DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

EMERGENCY OPERATIVE ROOM REPORT

Wednesday, November 6th 2019

Resident on Duty:

Dr. Bagus Hilmawan

Dr. Mughan Sukardo

Dr. At Thariq A

Dr. Febri Stevi A

Supervisor :
Dr. H. Patiyus Agustiansyah, OBGYN(C), MARS
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

EMERGENCY OPERATIVE ROOM REPORT

Wednesday, November 6th 2019

Obstetric Gynecolocy Total

1 0 1
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

No IDENTIFICATION DIAGNOSIS ICD 10 PROCEDURE ICD 9 RECENT

DIAGNOSIS
Mrs. SRI/ 25 YO G1P0A0 29 weeks O60 - LSCS 74.1 P1A0 post LSCS oi
1. 1147634/ UA/ HIL- gestational age not O15.9 eclampsia
MUG-ITW / NS inlabor with O14.23 antepartum + partial
eclampsia O41.8 HELLP syndrome +
antepartum + I46.9 post ROSC 1x +
partial HELLP J81.0 desaturation + acute
syndrome + post O36.4 pulmonary edema
ROSC 1x +
desaturation + acute
pulmonary edema
SDF cephalic
presentation +
Anhydramnios

Procedure Case Outcome

Mrs. SRI/ 25 YO 02.45 PM. Operation started
- LSCS 1147634/ UA/ NS Patient on supine position and on general anesthesia.
Aseptic and antiseptic procedure on surgical site and its
ICD 10 surrounding was performed. Pfanennsteil incision was
O60 Preop diagnosis: made at 2 fingers above symphysis. After peritoneum was
O15.9 G1P0A0 29 weeks opened, uterus was as 29 week gestational age, LSCS was
O14.23 gestational age not performed  Semilunar incision on lower uterine segment
O41.8 inlabor with (+), amniotic membrane ruptured, amniotic fluid minimal
I46.9 eclampsia antepartum (+), green, odor (+).
J81.0 + partial HELLP
O36.4 syndrome + post 02.50 PM. Female, died baby was born, with birth body
ROSC 1x + weight 1400 g, body length: 39 cm, rigor mortis (+)
ICD 9-CM desaturation + acute
74.1 pulmonary edema 02.55 PM. Placenta was delivered completely, placental
SDF cephalic weight: 300 grams, umbilical cord length 37 cm ø 14x15
OP : presentation + cm
HIL-MUG-ITW / NS Anhydramnios Lower uterine segment closed with continuous suture with
PGA 1.0
Post op diagnosis: Abdominal cavity washed with NaCl 0,9%
P1A0 post LSCS oi Peritoneum and muscles were sutured with continuous
eclampsia antepartum suturing using plain catgut 2.0
+ partial HELLP Fascia sutured with continuous suturing using PGA 1.0
syndrome + post Subcutis sutured with single interrupted suture using plain
ROSC 1x + cat gut 2.0
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

desaturation + acute Cutis sutured with subcuticuler suturing using PGA 3.0
pulmonary edema Intraoperative bleeding 300 cc

03.45 PM Operation finished

Identity 1. Mrs. SRI/ 25 YO 1147634/ UA/ HIL-MUG-ITW / NS

Chief complaint Preterm pregnancy with seizure and decrease of consciousness
History About 8 hours before admission patient had seizure 3x at home. After first seizure
05-11-2019 patient was unconscious, 4 minutes later the second seizure and 2 minutes later patient
01.15 AM was awake for 20 minutes. After that the patient has another seizure for 5 minutes and
was unconscious again. The patient is then taken to Ar Rasyid hospital.
About 6 hours before admission patient had fourth seizure about 10 minutes. Patient
got Furosemid and MgSO4, her seizure stopped but patient was unconscious. 2 hours
later her baby was died. The patient was decided to be referred to Moh. Hoesin hospital
but because of the long wait the family finally took the patient himself to Moh. Hoesin
hospital. History of abdominal contraction spreading to waist and back (-), amnionic
leakage (-), bloody show (-). History of hypertension in this pregnancy (-), history of
hypertension before pregnancy (-), hypertension in family (-), history of headache (+),
blurry vision (-), epigastric pain (+), nausea (+) and vomiting (+) before seizure,
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

history of abdominal massage (-), history of abdominal traumatic (-), history of got
traditional medicine (-).

Marital status 1x : 1 year

Reproduction status Menarche since 13 yo, regular, cycle of 28 days, last 7 days. LMP : ?/03/2019
Obstetric history 1. Current pregnancy

Past iIlness history -

General Physical Sens: Coma, GCS E1M1Vt, BP: 102/85 mmHg, P : 141x/min, RR : 29x/min
Examination (ventilator), SpO2 84%, T : 36.8 C
Head: normocephali, pallor conjunctival (-/-), scleral icterus (-/-)
Neck: JVP (5-2) cmH2O, lymph nodes enlargement (-)
Thorax: Heart: I-II HR N, regular, murmur (-), gallop (-)
Lungs: vesicular (+/+) normal, ronkhi (-/-), wheezing (-/-)
Abdominal: Fundal height 2 fingers above umbilical (20 cm), longitudinal lie, left
spine fetus, head, U 5/5, uterine contraction (-), FHR (-)
Extremity: edema (+/+)
Genital:
VT : Portio soft, posterior, eff 0 %, dilatation (-), head, HI, amniotic membrane and
denominator can’t assessed
US ER (ICA) There’s SDF Cephalic presentation
05-11-2019 Fetal Biometry : BPD: 7.08 cm AC: 27,10 cm EFW: 936 g
HC: 25.02 cm FL : 5.23 cm
Placenta at posterior corpus
Amniotic fluid was minimal  anhydramnios
C/ 29 weeks gestational age SDF cephalic presentation
-
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

3 3
Lab results Hb :16.1 g/dL, Ht: 45 %, WBC: 32.91/mm , PLT: 146.000/mm
05-11-2019
MCV: 90.1, MCH: 32, MCHC: 35, Diff 0/0/87/7/6 Pt 15.4 (18.4) INR 1.4 APTT 33.2
(58.6) Fibrinogen 274.0 (314.0) D-Dimer 16.61 Total Bilirubin 1.10 AST 501 ALT
3234, LDH 1494, Albumin 3.0 BSS 79 Ureum 43 Uric Acid 13.4 Creatinin 1.62 Ca
7.6 Mg 4.5 Na 146 K 4.2 Cl 118 HBsAg / VDRL / HIV Non reactive
Diagnosis G1P0A0 29 weeks gestational age not inlabor with eclampsia antepartum + partial
HELLP syndrome SDF cephalic presentation + Anhydramnios
Therapy • Stabilization 3-6 hours
• Vital signs, seizure and labor signs observation
• IVFD RL + MgSO4 40% 6 g XXVIII bpm  postpone
• Laboratory examination
• Urinary catheter, monitor I/O
• Nifedipine 10 mg/8 hours PO  postpone
• Assessment to Internal medicine Department, Opthalmology Department and
Neurology Department.
• P/ Vaginal delivery after stabilization
A/ Septic shock post ROSC post Resuscitation Cor Pulmo
Assesment Internal Dept. Metabolic acidosis
Elevated liver enzyme cb septic
AKI stage I
G1P0A0 29 weeks gestational age SDF cephalic presentation
P/ Dobutamin 1 amp in 100 cc NaCl 0.9% drops x/minute micro titration
Norepinephrine 1 amp in 100 cc NaCl 0.9% drops x/minute micro titration
ECG
Ceftriaxone 1 g/ 12 hours IV
Laboratory : Urine routine
Rontgen thorax PA
NGT
Opthalomogy A : There were no signs of Retinopathy/ Choroidopathy hypertension
Departement P : Education
05-11-2019 Anti hypertension ~ Obgyn
03.00 AM Reconsult if her visus was decreased
Assesment Neurology A/ Observation of decreased consciousness + Observation generalized tonic clonic
Dept. cb eclampsia antepartum
05-11-2019 P/ Therapy of seizure ~ Obgyn
04.15 AM If there are still seizures after administration of MgSO4, treatment can be given
Epilepticus status protocol.
Head CT scan (if transportable)
Follow up Obgyn Dept S : Reassessment of Anesthesiology Dept
05-11-2019
 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

Dr. MOH. HOESIN GENERAL HOSPITAL PALEMBANG

11.00 AM O: Sens: Coma, GCS E1M1Vt, BP: 126/89 mmHg, P : 127x/min, RR : 22x/min
(ventilator), SpO2 94%
Abdominal: Fundal height 2 fingers above umbilical (20 cm), longitudinal lie, left
spine fetus, head, U 5/5, uterine contraction (-), FHR (-)
VT : Portio soft, posterior, eff 0 %, dilatation (-), head, HI, amniotic membrane
and denominator can’t assessed
A : G1P0A0 29 weeks gestational age not inlabor with eclampsia antepartum + partial
HELLP syndrome + post ROSC 1x + desaturation + acute pulmonary edema SDF
cephalic presentation + Anhydramnios
P : Observasion of vital sign, seizure and inlabor sign
Dexamethasone 15 mg/ 8 hours IV
Another therapy ~ Anesthesiology Dept
Planned for abdominal termination after stabilization max 12 hours
Assesment anestesiology for CS
Follow Up OBGYN S : Preterm pregnancy with history of seizure and loss of consciousness
05-11-2019 O : Sense: Coma, GCS E1M2Vt , BP 121/81 mmHg, P: 125x/menit RR 22x/menit
01.00 PM SpO2 95%
A : G1P0A0 29 weeks gestational age not inlabor with eclampsia antepartum + partial
HELLP syndrome + post ROSC 1x + desaturation + acute pulmonary edema
SDF cephalic presentation + Anhydramnios
P:
- Vital sign, seizure and inlabor sign
- IVFD RL gtt xx/minute
- Ceftriaxone 1gr/ 12 hours IV
- Paracetamol 1gr/8 hours
- N acetyl cysteine 1gr/ 8 hours per NGT
- Dexamethason 15 mg/ 8 hours IV
- Epinefrin 15 mcg/hours IV
- Inform consent to the family, CS with DOT risk