fk uns obgin usg 1i. skrining anomali trimester dua isuog guidelines jje 20120609
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SKRINING ANOMALI JANIN TRIMESTER KEDUA (ISUOG Guidelines)
Judi Januadi Endjun RSPAD GATOT SOEBROTO DITKESAD / FKUI – JAKARTA DEPARTEMEN OBSTETRI GINEKOLOGI 2012
BAHAN RENUNGAN • Apakah saya sudah kompeten dan
profesional?.......bukti …..?
• Komite Medik: KEWENANGAN KLINIS…..Buku Log & Portofolio
• Resertifikasi 2011 • Sistematika……trik-trik pemeriksaan • Dokumentasi: terstandarisasi
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AGENDA • Pendahuluan • Program skrining • Pemeriksaan berdasarkan
organ • Uterus dan adneksa • PESAN DIBAWA PULANG • Kepustakaan
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PENDAHULUAN • The Interna-onal Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scien(fic organiza(on that encourages sound clinical prac(ce, teaching and research for diagnos(c imaging in women's healthcare.
• The ISUOG Clinical Standards CommiAee (CSC) has a remit to develop Prac-ce Guidelines and Consensus Statements as educa-onal recommenda-ons that provide healthcare prac::oners with a consensus-‐based approach for diagnos-c imaging.
• They are intended to reflect what is considered by ISUOG to be the best prac:ces at the -me at which they were issued.
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Salomon LJ et al. Prac:ce guidelines for performance of the rou:ne mid-‐trimester fetal ultrasound scan, 2010
PENDAHULUAN • Although ISUOG has made every effort to ensure that guidelines are accurate when issued, neither the Society nor any of its employees or members accepts any liability for the consequences of any inaccurate or misleading data, opinions or statements issued by the CSC.
• They are not intended to establish a legal standard of care because interpreta-on of the evidence that underpins the guidelines may be influenced by individual circumstances and available resources. Approved guidelines can be distributed freely with the permission of ISUOG ([email protected]).
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Salomon LJ et al. Prac:ce guidelines for performance of the rou:ne mid-‐trimester fetal ultrasound scan, 2010
PENDAHULUAN • Ultrasonography is widely used for the prenatal evalua:on of growth and anatomy as well as for the management of mul-ple gesta-ons.
• The procedure provides diagnos-c findings that oWen facilitate the management of problems arising in later pregnancy.
• For example, abnormal fetal growth is a leading cause of perinatal morbidity and mortality in both industrialized and developing countries.
• In 2005, the World Health Organiza-on (WHO) concluded that impaired fetal growth had many causes related to: gene-c factors, maternal characteris-cs such as nutri-on, lifestyle including smoking, age and disease; complica-ons of pregnancy; and the physical, social and economic environment1, 2.
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Salomon LJ et al. Prac:ce guidelines for performance of the rou:ne mid-‐trimester fetal ultrasound scan, 2010
PENDAHULUAN • A mid-‐trimester fetal ultrasound scan serves as an important baseline against which later scans may be compared for the evalua-on of growth and health.
• Ultrasonography can also be used to detect congenital anomalies3–6. • The Eurofetus study7, a mul-center project involving 61 obstetric ultrasound units from 14 European countries, examined the accuracy of rou-ne mid-‐trimester ultrasonographic examina-on in unselected popula-ons.
• Over one half (56%) of 4615 malforma-ons were detected and 55% of major anomalies were iden-fied before 24 weeks of gesta-on.
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Salomon LJ et al. Prac:ce guidelines for performance of the rou:ne mid-‐trimester fetal ultrasound scan, 2010
PENDAHULUAN • Although many countries have developed local guidelines for the prac-ce of fetal ultrasonography, there are s-ll many areas of the world where they have not been implemented.
• Most countries offer at least one mid-‐trimester scan as part of standard prenatal care, although obstetric prac-ce varies widely around the world.
• This can be related to the availability of qualified prac((oners and equipment, local medical prac(ce and legal considera(ons; in some countries, insurance-‐related cost reimbursements strongly influence how rou-ne mid-‐trimester scans are implemented.
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Salomon LJ et al. Prac:ce guidelines for performance of the rou:ne mid-‐trimester fetal ultrasound scan, 2010
PENDAHULUAN • Nonetheless, a WHO Study Group stated: ‘Worldwide, it is likely that much of the ultrasonography currently performed is carried out by individuals with in fact liAle or no formal training.’8.
• The intent of this document is to provide further guidance for healthcare prac--oners in the performance of the mid-‐trimester fetal ultrasound scan.
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Salomon LJ et al. Prac:ce guidelines for performance of the rou:ne mid-‐trimester fetal ultrasound scan, 2010
PENDAHULUAN
• SELALU ditanyakan pasien : janin saya normal ?
• Kenapa skrining pada 18 – 22 minggu • Apa yg dinilai • Ketepatan diagnostik : harapan vs kenyataan
• EBM, Cochrane, ISUOG • Guideline : oke ! • Standar Indonesia : jauh lebih penting • Mari buat penelitian : mulai dari data dasar
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PROGRAM SKRINING • Banyak pilihan : AIUM, ISUOG, ASUM • Indonesia ? Perlu penyesuaian !! • Penjenjangan : Level I, II, dan III • Program skrining : 10 – 14 minggu, 18 – 22
minggu dan 28 – 32 minggu • Universal vs targeted (HRP) • Sistematis + peralatan USG memadai
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Prenatal screening examination -‐ cardiac ac-vity;
-‐ fetal number (and chorionicity if mul-ple pregnancy); -‐ fetal age/size; -‐ basic fetal anatomy; -‐ placental appearance and loca-on.
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KRITERIA PASIEN • Well informed, kelompok risiko tinggi • Sulit : obesitas, oligohidramnion, kelainan
jantung, palatoskizis • Perhatikan keluhan pasien • USG 3D dan 4D bukan segalanya • USG 2D dengan resolusi baik : lebih penting
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Practice guidelines for performance of the routine mid-‐trimester fetal ultrasound scan
Ultrasound in Obstetrics & Gynecology Volume 37, Issue 1, pages 116-‐126, 7 DEC 2010 DOI: 10.1002/uog.8831 hAp://onlinelibrary.wiley.com/doi/10.1002/uog.8831/full#fig1
SISTEMATIKA SKRINING • Janin : tunggal/gemelli, hidup/IUFD, presentasi, letak, posisi, dll ? • Plasenta : lokasi, DM, patologi ?
• Amnion : ICA, kekeruhan
• Tali pusat : 2A-1V, SUA, Doppler • Biometri : pola pertumbuhan, PJT, makrosomia ?
• Organ : kepala → kaki, khusus : jantung • Doppler • Aktivitas • Penilaian dan saran
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KEPALA : SSP
• Transversal : mulai dari puncak kepala hingga basis kranii : falks serebri, CSP, V-3, Thalamus dan ventrikel lateral →serebellum, CM, NF
• Sagital : dari kanan ke kiri
• Koronal : dari anterior ke posterior
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ISUOG Guidelines Sonographic examination of the fetal central nervous system: guidelines for performing the basic examination and
the fetal neurosonogram
http://www3.interscience.wiley.com/cgi-bin/fulltext/114032619/HTMLSTART (diunduh, 2 Januari 2009)
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Practice guidelines for performance of the routine mid-‐trimester fetal ultrasound scan
Ultrasound in Obstetrics & Gynecology Volume 37, Issue 1, pages 116-‐126, 7 DEC 2010 DOI: 10.1002/uog.8831 hAp://onlinelibrary.wiley.com/doi/10.1002/uog.8831/full#fig2
KEPALA : WAJAH & LEHER • Cari kepala dan ambil potongan transversal
(seperti mencari DBP)
• Putar transduser 900 ke arah wajah → potongan sagital wajah (tampak profil)
• Potar 900 geser ke bawah tampak hidung dan bibir
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2011
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Practice guidelines for performance of the routine mid-‐trimester fetal ultrasound scan
Ultrasound in Obstetrics & Gynecology Volume 37, Issue 1, pages 116-‐126, 7 DEC 2010 DOI: 10.1002/uog.8831 hAp://onlinelibrary.wiley.com/doi/10.1002/uog.8831/full#fig3
Practice guidelines for performance of the routine mid-‐trimester fetal ultrasound scan
Ultrasound in Obstetrics & Gynecology Volume 37, Issue 1, pages 116-‐126, 7 DEC 2010 DOI: 10.1002/uog.8831 hAp://onlinelibrary.wiley.com/doi/10.1002/uog.8831/full#fig4
Practice guidelines for performance of the routine mid-‐trimester fetal ultrasound scan
Ultrasound in Obstetrics & Gynecology Volume 37, Issue 1, pages 116-‐126, 7 DEC 2010 DOI: 10.1002/uog.8831 hAp://onlinelibrary.wiley.com/doi/10.1002/uog.8831/full#fig5
GENITALIA • BUKAN keharusan
• Penting pada sex linked disease dan ambigus
• Kesalahannya besar : 50%
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Practice guidelines for performance of the routine mid-‐trimester fetal ultrasound scan
Ultrasound in Obstetrics & Gynecology Volume 37, Issue 1, pages 116-‐126, 7 DEC 2010 DOI: 10.1002/uog.8831 hAp://onlinelibrary.wiley.com/doi/10.1002/uog.8831/full#fig6
UTERUS DAN ADNEKSA • Serviks : risiko preterm • Mioma uteri • Patologi bekas SC ? • Massa di adneksa dan kavum Douglas/Retzii • Skrining malignansi • Pemantauan hasil terapi & intervensi
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KETEPATAN DAN KESALAHAN DIAGNOSTIK • Kelainan mayor : tergantung jenis organ
• Kelainan minor : sulit, dapat diabaikan ?
• Disclaimer : penilaian sesaat, proses perubahan, dipengaruhi banyak hal
• Ketepatan tidak 100%, kesalahan …%
• Aspek medikolegal : tuntutan obstetri ± 80% kasus
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ASPEK MEDIKO-LEGAL • Informed consent • Tau keterbatasan yang ada : alat, diri, dan
pasien • Sediakan waktu yang cukup • Sistemtis dalam pemeriksaan • Manajemen sesuai SPM/SOP setempat • Buat laporan tertulis dan arsipkan minimal 5
tahun • CPD !!
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PESAN DIBAWA PULANG • Pelajari algoritma penapisan anomali
• Penelusuran anomali dimulai dari struktur normal
• Akurasi tidak 100%, jelaskan keterbatasan USG kepada pasien (TERUTAMA PEMERIKSA)
• Bila ragu, rujuk ke Unit USG Level III
• CPD berkala + mengajar (belajarlah dengan cara mengajar)
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THE NEXT GENERATION
DIVISI KEDOKTERAN FETO MATERNAL DEP. OBGIN RSPAD GATOT SOEBROTO DITKESAD
FK Ui JAKARTA
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62
ONE MOMMENT IN TIME
Sumber : YOUTUBE
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From SOLO for the Next-‐G
See U at the Next US & CTG Course
KEPUSTAKAAN
ISUOG teaching materials, 2009 at http://www.isuog.org/journal/
FMF : fetal medicine foundation
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