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GAWAT DARURAT OBGIN DENGAN NYERI ABDOMEN

dr. I Gede Mega Putra, SpOG LAB/SMF OBGIN FK UNUD/RSUP SANGLAH DENPASAR

TUJUAN

Identifikasi dini kegawatdaruratan Obgin dengan nyeri abdomen Memahami cara diagnostik dan pilihan penanganan

Nyeri abdomen pada kasus Obgin

Ectopic pregnancy Ovarian Torsion Septic abortion

Kehamilan ektopik

Insiden4.5 per 1,000 kehamilan pada tahun 1970 20 per 1,000 kehamilan pada tahun 1992

Penyebab tersering kematian pada kehamilan muda (TR I) Early detection and treatment is essentialACOG Practice Bulletin No. 3, 1998

Faktor risiko Kehamilan ektopik

Riwayat PRP Riwayat kehamilan ektopik Perokok Riwayat operasi pada tuba DES exposure Hamil usia tua Riwayat infertil Penggunaan obat induksi ovulasi dan obat infertil lainnyaNEJM 1997;336:762-7

Gambaran klinik kehamilan ektopik

KE muda yg belum terganggu memberi gejala seperti kehamilan normal KET :Amenore (tes kehamilan positip) Perdarahan pervaginam Akut abdomen Anemia Hipotensi s/d syok Pingsan

Diagnosis

Diagnosis sering sulit karena gejala yg beraneka ragam, terutama KE yg belum terganggu Perhatikan gejala-gejala seperti : amenore, perdarahan, nyeri abdomen,dll KU penderita tergantung banyaknya perdarahan intra abdomen, bukan perdarahan pervaginam Dari pemeriksaan fisik :Anemia Distensi abdomen, nyeri spontan dan tekan Pada pemeriksaan dalam ditemukan nyeri goyang pada portio dan cavum douglas menonjol

Diagnosis

Pemeriksaan penunjangTes kehamilan Dilatasi dan kerokan : desidua tanpa villi korialis Laparaskopi Ultrasonografi Kuldosintesis

Patologi anatomi

Diagnosis banding

Infeksi pelvik Abortus iminens Tumor ovarium Apendiksitis perforasi

Penanganan

KEKonservatif ~ MTX (metotrexate) Laparaskopi / laparatomi

Absolute indications MTXHemodynamically stable No signs of bleeding Desires future fertility Able to return for follow up No contraindications to MTX

Relative indications MTX :Mass less than 3.5 cm No fetal heart motion HCG < 15,000 Absolute contra indications MTX :

Breastfeeding Immunodeficiency Alcoholism or liver disease Leukopenia, thrombocytopenia, anemia Sensitivity to MTX Pulmonary disease Peptic ulcer disease Hepatic, renal, or hematological dysfunction

Penanganan

KET :Laparatomi Laparaskopi Salpingektomi Salpingostomi Perbaikan KU dan anemia

Torsi kista ovarium

Pregnancy (25%) Ovulation induction Ovarian tumors (50-60%)Usually benign 8 to 12 cm Dermoid most common, Paraovarian cysts Benign solid Serous cysts Right > Left (2/3)Comprehensive Gynecology, 3rd ed.

Early diagnosis is key !!!!

75% can be managed conservatively Laparoscopic unwinding, possible cystectomy, shortening of uteroovarian ligament, or oopexy If vascular compromise, necrosis, or suspected malignant neoplasia, salpingooophorectomy is appropriate

Masalah :

Torsinya terdiagnosis lebih dulu dibandingkan kista ~ akut abdomen

Ovarian Torsion: Diagnosis

Ultrasound Doppler93% will reveal decreased or absent arterial or venous flow Keep high index of suspicion, even if normal flow

Albayram et al. J Ultrasound Med 2001, 20(10):1083-9.

Septic Abortion

Abortus ilegal >> Masalah sosial >> Diawali abortus infeksiosus tdk tertangani dengan optimal Infection occurs in 1-2% Febris Nyeri goyang portio dan nyeri supra simpisis Fluksus berbau

Etiologi dari abortus septik

Polymicrobial Escherichia coli and aerobic gram negative rods Group B beta-hemolytic streptococci Anaerobic streptococci Bacteroides Staphylococci Clostridium perfringens Chlamydia

Penanganan abortus septik

Lab : DL dan golongan darah Urinalysis Electrolytes Faal hemostasis Blood cultures Uterine discharge for gram stain, cultures, and sensitivities Supine and upright radiographs of abdomen

Management of septic abortion

Antibiotika triple

Ampicilin/gentamicin/metronidazoleCefoxitin or Timentin or Imipenem or Unasyn or Zosyn + doxycycline Clindamycin + Gentamicin or Ceftriaxone

Broad spectrum IV antibiotics

Evakuasi sisa konsepsi setelah infeksi reda Uterine evacuation after blood levels of antibiotics are adequate Tetanus toxoid 0.5 mL SQ or immune globulin 250 U IM Hysterectomy if severe sepsis and uterus cannot be evacuated Treat the shock