CASE REPORT SESSION Prolaps Funiculi

Created by :Group 11

M. Rizki DwikaneM. Amri Kautsar

Erni MaryamAgli Adhitya A. PAnnisa Febrieza ZVivi Herliyanti M

Introduction

Prolaps of umbilical is one of emergency case in obstetric

prolapsus funikuli aproximately 1: 2000

of birth

Mortality occurs prolapsus fonikuli in

fetus aproximataly 11-17%

Prolapsus funikuli not influence directly

maternal condition, however very danger

to the fetus

Prolapsus funiculi is umbilical that occurs when

premature rupture of membrane and the

umbilical cord there is in lower of fetus.

CASE

IDENTITY: Date / Time entry SYAMSUDIN SH Hospital: August 22, 2013.

07:00

Name: Ny.NAge: 18 YearsEducation: junior high schoolOccupation: HousewifeReligion: IslamEthnicity: SundaAddress: Kp. Cidolag

ANAMNESA

• 9 months pregnant patient complaining of fluid from the birth canalChief

complaint

ANAMNESA

• G1P0A0 patients feel pregnant 9 months to come to the hospital with a complaint brought by midwife clear fluid output from the birth canal that quite a lot of since 23:00 last night.Another complaint is accompanied contraction in abdomen. contraction is felt more and more frequent and stronger. Fetal movement was felt.

• nothing

History family history

• nothing

History other disease

• Menarche : 13 Tahun• cycle : Teratur (28 hari)• Long menstruated : 7 hari• Dysmenorrea : Kadang-kadang• quantity : ± 2 pembalut• HPHT : 20 November

2012• Taksiran Persalinan : 27 Agustus 2013

History of menstrual

Married once with present husband

History marital

Never use contraception anything

Contrace-ption

Patient examinatioto the mide wife two times in month

ANC

Obstetric history : Now pregnant

Chronology • 22-08-2013, 04.00 o’clock

VT = Ø 4cm, amnion (-) clear, head with decreased H1 and feel umbilical cord

BP = 110/70 , HR= 80x/menit , Rr= 20x/menit, T= AffTFU = 31 cm, head presentation,FHR= 138x/menit, HIS = 3x10’-20’

Patients come to the midwife with complaints of heartburn and heartburn-clear liquid out of the birth canal since last night (23:00 hours)

- Trendelenburg position- Oksigen 5 Liter/minute

- Infuse RL

G1P0A0 parturient aterm with prolapsus funiculi, single fetal life in intrauterine

Physical Examination(in hospital)

General status:• General appearance: The patient was restless,

looking sickAwareness: Compost Mentis

• Vital sign:BP= 110/70 mmHg, HR=80x/minute, Rr= 20x/minute, T= Aff

• BW= 60 kg, BH = 159 cm

General physical exam:

• eyes:- Conjunctiva anemic + / +,- Sclera jaundice - / -,- Pupil 3mm/3mm,- The light reflex + / +Nose: Septum Deviation (-), secret (-)Mouth: moist oral mucosaEar: no justice no abnormalities

• Neck: Not palpable enlargement of the KGBThorax: cor and pulmo there is no pulmonary abnormalities

Abdomen : Inspection : Linea nigra (+), Striae Gravidarum (+), convex Palpation : Leopold I : Palpable part rather soft, round and bouncy, TFU 31 cmLeopold II: right: fetal spine (FHR: 122x/menit)left: fetal limbLeopold III: Palpable hard part, round and bouncyLeopold IV: Already entered PAP

TFU = 31 cm, Head presentation, FHR = 112x/mHIS = 3x10’-20’VT = Ø 6cm,Amniotic sac(-) , head with a palpable decline in H1 and palpable pulsating umbilical cord.

• Upper extremity: warm, CRT <2 Seconds, Edema - / - Lower extremity: cold, CRT <2 Seconds, Edema - / - Skin: pale Looks

Laboratory exam:Hb : 10.8Leukosit :13.000Trombosit :315.000Ht :31.3 %Golongan Darah : A

DIAGNOSA

G1P0A0 Parturient Aterm Kala I active phase with prolaps funiculi

Planning• Observation fetal and maternal condition• Trendelenburg position• Oksigen• Pro SC cito

DISCUSSION

1. Whether the diagnosis is correct in this case?2. Whether risk factors were found in this

patient? 3. Whether treatment was appropriate in this

case? 4. How prognosis of this case?

• Whether the diagnosis is correct in this case?

Anamnesa :complaining of fluid from the birth canal

Obstetric exam :TFU = 31 cm, Head presentation, FHR = 112x/m,HIS = 3x10’-20’,VT = Ø 6cm, Amniotic sac(-) , head with a palpable decline in H1 and palpable pulsating umbilical cord.

vaginal toucher visible or palpable cord in the vagina that sometimes it is sticking up out of the vulva as in this case and palpable pulsating umbilical cord indicating that the fetus is alive

• Prolaps fulikuli : if a palpable cord out / be in the side and passes the lowest part of the

fetus in the birth canal, the umbilical cord can prolapse into the vagina or even outside the

vagina after rupture

Leading cord

Occult prolapsed

• Investigations CTG bradycardia • Examination of the fetal heart rate, decreased

heart rate obtained

CLINICAL SYMPTOMS

• There are two main problems occur: 1. Umbilical cord wedge between the lowest part of the fetus in the mother's pelvis. 2. umbilical cord vessel spasm due to central chilled temperatures outside the mother's body.

• Gejala : -Bradikardia/Takikardi- Irreguler- VT : Palpable funiculi prolaps- CTG = Deselerasi Variabel

Whether risk factors were found in this patient?

Fetal Factor

• Abnormal Presentation

• Prematuritas• Gemelli• Hydramnion

Maternal History

• CPD• The lowest

part of the high

In this case found that the risk factors in patients are:

1. Rupture of membranes before time 2. The lowest part of the fetus is still high 3. Long umbilical cord (known after childbirth) 4. CPD?

Whether treatment was appropriate in this case?

MidwifeTrendelenburg

position

Hospital- Trendelenberg

position- Infus

- Report for Obgyn dept

Emergency Treatment(SC cito)

General treatment

– In the case of prolapse required immediate management– Informed Consent carried on the family – Definitive therapy is the delivery of a fetus with immediate– Vaginal delivery is possible only when the complete

opening, the lowest part of the fetus has entered the pelvis, and there is no CPD

– Danger to the mother and fetus will be reduced – if the SC Pending the preparation of SC mother remained

Trendelenburg position – O2 provide 5-8 liters / minute – Giving fluids through the infusion– DJJ observation

Prolaps Funiculi

On the location of the head :a. If the opening is small / incomplete done cesarean section, unless the heart sounds is a very bad boy. During the wait for surgery preparation, intrauterine resuscitation attempted. Also try pressure on the cord so avoided or reduced, for example by placing the mother in Trendelenburg position. Before performing cesarean sections examined fetal heart sounds again.

If the opening is complete : - Perform cesarean section if the head is still high, head rocking version and extraction or cesarean section. -With vacuum extraction or forceps if the head of the largest size has passed the pelvic brim. - In small children (children gemeli II) can be arranged in advance fundus expression and if the requirements are extraction with forceps. Do not waste time try repositioning the umbilical cord

How prognosis of this case?- Anemia

- Fever

Maternal Prognosis

- Fetal distress

- Death

Fetal Prognosis

• In this case not obtained a poor prognosis because appropriate treatment and managed to prevent fetal distress leading to death. Baby is born, female sex weighing 3150 g, Apgar score 7-9, congenital abnormalities (-), clear amniotic fluid. Circumstances both mother and baby

• Baby is born, female sex weighing 3150 g, Apgar score 7-9, congenital abnormalities (-), clear amniotic fluid. Circumstances both mother and baby.

REFERENCE 1. Sastrawinata S, Martaadisoebrata D, dkk. Kelainan Plasenta, Tali Pusat, Gangguan Janin dan Distasia. Obstetri Patologi Ilmu

Kesehatan Reproduksi. Jakarta : ECG. 2005. 37-8,155-7.

2. Cunningham G.F, Gant N.F, dkk. Penyakit dan Kelainan Plasenta. Obstetri Williams. Edisi 2. Volume 2. Jakarta : ECG. 2006 : 926.

3. Liewellyn D, Jones. Prolaps Tali Pusat. Dasar-dasar Obstetri dan Ginekologi. Edisi 6. Jakarta : ECG. 2002:162.

4. Wikipedia, the Free Encyclopedia. Umbilical Cord Prolapse. Available fromhttp://www.en.wikipedia.org/wiki/cordProlapsed. Accessed : 28/08/2013.

5. Benson Ralph C. Complication of Labor and Delivery. Current Obstetric, Gynecologic, Diagnosis, Treatment. Lange Medical Publication. California. 2004: 617-18.

6. Boyle JJ. Prolapsed Cord. Available from :http://www.merck.com/mmpe/topic/prolapsedcord.htm. Accessed : 28/08/2013

7. Cleaveland Clinic. Umbilical Cord Proplase. Available from: http://www.cleavelandclinic.org/healt/health-info.Umbilicalcord-asp. Accessed:28/08/2013