CLINICAL CONFERENCEMonday, August, 9th 2013PPDS Obstetri dan GYNECOLOGY FK UNS/ RS. Dr. Moewardi Surakarta, 2013*Reporting Gynecology Oncology patients from August, 6th-8th 2013

Reporter:dr. Pritasari Dewi Damayanti

StatementsI am , dr. Pritasari Dewi Damayanti said that all the data that I show in this report are true to what it is.*

Resume:MINOR GYNECOLOGY: 3 CASESPATIENTS ADMITTED TO WARDGYNECOLOGY: 11 CASESONCOLOGY: 5 CASESMAYOR GYNECOLOGY: 4 CASESJOINT WITH OTHER DEPARTEMENT: 1 CASEDEATH REPORT: 1 CASEDISCUSSION CASE: 1 CASE

KONFERENSI KLINIK OBSTETRI GYNECOLOGYRESIDEN OBSGIN, 2013*

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New patient :Incomplete abortion: 1 CASEThreatened abortion: 2 CASESMissed abortion : 1 CASEBartholin cyst : 1 CASEOvarian cyst : 4 CASESUterine Myoma : 1 CASEHyperemesis Gravidarum : 1 CASE

KONFERENSI KLINIK OBSTETRI GYNECOLOGYRESIDEN OBSGIN, 2013*

Mrs. N, G2P1A0, 25 yo, 7 wgaDx : Threatened abortionTx : - Totally bedrest - Didrogesteron 3x10 mg - Folic acid 1x400 mg2. Mrs. R, G1P0A0, 29yo, 7 wgaDx : Threatened abortionTx : - Totally bedrest - Didrogesteron 3x10 mg - Folic acid 1x400 mg

KONFERENSI KLINIK OBSTETRI GYNECOLOGYRESIDEN OBSGIN, 2013*

3. Mrs. F , G1P0A0, 20 yo, 9 wgaDx : incomplete abortionTx : suggest curratage

4. Mrs. S, P3A0, 42 yoDx : Bartholini cyst + hiperglicemiaTx : Suggest marsupialization Suggest staff ward examination consult interna divisionKONFERENSI KLINIK OBSTETRI GYNECOLOGYRESIDEN OBSGIN, 2013*

*5. Mrs. P , P2A1, 51 yoDx : ovarian tumor suspect malignancy + anemia + leukositosis+ thrombositosis + renal insuffisiencyTx : - general condition improvement - suggest tumor mass removal + FS - consult interna division - suggest staff ward examination

6. Mrs. S , P5A0, 35 yoDx : ovarian cystTx : - suggest cystectomy + FS - suggest staff ward examination

*7. Mrs. R , P4A2, 43 yoDx : uterine myomaTx : - suggest histerectomy - suggest staff ward examination 8. Mrs. S , P5A0, 35 yoDx : ovarian cystTx : - suggest cystectomy + FS - suggest staff ward examination 9. Mrs. W, P2A0, 53 yo Dx : ovarian cyst Tx : - suggest cystectomi + FS - suggest staff ward examination

*10. Mrs. N , G3P2A0, 26 yo, 15 wga Dx : Hiperemesis Gravidarum Tx : - Inf. D5% : NaCl 12 gtt/mnt - Inj. Ondancentron 1 amp/8 hour - Vit B6 3x1 - folic acid 3x1

11. Mrs. R , G1P0A0, 21 yo, 18 wgaDx : missed abortionTx : suggest induction + curratage

Minor GYNECOLOGYCurratage b.i death conseptus :1 CASECurratage b.i incomplete abortion :1 CASEMarsupialization b/I bartholini cyst :1CASEKONFERENSI KLINIK OBSTETRI GYNECOLOGY*

MINOR GYNECOLOGYMrs. N, G2P1A0, 25 yp , 10 wgaDx : Death conceptusTx : dilatation and curratage

2. Mrs. S, P3A0, 42 yo Dx : Bartholin cyst Tx : marsupialization

3. Mrs. F , G1P0A0, 20 yo, 9 wgaDx : incomplete abortionTx : curratage

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MAYOR GYNECOLOGYMrs S,G2P1A0,35 yo,11 wgadr. Yudi (R4) supervised by dr. Pram (R4 ) assisted by dr. Indra (R2) under permission by Dr. dr, Hj. Sri Sulistyowati SpOG (K) had performed Salpingooovorectomy sinistra b/i ovarial pregnancydx pre op : ectopic pregnancydx post op : ovarial pregnancy

This case will be discussed*

MAYOR GYNECOLOGY2. Mrs Z, P0A0, 40 yodr. Nanda (R5) supervised by dr. Wuryatno SpOG, assisted by dr. Aini (R2) had performed subtotal histerectomy b/i uterine myoma pre op dx : uterine myoma post op dx : intramural uterine myoma + endometriosis

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During the operation

Peritoneal parietale had opened identification and exploration - seem enlarged uterus , size 12x10x10 cm, endometriosis nests adhese posteriorly of the left uterus and the rectum - tube and ovarium sinistra in normal condition - tube and ovarium dextrain normal condition2. Diagnosed as uterine myoma with endometriosis3. Performed subtotal hysterectomy sent to Anatomy Pathology4. Control bleeding 5. Abdominal wall closed layer by layer 6. Blood loss during operation 300 cc7. Condition of patient before/during/after the operation was good

MAYOR GYNECOLOGY3. Mrs S, G1P0A0, 24 yo, 6 wgadr. Gunawan (R4) supervised by dr. Wendi (R6) under permission by Dr. dr. Soetrisno SpOG, assisted by dr. Tanjung (R2) had performed salphingoovorectomy dextra b/I pars ampullaris dextra tube rupture pre op dx : Ectopic pregnancy post op dx : pars ampularis dextra tube rupture

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During the operation

Peritoneal parietale had opened identification and exploration - enlarged uterus , size as swan egg- stolsel 500 cc - tube and ovarium sinistra in normal condition - pars ampullaris dextra tube was ruptured and adhesion with right ovarium2. Diagnosed as pars ampullaris dextra tube rupture3. Performed salpingooovorectomy dextra4. Control bleeding 5. Abdominal wall closed layer by layer 6. Blood loss during operation 1000 cc7. Condition of patient before/during/after the operation was good

Joint with other department1. Mrs.S,G4P2A1, 34 yo,14 wga Dx: Abortus incompletus with Dilatated cardiomyopathy, decompensated cordis NYHA II + Pulmonal hypertention + Azotemia (ur : 75/ Cr: 2,4) Tx: curretage with multidiciplin superviser *

This morning condition:GC : good, CMVS : BP: 140/90 mmHg RR: 20x/minute HR: 88x/minute T : 36,8 CBC : -125 ccUO: 50 cc/jam*

KONFERENSI KLINIK OBSTETRI GYNECOLOGYRESIDEN OBSGIN, 2013*

Oncology new patientsOvarian Cancer continue chemotherapy : 1 CASECervical Cancer pro radical hysterectomi : 2 CASESClinical cervical cancer pro biopsy : 1 CASEEndometrial Cancer continue chemotherapy : 1 CASE

KONFERENSI KLINIK OBSTETRI GYNECOLOGYRESIDEN OBSGIN, 2013*

NEW PATIENTS1. Mrs. S, P1A0 52 yoDx : endometrial cancer stage IC post complete surgical staging post AP ITx: Pro AP II

2. Mrs. F, P2A0, 48 YOdx: clinical cervical cancer stage II A with anemiatx : sugest to cervical biopsy general condition improvement sugest to staf ward examination

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*3. Ny N, P4 A0 50 yoDx: Ca ovaii III C post optimal debulking post CAP II with anemia Tx: improve conditions transfusion untill Hb > 10 gr%Pro CAP III

4. Mrs. S, P4A0, 68 yoDx : Ca Cervix IB2Tx : pro radical Hysterectomy

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5. Mrs.W , P4A1, 41 yoDx : Ca Cervix IB2Tx: Pro radical Hysterectomy

MAJOR GYNECOLOGY1. Mrs. Amini, P6A0, 56 yodr. Heru P SpOG (K) onk assisted by dr. Alfun (R7) and dr. Nanda (R5) had performed radical hysterectomy , bilateral salphingoovorectomy, bilateral pelvic lymphadenectomypre op dx : cervical cancer IB2 post op dx : cervical cancer IB

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During the operation

Peritoneal parietale had opened identification and exploration - seem normal uterus , size 5x4x4 cm - tube and ovarium dextra et sinistra in normal condition - parametrium, hepar, lien , gaster and omentum in normal condition2. Diagnosed as cervical cancer IB23. Performed radical hysterectomy + BSO + LPB sent to Anatomy Pathology4. Control bleeding 5. abdominal wall was closed all layer6. Bleeding during operation 350 cc7. Condition of patient before/during/after the operation was good

Plan for Major GynecologyMrs. S, P4A0, 47 yoDx : suspect ovarian carsinoma + bilateral pleural effusion Tx : Removal tumor mass + FSOperator : dr Teguh P SpOG (K) onkAssistant : dr Alfundr NandaPlace : OK I 08.00 *

KONFERENSI KLINIK OBSTETRI GYNECOLOGYRESIDEN OBSGIN, 2013*

CHRONOLOGY*History of heart disease/DM/Hipertention was deniedContraseption: DMPA injection for 5 years.

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*USG: VU enough filling, seems enlarged uterus,size: 9x7x4, endometrial line (+), nor intra-uterine and extra uterine GS was seen, Hematokel Retrouterina (+)Impression: ectopic pregnancyGenital: Inspekulo: v/u normal, vaginal wall in normal range, portio livide, osteum uteri externum closed, blood (+) minimal, discharge (-) VT: v/u normal, vaginal wall in normal range, portio soft, osteum uteri externum closed, CU as a duck egg, slinger pain (+) , cavum douglass bulging (+)

*Hematocele retro uterina

Laboratorium28Hb: 7,2Hct: 23L :15,500T:486.000 E : 2,54 PT:13,2APTT:24,2GDS:142Alb:4,2 Cr: 0,8 Ur:29 HbsAg: (-) Pp test (+) BT: BKONFERENSI KLINIK OBSTETRI GYNECOLOGYRESIDEN OBSGIN, 2013*

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*During the operation

1. Peritoneal parietale had opened identification and exploration - stolsel 300 cc- the uterus enlarge as big as duck egg - tube and ovarium dextra in normal condition - tube and ovarium sinistra was ruptureddecided diagnosed as rupture ovarian pregnancyAnd performed salpingoovorectomy sinistra4. Control bleeding5. Abdominal wall closed layer by layer 6. Opertion was done7 Blood loss 1000 cc8. Condition of patient before/during/after the operation was good

The problems of this case are:*

To diagnose ovarian pregnancy using Spiegelberg criteria:Ipsilateral tube in intact condition gestational sac must be placed in ovariumThe Ovarium must be connected by ligamentum suspensorium ovarii to uterusOvarian tissue must be found in gestational sac by microscopic examination.

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from universities, journals, and other research organizations (May 2013) in:After Ectopic Pregnancy: First Randomised Trial Finds Reassuring Evidence On the Effect of Different Treatments*A total of 207 women in the first arm were randomised to either medical treatment or conservative surgery, while 199 were randomised to conservative or radical surgery in the second arm.

After two years the rates of spontaneous pregnancies in the uterus (intrauterine pregnancy) were 67% after medical treatment and 71% after conservative surgery in the first arm. The rates in the second arm were 70% after conservative surgery and 64% after radical surgery. The differences between the rates in each arm of the trial were not statistically significant.Conclutions: The first randomised trial to compare treatments for ectopic pregnancies has found no significant differences in subsequent fertility between medical treatment and conservative surgery on one hand, and conservative or radical surgery on the other.

DEATH REPORTMrs. S, P3A0, 39 yo Early Dx: Septic cervical cancer II A post radical Hysterectomy LPB BSO post complete radiotherapy post 5 FU Cysplastin III post TC III + ca pulmo dd susp metastasis cervical cancer HAP late onset Final Dx: Septic shock cervical cancer II A post radical Hysterectomy LPB BSO post complete radiotherapy post 5 FU Cysplastin III post TC III + ca pulmo dd susp metastasis cervical cancer HAP late onsetCOD: septic shock*

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TglKronologi27 Agt 2013Pasien datang ke UGD Triase dengan keluhan : sesak napas berat28 Agt 2013Pasien dikonsulkan ke bagian ObsgynDx : Multigravida hamil 12+5 minggu dengan DCM, Decomp cordis NYHA III, EF 32%, anemia, azotemia, hiponatremi29 Agt 2013Diajukan di Konferensi Klinik Obsgyn : apakah kehamilan pasien tersebut masih dapat diteruskan atau tidak.Keputusan konferensi obsgyn : Terminasi Kehamilan, sambil meminta second opinion ke bagian jantung apakah mungkin terapi konservatif30 Agt 2013Jawaban dari bagian Jantung : Risiko kehamilan tinggi dan kontra indikasi kehamilan2 Sept 2013Memohon persetujuan Terminasi Kehamilan kepada Komite Medik4 Sept 2013Mendapat jawaban dari KOMDIK untuk Joint Conference dengan bagian Jantung

A high maternal mortality risk is reported 3050% in patients with severe PAH.Maternal death occurs in the last trimester of pregnancy and in the rst months after delivery because of pulmonary hypertensive crises, pulmonary thrombosis, or refractory right heart failureRisk factors for maternal death are : late hospitalization, severity of pulmonary hypertension, and general anaesthesia. The risk probably increases with more elevated pulmonary pressures. Sumber : European Heart Journal 2011

Mortalitas Maternal Penyakit jantung pada kehamilan

KelompokPenyakit JantungRisiko MortalitasIAtrial Septal Defect (ASD)Ventricular Septal Defect (VSD)Patent Ductus Arteriosus (PDA)Mitral Stenosis NYHA kls I-IIGangguan katup pulmonal/ trikuspidalTetralogi Fallot yang dikoreksi< 1 %II2AMitral Stenosis NYHA kls III-IVAorta stenosisKoarktasio aorta tanpa kelainan katupTetralogi Fallot tanpa koreksiSindroma Marfan dengan aorta normalRiwayat Miokard infark2 BKatup prostetik mekanisMitral stenosis dengan atrial fibrilasi5 15 %IIIHipertensi pulmonal primerSindroma EisenmengerKoarktsio aorta dengan kelainan katupSindroma Marfan dengan kelainan AortaKardiomiopati peripartum dengan disfungsi ventrikel kiri persisten25 50 %

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