Tesis

Hubungan Proses Rujukan terhadap Luaran Neonatus pada KetubanPecah Dini pada Kehamilan Preterm di RS. DR. Cipto Mangunkusumo = Correlation between referral process with neonatal outcome in preterm premature ruptured of membrane in Cipto Mangunkusumo hospital .

Latar Belakang : Pelayanan obstetrik yang tepat dalam menangani kehamilan dengan masalah dibutuhkan untuk mencegah mortalitas dan morbiditas pada janin. Mortalitas neonatus secara global terjadi pada 19/1000 kelahiran hidup dengan 35% akibat komplikasi prematuritas dan kejadian ketuban pecah dini preterm terjadi pada 30-40% dari seluruh kasus. Penatalaksanaan kasus ketuban pecah dini pada kehamilan preterm memerlukan ketepatan dalam diagnosis, rujukan, dan intervensi obstetri agar tidak terjadi morbiditas maupun mortalitas pada ibu dan janin. Di RS Cipto Mangunkusumo terdapat 737 persalinan preterm dari 1524 total kelahiran pada tahun 2017. Penelitian ini ingin melihat bagaimana sistem rujukan berlangsung dan apakah sistem rujukan mempunyai hubungan dengan luaran neonatus. Tujuan : Mengetahui hubungan proses rujukan terhadap luaran neonatus pada kasus ketuban pecah dini pada kehamilan preterm. Metode : Penelitian ini menggunakan desain kohort retrospektif di RS Cipto Mangunkusumo pada pasien rujukan ketuban pecah dini preterm pada bulan Januari 2016 hingga September 2017. Data proses rujukan dan luaran neonatus yang memenuhi kriteria inklusi dicatat dan dilakukan analisis statistik. Hasil : Dari pengumpulan data Januari 2016 hingga Juli 2017 di RS Cipto Mangunkusumo didapati 334 kasus ketuban pecah dini preterm dan 214 kasus memenuhi kriteria inklusi. Asal rujukan terutama berasal dari rumah sakit, total 102 kasus (47.66%) dan rujukan dilakukan karena tidak adanya fasilitas NICU pada 36 kasus (35.29%) dan karena fasilitas yang ada tidak mencukupi 66 kasus (64.71%). Pemeriksaan awal sesuai standar terdapat pada 91 kasus (42.52%) dan tidak sesuai pada 123 kasus (57.48%). Pemberian antibiotika pada 161 kasus (75.23%) di tempat rujukan dan 53 kasus (24.77%) tidak diberikan antibiotika. Pemberian kortikosteroid di tempat rujukan dilakukan pada 143 kasus (66.82%) dan tidak dilakukan pada 71 kasus (33.18%). Terdapat 120 (56.06%) neonatus tanpa komplikasi dan 94 neonatus (43.93%) dengan komplikasi. Komplikasi neonatus tersebut adalah korioamnionitis klinis (18.69%), APGAR skor menit 1 < 7(19.16%), APGAR skor menit 5 < 7 (9.8%), RDS (32.34%), sepsis neonatus (37.38%) dan mortalitas dini neonatus (9.8%). Dari analisis bivariat, terdapat hubungan antara asal rujukan dengan APGAR skor menit 1 < 7 (p= 0.002), RDS (p= 0.003), dan sepsis neonatus (p= 0.01). Pemberian kortikosteroid berhubungan dengan APGAR skor menit 1 < 7 (p= 0.003, RR 0.4, CI 95% 0.23 - 0.96), RDS (p= 0.002, RR 0.46, CI 95% 0.27 – 0.79) dan sepsis neonatus (p = 0.001, RR 0.46, CI 95% 0.28 – 0.75). Lama rujukan dan korioamnionitis klinis dengan sepsis neonatus (p= 0.014, RR 1.7, CI 95% 1.2 – 1.26). Setelah dilakukan analisis multivariat, hubungan didapatkan antara asal rujukan dengan APGAR skor menit 1, usia kehamilan dan kortikosteroid dengan RDS, usia kehamilan, lama rujukan, kortikosteroid dan korioamnionitis klinis dengan sepsis neonatus. Kesimpulan : Alur rujukan kasus KPD preterm sudah berlangsung sesuai alur rujukan berjenjang. Terdapat hubungan antara proses rujukan dengan luaran neonatus yaitu asal rujukan dengan APGAR menit 1, pemberian kortikosteroid dengan RDS dan sepsis neonatus, dan lama rujukan dengan sepsis neonatus.
Kata Kunci : Ketuban pecah dini preterm, korioamnionitis, APGAR skor, respiratory distress syndrome, sepsis neonatus, mortalitas neonatus.


Background : Appropiate obstetric care in the management of pregnancy with complication is necessary in order to prevent maternal and neonatal morbidity and mortality. Neonatal mortality rate is 19/1000 live birth worldwide with 35% mortality due to complication of prematurity. Preterm premature ruptured of membrane caused 30 – 40% preterm birth. To prevent neonatal and maternal morbidity and mortality, prompt diagnosis, referral process and obstetric intervention are needed. In Cipto Mangunkusumo hospital, total of peterm birth in 2017 was 737 cases from 1524 total birth. This research was conducted to evaluate correlation between referral process and neonatal outcome. Purpose : To evaluate the correlation between referral process and neonatal ocutcome in preterm premature ruptured of membrane. Method : This research was conducted in Cipto Mangunkusumo hospital on January 2016 to September 2017 with retrospective cohort study. Referral data and neonatal outcomes who fulfilled the inclusion criteria were collected and analyzed. Result : From data collection during January 2016 to July 2017, 334 cases with preterm premature ruptured of membrane and 214 cases fulfilled the inclusion criteria. Patients mostly reffered from hospital (102 cases, 47.66%) and 36 cases (35.29%) were referred due to limited facility and 66 cases (64.71%) due to NICU was full. Appropiate initial examination was found in 91 cases (42.52%) and unappropiate initial examination was found in 123 cases (57.48%). Administration of antibiotic was found in 161 cases (75.23%). There was 143 cases (66.82%) with corticosteroid administration from the first referral provider and 71 cases (33.18%) without corticosteroid administration. Newborn without complication was fount in 120 babies (56.06%) and newborn with complication was fount in 94 babies (43.93%). The complications were clinical chorioamnionitis (18.69%), APGAR score minute 1 < 7 (19.16%), APGAR score minute 5 < 7 (9.8%), RDS (32.34%), neonatal sepsis (37.38%) and early neonatal mortality (9.8%). From bivariate analysis, first care provider has correlation with APGAR score minute 1 < 7 (p = 0.00 1), RDS (p = 0.003), and neonatal sepsis (p = 0.01). Administration of corticosteroid correlated significantly with APGAR score minute 1 < 7 (p = 0.003, RR 0.4, CI 95% 0.23 - 0.96), RDS (p = 0.002, RR 0.46, CI 95% 0.27 – 0.79) and neonatal sepsis (p = 0.001, RR 0.46, CI 95% 0.28 – 0.75). Time of referral correlated significantly with neonatal sepsis (p = 0.014, RR 1.7, CI 95% 1.2 – 1.26). After multivariate analysis was performed, correlation found in: first care provider with APGAR score minute 1, gestational age and corticosteroid administration with RDS, gestational age, length of referral and corticosteroid administration with neonatal sepsis. Conclusion : Referral process in the case of preterm premature ruptured of membrane was already gradually performed by the first care provider. There is correlation between referral process and neonatal outcome in: first care provider with APGAR score minute 1, corticosteroid administration with RDS and neonatal sepsis, referral length with neonatal sepsis.
Keywords : premature ruptured of membrane, preterm birth, APGAR score, respiratory distress syndrome, neonatal sepsis, neonatal mortality, chorioamnionitis.