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

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 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 segmen

Cervix
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
Amnion Cervix

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
Plasenta SBR

Tak ada bagian-bagian plasenta yg lepas lagi

Tak ada perdarahan baru

Pemecahan ketuban

Ketuban

Plasenta ikut dg pembukaan

SBR

Syarat : Derajat luasnya penutupan ostium oleh plasenta Letak plasenta 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 tersembunyi
Pelepasan biasanya komplit Hanya merupakan 20% dari solusio plasenta

Dengan perdarahan ke luar

Biasanya inkomplit Merupakan 80% dari solusio 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 Uterus

antepartum yang bersifat nyeri

tegang dan nyeri

Setelah

plaenta lahir terdapat impresi pada permukaan maternal

DIFFERENSIAL DIAGNOSIS :
PLASENTA
RUPTURA

PREVIA

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 :
Pada

solusio plasenta yang berat prognosis untuk anak adalah buruk (90%) ibu juga berbahaya, tetapi dengan persediaan darah yang cukup dan pengelolaan yang baik, kematian dapat ditekan

Bagi

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 Seksio

drip

sesarea, bila :

Anak hidup

Serviks tertutup Dua jam setelah oksitosin drip his (-)

Post partum mungkin terjadi perdarahan karena :

Plasenta
Daerah Daya

Akreta

perlekatan luas

kontraksi SBR kurang

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

BAHAYA UNTUK ANAK : Hipoksia Perdarahan & syok