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OBSTETRICAL HEMORRHAGE
Antepartum hemorrhage
Post partum hemorrhage
Abruptio placentae
ANTEPARTUM HEMORRHAGE
Placenta Previa
Abruptio placentae
PLACENTA PREVIA :
DEFINITION :
Placenta is located over or very near the internal os Prae : Front Vias : Route
VASA PREVIA :
The fetal vessels course through membranes and present at the cervical os
Uncommon cause of antepartum hemorrhage, associated with a high rate or fetal death
cervix
Dilatation
Bleeding Retracted
Amnion
Lower segmen
Lower segmen
Cervix
Bleeding
< 1/2 O
BLEEDING >
Depent in large measure on the cervical dilatation at the time of examination Eg. Low lying placenta at 2 cm dilatation may become a partial placenta previa at 8 cm dilatation because the dilating cervix has uncovered placenta
PREDISPOSISING FACTOR :
CLINICAL FINDINGS :
Hemorrhage :
Frequent Usually does not appear until near the end of the second trimester or after
Painless
Spontaneously
Initial bleeding is rarely profuse as to prove fatal
CLINICAL FINDINGS :
Lacunae
Maternal vessels
HAFT ZOTE
Fetal vessels
DIAGNOSIS :
Speculum
Fornix palpation Double set up examination at the operating room USG
WARNING :
Digital palpation to try to ascertain changing relations between the edge of the placenta and the internal os as the cervix dilates can incite severe hemorrhage
Examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean section
MANAGEMENT :
Active : Termination Vaginally CS Expectative : Depend on maturity (< 37 weeks ; < 2500 gr) Bleeding Maternal condition
VAGINAL DELIVERY :
Amniotomy tamponade
Braxton Hicks version Cunam Willet
Placenta
Amnion Cervix
In tact
Amnion (+)
Head Breech
CUNAM-WILLETT
PLACENTAL ABRUPTION :
DEFINITION :
The separation of the placenta from its site of implantation before the delivery of the fetus after 22 weeks of pregnancy
SINONYM :
Solutio placentae
Ablatio placentae
PATHOLOGY
Hemorrhage into the decidua basalis Decidua then splits, leaving a thin layer adherent to the myometrium Decidual hematoma
TYPE :
Concealed hemorrhage separated completelly freq 20% fatal External hemorrhage incomplete freq 80%
CONCEALED HEMORRHAGE
EXTERNAL HEMORRHAGE
COMBINED
ETIOLOGY :
Hipertension Trauma Multiparity Folic acid deficiency Hidramnion ; gemelly Umbilical cord - short
CLINICAL DIAGNOSIS :
Uterine hypertonus
Anemi shock
Amnion bulging
COMPLICATION :
MANAGEMENT :
Transfusion
Electrolyte solution
Corticosteroids Fibrinogen
OBSTETRIC MANAGEMENT :
Amniotomi Oxytocin infusion Cesarean section : Fetus alive Cervix not dilated 2 hours after oxytocin infusion uterine contraction (-)
Pemecahan ketuban
Ketuban
SBR
Syarat : Derajat luasnya penutupan ostium oleh plasenta Letak plasenta Presentasi anak
SOLUSIO PLASENTA
DEFINISI :
Pelepasan sebagian atau seluruh plasenta yang normal implantasinya antara minggu ke-22 - lahirnya anak
Implantasi plasenta dan mekanisme terjadinya perdarahan pada plasenta letak rendah / plasenta previa
NAMA LAIN :
Darah yg berasal dari solusio plasenta mengalir antara selaput janin & dinding rahim dan akhirnya ke luar perdarahan ke luar Bila darah tidak ke luar tetapi berkumpul di belakang plasenta disebut Haematom Retroplacentair Darah masuk ruang amnion Solusio dengan perdarahan tersembunyi memberikan ciri khas
Perdarahan tersembunyi lebih berbahaya dibandingkan solusio plasenta dengan perdarahan ke luar
Dengan perdarahan tersembunyi
Pelepasan biasanya komplit Hanya merupakan 20% dari solusio plasenta
ETIOLOGI :
Sebab primer belum jelas, tetapi diduga disebabkan oleh :
Hipertensi
esensial atau preeklamsi Tali pusat yang pendek Trauma Tekanan oleh rahim pd vena cava inferior Uterus yg sangat mengecil (hidramnion, gemelli) Umur lanjut Multipara Defisiensi asam folat
GEJALA :
Perdarahan
disertai nyeri, juga di luar his Beratnya anemi tdk sesuai dg banyaknya darah yg ke luar Rahim keras Palpasi sukar Fundus uteri makin lama makin naik BJA biasanya tidak ada Pada toucher, ketuban tegang terus menerus Sering proteinuria karena disertai toksemia
Setelah
DIFFERENSIAL DIAGNOSIS :
PLASENTA
RUPTURA
PREVIA
UTERI
Plasenta previa
Perd. tanpa nyeri Perd. berulang sblm partus Perd. ke luar banyk Bagian depan tinggi Biasanya teraba jar. plasenta Robekan selaput marginal
TIMBUL SEGERA :
Perdarahan Syok
pembekuan darah, karena Hipofibrinogenemi Uterus couvelaire (Apoplexi utero placentair) Gangguan faal ginjal
HIPOFIBRINOGENEMI
Kadar
< 150 mg% D/ : Clot observation test Fase coagulopati : I. Disseminated intravascular clotting koagulopati konsumtif II. Regulasi reparatif dengan fibrinolisis
PROGNOSIS :
Pada
solusio plasenta yang berat prognosis untuk anak adalah buruk (90%) ibu juga berbahaya, tetapi dengan persediaan darah yang cukup dan pengelolaan yang baik, kematian dapat ditekan
Bagi
PENGOBATAN
I. UMUM : Transfusi darah O2 Antibiotika Pada syok yang berat diberi kortikosteroid dosis tinggi
II. KHUSUS : Thd : - Hipofibrinogenemi - Human hipofibrinoge/darah segar - Trasylol Merangsang diuresis - manitol
III. OBSTETRIK : Akselerasi persalinan < 6 jam
TINDAKAN OBSTETRI
Amniotomi Oksitosin Seksio
drip
sesarea, bila :
Anak hidup
Akreta
perlekatan luas