mioma servikal
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mioma servikalTRANSCRIPT
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Laporan Kasus MIOMA SERVIKAL
PEMBIMBING :dr. Jeno, spOG
PENYUSUN : Stefanie Karina07120110100
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IDENTITAS
Nama : Ny. H Usia : 46 tahun Pekerjaan : Ibu Rumah Tangga Agama : Islam Suku : Jawa Status : Sudah menikah Alamat : Sukajadi RM : 00-69-39-XX MRS : 14 Maret 2016
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ANAMNESIS
Keluhan Utama
•Benjolan di perut bagian bawah
Keluhan Tambahan
•Perdarahan sehabis berhubungan seksual
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Riwayat Penyakit Sekarang
• Terdapat benjolan di perut bagian bawah ± 4 bulan
• Perdarahan seusai berhubungan seksual sejak 7 hari SMRS, ganti pembalut 5x.
• Menstruasi tidak lancar 3-4 bulan terakhir
• BAK sering• Nyeri pinggang terus menerus
Riwayat Penyakit Dahulu
•Keluhan serupa (-)•Riwayat penyakit jantung (-), ginjal (-), HT (-), DM (-), dan asma (-)
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Riwayat Penyakit Keluarga
• Keluhan serupa (-)
• Riwayat lain-lain (-)
Riwayat Penyakit Alergi
• Obat (-)• Makanan (-)
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Riwayat Pasien
• Menikah : 1x, 25 tahun.• Menarke : 11 tahun. • Pasien : siklus haid teratur
(±28hari)• Durasi : 5 hari• Perdarahan : Sedang• Riwayat KB : (-)• Post coital bleeding : (+)
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Riwayat Obstetri
No P/L Umur Anak Ku Anak BBL (grams)
Riwayat Persalinan
Ditolong oleh dan ditempat
1 L 24 tahun Baik 3000 Spontan Rs. Sari Asih
2 L 23 tahun Baik 3200 Spontan Rs. Sari Asih
3 P 19 tahun Baik 3400 Spontan Rs. Melati
4 P 17 tahun Baik 3600 Spontan Rs. Keluarga Ibu
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Status Generalis
Keadaan umum: baik Kesadaran : compos mentis Tanda Vital
Tekanan darah : 120/80 mmHg Frekuensi nadi : 80 x/menit Frekuensi napas : 20 x/menit Suhu : 36,5oC
Berat badan : 70 kg Tinggi badan : 160cm BMI :
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Status Ginekologi
Inspeksi : perut bagian bawah terlihat cembung Palpasi : teraba benjolan ±2 jari diatas umbilicus, keras, nyeri tekan (-), batas
tegas, 7x7 cm VT :
Dinding vagina normal, massa (+), porsio licin, nyeri goyang porsio (-), perdarahan aktif (+)
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Pemeriksaan
Laboratorium
•Hb : 9,90•Hematokrit : 31,00•RBC : 3,85•WBC : 8,06•Platelet : 349,00•MCV : 80,50 fL•MCH : 25,7 pg•MCHC : 31,9 g/dL•PT : 10,40•APTT : 33,30•HbSAg : (-)•GDS: 84•Ureum : 12•Kreatinin : 0,57•SGOT : 13•SGPT : 14•Natrium : 138•Kalium : 3,8•Chloride : 100
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Pemeriksaan Imaging
Kesan: Tampak mioma geburt dengan diameter 7 x 6 cm, tampak kista pada adneksa kanan diameter 3 cm
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Penatalaksanaan
Rencana Diagnosis
• Cek DL, PT, APTT, SGOT, SGPT, Ureum, Creatinine
Rencana Terapi • Pro TAH, Kistektomi
Rencana Monitoring
• Observasi keadaan umum dan vital sign
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Tindakan Operasi
Diagnosa Pra Operasi : multiple mioma + mioma geburt Diagnosa Post Operasi : multiple mioma + mioma servikal + adhesi Waktu Operasi : 08:00 – 10:30 (16/4/26) Tindakan : TAH + kistektomi – kiri +
adhesiolosis Perdarahan : 350 CC
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Tindakan OPERASI
• TAH + adhesiolosisTindakan Operasi
• Massa serviks kurang lebih 9cmPenemuan
Operasi• Cefotaxime 1gr IV• Ketorolac 3 mg IV
Instruksi Post
Operasi
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Mioma Servikal
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Waktu Subjektif Objektif Assesment Rencana Terapi
14/03/1607:00
Keluar darah pervaginam (+), nyeri pinggang, BAK sering.
SS/CM130/70 mmHg78 x/menit18x/menit36,8oC
Mioma geburt
RL 500ml/8 jam
15/03/1607:30
Keluar darah pervaginam (+), BAK sering
SS/CM120/80 mmHg80x/menit20x/menit36,4oC
Pro TAH IV StopperPRC 220ccCeftriaxon 1g/IV
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16/03/16
Nyeri luka post op
KU : baikTD : 120/80 mmHgN : 96 x/menitRR: 24x/menitT: 36,9oC
Post TAH a/i Mioma Servikal
IV RL 800 ml/8 jamCeftriaxone 1gr IVKetorolac 30 mg IVPRC 200 CC
17/03/16
Nyeri luka post op
KU : baikTD : 130/80 mmHgN : 92 x/menitRR: 24x/menitT: 36,8oC
HB 9,6 g/dLHT 30%RBC 3,63 10^6/uLPlatelet 269 10^3/uLMCV 82,6 tlMCH 26,4 pgMCHC 32 g/dL
Post TAH a/I Mioma servikal
IV RL 500ml/8jamCefadroxil 3x500mgAsam mefenamat 3x500mgPRC 200 CC
18/03/16
Keluhan (-)
KU : baikTD : 130/80 mmHgN : 92 x/menitRR: 24x/menitT: 36,8oC
Post TAH a/I Mioma servikal
Cefadroxil 3x500mgAsam mefenamat 3x500mg
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19/03/16
Keluhan (-)
KU : baikTD : 130/80 mmHgN : 92 x/menitRR: 24x/menitT: 36,8oC
Post TAH a/I Mioma servikal
Cefadroxil 3x500mgAsam mefenamat 3x500m
20/03/16
Keluhan (-)
KU : baikTD : 130/80 mmHgN : 92 x/menitRR: 24x/menitT: 36,8oC
Post TAH a/I Mioma servikal
Cefadroxil 3x500mgAsam mefenamat 3x500m
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Prognosis
Ad vitam : bonam Ad functionam : malam Ad sanationam : bonam
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Mioma
Definisi
Epidemiologi
Etiologi
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Gejala Klinis
Massa di perut bawah
Perdarahan abnormal
Nyeri perut
Pressure Effect
Penurunan kesuburan dan abortus
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Diagnosis
Anamnesis Pemeriksaan Fisik
Pemeriksaan Laboratoriu
m
Pemeriksaan Imaging
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Tata Laksana
Konservatif Medikamentosa
Operatif Radiasi
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Medikamentosa
GnrH analogue
Progesterone
Danazol
Gestrinon
Tamoxifen
Goserelin
Antiprostaglandin
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Operatif
MiomektomiHisterektomiEmbolisasi arteri uterus
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Komplikasi
Degenerasi ganas Torsi (putaran tangkai)
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Prognosis
Histerektomi dengan mengangkat seluruh mioma adalah kuratif. Myoma yang kambuh kembali (rekurens) setelah miomektomi terjadi pada 15-40%
pasien dan 2/3nya memerlukan tindakan lebih lanjut.
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Thank you