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Laporan Perinatologi

Kamis, 16 Mei 2019


Ratih Kumalasari
IDENTITAS
Nama : Bayi Ny. S R W
Usia : 8 hari
jenis kelamin : perempuan
Diagnosis:
• Omphalocele
• Neonatal jaundice membaik
• Konjuntivitis OS
• Berat Badan lahir Cukup, Cukup Bulan, Sesuai Masa Kehamilan,
SC a.i janin dengan omphalocele
ANAMNESIS
POLI Kronologis
6/5/2019
10.00 S: Pasien datang membawa pengantar SpOG (K), merasa hamil 9
dr. WAN bulan, rutin kontrol dikatakan janin terdapat omphalocele,
terdiagnosis saat usia kehamilan 3 bulan, keluhan kenceng-
G3P0A2, 29 tahun kenceng(+), AK rembes(-), lendir darah(-), gerak janin dirasakan
HPHT 9/8/2018 aktif.
HPL 16/5/2019
UK 38 minggu 4 hari Riwayat menikah 1x~ 3 tahun
Riwayat operasi (-)
TD 117/75 mmHg Riwayat ANC >5x di SpOG
N 93 kpm
R 20 kpm
Riwayat obstetri:
T 36,5 C
I. 2016, abortus UK 3 bulan, kuret di RS
II. 2017, abortus UK 7 minggu, tidak dikuret
BB 43,5 kg III. hamil ini
TB 155 cm Riwayat HT(-), DM(-), alergi(-), asma(-), penyakit jantung(-)
↑BB 9,5 kg
IMT 14,15 kg/m2
ANAMNESIS
O: KU: baik, sadar
POLI Mata: CA-/-, SI-/-
6/5/2019 Thorax: ves+/+, rh-/-, wh-/-, S1-S2 reg
10.00
Abdomen: janin tunggal, memanjang, preskep, DJJ 145 kpm, TFU 32 cm,
dr. WAN
his (+) 1x/10’/20”/L
G3P0A2, 29 tahun
PD: V/U normal, dinding vagina licin, serviks lunak, di belakang, eff 50%,
HPHT 9/8/2018 pembukaan 0 cm, LD(-), AK(-), selket(+), kepala di S-2
HPL 16/5/2019
UK 38 minggu 4 hari A: G3P0A2 hamil 38 minggu 4 hari, bdp, dengan janin omphalocele

TD 117/75 mmHg P:
N 93 kpm -Rencana SC elektif selasa 7/5/2019
R 20 kpm
T 36,5 C

BB 43,5 kg
TB 155 cm
↑BB 9,5 kg
IMT 14,15 kg/m2
7/5/2019 Bayi lahir secara abdominal, dengan BBL 2680 gram, PB 48
13.20 cm, LK/ LD 33/30 cm, A/S 8/9
ULTRASONOGRAFI
USG 2/5/19
 
Janin tunggal, memanjang, preskep,
DJJ(+), gerak(+), plasenta di fundus
meluas ke posterior grade III, AK
cukup (SDP3,5cm), tampak defek di
anterior dinding abdomen Ø 2,28cm, di
anterior dinding abdomen tampak
massa dengan selaput ukuran
5,5x4,5cm
BPD 8,85cm~ 35 minggu 6 hari
HC 33,08cm~ 37 minggu 5 hari
AC 28,55cm~ 32 minggu 4 hari
FL 6,51cm~ 33 minggu 4 hari
TBJ 2322 g
STATUS ANTROPOMETRI
BBL : 2680 gram
PB : 48 cm
LK : 33 cm
LD : 30 cm

Sesuai Masa Kehamilan


PEMERIKSAAN FISIK
• Vital sign :HR 138 bpm, RR 40 bpm, T 36.8 C, SpO2 98%
• Kulit : sianosis (-), anemis (-)
• Kepala : caput succaedenum (-), dysmorphic face (-)
• Mata : discharge (+)
• Hidung : darah (-/-)
• Telinga : darah (-/-), low set ear (-/-)
• Mulut : labiopalatoschizis (-)
• Leher : webbed neck (-)
• Dada : simetris, retraksi (-/-)
• Jantung : S1 normal, S2 split, murmur (-)
• Paru : vesicular, Rh (-/-), Wh (-/-)
• Abdomen : tampak viscera abdomen terbungkus selaput wharton jelly, kesan
viscera abdomen: sistema usus halus, diameter 4 cm
• Anus : anal dimple +
• Genita l : laki-laki
• Extremities : normal eutrophy
LABORATORIUM
Parameters Units 9/5/2019 12/5/2019 Normal Value

Hemoglobin g/dL 20.1 16.5 – 21.5

RBC x10 6 5.83 4.1-6.1

Hematokrit % 58 34 – 48

Platelets /mm3 319 150.000-450.000

WBC /mm3 14.05 9.000-37.000

PPT second 16.5/14.4 12.3-15.3

APTT second 34.9/30.8 27.9-37

Natrium mmol/L 140 136-145

Kalium mmol/L 4.62 3.5-5.1

Chlorida mmol/L 101 98-107

Calsium Mmol/L 2.17 2.15-2.55

RBG mg/dl 151 74-140

Bilirubin Total mg/dl 12.60 <12.60

Bilirubin Direk mg/dl 0.64 <0.60

Bilirubin Indirek mg/dl 11.96 <8.10


Babygram

Cor dan pulmo Normal


Abdomen : soft tissue mass di
regio umbilical -->omphalocele
dilatasi sebagian usus halus, tidak
ada tanda obstruksi dan
peritonitis
Diagnosis
• Omphalocele
• Neonatal jaundice membaik
• Konjuntivitis OS
• Berat Badan lahir Cukup, Cukup Bulan, Sesuai
Masa Kehamilan, SC a.i janin dengan
omphalocele
Manajemen
• Termoregulasi
• Kebutuhan cairan 180 ml/kgBB/24 jam
• Rawat bersama dengan TS Bedah Anak
• Perawatan omphalocele dengan Burnazine dan
kassa tegak kering sampai dengan reepitelisasi, latih
orang tua
• Chloramphenicole eye zalf 2 dd ue
Bedah Anak
DIAGNOSIS
Omphalocele

PLAN:
• Observasi vital sign dan tanda-tanda akut abdomen
• IVFD ~ TS Anak
• Terapi ~ TS Anak
• Perawatan tegak kering dengan burnazine salep, kassa kering dan
donat kassa
Kondisi Pagi Ini
• Bayi dirawat di ruang H, dengan box terbuka, tanpa
alat bantu nafas, HR 136 bpm, R 42 tpm, t 37.5C,
SpO2 96%
DISKUSI
Omphalocele -->
screening diagnosis
prenatal
ANALISIS
Management

Bayi dengan
omphalocele, BBLC,
CB, SMK

Prognosis
Omphalocele
• Omphalocele is a defect in the closure of the abdominal wall
that also involves the cord insertion. It results from the failure
of loops of bowel to return to the abdominal cavity after
physiological herniation into the umbilical cord from the sixth
to tenth week of development
Prenatal Diagnosis
An omphalocele is sonographically represented by a bulging
structure that
(1)Arises from the anterior abdominal wall,
(2)contains some abdominal viscera (liver and/or bowel), and
(3)presents the cord insertion on its convexity
Associated Aneuploidies
Risk of chromosomal anomaly is high
• Trisomy 18, most common, 62-75%
• Trisomi 13, common 11-24%
Associated syndromes
Risk of nonchromosomal syndromes  high
The most common syndromes detectable in utero that can be associated with
omphalocele are as follows:
• Beckwith–Wiedemann syndrome: look for ► omphalocele + macroglossia +
somatic hemihypertophy + polycystic kidney;
• Pentalogy of Cantrell: look for ► midline anterior ventral wall defect +
diaphragmatic defect + cleft distal sternum + defect of the apical pericardium
with communication into the peritoneum + CHD;
• Cloacal exstrophy: look for ► omphalocele + exstrophy of the urinary
bladder + anorectal malformations + spinal defects
Delivery
Delivery at tertiary level hospital
C-section may be indicated in cases with huge (5 cm)
omphalocele to reduce the risk of traumatic rupture of the
sac, with spontaneous delivery for smaller lesion
Management
• Surgical correction of the defect may be performed in a single intervention or may require a
two-step procedure, according to the size of the omphalocele.
• If omphalocele is small (omphalocele minor/ <5 cm), usually it is treated with surgery soon
after birth.
• If the omphalocele is large (omphalocele major/ > 5 cm), the repair might be done in stages.
The exposed organs should be covered by nonadherent dressing and slowly, over time, the
organs will be moved back into the abdomen. When all the organs have been put back in the
abdomen, the opening is closed surgically.
• In those cases in which the whole liver has herniated, the limited intra-abdominal pressure is
insufficient to allow normal growth of the abdomen. The final closure is delayed until the
growth of the abdominal wall will allow complete closure without an abnormal increase in
intra-abdominal pressure.
Prognosis
• Early neonatal mortality is generally due to the associated
anomalies, and it may be as high as 80% in the case of multiple
anomalies or even 95%–100% in the case of severe
aneuploidies or syndromes.
• Isolated omphalocele and the liver is not in the sac, the
prognosis is excellent.
• If liver in the sac, the prognosis is relatively poor and significant
respiratory sequelae have been reported.
TERIMAKASIH