IUGR, Fetal Distress dan Fetal Death
dr. Hydrawati Sari, MCE, SpOG
Definisi
Intrauterine growth restriction (IUGR) adalah berat janin dibawah BB persentil ke-10 pada umur kehamilannya. Janin dipengaruhi oleh keadaan patologi sehingga
mengganggu kemampuannya utk tumbuh.
BBLRBBLR: BB lahir bayi < 2500 gram yg dapat
terjadi karena IUGR atau prematuritas
Insidensi
3-10% dari seluruh kehamilan 20% dari bayi stillbirth Kematian perinatal: 4-8 kali lebih tinggi
Karakteristik
SimetrisSimetris AsimetrisAsimetris
Disproporsi pada Disproporsi pada pertumbuhan abdomen, pertumbuhan abdomen, kmk problem terjadi stlh kmk problem terjadi stlh perkembangan janin yg sdh perkembangan janin yg sdh lanjut. lanjut.
kepala dan badan bayi kepala dan badan bayi kecil, kmk terjadinya kecil, kmk terjadinya problem pd awal problem pd awal perkembangan janinperkembangan janin
In a normal infant, the brain weighs about three times more than the liver. In In a normal infant, the brain weighs about three times more than the liver. In
asymmetrical IUGR, the brain can weigh five or six times more than the liver.asymmetrical IUGR, the brain can weigh five or six times more than the liver.
Simetris Early onset Constitutional or “normal” small Decreased growth potential Normal ponderal index Lower risk for transitional problems Brain symmetrical to body
Contoh: Genetic causes, chromosomal
Karakteristik IUGR
Karakteristik IUGR
Asimetris Late onset
Environmental
Growth arrest
Higher risk for transitional problems
Brain sparing
Contoh:
Hipoksia kronik
Preeklamsia
Hipertensi kronik
Malnutrisi
Simetris Asimetris
Kecil dan simetris Kepala > abdomen
Ponderal indeks normal Ponderal indeks rendah
Rasio H/A dan F/A normal Rasio H/A dan F/A meningkat
Kelainan Genetik, infeksi Insufisiensi vaskuler plasenta
Prognosis jelek Prognosis lebih baik jika komplikasi dapat dicegah atau tx adekuat
IUGR
Etiologi
1. Maternal
2. Fetal
3. Plasenta
Faktor maternal Genetik Demographics
Umur (extremes of reproductive age)RasStatus sosioekonomi
BB kurang sblm hamil atau malnutrisi Penyakit kronik Terpapar teratogen (obat-obatan,
radiasi, dll.)
Faktor maternal
Penyakit jantung Penyakit ginjal Hipertensi Penyakit paru Hemoglobinopathies Penyakit Collagen-
vascular Diabetes
Postmatur Kehamilan multipel Thrombotic disease High altitude
environment Merokok Drug abuse (kokain)
Faktor-faktor yg mempengaruhi aliran dan fungsi plasenta
Faktor fetal
Constitutional – genetically small, but genetically normal
Kelainan kromosom Malformasi – SSP, skeletal, gastroschisis Infeksi kongenital – CMV, rubella
Faktor plasenta
Malformasi – vaskular Infark Solusio plasenta Plasenta previa Invasi trofoblas yg abnormal
Faktor plasenta
Insufisiensi Uteroplasental Ketidaksesuaian/tidak adekuatnya invasi trophoblast dan
plasentasi pada trimester pertama. Berkurangnya aliran darah maternal ke placental bed.
Insufisiensi Fetoplasental Kelainan vaskular plasenta dan tali pusat Menurunnya fungsi plasenta
Plasenta kecil, solusio plasenta, plasenta previa, kehamilan posterm
1. Identifikasi pasien risiko tinggi Pasien dgn faktor risiko tinggi Pasien dgn usia kehamilan tdk jelas TFU tidak sesuai
Riwayat keluarga atau penyakit Pemeriksaan fisik
Manajemen
2. Membedakan IUGR dgn small and healthy fetus USG
F/A ratio H/A ratio The fetal PI Rasio S/D umbilikalis:
menunjukkan IUGR Aliran diastole terbalik atau absen
Manajemen
Diagnosis
Indeks ponderal rendah Berkurangnya lemak subkutan Tdp keadaan sbb:
Hipoglikemia Hiperbilirubinemia, Necrotizing enterocolitis, Hyper viscosity syndrome
Neonatal -
Neonate and Placenta in IUGR
Normal & IUGR Newborn babies
Normal & IUGR Placentas
Antepartum surveillance of the IUGR fetus (Biophysical Profile)
Electronic monitoring of the fetal heart
Non stress test Contraction stress test
Pemeriksaan cairan amnion Amniosentesis: menilai maturasi paru
Manajemen
1. Antepartum Stillbirth Oligohidramnion:
urine output janin menurun karena perfusi renal menurun
Intrapartum fetal acidosis: Deselerasi lambat Penurunan variabilitas Bradikardi
Komplikasi
Deselerasi lambat
2. Neonatal Asfiksia dan asidosis perinatal
Aspirasi mekoneum Hypoxic-ischemic encephalopathy Gangguan metabolik: hipoglikemi, hipokalsemi,
sindrom hiperviskositas, dan hipotermi
Komplikasi
Pencegahan
Strategies include Perawatan prenatal Suplementasi protein/energy Terapi anemiavitamin/mineral supplementation, Pencegahan dan terapi
hipertensi infeksi
Treatment
IUGR has IUGR has many causes, therefore, there is causes, therefore, there is not one treatment that always works. not one treatment that always works.
Treatment Persalinan atau memperbaiki aliran darah ke uterus
Jika IUGR disebabkan oleh kelainan plasenta dan janin msh baik, diagnosis dan penanganan awal akan mengurangi kmk hasil yg jelek
Tidak ada terapi yg dpt memperbaiki pertumbuhan janin, ttp janin IUGR yg sdh cukup bulan akan memberikan outcome yg lbh baik jika dilahirkan segera.
Short Term Risks of IUGR Morbiditas dan mortalitas perinatal meningkat
Intra uterine / Intrapartum death. Intrapartum fetal asidosis ditandai dengan:
Late deceleration. Severe variable deceleration. Beat to beat variability. Episodes of bradicardia.
Intrapartum fetal asidosis dp terjadi pada 40% kasus IUGR shg meningkatkan kejadian bedah Sesar
Bayi IUGR berisiko lbh besar utk tjd kematian krn komplikasi neonatal: - asfiksia, asidosis, sindrom aspirasi mekoneum, infeksi, hipoglikemia, hipotermi, dll.
Bayi IUGR lebih rentan thd infeksi krn terganggunya imunitas
Long term Prognosis
Bayi IUGR berisiko utk tjd nya gangguan perkembangan, risiko ini meningkat seiring dgn beratnya growth restriction.
Setiap kasus adl unik. Tdk dpt diprediksi scr akurat progres yg akan datang. Beberapa bayi akan berkembang scr normal, sementara yg lain mempunyai komplikasi sistem saraf/intelectual problems
Fetal distress
LIN QI DE
2005.9.5
Fetal distress: berkurangnya oksigen dan
akumulasi CO2 shg terjadi “hypoxia dan
acidosis ” intra uterin.
Definisi
Maternal factors Iskemia mikrovaskuler (PIH) Anemia Perdarahan akut (placenta previa, placental
abruption) Shock and acute infection
Etiology
Placenta-umbilical factors Obstructed of umbilical blood flow Disfungsi plasenta Fetal factors Malformations of cardiovascular system Intrauterine infection
Etiology
Hypoxia 、 accumulation of carbon dioxide ↓
Respiratory Acidosis↓
FHR ↑ → FHR ↓→ FHR ↑↓
Intestinal peristalsis↓
Relaxation of the anal sphincter↓
Meconium aspiration↓
Fetal or neonatal pneumonia
Pathogenesis
Acute fetal distress
Chronic
Fetal
distress
Pathogenesis
IUGR(intrauterine
growth retardation)
Clinical manifestation
Acute fetal distress (1)FHR FHR>160 beats/min (tachycardia) <100 beats/min (bradycardia) (LD) Repeated Late deceleration Placenta dysfunction (VD) Variable deceleration Umbilical factors
FHR:120~160 bpm / FHR variability
Early deceleration
Late deceleration
Variable deceleration
Clinical manifestation
Acute fetal distress (2) Meconium staining of the amniotic fluid (3) Fetal movement Frequently→decrease and weaken (4) Acidosis FBS (fetal blood sample) pH<7.20
pO2<10mmHg (15~30mmHg)
CO2>60mmHg (35~55mmHg)
Clinical manifestation
Chronic fetal distress
(1) Placental function
(2) FHR
(3) BPS
(4) Fetal movement
(5) Amnioscopy
Management
Remove the induced factors actively
Koreksi acidosis: 5%NaHCO3 250ML
Terminasi kehamilan (1) FHR>160 or <120 bpm, mekoneum stain (2) Meconium staining grade III amniotic fluid volume<2cm (3) FHR<100 bpm continually
Management
Terminasi kehamilan (4) Repeated LD and severe VD
(5) Baseline variability disappear with LD
(6) FBS pH<7.20
Forceps delivery
Caesarean section
Treatment for Fetal Distress
Reposition patient: miring kiri Berikan oksigen Pemeriksaan vaginal utk mengetahui ada/tdk prolaps tali
pusat Ensure that qualified personnel are in attendance for
resuscitation and care of the newborn. Note: each institution shall define in writing the term
qualified personnel for resuscitation and care of the newborn.
Each of the following actions should be performed and documented prior to starting a Cesarean section for fetal distress: Perform vaginal exam to rule out imminent
vaginal delivery; Initiate preoperative routines; Monitor fetal heart tones (by continuous fetal
monitoring or by auscultation) immediately prior to preparation of the abdomen;
Ensure that qualified personnel are in attendance for resuscitation and care of the newborn (each institution shall define in writing the term qualified personnel for resuscitation and care of the newborn).
Stop using oxytocin, because oxytocin can strengthen the contraction of uterine which affects the baby's heart rate.
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