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PLACENTA PREVIA

Perdarahan antepartum / Antepartum Haemorrhage (APH)

Bleeding from genital tract after the 28th week of pregnancy and before labour.
Seems reasonable that 24 weeks should also form the new boundary between the
definition of APH and bleeding of early pregnancy2

Perdarahan pada trimester terakhir dari kehamilan3

Perdarahan dari jalan lahir pada wanita hamil dengan usia kehamilan 20 minggu
atau lebih4
Plasenta previa / Placenta praevia / Placenta previa

Placenta is located over or very near the internal os1

Placenta is partly or wholly implanted in the lower uterine segment2

Plasenta yang berimplantasi rendah sehingga menutupi sebagian atau seluruh


ostium uteri internum3

Plasenta yang letaknya tidak normal sehingga menutupi sebagian atau seluruh
ostium uteri internum4
Degrees of placenta previa1
1. Total placenta previa
2. Partial placenta previa
3. Marginal placenta previa
4. Low-lying placenta

:
:
:
:

internal cervical ostium (ICO) covered completely


ICO partially covered
the placenta is at the margin of ICO
the placenta is implanted in the lower uterine segment,
placenta edge actually is does not reach the ICO but is
in close proxymity to it

Grading of placenta praevia2


1. Lateral (grade I)
: the placenta just encroaches on the lower uterine
segment
2. Marginal (grade II)
: the placenta reaches the margin of cervical os
3. Complete (grade III)
: the placenta covers parts of the os
4. Complete (grade IV)
: the placenta covers the os when dilated
Klasifikasi3
1. Plasenta previa totalis
: seluruh OUI tertutup plasenta
2. Plasenta previa lateralis
: sebagian OUI tertutup plasenta
3. Plasenta previa marginalis : hanya pada pinggir OUI terdapat plasenta
Terdapat satu kelompok yang tidak dimasukkan ke dalam plasenta previa yaitu
plasenta letak rendah
The degree of placenta previa will depend in large measure on the cervical dilatation
at the time of examination1
Penentuan macamnya plasenta previa bergantung pada besarnya pembukaan3
Etiology1
Maternal age; at Parkland Hospital 1988-1999, 1 in 1500 for women 19 or less
and for women over 35 it is 1 in 100
Multiparity; Babinszki and collaborators (1999) reported the incidence was
increased 2.2 percent in women who were para 5 or greater

Prior cesarean delivery; Miller and associates (1996) cited a threefold increase in
women with prior cesarean delivery
Smoking; Williams and collagues (1991b) found the relative risk to be increased
twofold related to smoking

Risk factors2
Previous abortions; recent studies, however, have found a clear association with
previous spontaneous or induced abortion (Annath et al 1997a, Macones et al
1997)
Ethnic origin; American women of Asian origin were 86% more likely to have
placenta praevia than were White women, particularly primigravidae (Taylor et al
1995)
Hypertension; there is a reduced incidence of hypertension of pregnancy among
women with placenta praevia (Annath et al 1997b)
Increased of the placenta area; such as twins and placenta membranacea
Etiologi3
Mioma uteri
Hipoksemia yang terjadi akibat karbon monoksida akan dikompensasi dengan
hipertrofi plasenta. Hal ini terjadi terutama pada perokok berat (lebih dari 20
batang perhari)
Plasenta yang besar dan luas; seperti pada eritoblastosis, diabetes mellitus, dan
kehamilan multipel
Manifestasi klinik / Clinical findings
Gejala / Symptoms. The most characteristic event is painless hemorrhage, wich
usually does not appear until near the end of the second trimester or after. 1 The
bleeding is usually unprovoked, although there is occasionally a history of coitus just
beforehand.2 The most catasthropic cases of haemorrhage occur from ill-advised
attemps at vaginal examination2
The formation of the lower uterine segment and the dilatation of the internal os result
inevitably in tearing of placental attachments. The bleeding is augmented by the
inability of the myometrial fibers of the lower uterine segment to contract and thereby
constrict the torn vessels1
Perdarahan bersifat berulang-ulang karena dengan majunya kehamamilan regangan
dinding rahim dan tarikan serviks akan bertambah dan menimbulkan perdarahan
baru.3 Setelah bulan ke-4 terjadi regangan dinding rahim karena isi rahim lebih cepat
tumbuhnya dibanding dinding rahim, akibatnya istmus uteri tertarik menjadi bagian
dinding korpus uteri yang disebut segmen bawah rahim. Jadi, dalam kehamilan tidak
diperlukan his untuk menimbulkan perdarahan, namun sudah jelas his pembukaan
menyebabkan perdarahan pada persalinan.3
Tanda / Signs. The abdomen is soft with no tenderness. The presenting part is easily
felt and the fetal heart rate should be normal. The low placenta displace the presenting
part, with a high incidence of malpresentation. The condition should be suspected if
there is an unstable lie even without any bleeding2

Bagian terendah anak sangat tinggi karena plasenta terletak pada kutub bawah rahim
sehingga tidak dapat mendekati pintu atas panggul dan panjang rahim berkurang
hingga sering disertai kelainan letak3
Such examination of the cervix is never permissible unless the women is in operating
room with all the preparation for the immidiate cesarean delivery, because even the
gentlest examination of this sort can cause torrential hemorrhage (double set up).
Furthermore, such an examination should not be made unless delivery is planned. 1 If
there is a doubt about the cause of vaginal bleeding in admission, while digital vaginal
examination is contraindicated, a speculum examination is often helpful before
arranging a scan.2 Pada pemeriksaan in speculo plasenta previa, darah akan terlihat
darah yang keluar dari ostium uteri eksternum3
Dapat juga dilakukan perabaan fornises dengan hati-hati. Pemeriksaan ini hanya dapat
dilakukan pada presentasi kepala karena pada letak sungsang bagian terendahnya
lunak hingga sukar dibedakan dengan jaringan lunak plasenta. Pada presentasi kepala,
jika tulang kepala dapat diraba dengan mudah, kemungkinan plasenta previa kecil.
Sebaliknya, jika antara jari dan kepala teraba bantalan lunak, kemungkinan plasenta
previa besar sekali3
Ultrasonography (USG). According to Laing (1996), the average accuracy is about
96%, and rates as high as 98% have been obtained. False-positive results are often as
result of bladder distention. Therefore, ultrasonic scans in apparently positive cases
should be repeated after emptying the bladder1
Migrasi plasenta. Dengan bantuan USG, diagnosis plasenta previa/plasenta letak
rendah sering kali sudah dapat ditegakkan sebelum kehamilan trimestes ke-tiga.
Namun, dalam perkembangannya dapat terjadi migrasi plasenta (placental
migration).3
The apparent movement of the low-lying placenta relative to the internal os probably
results from inability to precisely define this relationship in a three-dimensional
manner using two-dimensional sonography in early pregnancy. The difficulty is
coupled with differential growth of lower and upper myometrial segments as
pregnancy progress. Thus, the placentas that migrates most likely never had actual
circumferential villus invasion that reached the internal cervical os in the first place1

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