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Ilustrasi kasus
Ny. Leli, 36 thn Masuk RS: 22 Desember 2012
Keluhan utama : Keluar air-air sejak 2 jam SMRS
Perjalanan Penyakit
VK 22-12-2012, 12.00
Alloanamnesis
RPD dan RPK DM, HT, penyakit jantung, asma, alergi (-)
Ps dirujuk bidan dengan febris ec IIU Hamil 34 minggu, ANC di bidan, USG 1x dikatakan kembar, I 2000, I 1600 gr ~ 32 minggu, 2 minggu yg lalu. Saat ini ketuban pecah 3 jam SMRS, demam 2 jam SMRS. Keputihan (+), nyeri BAK (-). Mulas-mulas sejak 1 hari, gerak janin aktif.
Riwayat pernikahan 1 kali Riwayat KB Riwayat obstetri G3P2 I. Perempuan, 19 thn, 3000 gr, spontan, paraji 2. Perempuan, 12 thn, 3000 gr, spontan, paraji
KU sakit sedang Kesadaran CM TD : 140/98 P : 20x/m FN : 98x/m S : 38.5 St generalis : dbn St. Obs : TFU : 35 cm, teraba gemeli, pres kepala kepala , His + 3x/10/40, DJJ 1 : 200, DJJ 2 : 198 I : v/u tenang Io : tidak dilakukan VT : pembukaan 7-8 cm, ket (-), kepala H II-II
Dx/ G3P2 Hamil 34 Minggu, gemeli, pres kepala-kepala, hidup keduanya, PK I aktif, HDK, IIU
Rencana diagnosis : Observasi KU, TV, DJJ , Suhu Cek DPL, UL, GDS, BT/CT, ureum creatinin, sgot, sgpt CTG
Rencana terapi: Melakukan akselerasi persalinan dgn titrasi oxytoxin 5IU/500cc Rl 20 tpm sehingga His adekuat. Resusitasi : Loading cairan 1000 cc Paracetamol 3x1000 po Farmadol iv, hingga suhu < 37.5 O2 2L Miring kiri Makan minum
Laboratorium
DPL: 11.3/31/ 15000/ 505000 BT/CT 2/11 GDS 89 HBsAg (-) Golongan darah A+ Protein urin (-)
Rencana awal partus pervaginam perbaikan KU (hidrasi, antibiotik, antipiretik) 3 jam kemudian suhu turun, takikardi janin membaik DJJ 180 bpm
Dilakukan VT ulang: pembukaan lengkap, presentasi kepala di H-1, his inersia (1-2x/10/20)
inersia
ketuban dipecahkan: ketuban jernih, kepala masih di H-1, djj 130 bpm
diputuskan SC CITO
Lanjutkan Sectio Sesarea a/i gemelli janin kedua, presentasi kepala, PK II, syarat ekstraksi tak terpenuhi Lahir bayi perempuan, tunggal hidup, 2105 gr, 42 cm, AS 8/9, ketuban kehijauan, kering, plasenta lahir lengkap
Pasca plasenta lepas, uterus hipotoni diberikan uterotonik maksimal (misoprostol 1000, oksitosin 20 IU drip, 40 IU intramural, metergin 4x0.2 mg iv bolus) tetap hipotoni diputuskan dilakukan B-Lynch. Perdarahan pervaginam (-). Dilanjutkan dengan MOW Perdarahan 800 cc, urin 100 cc jernih
B-Lynch
Delivery of Twins
International
Delivery of Twins
Delivery of Twins
International
Objectives
Incidence Types of presentation Where to deliver Mode of delivery
Management of labour
Delivery of Twins
International
Incidence
spontaneous twins occur in approximately 1 in 90 pregnancies
increased use of reproductive technology has significantly increased this rate
Delivery of Twins
International
Cephalic
39
26 8
13
9 4
0.6
0.6 0.5
SECOND TWIN
Breech Other
Delivery of Twins
International
Delivery of Twins
International
Delivery of Twins
International
Method of Delivery
consider the lie and presentation of each fetus
vaginal delivery is the goal unless there are specific contraindications placenta should not be drained and cord bloods not taken until after delivery of second twin
Delivery of Twins
International
Delivery of Twins
International
First Twin Breech selection for labour and vaginal delivery similar to singleton breech consider risk of locked twins if twin B is cephalic second twin (if first twin delivered vaginally) cephalic - vaginal breech - vaginal - breech extraction acceptable - caution if EFW of B >> A other - prompt internal or external version - if fails perform caesarean
Delivery of Twins
International
Delivery of Twins
International
Management of Labour preterm labour common educate re: warning signs steroids indicated as in singleton use tocolytics judiciously (pulmonary edema) induction as per singleton indications plus twin specific indications (e.g. EFW disparity)
Delivery of Twins
International
Management of Labour - Fetal Well-Being intermittent auscultation of both fetal heart rates no absolute time limit on duration between delivery of twins if second twin is well
Delivery of Twins
International
Terimakasih