Lapkas obstet pp
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Transcript of Lapkas obstet pp
Program Pendidikan Profesi DokterSMF Obstetri & Ginekologi
FK USU / RSUP DR PirngadiMedan
Laporan Kasus
Pembimbing : dr. Fadjrir, Sp.OGMentor : dr. T. Larry Arthit
Program Pendidikan Profesi Dokter
SMF Obstetri & Ginekologi
FK USU / RSUP DR Pirngadi
Medan
Pembimbing : dr. Fadjrir, Sp.OGMentor : dr. T. Larry Arthit
Di susun oleh :
Pendahuluan Angka Kematian Ibu (AKI) di Indonesia sebesar 228
per 100.000 kelahiran hidup. (SKDI, 2007)
Perdarahan (28%), eklamsia (24%), infeksi (11%),abortus (5%), persalinan macet (5%), emboliosbtruktif (3%).
Hipertensi dalam Kehamilan (HDK) : 5-15% penyulitkehamilan. Termasuk tiga besar morbiditas &mortalitas ibu bersalin.
Pendahuluan Di Negara maju, HDK merupakan 16% mortalitas ibu,
lebih besar dari tiga penyebab utama lain sepertiperdarahan (13%), aborsi (8%), dan sepsis (2%).(WHO)
Di Indonesia, mortalitas dan morbiditas HDK jugamasih tinggi. Etiologi yang tidak jelas, perawatandalam persalinan masih ditangani oleh petugas nonmedik dan sistem rujukan yang belum sempurnamenjadi alasan.
Hipertensi dalam Kehamilan Yang dipakai di Indonesia : Report of the National
High Blood Pressure Education Program WorkingGroup on High Blood Pressure in Pregancy, 2001
Hipertensi Kronik
Preeklampsia-eklampsia
Hipertensi Kronik dengan superimposed preeklampsia
Hipertensi Gestasional
HDK
Faktor Risiko Primigravida, primiparitas
Hiperplasentosis : mola hidatidosa, kehamilanmultipel, DM, hidrops fetalis, makrosomia
Umur yang ekstrim
Riwayat keluarga pernah PE/E
Penyakit-penyakit ginjal dan hipertensi yang sudahada sebelum hamil
Obesitas
PatofisiologiTeori kelainan vaskuler
plasenta
Teori iskemik plasenta, radikal bebas dan disfungsi endotel
Teori intoleransi imunologik antara ibu dan janin
Teori adaptasi CV genetik
Teori defisiensi gizi
Teori inflamasi
Disease of Theory
Gangguan Implantasi Trofoblas
Penyakit Vaskuler Ibu Gangguan Placentasi Trofoblas Berlebihan
Faktor Genetik, Imunologik,Atau
Inflamasi
Penurunan PerfusiUteroplacenta
Zat Vasoaktif: Prostaglandin, Nitrat
Oksida, Endotelin
Zat Perusak: Sitokin, Peroksidase Lemak
Kebocoran Kapiler
Aktivasi endotel
Vasospasme Aktivasi Koagulasi
Trombositopenia•Edema•Hemokonsentrasi•proteinuria
Hipertensikejangoligouriasolusioiskemia hepar
PATOFISIOLOGI
PenatalaksanaanDASAR PENGELOLAAN PEB
Ekspektatif/konservatif : bila umur kehamilan < 37 minggu, artinya: kehamilan dipertahankan selama mungkin sambil memberikan terapi medikamentosa.
Aktif/agresif : bila umur kehamilan ≥ 37 minggu, artinya kehamilan diakhiri setelah mendapatkanterapi medikamentosa untuk stabilisasi ibu.
Indikasi Terminasi Indikasi Ibu :
Kegagalan medikamentosa
Muncul tanda-tanda impending eklampsia
Gangguan Fungsi Hepar/Ginjal
Kecurigaan solusio plasenta
Inpartu, KPD, perdarahan
Indikasi Janin :
Usia Kehamilan >= 37 minggu
PJT berat (USG)
NST non-reaktif & profil biofisik abnormal
Oligohidramnion
Indikasi Laboratorium :
Sindroma HELLP
Medikamentosa Tirah Baring, Oksigen,
Kateter menetap, IVFD : Ringer Asetat, Ringer Laktat, Koloid
Awasi balans cairan.
Pematangan Paru (Kehamilan <37 minggu) : Dexametashone 6 mg/12 jam 4 kali.
Magnesium Sulfat LD. 4 gr (20 cc) MgSO4
20% IV bolus pelan 10-15 menit
MD. 6 gr (60 cc) MgSO4 40% : dalam 500cc RL (1 gr/jam) --> 28 gtt/i
Antihipertensi : nifedipin 10 mg PO diulangi 30 menit (max 120 mg/24 jam)
Case Report Patient Identity: No. MR : 93.06.34 Name : Mrs. RRI Age : 29 y.o Address : Jl. HM Joni Blok H no.5 Medan Religion : Moslem Race/Nationality : Javanese/Indonesian Education : SLTA Profession : Housewife Status : Married Date of admission : 28th June 2014 Time of admission : 23.57 Tgl Keluar : Parity : G2 P1 A0
Chief complaint : Vaginal bleeding
Telaah : It is experienced 2 days before admission, blood spot . Four hours before admission, the bleeding recurred, the bleeding worsen from two days ago, mking the patient has to change her cloth twice. Bleeding occured spontaneously, history of trauma (-). Abdominal pain (+). Watery discharge from vagina (-). History of high blood pressure before pregnancy (-). History of high blood pressure on previous pregnancy (+). Blurred vision (-) Epigastric pain (-). History of headache (-). Nausea and vomting (-). Urination and bowel movement are normal
History of Menstruation HPHT : 15-10-2013
Predicted pregnancy date : 22-07-2014
History of operation : -
History of contraception usage :-
ANC : Midwife 6x
History of Pregnancy1. Male, aterm, vaginal birth, hospital, by doctor, 2700
grams, 5 y.o., healthy
2. This pregnancy
Presence Status Sens : Compos Mentis BP : 220/140 mmHg HR : 92x/i RR : 20x/i Temp : 37,00 C Anemia (-) Icteric (-) Dyspnea (-) Cyanosis(-) Pretibial oedema (-) Proteinuria (+2)
Kepala :
Mata : Inferior palpebra conjunctiva anemia(-/-), icteric (-/-), Light reflex (+/+), pupil isokor left=right
E/N/T : normal
Neck : Trachea medial, Lymph node enlargement (-)
Thorax : Inspection : Simetris fusiformis
Palpation : Stem fremitus right=left
Percussion : Sonor on both lung
Auscultation : Breath sound : Vesiculer (+/+)
Additional sound: (-/-)
Heart : 92 x/i,reg, S1 & S2 normal, murmur (-)
Extremities : Pretibial oedem (+)
Initial urine : ± 300 cc
BW : 78 kg
Body height : 155 cm
BMI : 32,4
Obstetric Status Abdomen : Membesar asimetrically enlarged
Uterine Funda height : 3 fingers below Processus xypoideus (29 cm)
Tegang : Right
Lowest part : Head (5/5)
Movement : (+)
HIS : 3 x 20”/10’
Fetal heart rate: 147 x/i
EBW : 2400 – 2600 grams
Inspekulo: Blood is visible menggenang on the vagina, the blood is then cleaned. Bleeding was actively draining from the eou
PEMERIKSAAN DALAM
VT : TDP
ST : TDP
USG-TAS :
Single fetus, Normal, PK
FM (+), FHR (+)
BPD : 88,2 mm (35 weeks 5 days)
FL : 69,1 mm (35 weeks 5 days)
AC : 29,2 mm (33 weeks 3 days)
Plasenta previa totalis
EBW : 2401 gram
Amniotic fluid : normal
IUP (35-36) weeks + PK + AH + Plasenta previa totalis
LABORATORIUM 28th june 2014, 23.03 Leukocyte : 15.200/mm3
Hb/Ht : 11.3 gr % /33.0 % Trombocyte : 257.000 /mm3
PT/INR/APT : 14,0 (c: 14,6) / 1.11/ 23.5 (c: 34) Random Blood Glucose : 74 SGOT/SGPT : 13/10 ALP : 144 Total/Direct Bilirubin : 0,31 / 0,10 LDH : 377
DIAGNOSA SEMENTARA
Plasenta Previa Totalis with profuse bleeding + PEB + SG + IUP (35 - 36) weeks + PK + AH + not Inpartu
RENCANA
SC cito on KBE d/t Plasenta Previa Totalis with profuse bleeding + PEB + SG + IUP (35 - 36) weeks + PK + AH +not Inpartu
Therapy on emergency ward O2 2L/i
Inj. MgSO4 20% 20 cc (slow bolus/IV 15 min) -> Loading Dose
IVFD RL + MgSO4 40% 30 cc (14 gtt/i) -> Maintenance Dose
Nifedipin loading dose 20 mg, if BP ≥ 180/110 mmHg, give nifedipin 10 mg/ 30 min ( max: 120 mg/24 jam)
Inj. Ceftriaxone 2 gram/ IV (skin test)
Inj. Dexamethasone 15 mg single dose
Foley catheter
Sectio Caesaria Report Patient lying on supine position on operation table, IV
line and catheter are inserted
Under spinal anesthetic, aseptic and antiseptic procedure using povidone iodine and alcohol 70% is done on abdomen, then it is closed using surgical drap except the operation field
Pfannensteil incision is done from cutis, subcutis, and fascia
Muscle is the bluntly opened, Peritoneum dijepit with two klem, and then it is cut betwen them. Gravid Uterus can be viewed
Low cervical incision is done on the uterus, Amniotic selaput can be viewed and then opened. Amniotic fluid is clear.
Dengan meluksir kepala, a female baby was born, BW : 2400 gram, Body lenght: 42 cm, head circumference 32 cm, A/S: 6/8, anus (+).
Placental cord diklem on two sides and cut between them. Placental is completely born by Coordinated Cord traction
Two sides of uterus incision is dijepit using oval klem
Cavum uteri is cleaned from selaput ketuban and blood.
Uterus is then sutured by continous interlocking, and then over hecting Bleeding was controlled.
Left and Right fallopiian tube and ovarium are normal
Abdominal cavity is cleaned from the remaining amniotic fluid and blood clot
Abdominal wall is sutured layer by layer from peritoneum, muscle, and fascia, subcutis and cutis.
Incisioin wound is closed using sufratulle, kassa and hipafix
Vagina is cleaned from remaining blood
Patient condition post operative is stabile
Post Operation Therapy Bed rest
IVFD RL + MgSO4 40 % (30 cc / 12 gr ) 14 gtt / i (24 hours )
IVFD RL + Oxytocin 20-10-5-5 IU 20 gtt/i
Inj. Ceftiaxone 1 gr/12 hours
Inj. Ketorolac 30mg/8 hours
Inj. Transamin 500mg/8 jam selama 24 hours
Inj. Ranitidine 50 mg/12 hours
Kala 4
NEONATUS Jenis Kelahiran : Tunggal Birth date : 29th June 2014 Fetus status : Live, healthy APGAR score : 6/8 Assisted Ventilation :+ Sex : Female Body weight : 2400 grams Body length : 42 cm Head circumference: 38 cm Congenital anomaly : - Trauma : -Consultation : -
Post SC Labs LABORATORIUM POST SC
29th June 2014, 06.00
Leukocyte : 18.600/mm3
Hb/Ht : 10,0 gr % / 28,9 %
Trombocyte : 229.000 /mm3