CASE NO.

7
 IDENTITY
Name : Mrs. J
Age : 40 years
Address : Lubeg, Padang
MR : 98 16 33
Date : July 3rd 2017
 Anamnesis (Alloanamnesis)
A 40 years old patient was admitted to the emergency room of Dr. M. Djamil
Central General Hospital on July 2th, 2017 at 11:00 pm referred from Primary
Hospital with diagnose G3P2A0H2 34-35 weeks of preterm pregnancy + total
placenta previa suspect
Present illness History
There was massive vaginal bleeding in 2 hour ago, colour was red,
wetting one cloth, and then the patient was consult with obstetrician and
gynaecologist in Padang Primary Hospital and then the patient referred
from Padang Primary Hospital to the emergency room of Dr. M. Djamil
Central General Hospital with diagnose G3P2A0H2 34-35 weeks of
preterm pregnancy + total placenta previa suspect.
At emergency room wasnt massive bleeding.
Pelvic pain to the groin was (-)
Bloody show from the vagina (-)
There was no fluid leakage from the vagina
Amenorrhea since 8 months ago.
First date of last menstrual period on november 23rd 2017
Estimation date of delivery on august 1st 2017.
No complain of nausea, vomiting, or vaginal bleeding neither during early
nor late pregnancy
Fetal movement was felt since 4 months ago.
Menstrual history : menarche at 13th years old with irregular menstrual
period, last for 5-7 days, 2-3 times pad change/day. Menstrual pain was
(-).
 Previous Illness History :
There wasnt previous history of heart, lung, liver, kidney, DM and
hypertension.
Theres no allergic history

Family Illness History :

There wasnt history of hereditary disease, contagious and
physicological illness in the family.
 Marriage history : 1 x on 2012
History of pregnancy/abortion/delivery : 3/0/2
1. 2013/ Female/ 4000 gr/ term pregnancy/ CS/ OBGYN/alive
2. 2015/male / 3800 gr/ term pregnancy / CS/ OBGYN/alive
3. Present

History of family planning : (-)

History of immunization : (-)
History of education : Elementary school graduated
History of occupation : housewife
Habitual history : alkoholic (-), Smoking (-), drugs(-)
Physical Examination
GA Cons BP PR RR T
Moderate CMC 120/80 84 21 36,5

EBW before : 45 kg
BW : 55 kg
BH : 150 cm
BMI : 22,9(normoweight)
UAC : 24 cm
Eyes : Conjunctiva wasnt anemic, Sclera wasnt icteric
Neck : JVP 5-2 cmH2O, no enlargement of thyroid gland
Chest : H/L normal
Abdoment : OR
Genitalia : OR
Extremity : Edema -/-, Physiological Reflex +/+ (achiles),
Pathological Reflex -/-
Obstetric Record
Abdomen
Inspection : Abdomen seems enlarged in accordance to term pregnancy,
mid line hyperpigmentation (+), striae gravidarum (+), cicatrix (-)

Palpation :
L1 Uterine fundal height was palpated 3 fingers upper the umbilicus. A large,
soft, nodular mass was palpated.
L2 hard and resistance structure was palpated on the left side.
Numerous small, irregular structure were palpated on the right side
L3 NO mass was palpated
L4 -
UFH: delivery couldnt be determined ; Uterine contraction : (-)
Percussion : Tympani
Auscultation : Peristaltic sound was normal,
Fetal heart rate: 140-150 bpm.
Genitalia : I : V/U were normal
 LABOR, ON JULY 1ST 2017
PEMERIKSAAN HASIL SATUAN NILAI RUJUKAN
Hb 8,4 g/dl 12-16

Lekosit 7.210 /mm3 5000-10000

Trombosit 217.000 /mm3 150.000

Hematocrit 25 % 37-43

PT 10,2 Detik 9,2 12,4

APTT 36,3 detik 28,2 38,2

INR <1,2
GDS 84 Mg/dl <200

Ureum darah 8 Mg/dl 10,0 50,0

Kreatinin darah 0,6 Mg/dl 0,6 1,1

Kalsium 7,0 Mg/dl 8,1 10,4

Natrium 138 Mmol/L 136 145

Kalium 3,1 Mmol/L 3,5 5,1

Klorida serum 111 Mmol/L 97 111

Total pretein 4,5 g/dl 6,6 8,7

Albumin 2,7 g/dl 3,8 5,0

Globulin 1,8 g/dl 1,3 2,7

Bilirubin total 0,4 Mg/dl 0,3 - 1,0

Bilirubin direk 0,2 Mg/dl < 0,20

Bilirubin indirek 0,2 Mg/dl < 0,60

SGOT 13 u/l < 32

SGPT 6 u/l < 31

LDH 513 u/l 240 480

USG
Ultrasound:

Fetal alive singletone intrauterine head presentation

Fetal movement was good
Biometri :
BPD : 89,1 mm
FL : 69,9 mm
AC : 318 mm
EFW : 2016 gr
AFI : 21,3 mm

Plasenta planted at anterior corpus expanding to OUI

grade II III
Impression : 35-36 weeks of preterm pregnancy
CTG
 Baseline : 135 dpm
Variabilitas : 5-10 dpm
Aceleration : (+)
Deseleration : (-)
Contraction : (-)
Impression : reactive CTG
D/ G3P2A0H2 36-37 weeks of preterm pregnancy + Total placenta previa
suspect accreta + twice previous cs
fetal alive singleton, intra uterine, head presentation

Management
Control GA, VS, His, FHS, fluid balance
Complete labor examination (blood)

Plan : USG fetomaterna

Consult accreta team
USG
Ultrasound:

Fetal alive singletone intrauterine head presentation

Fetal movement was good
Biometri : Accreta index :
BPD : 88,6 mm After Cesarean : 3,0
HC : 61,3 mm Lacunae grade 3 : 1,0
FL : 68.6 mm Thick myometrium: 1,0
AC : 318,9 mm Placenta accrete : 1,0
EFW : 2766 gr Bridging vein : 0,5 +
AFI : 12,23 cm 6,5 (63%)
SDAU : 2,13
Plasenta planted at anterior corpus expanding to OUI
grade III
Impression : 35-36 weeks of Aterm pregnancy
Total Placenta previa suspect accreta (63%)
CTG
 Baseline : 140 dpm
Variabilitas : 5-15 dpm
Aceleration : (+)
Deseleration : (-)
Contraction : (-)
Impression : reactive CTG
Follow up on July 4th 2017 :

S/
There was massive vaginal bleeding (+)
Pelvic pain to the groin was (-)
O/
GA Cons BP PR RR T
Moderate CMC 120/80 84 21 36,5
Abdomen
UFH: - Uterine contraction : (-)
Fetal heart rate : 140-150 bpm.
Genitalia : I : V/U were normal
D/ G3P2A0H2 36-37 weeks of preterm pregnancy + Total placenta previa
suspect accreta + twice previous CS
fetal alive singleton, intra uterine, head presentation
Management
Control GA, VS, His, FHS, fluid balance
Report to urologist
Consult to anesthesiologist & perinatology
Plan : section caesarean + tubectomy pomeroy
July 5th 2017, At 08.00 am
Caesarean sectio was performed
A male baby was born with 2700 gr weight, 46 cm height and Apgar
Score was 8/9
Placenta was delivered by little traction on umbilical cord, not
complete, 14 x 12 x 3 cm size and 400 gr weight.
Umbilical cord was 50 cm length, paracentral insertion.
Bleeding can not stop, histerektomi was performed
Uterine was delivered
Bleeding during procedure 350 cc

Diagnose :
P3A0L3 post caesarean histerektomi oi Total placenta previa accreta
Suspected + twice previous CS
Mother and child were in care
Plan:
Post Op Observation in ICU
Control general condition, vital sign,
Injection ceftriaxone 2x1 gr
Transfusion PRC 6 unit
Injection tranexamat acid 3x500mg
Pronalges supp if needed