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    Case Ikterus Neonatorum

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    Hans Natanael
    This document describes a case study of neonatal jaundice in a 9 day old female infant. It includes information about the patient's history, examination findings, lab results, diagnosis of physiological neonatal jaundice, and treatment with phototherapy. The study aims to compare the efficacy of phototherapy at 20cm versus 40cm distance from the light source.

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    Case Ikterus Neonatorum

    Uploaded by

    Hans Natanael
    26 views40 pages
    This document describes a case study of neonatal jaundice in a 9 day old female infant. It includes information about the patient's history, examination findings, lab results, diagnosis of physiological neonatal jaundice, and treatment with phototherapy. The study aims to compare the efficacy of phototherapy at 20cm versus 40cm distance from the light source.

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    This document describes a case study of neonatal jaundice in a 9 day old female infant. It includes information about the patient's history, examination findings, lab results, diagnosis of physiological neonatal jaundice, and treatment with phototherapy. The study aims to compare the efficacy of phototherapy at 20cm versus 40cm distance from the light source.

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    26 views40 pages

    Case Ikterus Neonatorum

    Uploaded by

    Hans Natanael
    This document describes a case study of neonatal jaundice in a 9 day old female infant. It includes information about the patient's history, examination findings, lab results, diagnosis of physiological neonatal jaundice, and treatment with phototherapy. The study aims to compare the efficacy of phototherapy at 20cm versus 40cm distance from the light source.

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    CASE

    ICTERUS NEONATORUM
    Theresia Bintang - 1015157

    Pembimbing : dr. Erma Charlotte

    SMF Ilmu Kesehatan Anak - RS Immanuel


    Fakultas Kedokteran
    Universitas Kristen Maranatha
    Bandung
    2015
    Identitas Pasien
    Perempua
    Bayi S n

    0 bulan (9
    01.187.661
    hari)

    Datang dengan Tanggal dirawat


    rujukan dari :
    dr. Christianus W. H. :
    MSi. Med. Sp.A 5 Februari 2015

    Tanggal
    diperiksa :
    7 Februari 2015
    Identitas Orang Tua
    Ayah Ibu

    Nama Tn. R Ny. C

    Umur 23 tahun 20 tahun

    Pendidikan SMA SMA

    Pekerjaan Karyawan Swasta IRT

    Alamat Jl. Bojongloa No.69 Kelurahan Panjunan


    Kecamatan Astana Anyar, Bandung
    Anamnesis
    Neonatal jaundice is one of the most
    common problems in newborns.

    The bilirubin level in all newborn infants, term or


    premature, increases in the few days after birth.

    Hyperbilirubinemia can progress to complications such


    as encephalopathy (kernicterus) -> RARE.
    Anamnesis
    Phototherapy has remained the standard of care for
    hyperbilirubinemia treatment of infants for four
    decades.
    Efficient phototherapy rapidly reduces serum bilirubin
    concentration.

    The efficacy of phototherapy is influenced by the


    following factors: the wavelength delivered, the
    irradiance of the phototherapy, and the infant surface
    area exposed to phototherapy. Placing the light source
    closer to the infant may increase the irradiance of
    overhead phototherapy systems.
    Riwayat kehamilan dan persalinan :
    Jaundice is the visible manifestation of elevated serum
    concentrations of bilirubin in the skin and sclera.
    Jaundice is visible when the serum bilirubin level
    reaches 5 – 7 mg/dL.

    Ten percent of term infants and 25% of near-term


    infants have significant hyperbilirubinemia
    requiring phototherapy
    Susunan Keluarga

    Hubungan keluarga,
    No Nama Umur L/P
    sehat, sakit, meninggal
    1. Tn. R 23 th L Ayah (sehat)

    2. Ny. C 20 th P Ibu (sehat)

    3. By. S 9 hari L Anak 1 (pasien)


    Imunisasi

    Imunisasi Dasar : Hep B usia 0 hari


    • This randomized, open-label, controlled trial
    was conducted between August 2009 and
    March 2010 at H. Adam Malik and Pirngadi
    Hospitals, Medan, North Sumatera, Indonesia.
    Pemeriksaan Fisik
    Term newborns with total serum bilirubin levels above 10 mg/dL
    and preterm newborns with total serum bilirubin level above 12
    mg/dL, who presented with neonatal jaundice in the first week of
    life were eligible for the study.

    Multiple congenital anomalies, birth weight below 1000 grams,


    direct hyperbilirubinemia, term newborns with serum bilirubin
    level ≥25 mg/dL and preterm newborns with serum bilirubin level
    ≥17 mg/dL.
    Participants were randomly assigned to receive
    phototherapy at either a 20 cm distance or a 40 cm
    distance.

    The phototherapy units were manufactured by Tessna,


    USA (Tessna phototherapy unit with five compact blue
    fluorescent lamps) with wavelength 452-475 nm.

    All infants who received phototherapy were placed in


    bassinets. Infants wore only diapers and eye patches
    during phototherapy.

    Both methods -> assessed and compared by monitoring


    subejcts’ body temperature, hydration status, skin
    problems and gastrointestinal problems.
    Phototherapy was stopped if we found dehydration,
    hyperthermia, lethargy, irritability or serum bilirubin
    level decreased more than 2 mg/dL compared to the
    serum bilirubin level limit for phototherapy.

    Total serum bilirubin level and light intensity were


    measured at baseline, as well as after 12 hours and 24
    hours of phototherapy. Light intensity was measured as
    spectral irradiance (μW/cm2/nm) using a light intensity
    meter (Dale 40, USA).

    The minimum sample size required was estimated to be 30


    newborns for each group. The significance level was accepted as
    P<0.05 with a 95% confidence interval (95% CI). Numerical
    variables were compared using ANOVA. Independent t-test was
    used to compare the reductions in total serum bilirubin levels.
    Abdomen :
    Inspeksi: Datar, warna kulit kuning
    Auskultasi : Bising usus (+)
    Palpasi : Soepel, Hepar dan lien tidak teraba membesar.
    Perkusi : Timpani

    Genital : Perempuan, tidak ada kelainan


    Anus dan rectum : Anus tidak ada kelainan, rektum tidak diperiksa
    Anggota gerak/ekstremitas: Akral hangat, capillary refill < 2 detik
    Pemeriksaan Penunjang

    Tanggal Bilirubin Total Bilirubin Indirek Bilirubin Direk

    5 Februari 2015 15,42 mg/dL 14,22 mg/dL 1,2 mg/dL

    6 Februari 2015 12, 6 mg/dl 12,1 mg/dl 0,5 mg/dl

    7 Februari 2015 9,09 mg/dl 8,68 mg/dl 0,41 mg/dl


    Resume
    Total serum bilirubin at 12 hours and 24 hours were significantly
    different between the groups (P=0.001). On both follow-up time
    points, we found lower serum bilirubin levels in the 20 cm distance
    phototherapy group.

    The decreases in total serum bilirubin levels At follow-up were greater


    in the 20 cm group than in the 40 cm group, at both 12 and 24 hours
    (P=0.001). In the 20 cm distance phototherapy group.

    In this study, the light intensity was 13-14 μW/cm2/nm for


    the 20 cm group and 6-7 μW/cm2/nm for the 40 cm group.
    Pemeriksaan Fisik
    Keadaan umum
    Kesadaran : Compos Mentis (E = 4, M=6, V=5), Kramer III
    Keadaan sakit : Sedang
    Posisi : Tidak terdapat letak paksa

    Tanda vital
    Nadi : 120x / menit , regular, equal, isi cukup
    Respirasi: 40x / menit , abdominothorakal
    Suhu : 36,4C ( aksiler )

    Pengukuran
    Umur : 0 bulan (9 hari) Berat Badan : 2300 gram Panjang Badan: 47cm
    Lingkar kepala : 33 cm Lingkar dada : 35 cm Lingkar perut : 34 cm
    Lingkar lengan atas : 7 cm
    Kulit : Ikterik (+), pucat (-), sianosis (-),

    Kepala : Bentuk simetris, ubun-ubun


    lembut, sutura belum menutup.
    Mata : Konjungtiva anemis -/-, sklera
    ikterik +/+

    THT: Dalam batas normal

    Mulut : POC -. Langit-langit intak, Frenulum


    lingua ikterik
    Leher : Warna kulit kuning, KGB tidak
    teraba membesar
    Thorax : Warna kulit kuning
    Paru-paru : dbn
    Jantung : dbn

    Abdomen : Warna kulit kuning, lain-lain dbn


    Genital : perempuan, tak
    Anus dan rectum : anus tak, rektum tidak diperiksa
    Anggota gerak/ekstremitas: akral hangat, capillary refill < 2 detik,
    Pemeriksaan Penunjang

    Tanggal Bilirubin Total Bilirubin Indirek Bilirubin Direk

    5 Februari 2015 15,42 mg/dL 14,22 mg/dL 1,2 mg/dL

    6 Februari 2015 12, 6 mg/dl 12,1 mg/dl 0,5 mg/dl

    7 Februari 2015 9,09 mg/dl 8,68 mg/dl 0,41 mg/dl


    Diagnosis Kerja

    Icterus Neonatorum
    Usul Pemeriksaan
    ●
    Hematologi Rutin -> SADT, hitung jenis
    ●
    Kimia Darah  SGOT, SGPT, Bilirubin Total, Direk, Indirek

    ●
    Urinalisis rutin

    ●
    Golongan darah Ibu dan rhesus

    ●
    Enzim G6PD
    Penatalaksanaan
    Multiple phototherapy units and the use of reflecting curtains in
    phototherapy are used to increase the light intensity and thus
    improve the efficacy of phototherapy.

    Blue light phototherapy units -> wavelength 452-475 nm.

    We observed no side effects of phototherapy in our subjects at a


    20 cm distance from the light source.
    Prognosis

    Jaundice is observed during the first week of life in


    approximately 60% of term infants and 80% of
    preterm infants.

    In this study, phototherapy as a treatment to


    reduce total serum bilirubin in neonatal jaundice
    patients.

    Phototherapy -> noninvasive and safety.


    Icterus Neonatorum
    Icterus adalah perubahan warna kulit, sklera mata atau
    jaringan lainnya (membran mukosa) yang menjadi
    kuning akibat akumulasi / peningkatan kadar
    bilirubin.
    Ikterus neonatorum adalah keadaan klinis pada bayi
    yang ditandai oleh ikterus pada kulit dan sklera akibat
    akumulasi bilirubin tak terkonjugasi yang berlebih.
    Ikterus secara klinis akan mulai tampak pada bayi baru
    lahir bila kadar bilirubin darah 5-7 mg/dl.
    Etiologi

    Unconjug
    ated Fisiologis
    ●

    ●
    Anemia hemolitik
    ●
    Polisitemia
    ●
    Adanya darah pada jaringan /ekstravaskuler

    hyperbilir Gangguan dari proses konjugasi


    ●

    ●
    Breast feeding dan breast milk jaundice
    ●
    Kelainan metabolik : hipotiroid
    ●
    Peningkatan sirkulasi enterohepatik

    ubinemia Kelainan dan obat – obatan yang mengganggu


    ●

    ikatan bilirubin terhadap albumin

    :
    Etiologi

    Conjugat
    ed Penyakit bilier ekstra hepatik:
    ●

    obstruksi bilier bisa karena adanya


    batu

    hyperbilir Penyakit intra hepatik / kerusakan


    ●

    parenkim hepar : infeksi virus, obat


    –obatan

    ubinemia Keadaan tertentu seperti syok


    ●

    hipovolemik

    :
    Klasifikasi
    – Icterus neonatorum fisiologis
    • Pada setiap bayi baru lahir , terutama bayi prematur,
    akan terjadi peningkatan kadar bilirubin indirek
    dalam serum secara fisiologis , timbul dalam minggu
    pertama.
    • Icterus timbul pada hari ke 2 – 5, kemudian
    menurun, dan menghilang pada hari ke 7 – 10
    • Kadar bil. Unconjugated : 6 – 10 mg/dL
    – Icterus neonatorum patologis
    • Ikterus timbul pada 24 jam pertama
    • Peningkatan kadar bilirubin serum > 5
    mg/dL/hari
    • Bilirubin total serum mencapai > 12 mg/dL
    (Bil total > 17 mg/dL pada bayi yang mendapat ASI)
    • Kadar bilirubin direk > 2mg/dL
    • Ikterus menetap sesudah 8 hari pada BCB, dan
    14 hari pada BKB
    – Pada bayi baru lahir karena fungsi hepar belum matang atau
    bila terdapat gangguan dalam fungsi hepar akibat hipoksia,
    asidosis atau bila terdapat kekurangan enzim glukoronil
    transferase atau kekurangan glukosa, kadar bilirubin indirek
    dalam darah dapat meninggi.
    – Bilirubin indirek yang terikat pada albumin sangat tergantung
    pada kadar albumin dalam serum.
    – Pada bayi kurang bulan biasanya kadar albuminnya rendah
    sehingga dapat dimengerti bila kadar bilirubin indirek yang
    bebas itu dapat meningkat dan sangat berbahaya karena
    bilirubin indirek yang bebas inilah yang dapat melewati BBB.
    • Gilbert’s Syndrome : Defek yang kompleks
    dalam proses pengambilan bilirubin dari
    plasma, sehingga menyebabkan kenaikan
    Bilirubin unconjugated. Dapat dengan mudah
    dibedakan dengan hepatitis, yaitu tes faal hati
    normal, tidak terdapat empedu dalam urine,
    dan fraksi bilirubin indirek yang dominan.
    • Crigler-Najjar Syndrome : Adanya keadaan
    defisiensi enzim glukoronil transferase, sehingga
    konjugasi terganggu. Ada dua tipe yaitu tipe 1
    (komplit) ditandai hiperbilirubinemia yang berat
    dan tipe 2 (inkomplit) ditandai dengan
    hiperbilirubinemia yang kurang berat.
    • Dubin –Johnson Syndrome dan Rotor Syndrome
    : terjadi gangguan transfer dan ekskresi bilirubin
    konjugasi ke saluran bilier
    Penatalaksanaan
    • Fototerapi
    • Transfusi tukar
    Berat Badan (g) Terapi
    <1000 Fototerapi
    Transfusi ganti pada kadar bilirubin 10-12
    mg/dL
    1000-1500 Fototerapi pada kadar 7-9 mg/Dl
    Transfusi ganti pada kadar 12-15 mg/dL
    1500-2000 Fototerapi pada kadar 10-12 mg/dL
    Transfusi ganti pada kadar 15-18 mg/dL
    2000-2500 Fototerapi pada kadar 13-15 mg/dL
    Transfusi ganti pada kadar 18-20 mg/dL
    >2500 dan bayi dalam keadaan sakit Fototerapi pada kadar 12-15 mg/dL
    Transfusi ganti pada kadar 18-20 mg/dL

    Indikasi Fototerapi dan Transfusi Ganti


    Berdasarkan Berat Badan
    Transfusi Ganti

    Berat Lahir (g)


    Bayi
    <1.250 1.250-1.499 1.500-1.999 2.000-2.499 >2.500

    Sehat 13 15 17 18 20
    Risiko 10 13 15 17 18
    Komplikasi
    Kern ikterus (Encephalopathy)

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