ATONIA UTERI
Pembimbing:
dr. Maroef, Sp.OG
Disusun oleh :
Anisa Wahyuniarti, S.Ked
201210401011026
201210401011001
201210401011034
2012104010110
RS MUHAMMADIYAH LAMONGAN
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH MALANG
2013
LEMBAR PENGESAHAN
Nama/NIM
September
2013
Mengetahui,
Pembimbing
DAFTAR ISI
LEMBAR PENGESAHAN ................................................................................... ii
DAFTAR ISI .......................................................................................................... iii
DAFTAR GAMBAR ............................................................................................. iv
BAB 1 PENDAHULUAN ...................................................................................... 5
1.1. Latar Belakang ....................................................................................... 5
BAB 2 LAPORAN KASUS .................................................................................. 7
2.1. Identitas Penderita ................................................................................. 7
2.2. Anamnesis .............................................................................................. 7
2.2.1. Keluhan Utama : ............................................................................. 7
2.2.2. Riwayat Penyakit Sekarang :........................................................ 7
2.2.3. Riwayat ANC : ............................... Error! Bookmark not defined.
2.2.4. Riwayat menstruasi ........................................................................ 8
2.2.5. Riwayat Persalinan dan Kehamilan ............................................. 8
2.2.6. Riwayat Penyakit Dahulu : ............................................................ 8
2.2.7. Riwayat Penyakit Keluarga : ......................................................... 8
2.3. Pemeriksaan Fisik ................................................................................. 8
2.3.1. Status Generalis ........................................................................... 8
2.3.2. Status Obstetrik .............................................................................. 9
2.4. Pemeriksaan penunjang ....................................................................... 9
2.5. Diagnosis .............................................................................................. 10
2.6. Rencana Tindakan .............................................................................. 10
Lembar SOAP ..................................................................................................... 11
BAB 3 TINJAUAN PUSTAKA ........................................................................... 16
3.1. Atonia Uteri ........................................................................................... 16
BAB 4 ................................................................................................................... 17
PEMBAHASAN ................................................................................................... 17
4.1. Resume ................................................................................................. 17
4.2. Pembahasan ........................................................................................ 17
DAFTAR PUSTAKA ........................................................................................... 18
iii
DAFTAR GAMBAR
Gambar 1 ....................................................................................................6
Gambar 2 ....................................................................................................6
Gambar 3 ....................................................................................................8
Gambar 4 ..................................................................................................10
Gambar 5 ..................................................................................................13
iv
BAB 1
PENDAHULUAN
berhubungan
dengan
perdarahan,
karena
semua
kejadian
perdarahan
postpartum
setelah
persalinan
BAB 2
LAPORAN KASUS
: Ny. Rohmaniatin
Umur
: 25 tahun
Jenis kelamin
: Perempuan
Pend Terakhir
: SMA
Pekerjaan
: Swasta
Agama
: Islam
Suku
: Jawa
Status
: Menikah
Alamat
Nama Suami
: Tn.Syahrul Arifin
Umur
: 30 tahun
Alamat
Pekerjaan
: Swasta
Suku
: Jawa
Tanggal MRS
: 23 Juli 2013
No.RM
: 03.88.95
2.2. Anamnesis
2.2.1.
Keluhan Utama :
Keluar darah dari jalan lahir
: 456
Vital sign
Tekanan Darah
: 172/91 mmHg
Nadi
: 77x/ mnt
Suhu
: 36,8
RR
: 18x/menit
Kepala
Dispneu (-),
Reflek cahaya +/+.
Leher : Pembesaran KGB (-), Pembesaran kelenjar thyroid
(-).
Thorax : Simetris (+), Reguler (+), Retraksi (-).
C/ S1 S2 Tunggal, Mumur (-), Gallop (-)
P/ Vesicular +/+, Rh -/-, Whez -/
gravidarum (+).
Palpasi
Vaginal Toucher :
: 5/1/64/27/3 (1-2/0-1/49-67/25-33/3-7)
Hematokrit
: 21,9%
(L 40-54%, P 35-47%)
Hemoglobin
: 7,9 g/dl
(P=12,0-16,0mg/dl,L=13,0-
Leukosit
: 15200
(4000-10.000)
Trombosit
: 546000
(150.000- 450.000)
18,0mg/dl)
LED
: 68/99
(L 0-5/jam, P 0-7/jam)
: 168
o Faal Hemostasis
Bleeding Time 2 00
( 1-5 menit )
Clothing Time 7 30
( 5-11 menit )
2.5. Diagnosis
Berdasarkan
data
dari
anamnesa,
pemeriksaan
fisik,
dan
10
Lembar SOAP
NO
Tanggal
Subjektif
Objektif
Assesment
Planning
Loading
2000cc
Drip oxitocin
2 amp/ 24
jam
Tranfusi PRC
2bag Hb >
10 gr
Meropenem
3x1 gr
Alinamin 3x1
NTC 2x1
Kalnex 3x1
Drip
analgesik
IVFD
Aseering
1500cc/24
jam
Drip oxitocin
2 amp/ 24
jam
Meropenem
3x1 gr
Alinamin 3x1
NTC 2x1
Kalnex 3x1
Drip
analgesik
IVFD
Assering
1500 cc/24
jam
Aff tampon
Cefotaxim
3x1 (3hari)
1.
24/07/13
Pasien
mengatakan
badannya
sakit semua
Perdarahan
sedkit
2.
25/07/13
Pasien
mengatakan
badannya
lemes dan
sakit semua
Perdarahan
sedikit
3.
26/07/13
Pasien
mengatakan
sudah agak
enakan, nyeri
berkurang
Perdarahan -
Tensi 110/60
Nadi 100
RR 22x/m
t 360C
SpO2 99%
K/L : a/i/c/d +/-/-/Abdomen : Soepel,
Nyeri tekan -, BU+N,
perdarahan
11
pervaginam sedikit
Ext : HKP
Terpasang tampon
Bleeding KU : Baik
Tensi 127/88
Nadi 109x/menit
RR 19x/m
t 360C
Abdomen : Soepel,
Nyeri tekan +, BU+N,
Ext : HKM
Perdarahan
pervaginam -
Vit C 2x1
Kalnex 3x1
Antrain 3x1
4.
27/07/13
Pasien
mengatakan
sudah tidak
ada keluhan
Perdarahan -
28/07/13
Perdarahan
Luka bekas
oprasi terasa
cekot cekot
KU : Baik
Tensi 126/90
Nadi 90x/menit
RR 20x/m
t 360C
Abdomen : Soepel,
Nyeri tekan +, BU+N,
Ext : HKM
Perdarahan
pervaginam -
29/07/13
Nyeri bekas
oprasi ketika
batuk
Batuk kering
+
Perdarahan
sedikit
30/07/13
Nyeri bekas
oprasi ketika
batuk
Batuk kering
+
Perdarahan -
KU : Baik
Tensi 137/71
Nadi 68x/menit
RR 19x/m
t 360C
Abdomen : Soepel,
Nyeri tekan +, BU+N,
Ext : HKM
Perdarahan
pervaginam minimal
KU : Baik
Tensi 122/84
Nadi 80x/menit
RR 19x/m
t 360C
Abdomen : Soepel,
Nyeri tekan +, BU+N,
Ext : HKM
Perdarahan
pervaginam -
12
IVFD
Assering
1500 cc/24
jam
Cefotaxim
3x1 (3hari)
Vit C 2x1
Kalnex 3x1
Antrain 3x1
Diet TKTP
IVFD
Assering
1500 cc/24
jam
Cefotaxim
3x1 (3hari)
Vit C 2x1
Kalnex 3x1
Antrain 3x1
Diet TKTP
Aff Infus
Oral :
Plasminex
Diet TKTP
Oral :
Plasminex
Diet TKTP
31/07/13
Pasien
merasa
masih sedikit
nyeri
Mual -,
Muntah -,
nyeri kepala
Perdarahan -
KU : Baik
Tensi 133/96
Nadi 80x/menit
RR 19x/m
t 360C
Abdomen : Soepel,
Nyeri tekan +, BU+N,
Ext : HKM
Perdarahan
pervaginam -
13
BLPL
14
LEMBAR LABORATORIUM
23/030/13
4.09
Diff
5/1/64/27/3
Hct
21,9
Hb
7,9
Leukosit
15200
Trombosit 546000
LED
GDA
168
Bleeding 2 00
Time
Clothing
7 30
Time
APTT
28,3
PT
12,0
Albumin
-
23/030/13
14.30
0/0/20/4/76
14,8
5,1
31600
183000
-
24/07/13
7.30
0/0/81/74/5
26,7
8,9
18500
154000
1 30
24/07/13
16.44
0/0/91/7/1
29,1
9,8
4800
53000
31/58
-
8 30
34,1
16,3
-
1,9
15
BAB 3
TINJAUAN PUSTAKA
3.1. Atonia Uteri
16
BAB 4
PEMBAHASAN
4.1. Resume
4.2. Pembahasan
17
DAFTAR PUSTAKA
18