Case No

Name : Ms. R
Age : 16 years old
MR No. : 998356
Date : January 30th, 2018

A 16 years old patient was admitted to the gynecology ward room of

Dr. M. Djamil Central General Hospital on January 30th 2018 at 15.00
am referred from gynecology polyclinic with diagnose primary
amenorrhe due to agenesis uterine et vagina pro laparoscopy
 Present illness hystory
• Patient chief complain there's no menstrual period until now
• Secundary sexual like breast, pubic and armpit hair was appear
• Enlargement of the abdomen was (-)
• History of Fluor albus (-), fever (-), trauma (-)
• Decrease of body weight (-)
• Patient single
• Bowel and bladder was normal
Previous Illness History :
• There wasn’t previous history of heart, lung, liver,
kidney, DM, hypertension, and allergy
Family Illness History :
• There wasn’t history of contagious disease,
hereditary and physicological illness in the family
Physical Examination :
GA Cons BP HR RR T
Mdt CMC 110/70 84 20 37

BW : 45 kg
BH : 150 cm
Eyes : Conjunctiva wasn’t anemic, Sclera wasn’t icteric
Neck : JVP 5-2 cmH2O, tyroid gland no enlargement
Chest : lung/heart was Normal
Abdoment : GR
Genitalia : GR
Extremity : Edema -/-, Physiological Reflex +/+,
Pathological Reflex -/-
Gynecology record
• Inspection : there’s no enlargement of abdomen
• Palpation : fundal uterine wasn't palpated, tenderness
(-), rebound tenderness (-), deffence muscular (-)
• Percution : thympani
• Auscultation : peristaltic sound was normal

Genitalia
I: V/U normal PPV (-)
USG

Uterine does not exist

There is mass cystic right adnexa size 4,22 x 2,70 cm with fibrin
yarns
Left ovarian hard to identify

Impression: Agenesi uterine et vagina

 Laboratory finding
Parameter Result Unit Parameter Result Unit
Haemoglobin 12,4 g/dl SGOT/SGPT 24/13 u/l
Leucocyte 8.890 103/mm3 RBG 96 mg/dL
Thrombocyte 285.000 103/mm3 Ur/Kr 18/1,5 mg/dL
Hematocrit 37 % Total protein 6,9 %
PT 9,0 Detik Albumin 3,6 u/l
APTT 42,4 Detik Globulin 3,3 mg/dL
Natrium 145 mmol/L LDH 418 u/L
Kalium 3,5 mmol/L Ca125 14,86
Chlorida 110 mmol/L
Calsium 9,2 mg/dl
Ca-125 14,86 U/ml
Diagnose
Primary amenorrhe due to agenesis uterine et vagina

Management :
Control GA, VS
Informed consent
Consult to anestesiologist

Plan
laparoscopy on January 31st , 2018
January 31st ,2018, 11.00 am, Laparoscopy was performed
- Seem uterine does not exist. Looks both tubes and ovaries was
normal
- Look both ureter was normal
- Impression : MRKH syndrome

Diagnose
• Post laparoscopy diagnostic on indication primary amenorrhe
due to MRKH syndrome
M / Post surgery observation
• Control GA, VS
• IVFD RL 20 gtt
• Ceftriaxone 2x1gr I.V
• pronalges supp if nessesary
• Check laboratorium post op
Laboratory post op
Parameter Result Unit
Haemoglobin 10,4 g/dl
Leucocyte 12.090 103/mm3
Thrombocyte 185.000 103/mm3
Hematocrit 30 %
Thank You