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9. Sebutkan
3
etiologi
yang
menyebabkan abortus (salah satunya
harus most common etiology)!
10.Salah satu etiologi terjadinya abortus
adalah inkompetensi serviks. 2 tipe
cerclage
procedurs
pada
kasus
tersebut yang paling sering digunakan
adalah...
11.Prune juice discharge adalah ciri khas
pada abortus tipe.....
12.Sebutkan 2 tatalaksana tersering
yang dilakukan pada abortus!
ABORTION
Credits to :
Tamara Ayu Widyasuri
VASKULARISASI
INERVASI
LIGAMENTUM
ALIRAN LIMFE
Menstruasi (Haid)
Ovarium
Fase Follikular
Fase Luteal
Ovulasi
P
Menstruasi
Endometrium
(Uterus)
Fase Proliferatif
Fase Sekretorik
= fase proliferatif
= fase sekretorik
Implantation:
5-7 days after fertilization
Takes ~72 hours
Invasion of trophoblast
into decidua
Embryonic disc:
1 wk post-implantation
If no embryonic disc, trophoblast still
grows, but no embryo (anembryonic
pregnancy)
Embryonic disc
embryonic/fetal pole
Implantation
1 week after ovulation, morula has
descended into uterus and continued to
proliferate and differentiate into blastocyst
which capable to implantation
Blastocyst is consisted of 2 parts: inner cell
mass
(which
become
fetus)
and
trophoblast (outermost layer of blastocyst)
Trophoblast accomplish implantation, after
which develops into fetal portion of placenta
When blastocyst is ready to implant, its surface
becomes sticky, by the time endometrium is
ready to accept the early embryo
First Trimester
Bleeding Causes
1-Spontaneous abortion / miscarriage
2- Ectopic pregnancy
3- Trophoblastic disease
4- Cervical polyps
5- Friable cervix
6- Trauma
7- Cervical cancer
Abortus
Perdarahan dari uterus yang disertai
dengan keluarnya sebagian atau seluruh
hasil
konsepsi
sebelum
pada
usia
kehamilan < 20-24 minggu dan atau berat
< 500 gr.
Etiology cont
Immunological causes:
(intrauterine adhesions).
Etiology cont
The exact mechanism responsible for abortion
are
not apparent
In the
In subsequent months
The fetus frequently does not die before expulsion
Other explanations for its expulsion should be sought
T9-1
Incompetent cervix
Painless dilatation of cervix in the 2 nd or early in the 3rd
trimester
prolapse & ballooning of membranes into vagina
rupture of membrane & expulsion of immature fetus
Unless effectively treated, tends to repeat in each pregnancy
The more advanced the pregnancy, the more likely the risk
that surgical intervention stimulate preterm labor or membrane
rupture
Usually do not perform after about 23 weeks
STATISTICS OF ABORTIONS
50 - 60% of all pregnancies end in
spontaneous abortion (SAB) since 2-4 wk
pregnancies will often go unnoticed.
15% of all recognized pregnancies 4-20 wks
end in SAB.
30% lost between implantation and the 6th
wk.
TYPES
TYPES OF ABORTIONS
1. Induced
2. Threatened
3. Inevitable
4. Incomplete
5. Complete
6. Septic
7. Missed
8. Recurrent
Spontaneous abortion
Etiology
Fetal Factors
Maternal Factors
Paternal Factors
Categories of Spontaneous Abortion
Induced abortion
History of abortion
Indications
Elective (Voluntary) Abortion
Threatened abortion
Inevitable abortion
Missed abortion
Recurrent abortion
Threatened Abortion
Peristiwa perdarahan dari uterus pada kehamilan <
20 minggu, hasil konsepsi masih dalam uterus,
tanpa adanya dilatasi serviks.
Gejala :
effect
of
semen
Treatment of controversy:
Progestogens.
Gonadotrophins may be of benefit in cases of
luteal phase deficiency and those get pregnant
with ovulatory drugs.
If GA > 16/40 give - tocolytics
Vaginal sonography
Gestational sac(+) & hCG < 1000mIU/ml
gestation is not likely to survive
If any doubt(+), check the serum hCG level at intervals of 48hrs
if not increase more than 65%, almost always hopeless
Prognosis:
If the blood loss is less than a normal
menstrual flow and is not accompanied
by pain of uterine contraction there is a
reasonable chance for continuing
pregnancy. This occurs in 50% of cases
while other half will proceed to inevitable
or missed abortion.
INEVITABLE ABORTION
Peristiwa perdarahan uterus pada kehamilan < 20
minggu, dengan dilatasi serviks uteri yang
meningkat, hasil konsepsi masih dalam uterus.
Gejala dan Tanda :
Mules sering & kuat, perdarahan bertambah banyak ,
terjadi dilatasi serviks.
Penanganan
Pengeluaran hasil konsepsi, bisa dengan kuret
vakum atau cunam, disusul dengan kerokan.
Pada kehamilan > 12 mg, perdarahan tidak banyak,
bahaya perforasi > besar Infus oksitosin.
Bila janin sudah keluar, plasenta tertinggal
pengeluaran plasenta secara digital kerokan.
Management of Inevitable
Abortion cont,
1. Resuscitation: IV fluids: RL, NS
2. Blood grouping & Cross matching
3. Evacuation
Prognosis:
Refers to a stage in the abortion
when it is not possible for the
pregnancy to continue.
INCOMPLETE ABORTION
Pengeluaran sebagian hasil konsepsi pada kehamilan
< 20 minggu, dengan sisa yang tertinggal dalam
uterus.
Diagnosis :
Nyeri perut hebat, kanalis servikalis terbuka, jaringan
dapat teraba dalam kavum uteri/ menonjol dari OUE,
perdarahan bisa banyak sekali, tak akan berhenti
sebelum sisa konsepsi dikeluarkan syok, usia gestasi
tidak sesuai dengan usia kehamilan, terjadi dilatasi
serviks.
Terapi :
Penanganan syok infus NaCl/RL transfusi kerokan
ergometrin im.
Management of Incomplete
Abortion cont,
1. Resuscitation: IV
fluids: RL, NS
indicated
3. Evacuation
MVA for GA < 12/40
Augment if the GA > 12/40
Oxytocin
If some PoC remain after abortion manage like
incomplete abortion.
COMPLETE ABORTION
Semua
hasil
dikeluarkan.
konsepsi
sudah
Gejala :
Tabel 4-3
DERAJAT ABORTUS
Diagnosi
s
Perdarahan
Serviks
Besar
uterus
Abortus
iminens
Sedikit
sedang
Tertutup
Lunak
Sesuai
usia
kehamilan
Abortus
insipien
s
Sedang
banyak
Terbuka
Lunak
Sesuai
atau
lebih kecil
Abortus
inkompl
it
Sedikit
banyak
Terbuka
Llunak
usia
kehamilan
Abortus
komplit
Sedikit
tidak ada
Tertutup
Lunak
usia
kehamilan
Gejala lain
Pt positif
Kram ringan
Uterus lunak
Kram sedang/kuat
Uterus lunak
Kram kuat
. Keluar jaringan
Uterus lunak
Sedikit/tanpa
kram
massa kehamilan
(+/-)
Uterus agak
kenyal
MISSED ABORTION
Kematian janin < 20 Mg, tapi tidak dikeluarkan selama 8 Mg.
Retention of dead products of conception for 4 weeks or more.
Symptoms :
Symptoms of threatened abortion may or may not be developed.
Diawali dengan abortus imminens yang kemudian menghilang
spontan atau setelah terapi.
Gejala subyektif kehamilan menghilang (The foetal movements
are not felt or ceases if previously present).
Mammae mengendor, uterus mengecil, tes kehamilan (-).
A dark brown vaginal discharge may occur (prune juice
discharge).
Terapi :
Tergantung KU & kadar fibrinogen serta psikis os.
Jika < 12 Mg DC, jika > 12 Mg infus oksitosin 10 IU/D5 500
cc atau Prostaglandin E
Management of Missed
Abortion
The
conceptus
is
expelled
spontaneously in the majority of cases.
dead
SEPTIC ABORTION
An abortion complicated by infection
Symptoms
Abdominal pain
Fever
Vaginal discharge (foul smelling)
Signs
Sick looking, febrile or jaundiced (due to
chemicals used in criminal abortion or
haemolytic infection as Clostridium welchii).
Tender uterus
Offensive vaginal discharge or bleeding
Cervix is soft and may be dilated
Complications of septic
abortions
Immediate cpx
Late cpx
Haemorrhage
PID
Peritonitis
Pelvic
Pelvic abscess,
endometritis,
Septicemia,
Septic/haemorrha
gic shock
adhesions
2 Infertility
Chronic LAP
Management of Septic
Abortion
1. Resuscitation
IV fluids: RL, NS
Monitor Input/output
Haematenics
RECURRENT PREGNANCY
LOSSES
Defined as 3 or more consecutive pregnancy
losses
Other names:
habitual abortions
habitual miscarriages
recurrent abortions
recurrent miscarriages
Etiology
causes
Anatomic
and
immunologic
RECURRENT PREGNANCY
LOSSES cont,
Clinical investigation of recurrent miscarriage
Parental cytogenetic analysis
Lupus anticoagulant & anticardiolipin antibodies
assays
Postconceptional evaluation
Serial monitoring of hCG from missed mens period
hCG>1500mIU/ml USG
Maternal serum -fetoprotein assessment (GA1618wks)
Amniocentesis fetal karyotype
Management and Prognosis
Depends on potential underlying etiology & number of
prior losses
INDUCED ABORTION
Intentional
or
surgical
performed
for a
desires
medical
termination of a pregnancy
Types
Criminalis
womans
if
MANAGEMENTS OF
ABORTION
No fetal pole
>25 mm (transabdominal) OR
>18 mm (transvaginal)
<4 mm growth in 7 days
(No yolk sac, with mean sac diameter >10
mm)
Embryonic Demise
No cardiac activity with CRL 5 mm
Surgical Options
Sharp curettage (D and C) no longer an
acceptable
option
due
to
higher
complication rates
Vacuum aspiration includes Manual
Vacuum Aspiration (MVA) vs. Electrical
Vacuum Aspiration (EVA)
Uterine Aspiration
Manual Vacuum
Aspirator
Electric
Vacuum
Aspirator
Surgical management is
recommended when...
The patient is febrile (>37.50 C)
After appropriate antimicrobial management
diam
The patient has miscarried twice before
Collect tissue for chromosomes
Medical management is
recommended when...
There are fetal parts >14 weeks in size
Surgical evacuation is unsafe
contraindication to surgery or
anaesthesia
Conservative management
of early pregnancy failure
incomplete miscarriage
or
2nd
Prostaglandins
Used extensively to terminate pregnancies, especially in the
2nd T
PG E1, E2, F2
Technique
: Can act effectively on the cervix & uterus (86~95%
effectiveness)
Vaginal prostaglandin E2 suppository & prostaglandin E1
(misoprostol)
As a gel through a catheter into the cervical canal & lowermost
uterus
Injection into the amnionic sac by amniocentesis
Parenteral injection
Oral ingestion
Death
Hyperosmolar crisis (early into maternal circulation)
Cardiac failure
Septic shock
Peritonitis
Hemorrhage
DIC
Water intoxication
Hyperosmotic urea : less likely to be toxic
Antiprogesterone RU 486
Oral agent used alone in combination with oral PG to
effect abortions in early gestation
High receptor affinity for progesterone binding site
Block progesterone action
Abortion rate
Single 600mg dose prior 6 weeks 85%
Addition of oral, vaginal or injected PG over 95%
Side effects
Nausea, vomiting, & gastrointestinal cramping
Major risk hemorrhage is a risk if abortion is incomplete
Epostane
3-hydroxysteroid dehydrogenase inhibitor
blocks the synthesis of endogenous progesterone
Frequent side effect nausea
Hemorrhage is a risk if abortion is incomplete
Thank You...