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Obstetrical Hemorrhage,

may be antepartum such as with placenta previa or placental abruption, or postpartum


from uterine atony or genital tract lacerations.

Antepartum hemorrhage
Placental Abruption
- placental sepatarion from its implantation site before delivery , initiated by
hemorrhage into decidua basalis.
- causing external hemorrhage
- less often, leading to concealed hemorrhage
Risk Factors :
Increased age and parity (>40 th), preeclampsia, chronic HT, preterm ruptured membranes,
multifetal gestation, low birhtweight, hydramnion, cigarette smoking, thrombophilias, cocaine
use, prior abruption, uterine leiomyoma, traumatic abruption.
Clinical :
- external bleeding, can be profused, less, or no external bleeding
- painfull
Management
- with fetus of viable age, and if vaginal delivery is not imminent -> emergency caesarean
delivery
- with massive external bleeding -> intensive resuscitation with blood + crystalloid and
prompt delivery to control hemorrhage and lifesaving for the mother and hopefully for
fetus.
- If placental separation is so severe that the fetus died -> vaginal delivery (biar uterus
bisa kontraksi secara fisiologis, ngurangin hemorrhage)

Placenta Previa
Total placenta previa : internal os is covered completely by placenta
Partial placenta previa : the internal os is partially covered
Marginal placenta previa : the edge of placenta is at the margin of internal os
Low lying placenta : the placenta is implanted in the lower uterine segment
Vasa previa : the fatal vessels course through membranes and present at
cervical os.
GABOLEH DIGITAL PALPATION ! CAUSES SEVERE HEMORRHAGE
Associated Factors :
Maternal age, multiparity, multifetal gestations, prior caesarian delivery, smoked cigarettes
Clinical Findings :
Painless hemorrhage, usually does not appear until the end of second semester or after
Diagnosis :
Transabdominal sonography or transvaginal sonography
Management :
- with preterm fetus, but without persisten active uterine bleeding -> close observation
- caesarean delivery

Postpartum Hemorrhage
Loss of 500 mL of blood or more after completion of the third stage of labor (after baby was
born) vaginal delivery
Loss of blod >/ 1L (caesarean)
Dibagi 2 : early onset (<24 jam), late onset (>24 jam)
4 T : Tone, Tissue, Trauma, Thrombin

TONE : Uterine Atony (75-90% PPH)


- happens when uterus doesnt contract
- uterus is soft -> blood vessels at placental bed is wide open
Risk Factors :
Overdistended uterus (large fetus, multiple fetus, hydramnions), high parity, had a prior
postpartum hemorrhage, prolong labor, precipitate labor, induction and augmentation of labor,
uterine infection.

Management after placental delivery :


1. Intramuscular Oxytocin injection
2. If oxytocin does not prove effective to reverese uterine atony, administer 0,2 mg
methylergonovine (ergot) IM. *ergot may cause dangerous hypertension, especially in
women with preeclampsia.
3. Prostaglandin Analog
Bleeding unresponsive to Oxytocics
May be from unrecognized genital tract lacerations, including uterine rupture. Initial steps :
1. Initiate bimanual uterine compression
2. Call for help !
3. Add a second large-bore IV catheter so crystalloid with oxytocin may be continued at
the same time blood is given.
4. Begin blood transfusion
5. Explore uterine cavity manually for retained placental fragments or lacerations
6. Inspect cervix and vagina for lacerations
7. Insert foley catheter to monitor UO
8. Begin volume resuscitation

Masih terus bleeding :


Surgical (ligation uterine artery) / uterine compression sutures using B lynch / Uterine
packing (balloon foley catheter filled with 60-80 mL saline)

TISSUE :
Placental Retention
Belum lahir setelah 30 menit
- manual placental removal (tali pusat terkendali)
- 20 U oxytocin in 1000 mL RL or normal saline IV, 10mL/min with effective uterin
massage.

Placenta Accreta, Increta, Percreta


Placenta Accreta : abnormally firm adherence to uterine wall
Pacenta Increta : vili actually invade into myometrium
Placenta percreta : vili penetrate through myometrium
Risk Factors: previous caesarian delivery scar, after uterine curettage (biasanya in lower
segment)
Diagnosis : trasabdomanial sonogram, MRI
Management
Depens on site of implantation, depth of myometrial penetration, number of lobules involved.
Placental Fragment Retention
Fragmen masih intact di endometrium

Inversion of Uterus
May be incomplete or complete
Management, steps :
1. Immediate assistance include anesthesial personnel
2. Kalo placenta uda lepas, replaced uterus simply by pushing up on the fundus with the
palm of the hand and fingers in direction of long axis of vagina
3. Adequate large bores IV, crytalloid and blood are given to treat hypovolemia
4. If placenta still attached, the placenta is not removed until infusion systems are
operational, fluids are being given, and uterine relaxing anesthetic uch as halogenated
inhalation agent has been administerd. Other tocolytic : terbutaline, ritodrine, MgSO4,
and nitroglycerin have been used successfully for uterin relaxation and repositioning.
5. After removing placenta, steady pressure with the fist applied in the inverted fundus in
an attempt to push it up into the dilated cervix. 2 fingers are rigidly extended and are
used to push the center of the fundus upward. Tocolytic agent stopped as soon as the
uterus is restored to its normal configuration. Oxytocin infusion is begun while the
operator maintains the fundus in its normal position.
6. Kalo gabisa pake manual, laparotomy

TRAUMA :
Genital Tract Lacerations
Perineal lacerations / vaginal lacerations / injuries to levator ani muscles / injuries to cervix
Diagnosis :
Bleeding while the uterus is firmly contracted is strong evidence of genital tract laceration,
retained placental fragments, or both.
Visualization is best accompanied when an assistant applies firm downward pressure on the
uterus while the operator exerts traction on the lips of the cervix with ring forceps.
Management :
Surgical repair / suturing

Puerperal Hematomes
Risk factors : nulliparity, episiotomy, forceps delivery
Vulvar hematom / vulvovaginal / paravaginal / retroperitoneal.
Diagnosis : severe perineal pain and usually rapid appearance of tense, fluctuant, and sensitive
swelling of varying size by discolored skin.
Treatment : incision and drainage

Rupture of Uterus
Most common cause is separation of a previous caesarean hystrotomy scar.
Predisposising factors : previous traumatizing operations such as curettage, perforation, or
myomectomy. Excessive or inappropriate uterine stimulation with oxytocin has become
uncommon.

THROMBIN : Consumptive Coagulopathy


- Normal pregnancy : increase coagulation factors I (fibrinogen), VI, VIII, IX, X,
plasminogen. Increased activation of platelets, clotting, and fibrinolytic mechanism.
- In pathological states, abnormal cycle of coagulation and fibrinolysis may be initiated -
> depletion of platelets and coagulation factors in variable quantities -> bleding results
Factors for consumptive coagulation :
include thromboplastin from placental abruption.
Clinical and Laboratory :
Hypofibrinogenemia, thrombocytopenia, D- dimer high, prolonged PT APTT
ABORTION
Terhentinya proses kehamilan pada usia kehamilan < 20 minggu atau berat janin < 500 g.
Type of Abortion :
- Spontaneous Abortion
- Induced Abortion
Etiology :
- Fetal : chromosomal abnormalities
- Maternal : Infections (TORCH), Endocrine (hypotiroid, DM), Nutrition, Drug and
environmental (tobacco, alcohol, caffeine), kontrasepsi, immunological factors
(antifosfolipid sindrom- APS), uterine defects , incompetent cervix
- Paternal: chromosomal abnormalities in sperm

Clinical Classification
1. Threatened Abortion/ iminens
2. Inevitable abortion : gabisa dicegah, sedang berlangsung
3. Incomplete abortion : janin sudah ada yang keluar
4. Missed abortion : janin masih di dalam tp sudah tidak ada aktivitas jantung
5. Septic abortion : setelah complete abortion, terjadi infeksi
6. Recurren abortion/abortion habitualis : minimal 3x keguguran berulang
7. Complete abortion : sudah keluar semua
8. Blighted ovum : hanya gestational sac, janin tidak ada
Septic Bervariasi, Bervariasi Terbuka, Ekspulsi jaringan
Abortion
berbau biasanya bervariasi
busuk
Recurrent/ Bervariasi Bervariasi Terbuka, Ada Ekspulsi
Habitualis
biasanya jaringan konsepsi

Laboratory Examination :
Kuantitatif hCG, kualitatif dan kuantitatif serum hCGm CBC
USG :
Gestational sac (4-5 minggu), yolk sac (5-6 minggu),denyut jantung transvaginal (6 minggu) ,
denyut jantung transabomen (7 minggu)

Management
- Misoprostol
- D&C
Abortion with Hemorrhagic Shock
- ABC
- Two large bore IV lines
- CBC, coagulation, type and cross-match blood, rhogam for Rh patients
- Perlvic exam : uterin size, lacerations, cervival dilatations, degree of active bleeding
- Ultrasound : reveal any retained products of conception
- Empty uterus with Pitocin, methergine, antibiotics, massage
- Blood transfusion with correction of any clotting abnormalities
- Retaine products of conception require D&C
- For patiens with septic abortion, triple antibiotics should be given