Revisi POMR Dafa Azmi S.S._DM K39 RSU UMM_ Laporan Kasus Kampus KPD.pptx

POMR obgyn

1. POMR LAPORAN KASUS SMF ILMU OBSTETRI DAN GINEKOLOGI RSU UNIVERSITAS MUHAMMADIYAH MALANG FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANG 2023 Pembimbing: dr. Moch. Ma’roef, Sp.OG Dafa Azmi Syauqi Shihab 202220401011085 DM K 39 RS UMM

2. رَبِّ اشْرَحْ لِي صَدْرِي وَيَسِّرْ لِي أَمْرِي وَاحْلُلْ عُقْدَةً مِنْ لِسَانِي يَفْقَهُوا قَوْلِي Robbis rohlii shodrii, wa yassirlii amrii, wahlul 'uqdatam mil lisaani yafqohu qoulii ’ “Ya Allah, lapangkanlah dadaku, dan mudahkanlah urusanku, dan lepaskanlah kekakuan dari lidahku, supaya mereka mengerti perkataanku” (QS. Thoha: 25-28)

3. اَللَّهُمَّ لا سَهْلَ إِلاَّ مَا جَعَلْتَهُ سَهْلاً وَ أَنْتَ تَجْعَلُ الْحَزْنَ إِذَا شِئْتَ سَهْلاً “Rabbi zidnii ‘ilman war zuqnii fahman”. Allaahumma Laa Sahla Illaa Maa Ja’altahu Sahlaa Wa Anta Taj’alul Hazna Idza Syi’ta Sahlaa “Ya Allah, tambahkanlah kepadaku ilmu dan berikanlah aku pengertian yang baik”. (QS. Thaha : 114) “Ya Allah, tidak ada kemudahan kecuali apa yang Engkau jadikan mudah. Dan apabila Engkau berkehendak, Engkau akan menjadikan kesusahan menjadi kemudahan.” (HR Anas bin Malik ra)

4. اَللَّهُمَّ إِنِّيْ أَسْأَلُكَ عِلْمًا نَافِعًا وَرِزْقًا طَيِّبًا وَعَمَلاً مُتَقَبَّلاً Allahumma inni as’aluka ilman naafi’an wa rizqon thoyyiban wa ‘amalan mutaqobalan “Ya Allah aku mohon kepadamu berikanlah kepadaku ilmu yang bermanfaat, rizki yang baik dan amalan yang diterima di sisi-Mu.” (HR Ibnu Majah dishahihkan oleh Syaikh Al Bani dalam Shahih Ibnu Majah no 762)

5. SUMMARY OF DATABASE CLUE AND CUE PROBLEM LIST INITIAL DIAGNOSIS PLANNING DIAGNOSIS THERAPY MONITORING EDUCATION Identitas : Ny. I 28 th HPHT : 16 Februari 2023 Keluhan Utama : Keluar cairan merembes RPS : Keluar cairan merembes dari jalan lahir berwarna bening sejak pukul 6.30 WIB Gerak janin masih aktif 1. Ny. I, 28 tahun 2. HPHT : 16 Februari 2023 3. Keluar cairan merembes dari jalan lahir berwarna bening 4. Kehamilan pertama 5. Leopold I: TFU 29 cm, teraba lunak (bokong) 6. Leopold II: Punggung kanan. DJJ: 146 x/mnt 7. Leopold III: Kepala belum masuk PAP ( Merapat ) 8. Leopold IV: Sejajar 1. GI P0000 Ab000 (Textbook) (Level of evidence V) Bernstein H.B., & VanBuren G (2013). Chapter 6. normal pregnancy and prenatal care. DeCherney A.H., & Nathan L, & Laufer N, & Roman A.S.(Eds.), CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=498&sectionid=41008595 1.1 GI P000 Ab000 (Textbook) (Level of evidence V) Bernstein H.B., & VanBuren G (2013). Chapter 6. normal pregnancy and prenatal care. DeCherney A.H., & Nathan L, & Laufer N, & Roman A.S.(Eds.), CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=498&sectionid=41008595 Cunningham F. G. Leveno K. J. Bloom S. & Gilstrap L. (2010). Williams obstetrics (23rd edition) (23th ed.). McGraw-Hill Professional Publishing. 1 . Darah lengkap ( Memeriksa tanda infeksi seperti Peningkatan leukosit & Peningkatan Neutrofil Limfosit Ratio ) ( Q1), (Level of evidence 3d ) Zhan F, Zhu S, Liu H, Wang Q, Zhao G. Blood routine test is a good indicator for predicting premature rupture of membranes. J Clin Lab Anal. 2019 Feb;33(2):e22673. doi: 10.1002/jcla.22673. Epub 2018 Sep 21. PMID: 30239051; PMCID: PMC6818580. 1. MRS IVFD Ringer lactate 1000 cc 28 tpm/ hari ( Cairan maintenance untuk ibu hamil) (Q1) (Level Ib) Friederich, A., Martin, N., Swanson, M. B., Faine, B. A., & Mohr, N. M. (2019). Normal Saline Solution and Lactated Ringer's Solution Have a Similar Effect on Quality of Recovery: A Randomized Controlled Trial. Annals of emergency medicine, 73(2), 160–169. https://doi.org/10.1016/j.annemergmed.2018.07.007 Keadaan Umum dan Keluhan Pasien ( Keluhan nyeri & kenceng kenceng Tanda tanda vital pasien ( Tekanan darah, Nadi, RR, Suhu ) (Q1) (Level of evidence V) Middle-East OBGYN Graduate Education (MOGGE) Foundation (2020). Prelabor rupture of membranes; Practice guideline. Journal of Global Health, 1-17. (Q1) Menjelaskan kepada pasien dan keluarga tentang : 1. Kondisi pasien ( Pasien mengalami ketuban pecah dini, sehingga perlu dilakukan tatalaksana lebih lanjut ) 2. Pemeriksaan penunjang yang akan dilakukan ( Meliputi darah lengkap untuk menilai adanya tanda infeksi, serta nitrazine test untuk mengonfirmasi apakah cairan yang keluar dari jalan lahir tersebut ketuban atau cairan vagina )

6. SUMMARY OF DATABASE CLUE AND CUE PROBLEM LIST INITIAL DIAGNOSIS PLANNING DIAGNOSIS THERAPY MONITORING EDUCATION RPD : DM (-), HT (-),Penyakit Jantung (-), Asma (-), RPK : DM (-), HT (-),Penyakit Jantung (-), Asma (-) RPSos : Pendidikan terakhir S1. Bekerja sebagai wiraswasta R Alergi : - Riwayat Menstruasi : Menarche : Sekitar Usia 10 tahun Menstruasi teratur Nyeri haid (+) Jarang Riwayat KB : - 9. His: 1.10'.15 10.Pembukaan satu ujung jari eff 25%, Ketuban Merembes (+). H1, Kepala. 11.Pemeriksaan lakmus berubah warna dari merah menjadi biru 2. UK 39-40 minggu (Q2) ( Level of Evidence IIb ) Lawson G. W. (2021). Naegele's rule and the length of pregnancy - A review. The Australian & New Zealand journal of obstetrics & gynaecology, 61(2), 177–182. https://doi.org/10.1111/ajo.13253 1.2 UK 39-40 minggu (Q2) ( Level of Evidence IIb ) Lawson G. W. (2021). Naegele's rule and the length of pregnancy - A review. The Australian & New Zealand journal of obstetrics & gynaecology, 61(2), 177–182. https://doi.org/10.1111/ajo.13253 Horasanli, J. E., Alp, E. C. & Bulbul, R., 2022. Evaluation of Complete Blood Cell Count Parameters in the Diagnosis of Threatened Preterm Labor and Premature Rupture of Membranes. Dubai Med J , p. 157–162. 3. Melakukan terminasi kehamilan ( Bisa dilakukan oksitosin drip & Evaluasi kemajuan persalinan atau dilakukan SC ) (Q3) (Level of evidence 1b) Awkadigwe, et al (2023). Active versus expectant management for premature rupture of membranes at term: A randomized, controlled study. The Journal of international medical research, 51(8), 3000605231195451. https://doi.org/10.1177/03000605231195451 3. Kontraksi uterus 4. Denyut Jantung Janin 5. His 6. Evaluasi pendarahan post partum selama 2 jam (Q1) (Level of evidence V) Middle-East OBGYN Graduate Education (MOGGE) Foundation (2020). Prelabor rupture of membranes; Practice guideline. Journal of Global Health, 1-17. Q1) Q1) (Level of evidence V) Middle-East OBGYN Graduate Education (MOGGE) Foundation (2020). Prelabor rupture of membranes; Practice guideline. Journal of Global Health, 1-17. (Q1)

7. SUMMARY OF DATABASE CLUE AND CUE PROBLEM LIST INITIAL DIAGNOSIS PLANNING DIAGNOSIS THERAPY MONITORING EDUCATION R. Imunisasi : Imunisasi lengkap Riwayat Pemeriksaan : Hbs Ag. HIV, TPHA Non Reaktif tanggal 7 Juli 2023 Riwayat Kelahiran Hamil ini Riwayat Pengobatan : Tablet vitamin ibu hamil Pemeriksaan fisik : TD: 130/80 mmHg Nadi: 84 x/menit Suhu: 36,1 derajat celcius RR: 20 x/menit Spo2: 98 % BB : 64 kg ( Sebelum hamil 46 kg TB : 162 cm KU : Baik Kepala/Leher : a-/i-/c-/d- 3. Inpartu kala 1 fase laten (Q1) ( Level of Evidence V ) Cohen, W. R., & Friedman, E. A. (2023). The latent phase of labor. American journal of obstetrics and gynecology, 228(5S), S1017–S1024. https://doi.org/10.1016/j.ajog.2022.04.029 Hutchison J, Mahdy H, Hutchison J. Stages of Labor. [Updated 2023 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544290/ 1.3 Inpartu kala 1 fase laten (Q1) ( Level of Evidence V ) Cohen, W. R., & Friedman, E. A. (2023). The latent phase of labor. American journal of obstetrics and gynecology, 228(5S), S1017–S1024. https://doi.org/10.1016/j.ajog.2022.04.029 Hutchison J, Mahdy H, Hutchison J. Stages of Labor. [Updated 2023 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544290/ 2. Pemeriksaan PH dengan kertas lakmus ( Nitrazine test ) (Q2) (Level of evidence 3B) Olarinoye, A. O., Olaomo, N. O., Adesina, K. T., Ezeoke, G. G., & Aboyeji, A. P. (2021). Comparative diagnosis of premature rupture of membrane by nitrazine test, urea, and creatinine estimation. International journal of health sciences, 15(6), 16–22. 4. Injeksi Cefazolin diberikan 2 kali per hari. (Q3) ( Level of evidence IV) Lima, T. S., Pagani, F. M., Borges, C. B., Petrini, C. G., Paschoini, M. C., Araújo Júnior, E., & Peixoto, A. B. (2023). Association between antibiotic prophylaxis and adverse perinatal outcomes in premature rupture of membranes. Revista da Associacao Medica Brasileira , 69(1), 24–29. 3. Tatalaksana yang akan dilakukan ( Dilakukan injeksi antibiotic untuk mencegah terjadinya infeksi lebih lanjut, serta dilakukan terminasi kehamilan untuk menurunan risiko terjadinya infeksi pada janin. (Q1) (Level of evidence V) Middle-East OBGYN Graduate Education (MOGGE) Foundation (2020). Prelabor rupture of membranes; Practice guideline. Journal of Global Health, 1-17. Q1)

8. SUMMARY OF DATABASE CLUE AND CUE PROBLEM LIST INITIAL DIAGNOSIS PLANNING DIAGNOSIS THERAPY MONITORING EDUCATION Thorax : Cor : S1/S2 tunggal Murmur (-) Gallop (-) Pulmo : Rhonki (-), Wheezing (-) Abd : Bising Usus (+) Normal Ext : Edema (-) Pemeriksaan Obstetri Leopold I: TFU 29 cm, teraba lunak (bokong) Leopold II: Punggung kanan. DJJ: 146 x/mnt Leopold III: Kepala belum masuk PAP ( Merapat ) Leopold IV: Sejajar His: 1.10'.15 VT Obstetri Pembukaan satu ujung jari eff 25%, Ketuban (+) Merembes. H1, Kepala. 4. Ketuban Pecah dini Enjamo, M., Deribew, A., Semagn, S., & Mareg, M. (2022). Determinants of Premature Rupture of Membrane (PROM) Among Pregnant Women in Southern Ethiopia: A Case-Control Study. International journal of women's health, 14, 455–466. https://doi.org/10.2147/IJWH.S352348 Garg, A., & Jaiswal, A. (2023). Evaluation and Management of Premature Rupture of Membranes: A Review Article. Cureus, 15(3), e36615. https://doi.org/10.7759/cureus.36615 1.4 Ketuban Pecah Dini Enjamo, M., Deribew, A., Semagn, S., & Mareg, M. (2022). Determinants of Premature Rupture of Membrane (PROM) Among Pregnant Women in Southern Ethiopia: A Case-Control Study. International journal of women's health, 14, 455–466. https://doi.org/10.2147/IJWH.S352348 Garg, A., & Jaiswal, A. (2023). Evaluation and Management of Premature Rupture of Membranes: A Review Article. Cureus, 15(3), e36615. https://doi.org/10.7759/cureus.36615 (Q1) (Level of Evidence 2b ) Ji-Hee Sung, Jin-Ha Kim, Yejin Kim, Yun-Sun Choi, Siryeon Hong, Suk-Joo Choi, Jung-Sun Kim, Cheong-Rae Roh, Soo-young Oh. 2023. A randomized clinical trial of antibiotic treatment duration in preterm pre-labor rupture of membranes: 7 days vs until delivery. American Journal of Obstetrics & Gynecology MFM, 5:4. https://doi.org/10.1016/j.ajogmf.2023.100886. 4. Komplikasi dan Prognosis apabila tidak segera diberi penanganan seperti resiko infeksi lebih lanjut salah satunya terjadi chorioamnionitis. (Q1) (Level of evidence V) Middle-East OBGYN Graduate Education (MOGGE) Foundation (2020). Prelabor rupture of membranes; Practice guideline. Journal of Global Health, 1-17. Q1)