Case no.

Name : Mrs. T
Age : 35 years old
No. MR : 01.00.53.78
Admission date : January 28th 2018
Address : padang

A 35 years old patient was admitted to the Emergency Room of Dr.

M. Djamil Central General Hospital on January 28th 2018 at 12.00 am
referred from Rasyidin District hospital with diagnosed vaginal
bleeding due to molar pregnancy
Present Illness History:
• Bleeding from vagina (+) since 2 days ago spotted on underwear, massive
bleeding since 4 hours ago, wetting 2 pieces of saroong
• pain in the lower abdomen (-)
• Fish-eye like tissue came out from vagina (-)
• massive bleeding from vagina (-)
• Felt mass in abdomen was denied
• History of body weight 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
• Last menstrual period: october 2017
• she never performed pregnancy test although her LMP was on october
• Urination and defecation was normal
• this is her fifth pregnancy
Previous Illness History
• There was no previous history of heart, lung, liver, kidney,
hypertension and allergy.

Family Illness History

• There was no history of hereditary disease, contagious and
physiological illness in the family
History of formal education : Senior high school
History of Occupation : house wife
History of contraception : none.
History of Habit : Smoke (-), Alcohol (-),
Drugs (-)
Physical Examination

GA Cons BP HR RR T
Mdt CMC 110/80 88 18 36,8
BW : 50kg
BH : 150 cm
BMI : 22,22 kg/m2
UAC : 22 cm

Eyes Conjunctiva was anemic, Sclera wasn’t icteric

Neck JVP 5-2 cmH2O, tyroid gland no enlargement
Chest H/L normal
Abdoment Gyn Record
Genitalia Gyn Record
Extremity Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-
 Gynecologic record
Abdomen
I : Seems no enlargement
Pa : Uterine fundal was not palpated, Tenderness (-),Rebound
Tenderness (-), DM (-)
Pe : Tympani
Au : Peristaltic sound was normal

Genitalia
I : V/U normal, bleeding from vagina (-)
Inspeculo
• Vagina : Tumor (-), Laceration (-), Fluxus (+) black reddish blood
piled in posterior fornix ,
• Portio : MP size equal an adult toe, Tumor (-), Laceration (-), AF,
fluxus (-),no active bleeding
Bimanual VT
• Vagina : Tumor (-), laseration (-)
• Portio : MP equal an adult toe, tumor (-),
laceration (-), OUE was open fit to 1 finger
• CUT : Uterus was palpable as big as duck egg
• AP : Soft right - left
• CD : Not protruted
Laboratory, January 28th, 2018
Parameter Result Normal Range
Haemoglobine 8,2 gr/dl 9,5 – 15

Haematocryte 25 % 28 – 40

Leucocyte 11450/mm3 5,9 - 16,9.103

Trombocyte 187000/mm3 146 - 429.103

APTT 31,4 22.6 – 35.0

PT 16,8 9.6 – 12.9

Albumin 3,0 g/dL 3,5 – 5,2

Globulin 1,9 g/dl 1,3-2,7

Cloride 108 mmol/L 97 – 111

Potassium 4,5 mmol/sec 3,5 – 5,1

Sodium 137 mmol/sec 139 – 145

Ureum 15 mg/dL 15.0-40.0

Creatinin 0,7 mg/dL 0,6 – 1,2

SGOT 12 u/L 0 – 31

SGPT 12 u/L 0 – 34

HbsAg negative negative

T3 0,86 0,9-2,5

T4 64,81 60-120

TSH 1,46 0,25-5

Bhcg 145,6

10
USG

Uterus size was bigger than normal 13,4x5,96x8,41cm

• there was hyper-hypo echoic mass intra caviter, sized 7,56x 3,44x5,77 cm
(honey comb appeareance)
• Right ovaryan size: 3,37 cm x 1,76 cm
• Left ovaryan size: 3,83 cm x 3,6 cm
• Impression : hydatidiform mole
Diagnosis
Hydatidiform mole DD/ rest of conception + moderate anemia

Plan
Control GA,VS,VB
Informed consent
transfussion of PRC 2 units
consult to anesthesiologyst
Curretage after general condition improvement --> Hb post
transfussion was 9,4 gl/dl
January, 31st , 2018 at 08.00 am
• Curretage was performed, there was tissue seems like rest of conception
curretaged from uterus
• Bleeding during curretage 50cc
• Tissues was delivered to Laboratorium of Patalogic Anatomi

Diagnosis
• Post curretage oi rest of conception

Plan
Monitoring post operation
IVFD RL drip Oxitocyn : methergin 1:1 20gtt/min
Inj Ceftriaxon 2x1 gr IV
methilergometrine 3x1 po
blood test after op
THANK YOU