Case no

Identity
• Name : Mrs. R
• Age : 26 years old
• Address : Padang
• No. MR : 51 25 18
Chief complaint

A 26 years old patient referred from policlinic of gynaecology of Dr.

M. Jamil Central General Hospital on Sept 5th 2017 at 11.00 am with
diagnose primary amenorrhea ec cervical agenesis + history of
laparotomy oi perforated appendicitis.
Present illness history :

• Menstruation History : (-)

• Cyclical lower abdominal pain (+)
• Patient was married for 8 months
• Urinary and bowel was normal
Past history of disease
• There was no previous history of heart disease, liver disease, kidney disease, DM,
hypertension and allergy.
• Hystory of laparotomy oi perforated appendicitis

Family history of disease

• There was no history of hereditary disease, contagious disease and physicological
illness in the family
• Marrital history : (-)
• History of family planning : (-)
• Education : S1
• Occupation : employe
Physical examination
• GA : Moderate
• Cons : Cmc
• BP : 120/80 mmHg
• PR : 88x/min
• RR : 20x/min
• Temp : 37 °C
• Eye : Conjunctiva was not anemic
sclera was not icteric
• Torax : Cor and Pulmo within normal limits
• Abdomen : Gynecological status
• Genital : Gynecological status
• Extremities: Edema -/-, physiological reflex + / +,
Pathological reflex - / -
Gynecological Record
Secondary sex characteristic :

• Enlargement of breasts and erection of nipples (+)

• Growth of body hair in underarm and pubic hair (+)

Abdomen:
Inspection : Seem no enlarge
Palpation : No mass was palpable
Tenderness (-), Rebound tenderness (-), Defans muscular (-)
Percussion : Tympani
Auscultation : Normal peristaltic sound
Ginekology
Inspeksi : V/U within normal limit, bleeding (-)

Inspeculo:
Vaginal : a little bit short, tumor (-), laceration (-)
There is no cervix and external uterine ostium (-)
 USG
• Uterus size and shape a little bit small with
size 4,9 x 3,08
• Both of ovary was normal
• Cervix/portio (-)
• Impression : cervical agenesis
Laboratory:
No Parameter Results Normal range

1 Hemaglobin 13,2 g/dl 12-14

2 Hematokrit 40% 37-43

3. Leukosit 9300/mm3 5-10

4. Eritrosit 4.69 x106/mm3 4-5 x106/mm3

5. Trombosit 305.000/mm3 150.000-400.000

6. APTT 33.2 det 29,2 – 39,4 det

7. PT 10.1 det 10,0 – 13,6 det

No Parameter Results Normal Range

1 FSH 5,91 mlU/ml 3-20

2 LH 2,39 mlU/ml <7

3. TSH 1,2 uIU/ml 0,4-4

4. AMH 1,94 >1,26

5. EL 99 pg/ml 25-75

6. Prolaktin 9,7 ng/ml <24

Diagnosis
Primary amenorrhea ec cervical agenesis + history of laparotomy oi perforated
appendicitis.

Attitude
• Control GA, VS,
• Informed consent
• Consult to anesthesiologist
• Report to operation room

Plan
• Laparoscopy and vaginal approach for utero-vaginal anastomosis
07-09-2017 (08.00 a.m)
Laparascopy performed
Theres are massives adhesive  adhesiolysis
Separation of plica vesicouterina until lower segment of uterine
With Sondage from vaginal, the uterine push to upward
Make longitudinal incision in lower segment of uterine
Until penetrate to uterine cavum. Then make incision in vaginal
area, sondage replaced with silicon cathether no 16. The silicon
catheter was discharged from vagina until uterine cavum anad
the ballon cathether expanded.
Between uterine and vaginal was sutured

Diagnosis
Utero-vaginal anastomosis with laparoscopy and vaginal
approach + adhesiolysis

Plan
Control after operation