BACKGROUND: As of January 2021, Indonesia had the 21st highest number of total COVID-19 cases and the 17th highest total deaths among all countries. COVID-19 infection in pregnant women seems to negatively affect both maternal and neonatal outcomes. CASE REPORT: We describe four cases of pregnant women confirmed with severe and critical COVID-19 that resulted in maternal death from November until December 2020. The first case was complicated with thrombocytopenia, her condition quickly deteriorated post-delivery. Pulmonary embolism was suspected as the cause of death. Second and third cases were complicated with preeclampsia, obesity, and advanced maternal age. Second case came in sepsis condition. Her SARS CoV-2 RTPCR swab test came out after her death. Third patient did not have COVID-19 symptoms at admission. She starts having symptoms on second day and was confirmed positive a day after. She falls in septic shock. Fourth patient has history of fever, cough, and dyspnea. She was confirmed positive on first day and her condition worsened, diagnosed with bacterial co-infection sepsis on day eight. All patients underwent cesarean section. CONCLUSION: Limited information and studies for COVID-19 management in pregnant women are challenging for obstetricians. Management should be individualized weighing the benefit and risks in presence of comorbidities or accompanying disease.

Introduction and importance Placenta accreta spectrum (PAS) is a state of abnormal attachment of the placenta, including placenta accreta, placenta increta, and placenta percreta. This condition can be life-threatening due to the placenta cannot spontaneously separated, resulting in continuous bleeding. Cesarean section followed by hysterectomy is one of the treatment options for PAS. There was a great liability for urinary tract injuries during the operation of PAS patient. Case presentation We present the case of ureter injury during subtotal hysterectomy in patient with PAS. A 30-years-old female patient was diagnosed with recurrent antepartum hemorrhage due to placenta previa accreta spectrum on G2P1 33 weeks of gestational age, singleton live breech presentation, previous c-section 1×. After uterine transverse incision, the baby was delivered. We decided to perform subtotal hysterectomy. There was severe adhesion. On the exploration after subtotal hysterectomy was performed, we found ruptured of the right ureter. Clinical discussion Hysterectomy peripartum is one of the treatment of PAS, either to prevent or to control postpartum hemorrhage. In pregnant women with morbid placental adherence, there was a great liability for urinary tract injuries. Distal ureters are the most commonly injured while hysterectomy. Injuries to the ureters in this patient occurred due to severe adhesions and unclear visual organ. Conclusion Although it is rare, ureter injury may occur during subtotal hysterectomy in patient with placenta accreta spectrum. To prevent that condition, inserting ureter stent can be perform before the operation. Multidisciplinary approach is carried out so that patient outcomes are good.

Maternal mortality remains a worldwide concern to this day. Three main causes of maternal mortality during 2010–2013 were hemorrhage, hypertension, and infection, which all of them are the direct causes. The high MMR is also due to the presence of 3 delay which is Delay in seeking assistance (type–1), delay in identifying and accessing medical center (type–2) and delay in having prompt treatment (type–3) . Therefore, this study aims to describe maternal mortality cases in tertiary hospital which is Cipto Mangunkusumo Hospital (CMH) so that the root of problems in maternal deaths can be discovered and improvements can be done in the future. This was a descriptive study conducted in the Department of Obstetrics and Gynecology at CMH, Jakarta. Data collection was taken from 2016 – 2018 where subjects were taken from secondary data on maternal mortality. Based on the data that has been collected in CMH total live births in Emergency Department CMH during 2016-2018 which was 4.226 cases. There was 22 maternal death cases (0.52%). Most deaths were occurred in 2017 (50% of all cases). Indirect causes of maternal mortality were the leading cause in this study, including septic shock, hypovolemic shock due to Dengue Shock Syndrome, cardiogenic shock, and acute respiratory failure. Three delay models were three main factors contributing to maternal mortality interrelated and influenced by other factors with delay in looking for assistance and treatment (31,8%) was the upmost factor of maternal mortality. More than half maternal deaths in CMH during 2016 – 2018 caused by indirect causes. Among three delay models, delay in looking for assistance and treatment was the upmost factor of maternal mortality. Keywords: maternal mortality, three-delay model.   Tiga Model Keterlambatan pada Kasus Kematian Ibu di Rumah Sakit Tersier di Indonesia Kematian ibu masih menjadi perhatian dunia hingga saat ini. Tiga penyebab utama angka kematian ibu (AKI) selama 2010-2013 adalah perdarahan, hipertensi, dan infeksi, yang semuanya merupakan penyebab langsung. Tingginya AKI juga disebabkan oleh adanya 3 keterlambatan yaitu keterlambatan dalam mencari pertolongan, keterlambatan dalam mengidentifikasi dan mengakses pusat kesehatan, dan keterlambatan dalam mendapatkan pengobatan yang tepat. Penelitian ini bertujuan untuk mendeskripsikan kasus kematian ibu di rumah sakit tersier yaitu Rumah Sakit Cipto Mangunkusumo (RSCM) sehingga akar permasalahan kematian ibu dapat ditemukan dan dapat dilakukan perbaikan di masa yang akan datang. Penelitian ini merupakan penelitian deskriptif yang dilakukan di Bagian Obstetri dan Ginekologi RSCM, Jakarta. Pengambilan data diambil dari tahun 2016 – 2018, subjek diambil dari data sekunder kematian ibu. Berdasarkan data yang terkumpul di RSCM jumlah kelahiran hidup di Instalasi Gawat Darurat RSCM selama tahun 2016-2018 sebanyak 4.226 kasus. Terdapat 22 kasus kematian ibu (0,52%). Kematian terbanyak terjadi pada tahun 2017 (50% dari seluruh kasus). Penyebab tidak langsung kematian ibu merupakan penyebab utama dalam penelitian ini, antara lain syok septik, syok hipovolemik akibat dengue shock syndrome, syok kardiogenik, dan gagal napas akut. Tiga model keterlambatan merupakan tiga faktor utama penyebab kematian ibu yang saling berkaitan dan dipengaruhi oleh faktor lain dengan keterlambatan mencari pertolongan dan pengobatan (31,8%) merupakan faktor penyebab kematian ibu yang paling tinggi. Lebih dari separuh kematian ibu di RSCM selama tahun 2016 – 2018 disebabkan oleh penyebab tidak langsung. Di antara tiga model keterlambatan, keterlambatan dalam mencari bantuan dan pengobatan merupakan faktor utama kematian ibu. Kata kunci: kematian maternal, model tiga terlambat.

The intrauterine device (IUD) is one type of long-acting reversible contraception (LARC) method available. The objective of this article was to report the case of a symptomatic partial expulsion of IUD. A 41-year-old woman presented herself to Dr. Cipto Mangunkusumo National General Hospital with the chief complaint of pelvic pain. She had been using intrauterine levonorgestrel-releasing system for the last 4 years as her adenomyosis treatment. On ultrasound examination, there was no IUD visualized. A pelvic x-ray imaging with Copper-T IUD as a marker was done and suspected IUD displacement. The IUD was then removed successfully.