Asuhan Kebidanan Berkesinambungan pada Ny K Usia 41 Tahun G2P1Ab0Ah1 dengan Kehamilan Risiko Sangat Tinggi (KRST) di Puskesmas Sleman

Angka kematian ibu dan bayi di Indonesia sangat tinggi. Angka kematian tersebut disebabkan oleh adanya komplikasi. Ny K berisiko mengalami komplikasi karena termasuk kedalam kehamilan risiko sangat tinggi. Oleh karena itu, diperlukan pendampingan dan asuhan berkesinambungan, agar komplikasi tidak terjadi. Kehamilan Ny K terdapat kelainan letak plasenta yaitu plasenta previa marginalis yang baru diketahui pada usia kehamilan 37+1 minggu. Hal inilah yang mendasari ibu untuk segera dirujuk ke RSUD Sleman secara tepat waktu. Pada kunjungan kehamilan terakhir hasil pemeriksaan yang diperoleh adalah presentasi normal, telah masuk panggul, dan TBJ 2765 gram. Tanggal 25 Maret 2017 ibu mengalami perdarahan ±90 cc pada usia kehamilan 40+3 minggu. Persalinan dilakukan secara SC atas indikasi plasenta previa marginalis. Bayi lahir dengan berat badan 2850 gram dan keadaan fisik normal. Tidak ada penyulit yang dialami ibu pada masa nifas. Pada awal pengkajian ibu menginginkan KB MOW, akan tetapi pada saat menjelang persalinan ibu mengalami perdarahan akibat plasenta previa marginalis, hal ini menyebabkan ibu harus segera mendapatkan tindakan. Oleh sebab itu dokter melakukan operasi sesar pada saat itu juga. Sehingga tidak terfikirkan oleh ibu untuk berdiskusi dengan dokter agar sekalian MOW. Karena pada saat penulis mengkaji ulang tentang alat kontrasepsi, ibu sudah tidak mau apa bila harus dibedah lagi, maka ibu memutuskan untuk kembali menggunakan KB suntik 3 bulan. Hampir semua asuhan yang dilakukan sesuai dengan teori. Adapun asuhan yang tidak sesuai dengan teori yaitu pada asuhan kehamilan. Hal yang tidak sesuai dengan ANC adalah ibu hamil yang memiliki risiko tinggi tidak diberikan KIE untuk melakukan pemeriksaan USG. Hal ini dinilai kurang efektif untuk pencegahan terjadinya komplikasi pada ibu dan janinnya jika hanya dilakukan pemeriksaan palpasi leopold saja. Sebagian besar asuhan yang diberikan kepada Ny K sudah tepat sehingga tidak terjadi komplikasi. Saran yang diberikan penulis adalah agar bidan dapat menerapkan manajemen asuhan kebidanan yang diberikan pada pasien dengan risiko tinggi, meningkatkan rujukan efektif demi keselamatan pasien, dan menggali informasi yang cukup dari pasien agar dapat melakukan penapisan dengan tepa

Effect of Enhanced Information, Values Clarification, and Removal of Financial Barriers on Use of Prenatal Genetic Testing: A Randomized Clinical Trial

ImportancePrenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood.ObjectiveTo analyze the effect of a decision-support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision making among pregnant women of varying literacy and numeracy levels.Design, setting, and participantsRandomized trial conducted from 2010-2013 at prenatal clinics at 3 county hospitals, 1 community clinic, 1 academic center, and 3 medical centers of an integrated health care delivery system in the San Francisco Bay area. Participants were English- or Spanish-speaking women who had not yet undergone screening or diagnostic testing and remained pregnant at 11 weeks' gestation (n = 710).InterventionsA computerized, interactive decision-support guide and access to prenatal testing with no out-of-pocket expense (n = 357) or usual care as per current guidelines (n = 353).Main outcomes and measuresThe primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge about testing, risk comprehension, and decisional conflict and regret at 24 to 36 weeks' gestation.ResultsWomen randomized to the intervention group, compared with those randomized to the control group, were less likely to have invasive diagnostic testing (5.9% vs 12.3%; odds ratio [OR], 0.45 [95% CI, 0.25-0.80]) and more likely to forgo testing altogether (25.6% vs 20.4%; OR, 3.30 [95% CI, 1.43-7.64], reference group screening followed by invasive testing). Women randomized to the intervention group also had higher knowledge scores (9.4 vs 8.6 on a 15-point scale; mean group difference, 0.82 [95% CI, 0.34-1.31]) and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and their estimated age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs 46.1%; OR, 1.66 [95% CI, 1.22-2.28]). Significant differences did not emerge in decisional conflict or regret.Conclusions and relevanceFull implementation of prenatal testing guidelines using a computerized, interactive decision-support guide in the absence of financial barriers to testing resulted in less test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing.Trial registrationclinicaltrials.gov Identifier: NCT00505596

Rationale and Design of the Randomized Bayesian Multicenter COME-TAVI Trial in Patients With a New Onset Left Bundle Branch Block

Patients with new-onset left bundle branch block (LBBB) after transcatheter aortic valve implantation (TAVI) are at risk of developing delayed high-degree atrioventricular block. Management of new-onset LBBB post-TAVI remains controversial. In the Comparison of a Clinical Monitoring Strategy Versus Electrophysiology-Guided Algorithmic Approach in Patients With a New LBBB After TAVI (COME-TAVI) trial, consenting patients with new-onset LBBB that persists on day 2 after TAVI, meeting exclusion/inclusion criteria, are randomized to an electrophysiological study (EPS)-guided approach or 30-day electrocardiographic monitoring. In the EPS-guided approach, patients with a His to ventricle (HV) interval ≥ 65 ms undergo permanent pacemaker implantation. Patients randomized to noninvasive monitoring receive a wearable continuous electrocardiographic recording and transmitting device for 30 days. Follow-up will be performed at 3, 6, and 12 months. The primary endpoint is a composite outcome designed to capture net clinical benefit. The endpoint incorporates major consequences of both strategies in patients with new-onset LBBB after TAVI, as follows: (i) sudden cardiac death; (ii) syncope; (iii) atrioventricular conduction disorder requiring a pacemaker (for a class I or IIa indication); and (iv) complications related to the pacemaker or EPS. The trial incorporates a Bayesian design with a noninformative prior, outcome-adaptive randomization (initially 1:1), and 2 prespecified interim analyses once 25% and 50% of the anticipated number of primary endpoints are reached. The trial is event-driven, with an anticipated upper limit of 452 patients required to reach 77 primary outcome events over 12 months of follow-up. In summary, the aim of this Bayesian multicentre randomized trial is to compare 2 management strategies in patients with new-onset LBBB post-TAVI—an EPS-guided approach vs noninvasive 30-day monitoring. Trial registration number: NCT03303612. Résumé: Les patients chez qui un bloc de branche gauche (BBG) est récemment apparu à la suite de l’implantation valvulaire aortique par cathéter (IVAC) présentent un risque de bloc auriculoventriculaire de haut degré tardif. La prise en charge d’un BBG récemment apparu après une IVAC demeure controversée. Dans le cadre de l’essai COME-TAVI (Comparison of a Clinical Monitoring Strategy Versus Electrophysiology-Guided Algorithmic Approach in Patients With a New LBBB After TAVI, ou comparaison d’une stratégie de surveillance clinique, par rapport à une approche guidée par étude électrophysiologique et fondée sur un algorithme, chez des patients présentant un BBG d’apparition récente à la suite d’une IVAC), des patients qui présentent un BBG d’apparition récente persistant le 2e jour après une IVAC, qui répondent aux critères d’admissibilité et qui ont donné leur consentement sont répartis aléatoirement pour être suivis à l’aide d’une approche guidée par une étude électrophysiologique (EEP) ou faire l’objet d’une surveillance électrocardiographique d’une durée de 30 jours. Un stimulateur cardiaque est implanté chez les patients du groupe de l’EEP dont l’intervalle HV (temps de conduction dans le tronc du faisceau de His jusqu’aux ventricules) est ≥ 65 ms. Les patients du groupe de surveillance non invasive reçoivent un dispositif portable d’enregistrement et de transmission continue de données électrocardiographiques pour une période de 30 jours. Le suivi sera réalisé aux 3e, 6e et 12e mois. Le critère d’évaluation principal est un paramètre composite conçu afin de saisir le bienfait clinique net. Il comprend les conséquences majeures des deux stratégies chez les patients présentant un BBG d’apparition récente après une IVAC, comme suit : (i) mort subite d’origine cardiaque; (ii) syncope; (iii) trouble de la conduction auriculoventriculaire nécessitant la pose d’un stimulateur cardiaque (pour une indication de classe I ou IIa); et (iv) complications relatives au stimulateur cardiaque ou à l’EEP. L’essai intègre une conception bayésienne avec une répartition aléatoire (dans un rapport initial de 1:1) antérieure non informative adaptée aux résultats et deux analyses intermédiaires définies au préalable lorsque 25 % et 50 % du nombre anticipé des critères d’évaluation principaux seront atteints. L’essai est axé sur les événements, et la limite supérieure anticipée pour atteindre 77 événements relatifs aux critères d’évaluation principaux sur 12 mois de suivi est de 452 patients. En résumé, l’objectif de cet essai bayésien multicentrique à répartition aléatoire est de comparer deux stratégies de prise en charge de patients présentant un BBG d’apparition récente après une IVAC, soit une approche guidée par une EEP, par rapport à une surveillance non invasive de 30 jours. Trial registration number: NCT03303612

Genetic Association Study Of Exfoliation Syndrome Identifies A Protective Rare Variant At Loxl1 And Five New Susceptibility Loci

Exfoliation syndrome (XFS) is the most common known risk factor for secondary glaucoma and a major cause of blindness worldwide. Variants in two genes, LOXL1 and CACNA1A, have previously been associated with XFS. To further elucidate the genetic basis of XFS, we collected a global sample of XFS cases to refine the association at LOXL1, which previously showed inconsistent results across populations, and to identify new variants associated with XFS. We identified a rare protective allele at LOXL1 (p.Phe407, odds ratio (OR) = 25, P = 2.9 x 10(-14)) through deep resequencing of XFS cases and controls from nine countries. A genome-wide association study (GWAS) of XFS cases and controls from 24 countries followed by replication in 18 countries identified seven genome-wide significant loci (P < 5 x 10(-8)). We identified association signals at 13q12 (POMP), 11q23.3 (TMEM136), 6p21 (AGPAT1), 3p24 (RBMS3) and 5q23 (near SEMA6A). These findings provide biological insights into the pathology of XFS and highlight a potential role for naturally occurring rare LOXL1 variants in disease biology.Wo