dr.

Udin Sabarudin, SpOG, MM

Depart. of Obstetrics - Gynecology Padjadjaran

University / Hasan Sadikin Hospital
BANDUNG
 OBSTETRICAL HEMORRHAGE

Bleeding before 20 weeks of pregnancy

Antepartum hemorrhage

Post partum hemorrhage

Cause of vaginal bleeding at the
third trimester

Rupture of vaginal varicose

Laceration of vagina or cervix
Placenta previa
Abruptio placentae
ANTEPARTUM HEMORRHAGE

Placenta Previa

Abruptio placentae
Normal implantation of the placenta
Fundal Corpus
Implantation at the lower segment
Front Behind
 PLACENTA PREVIA :

DEFINITION :
Placenta is located over or very near the
internal os

Prae : Front
Vias : Route
 FOUR DEGREES OF THIS ABNORMALITY

1. Total placenta previa

The internal cervical os
is covered completely

2. Partial placenta previa

A B
The internal cervical os
is partially covered
 FOUR DEGREES OF THIS ABNORMALITY

3. Marginal placenta previa

The edge of placenta is at
the margin of the internal os
2. Low lying placenta
The placenta is implanted in
the lower uterine segment A B
such that the placental edge
actually does not reach the
internal os but is in close
proxymity to it
 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
Total placenta previa

BLEEDING >>> !!!

Marginal placenta previa

Placenta

cervix
CHANGING THE DEGREE OF P.P

Marginal

Amnion (+)
Lateral

Dilatation >
 Dilatation

Bleeding

Retracted
Amnion
Lower segmen

Lower Cervix
segmen
Bleeding
 Partial placenta previa

> 1/2 O BLEEDING >>>

< 1/2 O BLEEDING >

THE DEGREE OF PLACENTA PREVIA

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 :

Multipara, with interval <

Fibroids

Habitual abortion
 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 :

Oblique or lie position

Presenting part - high

 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
 TAMPONADE BY PRESENTING PART

Placenta

Cervix
Amnion

In tact
 Head press
the placenta

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 :

Accidental hemorrhage
Abruptio placentae
Solutio placentae
Ablatio placentae
Premature separation of the normally
implanted placenta
 PATHOLOGY

Hemorrhage into the decidua basalis

Decidua then splits, leaving a thin layer

adherent to the myometrium

Decidual hematoma

Separation, compression and the ultimate

destruction of the placenta adjacent to it
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 :

Hemorrhage with pain

Fetal - Not palpable
Heart beat - not detected
Uterine hypertonus
Anemi shock
Amnion bulging
COMPLICATION :

Early : - Hemorrhage
- Shock

Late : - Consumtive coagulopathy

- Hypofibronogenemia
- Utero placental apoplexy
(couvelaire uterus)
- Renal failure
MANAGEMENT :

Depend on status of the mother & fetus:

Transfusion
Electrolyte solution
Corticosteroids
Fibrinogen
OBSTETRIC MANAGEMENT :

Amniotomi
Oxytocin infusion
Cesarean section :
Fetus alive
Cervix not dilated
2 hours after oxytocin infusion
uterine contraction (-)
 MANFAAT PEMECAHAN KETUBAN

Ketuban Tak ada bagian-bagian

Plasenta plasenta yg lepas lagi

SBR
Tak ada perdarahan baru
Pemecahan ketuban Syarat :
Derajat luasnya
Ketuban penutupan ostium oleh
Plasenta ikut
plasenta
dg pembukaan
Letak plasenta
SBR 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 :

Abruptio placentae
Ablatio placentae
Accidental haemorrhage
Premature separation of the normally
implanted placenta
 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 Dengan perdarahan
tersembunyi ke luar
Pelepasan biasanya Biasanya inkomplit
komplit
Hanya merupakan Merupakan 80% dari
20% dari solusio solusio plasenta
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
 DIAGNOSIS DITEGAKKAN DENGAN :

Perdarahan antepartum yang bersifat nyeri

Uterus tegang dan nyeri

Setelah
plaenta lahir terdapat impresi pada
permukaan maternal
DIFFERENSIAL DIAGNOSIS :

PLASENTA PREVIA

RUPTURA UTERI
 Perbedaan solusio plasenta dengan
plasenta previa
Solusio plasenta
Perd. dg nyeri
Perd. segera diikuti partus
Perd. ke luar hanya
sedikit
Palpasi sukar
BJA biasanya tdk ada
Pada toucher teraba ket.
Yg terus menerus tegang
Ada impressi pd jar.
plasenta
Plasenta previa
Perd. tanpa nyeri
Perd. berulang sblm
partus
Perd. ke luar banyk
Bagian depan tinggi
Biasanya teraba jar.
plasenta
Robekan selaput
marginal
 PENYULIT SOLUSIO PLASENTA

TIMBUL SEGERA :
Perdarahan
Syok

TIMBUL AGAK LAMBAT :

Kelainan 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 :

Padasolusio plasenta yang berat

prognosis untuk anak adalah buruk (90%)

Bagiibu juga berbahaya, tetapi dengan

persediaan darah yang cukup dan
pengelolaan yang baik, kematian dapat
ditekan
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 drip
Seksio sesarea, bila :
Anak hidup
Serviks tertutup
Dua jam setelah oksitosin drip his (-)
Post partum mungkin terjadi perdarahan
karena :

Plasenta Akreta

Daerah perlekatan luas

Daya kontraksi SBR kurang

BAHAYA UNTUK IBU :
Perdarahan hebat
Infeksi-sepsis
Emboli udara (jarang)

BAHAYA UNTUK ANAK :

Hipoksia
Perdarahan & syok