CASE NO.

11
 IDENTITY
Name : Mrs. L
Age : 35 years
Address : Padang Besi
MR : 97 57 24
Date : July 3rd 2017
 Anamnesis (Alloanamnesis)
A 35 years old patient was admitted to the ward room of Dr. M. Djamil Central
General Hospital on July 3th, 2017 at 10:00 am referred from policlinic room of Dr.
M. Djamil Central General Hospital with diagnose G3P2A0H2 term pregnancy +
twice previous CS + suspect placenta accreta 63%

Present illness History

Before a 35 years old patient was admitted to the ward room of Dr. M. Djamil
Central General Hospital on July 3th, 2017 at 10:00 am referred from policlinic
room of Dr. M. Djamil Central General Hospital with diagnose G3P2A0H2 term
pregnancy + twice previous CS + suspect placenta accreta 63%
Pelvic pain to the groin was (-)
Bloody show from the vagina (-)
There was no fluid leakage from the vagina
Massive bleeding from the vagina (-)
Amenorrhea since 8 months ago.
First date of last menstrual period was forgotten
Estimation date of delivery couldnt be determined.
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/ 3500 gr/ term pregnancy/ CS/ OBGYN/alive
2. 2015/male / 3000 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 A hard mass was palpated, floating
L4 Convergent
UFH: 34 cm EBW: 3255 gr; Uterine contraction : (-)
Percussion : Tympani
Auscultation : Peristaltic sound was normal,
Fetal heart rate: 140-150 bpm.
Genitalia : I : V/U were normal
 LABOR, ON JULY 3rd 2017
PEMERIKSAAN HASIL SATUAN NILAI RUJUKAN
Hb 10,4 g/dl 12-16

Lekosit 6.030 /mm3 5000-10000

Trombosit 236.000 /mm3 150.000

Hematocrit 31 % 37-43

PT 9,5 Detik 9,2 12,4

APTT 37,1 detik 28,2 38,2

INR <1,2
GDS 120 Mg/dl <200

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

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

Kalsium 8,3 Mg/dl 8,1 10,4

Natrium 134 Mmol/L 136 145

Kalium 3,6 Mmol/L 3,5 5,1

Klorida serum 105 Mmol/L 97 111

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

Albumin 3,9 g/dl 3,8 5,0

Globulin 2,6 g/dl 1,3 2,7

Bilirubin total 02,7 Mg/dl 0,3 - 1,0

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

Bilirubin indirek 0,7 Mg/dl < 0,60

SGOT 40 u/l < 32

SGPT 33 u/l < 31

LDH 460 u/l 240 480

USG
Ultrasound:

Fetal alive singletone intrauterine head presentation

Fetal movement was good
Biometri : Accreta index :
BPD : 91,6 mm After Cesarean : 3,0
HC : 46,9 mm Lacunae grade 2 : 1,0
FL : 75,7 mm Thick myometrium0,67 : 0,25
AC : 346 mm Placenta accreta : 2,0
EFW : 3422 gr Bridging vessel : 0,5 +
AFI : 15,36 cm 6,75
SDAU : 2,64 % Accreta : (63%)
Plasenta planted at anterior corpus grade II III
Impression : Term pregnancy
Suspect placenta accreta (63%)
CTG
 Baseline : 135 dpm
Variabilitas : 5-15 dpm
Aceleration : (+)
Deseleration : (-)
Contraction : (-)
Impression : reactive CTG
D/ G3P2A0H2 term pregnancy + suspect placenta accreta + twice previous
CS
fetal alive singleton, intra uterine, head presentation

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

Plan : Consult accreta team

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 term pregnancy + suspect placenta 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
Crossmatch PRC 4 unit
Plan : section caesarean + tubectomy pomeroy
CTG
 Baseline : 135 dpm
Variabilitas : 5-15 dpm
Aceleration : (+)
Deseleration : (-)
Contraction : (-)
Impression : reactive CTG
Follow up on July 5th 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 : 135 -145 bpm.
Genitalia : I : V/U were normal
D/ G3P2A0H2 term pregnancy + suspect placenta accreta + twice previous
CS
fetal alive singleton, intra uterine, head presentation
Management
Control GA, VS, His, FHS, fluid balance
Crossmatch PRC 4 unit (ready)
Plan : section caesarean + tubectomy pomeroy
CTG
 Baseline : 135 dpm
Variabilitas : 5-15 dpm
Aceleration : (+)
Deseleration : (-)
Contraction : (-)
Impression : reactive CTG
July 6th 2017, At 10.30 am
Caesarean sectio was performed
A male baby was born with 3200 gr weight, 48 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 placenta accreta
+ twice previous CS
Mother and child were in care
Plan:
Post Op Observation in ROI
Control general condition, vital sign,
Injection ceftriaxone 2x1 gr
Transfusion PRC 4 unit
Injection tranexamat acid 3x500mg
Pronalges supp if needed