This document reports on a case of a 29-year-old woman admitted to the hospital with vaginal bleeding at 35-36 weeks of pregnancy. She was diagnosed with severe preeclampsia, placenta previa totalis, and was at risk of eclampsia. She underwent an emergency cesarean section to deliver a healthy baby girl weighing 2400 grams. Post-operation, the mother received magnesium sulfate and antihypertensive treatment and recovered well.

1. Program Pendidikan Profesi Dokter
SMF Obstetri & Ginekologi
FK USU / RSUP DR Pirngadi
Medan
Laporan Kasus
Pembimbing : dr. Fadjrir, Sp.OG
Mentor : dr. T. Larry Arthit

2. Di susun oleh :
Pembimbing : dr. Fadjrir, Sp.OG
Mentor : dr. T. Larry Arthit
Program Pendidikan Profesi Dokter
SMF Obstetri & Ginekologi
FK USU / RSUP DR Pirngadi
Medan

3. Pendahuluan
 Angka Kematian Ibu (AKI) di Indonesia sebesar 228
per 100.000 kelahiran hidup. (SKDI, 2007)
 Perdarahan (28%), eklamsia (24%), infeksi (11%),
abortus (5%), persalinan macet (5%), emboli
osbtruktif (3%).
 Hipertensi dalam Kehamilan (HDK) : 5-15% penyulit
kehamilan. Termasuk tiga besar morbiditas &
mortalitas ibu bersalin.

4. Pendahuluan
 Di Negara maju, HDK merupakan 16% mortalitas ibu,
lebih besar dari tiga penyebab utama lain seperti
perdarahan (13%), aborsi (8%), dan sepsis (2%).
(WHO)
 Di Indonesia, mortalitas dan morbiditas HDK juga
masih tinggi. Etiologi yang tidak jelas, perawatan
dalam persalinan masih ditangani oleh petugas non
medik dan sistem rujukan yang belum sempurna
menjadi alasan.

5. Hipertensi dalam Kehamilan
 Yang dipakai di Indonesia : Report of the National
High Blood Pressure Education Program Working
Group on High Blood Pressure in Pregancy, 2001
 Hipertensi Kronik
 Preeklampsia-eklampsia
 Hipertensi Kronik dengan superimposed preeklampsia
 Hipertensi Gestasional

6. HDK

7. Faktor Risiko
 Primigravida, primiparitas
 Hiperplasentosis : mola hidatidosa, kehamilan
multipel, DM, hidrops fetalis, makrosomia
 Umur yang ekstrim
 Riwayat keluarga pernah PE/E
 Penyakit-penyakit ginjal dan hipertensi yang sudah
ada sebelum hamil
 Obesitas

8. Patofisiologi
Teori kelainan vaskuler
plasenta
Teori iskemik plasenta, radikal
bebas dan disfungsi endotel
Teori intoleransi imunologik
antara ibu dan janin
Teori adaptasi CV genetik
Teori inflamasi
Teori defisiensi
gizi
Disease of Theory

9. Gangguan Implantasi Trofoblas

10. Penyakit Vaskuler Ibu Gangguan Placentasi Trofoblas Berlebihan
Faktor Genetik,
Imunologik,Atau
Inflamasi
Penurunan Perfusi
Uteroplacenta
Zat Vasoaktif:
Prostaglandin, Nitrat
Oksida, Endotelin
Zat Perusak: Sitokin,
Peroksidase Lemak
Aktivasi endotel
Vasospasme Kebocoran Kapiler
Aktivasi Koagulasi
•Edema Trombositopenia
•Hemokonsentrasi
•proteinuria
Hipertensi
kejang
oligouria
solusio
iskemia hepar
PATOFISIOLOGI

11. Penatalaksanaan
DASAR PENGELOLAAN PEB
 Ekspektatif/konservatif :
bila umur kehamilan < 37
minggu, artinya:
kehamilan dipertahankan
selama mungkin sambil
memberikan terapi
medikamentosa.
 Aktif/agresif : bila umur
kehamilan ≥ 37 minggu,
artinya kehamilan diakhiri
setelah mendapatkan
terapi medikamentosa
untuk stabilisasi ibu.

12. Indikasi Terminasi  Indikasi Ibu :
 Kegagalan
medikamentosa
 Muncul tanda-tanda
impending eklampsia
 Gangguan Fungsi
Hepar/Ginjal
 Kecurigaan solusio
plasenta
 Inpartu, KPD, perdarahan
 Indikasi Janin :
 Usia Kehamilan >= 37
minggu
 PJT berat (USG)
 NST non-reaktif & profil
biofisik abnormal
 Oligohidramnion
 Indikasi Laboratorium :
 Sindroma HELLP

13. Medikamentosa
 Tirah Baring, Oksigen,
Kateter menetap, IVFD :
Ringer Asetat, Ringer Laktat,
Koloid
 Awasi balans cairan.
 Pematangan Paru
(Kehamilan <37 minggu) :
Dexametashone 6 mg/12
jam 4 kali.
 Magnesium Sulfat
 LD. 4 gr (20 cc) MgSO4
20% IV bolus pelan 10-15
menit
 MD. 6 gr (60 cc) MgSO4
40% : dalam 500cc RL (1
gr/jam) --> 28 gtt/i
 Antihipertensi : nifedipin 10
mg PO diulangi 30 menit
(max 120 mg/24 jam)

14. Case Report
 Patient Identity:
 No. MR : 93.06.34
 Name : Mrs. RRI
 Age : 29 y.o
 Address : Jl. HM Joni Blok H no.5 Medan
 Religion : Moslem
 Race/Nationality : Javanese/Indonesian
 Education : SLTA
 Profession : Housewife
 Status : Married
 Date of admission : 28th June 2014
 Time of admission : 23.57
 Tgl Keluar :
 Parity : G2 P1 A0

15.  Chief complaint : Vaginal bleeding
 Telaah : It is experienced 2 days before
admission, blood spot . Four hours before admission, the
bleeding recurred, the bleeding worsen from two days ago,
mking the patient has to change her cloth twice. Bleeding
occured spontaneously, history of trauma (-). Abdominal
pain (+). Watery discharge from vagina (-). History of high
blood pressure before pregnancy (-). History of high blood
pressure on previous pregnancy (+). Blurred vision (-)
Epigastric pain (-). History of headache (-). Nausea and
vomting (-). Urination and bowel movement are normal

16. History of Menstruation
 HPHT : 15-10-2013
 Predicted pregnancy date : 22-07-2014
 History of operation : -
 History of contraception usage :-
 ANC : Midwife 6x

17. History of Pregnancy
1. Male, aterm, vaginal birth, hospital, by doctor, 2700
grams, 5 y.o., healthy
2. This pregnancy

18. Presence Status
 Sens : Compos Mentis
 BP : 220/140 mmHg
 HR : 92x/i
 RR : 20x/i
 Temp : 37,00 C
 Anemia (-)
 Icteric (-)
 Dyspnea (-)
 Cyanosis(-)
 Pretibial oedema (-)
 Proteinuria (+2)

19.  Kepala :
 Mata : Inferior palpebra conjunctiva anemia(-/-),
icteric (-/-), Light reflex (+/+), pupil isokor left=right
 E/N/T : normal
 Neck : Trachea medial, Lymph node enlargement (-)
 Thorax : Inspection : Simetris fusiformis
 Palpation : Stem fremitus right=left
 Percussion : Sonor on both lung
 Auscultation : Breath sound : Vesiculer (+/+)
 Additional sound: (-/-)
 Heart : 92 x/i,reg, S1 & S2 normal, murmur (-)

20.  Extremities : Pretibial oedem (+)
 Initial urine : ± 300 cc

 BW : 78 kg
 Body height : 155 cm
 BMI : 32,4

21. Obstetric Status
 Abdomen : Membesar asimetrically enlarged
 Uterine Funda height : 3 fingers below Processus
xypoideus (29 cm)
 Tegang : Right
 Lowest part : Head (5/5)
 Movement : (+)
 HIS : 3 x 20”/10’
 Fetal heart rate: 147 x/i
 EBW : 2400 – 2600 grams

22.  Inspekulo: Blood is visible menggenang on the vagina,
the blood is then cleaned. Bleeding was actively
draining from the eou

23.  PEMERIKSAAN DALAM
 VT : TDP
 ST : TDP

24.  USG-TAS :
 Single fetus, Normal, PK
 FM (+), FHR (+)
 BPD : 88,2 mm (35 weeks 5 days)
 FL : 69,1 mm (35 weeks 5 days)
 AC : 29,2 mm (33 weeks 3 days)
 Plasenta previa totalis
 EBW : 2401 gram
 Amniotic fluid : normal

25.  IUP (35-36) weeks + PK + AH + Plasenta previa
totalis

26.  LABORATORIUM
 28th june 2014, 23.03
 Leukocyte : 15.200/mm3
 Hb/Ht : 11.3 gr % /33.0 %
 Trombocyte : 257.000 /mm3
 PT/INR/APT : 14,0 (c: 14,6) / 1.11/ 23.5 (c: 34)
 Random Blood Glucose : 74
 SGOT/SGPT : 13/10
 ALP : 144
 Total/Direct Bilirubin : 0,31 / 0,10
 LDH : 377

27.  DIAGNOSA SEMENTARA
 Plasenta Previa Totalis with profuse bleeding + PEB +
SG + IUP (35 - 36) weeks + PK + AH + not Inpartu

28.  RENCANA
 SC cito on KBE d/t Plasenta Previa Totalis with profuse
bleeding + PEB + SG + IUP (35 - 36) weeks + PK + AH
+not Inpartu

29. Therapy on emergency ward
 O2 2L/i
 Inj. MgSO4 20% 20 cc (slow bolus/IV 15 min) ->
Loading Dose
 IVFD RL + MgSO4 40% 30 cc (14 gtt/i) ->
Maintenance Dose
 Nifedipin loading dose 20 mg, if BP ≥ 180/110 mmHg,
give nifedipin 10 mg/ 30 min ( max: 120 mg/24 jam)
 Inj. Ceftriaxone 2 gram/ IV (skin test)
 Inj. Dexamethasone 15 mg single dose
 Foley catheter

30. Sectio Caesaria Report
 Patient lying on supine position on operation table, IV
line and catheter are inserted
 Under spinal anesthetic, aseptic and antiseptic
procedure using povidone iodine and alcohol 70% is
done on abdomen, then it is closed using surgical drap
except the operation field
 Pfannensteil incision is done from cutis, subcutis, and
fascia
 Muscle is the bluntly opened, Peritoneum dijepit with
two klem, and then it is cut betwen them. Gravid
Uterus can be viewed

31.  Low cervical incision is done on the uterus, Amniotic
selaput can be viewed and then opened. Amniotic
fluid is clear.
 Dengan meluksir kepala, a female baby was born, BW
: 2400 gram, Body lenght: 42 cm, head circumference
32 cm, A/S: 6/8, anus (+).
 Placental cord diklem on two sides and cut between
them. Placental is completely born by Coordinated
Cord traction
 Two sides of uterus incision is dijepit using oval klem

32.  Cavum uteri is cleaned from selaput ketuban and
blood.
 Uterus is then sutured by continous interlocking, and
then over hecting Bleeding was controlled.
 Left and Right fallopiian tube and ovarium are normal
 Abdominal cavity is cleaned from the remaining
amniotic fluid and blood clot

33.  Abdominal wall is sutured layer by layer from
peritoneum, muscle, and fascia, subcutis and cutis.
 Incisioin wound is closed using sufratulle, kassa and
hipafix
 Vagina is cleaned from remaining blood
 Patient condition post operative is stabile

34. Post Operation Therapy
 Bed rest
 IVFD RL + MgSO4 40 % (30 cc / 12 gr ) 14 gtt / i (24
hours )
 IVFD RL + Oxytocin 20-10-5-5 IU  20 gtt/i
 Inj. Ceftiaxone 1 gr/12 hours
 Inj. Ketorolac 30mg/8 hours
 Inj. Transamin 500mg/8 jam selama 24 hours
 Inj. Ranitidine 50 mg/12 hours

35. Kala 4

36.  NEONATUS
 Jenis Kelahiran : Tunggal
 Birth date : 29th June 2014
 Fetus status : Live, healthy
 APGAR score : 6/8
 Assisted Ventilation :+
 Sex : Female
 Body weight : 2400 grams
 Body length : 42 cm
 Head circumference: 38 cm
 Congenital anomaly : -
 Trauma : -
Consultation : -

37. Post SC Labs
 LABORATORIUM POST SC
 29th June 2014, 06.00
 Leukocyte : 18.600/mm3
 Hb/Ht : 10,0 gr % / 28,9 %
 Trombocyte : 229.000 /mm3