LAPORAN PERINATOLOGI

Selasa, 26 Januari 2021

Staf Jaga :
dr. Darto, Sp.OG (K)-Urogin
Chief Jaga :
dr. Ida
Program Pendidikan Dokter Spesialis Obstetri Ginekologi
Fakultas Kedokteran Universitas Sebelas Maret
RSUD Dr. Moewardi Surakarta
2021
RESIDEN JAGA :
dr. Yaya / dr. Rano
dr. Mifta / dr. Iman / dr. Devi
dr. Salman / dr. Cony
dr. Fika / dr. Noval
dr. Ikhwan / dr. Rosi
 RESUME
NICU :2
HCU NEONATUS
▪ R. Pemulihan :5
▪ R. Non Infeksi :-
▪ R. Infeksi :-
▪ R. Isolasi :-
▪ Laporan Kematian :-
 NICU
2 Pasien
1. By. Ny. NDY, Lelaki, BBL 2400gram, AS 5-6-7 , DPH 7 (01527566)
DX IBU : UK 38+6 minggu, ibu inpartu kala I fase laten tsk janin meningoencephalocele

DX : TX :
• O2 NK 1lpm
• Neonatal infeksi
• Diet ASI/susu formula 15-20ml/3 jam
• encephalocele Cairan
• DE: PJB asianotik, DA: PPD (0.3 • IVFD D %: d5 ¼ NS + D40% +KCl+CAGlukonas
• Inf Aminosteril 10%
cm), PDA (0.5cm) TR Mild, DF:
• Inf Smoflipid 20% + vitalipid 2ml
Ross II
Obat
• Neonatus, lelaki, BBLC, CB, SMK, • Inj ampicillin (50 mg/kg/12 jam) 155mg/12 jam (VI/VI)
lahir SC ai ibu inpartu kala I fase • Inj gentamycin (4mg/kg/24 jam) 12mg/24 jam (VI/VI)
laten tsk janin • Inj paracetamol ( 15mg/kg/kp) 37.5mg/kp
meningoencephalocele • Dorner 1/5tab/12 jam pu
Plan
• Menunggu hasil kultur darah dan GDT IT (19/1/21)
Monitoring
• KUVS BCD/8 jam
• GDS/24 jam
2. By. Ny. AFR, Perempuan, BBL 2300gram, AS 5-6-7 , DPH 5 (01527307)
DX IBU : UK 40 minggu, ibu KPD 12 jam, Ibu terkonfirmasi Covid-19
DX :
• Sepsis neonatarum
• gangguan napas ringan ec HMD
dd pneumonia kongenital
• hiperbilirubinemia ec sepsis dd
prematuritas
• caput susedaneum (perbaikan)
• feeding intolerance
• Neonatus, perempuan, BBLSR, KB,
SMK lahir spontan ai ibu KPD 12
jam, Ibu terkonfirmasi Covid-19
TX :
• O2 CPAP PEEP6 FiO2 40%
• Diet ASI/ASB 3-5ml/3jam naik bertahap
Cairan
• IVFD D %: d5 ¼ NS + D40% +KCl+CAGlukonas
• Inf Aminosteril 10%
• Inf Smoflipid 20% + vitalipid 2ml
Obat
• Inj ampicillin (50 mg/kg/12 jam) 75mg/12 jam (IV/VI)
• Inj gentamycin (4.5mg/kg/36 jam) 6mg/36 jam (IV/VI)
• Inj aminofilin (50 mg/kg/12 jam) 3mg/kg/8 jam
• Inj gentamycin (4.5mg/kg/36 jam) 6.75mg/6 jam (II/VI)
Plan
• Transfusi FFP serial (20ml/kg) 30ml (II/III)
• Menunggu hasil kultur darah (22/1/21)
Monitoring
• KUVS/BCD/8 jam
• GDS/24 jam
Ruang Pemulihan
1. By. Ny. YYN, Laki-laki, BBL 2400gram, AS 5-6-7 , DPH 3 (01527566)
DX IBU : UK 33 minggu,ibu KPD infected inpartu kala I, fase aktif, Riw.SC

DX :
• Gangguan nafas sedang ec HMD
dd pneumonia kongenital dd
hipotermia
• Neonatal infeksi
• Riw.hiptermia ringan
• Riw.asfiksia sedang
• Neonatus, laki-laki, BBLR, KB,
SMK, lahir SC ai ibu KPD infected
inpartu kala I, fase aktif, Riw.SC
TX :
• O2 CPAP PEEP 6, Fi02 40%
• Diet tropik feeding 3-5ml/3 jam
Cairan
• IVFD D %: d5 ¼ NS + D40% +KCl+CAGlukonas
• Inf Aminosteril 10%
• Inf Smoflipid 20% + vitalipid 2ml
Obat
• Inj ampicillin (50 mg/kg/12 jam) 120mg/12 jam (II/VI)
• Inj gentamycin (4.5mg/kg/36 jam) 11mg/36 jam (II/VI)
• Inj aminofilin (3 mg/kg/8 jam) 7.5mg/kg/8 jam
Plan
• Ambil hasil babygram
Monitoring
• KUVS BCD/8 jam
• GDS/24 jam
2. By. Ny. TWH, Perempuan, BBL 2400gram, AS 5-6-7 , DPH 5 (01527566)
DX IBU : UK 38+6 minggu, ibu susp ventrikulomegali, dandy walker syndrome

DX : TX :
• Hidrocephalus non communicans • O2 NK 0,5lpm
• Dandy walker syndrome • Diet ASI/susu formula standard on demand
• DE: PJB asianotik, DA: HLHS, PDA, Obat
ASD II L to R shunt, DF: Ross II • Bisoprolol 0,25mg/12 jam PO
• Neonatus, perempuan, BBLC, CB, Plan
SMK, lahir SC ai ibu susp • Melakukan intake oral
ventrikulomegali, dandy walker
syndrome • Konsul bedah saraf (25/1/21)
• SSD cardio rencana edukasi keluarga
• Hindari NSAID (PDA-dependent) (SSD Cardio)
Monitoring
• KUVS/ BCD/8 jam
3. By. Ny. WND, Perempuan, BBL 3000gram, AS 5-6-7 , DPH 3 (01527605)
DX IBU : UK 38 minggu, fetal hipoksia, oligohidramnion, Ibu discarded Covid-19

DX : TX :
• DE: Tsk PJB asianotik, DA: Tsk VSD • O2 NK 0,5lpm
dd PDA, DF: Ross I • Diet ASI on demand
• Neonatus perempuan, BBLC, CB, Plan
SMK, lahir SC ai fetal hipoksia, • Naikkan intake oral
oligohidramnion, Ibu discarded
Covid-19 • Echocardiography (25/1/21)
Monitoring
• KUVS/ BCD/8 jam
4. By. Ny. UMC , Perempuan, BBL 1800 gram, AS 5-6-7 , DPH 2 (01527370)
DX IBU : G1P0-0, UK 36+6 minggu, fetal hypoxia PEB

DX : TX :
• O2 NK 0.5 lpm
• Gangguan nafas ringan ec ISK
• Diet ASI/ASB 30-40ml/3jam naik bertahap
pneumonia kongenital dd
hipothermia Cairan
• IVFD D %: d5 ¼ NS + D40% +KCl+CAGlukonas
• Neonatal infeksi
• Inf Aminosteril 10%
• IUGR simetris • Inf Smoflipid 20% + vitalipid 2ml
• Neonatus, laki-laki, BBLR, KB, Obat
KMK, lahir SC ai fetal hypoxia PEB • Inj ampicillin (50 mg/kg/jam) 90mg/12 jam (V/VI)
Plan
• Menunggu hasil GDT IT ratio dan kultur darah Monitoring
• KUVS/BCD/8 jam
• GDS/24 jam
5. By. Ny. NML, Perempuan, BBL 2700gram, AS 5-6-7 , DPH 6 (01527370)
DX IBU : UK 39 minggu, ibu KPD 12 jam, Ibu terkonfirmasi Covid-19

DX : TX :
• O2 ruangan
• Neonatal infeksi
• Diet ASI/ASB 10-20ml/3jam
• caput susedaneum Cairan
• Neonatus, perempuan, BBLC, CB, • IVFD D %: d5 ¼ NS + D40% +KCl+CAGlukonas
• Inf Aminosteril 10%
SMK, lahir SC ai ibu PEB, Ibu
• Inf Smoflipid 20% + vitalipid 2ml
terkonfirmasi Covid-19
Obat
• Inj ampicillin (50 mg/kg/12 jam) 135mg/12 jam (IV/VI)
Plan
• Naikkan intake oral
• Menunggu hasil kultur darah (20/1/21)
• Usul baby gram (24/1/21)
Monitoring
• KUVS/BCD/8 jam
• GDS/24 jam
Ruang Non Infeksi
NIHIL
Ruang Infeksi
NIHIL
Ruang Isolasi
NIHIL
LAPORAN KEMATIAN
NIHIL
TERIMA KASIH