the book of obstetrics Williams vol. 1
edition of 21 things: 709),
In this case the patient had a history of cesarean 5 years ago a.i Plasenta Previa totalist.
While one of the etiological factors occurrence of retentio placenta is already history of
cesarean , then these patients had one etiological factor the can be lead of retentio placenta.

CHAPTER I
INTRODUCTION

Retentio placenta is the case that many of us encounter in healthcare, especially in


cases of obstetrics, therefore, retentio placenta could be a trigger factor in maternal
mortality.

Retentio placenta is not yet release of the placenta to exceed half an hour. This
situation can be followed by bleeding a lot, meaning that only part of the placenta that
have been separated so that requires action placenta manually immediately.2
Bleeding is the number one cause of death (40% -60%) of maternal mortality in
Indonesia. The incidence of postpartum hemorrhage due to retained placenta reported to
range from 16% -17%. One of the data the incidence of retained placenta in hospitals that
have been reported are in RSU H. Damanhuri Barabai, South Kalimantan for 3 years
(1997-1999) earned 146 referral cases postpartum hemorrhage due to retained placenta.
From a number of such cases, there is one case (0.68%) ended with the death ibu.1
Management kala 3 Management of physiological / wait Awaiting signs placenta
separated spontaneously. Active management of the third stage,Giving uterotonic prior to
delivery of the placenta. Stretching controlled cord.Massage uterus after delivery of the
placenta. Through check in or pull on the umbilical cord can be known whether the
placenta had separated or not, and if more than 30 minutes then we can do the placenta
manually

CASE REPORT
RETENTIO PLACENTA

Supervised by:
dr.Hesty Duhita P, Sp.OG
Presented by:
Dyah Raras Puruhita
(2011730130)

Department of Obstetrics and Gynecology


Medical Faculty of Muhammadiyah Jakarta University
RSUD R. Syamsudin, S.H., Sukabumi
2016

REFERENCE

1. Khoman, J.S. perdarahan hamil tua dan perdarahan post partum. Cermin dunia
kedokteran, (online). (www.portal
kalbefarma/files/cdk/files/19_PerdarahanHamilTuaDanPerdarahanPostPartum.pdf/,
diakses tanggal 26 Februari 2012).
2. Cunningham, G, F, dkk (2006). Obstetri Williams (Volume 1). Jakarta : Penerbit Buku
Kedokteran EGC. Edisi : 21.
3. Mochtar Rustam MPH, Sinopsis Obstetri (jilid 2). Jakarta : EGC, 1998.
4. Supono. Ilmu Kebidanan Bab Fisiologi. Palembang: Bagian Departemen Obstetri dan
Ginekologi Fakultas Kedokteran Universitas Sriwijaya, 2004.
5. Prawirohardjo, Sarwono. Ilmu Kebidanan Edisi Ketiga, Eds: Hanifa Wiknjosastro
dkk. Yayasan Bina Pustaka Sarwono Prawirohardjo, 2005.

CHAPTER IV
CONCLUTION

Final Diagnose
Mrs.N P4A0, 35 years, post partus maturus with vaginal delivery
(outside) post manual placenta a/i post partum bleeding e.c retensio

placenta + severe Anemia + Syok Hemoragic.


Management
1. Repair KU (infusion, oxygen, control bleeding, blood transfusion).
2. Search etiology..
3. Massage uterus and administration of uterotonic.
4. If unsuccessful, perform bimanual compression.
5. If unsuccessful laparotomy and uterine artery ligation and hypogastric.
6. If no unsuccessful: hysterectomy.
7. Exploration lacerations of the birth canal. If there is to do sewing.
8. Exploration intrauterine, if the placenta has not been born, was born
with a pull cord manually.
9. When the suspect placenta accreta, do a hysterectomy,
10. If the suspect retained placenta, digitally remove or curettage.
11. When there is suspicion of a blood clotting disorder patient : consul

Internist.
Etiology retention placenta in this case
In this case the patient had a history of cesarean 5 years ago a.i Plasenta
Previa totalist. While one of the etiological factors occurrence of retentio
placenta is already history of cesarean , then these patients had one
etiological factor the can be lead of retentio placenta.

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