LAPORAN MINGGUAN POLI OBGYN

RSUD ULIN BANJARMASIN

TANGGAL 1-7 AGUSTUS 2016

POLI OBSTETRI Baru Lama

1. KehamilanRisikoRendah 6 1
2. KehamilanRisikoTinggi
2.1 Preeklampsia 1 1
2.2 Letsu - -
2.3 Gemelli - -
2.4 Postdate 1 -
2.5 CPD - -
2.6 KPP - 1
2.7 PlasentaPrevia - 1
2.8 HT Kronis - -
2.9 HEG - -
2.10 Oligohidramnion - 1
2.11 Umur ibu >35th - -
2.12 Hipertiroid - -
2.13 BSC - 1
2.14 B20 2 1
2.15 SLE - -
2.16 Kelainan Kongenital - -
3 Kontrol Post OP
3.1 Kontrol post SC - 3
3.2 Kontrolpost partum - -
TOTAL OBSTETRI 10 10
POLI GINEKOLOGI
4. PoliGinekologiUmum
4.1 Fluor albus - -
4.2 Ca vulva - -
4.3 Myoma Uteri 3 2
4.4 Dead Conceptus - -
4.5 Abortus inkomplit - -
4.6 Abortusimminens 4 -
4.7 Amenorheasekunder 1 -
4.8 AUB 1 5
4.9 Tumor Solid Ovarium - -
4.10 Kistaovarium c ganas 2 1
4.11 Adenomiosis - -
4.12 Kistaovarium - 7
4.13 Tumor vagina - -
4.14 MiomaGebur - 1
4.15 Erosiportio 1 -

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 4.16 Hiperplasia Endometrium - -
4.17 KET - -
4.18 Vesicocele - -
4.19 Ca Endometrium - -
4.20 S. Ca Cervix - -
4.21 KistaCoklat - -
4.22 Dismenorrhea - -
4.23 MolaHidatidosa - 1
4.24 ISK - -
4.25 AbortusKomplit - -
4.26 Blighted Ovum 1 -
5. Lain-lain
5.1 Kontrol post op Myoma - -
5.2 Kontrolkuret - 1
5.3 KontrolkuretMolaHidatidosa - -
5.4 Kontrol post op KET 1 -
5.5 Kontrol post op Caovarium - 1
5.6 Kontrol post op Kista - 1
5.7 Kontrol post konisasi 1 -
5.8 Akseptor IUD - 1
5.9 Akseptor KB Suntik - -
6. PoliOnkologi
6.1 Ca. Cervix 2 17
6.2 Ca. Ovarium - 5
6.3 Ca. Endometrium - 1
6.4 PTG - 1
6.5 Ca Corpus Uteri - -
6.6 Sarcoma Uteri - -
6.7 Ca Vulva - 1
6.8 Ca Vagina - -
6.9 Tumor PadatOvarium - 1
6.10 Chorio Carcinoma - -
7. Poli FER
7.1 Infertilitas primer 4 1
7.2 Kista Endometriosis - -
7.3 PCOS - -
7.4 GangguanHaid - 1
7.5 Infertilitassekunder - -
7.6 KistaOvarium - -
7.7 IPA - 1
7.8 Gravidamuda 1 2
7.9 Program KB - 1
8. PoliUroginekologi
8.1 Cystokel - -
8.2 Rectocele - -

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 8.3 Prolaps Uteri - 1
8.4 Retensio urine - -
8.6 Fistula rectovagina - -
8.7 Agenesis vagina - -
8.8 Tumor solid urethra - -
8.9 Tumor labia - -
8.10 Ruptur Perineum - -
8.11 Inkontinensia Urine 1 -
TOTAL GINEKOLOGI 23 54

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 LAPORAN MINGGUAN
RUANG CEMPAKA/TULIP II
TANGGAL 1-7 AGUSTUS2016

I. KASUS OBSTETRI :
1. Ny. PrihartiniAmindini/42 th
MRS Tanggal 02-08-2016
GIV P2103 28/29 mgg THIU + Preskep + BSC + PPI + U>35 th + TBJ 1100 g
Perawatan konservatif
2. Ny. Norhasanah/32 th
MRS Tanggal 02-08-2016
P4001 Post SC (a.i. BSC 3x) + curiga Ileus obstruktifParsial
Perawatan konservatif
3. Ny. Lidyawati/25 th
MRS Tanggal 03-08-2016
G1 P000034/35 minggu THIU + Preskep + PPI + TBJ 2300 g
Perawatan konservatif

II.OPERASI GINEKOLOGI :
1. Ny. Sriaton/40th
MRS Tanggal 25 Juli 2016
P0000 ATK : (-)
HPHT : 16Juli 2017

DPO : CaOvarium + Post Open Biopsy (th 2013) + Post Brexel 4x + Post
Carboplatin 4x + Hidronefrosis
DDO : CaOvarium Post Open Biopsi + Adhesiolisis + Repair Serosa Sigmoid +
Hidronefrosis D/S
Terapi : Surgical Staging (TAH-BSO) + Adhesiolisis + Repair Serosa Sigmoid +
Pasang DJ Stent D/S

2. Ny. Rukinah/28 th
MRS Tanggal 30 Juli 2016
P1001 ATK : 5 bulan

DPO : Defek Sphincter Ani gr. III

DDO : Defek Sphincter Ani gr. III
Terapi : Repair Defek Sphincter Ani gr. III

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3. Ny. Maria Bongi/29 th
MRS Tanggal 1 Agustus 2016
P1001 ATK : 10 tahun

DPO : Kista Endometriosis D/S

DDO : Kista Endometriosis D/S + Adhesi
Terapi : Kistektomi Bilateral + Adhesiolisis

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 LAPORAN MINGGUAN UNIT GAWAT DARURAT
KAMAR BERSALIN
TANGGAL 1-7 AGUSTUS2016

I. JUMLAH KASUS
PERSALINAN FISIOLOGIS:5
PERSALINAN PATOLOGIS :
Perabdominam :17
Pervaginam :11
TOTAL :33

MODE OF DELIVERY
SptB :12
SptBracht :1
Spt Abortus :-
SptIUFD :-
SectioCaesarea : 17
TarikanForsep :-
Tarikan Vakum :1
:-
Manual Aid :2
Laparotomi :1

KASUS ABNORMAL OBSTETRI

KASUS TOTAL
A LetakLintang 1
B BSC 6
C PEB 10
D PE -
E HT kronis 1
F ImpendingEklampsia -
G Eklampsia -
H SindromHELLP 1
I Plasenta previa -
J Letaksungsang 5
K APB -
L Prolaps tali pusat -
M Gemelli -
N POPP -
O Severe Oligohydramnion 1
P Abnormal NST 3
Q Preterm 2

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 R Postdate 4
S KPD 4
T IUFD 1
U IUGR -
V Kala II Lama 1
W CPD 3
X ROJ 1
Y HPP -
Z Retensio plasenta 1

KASUS OBSTETRI
NO KASUS TOTAL
1 Abortusimminens 1
2 AbortusInkomplit 1
3 Dead conceptus -
4 Blighted Ovum 1
5 KehamilanEktopikTerganggu 1
TOTAL 4

KASUS GINEKOLOGI
NO KASUS TOTAL
1 Ca Cervix 2
2 MolaHidatidosa -
3 Kista Ovarium -
4 Ca Endometrium 2
5 Myoma Uteri -
6 Straddle Injury 1
TOTAL 5

II. TOTAL TINDAKAN

NO KASUS TOTAL
1 Kuretase 4
2 Manual plasenta 1
3 Biopsi Cervix -
TOTAL 5
PERSALINAN PATOLOGIS

I. Hipertensi dalam Kehamilan (Preeklampsia, Eklampsia, HELLP syndrome)

1. Ny.Sutini/30th
MRS tgl. 01-08-2016 jam 13.45 WITA

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 GII P1001 37/38 minggu THIU + Letak kepala + Inpartu Kala I fase aktif + PEB
+ Obesitas gr. I (BMI 30,22) + TBJ 3100 g
Tanggal 01-08-2016 pkl 17.00
LahirbayiSptB, P/2900/50 cm/ AS :7-8

2. Ny.Farida/32th
MRS tgl. 02-08-2016 jam 01.00 WITA
GIV P3002 39/40 minggu THIU + Preskep + KPP + PEB + TBJ 3100 g
Tanggal 02-08-2016 pkl 12.00
LahirbayiSptB, P/3400/49 cm/ AS :7-8

3.Ny.Marliani/38th
MRS tgl. 02-08-2016 jam 01.00 WITA
GIV P2012 37/38 minggu THIU + Letak Sungsang + Tak Inpartu + PEB + U> 35
tahun + Primitua Sekunder + Obesitas gr. I (BMI 34,89) + TBJ 3400 g
Tanggal 02-08-2016 pkl 11.30
Lahirbayi SC + MOW, P/3750/51 cm/ AS :8-9

4.Ny.Kursiah/40th
MRS tgl. 31-07-2016 jam 08.45 WITA
GIV P3002 22/23 minggu THIU + Preskep + HT Kronis SI PEB + HELLP
Syndrome + Obesitasgr.I (BMI 32) + U>35 tahun + TBJ 775 g
Tanggal 03-08-2016 pkl 12.15
LahirbayiHisterotomi + MOW, P/600/29 cm/ AS : 1-1-1

5.Ny.Uswatun/32th
MRS tgl. 03-08-2016 jam 16.10 WITA
GII P1001 37/38 minggu THIU + Preskep + PEB + ATK < 2 tahun + TBJ 3000 g
Tanggal 04-08-2016 pkl 03.00
LahirbayiSptB, L/3200/51 cm/ AS :7-8

6.Ny.Muslina/28th
MRS tgl. 04-08-2016 jam 09.50 WITA
GII P1001 40/41 minggu THIU + Preskep + Inpartu Kala II lama + PEB + BSC
+ Primitua Sekunder + Obesitas grade II (BMI 35,7) + TBJ 3800 g
Tanggal 04-08-2016 pkl 10.09
Lahirbayi VE, P/4000/53 cm/ AS :7-8

7.Ny.Raminah/32th
MRS tgl. 05-08-2016 jam 02.00 WITA
GII P1001 39/40 minggu THIU + Preskep + Inpartu Kala II + PEB + TBJ 3100 g
Tanggal 05-08-2016 pkl 02.05
LahirbayiSptB, L/3100/51 cm/ AS :7-8

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8.Ny.Itun/47th
MRS tgl. 06-08-2016 jam 23.30 WITA
GII P1001 39/40 minggu THIU + Preskep + Inpartu Kala II + PEB + Obesitas
gr. III (BMI 42,97) + U>35 tahun + curiga Bayi Besar + TBJ 4000 g
Tanggal 07-08-2016 pkl 01.30
Lahirbayi SC + MOW, L/3900/55 cm/ AS :8-9

9.Ny.Rista/33th
MRS tgl. 07-08-2016 jam 04.05 WITA
GIII P2002 41/42minggu THIU + Preskep +Inpartu Kala II + Arrest of Descent
e.c. Power + PEB + Abnormal NST (kategori III) + TBJ 3500 g
Tanggal 07-08-2016 pkl 08.45
Lahirbayi SC + IUD, L/3700/52 cm/ AS : 2-4-6
Ketuban mekoneal

10.Ny.Norjanah/39th
MRS tgl. 07-08-2016 jam 04.10 WITA
GIII P2002 39/40minggu THIU + Preskep +Inpartu Kala I faseAktif + HT
Kronis SI PEB + Fetal Distress + U>35 th + TBJ 3000 g
Tanggal 07-08-2016 pkl 07.57
Lahirbayi SC + MOW, P/3000/50 cm/ AS : 7-8-9

11.Ny.Khairunnida/32th
MRS tgl. 06-08-2016 jam 08.20 WITA
GIIP1001 35/36minggu TIUFD + Preskep +PEB + Solusio Placenta + BSC +
TBJ 2100 g
Tanggal 06-08-2016 pkl 10.00
Lahirbayi SC + IUD, L/2100/46 cm/ AS : 0, lebam mayat (+), RPH 50%

II.BSC
1. Ny.Leonita Albertina/ 33th
MRS tgl. 03-08-2016 jam 21.20 WITA
GIII P2002 37/38 minggu THIU + Preskep+ TakInpartu+ ObservasiFebris hr-1
+ Fetal Takikardi + Suspicious NST + BSC + TBJ 2800 g
Tanggal 04-08-2016 pkl 01.10
Lahirbayi SC + IUD, L/3000/50 cm/ AS : 6-7
Ketuban hijau keruh, bayi hidrocele (+)

2. Ny.Emalia Rizka/ 19th

MRS tgl. 05-08-2016 jam 02.15 WITA
GII P1001 41/42minggu THIU + Preskep+ KPP>12 jam + BSC + Postdate + TBJ
2900 g
Tanggal 05-08-2016 pkl 10.10
Lahirbayi SC + IUD, L/2750/48 cm/ AS : 8-9

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3.Ny.Aminah/29th
MRS tgl. 07-08-2016 jam 03.00 WITA
GIIP1001 41/42minggu THIU + Preskep +Inpartu Kala II + BSC + CPD + ROJ
+ curigaBayiBesar+ TBJ 4000 g
Tanggal 07-08-2016 pkl 04.55
Lahirbayi SC + IUD, L/3800/51 cm/ AS : 6-7

III. LAIN-LAIN
1.Ny.Gusti Nur Hidayah/27th
MRS tgl. 01-08-2016 jam 23.00 WITA
GI P0000 39 minggu THIU + LetakSungsang + Presentasi Kaki + Inpartu Kala I
fs. Laten + TBJ 3000 g
Tanggal 02-08-2016 pkl 01.15
Lahirbayi SC + IUD, L/2900/51 cm/ AS : 6-8
Lilitan tali pusat erat 1x di leher

2.Ny.Nurlaila Salpinah/20th
MRS tgl. 01-08-2016 jam 13.05 WITA
GI P0000 37/38 minggu THIU + Letak Kepala + Tak Inpartu + Janin Curiga
Hidrocephalus + Labiopalatoskizis + TBJ 3255 g
Tanggal 02-08-2016 pkl 15.30
Lahirbayi SC, L/3500/51 cm/ AS : 7-8
Hidrocephalus, labiopalatoschizis (+)

3.Ny.Nurlaila/21th
MRS tgl. 01-08-2016 jam 20.55 WITA
GII P1001 41/42 minggu THIU + Preskep + Inpartu Kala I fs. Laten + Postdate
+ Oligohidramnion (AFI 7,2) + TBJ 2700 g + Gagal OD
Tanggal 02-08-2016 pkl 20.15
Lahirbayi SC + IUD, P/2800/48 cm/ AS : 8-9
Ketuban berkurang

4.Ny.Asti Nurbaiti/29th
MRS tgl. 04-08-2016 jam 06.00 WITA
GII P1001 40/41 minggu THIU + Letak Sungsang + TakInpartu + Severe
Oligohidramnion(AFI 5,8) + TBJ 2975 g
Tanggal 04-08-2016 pkl 11.15
Lahirbayi SC, P/2800/48 cm/ AS : 7-8
Ketuban minimal

5.Ny.Sri Rahayu/23th
MRS tgl. 03-08-2016 jam 16.50 WITA

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 GI P0000 39/40 minggu THIU + Preskep +TakInpartu + CPD + curigabayibesar
+ TBJ 3900 g
Tanggal 04-08-2016 pkl 13.05
Lahirbayi SC + IUD, P/3700/52 cm/ AS :7-8

6.Ny.Rizka Amelia/21th
MRS tgl. 06-08-2016 jam 04.30 WITA
GI P0000 39/40 minggu THIU + Preskep +Inpartu Kala I faseLaten + Obesitas
gr. III (BMI 40,8) + TBJ 3200 g
Tanggal 06-08-2016 pkl 12.25
Lahirbayi SC + IUD, L/3200/50 cm/ AS : 8-9

7.Ny.Indah Wahyuningsih/24th
MRS tgl. 06-08-2016 jam 01.15 WITA
GIIP0100 40/41minggu THIU + Preskep +Inpartu Kala I faseLaten + LH~CPD
+ ROJ + TBJ 3000 g
Tanggal 06-08-2016 pkl 03.38
Lahirbayi SC + IUD, L/2850/50 cm/ AS : 7-8

8.Ny.Muhilmah/28th
MRS tgl. 07-08-2016 jam 07.10 WITA
GI P0000 39/40minggu THIU + Preskep +Secondary Arreste.c.
MalpresentasiLetakPuncak + PE + TBJ 3000 g
Tanggal 07-08-2016 pkl 11.23
Lahirbayi SC + IUD, L/3150/52 cm/ AS : 8-9
Wajah bayi menghadap ventral

Laparatomi
1. Ny. Novriana/38 th
MRS tgl. 03-08-2016 jam 12.30 WITA
P1001, ATK 13 th
Menikah 1x 14 th
DPO : KET
DDO : Ruptura kehamilan Pars ampularis Tuba D
Terapi : Salphingektomi D

Laporan Kematian
1. Ny. Lamiah/66 th
MRS tgl. 27-07-2016 jam 11.00 WITA
Meninggal tgl. 02-08-2016 pkl. 18.10 WITA

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 Kista Ovarium curiga Ganas + Ascites + KU lemah

2. Ny. Aisyah/34 th
MRS tgl. 14-07-2016 jam 13.20 WITA
Meninggal tgl. 02-08-2016 pkl. 13.50 WITA
Ca Cervix IVB + Efusi Pleura (S) + Terpasang WSD + Metastase Paru

3. Ny. Sumini/53 th
MRS tgl. 04-08-2016 jam 03.00 WITA
Meninggal tgl. 07-08-2016 pkl. 05.25 WITA
Ca Endometrium Post Open Biopsy Juli 2016 + curiga Metastasis Paru +
Anemia (Hb 7,6) + Hipoalbumin (Alb 2,9) + Peningkatan RFT

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