PEMBEKALAN

FARMAKOTERAPI
ROTASI KLINIK
OBSTETRI GINEKOLOGI

TIM FARMAKOLOGI
FK UNISSULA
NO DAFTAR PENYAKIT MENURUT SKDI LoC
OBSTETRI GINEKOLOGI
1 Kehamilan dan persalinan normal 4A
2 Anemia defisiensi besi pada kehamilan 4A
3 PREEKLAMPSIA dan Eklampsia 3B
4 Salphingitis 4A
5 Abortus spontan komplit 4A
6 Abortus mengancam 3B
7 Abortus spontan inkomplit 3B
8 Hiperemesis gravidarum 3B
9 Partus lama 3B
KONSELING KB
10 Konseling KB 4A
11 AKDR/IUD 4A
12 Suntik KB 4A
13 Komplikasi KB 4A
14 Implant 3B
 HARMFUL EFFECT ON THE FETUS

The stage of gestation influences the effects of

drugs on the fetus. It is convenient to divide
pregnancy into four stages, namely :
1. Fertilization and implantation (17 days)
2. The organogenesis / embryonic stage (17
57 days)
3. The fetogenic stage
4. Delivery
 FERTILIZATION & IMPLATATION
Animal studies suggest that interference with
the fetus before 17 days gestation causes
abortion, i.e. if pregnancy continues the fetus
is unharmed.
 ORGANOGENESIS/EMBRYONIC STAGE
At this stage, the fetus is differentiating to form major
organs, and this is the critical period for teratogenesis.
Teratogens cause deviations or abnormalities in the
development of the embryo that are compatible with
prenatal life and are observable postnatally.
Drugs that interfere with this process can cause gross
structural defects (e.g. thalidomide phocomelia). Some
drugs are confirmed teratogens, but for many the
evidence is inconclusive. Thalidomide was unusual in
the way in which a very small dose of the drug given on
only one or two occasions between the fourth and
seventh weeks of pregnancy predictably produced
serious malformations.
 FETOGENIC STAGE
In this stage, the fetus undergoes further development
and maturation. Even after organogenesis is almost
complete, drugs can still have significant adverse effects
on fetal growth and development.
ACE inhibitors and angiotensin receptor blockers cause
fetal and neonatal renal dysfunction.
Drugs used to treat maternal hyperthyroidism can cause
fetal and neonatal hypothyroidism.
Tetracycline antibiotics inhibit growth of fetal bones
and stain teeth. Aminoglycosides cause fetal VIIIth nerve
damage.
 FETOGENIC STAGE
Warfarin can cause fetal intracerebral bleeding.
Indometacin, a potent inhibitor of prostaglandin
synthesis, is used under specialist supervision to assist
closure of patent ductus arteriosus in premature
infants.
Some hormones can cause inappropriate virilization or
feminization.
Anticonvulsants may possibly be associated with
mental retardation.
Cytotoxic drugs can cause intrauterine growth
retardation and stillbirth.
 DELIVERY
Some drugs given late in pregnancy or during
delivery may cause particular problems. Pethidine,
administered as an analgesic can cause fetal apnoea
(which is reversed with naloxone). Anaesthetic
agents given during Caesarean section may
transiently depress neurological, respiratory and
muscular functions. Warfarin given in late
pregnancy causes a haemostasis defect in the baby,
and predisposes to cerebral haemorrhage during
delivery.
 PHARMACOKINETICS IN PREGNANCY
ABSORPTION : Gastric emptying and small intestinal
motility are reduced. This is of little consequence unless
rapid drug action is required. Vomiting associated with
pregnancy may make oral drug administration
impractical.
DISTRIBUTION : For water-soluble drugs (which usually
have a relatively small volume of distribution), this
increases the apparent volume of distribution and,
although clearance is unaltered, their half-life is
prolonged. During pregnancy, the plasma protein
concentration falls and there is increased competition
for binding sites due to competition by endogenous
ligands, such as increased hormone levels.
 PHARMACOKINETICS IN PREGNANCY
DISTRIBUTION : These factors alter the total amount
of bound drug and the apparent volume of
distribution. However, the concentration of free drug
usually remains unaltered, because a greater volume
of distribution of free drug is accompanied by
increased clearance of free drug. Thus, in practice,
these changes are rarely of pharmacological
significance. They may cause confusion in monitoring
of plasma drug levels, since this usually measures
total (rather than free) drug concentrations.
 PHARMACOKINETICS IN PREGNANCY
METABOLISM : Metabolism of drugs by the pregnant
liver is increased, largely due to enzyme induction,
perhaps by raised hormone levels. Liver blood flow
does not change. This may lead to an increased rate of
elimination of those drugs (e.g. theophylline), for
which enzyme activity rather than liver blood flow is
the main determinant of elimination rate.
RENAL EXCRETION : Excretion of drugs via the kidney
increases because renal plasma flow almost doubles
and the glomerular filtration rate increases by two-
thirds during pregnancy. This has been documented
for digoxin, lithium, ampicillin, cefalexin and
gentamicin.
 PRESCRIBING IN PREGNANCY
The prescription of drugs to a pregnant woman is a
balance between possible adverse drug effects on
the fetus and the risk to mother and fetus of
leaving maternal disease inadequately treated.
Effects on the human fetus cannot be reliably
predicted from animal studies hence one should
prescribe drugs for which there is experience of
safety over many years in preference to new or
untried drugs.
The smallest effective dose should be used. The
fetus is most sensitive to adverse drug effects
during the first trimester.
 ANTIMICROBIAL DRUGS
Antimicrobial drugs are commonly prescribed
during pregnancy.
The safest antibiotics in pregnancy are the
penicillins and cephalosporins.
Trimethoprim is a theoretical teratogen as it is a
folic acid antagonist.
The aminoglycosides can cause ototoxicity.
There is minimal experience in pregnancy with the
fluoroquinolones (e.g. ciprofloxacin) and they
should be avoided.
 ANTIMICROBIAL DRUGS
Erythromycin is probably safe.
Metronidazole is a teratogen in animals, but there
is no evidence of teratogenicity in humans, and its
benefit in serious anaerobic sepsis probably
outweighs any risks. Unless there is a life-
threatening infection in the mother, antiviral
agents should be avoided in pregnancy.
 ANALGESICS
Opioids cross the placenta. This is particularly
relevant in the management of labour when the
use of opioids, such as pethidine, depresses the
fetal respiratory centre and can inhibit the start of
normal respiration. If the mother is dependent on
opioids, the fetus can experience opioid
withdrawal syndrome during and after delivery,
which can be fatal. In neonates, the chief
withdrawal symptoms are tremor, irritability,
diarrhoea and vomiting. Chlorpromazine is
commonly used to treat this withdrawal state.
 ANALGESICS
Paracetamol is preferred to aspirin when mild
analgesia is required. In cases where a systemic
anti-inflammatory action is required (e.g. in
rheumatoid arthritis), ibuprofen is the drug of
choice. Non-steroidal anti-inflammatory drugs
can cause constriction of the ductus arteriosus.
Occasionally, this may be used to therapeutic
benefit.
 ANAESTHESIA
Anaesthesia in pregnancy is a very specialist area and should
only be undertaken by experienced anaesthetists. Local
anaesthetics used for regional anaesthesia readily cross the
placenta. However, when used in epidural anaesthesia, the
drug remains largely confined to the epidural space. Pregnant
women are at increased risk of aspiration. Although
commonly used, pethidine frequently causes vomiting and
may also lead to neonatal respiratory depression.
Metoclopramide should be used in preference to
prochlorperazine (which has an anti-analgesic effect when
combined with pethidine), and naloxone (an opioid
antagonist) must always be available. Respiratory depression
in the newborn is not usually a problem with modern general
anaesthetics currently in use in Caesarean section.
 ANTI-EMETICS

Nausea and vomiting are common in early

pregnancy, but are usually self-limiting, and
ideally should be managed with reassurance and
non-drug strategies, such as small frequent
meals, avoiding large volumes of fluid and raising
the head of the bed. If symptoms are prolonged
or severe, drug treatment may be effective. An
antihistamine, e.g. promethazine or cyclizine may
be required. If ineffective, prochlorperazine is an
alternative.
 ANTI-EMETICS
Metoclopramide is considered to be safe and
efficacious in labour and before anaesthesia in
late pregnancy, but its routine use in early
pregnancy cannot be recommended because of
the lack of controlled data, and the significant
incidence of dystonic reactions in young
women.
The FDA criteria of Ondancetron is B.
 DYSPEPSIA AND CONSTIPATION
The high incidence of dyspepsia due to gastro-
oesophageal reflux in the second and third
trimesters is probably related to the reduction in
lower oesophageal sphincter pressure. Nondrug
treatment (reassurance, small frequent meals and
advice on posture) should be pursued in the first
instance, particularly in the first trimester.
Fortunately, most cases occur later in pregnancy
when non-absorbable antacids, such as alginates,
should be used.
 DYSPEPSIA AND CONSTIPATION

In late pregnancy, metoclopromide is

particularly effective as it increases lower
oesophageal sphincter pressure. H2-receptor
blockers should not be used for nonulcer
dyspepsia in this setting.
 PEPTIC ULCERATION
Antacids may relieve symptoms. Cimetidine and
ranitidine have been widely prescribed in
pregnancy without obvious damage to the fetus.
There are inadequate safety data on the use of
omeprazole or other proton pump inhibitors in
pregnancy.
Sucralfate has been recommended for use in
pregnancy in the USA, and this is rational as it is
not systemically absorbed.
Misoprostol, a prostaglandin which stimulates the
uterus, is contraindicated because it causes
abortion.
 ANTI-EPILEPTICS
Epilepsy in pregnancy can lead to fetal and
maternal morbidity/mortality through
convulsions, whilst all of the anticonvulsants used
have been associated with teratogenic effects
(e.g. phenytoin is associated with cleft palate
and congenital heart disease). However, there is
no doubt that the benefits of good seizure control
outweigh the drug-induced teratogenic risk.
Thorough explanation to the mother, ideally
before a planned pregnancy, is essential, and it
must be emphasized that the majority (90%) of
epileptic mothers have normal babies.
 ANTI-EPILEPTICS
(The usual risk of fetal malformation is 23% and
in epileptic mothers it is up to 10%.)
In view of the association of spina bifida with
many anti-epileptics, e.g. sodium valproate and
carbamazepine therapy, it is often recommended
that the standard dose of folic acid should be
increased to 5 mg daily. Both of these anti-
epileptics can also cause hypospadias. As in non-
pregnant epilepsy, single-drug therapy is
preferable.
 ANTI-EPILEPTICS
Plasma concentration monitoring is particularly
relevant for phenytoin, because the decrease in
plasma protein binding and the increase in hepatic
metabolism may cause considerable changes in the
plasma concentration of free (active) drug. As
always, the guide to the correct dose is freedom
from fits and absence of toxicity. The routine
injection of vitamin K recommended at birth
counteracts the possible effect of some anti-
epileptics on vitamin K-dependent clotting factors.
Magnesium sulphate is the treatment of choice for
the prevention and control of eclamptic seizures.
 ANTICOAGULATION
Warfarin has been associated with nasal
hypoplasia and chondrodysplasia when given in
the first trimester, and with CNS abnormalities
after administration in later pregnancy, as well as
a high incidence of haemorrhagic complications
towards the end of pregnancy. Neonatal
haemorrhage is difficult to prevent because of
the immature enzymes in fetal liver and the low
stores of vitamin K. It is not rcommended for use
in pregnancy unless there are no other options.
 ANTICOAGULATION
Low molecular weight heparin (LMWH), which
does not cross the placenta, is the anticoagulant
of choice in pregnancy in preference to
unfractionated heparin. LMWH has predictable
pharmacokinetics and is safer unlike
unfractionated heparin there has never been a
case of heparin-induced thrombocytopenia /
thrombosis (HITT) associated with it in pregnancy.
 CARDIOVASCULAR DRUGS
Hypertension in pregnancy can normally be managed
with either methyldopa which has the most extensive
safety record in pregnancy, or labetalol.
Diuretics should not be started to treat hypertension
in pregnancy, although some American authorities
continue thiazide diuretics in women with essential
hypertension, who are already stabilized on these
drugs.
Modified-release preparations of nifedipine are also
used for hypertension in pregnancy, but angiotensin-
converting enzyme inhibitors and angiotensin II
receptor antagonists must be avoided.
 HORMONES
Progestogens, particularly synthetic ones, can
masculinize the female fetus. There is no evidence that
this occurs with the small amount of progestogen (or
oestrogen) present in the oral contraceptive the risk
applies to large doses. Corticosteroids do not appear to
give rise to any serious problems when given via
inhalation or in short courses. Transient suppression of
the fetal hypothalamicpituitaryadrenal axis has been
reported. Rarely, cleft palate and congenital cataract
have been linked with steroids in pregnancy, but the
benefit of treatment usually outweighs any such risk.
Iodine and antithyroid drugs cross the placenta and can
cause hypothyroidism and goitre.
 TRANQUILLIZERS AND
ANTIDEPRESSANTS
Benzodiazepines accumulate in the tissues and
are slowly eliminated by the neonate, resulting in
prolonged hypotonia (floppy baby), subnormal
temperatures (hypothermia), periodic cessation
of respiration and poor sucking. There is no
evidence that the phenothiazines, tricyclic
antidepressants or fluoxetine are teratogenic.
Lithium can cause fetal goitre and possible
cardiovascular abnormalities.
 KEHAMILAN DAN PERSALINAN
NORMAL
A.KEHAMILAN NORMAL
Peresepan obat saat ANC : preparat besi, asam
folat, vitamin dan mineral lainnya.
IRON AND FOLIC ACID THERAPY
IN PREGNANCY
 IRON REPLACEMENT THERAPY
Ferrous iron is best absorbed from the small
intestine.
Iron deficiency is the most common cause of
anaemia (e.g. malabsorption, menstrual, occult or
gastrointestinal blood loss always determine the
cause).
For iron deficiency, 100200 mg of elemental iron
are given orally per day and continued until iron
stores are replete, usually within three to six months.
 FOLIC ACID
Folic acid is given to correct or prevent deficiency states
and prophylactically during pregnancy.
Folate deficiency may be due to : poor nutrition in
children, the elderly or those with alcoholism;
malabsorption; excessive utilization in pregnancy,
chronic haemolytic anaemias (e.g. sickle cell disease)
and leukaemias; anti-epileptic drugs (e.g. phenytoin).
The normal requirement for folic acid is about 200 g
daily.
 VITAMIN B12
Vitamin B12 is needed for normal erythropoiesis and
for neuronal integrity. Vitamin B12 is also involved in
the control of folate metabolism, and B12 and folate
are required for intracellular nucleoside synthesis.
Deficiency of vitamin B12 traps folate as methylene
tetrahydrofolate, yielding a macrocytic anaemia with
megaloblastic erythropoiesis in the bone marrow, and
possible neurological dysfunction, i.e. peripheral
neuropathy, subacute combined degeneration of the
spinal cord, dementia and optic neuritis.
 KEY POINTS
VITAMIN B12 AND FOLATE THERAPY
Healthy subjects require 35 g of vitamin B12 and 200
g of folate daily.
Vitamin B12 and folate are absorbed from the small
intestine, and vitamin B12 is specifically absorbed from
the terminal ileum.
The most common cause of B12 or folate deficiency is
dietary or malabsorption, or due to gastric surgery.
Drugs may cause vitamin B12 (e.g. metformin) or folate
(e.g. phenytoin, other anti-epileptic drugs) deficiency.
 Folic acid 400g tab No. XIV
S 1 dd 1

R/ Vitamin B12 1000 mcg tab No. XIV

S 1 dd 1

R/ Sulfas ferosus 300mg tab No. XLV

S 3 dd 1
 KEHAMILAN DAN PERSALINAN
NORMAL
B. PERSALINAN NORMAL
Peresepan obat saat persalinan normal : oksitosin
10 unit intra muskular.
Oxytocin 10 U amp No. I
Spuit disposible 3cc No. I
S imm
 PRE EKLAMPSI DAN EKLAMPSI
Pre-eklampsia dibagi dalam golongan ringan dan berat.
Penyakit digolongkan berat bila ditemukan satu atau lebih
tanda / gejala di bawah ini :
Tekanan sistolik 160 mmHg atau tekanan diastolik 110
mmHg.
Proteinuria 5 g dalam 24 jam atau +3 atau +4 pada
pemeriksaan kualitatif.
Oliguria (produksi urin 400ml dalam 24 jam) ~ min 0,5
cc/kgBB/jam.
Keluhan serebral, gangguan penglihatan atau nyeri di
epigastrium.
Edema paru paru atau sianosis.
Eklampsi = pre eklampsi + kejang
TATALAKSANA PREEKLAMPSI RINGAN
Bed rest
Pemberian phenobarbital 3x30 mg sehari
menenangkan dan dapat menurunkan
tekanan darah
Phenobarbital 30mg tab No. XV
S 3 dd 1
 TATALAKSANA PREEKLAMPSI BERAT
Pemberian sedativa kuat untuk mencegah timbulnya
kejang.
Setelah kondisi akut teratasi > 12 24 jam
pertimbangkan untuk terminasi kehamilan.
Phenobarbital 3 x 30 mg sehari menenangkan dan
dapat menurunkan tekanan darah.
Pencegahan kejang dosis awal : larutan sulfas
magnesikus 40% sebanyak (4 gr) i.m diberikan ke
bokong kanan dan kiri diulang 4 gr tiap 6 jam
tergantung kondisi pasien. Syarat : diuresis baik,
reflek patella (+), RR 16x/menit.
 TATALAKSANA EKLAMPSI
Tujuan : menghentikan berulangnya serangan kejang dan
mengakhiri kehamilan secepatnya dengan cara yang
aman.
Sulfas magnesikus vasodilatasi, menurunkan tekanan
darah, meningkatkan diuresis dan menambah aliran
darah ke uterus.
Dosis awal : larutan sulfas magnesikus 40% sebanyak (8
gr) i.m diberikan ke bokong kanan dan kiri diulang 4 gr
tiap 6 jam tergantung kondisi pasien. Syarat : diuresis
baik (> 600 ml/hari), reflek patella (+), RR 16x/menit.
Dosis awal : 4 gram MgSO4 40% dilarutkan dalam 10 ml
aquabidest secara iv perlahan.
MgSO4 40% vial No. I
Aquabidestilata steril 25cc No. I
Spuit disposible 25cc No. I
Needle disposible 23G No. I
S imm
 SALPHINGITIS
Merupakan salah satu Pelvic Inflammatory Disease
(PID).
Agen penyebab
Agen patologis : Neisseria gonorrhoeae,
Chlamydia trachomatis, Mycoplasma genitalium
dan bakteri anaerob lainnya.
Flora normal vagina : streptococci, staphylococci,
E. coli, H. Influenzae.
 SALPHINGITIS
Signs and symptoms :
Lower abdominal pain usually bilateral
Deep dyspareunia
Abnormal bleeding intermenstrual bleeding,
post cotal bleeding, menorrhagia
Abnormal vaginal / servical discharge
Lower abdominal tenderness
Adnexal tenderness on bimanual vagina
examination
Fever (>38oC)
 SALPHINGITIS
Therapy
Broad spectrum antibiotic
Azithromycin and moxifloxacin effective against M.
genitalium
Outpatient regimens :
Ceftriaxone 500 mg i.m. single dose or (i.m. cefoxitin 2 g
single dose with oral probenecid 1 g) followed by oral
doxycycline 100 mg twice daily + metronidazole 400 mg
twice daily for 14 days, OR
Oral ofloxacin 400 mg twice daily + oral metronidazole
500 mg twice daily for 14 days, ofloxacin may be replaced
by levofloxacin 500 mg once daily.
 SALPHINGITIS
Inpatient regimens :
Cefoxitin 2 g i.v. four times daily (or i.v. cefotetan 2 g twice
daily or i.v./i.m. ceftriaxone 1 g once daily) + doxycycline
100 mg i.v. twice daily (oral doxycycline may be used if
tolerated), followed by oral doxycycline 100 mg twice
daily plus oral metronidazole 400 mg twice daily to
complete 14 days, OR
Clindamycin 900 mg three times daily plus i.v. gentamicin
(2 mg/kg loading dose followed by 1.5 mg/kg three times
daily [a single daily dose may be substituted]), followed
by either (oral clindamycin 450 mg four times daily to
complete 14 days) or (oral doxycycline 100 mg twice daily
+ oral metronidazole 400 mg twice daily to complete 14
days).
 Ceftriaxon 1g vial No. I
S imm

R/ Doksisiklin 100mg caps No. XXVIII

S 2 dd 1

R/ Metronidazole 400mg tab No. XXVIII

S 2 dd 1
 VULVO-VAGINITIS
CAUSES : INFECTIONS
YEAST INFECTION are one of the most common causes of
vulvovaginitis in women. Yeast infections are most often due
to the fungus Candida albicans. Yeast infections typically
cause genital itching, a thick white vaginal discharge, and
other symptoms.
The vagina normally contains both healthy bacteria and
unhealthy bacteria. Bacterial vaginosis (BV) occurs when
more unhealthy bacteria than healthy bacteria grow. BV may
cause a thin, grey vaginal discharge and a fishy odor.
A less common type of vaginitis is spread by sexual contact.
It is called TRICHOMONIAS. Symptoms in women include
genital itching, vaginal odor, and a heavy vaginal discharge
that may be yellow-grey or green in color.
 VULVO-VAGINITIS
TREATMENT
Creams or suppositories are used to treat yeast
infections in the vagina.
The treatment of BV or trichomoniasis :
Antibiotic
Suppositoria antibiotic creams
Other medicines that may help include:
cortisone cream and antihistamine pills to help
with itching
 DRUG OF CHOICE FOR CANDIDOSIS
VAGINA
Clotrimazole : 100 mg tablets administered
intravaginally for seven days.
Terconazole 0.8 percent cream : one full
applicator (5 g) administered intravaginally for
three days.
Fluconazole : 150 mg administered orally (one
dose)
Ketoconazole : 200 mg administered orally once
daily for 14 days or 400 mg administered orally
once daily for 14 days.
Nystatin : 1 juta unit intavaginally for 14 days.
 ABORTUS
Abortus Imminens : ppv pada kehamilan < 20 minggu, hasil
konsepsi masih dalam uterus, dilatasi serviks (-) bed rest +
progesteron (allylestrenol 3x5 mg selama 7 hari).
Abortus Spontan Inkomplit : pengeluaran sebagian hasil
konsepsi pada kehamilan < 20 minggu, kanalis servikalis
terbuka, jaringan konsepsi dapat diraba dalam cavum uteri /
menonjol dari OUE, perdarahan >> dan ancaman syok
infus cairan NaCl fisiologis / RL, metil ergometrin intra
muskular .
Abortus Spontan Komplit : semua hasil konsepsi sudah
dikeluarkan, perdarahan <<, OUE telah menutup, uterus
mengecil. Apabila terjadi anemia sulfas ferosus /
transfusi.
Allystrenol 5mg tab No. XXI
S 3 dd 1
 Pemberian Agen Uterotonik
Agen uterotonik yang umum digunakan ada 3 kelompok :
oksitosin, alkaloid ergot, prostaglandin.
Oksitosin merangsang otot polos uterus untuk
berkontraksi lebih kuat pada akhir kehamilan, saat
persalinan, dan pada masa nifas (reseptor oksitosin di
miometrium meningkat). Bekerja cepat dengan masa
laten di bawah 1 menit setelah injeksi iv dan 2 4 menit
setelah injeksi im. Pemberian secara infus kontinu
memberikan respon cepat terhadap uterus secara
perlahan dan mencapai kondisi stabil dalam 20 40
menit.
Dosis & sediaan : 10 unit iv atau im uterotonik
profilaksis rekomendasi WHO.
 Pemberian Agen Uterotonik

Alkaloid ergot (metil ergometrine dan metil

ergonovine) im atau iv ESO peningkatan
tekanan darah, nyeri. Dosis & sediaan metil
ergometrine 0,2 mg im.
Prostaglandin relaksasi otot serviks dan
meningkatkan kalsium intraselular sehingga
memfasilitasi kontraksi miometrium. Analog
sintetik PGE1 alamiah = misoprostol, dosis 600
g per oral, sediaan 200 g.
 HIPEREMESIS GRAVIDARUM
Perasaan mual dan muntah disebabkan oleh karena
meningkatnya kadar hormon estrogen dan HCG dalam
serum.
Penatalaksanaan :
Isolasi : kamar yang tenang
Terapi psikologik
Cairan parenteral
Obat obatan : tidak memberikan obat yang
teratogen. Sedativa : phenobarbital. Vitamin : B1 dan
B6. Antihistamin : dimenhidrinate 50 mg. Preparat
lain : pyrathiazine. Antivomitas : metoclopramid 10
mg, ondancetron 4 mg.
 Anvomer B6 tab No. X
S 1 dd 1 prn

ATAU

R/ Vit amin B6 10mg tab No. XX

S 3 dd 1 prn
Ondancetron 4mg amp No. I
Ringer lactate inf flab No. I
Spuit disposible 3cc No. I
Abbocath no. 20 No. I
Cum infus set No. I
S imm
 PARTUS LAMA
Misoprostol Oksitosin 5 unit dalam 500 cc RL (8
25 g tpm) naikkan 4 tpm per 30 menit
Tunggu sampai his adekuat (maksimal 20 tpm)
6 jam
Gagal

Terminasi Komplikasi : fetal

Tanpa komplikasi
kehamilan distress, hipertonus,
ruptur uteri
Oksitosin 5 unit dalam 500 cc
RL (20tpm) sampai habis

Gagal

Istirahat / jeda 1 x 24 jam

(evaluasi kesejahteraan janin)
Oxytocin 10 U amp No. I
Ringer lactate inf flab No. I
Spuit disposible 3cc No. I
Abbocath no. 20 No. I
Cum infus set No. I
S imm
 KONSELING KB

Pil
AKDR
Suntik
Implant
Depogeston vial No. I
Spuit disposible 3cc No. I
Needle disposible no. 23 No. I
S imm
Andalan pil KB No. I
S 1 dd 1 nocte
 TERIMA KASIH
SELAMAT BELAJAR