P1A0M0 gr.

aterm + IUFD + Riwayat Infertilitas + HbsAg Reaktif

+ Susp. Sepsis + Penurunan Kesadaran e.c. Susp.
Meningoencephalitis + Death

Oleh:
Pembimbing:
Kevin Chikrista, S. Ked
dr. Davis Shian, Sp. OG, M. Kes
I4061172039
 Identitas Pasien

Nama Pasien: Alamat:

Ny. SI Dsn. Guntur RT 005/003, Ds. RukmaJang

Tanggal Lahir: Pekerjaan:

16 April 1987 Ibu Rumah Tangga
Usia: Pendidikan Terakhir
32 tahun SMP

Jenis Kelamin Agama/Suku

Perempuan Islam/Melayu

Status Pernikahan Tanggal Masuk RS

Kawin 5 Juli 2019
 Anamnesis
Pasien datang ke IGD dengan G1P0A0 hamil 38-39 minggu.

5 Juli 2019
17.40

Keluhan Utama
Demam
1 hari yang lalu
Merasakan mual dan muntah (2x) berisi
air bercampur darah (merah-kecoklatan)
2 hari yang lalu
Merasakan nyeri pada perut bagian bawah.
4 hari yang lalu
Demam naik turun, merasa tidak ada lagi pergerakan janin
1 minggu yang lalu
Merasa pergerakan janin berkurang, ke dukun untuk diurut bagian
perutnya karena merasa sakit dan janin terlihat letak melintang
Riwayat USG
Pemeriksaan USG bulan 6 & 8 masa kehamilan  kondisi kehamilan baik.
 Anamnesis

Riwayat Penyakit Dahulu Riwayat Obstetri dan Ginekologi Riwayat Alergi Riwayat Sosial

 HT (x)  HPHT: 10-10-18 Riwayat alergi terhadap obat  Pasien merupakan istri
 DM (x)  HTP: 17-7-19 maupun makanan disangkal ke-4 dari suaminya.
 Asma (x)  Pasien didiagnosis infertilitas dan
 Penyakit Jantung (x) mendapatkan kehamilan pada
 Hepatitis B (x) tahun ke-9 pernikahan.
 Selama hamil, pasien mendapatkan
ANC di puskesmas pada:
 Trimester 1: 0x
 Trimester 2: 2x ( bulan ke 4 & 6 )
 Trimester 3: 4x ( bulan ke 8 & 9 )
 Catatan ANC
Tgl Keluhan TD BB Usia kehamilan
(mmHg) (kg) (minggu)
14/01/19 Emesis 110/70 73 12

06/03/19 Emesis 120/80 76 20

09/05/19 - 160/100 80 30

13/06/19 - 140/90 82 35

03/07/19 Demam +/- 2 hari, tidak nafs 130/90 83 38

u makan
05/07/19 Demam 4 hari, mual dan mu 100/80 83 38
ntah sejak 2 hari, pusing
 Pemeriksaan Fisik

Kesadaran Umum : Compos Mentis TD : 120/80 mmHg

Keadaan Umum : Baik HR : 136x/menit

GCS : 15 (E4 V5 M6) RR : 22

Berat Badan : 75 kg Suhu : 38,1˚C

Tinggi Badan : 157 cm SpO2 : 98%

 Status Generalis
Mata Jantung
CA ( - / - ), SI ( - / - ) S1S2 reg, murmur (-), gallop (-)

Abdomen
Leher
TFU 35 cm, presentasi kepala,
Perbesaran KGB ( - ) pu-ki, DJJ tidak terdeteksi.

Paru
SND VES ( + / + ) Ekstremitas
Rhonki ( - / - ) Akral hangat, CRT < 2”, edema (+)
Wheezing ( - / - )

Vaginal Toucher
Pembukaan seujung jari.
Sarung tangan: lendir (+), darah (+)
 Pemeriksan Penunjang
Pemeriksaan Laboratorium (5 Juli 2019)

Pemeriksaan Hasil Nilai normal

Hemoglobin 13,7 g/dL 11,0 -15,5 g/dL
Leukosit 15.670 /uL 3.600 – 11.000 /uL
Trombosit 218.000 /uL 150.000 – 440.000 /uL
Hematokrit 39,1 % 35 - 47%
Eritrosit 4,72 Juta 3,8 – 5,2 Juta
Golongan Darah O
HbsAg Reaktif Non Reaktif
HIV Non Reaktif Non Reaktif
 G1P0A0 h. aterm + IUFD Diagnosis Kerja
+ HbsAg (+)
 Terminasi kehamilan pervaginam
 Drip Oxytocin 5 unit dalam 500 cc, Rencana Terapi / Tindakan
20 gtt/menit.
 Infus PCT k/p demam
 Perkembangan Pasien (1)
5 Juli 2019 – 21.30

01 02 03 04

Subjective Objective Assessment Plan

 Mules (+)  KU : baik G1P0A0 gravida 37-38  Drip Oxytocin 5 IU

 Perdarahan  CA (-/-), SI (+/+) minggu + IUFD + dalam RL, 20 gtt/menit
pervaginam (-)  TD : 100/80 mmHg riwayat infertilitas +  Inj. Cefotaxime 1 gr/12
 USG: HbsAg reaktif jam (IV)
 Gr. 37-38 miggu
 Letak kepala
 Ketuban cukup
 TBBJ = 3550 gram
 DJJ (-)
 Perkembangan Pasien (2)
6 Juli 2019 – 07.00

01 02 03 04

Subjective Objective Assessment Plan

 Mules (+) jarang  KU : baik G1P0A0 gravida 37-38  Pro SC a/i PTM + Gagal
 Perdarahan  CA (-/-), SI (+/+) minggu + IUFD + Induksi
pervaginam (-)  TD : 120/80 mmHg riwayat infertilitas +
 His 1 x 10’, 20” HbsAg reaktif + PTM +
 VT:
Gagal Induksi
 1 cm , portio tebal
 Ketuban (+)
 SECTIO CAESAR

Temuan SC
o Air ketuban Hijau keruh + berbau
o BB 4,15 kg
o PB 57 cm
o Temuan klinis IUFD Maserasi grade 3
o Tidak ditemukan tanda-tanda kehidupan pada bayi
o Pendarahan OP ± 350 cc
 Perkembangan Pasien (3)
POST OP - 6 Juli 2019 – 10.50

01 02 03 04

Subjective Objective Assessment Plan

 Perdarahan  KU : baik P1A0 partus maturus  Drip tramadol + oxytocin 20 IU

pervaginam  CA (-/-), SI (+/+) dengan SC a/i + PTM dlm RL 20 tpm
minimal  TD : 120/80 mmHg + Gagal Induksi +  Inj. Cefotaxime 1 gr/12 jam (IV)
 HR : 92 x/min riwayat infertilitas +  Inj. As. Traneksamat 1 amp/12
 TFU tepat pusar jam (IV)
HbsAg reaktif + IUFD
 Kontraksi Kuat  Inj. Ondansetron 1 amp/8 jam
 Inj. Deksketoprofen 1 amp/8 jam
 Perkembangan Pasien (4)
POST OP - 6 Juli 2019 – 10.50

01 02 03 04

Subjective Objective Assessment Plan

 Perdarahan  KU : baik P1A0 partus maturus  Drip tramadol + oxytocin 20 IU

pervaginam  CA (-/-), SI (+/+) dengan SC a/i + PTM dlm RL 20 tpm
minimal  TD : 120/80 mmHg + Gagal Induksi +  Inj. Cefotaxime 1 gr/12 jam (IV)
 HR : 92 x/min riwayat infertilitas +  Inj. As. Traneksamat 1 amp/12
 TFU tepat pusar jam (IV)
HbsAg reaktif + IUFD
 Kontraksi Kuat  Inj. Ondansetron 1 amp/8 jam
 Inj. Deksketoprofen 1 amp/8 jam
 Hb: 13,4 g/dL
 Perkembangan Pasien (5)

7 Juli 2019 (POH-1) 8 Juli 2019 (POH-2)

S Nyeri luka OP (+) S Nyeri luka OP (+)
O KU: Baik O KU: Baik
CA (-/-), SI (+/+) CA (-/-), SI (+/+)
TD: 110/70 mmHg TD: 110/70 mmHg
HR: 70x/min HR: 80x/min
RR: 20x/min RR: 20x/min
T: 36,6°C T: 36,3°C
A P1A0 partus maturus dengan SC a/i + PTM + A P1A0 partus maturus dengan SC a/i + PTM + Gagal
Gagal Induksi + Riwayat Infertilitas + HbsAg reaktif Induksi + Riwayat Infertilitas + HbsAg reaktif + IUFD
+ IUFD P • Ciprofloxacin 2x500 mg
P • Ciprofloxacin 2x500 mg • Metronidazole 3x500 mg
• Metronidazole 3x500 mg • Asam Mefenamat 3x500 mg
• Asam Mefenamat 3x500 mg • Feritrin 1x1 tab
• Feritrin 1x1 tab • Crispa 2x1 tab
• Crispa 2x1 tab • Obs KU, TTV dan Perdarahan
• Obs KU, TTV dan Perdarahan
 Perkembangan Pasien (6)

9 Juli 2019 POH-3 (07.15) 9 Juli 2019 (12.30)

S Nyeri luka OP (+), nyeri kepala hebat S Nyeri luka OP (+), gaduh gelisah
O KU: Tampak sakit berat O KU: Gaduh gelisah Hb: 12,0 g/dL
CA (-/-), SI (+/+) CA (-/-), SI (+/+) Leu: 27.810/uL
TD: 110/70 mmHg TD: 190/100 mmHg Trom: 221.000/uL
HR: 70x/min HR: 80x/min HCT: 32,9%
RR: 20x/min RR: 20x/min Eri: 4,08
T: 38°C T: 38,5°C
Luka OP: Baik Luka OP: Baik
A P1A0 partus maturus dengan SC a/i + PTM + A P1A0 partus maturus dengan SC a/i + PTM + Gagal Induksi +
Gagal Induksi + Riwayat Infertilitas + HbsAg reaktif Riwayat Infertilitas + HbsAg reaktif + IUFD
+ IUFD P • Konsul DPJP:
P • PO. PCT 3 x 500 mg k/p suhu ≥ 37,8°C • Loading dose MgSO4 4 gr/IV
• PO. Ciprofloxacin 2x500 mg • Nifedipine 1 tab/2 jam (2x pemberian)  3x1 tab
• PO. Metronidazole 3x500 mg • Cek Protein urine, SGOT, SGPT, Ur, Cr.
• PO. Asam Mefenamat 3x500 mg • Obs KU, TTV dan Perdarahan
• PO. Feritrin 1x1 tab
• PO. Crispa 2x1 tab
• Obs KU, TTV dan Perdarahan
• Cek H2TL
 Perkembangan Pasien (7)
9 Juli 2019 (17.00) 9 Juli 2019 (22.30)
S Penurunan Kesadaran dan demam tinggi S Penurunan kesadaran dan demam tinggi
O Kesadaran: Somnolen SGOT: 85 O Kesadaran: Somnolen
GCS: E3M4V4 SGPT: 46 CA (-/-), SI (+/+)
CA (-/-), SI (+/+) Ur: 71 TD: 110/80 mmHg
TD: 170/100 mmHg Cr: 2,58 HR: 120x/min
HR: 139x/min Proteinuria +1
RR: 17x/min
RR: 28x/min
T: 38,6°C
T: 39,8°C
Luka OP: Baik
Edema +/+
A P1A0 partus maturus dengan SC a/i + PTM + Gagal Induksi +
A P1A0 partus maturus dengan SC a/i + PTM + Gagal Induksi +
Riwayat Infertilitas + HbsAg reaktif + IUFD + susp. Sepsis Riwayat Infertilitas + HbsAg reaktif + IUFD + susp. Sepsis
P • Konsul DPJP: P • Konsul DPJP:
• Monitoring urine / 6 jam • Inf. Metronidazole 2x500 mg
• Maintenance MgSO4 8 gr dalam RL 500cc - 20 tpm • Tx. Antihipertensi STOP
• Nifedipine 3 x 10 mg • Pro ICU
• HCD 1 x 200mg • Edukasi
• NGT + NK O2
• Pro ICU – antrian 1
 Perkembangan Pasien (8)

10 Juli 2019 (15.30)

10 Juli 2019 (07.00)
S Penurunan kesadaran
S Penurunan kesadaran
O Kesadaran: Kaku kuduk (+)
O Kesadaran: Somnolen
CA (-/-), SI (+/+)
GCS: E3M4V2
GCS: E3M1V2
TD: 90/70 mmHg
TD: 120/90 mmHg  80/50 mmHg (19.30)
HR: 119 x/min
RR: 28 x/min
HR: 125x/min
T: 37,9°C RR: 28x/min
Edema: +/+ T: 38,1°C
GDS: 106 mg/dL A P1A0 partus maturus dengan SC a/i + PTM + Gagal Induksi +
A P1A0 partus maturus dengan SC a/i + PTM + Gagal Induksi + Riwayat Infertilitas + HbsAg reaktif + IUFD + sepsis +
Riwayat Infertilitas + HbsAg reaktif + IUFD + Sepsis P • Pro ICU • Konsul Interna
P • Pro ICU • Obs TTV dan • Cek GDS: 120 mg/dL
• IVFD RL 15 tpm kesadaran • Pasang kateter
• Inj. Ceftriaxone 1 gr / 12 jam • Obs urine output / 6 • Cek urinalisis
• Inf. Metronidazole 500 mg / 12 jam jam • Ro thorax
• Inj. PCT 1 gr / 8 jam (k/p) • O2 NK 3 lpm • IVFD Futrolit 20 tpm
• Obs TTV dan kesadaran • Inj. Ciprofloxacin 2x200 mg
• Obs urine output / 6 jam • Inj. Meropenem 2x1 gr
• O2 NK 3 lpm • Inj. Dexamethasone 2x1amp
NE via syringe pump mulai 0,03 meq
 Perkembangan Pasien (9)

11 Juli 2019 (07.00) 11 Juli 2019 (12.30)

S Penurunan kesadaran S Nafas (-)
O Kesadaran: Somnolen
O Arteri Karotis tidak teraba
GCS: E2M1V2
TD: 70/40 mmHg Respirasi (-)
HR: 112 x/min irreguler Refleks pupil (-/-) (dilatasi 5mm/5mm)
RR: 30 x/min SpO2: -
T: 39,1°C EKG: asistol
Edema: +/+
A P1A0 partus maturus dengan SC a/i + PTM + Gagal Induksi +
Riwayat Infertilitas + HbsAg reaktif + IUFD + syok sepsis +
A P1A0 partus maturus dengan SC a/i + PTM + Gagal Induksi + Riwayat
Infertilitas + HbsAg reaktif + IUFD + syok sepsis + penurunan penurunan kesadaran ec. Susp. Meningoencephalitis + Death
kesadaran ec susp. meningoencephalitis P • Keluarga memutuskan DNR
P • Pro ICU • Sucralfat syr 3xCI • Px dinyatakan meninggal pukul
• IVFD RL 15 tpm • NE 0,4 meq via 12.32 WIB
• Inj. Meropenem 1 gr / 12 jam syringe pump
• Inj. Dexamethasone 1 amp / 12 jam • Dopamin 15 meq
• Inj. Omeprazole 1 amp / 12 jam via syringe pump
• Inj. PCT 1 gr / 8 jam (k/p)
• Obs TTV dan kesadaran
• Obs urine output / 6 jam
• O2 NK 3 lpm
 Pertanyaan Pemicu

1.Apa itu IUFD dan apa saja penyebab IUFD?

2.Bagaimana mendiagnosis IUFD?
 Pasien muntah darah, apa penyebabnya?
Pasien muntah darah 2x berwarna merah kecoklatan 1 hari SMRS.
Beberapa hal yang dapat menyebabkan ibu hamil dapat mengalami muntah darah:
• GERD (gastroesophageal reflux disease): pengikisan lapisan sel pada kerongkongan hingg
a menyebabkan luka  komplikasinya berupa Barret’s Esophagus.
• Radang dan tukak lambung (gastritis): pada pasien dengan riwayat maag kronis, riwayat ko
nsumsi NSAID jangka panjang, alkohol dll.
• Efek samping morning sickness: sering mengalami mual dan muntah yang berkepanjangan
 melukai lapisan tenggorokan.
• Pecahnya varises esofagus: kondisi melebarnya pembuluh darah di kerongkongan dan rent
an pecah. Disebabkan oleh hipertensi porta. Biasanya terjadi pada sirosis hati.

Pada pasien ini, pasien menyangkal memiliki riwayat maag kronis dan muntah darah ini baru p
ertama kalinya terjadi. Pasien juga menyangkal adanya riwayat mengkonsumsi minuman beral
kohol dan obat anti nyeri.
HbsAg reaktif! Ikterik!
 Apa itu IUFD?
Definisi :
Kematian janin dalam rahim dengan USIA GESTASI ≥20 minggu (kalau usia kehamilan diketa
hui) ATAU berat badan janin ≥350 gram (kalau usia gestasi tidak diketahui).

Insidensi
• 2006 : 6.05 per 1000 kelahiran
• 2009 : 18,9% per 1000 kelahiran
Penyebab IUFD?
 Penyebab IUFD?
Pada pasien ini, permasalahan terjadi pada 1 minggu SMRS dimana pasien meras
a pergerakan janin berkurang. Pada hari yang sama, pasien juga pergi ke dukun un
tuk diurut bagian perutnya karena merasa sakit.

Kecurigaan #1: Kegiatan Versi Luar oleh Dukun

Teori:
Versi Luar adalah kegiatan memanipulasi presentasi fetus atau mengkonversi letak oblik atau
melintang menjadi letak longitudinal.
Versi luar mengurangi presentasi non-cephal pada persalinan. ACOG merekomendasikan ke
giatan versi luar ditawarkan dan dicoba kapanpun dimungkinkan. Oleh tenaga yang ahli, angk
a kesuksesannya dapat mencapai 60%!
Komplikasi: uterine rupture, fetomaternal haemorrhage, amniotic fluid embolism dan bahkan k
ematian janin.
 Penyebab IUFD?
Kecurigaan #2: HbsAg Reaktif

Teori:
Infeksi hepatitis B kronis sendiri tidak terlalu berdampak kepada fertilitas dan hasil
keluaran fetus! Namun, wanita dengan sirosis dekompensata sebagai hasil dari infe
ksi HBV memiliki gangguan fertilitas, serta memiliki risiko kematian ibu dan janin, hi
pertensi gestasional, abruption plasenta, kelahiran preterm, dan FGR.

Pada kasus ini, pasien serta keluarga menyangkal adanya penyakit hepatitis B seb
elumnya dan tidak menyadari bahwa pasien ini kuning sehingga pasien tidak memil
iki
Pasien juga belum pernah mendapatkan USG abdomen (yang bisa digunakan untu
k mendiagnosis sirosis hepatis).
 Penyebab IUFD?
Kecurigaan #3: Hipertensi - Preeklamsia?

Pada ANC, didapatkan bahwa pasien pernah mengalami TD melebihi normal – pen
gukuran 2x pada waktu yang berbeda. Hipertensi Gestasional or Preeklamsia?

Teori:
Kalaupun hipertensi gestasional, hampir 50% wanita ini akan berubah menjadi sind
rom preeklamsia.
Preeklamsia juga merupakan salah satu faktor risiko IUFD!!
 Apa itu SEPSIS?

Sepsis didefinisikan sebagai disfungsi organ yang mengancam nyawa yang DISEB
ABKAN oleh disregulasi respon host.
Secara umum, istilah SEPSIS DIGUNAKAN apabila sebuah FOKUS infeksi telah
terbukti atau setidaknya dengan kuat DICURIGAI dan respon tubuh menghasilkan
PENURUNAN FUNGSI organ lain yang tidak terinfeksi.
 SOFA SCORE
Screening untuk pasien yang berkemungkinan mengalami
9 Juli 2019 (17.00)
sepsis:
S Penurunan Kesadaran dan demam tinggi
qSOFA: skor ≥ 2  most likely to be septic! O Kesadaran: Somnolen SGOT: 85
GCS: E3M4V4 SGPT: 46
TD: 170/100 mmHg Ur: 71
HR: 139x/min Cr: 2,58
RR: 28x/min Proteinuria +1
T: 39,8°C
Edema +/+
A P1A0 partus maturus dengan SC a/i + PTM + Gagal Induksi +
Riwayat Infertilitas + HbsAg reaktif + IUFD + susp. Sepsis
P • Konsul DPJP:
• Monitoring urine / 6 jam
• Maintenance MgSO4 8 gr dalam RL 500cc - 20 tpm
• Nifedipine 3 x 10 mg
• HCD 1 x 200mg
SOFA Score: • NGT + NK O2
• Pro ICU – antrian 1
Sistem skoring yang menilai performa berbagai sistem or
gan tubuh (neurologis, blood, liver, kidney, and hemodyna
mic). Skor ini untuk menilai MORTALITAS!
 SOFA Score

Disfungsi organ dapat diidentifikasikan sebagai perubahan akut pada total skor SOFA ≥ 2
poin sebagai konsekuensi dari infeksi  meningkatkan risiko mortalitas pasien sebesar 2-25
x lipat.
Pada kasus, dengan anggapan bahwa pasien tidak memiliki riwayat penyakit organ selain liv
er, maka SOFA score sudah terpenuhi (Penggunaan NE, perubahan GCS, dan sCr).
 Penyebab Sepsis?
Kecurigaan #1: IUFD

Pada awalnya, dianggap bahwa :

• Fetus, meconium, cairan amniotik dan korioamnion adalah steril
• Inisial kolonisasi bakteri pada usus dari bayi baru lahir terjadi ketika bayi melewati jalan lahir.
• Keberadaan bakteri pada lingkungan tersebut biasanya hanya akan diinvestigasi apabila terdapat gejal
a infeksi atau kondisi yang memungkinkan seperti ketuban pecah, atau dilatasi serviks.
 Penyebab Sepsis?
Kecurigaan #2: Sectio Caesar

Pasien mengalami kegagalan kelahiran pervaginam karena PTM dan gagal induksi
, sehingga dilakukan sectio caesar untuk terminasi kehamilan.

Sekitar 25x peningkatan risiko infeksi dengan SC vs vaginal delivery!

 Perkembangan Pasien (5)

7 Juli 2019 8 Juli 2019 9 Juli 2019 9 Juli 2019

(07.15) (12.30)
S Nyeri luka OP (+) S Nyeri luka OP (+) S Nyeri luka OP (+), S Nyeri luka OP (+),
nyeri kepala hebat gaduh gelisah.
O KU: Baik O KU: Baik
TD: 110/70 mmHg TD: 110/70 mmHg O KU: Baik O KU: CM, gelisah
HR: 70x/min HR: 80x/min TD: 140/100 mmHg TD: 190/100 mmHg
RR: 20x/min RR: 20x/min HR: 85x/min HR: 80x/min
T: 36,6°C T: 36,3°C RR: 20x/min RR: 20x/min
Luka OP: Baik Luka OP: Baik T: 38°C T: 38,5°C
Luka OP: Baik
P
P P - Loading dose
P - PCT 3x1 tab MgSO4 4 gr/IV
k/p suhu ≥ - Nifedipine 1 tab/2
37,8°C jam (2x pemberian)
- Cek Hb, Leu,  3x1 tab
trombosit - Cek Protein urine
  Hb : 12,0 g/dL
 WBC : 27.810/uL
PLT : 221.000/uL
 HCT : 32,9%
 RBC : 4,08x106/uL
Pemeriksaan  Proteinuria : +1
 SGOT (AST) : 85 uL
Laboratorium
 SGPT (ALT) : 46 uL
 Ureum : 71 mg/dL
 Kreatinin : 2,58 mg/dL
 Pemeriksaan Fisik
Observasi / Jam (09 Juli 2019)
Jam Kesadaran TD HR RR Suhu
20.00 Delirium 150/80 Hijau keruh + berbau
o BB 4,15 kg
o PB 57 cm
o Temuan klinis IUFD Maserasi grade 3
o Tidak ditemukan tanda-tanda kehidupan pada bayi
o Pendarahan OP ± 350 cc
 Perkembangan Pasien (6)

9 Juli 2019 8 Juli 2019 9 Juli 2019 9 Juli 2019

(07.15) (12.30)
S Nyeri luka OP (+) S Nyeri luka OP (+) S Nyeri luka OP (+), S Nyeri luka OP (+),
nyeri kepala hebat gaduh gelisah.
O KU: Baik O KU: Baik
TD: 110/70 mmHg TD: 110/70 mmHg O KU: Baik O KU: CM, gelisah
HR: 70x/min HR: 80x/min TD: 140/100 mmHg TD: 190/100 mmHg
RR: 20x/min RR: 20x/min HR: 85x/min HR: 80x/min
T: 36,6°C T: 36,3°C RR: 20x/min RR: 20x/min
Luka OP: Baik Luka OP: Baik T: 38°C T: 38,5°C
Luka OP: Baik
P
P P - Loading dose
P - PCT 3x1 tab MgSO4 4 gr/IV
k/p suhu ≥ - Nifedipine 1 tab/2
37,8°C jam (2x pemberian)
- Cek Hb, Leu,  3x1 tab
trombosit - Cek Protein urine
 Perkembangan Pasien
6 Juli 2019 – 06.00

01 02 03 04

Subjective Objective Assessment Plan

 Mules (+) jarang  KU : baik G1P0A0 gravida 37-38  Pro SC a/i PTM + Gagal
 Perdarahan  TD : 120/80 mmHg minggu + IUFD + Induksi
pervaginam (-)  His 1 x 10’, 20” riwayat infertilitas +
 VT: HbsAg reaktif
 1 cm , portio tebal
 Ketuban (+)
46

• Subjective

Mules (+), Perdarahan

01
pervaginam (-) • Objective

KU : Baik
02
TD : 110/80 mmHg • Assessment
HR : 80 x/menit
RR : 20 x/menit • P1A0M1 Post P
03
T : 36,7oC artus Prematur • Plan
Abdomen : TFU 1 jari
di bawah pusat,
us dengan PE
B + Polihidroa
• IVFD RL 20 tpm
04
• Transfusi PRC 1 Kolf
Kontraksi uterus (+) mion + Anemi • Inj. Dexamethasone 1 amp IV (Pre Transfusi 1 Kolf)
baik a • Inj. Furosemide (Post Transfusi 1 Kolf jika TD ≥100 m
Genitalia : PPV (+) mHg)
• PO. Cefadroxil 2x500 mg
• PO. Asam mefenamat 3x500 mg
• PO. HCD 1x 100 mg
 Riwayat Obstetri Your Text Here
You can simply
 Pasien didiagnosis infertilitas
 Selama hamil, pasien mendapatkan impress your audience
ANC di puskesmas pada: and add a unique zing
 Trimester 1: 0x and appeal to your
 Trimester 2: 2x ( bulan ke 4 & 6 ) Presentations.
 Trimester 3: 4x ( bulan ke 8 & 9 )
Your Text Here Your Text Here
You can simply You can simply
impress your audience impress your audience
and add a unique zing and add a unique zing
and appeal to your and appeal to your
Presentations. Presentations.
Anamnesis
Identitas Pasien
 Our Team Layout
This text can be replaced with your own text

Name Here Name Here

Progrmmer Programmer
You can simply
impress your
audience and add a
unique zing.

Name Here Name Here

Programmer Programmer
You can simply You can simply
impress your impress your
audience and add a audience and add a
unique zing. unique zing.
 TimeLine Layout
This text can be replaced with your own text

Content Here Content Here

You can simply You can simply
impress your impress your
audience and add a audience and add a
unique zing and unique zing and
appeal to your appeal to your
2015 Presentations. 2017 Presentations. 2019

Content Here Content Here Content Here

2016 2018
You can simply You can simply You can simply
impress your impress your impress your
audience and add a audience and add a audience and add a
unique zing and unique zing and unique zing and
appeal to your appeal to your appeal to your
Presentations. Presentations. Presentations.
 Presentation Designed

Simple Portfolio
Presentation
You can simply impress your
audience and add a unique
zing and appeal to your
Presentations.
 Infographic Layout
This text can be replaced with your own text

Easy to change colors, photos and Text.

Simple
PowerPoint
1 Simple
PowerPoint
2 Simple
PowerPoint
3 Simple
PowerPoint
4 Simple
PowerPoint
5
Get a modern Get a modern Get a modern Get a modern Get a modern
PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint
Presentation that Presentation that Presentation that Presentation that Presentation that
is beautifully is beautifully is beautifully is beautifully is beautifully
designed. You can designed. You can designed. You can designed. You can designed. You can
simply impress simply impress simply impress simply impress simply impress
your audience and your audience and your audience and your audience and your audience and
add a unique zing. add a unique zing. add a unique zing. add a unique zing. add a unique zing.
 Infographic Layout
This text can be replaced with your own text

Simple PowerPoint
This PowerPoint Template has clean and neutral
design that can be adapted to any content and
meets various market segments.

Simple PowerPoint
55%
This PowerPoint Template has clean and neutral 30%
design that can be adapted to any content and
meets various market segments.
15%
Simple PowerPoint
This PowerPoint Template has clean and neutral
design that can be adapted to any content and
meets various market segments.
 Chart Layout
This text can be replaced with your own text

90 80 You can simply impress your audience

80 70
30% and add a unique zing.
70 60
60 You can simply impress your audience
50
50 80% and add a unique zing.
40
40
30 You can simply impress your audience
30
20 20 50% and add a unique zing.
10 10
You can simply impress your audience
0 0 20% and add a unique zing.
A B C A B C
You can simply impress your audience
Your Text Here Your Text Here 70% and add a unique zing.
You can simply You can simply
impress your impress your You can simply impress your audience
audience and add audience and add 40% and add a unique zing.
a unique zing. a unique zing.
Simple Your Text Here

Presentation Get a modern

Designed
Presentation Designed
This PowerPoint Template
has clean and neutral
design that can be adapted
to any content and meets
various market segments.
With this many slides you
are able to make a
complete PowerPoint
Presentation that best suit
your needs.
PowerPoint
Presentation that
is beautifully
designed. You can
simply impress
your audience and
add a unique zing.
Your Text Here
Get a modern
PowerPoint
Presentation that
is beautifully
designed. You can
simply impress
your audience and
add a unique zing.
 Infographic Layout
This text can be replaced with your own text

Your Text Here

You can simply impress your audience
and add a unique zing.
Your Text Here
You can simply impress your audience
and add a unique zing.
Your Text Here
You can simply impress your audience
and add a unique zing.
Your Text Here
You can simply impress your audience
and add a unique zing.
 Table Layout
This text can be replaced with your own text

Text Here Text Here Text Here Text Here

Simple Simple Simple Simple
PowerPoint PowerPoint PowerPoint PowerPoint

Easy to change Easy to change Easy to change Easy to change

colors, photos colors, photos colors, photos colors, photos
and Text. and Text. and Text. and Text.

$1,200 $1,200 $1,200 $1,200

 This
PowerPoint
Simple Template has
clean and
neutral design
Presentation that can be
adapted to any

Designed content and

meets various
market
Presentation Designed segments.

This PowerPoint Template has clean and neutral design

that can be adapted to any content and meets various
market segments. With this many slides you are able to
make a complete PowerPoint Presentation that best suit
your needs. This PowerPoint Template has clean and
neutral design that can be adapted to any content and
meets various market segments.
 Infographic Layout
This text can be replaced with your own text

This PowerPoint Template has clean and neutral

Simple Presentation design that can be adapted to any content and
Designed meets various market segments.
You can simply impress
your audience and add
Your Text Here Your Text Here
a unique zing.
01 You can simply 02 You can simply
impress your impress your
audience and add audience and add
a unique zing. a unique zing.

Your Text Here

03 You can simply
impress your
audience and add
a unique zing.
 Chart Layout
This text can be replaced with your own text

01 02 03 04

Subjective Objective Assessment Plan

Your Text Here Your Text Here Your Text Here Your Text Here
Get a modern Get a modern Get a modern Get a modern
PowerPoint PowerPoint PowerPoint PowerPoint
Presentation that is Presentation that is Presentation that is Presentation that is
beautifully designed. beautifully designed. beautifully designed. beautifully designed.
 Infographic Layout
This text can be replaced with your own text

Your Text Here Your Text Here

You can simply impress You can simply impress
your audience and add a your audience and add a
unique zing unique zing

Your Text Here Your Text Here

You can simply impress You can simply impress
your audience and add a your audience and add a
unique zing unique zing

Your Text Here Your Text Here

You can simply impress You can simply impress
your audience and add a your audience and add a
unique zing unique zing
Simple
Presentation
Designed
Presentation Designed

This PowerPoint Template has clean and neutral design

that can be adapted to any content and meets various
market segments. With this many slides you are able to
make a complete PowerPoint Presentation that best suit
your needs.
 Image & Content
This text can be replaced with your own text

Simple PowerPoint Simple PowerPoint Simple PowerPoint

This PowerPoint Template This PowerPoint Template This PowerPoint Template

has clean and neutral design has clean and neutral design has clean and neutral design
that can be adapted to any that can be adapted to any that can be adapted to any
content and meets various content and meets various content and meets various
market segments. market segments. market segments.
 14

Chart 12

Data 10

Designed 8
Presentation Designed
6
This PowerPoint Template has clean and
neutral design that can be adapted to
any content and meets various market 4
segments. With this many slides you are
able to make a complete PowerPoint
Presentation that best suit your needs. 2

Text Here Text Here Text Here 0

Category 1 Category 2 Category 3 Category 4
 Image & Content
This text can be replaced with your own text

Your Text Here Your Text Here Your Text Here

You can simply You can simply You can simply
impress your impress your impress your
audience and add audience and add audience and add
a unique zing. a unique zing. a unique zing.

Your Text Here Your Text Here

You can simply You can simply
impress your impress your
audience and add audience and add
a unique zing. a unique zing.
 Table Layout
This text can be replaced with your own text

Your Text Here Your Text Here Your Text Here Your Text Here

Your Text Here Your Text Here Your Text Here Your Text Here
Your Text Here Your Text Here Your Text Here Your Text Here
Your Text Here Your Text Here Your Text Here Your Text Here
Your Text Here Your Text Here Your Text Here Your Text Here
Your Text Here Your Text Here Your Text Here Your Text Here
Your Text Here Your Text Here Your Text Here Your Text Here
Your Text Here Your Text Here Your Text Here Your Text Here

Your Text Here Your Text Here Your Text Here Your Text Here
Image & Content
This text can be replaced with your own text

Simple PowerPoint
You can simply impress your audience and add a
unique zing and appeal to your Presentations.

Simple PowerPoint
You can simply impress your audience and add a
unique zing and appeal to your Presentations.

Simple PowerPoint
You can simply impress your audience and add a
unique zing and appeal to your Presentations.
 Table Layout
This text can be replaced with your own text

Text Text Text Text Text

Text Text Text Text Text

Your
Text Text Text Text Text Text
Here Text Text Text Text Text

Text Text Text Text Text

Text Here Text Here Text Here Text Here Text Here

Easy to change Easy to change Easy to change Easy to change Easy to change
colors, photos colors, photos colors, photos colors, photos colors, photos
and Text. and Text. and Text. and Text. and Text.

You can simply impress your audience and add a unique zing
 Image & Content
This text can be replaced with your own text

Your Text Here Your Text Here

You can simply impress You can simply impress
your audience and add a your audience and add a
unique zing and appeal unique zing and appeal
to your Presentations. to your Presentations.

Your Text Here Your Text Here

You can simply impress You can simply impress
your audience and add a your audience and add a
unique zing and appeal unique zing and appeal
to your Presentations. to your Presentations.
 Worldmap Infographic
This text can be replaced with your own text

Text Here
Easy to change colors, 200K
photos and Text.

Easy to Easy to
change change
colors, colors,
photos and photos and
Text. Text.

Text Here
200K Easy to change colors,
photos and Text.
Worldmap Infographic
This text can be replaced with your own text

55%
15%

30%
Presentation Designed

This PowerPoint Template has clean and neutral

design that can be adapted to any content and
meets various market segments.
 Image & Content
This text can be replaced with your own text

Your Text Here

You can simply impress your audience and add a unique zing
and appeal to your Presentations.

Your Text Here

You can simply impress your audience and add a unique zing
and appeal to your Presentations.

Your Text Here

You can simply impress your audience and add a unique zing
and appeal to your Presentations.

Get a modern PowerPoint Get a modern PowerPoint Get a modern PowerPoint

Presentation that is Presentation that is Presentation that is
beautifully designed. beautifully designed. beautifully designed.

Columns
Layout
This PowerPoint Template has
clean and neutral design that
can be adapted to any content
and meets various market
segments.
Your Text Here
Easy to change colors, photos and Text. Get a modern
PowerPoint Presentation that is beautifully designed. I
hope and I believe that this Template will your Time,
Money and Reputation. Easy to change colors, photos
and Text. I hope and I believe that this Template will
your Time, Money and Reputation. You can simply
impress your audience and add a unique zing and
appeal to your Presentations. Easy to change colors,
photos and Text.
Get a modern PowerPoint Presentation that is
beautifully designed. I hope and I believe that this
Template will your Time, Money and Reputation.

Columns
Layout
This PowerPoint Template has
clean and neutral design that
can be adapted to any content
and meets various market
segments.
Your Text Here Your Text Here
Easy to change colors, Easy to change colors,
photos and Text. Get a photos and Text. Get a
modern PowerPoint
Presentation that is
beautifully designed. I
modern PowerPoint
Presentation that is
beautifully designed. I
hope and I believe
that this Template will
your Time, Money and
hope and I believe
that this Template will
your Time, Money and
Reputation. Reputation.
Get a modern Get a modern
PowerPoint PowerPoint
Presentation that is Presentation that is
beautifully designed. beautifully designed.
Thank you
This text can be replaced with your own text

INSERT THE TITLE

OF YOUR PRESENTATION HERE
 Fully Editable Icon Sets : A

You can Resize without

losing quality

You can Change Fill Color &

Line Color

FREE
PPT
TEMPLATES
www.allppt.com
 Fully Editable Icon Sets : B

You can Resize without

losing quality

You can Change Fill Color &

Line Color

FREE
PPT
TEMPLATES
www.allppt.com
 Fully Editable Icon Sets : C

You can Resize without

losing quality

You can Change Fill Color &

Line Color

FREE
PPT
TEMPLATES
www.allppt.com