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Presentasi Kasus Persalinan Gemelli

PPDS: Ramie - Widya/Susie

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

22/12/2012 12.00 Pasien datang bersama bidan

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

akselerasi dg oksitosin 20 IU mulai 8 tpm tercapai his adekuat dalam 32 tpm


1 jam kemudian tercapai pembukaan lengkap, his kesan berkurang 2-3x/10/30, djj 130 bpm terus diberikan oksitosin titrasi maksimal PK II djj ireguler s/d 60 bpm, inersia (His 2x/10/20), kepala H-2(gawat janin pk II syarat ekstraksi tidak terpenuhi) diputuskan ekstraksi vakum Lahir bayi pertama laki-laki, tunggal, AS 0/0, 2300 gr 46 cm, Ketuban hijau

Dilakukan VT ulang: pembukaan lengkap, presentasi kepala di H-1, his inersia (1-2x/10/20)

dilakukan perbaikan his dg oksitosin s/d tetesan maksimal

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

Lies and Presentation of Twins (%)


FIRST TWIN
Cephalic Breech Other

Cephalic

39
26 8

13
9 4

0.6
0.6 0.5

SECOND TWIN

Breech Other

Thompson et al, 1987

Delivery of Twins
International

Location for Delivery of Twins


discussed and planned in advance consultation with patient, family, attending physician and obstetrician recommended delivery in hospital

Delivery of Twins
International

Location for Delivery of Twins


obstetrician in attendance for labour and delivery, if possible
same resources as required for singleton with extra staffing (nursing, physicians, midwives) consider transfer of labouring patient if resources unavailable locally

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

First Twin Cephalic

first twin cephalic - vaginal


second twin cephalic breech other - vaginal - vaginal

- breech extraction acceptable - caution if EFW of B >> A

- prompt internal or external version - if fails perform caesarean

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

First Twin NonLongitudinal


caesarean section

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)

augmentation as per singleton, may be helpful following delivery of first twin

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

Postpartum Management of Twins


active management of third stage pathology examination of placenta increased risk of postpartum depression discussion of issues from early pregnancy extra support with babies

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