ANTE PARTUM BLEEDINGANTE PARTUM BLEEDING

Dr.G.M PUNARBAWA, SpOG

SMF OBSTETRI-GINEKOLOGIRSUP NTB

Dr.G.M PUNARBAWA, SpOG

SMF OBSTETRI-GINEKOLOGIRSUP NTB

PENDAHULUANPENDAHULUAN

OBSTETRI ADALAH BLOODY BUSINESS OBSTETRI ADALAH BLOODY BUSINESS

KEMATIAN MATERNAL DAPAT DITURUNKAN KEMATIAN MATERNAL DAPAT DITURUNKAN

KAUSA PERDARAHAN MASIH MENONJOLKAUSA PERDARAHAN MASIH MENONJOL

A S 1979-92:4915 KEMATIAN MATERNAL NON ABORTUS30% KAUSA PERDARAHAN

A S 1979-92:4915 KEMATIAN MATERNAL NON ABORTUS30% KAUSA PERDARAHAN

PENDAHULUANLANJUTAN

PENDAHULUANLANJUTAN

KAUSA PERDARAHAN JUMLAH (%)

ABRUPTIO PLACENTAE 141 (19)LACERATION/UTERINE RUPTURE125 (16)UTERINE ATONY 115 (15)COAGULOPATHIES 108 (14)PLACENTA PREVIA 50 ( 7 )PLACENTA ADHESIVE 44 ( 6 )UTERINE BLEEDING 47 ( 6 )RETAINED PLACENTA 32 ( 4 )

KAUSA PERDARAHAN JUMLAH (%)

ABRUPTIO PLACENTAE 141 (19)LACERATION/UTERINE RUPTURE125 (16)UTERINE ATONY 115 (15)COAGULOPATHIES 108 (14)PLACENTA PREVIA 50 ( 7 )PLACENTA ADHESIVE 44 ( 6 )UTERINE BLEEDING 47 ( 6 )RETAINED PLACENTA 32 ( 4 )

CHICHACLI (1999), WILLIAM 21ST

PERDARAHAN ANTE PARTUMPERDARAHAN ANTE PARTUM

1. ABRUPTIO PLACENTAE/SOLUTIO PLACENTAE1. ABRUPTIO PLACENTAE/SOLUTIO PLACENTAE

2. PLACENTA PREVIA2. PLACENTA PREVIA

ABRUPTIO PLACENTAEABRUPTIO PLACENTAE

• PLASENTA LEPAS

• IMPLANTASI NORMAL

• SEBELUM BAYI LAHIR

• > 20 MINGGU

• PLASENTA LEPAS

• IMPLANTASI NORMAL

• SEBELUM BAYI LAHIR

• > 20 MINGGU

DEFINISIDEFINISI

ABRUPTIO PLACENTAEABRUPTIO PLACENTAE

•ACCIDENTAL HEMORRHAGE

•SOLUTIO PLACENTAE

•PREMATURE SEPARATION OF THE NORMALLY IMPLANTED PLACENTA

•ACCIDENTAL HEMORRHAGE

•SOLUTIO PLACENTAE

•PREMATURE SEPARATION OF THE NORMALLY IMPLANTED PLACENTA

TERMINATIONSTERMINATIONS

ABRUPTIO PLACENTAEABRUPTIO PLACENTAE

•EXTERNAL HEMORRHAGE

•CONCEALED HEMORRHAGE

•EXTERNAL HEMORRHAGE

•CONCEALED HEMORRHAGE

•TOTAL

•PARTIAL

•TOTAL

•PARTIAL

ABRUPTIO PLACENTAEABRUPTIO PLACENTAE

FREQUENCY AND INTENSITY

•CRITERIA DIAGNOSIS•ONSET SYMPTOMS

FREQUENCY AND INTENSITY

•CRITERIA DIAGNOSIS•ONSET SYMPTOMS

FREQUENCY: 1 PER 200 DELIVERIESFREQUENCY: 1 PER 200 DELIVERIES

ABRUPTIO PLACENTAEABRUPTIO PLACENTAE

PERINATAL MORTALITY & MORBIDITY

MOST 25%

KAREGARD (1986) 20%

KROHN (1987) 20/884 SOLUTIO

ANANTH (1999) 40%

PERINATAL MORTALITY & MORBIDITY

MOST 25%

KAREGARD (1986) 20%

KROHN (1987) 20/884 SOLUTIO

ANANTH (1999) 40%

ABRUPTIO PLACENTAEABRUPTIO PLACENTAE

RISK FACTOR RELATIVE RISK (%)

INCREASE AGE/PARITY NAPREECLAMPSIA 2,1-4,0CHRONIC HYPERTENTION 1,8-3,0PROM 2,4-3.0CIGARETTE SMOKING 1,4-1,9THROMBOPHILIA NACOCAINE USE NAPRIOR ABRUPTION 10-25UTERINE LEIOMYOMA NA

RISK FACTOR RELATIVE RISK (%)

INCREASE AGE/PARITY NAPREECLAMPSIA 2,1-4,0CHRONIC HYPERTENTION 1,8-3,0PROM 2,4-3.0CIGARETTE SMOKING 1,4-1,9THROMBOPHILIA NACOCAINE USE NAPRIOR ABRUPTION 10-25UTERINE LEIOMYOMA NA

ANANT AND KRAMER (WILLIAM 21ST)

ABRUPTIO PLACENTAEABRUPTIO PLACENTAEPATHOLOGY

HEMORRHAGICINTRA DECIDUA

DECIDUAL SPLITS DECIDUALHEMATOMA

•SEPARATION•COMPRESSION•DESTRUCTION

ABRUPTIO PLACENTAEABRUPTIO PLACENTAE

•CONCEALED HEMORRHAGE

•CHRONIC PLACENTAL ABRUPTION

•FETOMATERNAL HEMORRHAGE

•CONCEALED HEMORRHAGE

•CHRONIC PLACENTAL ABRUPTION

•FETOMATERNAL HEMORRHAGE

WAJIB BACA

ABRUPTIO PLACENTAEABRUPTIO PLACENTAEDIAGNOSISDIAGNOSIS

SIGN OR SYMPTOM FREQUENCY (%)

VAGINAL BEEDING 78UTERINE TENDERNESS OR BACK PAIN 66FETAL DISTRESS 60HIGH FREQUENCY CONTRACTIONS 17HYPERTONUS 17IDIOPATHIC PRETERM LABOR 22DEAD FETUS 15

SIGN OR SYMPTOM FREQUENCY (%)

VAGINAL BEEDING 78UTERINE TENDERNESS OR BACK PAIN 66FETAL DISTRESS 60HIGH FREQUENCY CONTRACTIONS 17HYPERTONUS 17IDIOPATHIC PRETERM LABOR 22DEAD FETUS 15

HURD (1983), WILLIAM 21ST

ABRUPTIO PLACENTAEABRUPTIO PLACENTAECOMPLICATIONSCOMPLICATIONS

•SHOCK ≈ ≠ BLEEDING

•CONSUMPTIVE COAGULOPATHY

•RENAL FAILURE

•COUVELAIRE UTERUS

•SHOCK ≈ ≠ BLEEDING

•CONSUMPTIVE COAGULOPATHY

•RENAL FAILURE

•COUVELAIRE UTERUS

ABRUPTIO PLACENTAEABRUPTIO PLACENTAEMANAGEMENTMANAGEMENT

STATUS OFTHE MOTHER

STATUS OFTHE FETUS

GESTATIONALAGE

PERDARAHAN ANTE PARTUMPERDARAHAN ANTE PARTUM

1. ABRUPTIO PLACENTAE/SOLUTIO PLACENTAE1. ABRUPTIO PLACENTAE/SOLUTIO PLACENTAE

2. PLACENTA PREVIA2. PLACENTA PREVIA

PLACENTA PREVIAPLACENTA PREVIA

•PATHOLOGIC IMPLANTATION

•LOW SEGMENT

•OVER OR VERY NEAR OS

•PATHOLOGIC IMPLANTATION

•LOW SEGMENT

•OVER OR VERY NEAR OS

PLACENTA PREVIAPLACENTA PREVIA

NORMAL IMPLANTATION:

•UTERINE FUNDAL

•UTERINE CORPORAL

NORMAL IMPLANTATION:

•UTERINE FUNDAL

•UTERINE CORPORAL

PLACENTA PREVIAPLACENTA PREVIA DEGREE

1. TOTAL PLACENTA PREVIA

2. PARTIAL PLACENTA PREVIA

3. MARGINAL PLACENTA PREVIA

4. LOW LYING PLACENTA

5. VASA PREVIA

1. TOTAL PLACENTA PREVIA

2. PARTIAL PLACENTA PREVIA

3. MARGINAL PLACENTA PREVIA

4. LOW LYING PLACENTA

5. VASA PREVIA

PLACENTA PREVIAPLACENTA PREVIA INCIDENCEINCIDENCE

IYASU (1993) 0,50%

FREDERIKSEN (1999) 0,55%

CRANE (1999) 0,33%

PARKLAND HOSPITAL 12YEARS 0,26%

IYASU (1993) 0,50%

FREDERIKSEN (1999) 0,55%

CRANE (1999) 0,33%

PARKLAND HOSPITAL 12YEARS 0,26%

WILLIAM, 21ST

PLACENTA PREVIAPLACENTA PREVIA ETIOLOGYETIOLOGY

•INCREASES MATERNAL AGE

•MULTIPARITY

•PRIOR CESAREAN DELIVERY

•SMOKING

•INCREASES MATERNAL AGE

•MULTIPARITY

•PRIOR CESAREAN DELIVERY

•SMOKING

PLACENTA PREVIAPLACENTA PREVIA CLINICAL FINDINGCLINICAL FINDING

•PAINLESS HEMORRHAGE

•SECOND TRIMESTER

•WITHOUT WARNING

•PAINLESS HEMORRHAGE

•SECOND TRIMESTER

•WITHOUT WARNING

PLACENTA PREVIAPLACENTA PREVIA

THE CAUSE OF SPONTANEOUSHEMORRHAGE IS RELATED TODEVELOPMENT OF THE LOWERUTERINE SEGMENT

THE CAUSE OF SPONTANEOUSHEMORRHAGE IS RELATED TODEVELOPMENT OF THE LOWERUTERINE SEGMENT

PLACENTA PREVIAPLACENTA PREVIA DIAGNOSISDIAGNOSIS

CLINICAL FINDINGPAINLESS HEMORRHAGEWITHOUT WARNING

DOUBLE SET-UPVAGINAL EXAMINATION

SONOGRAPHYTRANSABDOMINALTRANSVAGINAL

CLINICAL FINDINGPAINLESS HEMORRHAGEWITHOUT WARNING

DOUBLE SET-UPVAGINAL EXAMINATION

SONOGRAPHYTRANSABDOMINALTRANSVAGINAL

PLACENTA PREVIAPLACENTA PREVIA

MANAGEMENT:

1. FETUS IS PRETERM?

2. FETUS MATURE TO DELIVERY?

3. THOSE IN LABOR?

4. SEVERE HEMORRHAGE?

MANAGEMENT:

1. FETUS IS PRETERM?

2. FETUS MATURE TO DELIVERY?

3. THOSE IN LABOR?

4. SEVERE HEMORRHAGE?

PLASENTA PREVIAPLASENTA PREVIA

PERDARAHAN SEDIKIT( <250 cc )

PERDARAHAN SEDIKIT( <250 cc )

PERDARAHAN BANYAK( > 500 cc )

PERDARAHAN BANYAK( > 500 cc )

PRETERMPRETERM ATERM ATERM

ISTIRAHATISTIRAHATUSGUSG

TOTALTOTAL SUBTOTALSUBTOTAL

AMNIOTOMIAMNIOTOMI

PERDARAHANPERDARAHAN INPARTUINPARTU

PERVAGINAMPERVAGINAM

S E K S I O S E S A R E AS E K S I O S E S A R E A

PRETERMPRETERM ATERMATERM

ISTIRAHATISTIRAHAT

STOPSTOP ULANGULANG

DSUDSU

TOTALTOTAL

PARSIALPARSIAL

AMNIOTOMIAMNIOTOMI

DARAHDARAH INPARTUINPARTU

PERVAGINAMPERVAGINAM