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Ny.

A usia 23 tahun datang ke


Puskesmas dalam kondisi hamil pertama
kali dan mengeluhkan bercak-bercak
darah dari jalan lahir sejak 2 hari yang
lalu. Hasil p(x) fisik , TFU 3 jari di atas
symphisis pubis. P(x) inspekulo OUE
tertutup, keadaan psikologis terkendali.
1.Diagnosis anda?
2.Menurut anda, perlukah diberi preparat
progesteron pada kasus di atas? Sebutkan
alasan anda!
3.Dari hasil p(x) fisik, berapakah perkiraan usia
janin?
4.Sebutkan minimal 3 faktor risiko yang dapat
menyebabkan kasus di atas!

Pada proses embriologi perkembangan


janin, 1 minggu post-ovulasi morula
akan berkembang menjadi blastokista.
5.Sebutkan struktur pada endometrium yang
ditembus oleh blastokista!
6.Sebutkan faktor tuba dan faktor hormonal
mengapa morulla tidak turun ke arah uterus
pada hari 3 atau 4 post ovulasi!
7.Sebutkan 2 bagian dari blastokista dan hasil
dari masing-masing perkembangan bagian
tersebut!
8.Jika hanya outer part dari blastokista saja
yang
berkembang,
keadaan
tersebut
dinamakan....

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!

13. Dari 2 tatalaksana tersebut, yang lebih


direkomendasikan untuk dilakukan untuk
meminimalkan komplikasi adalah...
14. Sebutkan 2 komplikasi tersering pada
abortus!
15.There are three kinds of medications for
early medical abortion based on newest
management in ACOG. Mention it! (without
doses)
16.Ovulation may resume as early ......... after
an abortion
17.Posisi uterus dimana fundus dan corpus uteri
terletak
membelakangi
vagina
dinamakan......

A 23-year-old woman, who had undergone a D and C


procedure 3 days ago for an incomplete abortion,
complains of continued vaginal bleeding, lower
abdominal cramping, fever, and chills. Her temperature
is 39,16oC, BP 90/40 mmHg, and HR 120x/m. There is
moderately severe lower abdominal tenderness. The cx
is open and there is uterine tenderness. The lab studies
are significant for leucocytosis and a normal urinalysis.
18. What is your IV antibiotic recommendation (1st
line)?
19. Uterine
curretage
is
usually
performed
approximately ....... Hours after antibiotics are begun.
20. If she has been treated with antibiotics also D and C
to remove the nidus but still febrile and hypotensive in
48 hours, what is your next recommendation therapy?

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

Normal Implantation &


Development

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.

Termination of pregnancy before viability


of the foetus i.e. before 28 weeks (in
Britain) and before 20 weeks or if the
foetal weight is less than 500 gm (in USA
and Australia).

Chromosomal abnormalities: cause at least

50% of early abortions e.g. trisomy.


Maternal infections: Acute fever for whatever the
cause can induce abortion.
Trauma: external to the abdomen or during
abdominal or pelvic operations.
Endocrine causes: Progesterone deficiency,
Diabetes mellitus, Hyperthyroidism.
Drugs and environmental causes
Maternal anoxia and malnutrition.
Over distension of the uterus: e.g. acute
hydramnios.

Etiology cont

Immunological causes:

Systemic lupus erythematosus.


Antiphospholipid antibodies that are directed against
platelets and vascular endothelium leading to
thrombosis, placental destruction and abortion.

Ageing sperm or ovum.

Uterine defects Septum, Asherman's syndrome

(intrauterine adhesions).

Nervous, psychological conditions and over fatigue.


Idiopathic.

Etiology cont
The exact mechanism responsible for abortion

are

not apparent
In the

first 3 months of pregnancy

Death of the embryo or fetus nearly always precedes


spontaneous expulsion of the ovum
Finding of the cause of early abortion involves ascertaining
the cause of fetal death

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

Incompetent cervix Treatment


The operation is performed to surgically
Reinforcement of weak cervix by some type of purse string suture
( Cerclage )

Prophylactic surgery : generally performed between 12 &


16 weeks
Should be delayed until after 14 weeks gestation
Early abortion due to other factors will be completed

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

Incompetent cervix Cerclage procedures


Types of operations commonly used
McDonald
Modified Shirodkar
85~90% success rate

Hemorrhage into the decidua basalis, followed by


necrosis of tissues adjacent to the bleeding
If early, the ovum detaches, stimulating uterine
contractions

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.

70% of first trimester losses are due to


chromosomal abnormalities

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

Categories of spontaneous abortion

Threatened abortion

Inevitable abortion

Complete or incomplete 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 :

perdarahan dari OUE, mules sedikit/(-), besar uterus


= usia gestasi, OUI tertutup, tes kehamilan positif.
Penanganan :
Bedrest (1 week post-bleeding)
USG janin hidup / mati

No intercourse as it may disturb pregnancy by the

mechanical effect and the


prostaglandins on the uterus.

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

Threatened Abortion cont,

Treatment : slight bleeding persists for weeks


Vaginal sonography
Serial serum quantitative hCG
Serum progesterone
can help ascertain if the fetus is alive & its location

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

Serum progesterone value < 5 ng/ml


dead conceptus

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

MVA for GA < 12/40

Augment if the GA > 12/40


Oxytocin
If some PoC remain after abortion
manage like incomplete abortion.

MANUAL VACUUM ASPIRATOR

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

2. Blood grouping & Cross matching BT if

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 :

Perdarahan sedikit, ostium uteri


eksternum tertutup, uterus mengecil.
Penanganan :

Bila anemis Sulfas Ferrosus.

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

Missed Abortion cont,


Signs:

The uterus fails to grow and becomes firmer


and the cervix is closed.
The foetal heart sounds cannot be heard.
Investigations:

Pregnancy test becomes negative within two


weeks from the ovum death.
Ultrasound
shows
either
a
collapsed
gestational
sac,
absent
foetal
heart
movement or foetal movement.

Management of Missed
Abortion
The

conceptus
is
expelled
spontaneously in the majority of cases.

dead

Evacuation of the uterus is indicated in


the following conditions:
spontaneous expulsion does not occur within
four weeks,
there is bleeding,
infection or DIC developed or,
patient is anxious.

Evacuation is carried out as


following :
If the uterine size is less than 12 weeks
gestation: vaginal or suction evacuation is done
If the uterine size is more than 12 weeks'
gestation: evacuation can be done by :
Prostaglandins: given intravaginally (PGE2),
intravenously, intra-or extra- amniotic (PGF2).
Oxytocin infusion.
Combination.
Hysterotomy: is rarely indicated in 2nd trimester
missed abortion if the medical induction fails
initially and after repetition few days later.

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

2. Insert urethral catheter

Monitor Input/output

3. Blood grouping & Cross matching


4. Antibiotics:

Preferably cephalosporins, if not available


ampicilin and metronidazole

A cervico-vaginal swab is taken for culture


and sensitivity

Evacuation (after 4 hours or maybe earlier)

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

Medicinalis : if performed for reasons

of maintaining health of the mother


(incest, severe physical deformities)

MANAGEMENTS OF
ABORTION

Ultrasound Findings of EPL


Anembryonic Pregnancy

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

Do all patients require vaginal


exam?
Most patients deserve a pulse rate, BP
measure and abdominal palpation
Vaginal exam is required when...
Ultrasound is not readily available
There has been substantial bleeding

If the patient is hypotensive


It may be corrected by clearing the cervix

The patient reports passage of tissue

Clear the cervix


Collect any tissue to confirm the pregnancy
There is doubt about the source of bleeding

There is the possibility of ectopic pregnancy


But please be very gentle

Options for the management


of early pregnancy failure
Surgical evacuation of the uterus
Medical evacuation of the uterus
Wait and see
Recommended as first line by NICE

Surgical management is
recommended when...
The patient is febrile (>37.50 C)
After appropriate antimicrobial management

The cervix is closed and the sac > 5cm

diam
The patient has miscarried twice before
Collect tissue for chromosomes

The patient or your health facilities are


incapable of appropriate follow up

Medical management is
recommended when...
There are fetal parts >14 weeks in size
Surgical evacuation is unsafe

The pregnancy is >10 weeks in size, the


patient elects D&C & cervix is closed
Use Misoprostol 400 mcg to ripen the cervix 3-4 hrs
prior to dilatation

There is DIC or some other

contraindication to surgery or
anaesthesia

Conservative management
of early pregnancy failure
incomplete miscarriage

or

Repeat clinical and USS evaluation


after 3 days
Then 7 days and weekly
Must telephone or come in at any
hour if pain or bleeding is
unacceptable or fever occurs

Surgical techniques for abortion


Dilatation and curettage
Performed first by dilating the cervix & evacuating the
product of conception
Mechanically scraping out of the contents (sharp curettage)
Vacuum aspiration (suction curettage)
Both

Before 14 weeks, D&C or vacuum aspiration should be


performed
After 16 weeks, dilatation & evacuation (D&E) is performed
Wide cervical dilatation
Mechanical destruction & evacuation of fetal parts

Surgical techniques for abortion


Dilatation and curettage
Hygroscopic dilators
: swell slowly & dilate cervix cervical trauma can be
minimized
Laminaria tents : stem of brown seaweed ( Laminaria digitata
or japonica)
drawing water from proteoglycan complexes of cervix
dissociation allow the cervix to soften & dilate
Insertion technique : tip rests just at the level of internal os
Usually after 4-6hours, laminaria dilate the cervix
sufficiently to allow easier mechanical dilation & curettage
May cause cramping pain
easily managed with 60 mg codeine every 3-4 hours
Remove laminaria Uterus is sounded carefully to
Identify the status of the internal os
Confirm uterus size & position
Further dilatation of cervix with Hegar dilator

Surgical techniques for abortion


cont,
Menstrual aspiration
Aspiration of endometrial cavity using a
flexible cannula and syringe within 1-3
weeks after failure to menstruate
Several points at early stage of gestation

Woman not being pregnant


Implanted zygote may be missed by the curette
Failure to recognize an ectopic pregnancy
Infrequently, a uterus can be perforated

Surgical techniques for abortion


cont,
Laparotomy
Abdominal hysterotomy or hysterectomy
Indications
Significant uterine disease
Failure of medical induction during the 2nd
trimester

Medical induction of abortion


Early abortion
Outpatient medical abortion is an acceptable
alternative to surgical abortion in women with
pregnancies of less than 49 days gestation
(ACOG, 2001b)
Three medications for early medical abortion
Antiprogestin mifepristone
Antimetabolite methotrexate
Prostaglandin misoprostol

Medical induction of abortion _


trimester abortion

2nd

Medical induction of abortion


cont,
Oxytocin
Successful induction of 2nd trimester abortion is
possible with high doses of oxytocin administered in
small volumes of IV fluids
Satisfactory alternatives to PG E2 for midtrimester
abortion
Laminaria tents inserted the night before
Chance of successful induction is greatly enhanced

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

Intra-amnionic hyperosmotic solutions


20-25% saline or 30-40% urea injected into amnionic sac
stimulate uterine contraction & cervical dilatation
Action mechanism : prostaglandin mediated
Complications of hypertonic saline

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%

If given within 72 hours


Also highly effective as emergency postcoital contraception
Progressively less effective after 72 hours

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

Consequences of elective abortion


Impact on future pregnancies
Vacuum aspiration for a first pregnancy
: Do not increase the incidence of
2nd trimester spontaneous abortions
Preterm delivery
Ectopic pregnancy
LBW infants
Dilatations & curettage for a first pregnancy

: Increased risks for


Ectopic pregnancy
2nd trimester spontaneous abortions
LBW infants

Multiple elective abortion :


Not increased the incidence of preterm delivery & LBW
infants
Placenta previa
increased following multiple sharp curettage abortion
procedures

Resumption of ovulation after


abortion
Ovulation may resume as early 2 weeks
after an abortion
Therefore, if pregnancy is to be prevented,
effective contraception should be initiated
soon after abortion

Thank You...