Delivery Suite Report

Friday, April 7th 2017

Consultant:
DDr. Med. Damar Prasmusinto, OBGYN(C)(C)

Residents:
ER Team April 2017
 Reporting
1 Procedure:
• 1 Cesarean Section continued with Total Hysterectomy
(Maternal Mortality Report)
 Procedure No Case Outcome
Cesarean Section 1 Recurrent antepartum hemorrhage due to Next slide
continued with Total total placenta previa, suspected accreta
Hysterectomy
Mrs. J, 25 yo
MR: 4198644
O46.93 Antepartum hemorrhage due to total placenta
O43.21 previa on G3P2 33 wga, singleton live head
O44.13 presentation, suspected accreta, gestational
Z3A. 33 thrombocytopenia, previous C-Section 1x,
Z37.0 contraction (TS 4)

Process: Pre op preparation:

68.49 Patient came to ER 2 days before because of Hb 9.26 g/dL, PRC 500 cc (and
74.1 vaginal bleeding. At the time patient came to preparation 2000 cc more), FFP 500 cc,
75.34 ER there was no active bleeding anymore (Hb TC 20 unit, urologist back up
9.39 g%), but there was a irregular contraction,
TS 3, normal CTG. From fetomaternal US
expertise it stated a total anterior placenta
previa and placental accreta  tocolytic, lung
maturation, PRC transfusion. On 2 days
observation  active bleeding recurrent
bleeding  emergency C-Section with
possibility of Total Hysterectomy
Baby is in SCN 4 with NIV Peep 5, FiO2
Ogi (T4A) / Ciput (T4A) / NBC 21%, SaO2 98%, diagnosed with
Richie (T4A) / Dr. Med. Referred from Koja Hospital due to total respiratory distress ec susp HMD,
Damar P, SpOG(K) placenta previa and suspected placental already given ampicillin sulbactam
accreta a week before to Outpatient RSCM 2x100 mg, amikacin15 mg / 18 hrs
clinic
 ER 3rd Floor, April 5th 2017, 12.00 pm
Vaginal bledding since 8 hours before admission (History of
Referred from Koja Hospital due to total placenta previa
suspected accreta to outpatient RSCM clinic)
Patient admitted 8 months pregnancy, LMP forget.
ANC at PHC Cilincing for 2x, Koja Hospital from 3x. Previous C-S
1x.
US exam at Persahabatan Hospital for US fetomaternal 22
march 2017, diagnosed with placenta accreta.
On march 27th, 2017, outpatient clinic RSCM, patient was
examined US by dr. Yuditiya, OBGYN(C) and the result is total
placenta previa and accreta, polyhydramnios (AFI 23) and
advised for weekly follow up
BP 110/70 mmHg, HR : 83x, RR : 20x T : 36.20C
Contraction 1x/10’/25”, no cervical dilatation, fluxus (+), no
active bleeding
CBC: 9.39/28.3/7.470/139.000//86/28/33
Antepartum hemorrhage due to total placenta previa on G3P2
33 wga, singleton live head presentation, placenta accreta,
Previous C-Section 1x, (TS 4) with anemia normocytic and
normochromic ( Hb 9.39), Gestational thrombocytopenia
(Thrombocyte 139000)
Tocolytic, lung maturation, PRC transfusion, elective C-Section
at 36-37 wga
Analysis of Thrombocytopenia :
1. Gestational thrombocytopenia
Commonly happen 80-90% in all pregnancy
2. Viral infection
No history of fever, never exams the IgM and IgG
dengue.
3. HELLP syndrome
Patient don’t have sign of hypertension and
preeclampsia.
4. ITP ( Idiopathic thrombocytopenia purpura)
Discussion with Doctor in charge at obstetric and
gynaecology (Dr. Dwiana Ocvyanti, OBGYN(C);
1. Transfusion with PRC until Hb 12gr/ dL.
2. Consultation with urology division
3. Plan for lung maturation with dexamethasone 6
mg iv/ 12 hours for 2 days
4. Plan for termination of pregnancy if there is an
active bleeding, termination by emergency C-
Section. If there is no active bleeding, plan for
elective C-Section at 34 wga.
 April 7th 2017

04.30
Vaginal bleeding (+) + 100 cc (1 softex pad)
BP 110/80 mmHg, HR : 90x, RR : 20x T : 36.40C .
Contraction (+) irregular, FHR 148bpm.
I : v/u wnl, bleeding for 1 pad.
05.30
Discussion with Dr. dr. Dwiana Ocviyanti OBGYN (C) 
patient with recurrent HAP agreed to perform C-Section
and suggested Dr. dr. Yuditiya P, OBGYN (C) to perform the
C-Section

Laboratory result post transfusion 3rd bag of PRC

CBC : 9.26/27.9/8880/104000//87/28/33
Dr. dr. Yuditiya P, OBGYN (C) did not answer if he
Recurrent antepartum hemorrhage due to total accepted the suggestion
placenta previa susp accreta, on G3P2 33 wga,
singleton live head presentation, Previous C-Section
1x
Anemia normocytic normochromic (Hb 9.26) 08.40
Gestational thrombocytopenia (104.000)
Discussion with Dr. dr. Dwiana Ocviyanti OBGYN (C)
Post lung maturation suggested to transfer the procedure to DPJP at ER
morning, Dr. Med. Damar P, OBGYN (C)
Conclusion : anemia normocytic normochromic
Plan: transfusion PRC  Hb > 12 gr/dL
Placenta Accreta Index

Lacunae
Bridging vessels

Placenta Accreta Index 

5.25
Probability invasion 69%,
Sensitivity: 52%,
Lacunae Spesificity: 92%
PPV: 75 %
NPV: 79 %

Myometrial thickness
 April 7th 2017

Round at ER at 9.00 AM with Dr. Med . Damar P, OBGYN (C):

1. Will performed the US examination first to reevaluate the

implantation of placenta.
2. The result of exam : myometrium line 1 millimeter
3. Agree for emergency cesarean section due to recurrent
antepartum hemorrhage.
4. Ordering the PRC (blood) 2000 cc, TC product 20 unit and FFP
500 cc
 Pre Operative Preparation

1. Blood product
Hb (7/4/2017) 9.3 g/dL, trombocyte (104.000/mm3)
Preparation blood product PRC 2500 cc, TC 20 unit and FFP 500 cc

2. Urology consultation
Back up during the operation

3. Anesthesiology
Spinal analgesia until general anesthesia
Post operation  ICU
ASA III
Intraoperative

• Patient on supine position under general anesthesia

• A and anti sepsis
• Incision surrounding previous cesarean scar

Cranial
Intraoperative
• Seen gravid uterus and hypervascularization of placenta at LUS ~
placenta accreta
• Decided to incised above LUS, avoiding the placenta, by foot
extraction born baby Girl, 1980 g, A/S 6/8, clear amniotic fluid
• Try to do the umbilical cord traction gently  cannot be done 
leave the placenta  suture the uterus  uterine atonia

Cranial Cranial
Intraoperative
• Decided to performed total hysterectomy
• Both round ligament were clamped, cut, and sutured
• Performed windowing at both posterior broad ligaments 
Proximal tube, proper ovarian ligament were clamped, cut, and
sutured

Cranial

Cranial
Intraoperative

• Bladder was separated with meticulous dissection. Found

hypervascularization at serous layer of uterus  active bleeding

Cranial Cranial
Intraoperative

• Both uterine arteries was clamped, cut, and sutured  found

active bleeding from placental site around uterine arteries
• Both cardinal ligaments were clamped, cut, and sutured

Cranial Cranial
Intraoperative

• There was still active bleeding from the uterus  performed

tourniquet of uterine corpus with catheter no 18  active bleeding
reduced
• Decided to do incision at uterus as high as lower uterine segment 
to minimize source of bleeding

Cranial Cranial
Intraoperative
• Then continue to cut vagina as high as portio
• The vaginal wall was stiched continuosly using PGA No. 1
• There was diffuse bleeding from vesica fold
• Reperitonealization was performed, bleeding was stopped
• Urologist confirmed there was no bladder injury
• Inserted drain intraabdominal
• Complete gauze and instruments
• Abdominal wall was closed layer by layer
• Intraoperative bleeding was 5000 cc, urine 100 cc, clear
Cranial Cranial
Anterior Incised
 Vital Chart Intra Operatively Total PRC 848 cc
Total FFP 450 cc
NE 0.1 Total TC 300 cc
NE 0.3 mcg NE 1 mcg
mcg
140 Epinefrin 0.2-
Epinefrin 2 mcg
NE 2 mcg
Total estimated
bleeding 5000 cc
0,3 mcg
Drain 100 cc

120
Hb 5.99 Hb 7.99

100

80

60

40

20
PRC PRC FFP 450 TC 300
181 217 PRC 450
0
11.00 12.00 13.00 14.00 15.00 16.00 17.00
Operation Operation
Transfer to ICU
started finished
Systolic Diastolic HR RR SaO2
 ICU Vital Chart April 7 th – 8th 2017
Dobutamin 500 mcg/kgbb,
norepinephrine 16 mcg, Total PRC 648 cc
epinephrine 20 mg, vasopressin Total FFP 543 cc
20 unit
120
PRC PRC FFP PRC FFP FFP
207 220 129 221 221 193

100

80

60

Asystole CPR 1
cyle family agree
40 for DNR stop CPR.

Epinephrine
1 ampul iv
20

0
17 18 19 20 21 22 23 0 1 2 3 4

Systolic Diastolic sat pulse RR

Lab 5/4/2017 6/4/2017 7/4/2017 7/4/2017 7/4/2017 Normal Value
01.07 15.47 18.40
CBC 9,39/28,3/7470/ 9,31/28/9040/124.0 9,26/27,9/8880/104.0 5,99/18,4/20.600/1 7,96/24,9/23.20 12.0-15.0/36.0-46.0/5.0-10.0/150.0-
400.0//80.0-95.0/27.0-31.0/32.0-36.0
139.000//86,4/2 00//89,6/29,9/33,3 00//87/28,9/33,2 29.000//91/29,7/32 0/83.900//90,8/
8,6/33,1 ,6 29/32
PT/APTT 0.9x/0.8x Transfusion 23.1/10.2(2.3x)/ 0.5-1.0/1-4/1-3/55-70/20-40/2-8

>180/33.0
546 cc PRC (5.4x)
Ur/Cr 11.5/1.43 0-49/ 0.6-1,2

RBG 120 461 <200

SGOT/ SGPT 112/76 0-26/0-33 u/L

Albumin 1.19 3.4 – 4.8

Fib/D-Dimer <80,3/0.6 9,8-12.6/31.0-47.0

150-400/0-0.3

Electrolyte 141/3,8/112 149/5.6/106 0-5.6

LDH 0-599

Lactate 12,4 0,55-2,2

UL LEA +1, epitel +1, 11

leucocyte 4-5
PBS Anemia normocytic
normochromic
 Cause Of Death

Uncontrolled postpartum hemorrhage

 Lessons Learned
• Prevention of PPH caused by placenta accreta
• Planning of management should be done accurately,
even since in the outpatient clinic
• Operative preparation:
• Timing (gestational age)
• Team (surgeon, back-up team)
• Patient (Hb level, blood products preparation)
• Intra operative bleeding management:
• Evacuate source of bleeding immediately and controlled
bleeding
• Internal iliac arteries ligation
• It is possible to do subtotal hysterectomy first to reduce
masive blood loss
THANK YOU