Professional Documents
Culture Documents
Identity Patien
2.1
2.2
Identity
Name
: Mrs. N
Age
: 35 years old
Nationality
: Indonesian
Address
Education
: Elementary School
Marital Status
: Marrried
Occupation
: Housewife
Religion
: Moeslem
Date of Admision
: 17-07-1981
Anamnesis
Chief Complaint
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.
History of hypertension
History of diabetes mellitus
History of trauma
History of surgery
: denied
: denied
: denied
: 5 years ago SC
History of hypertension
History of diabetes mellitus
History of allergy
History of astma
History of genetic disorder
: denied
: denied
: denied
: denied
: denied
History of smoking
History of drug comsumtif
History of alcohol comsumtif
: denied
: denied
: denied
: 13 years old
Menstrual cycle
: 3-1-2016
Denied
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
History of Hipertantion
: denied
History of Anemia
: denied
: denied
: denied
Life
General condition
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
General Exanimation
Eyes
Mouth
Thorax
Heart
Lung
Mammae
Abdomen
Inspection
Palpation
Percussion
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
Vagina Toucher :
vulva looks umbilical cord baste
Vaginal palpable umbilical cord
Dilatation : 2-3 cm
Hb
: 4,9 g/dL
Ht
: 15,7%
Leukosit
: 14.300 cell/l
Eritrosit
Index erythrocyte
MCV : 92 fL
MCH : 32 fl
MCHC: 35 pg
: Non Reactive
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
moderatelt ill
Right : RL
appearance
(outside) post
1 gr IV
consciousness :
Compos mentis
x 500 mg IV
Vital sign
+ moderate anemia +
PRC
HR: 80x/minutes
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
RL
Urnation (+),
appearance
Defecation (+)
Level of
(outside) post
1 gr IV
consciousness :
Compos mentis
x 500 mg IV
Vital sign
: convex
P
: pain (-),
tenderness (-)
P
:-
: bowel sounds
Cefotaxime 2 x
Metronidazole 3
Observation of
vital sign
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.
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.
Postpartum hemorrhage
- Bleeding
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
Bleeding
Opened
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
Ultrasound
curette myometrium
2.
Management
Theory
Case
Management kala 3
Outside
Awaiting
signs
placenta
spontaneously.
Massage uterus after delivery of the suspect the existence of retained placenta : pro
placenta.
manual Placenta
curettage
Menagemnet
Theory
1. Repair
Case
KU (infusion, oxygen, control 1. Use O2, IVFD RL accelerated
If
unsuccessful,
compression.
of 2-3 cm.
ultrasound.
6. If no unsuccessful: hysterectomy.
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 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)
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
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.