Mrs. N, a 42-year-old housewife, presented with abnormal vaginal bleeding for 3 months. Physical examination and ultrasound revealed an enlarged uterus consistent with endometrial hyperplasia. She underwent a laparotomy and supravaginal hysterectomy. Intraoperative findings confirmed thickened endometrium and endometrial hyperplasia. The surgery was performed successfully with 200cc of blood loss. Her postoperative recovery was unremarkable with no fever or other complications.

1. Case No

2. IDENTITY
Patient
 Name : Mrs. N
 Age : 42 years old
 MR No. : 01.16.81.12
 Date : 08-03-2023
 Address : Padang
 Occupation : Housewife
 Education : Senior high school
Husband
 Name : Mr. M
 Age : 48 years old
 Address : Padang
 Occupation : Army
 Education : Senior high school

3. Clinical Examination
Anamnesis 13-03-2023, 15.00
Previously, patient was referred from Obsetrician with diagnose hyperplasia endometrium, patient complained bleeding from vagina since 10
days ago
 Bleeding from vagina (+) since 3 months ago, bleeding happens out of menstrual period, 3-4 times change pads daily.
 Abdominal pain (-)
 Felt mass in abdomen (-)
 History of Post coital bleeding (-) , dispareunia (-)
 Defecate and urination was normal
 History of body weigh decreasing extremely (-)
 History of fever, trauma, and fluor albus was (-)
 Menstruation History : menarche at 13 years old, irregular cycle, every month which last for about 5-7 days each cycle with the amount of 2-3
times pad change/day without menstrual pain
•Marriage history : once, at 2000
•Obstetric record : Have 3 children, were born on 2003, 2007 and 2009
•History of contraception (-)

4. Physical examination Supportive examination
GA Cons BP HR RR T
mdt CMC 130/79 80 20 37
Abdomen :
I : not enlarged, striae (-), sikatrik (-)
Pa : FUT was palpable 2 finger above sympihisis pubis, pressure pain (-),
release pain (-), muscular defense (-)
Pe : Tympani
Au : Peristaltic sound normal
Genitalia : I V/U
Inspeculo :
Vagina : Tumor (-), laceration (-), fluxus (+) red light blood
Portio : MP, size looks more larger as large as tennis ball, smooth
surface, tumor (-), laceration (-), OUE was closed, fluxus (+)
red light blood accumulated in posterior fornix, sondage
cannot be inserted
VT bimanual :
Vagina : Tumor (-) laceration (-) fluxus (+) red light blood
Portio : MP, size as adult toe, tumor (-), OUE was closed
CUT : Size as big as a fist man
A/P : the lowest part of tumor wasn’t palpable
CD : Not protrude
USG
Anteflexion uterine size 10,40 x 6,18 cm x 4.40 cm
There’s hypoechoic mass, size 1.03 x 0.61 cm
feeding artery (+)
Impression : hyperplasia endometrium
Laboratory : 08-03-2023
Hb/L/Ht/T : 11.8/8.170/32/309.000
Total protein : 6,6
Alb /Glb: 4.3/2.3
SGOT/SGPT : 13/12
Ur/Cr : 19/0.6
GDS : 92
Na/K/Cl : 145/3.8/111
Anti HIV : NR HBsAg : NR
B/E/N/L/M : 0/3/64/27/6

5. Diagnosis and Management
Diagnosis pre operatif
P3L3 + Hyperplasia endometrium
Plan : elective laparotomy
Instruction
• Control GA,VS,Urine output
• IVFD RL 20 tpm
• Crossmatch 1 units PRC
Proccess
P2L2 + abnormal bleeding ec hyperplasia endometrium  Supravaginal
hysterectomy
March, 14 2023, 17.15 Laparotomy was perfomed,
After perform exploration of internal genitalia, found there thickning of
endometrium  hyperplasia endometrium  Supravaginal hysterectomy

6. Op Date Diagnose and Management Outcome
14/03/2023
17.15
DPJP :
HSA
Pre Op :
P3L3 + abnormal bleeding ec hyperplasia endometrium
Management :
• Control GA,VS,Urine output
• IVFD RL 20 tpm
• Crossmatch 1 units PRC
Plan : Laparotomy
Process :
P3L3 + abnormal bleeding ec hyperplasia endometrium 
Supravaginal hysterectomy
14-03-2023
17.15 Laparotomy was perfomed,
After perform exploration of internal genitalia, found there
thickning of endometrium  Hyperplasia endometrium
was found  Supravaginal hysterectomy
Plan : Supravaginal hysterectomy
Supravaginal hysterectomy was performed
Intraop bleeding : 200 cc
Post Op :
Post supravaginal hysterektomy oi hyperplasia
endometrium
Plan :
IVFD RL 20 tpm
Inj. Ceftriaxon 2x1 gr
Pronalges supp II K/P
Inj. Asam tranexamat 3x500 mg
Inj. Vit K 3x1 amp
Check laboratory 6 hours post transfusion

7. Admission Letter

8. Laboratory

9. USG

11. USG INTEPRETATION
• Uterus AF size was normal 6,52 x
3x88 cm
• Endometrial thickness 1,2 cm
• Impression: endometrial
hyperplacia

12. Inspeculo

13. Operation Report
 Patient on supine position under general
anesthesia
 Aseptic and antiseptic procedure performed
 Inferior median incision performed, abdomen
opened layer by layer
 After peritoneal cavity opened, exploration of
internal genitalia, found there thickning of
endometrium and hyperplasia were found,
supravaginal hysterectomy then performed
 Abdominal layer closure then performed layer by
layer
 Intra operative bleeding approximately 200 cc
 transfusion 1 unit of PRC post Op

14. Follow up 2 hours post operative
S Post operative pain (+)
Fever (-)
P Control GA, VS
IVFD RL 20 tpm
Inj. Ceftriaxon 2x1 gr
Pronalges supp II K/P
Inj. Asam tranexamat 3x500 mg
Inj. Vit K 3x10 mg
Check laboratory 6 hours post op
Transfer to HCU
O GA Cons BP HR RR T
moderate CMC 125/76 95 20 36,8
Abd : tenderness (-) rebound tenderness (-) defans
muscular (-)
Gen : V/U normal, vaginal bleeding (-)
Urin : 200 cc/2 hours
A Post supravaginal hysterectomy oi hyperplasia
endometrium

15. Laboratory post op

17. Thankyou