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Transcript of Materi dr Kadek Sukamertha, Sp.OG, Gawat Darurat Obstetri filePANGGUL ---- EPISIOTOMI-VA.E-F.E...
![Page 1: Materi dr Kadek Sukamertha, Sp.OG, Gawat Darurat Obstetri filePANGGUL ---- EPISIOTOMI-VA.E-F.E Distosia bahu-Mc ROBERT ASPIKSIA BBL HPP • TONUS • TISSUE • TRAUMA • TROMBIN](https://reader034.fdocument.pub/reader034/viewer/2022052200/5c7b34b209d3f26c268baad1/html5/thumbnails/1.jpg)
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Curriculum Vitaeu 1993 - 2099 pdd dr Umum /FK Udayanau 2010 - 2011 Klinik Damayanti Nusa Duau 2012 - 2015 PTT PKM Gunungsari,
Lombok Barat, NTBu 2016 – 2011 pdd PPDS Obgyn RSUP
Sanglah / FK Udayanau 2011 – 2012 RSU Surya Husadhau 2013 – 2014 RSU Lombok Utara, NTBu 2015 – sekarang RSU Bhakti Rahayu
RS BaliMed
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GAWAT DARURAT OBSTETRI
dr. I Kadek Sukamertha, SpOGBagian Obstetri dan Ginekologi
RSU BHAKTI RAHAYU DENPASAR
26 Januari 2019
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uGAWAT DARURAT
- KEJADIAN/KEADAAN YANG DATANG SEKONYONG-KONYONG/TIBA-TIBA
- MENGANCAM IBU DAN ATAU JANIN- ADA UNSUR KEPERLUAN AMAT SANGAT
MENDADAK- GAWAT,DANGEROUS,DISTRESS,HAL
YANG MEMBAHAYAKAN
- PERLU PENANGANAN DENGAN SEGERA
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GAWAT DARURAT OBSTETRI
BISA SAAT KEHAMILANPERSALINANMASA NIFAS
u MUNGKIN DIPERKIRAKAN AKAN TERJADIu DAPAT DIKENALu LAKUKAN PPGD
u MERUJUK KETEMPAT YANG BENAR
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Perhatikanu ASPEK ANTISIPASIu BEDAKAN ANCAMAN PADA IBU, JANINu SANGAT PENTING K.I.E DAN KONSELING
u TINDAKAN BISA- KONSERVATIF- PERTOLONGAN PERTAMA- TINDAKAN DIFINITIF- MERUJUK
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Faktor risiko kegawat daruratan obsteteri
1. Empat terlalua. Terlalu muda umur < 20 thb. Terlalu tua umur > 35 thc. Terlalu banyak punya anak > 5 orangd. Terlalu dekat jarak kelahiran anak < 2 th
2. Tinggi badan ibu < 145 cm3. Hemoglobin < 11 g %4. Berat badan pada triwulan III < 45 kg5. Lingkar lengan atas < 23,5 cm
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KEGAWAT DARURATAN PADA KEHAMILAN DANPERSALIAN
I. KEGAWAT DARURATAN PADA KEHAMILAN
Yang termasuk kegawatdaruratan pada kehamilan
1. Perdarahan :*Pada kehamilan muda (UK < 20 mg )
kemungkinan :- abortus- kehamilan ektopik- mola
* Pada kehamilan >20 mg / saat persalinantetapi belum melahirkan dicurigai:- Plasenta previa- solutio plasenta- robekan dinding rahim
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2. Bengkak dikaki,tangan dan wajah atau sakit kepala beratkadang-kadang disertai kejang
3. Demam tinggi
4. Keluar air ketuban sebelum waktunya
5. Ibu muntah terus menerus
6. Gerakan bayi menurun atau tidak dirasakan lagi
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II. KEGAWAT DARURATAN PADA PERSALINAN
1. PerdarahanHPP curigai : robekan dinding uterus, atoniauteri, robekan jalan lahir, plasenta yang tertinggal.
2. Persalinan berlangsung 12 jam / lebih tanpakelahiran bayi
3. Gawat janin- DJJ < 100/mnt atau >180/mnt- air ketuban hijau kental
4. Tali pusat / tangan bayi menumbung5. Setelah bayi keluar, ari-ari tidak keluar6. Ibu mengalami kesakitan yang hebat / gelisah
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IBU HAMIL❐ PERDARAHAN❐ HDK
ANC CATATANBUMIL
PERSALINAN❐ PROTRECTED❐ ARRESTED❐ REST OF DECENT
KALA I PARTOGRAF WHO
FAILURE OF DECENT KALA II APN
KALA III MANAGEMENT AKTIF KL III
❐ RETENSIO PLC❐ REST. PLC❐ ATONIA UTERI
KALA IV 2 JAM P.Pa’ 15’- 1 jam Ia’ 30’ - 1 JAM II
90% FISIOLOGIS10% PATOLOGIS☛ PUSH☛ PULL☛ PANIK
❐ SUB INVOLUSI
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PERSALINAN
DISTOSIA
RUJUKAN
S.C
KEPALA DI DASAR PANGGUL ---- EPISIOTOMI
-VA.E-F.E
Distosia bahu-Mc ROBERT
ASPIKSIA BBL
HPP
• TONUS
• TISSUE
• TRAUMA
• TROMBIN
• Infeksi puer Sepsis• Eklamsia
10% PATOLOGIS 90% FISIOLOGIS
RESUSITASIBBL
ManagemenAtonia Uteri
Plc manualRepairHecktingTranfusi
P
O
N
E
D/
K
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PERDARAHAN TRIMESTER I
uABORTUS
uMOLA HIDATIDOSA
uKET
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ABORTUSu KEDARURATAN à PERDARAHAN.u PENANGANAN:
u A-u B-u C-u D- EVAKUASI
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MOLA HIDATIDOSA
u ABORTUS MOLA HIDATIDOSA
u SUSPEK MOLA HIDATIDOSA—RUJUK-EVAKUASI = EVAKUASI ABORTUS-PERLINDUNGAN OKSITOSIN DRIP-PERDARAHAN MINIMAL/BERHENTI
DIRUJUK---ADA TATA LAKSANA PENANGANAN LANJUTAN.
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KEHAMILAN EKTOPIK (K.E)u SUSPEK K E --- DIRUJUK ( R.D.B.)
Ingat TRIAS KLASIK: Amenore, Perdarahan,Nyeri abdomen
u KET ( TERGANGGU )-A-B-C: RESUSITASI CAIRAN
PENANGANAN SYOK HIPOVOLEMIK
DIRUJUK –PENANGANAN LANJUTAN
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KEHAMILAN LANJUT
uPerdarahan Dan Emergency Karena:
1. Plasenta previa
2. Solusio plasenta
3. Vasa previa pecah
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OBSTETRI ADALAH BLOODY BUSINESS
KEMATIAN MATERNAL BISA DITURUNKAN
KAUSA PERDARAHAN MASIH MENONJOLA S 1979-92:4915 KEMATIAN MATERNAL NON ABORTUS30% KAUSA PERDARAHAN
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KAUSA PERDARAHAN JUMLAH (%)
ABRUPTIO PLACENTAE141 (19)LACERATION/UTERRINE RUPTURE 125 (16)UTERINE ATONY
115 (15)COAGULOPATHIES
108 (14)PLACENTA PREVIA 50 ( 7 )PLACENTA ADHESIVE
44 ( 6 )
CHICHACLI (1999), WILLIAM 21ST
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PERDARAHAN ANTE PARTUM
1. ABRUPTIO PLACENTAE/SOLUTIO PLACENTAE
2. PLACENTA PREVIA
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ABRUPTIO PLACENTAE
• PLASENTA LEPAS
• IMPLANTASI NORMAL
• SEBELUM BAYI LAHIR
• > 20 MINGGU
DEFINISI
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ABRUPTIO PLACENTAE
•ACCIDENTAL HEMORRHAGE
•SOLUTIO PLACENTAE
•PREMATURE SEPARATION OFTHE NORMALLY
IMPLANTEDPLACENTA
TERMINATIONS
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ABRUPTIO PLACENTAE
•EXTERNAL HEMORRHAGE
•CONCEALED HEMORRHAGE
•TOTAL
•PARTIAL
FREQUENCY: 1 : 200 DELIVERIES
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ABRUPTIO PLACENTAE
DIAGNOSIS
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
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ABRUPTIO PLACENTAE
COMPLICATIONS
•SHOCK ≈ ≠ BLEEDING
•CONSUMPTIVE COAGULOPATHY
•RENAL FAILURE
•COUVELAIRE UTERUS
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ABRUPTIO PLACENTAE
MANAGEMENT
STATUS OFTHE MOTHER
STATUS OFTHE FETUS
GESTATIONALAGE
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PLACENTA PREVIA
•PATHOLOGIC IMPLANTATION
•LOW SEGMENT
•OVER OR VERY NEAR OS
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PLACENTA PREVIA
NORMAL IMPLANTATION:
•UTERINE FUNDAL
•UTERINE CORPORAL
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PLACENTA PREVIA DEGREE
1. TOTAL PLACENTA PREVIA
2. PARTIAL PLACENTA PREVIA
3. MARGINAL PLACENTA PREVIA
4. LOW LYING PLACENTA
5. VASSA PREVIA
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PLACENTA PREVIA
INCIDENCE
IYASU (1993) 0,50%
FREDERIKSEN (1999) 0,55%
CRANE (1999) 0,33%
PARKLAND HOSPITAL 12YEARS 0,26%WILLIAM, 21ST
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PLACENTA PREVIA
ETIOLOGY
•INCREASES MATERNAL AGE
•MULTIPARITY
•PRIOR CESAREAN DELIVERY
•SMOKING
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PLACENTA PREVIA
CLINICAL FINDING
•PAINLESS HEMORRHAGE
•SECOND TRIMESTER
•WITHOUT WARNING
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PLACENTA PREVIA
THE CAUSE OF SPONTANEOUSHEMORRHAGE IS
RELATED TODEVELOPMENT OF THE LOWERUTERINE SEGMENT
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PLACENTA PREVIA DIAGNOSIS
CLINICAL FINDINGPAINLESS HEMORRHAGEWITHOUT WARNING
DOUBLE SET-UPVAGINAL EXAMINATION
SONOGRAPHYTRANSABDOMINALTRANSVAGINAL
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PLACENTA PREVIA
MANAGEMENT:
1. FETUS IS PRETERM?
2. FETUS MATURE TO DELIVERY?
3. THOSE IN LABOR?
4. SEVERE HEMORRHAGE?
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PLASENTA PREVIA
PERDARAHAN SEDIKIT( <250 cc )
PERDARAHAN BANYAK( > 500 cc )
PRETERM ATERM
ISTIRAHAT USG
TOTAL SUBTOTAL
AMNIOTOMI
PERDARAHAN INPARTU
PERVAGINAM
S E K S I O S E S A R E A
PRETERM ATERM
ISTIRAHAT
STOP ULANG
DSU
TOTAL
SUBTOTAL
AMNIOTOMI
DARAH INPARTU
PERVAGINAM
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HIPERTENSI DALAM KEHAMILAN( H D K )
• HT Kronis• HT Gestasional• HT Kronis dg Superimposed PE• P.E : -RINGAN
=> -CEGAH BERAT -BERAT => -CEGAH KEJANG
• EKLAMPSIA : -----RUJUK ( RDB )
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EKLAMPSIA• Didahului oleh PE
• Gejala dan tanda = PE, diikuti kejang.
• impending : nyeri kepala, nyeri ulu hati, ggn penglihatan
• Dibedakan dg epilepsi, anestesi,koma sebab lain
• Komplikasi : solusio plasenta, hipofibrinogenemia,
hemolisis, perdarahann otak, kelainan mata,
edema paru, nekrosis hati,
HELLPS sindroma, kelainan ginjal,
prematur/dismatur/iufd
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Prinsip Penanganan
uHentikan kejangMgSO4 (siap Ca Glukonas 10%)anti HT (Nifedipin)
uKurangi vasospame
uMeningkatkan diuresis
uTerminasi
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Syok Obstetriu Klasifikasi :
– Hipovolumik– Septik– Kardiogenik– Anafilaktik, dll
u Terbanyak à hipovolumik ok. Perdarahan
u Yg sering menyebabkan : perdarahan, infeksiberat, solusio plasenta, luka jalan lahir, inversiouteri, emboli air ketuban,
u Penanganan : à ABC resusitasi, cari penyebabGAWAT DARURAT
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Partus Lama / Macet
uKala II melebihi waktu yang ditentukan– Primi : 2 jam– Multi : 1 jam
uPenyebab : 3 P
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Partus Kasep
uPersalinan macet dan lama shg tjdkomplikasi ibu dan janin
KOMPLIKASI JANINKaput, fetal distress, iufd
KOMPLIKASI IBUVagina/vulva edema, portio edema, rupture uteri, febris, ketuban hijau, dehidrasi
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Prinsip Penanganan
uRehidrasi, uO2uLakukan evaluasi menyeluruh #3P
uTentukan letak dan kondisi bayiuPersalinan pervaginam dg Va E/ FE
sesuai syaratuBila syarat tdk terpenuhi à SC
– Power à akselerasi– Passanger– Passage
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Penatalaksanaan
uPerbaiki KU IbuIVFD Normal saline 500cc, Dextrose 5-10% 500ccAntibiotika: Ampisilin, metronidazolePenurun panasKoreksi asam basa (Analisa AGD)
Terminasi kehamilan.
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uResusitasi intra uterine
Perbaiki sirkulasi darah intra uterine– Posisi ibu miring kiri– RL / Nacl 28tt/m– Relaksasi uterus ( K.p tokolitik )
Perbaiki oksigenasi janinoksigen sungkup 5-7 lt/mnt
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Perdarahan Post Partum Primer
u Perdarahan lebih dari 500 cc dlm 24 jam I u Penyebab :
– Rest plasenta– Retensio Plasenta– Luka jalan lahir– Atonia Uteri– Kelainan Pembekuan
u Penanganan :– Venus line, antibiotika– Penanganan sesuai penyebab– ABC HPP
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u Minta pertolonganu A..B..Cu O2 sungkup 10 l/mntu Priksa VS, kesadaran, TD, Nadi, tonus
uterus, perkirakan volume darah yg hilangu Baringkan dg kaki lebih tinggiu Infus dobel dg kanul G16
RL 2lt, Keloid 1-2 ltu Sampel darah utk labu Tranfusiu Psn tetap hangatu Pasang DC
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Retensio Plasentau Plasenta tidak lahir lebih dari 30 menitu Akreta, inkreta, perkretau Komplikasi :
– Perdarahan– Infeksi
u Penanganan :– Venus line, antibiotika– Manual plasenta– Kuretase– Histrektomi
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Perdarahan Post Partum Sekunder
u Perdarahan yg terjadi setelah 24 jam I persalinanu Penyebab :
– Rest plasenta– Infeksi– Kelainan Pembekuan
u Penanganan :– Venus line, antibiotika– Penanganan sesuai penyebab
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Sepsis Puerperalisu Definisi~ Febris puerpuralis
Demam oleh sebab apapun lebih dari 380 C selama 2 hari dalam 10 hari pertama dg mengecualikan hari pertama( febris à dg tanda sepsis)
u Faktor predisposisi : penurunan daya tahan tubuh, Partus lama, bedah pervaginam, patologi kala III
u Penanganan :– Antibiotika– Rehidrasi– Deksametason– Definitip ~ kausa
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DISTOSIA BAHUu Bahu tidak bisa lahir krn tersangkut dibawah
simpisis
u Komplikasi :– Bayi :hipoksia, fraktur/cedera, mati– Ibu : HPP, Ruptur uteri
u Faktor risiko : Post term, Kegemukan, Makrosomia, riwayat distosia, operatif pervaginam, partus lama, DM
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•Penanganan :A : ask for helpL : Lift/hiperfleksi of legA : Anterior shoulder disimpactionR : Rotation of posterior shoulderM : Manual removal posterior armE : EpisiotomiR : Roll over onto all four• Patahkan clavicula• Sympisiotomi• ZavanelliHindari : Pull, Push, Panic,!!
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Prolaps Tali Pusatu Tali pusat berada di samping atau melewati bag
terendah janin stl ketuban pecahu Predisposisi : kelainan letak, cpd, prematuru Lakukan vt bila ketuban pecah atau djj lambat dg
sebab tdk jelas.
u Penanganan :– Bayi hidup : - reposisi, sc à siapkan resusitasi– Bayi mati : Pervaginam
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Cepalo Pelvik Disproporsiu Ketidaksesuaian ukuran kepala bayi dg panggul
ibuu Bayi besar – panggul normalu Bayi normal panggul sempitu Bayi normal panggul normalà posisi diameter
kepalau Tanda awal : Kepala tidak masuk PAPu Komplikasi :
– Partus lama– Ruptur uteri
u Penanganan : SC
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RUPTUR UTERIu Diskontinuitas dinding uterus sehingga kavum
uteri berhubungan dengan kavum abdomenu Jenisnya : Iminen, spontan, ruptur totalu Gejala :
– nyeri hebat tiba – tiba, tetani, kontraksi menghilang– Bagian janin mudah diraba– Gawat janin à djj (-)– Ibu syok
u Penyebab :– Partus lama– Induksi/ akselerasi persalinan– CPD– Persalinan bekas SC– Perasat kristeler yang salah
u Penanganan : -Laparotomi
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Komplikasi Kala III
uPerdarahan pos partumuGangguan kala uriu Inversio uteriuPencegahan :
– Lakukan penanganan aktif kala III :uBeri oksitosin saat kepala lahiruMasase uterusuTarikan tali pusat terkendali
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RINGKASAN PENATALAKSANAAN
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Prinsip Dasar
uGawatuDaruratuGawat darurat
– Life saving– Mengembalikan fungsi vital– Mencegah kerusakan lebih parah
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Penilaian Awal
uKeadaan Umum– Penampakan pasien
uSakit berat – sedang – ringanuCemas
uVital signuKausa
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Penilaian Klinik Lengkap
uKeadaan Umum– Baik – sedang – jelek– GCS
uVital SignuPemeriksaan penunjang
– Laboratorium– Pencitraanà Penegakan diagnosa
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Syok HemoragikuOksigenasi – nutrisi alat vitaluPrinsip Umum
– Lakukan Penilaian klinik lengkap– Resusitasi cairan à donor darah– Perbaiki fungsi vital shg mendekati
optimal– Balance cairan– Cari dan tangani kausa– Informed concent
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Perdarahan Dalam Obstetrik
uKehamilan– Kehamilan muda– Kehamilan lanjut
uPersalinan– Penanganan ~kausa
uNifas– PP dini– PP lanjut
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