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