case no
IDENTITY
Patient Husband
Name : Mrs. E Name : Mr. M
Age : 34 years old Age : 50 years old
Admission number : 01082887 Education : Senior high school
Education : Senior high school Occupation : Enterpreneur
Occupation : Housewife Address : Alai, Pasaman
Address : Alai, Pasaman
Admission date: 25/05/2020
Primary survey
GA Conc BP Pulse RR T Σ urine SO2
mdrt CMC 120/60 100 30 36,7˚C 400cc/at the time /bright yellow 94%
GCS : 15
Airway : Patent
Breathing : Spontaneous, RR : 30 x/m SO2 94% O2 15 lpm (NRM)
Circulation : BP : 120/70 mmHg , Pulse 100 x/m IVFD RL 8 tpm
FHR 115-118 bpm
A/ Obs. Dyspneu ec MS-MR Severe on G3P2A0L2 36-37 weeks of preterm parturient latent phase of first stage
Management Plan:
Control GA, VS, FHR, Uterine contraction
Informed consent
Informed consent
Anestesiologist consult
O2 15 lpm NRM
Internist consult
IVFD RL 8 tpm
Cardiologist consult
Furosemide injection 5 mg/hour
Perinatologist consult
Half-sitting position
Pulmonologist consult
Laboratory check
Mrs. E, 34 years old, MR 01082887
Admission date Origin Preparation for surgery Diagnosis Plan
Cardiologist consult
Date : Origin: MS-MR severe NYHA FC III
Obs. Dyspneu ec MS-MR LSCS + bilateral
25/5/2020 PONEK RSUP Dr M Severe NYHA FC III on Fimbriectomy
Th/ CS with epidural anestesi
Djamil Padang Furosemid 5 mg/hour G3P2A0L2 36-37 weeks of
Time : echocardiography if the condition stable
operating tolerance
preterm parturient latent
18.30 Reffered from : risk of cardivascular complications : class II, 0,16 % (severe) phase of first stage + AFLP +
Lubuk Sikaping Hospital Internist consult PDP COVID-19 + fetal
DPJP : hypoglycemia distress
Liver impairment
VB Referral diagnose : AKI stage I ec pulmonary ec low cardiac output + metabolic acidosis
G3P2A0L2 36-37 weeks Mr-MS seveee NYHa FC III
of pregnancy + Progress Operation risk : to do operation in general anesthesia
Cardiological risk: evised cardiac risk index for preoperative risk
of labor + CHF + class III
suspected severe mitral Pulmonary risk: severe
Metabolic risk: severe
regurgitation Hematology risk: severe
Pulmonolgy consult :
PDP COVID-19
Anesthesiologist consult
Agree for operation
ASA 3
Perinatologist consult
Agree to assistance fetal resuscitation
Clinical Data Physical examination Supportive examination
Anamnesis GA Cons BP HR RR T Ultrasound
• The patient was reffered from Lubuk sikaping hospital to M. Djamil mdrt CMC 120/70 100 30 36,5 36-37 weeks of pregnancy according to biometric
Central General Hospital with diagnosed G3P2A0L2 36 -37 weeks of Fetal, Alive, singleton head presentation.
pregnancy + progress of labor + CHF + suspected severe mitral Weight : 68 kg
regurgitation Height : 150 cm CTG : category II
• shortness of breath since 3 weeks ago increased since 2 days before BMI : 29,8 ( overweight)
hospitalization
• patients complain of tightness at rest and reduced when half seated • Eyes : conjunctiva no anemic, sclera icteric Chest X-Ray : Pneumonia
• chest pain (-) palpitations (+) • Neck : JVP 5+2 cmH2O, no enlargement of thyroid gland
• headache (-) epigastric pain (-) blurred vision (-) Laboraorium
• Chest : Pulmo : vesicular, Rh (+/+), wh (-/-)
• Feeling pain from the waist referred to the groin since 3 hours ago Hb : 13,2
• cor :S1 S2 regular, pansystolic mur mur
• Bloody show from the vagina (+) since 3 hours ago Leu :9710
• Extremity : oedem -/-,
• Fluid leakage from the vagina was (-) Ht : 44
• Massive bleeding from the vagina was (-) Abdomen Plt : 133.000
• Amenorrhea since was 9 months Ins : Abdomen seemed enlarged in accordance to preterm Leukocytes count : 0/0/86/11/3
• first date of last menstrual period : 11-09-19 Estimation date of pregnancy, striae gravidarum (+), cicatrix (-) APTT : 42.2
delivery : 18-06-20 Leopold : PT: 18,3
• Fetal movement was felt since 5 months ago. L1 Uterine fundal palpated 4 finger below xyphoid processus, A Total protein : 6.6
• No complain of nausea, vomiting and vaginal bleeding neither large, soft, nodular mass was palpated Albumin : 3.6
during early pregnancy nor late pregnancy. L2 Hard and resistance structure was palpated on the left side. Globulin : 3.0
• Prenatal care to primary health care, once in a month since 2 months of Numerous small, irregular structure were palpated on the Bil tot/direk/indirek : 4.50/3.11/1.39
pregnancy, Control to obstetrician 3 times, 5,6,7 months pregnancy. right side SGOT/SGPT 438/171
L3 A hard mass was palpated, fixated Calsium : 9.1
• Menstrual history : menarche at 13 years old, irregular cycle since 6
month ago, 4-6 days each cycle with the amount of 5-6 times pad
L4 Convergen Ur/cr : 61/1,5
change/day with menstrual pain (-) RBG : 110
UFH : 29 cm EFW: 2480 gr Na : 133
Utrine contraction : 1-2/10-15”/weak K : 4.2
Previous illness history: Fetal heart sound : 115-118 x
• the patient is known as mitral regurgitation and has been Cl : 98
recommended for heart valve surgery, but the patient has refused GDS : 32
Genitalia
• There was no previous history of liver, kidney, DM, hypertension V/U within normal limit, vaginal bleeding (-) D-Dimer : >10.000
and allergic VT : cervical opening 2-3 cm, amnion sac (+), soft thick portio, HBsAg : non reactive
effacement 50-60 %, medial, transverse sagitalis suture palpated at Anti HIV : non reactive
Marriage history 1x in 2002 hodge I
History of pregnancy/abortion/delivery: 3/0/2
1. 2007/male/3700/term pregnancy/Spontaneous/midwife/alive
2. 2015/male/4200/term pregnancy/Spontaneous/midwife/alive
3. present
Operation Date Diagnose Outcome
date : Diagnose 25/5/2020 at 23.15 am
25/5/2020 Obs. Dyspneu ec MS-MR Severe NYHA FC III on G3P2A0L2 36-37 weeks of preterm parturient LSCS was performed
latent phase of first stage + AFLP + PDP COVID-19 + fetal distress male baby was born with
Operation date: BW : 2500 gram
BL : 46 cm
25/05/2020 Planning : A/S : 2/4
23.00 LSCS + bilateral fimbriectomy Placenta was delivered by mild traction on the umbilical
cord, complete, 1 piece, 17x 16 x 2,5 cm size ,
Operation: approximately 400 gr weight. The Umbilical cord lenght
LSCS + bilateral Instruction was approximately 43 cm, para central insertion.
fimbriectomy Control GA, VS, UC, FHR bilateral fimbriectomy was performed
Informed consent
DPJP : IVFD RL 8 tpm Postoperative Diagnosis
VB IVFD D 10% 6 hours/kolf P3A0L2 post LSCS oi fetal distress + MS-MR Severe
O2 15l/I NRM NYHA FC III + AFLP + PDP COVID-19 + post bilateral
D40% 2 Flc (IV) GDS : 425 fimbriectomy oi enough child
half-sitting position
Report to OK team Plan
Post operative treatment on ROI
Process
Instructions
Obs. Dyspneu ec MS-MR Severe NYHA FC III on G3P2A0L2 36-37 weeks of preterm parturient • Control GA, VS, UC, VB
latent phase of first stage + AFLP + PDP COVID-19 + fetal distress LSCS + bilateral • IVFD RL + 20 IU Oxytocin : metergin 1:1 28 dpm
fimbriectomy • Ceftriaxone inj 2 x 1 gram IV
• Pronalges supp (if needed)
• Post op laboratory check up
• Admitted to ROI
• intersivist appropriate therapy
Referral letter
CHEST X RAY
• Interpretation :
Cardiomegaly
CTR 65%
Pneumonia
PONEK CTG
Baseline : 105 bpm
Variability : 5-10 bpm
Acceleration : (-)
Deceleration : (+)
Fetal movement : (+)
Contraction : (+)
Conclusion : category II
Ultrasound
Ultrasound
Fetal, alive, singleton head presentation
Fetal movement was good
• BPD : 9.02 cm • EFW : 2613 gr
• HC : 32.52 cm • AFI : 8.4 cm
• AC : 32.29 cm
• FHR : 100 bpm
• FL : 6.12 cm
• SDAU : 4.30
• HL : 5.28 cm
• Placenta was implanted at corpus anterior , maturation grade II-III
Impression:
• 36-37 weeks of pregnancy according to fetal biometrics
• Fetal alive, singleton, head presentation
Laboratorium
Cardiolgist consult result
MS-MR severe NYHA FC III
Th/
LSCS with epidural anestesi
Furosemid 5 mg/jam
echocardiography if the condition stable
operating tolerance
risk of cardivascular complications : class
II, 0,16 % (severe)
Perinatologist consult
Agree to assistance fetal resuscitation
Internist consult result
Operation risk : to do operation in general anesthesia
Cardiological risk: evised cardiac risk index for preoperative risk class III
Pulmonary risk: severe
Metabolic risk: severe
Hematology risk: severe
Th/
• Bolus dextrose 40% 2 flacon than continue with IVFD dextrose 10% 6
hours / kolf -> check Glucose random / 30 minutes If GDS <100 --> repeat
dextrose bolus 40% 2 flc -> check glucose random / 30 minutes If the GDS
is still <100 and the patient is unconscious, continue inj. Hydrocortisone
100 mg/4 hours for 12 hours or dexamethasone 10 mg (bolus) followed by
2 mg / 6 hours. but if the patient is conscious -> give 20-30 grams of sugar
solution
• Drip Meylon 200 meq in 300 cc NaCL 0.9% -> run out in 8 hours
• as.folat 1x5 mg (po)
• bicnat 3x500 mg (po)-
• check hepatitis marker- check ur / cr per 3 days
Operation report
• Patient on supine position under General anaesthesia
• Antiseptic and septic procedure was performed mediana
incision was performed, layer by layer was opened until
peritoneal
• Semilunar incision on uterine low segment was performed
• Female baby was born by head traction, BW : 2500 gram, BL :
46 cm, A/S : 2/4
• Placenta was born with mild traction on the umbilical cord,
placenta size 17 x 14 x 2 cm, weight 400 gram
• Bilateral fimbriectomy was performed
• Double layer closure then performed
• Abdomen was closed layer by layer
• Skin closed by subcuticular closure
• Bleeding during operation approximately 250 cc
Follow up 26/05/2020 at 03.00
S/ under the influence of drugs
O/
GA Cons BP HR RR T sat 02
severe DPO 92/64 109 ON Ventilator 36.8 100%
Abd : Operation wound closed by verband. Uterine fundal palpated 3 fingers below umbilical, contraction was good
Genitalia : V/U normal. Vaginal bleeding (-)
A/ P3A0L2 post LSCS oi fetal distress + MS-MR Severe NYHA FC III + AFLP + PDP COVID-19 + post bilateral fimbriectomy oi medical
condition + puerperium day 1
P/ • Control GA, VS, UC, VB
• IVFD RL + 20 IU Oxytocin : metergin 1:1 28 dpm
• Ceftriaxone inj 2 x 1 gram IV
• Intersivist therapy :
• tranexamic acid injection 3x1 gr
• injection of vitamin K 3x10
• Ranitidine 2x50
• paracetamol 3x1 gr
• vascon titration
• dobutamine titration
• Meylon 200 meq
• folic acid 1x5 mg
Follow up 26/05/2020 at 07.00
S/ under the influence of drugs
O/
GA Cons BP HR RR T sat 02
severe DPO 110/70 80 ON Ventilator 36.8 100%
Abd : Operation wound closed by verband. Uterine fundal palpated 3 fingers below umbilical, contraction was good
Genitalia : V/U normal. Vaginal bleeding (-)
A/ P3A0L2 post LSCS oi fetal distress + MS-MR Severe NYHA FC III + AFLP + PDP COVID-19 + post bilateral fimbriectomy oi medical
condition + puerperium day 1
P/ • Control GA, VS, UC, VB
• IVFD RL + 20 IU Oxytocin : metergin 1:1 28 dpm
• Ceftriaxone inj 2 x 1 gram IV
• Intersivist therapy :
• tranexamic acid injection 3x1 gr
• injection of vitamin K 3x10
• Ranitidine 2x50
• paracetamol 3x1 gr
• vascon titration
• dobutamine titration
• Meylon 200 meq
• folic acid 1x5 mg
Thank You
