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

Patients Identity
Name Age Marital status Address Nationality Ethnic Occupation Graduated from Date of Admission Date of Examination : Mrs. y : 27 yo : married : Kapuk Muara, Jakarta : Indonesian : Javanese : House Wife : Senior High school : November 26th 2012 : November 26th 2012

History Taking (1)

Chief complain : Refered to Atmajaya hospital from PKC Penjaringan due to fetal distress and premature rupture of membrane.

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, moderate pain) 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.

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

 ANC 9 times at puskesmas

History taking (4)

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 of pregnancy Marriage:1st marriage,4 years. Contraception : Problems during pregnancy : -

Obstetrical History
No Date Gestationa l age Delivery Sex BW Result
Breast milk Explanation

1.

This

Status praesens (1) November 26th 2012 , at.07.30

General condition Level of Conciousness Blood Pressure Pulse Respiration Rate Temperature Body weight Body height : mildly ill : compos mentis : 120/80 mmHg : 80 beats/minute : 20 x/minute : 36,40C : 58 kg : 162 cm

Status praesens (2)

Head Eyes : normocephalus : 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

Status praesens (3)

Abdomen
Inspection : convex, striae gravidarum +, linea nigra + Palpation : supple, no pain Percussion : timpani Auscultation : bowel sounds (+) 4 times/minutes

Extremity
Oedema -/-, acral warm, CRT < 2 seconds, Physiologic Reflex +/+ Pathological Reflex -/-

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 -, head presentation , denominator cant be determined, Hodge 1

CTG

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, cervix dilatation 2 cm, effacement 25%; amnion sac , head presentation , denominator cant be determined, Hodge 1

CTG Report
Baseline frequency 150 bpm, normal variability 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

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

Admitting Diagnosis
Mother :
G1P0A0, 27 yo, gestational age 38-39 weeks by last menstrual period, inpartu, 1st stage of labor in laten phase with premature rupture of membranes.

Fetus

single intrauterine fetus, alive, with head presentation with fetal distress.

Prognosis of mother : bonam Prognosis of fetus : dubia

Analysis
From History Taking and Physical Examination, we can 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

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 october 2012 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.

Gestational age 38-39 weeks

In this patient we find:
Last menstrual period: March 1st 2012 38-39 weeks

Assessment of Gestational Age :

The time of onset of the last menstrual period used to predict date of labor.

Sonography

On admission, USG was not perform

She was in labor on admission

In this patient we find: Mother feel abdominal contraction, she felt it became more stronger and longer contraction. There was a bloodyshow VT : v/v normal, retro portio, cervix dilatation 2 cm, effacement 25%; amnion sac -, green amniotic fluid, head presentation , denominator cant be determined, Hodge 1 In the literature, sign of true labor Contractions come at regular intervals and get closer together as time goes on. (Contractions last about 30 to 70 seconds.) Contractions continue, despite moving or changing positions. Contractions steadily increase in strength. Contractions usually start in the lower back and move to the front of the abdomen. Bloody show from vagina usually appear before labor. Dilatation and depletion of cervix

Her amniotic membrane was ruptured

In this patient we find: In anamnesa, we found patient has history of watery greenish fluid 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 its source. Confirmation of rupture of membranes (ROM) : -Physical examination : speculum exam. -Laboratory testing : vaginal pH and fern testing. -Ultrasound : to evaluate amniotic fluid volume if the status of the membranes is still uncertain after physical and laboratory testing. -If the status of the membranes still remains uncertain after the above evaluations, a strip of nitrazine paper may be placed on a perineal pad and the patient re-evaluated after ambulating for a period of time. The patient should be questioned regarding the color of the liquid to determine the presence of blood or meconium.

Premature rupture of membranes (PROM)

In the literature, PROM: PROM is rupture of membranes prior to the onset of labor
Management Maternal vital signs and fetal monitoring. Ultrasonographic (gestational age, fetal weight, fetal presentation, and amniotic fluid index ). visual inspection of the cervix

Medical Treatment
Antibiotic
Ampicillin 2 g q6h and erythromycin 250 mg q6h iv for 48 hours.

Proceed to delivery

Fetal Distress
In this patient we find : Fetal activity in CTG (-) Fetal heart rate: 155bpm In CTG, we found variable deceleration We also found greenish meconium in amniotic fluid Diagnosis of fetal distress Reduced fetal activity Meconium in amniotic fluid Pattern on CTG :
Absent or decreased variability and one of the: o Persistent severe variable deceleration. o Persistent and nonremediable late decelerations. o Persistent severe bradycardia

Fetal metabolic acidosis/elevated fetal blood lactate level

NST
Left lateral recumbent position The record is should last 20 minutes The baseline fetal heart rate should be within in normal range (120 160 bpm)

Reactive NST
Reactive NST include at least 2 acceleration from the 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.

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

CST

Biophysical profile

CTG Analysis
Baseline frequency 150 bpm, 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 (<110 or >160 bpm).

INDICATION SECTIO CAESAREAN

Maternal
Repeat cesarean delivery Obstructive lesions in the lower genital tract, including malignancies, large vulvovaginal condylomas, obstructive vaginal septa, and leiomyomas of the lower uterine segment that interfere with engagement 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

INDICATION SECTIO CAESAREAN

Fetal
Breech Dystocia Fetal distress

Pre medication before Sectio Caesarea

On admission Prepare for Sectio Caesarea Position : left lateral potition O2 2 L / minute via nasal canule IVFD RL 20 drip/minute Cefotaxime 2 g IV Primperan 10 mg IV
In the literature, premedication: Repositioning of patient to the lateral position Discontinuation of uterine stimulants and correction of uterine hyperstimulation Correction of maternal hypotension Discontinuing oxytocin serve to improve uteroplacental perfusion Monitoring of fetal heart Administration of oxygen to mother

Operation Report
Preoperative Diagnosis : G1P0A0, 27 yo, gestational age 38-39 weeks by last menstrual period, inpartu, 1st stage of labor in laten phase with premature rupture of membranes, single intrauterine fetus, alive, with head presentation with fetal distress. Postoperative Diagnosis : - Mother: P1A0, 27 y.o, post partus maturus with SC due to 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 weight 2570 grams.

Operation report (2)

Operation duration = 1 hour 28 minute Type of procedure: transperitoneal profunda Csection 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 09.50 p.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.

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

Therapy post operation

Bed rest IVFD RL 1500 ml/24 hour Oxytocin 20 10 10 IU each kolf drip Cefotaxim 3 x 1 gr IV Kaltrofen 3 x 1 supp (per rectal) Tramadol 3 x 50 mg IV drip Hb check 6 hours post op Monitoring urine output and balance every 4 hours

Ovarian Cyst
Incidence 5-15 % of all women Histologically divided into:
Ovarian cyst Neoplasm Functional Ovarian Cyst

Symptom:
Mainly Asymptomatic Pain Hormonal imbalance

Management of Ovarian cyst

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

Diagnosis of Dermoid Cyst

Ultrasonography, with characteristic:
Rokistansky Protuberance Line and dots Fat fluid / hair fluid Tip of Iceberg

Treatment:
Definite treatmentSurgical excision

Surgical Excision of Dermoid Cyst

Cystectomy
Premenopause Preservation of reproductive capacity Small cyst

Oophorectomy
Postmenopause Large Cyst

Dermoid Cyst in Pregnancy

Treatment based on USG result
Cyst > 10 cm Resection Cyst 6- 10 cm Evaluate with USG doppler or MRI If there are malignancy tendency considered resection Most 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

When to do Resection in pregnancy?

Ovarian cyst initially noted ini first trimester,Surgical Excision mostly done in the 14-20 week of gestation Ovarian cyst initially detected in third trimester, surgical excision generally performed during labor or postpartum

Final Diagnosis
P1A0, 27 y.o, post partus maturus with SC due to fetal distress and cystectomy due to dermoid cyst sinistra. Fetal distress :
In CTG, we found variable deceleration with no fetal movement We also found green meconium in amniotic fluid

DATE

S O A P

VITAL SIGNS

2nd Day 27/11/2012

S : pain around operative BP : 130/70 mmHg wound + P : 82beats/min O : mildly ill Fundal height : T : 36,2 C RR : 22 breaths/min umbilicus Contractions intensity : UO: 0,8 cc/kg/hour moderate Lochia : A :P1A0, 27 y.o, post partus maturus with SC due to fetal distress and cystectomy due to dermoid cyst sinistra. P : coamoxiclav 3 x 625 mg p.o methergin 3 x 0,125 mg p.o mefinal 3 x 500 mg p.o

References
Cunningham, et al. Williams Obstetric, Twenty-Third Edition. United States: McGrawHill. 2010. Sarwono Prawiroherdjo. Ilmu Kebidanan. Jakarta: PT. Bina Pustaka Sarwono Prawirohardjo. 2010. http://emedicine.medscape.com/article/2634 24-overview http://www.aafp.org/afp/2008/0115/p245a.h tml