Presentasi Kasus

G2P1A0 Hamil Aterm Inpartu Kala 1 Fase Laten dengan KPSW 3 Hari Janin Tunggal Hidup Presentasi Kepala

Oleh

Widhi Astuti 0!1"0110"#$

Preceptor

dr% Tau&i'urahmman (ahim) Sp% *G

S+F *,ST-T(I .A/ GI/-K*L*GI (S0. dr% H% A,.0L +*-L*-K ,A/.A( LA+P0/G S-PT-+,-( 2013

I% .ATA KAS0S

/ama +ahasis1a /I+

2 Widhi Astuti 2 0!1"0110"#

I%1 I.-/TITAS PASI-/ NO REGISTER : 1022253 MRS Pu"ul : 32 5!3 : 0 #!5#3$

Na%a (%ur Pen'i'i"an Pe"er+aan *-a%a Su"u *la%at 2an'ar 1a%pun-

: N&# Isralin'a : 3) tahun : SM* : I,u ru%ah tan--a : Isla% : .a/a : .l# I%a% ,on+ol0 Gan- Tirta Kencan Kel 1an-"apura

Na%a sua%i (%ur Pe"er+aan Pen'i'i"an *-a%a Su"u *la%at 2an'ar 1a%pun-

: Tn# 2ra%anti Putra : 3) tahun : Pe'a-an: SM* : Isla% : .a/a : .l# I%a% ,on+ol0 Gan- Tirta Kencan Kel 1an-"apura

I%2 A/A+/-SIS 3ia%,il 'ari Tan--al4Pu"ul : *utoana%nesa : 13 Septe%,er 2013

1# Keluhan a# (ta%a ,# Ta%,ahan %asu" ru%ah sa"it : 5a%il cu"up ,ulan 'an %au %elahir"an : Keluar air6air se+a" 3 hari &an- lalu se,elu%

2# Ri/a&at pasien se"aran7 3 hari SMRS pasien %en-eluh "eluar air6air 'ari "e%aluann&a0 /arnan&a ,enin-0 ,au ti'a" a'a0 'an ,an&a"n&a 1 sa%pai 3 "ali -anti celana 'ala%# OS +u-a %en-eluh perut terasa %ules &an- %en+alar "e pin--an-0 perut %ules hilan- ti%,ul0 +aran-0 'an 'irasa"an se%a"in la%a se%a"in "uat# Ri/a&at "eluar 'arah len'ir a'a 0 ri/a&at 'e%a% ti'a" a'a0 ri/a&at sa"it

-i-i ti'a" a'a0 ri/a&at trau%a ti'a" a'a0 ri/a&at post coitus ti'a" a'a0 ri/a&at "eputihan ti'a" a'a0 ri/a&at %inu% +a%u atau o,at6o,atan ti'a" a'a# Os "e%u'ian per-i "e ,i'an0 'i"ata"an "etu,an su'ah pecah# Os %en-a"u ha%il cu"up ,ulan 'an -era"an ana" %asih 'irasa"an# 1alu os 'iru+u" untu" ,ero,at "e RS*M#

3# Ri/a&at 5ai' 5ai' perta%a u%ur Si"lus 1a%an&a 2an&a"n&a 5P5T Ta"siran persalinan : 13 tahun : 30 hari : ) hari : ,iasa 8 7 )0 cc9 : ! 3ese%,er 2013 : 11 Septe%,er 2013

!# Ri/a&at per"a/inan Per"a/inan "e Sela%a : Satu :) tahun

5# Ri/a&at O,stetri"
No T-l4,ln4thn Persalinan 1# Tahun 200 2# 5a%il ini .enis Kela%in 1a"i6la"i 6 2erat ,a'an 3!00 -r 6 (sia ana" 5 tahun 6 Penolon2i'an 6 Keteran-an *na" 'ala% "ea'aan sehat 6

)# Ri/a&at pen&a"it : a# Pen&a"it 'ahulu : I,u %en-ata"an ti'a" pernah %en'erita

pen&a"it %enular0 %enurun %aupun %enahun seperti hepatitis0 *I3S0 T2:0 5T0 +antun-0 'll serta ti'a" pernah %asu" Ru%ah Sa"it ,# Pen&a"it 'ala% "eluar-a : I,u %en-ata"an 'i 'ala%

"eluar-an&a ti'a" a'a &an- %en'erita pen&a"it %enular0%enahun %aupun %enurun seperti hepatitis0 5I;4*I3S0 +antun-0 "eturunan "e%,ar0 hia,etes %ellitus0 hipertensi0 'll <# Ri/a&at operasi # Ri/a&at "eluar-a ,erencana 4"ontrasepsi %en--una"an "ontrasepsi pil K2 $# Ri/a&at antenatal a# Sela%a ha%il 'iperi"sa 'i 'an oleh ,i'an ,# Keluhan 'an "elainan c# I%unisasi 10# 5al > hal lain : ti'a" a'a : 2 = sela%a "eha%ilan : Ti'a" a'a : 'iperi"sa 'i ,i'an 'an oleh : Ti'a" a'a : Sela%a 7 3 tahun

2%3 P-+-(IKSAA/ FISIK 1# Pe%eri"saan u%u% Kea'aan u%u% Kesa'aran Te"anan 'arah Na'i : Ta%pa" sa"it se'an: :o%pos %entis : 1204 0 %%5: 2 =4%enit

Respirator& rate Suhu Kea'aan -i?i Tin--i ,a'an 2erat ,a'an

: 20 =4%enit : 3)0<0 : : 2ai"0 lin-"ar len-an 2 c% : 155c% : )! "-

Kulit Mu"a Mata 5i'un1eher

: Sa/o %atan-0 chloas%a -ra@'i'aru% 869 : Mi%i" ,ai"0 e'e%a 8690 ',n : "on+uncti@a ane%is 8690 s"elera i"teri" 869 :ca@u% nasi ',n0 alae nasi ',n :pe%,esaran "elen+ar li%Aa 8690 stru%a 8690 pe%,en-"a"an @ena +u-ularis 869

.antun-

: 2un&i +antun- I'an II ,ai"0 Mur%ur 6460 -allop 6460

+antun- 'ala% ,atas nor%al

Kelen+ar li%Ae Kepala Telin-a Mulut4-i-i 3a'a

: Ti'a" a'a pe%,en-"a"an "elen+ar li%Ae : Nor%ochephal : *uricula 'e"stra 'an sinistra si%etris : sto%atitis 8690 ane%is 8690 caries 869 : pa&u'ara B ,entu" ,ulata %en--atn-0 areola

hiperpi-%entasi0 puttin- susu %enon+ol0 striae ti'a" a'a# Paru : ;esi"uler C4C0 /hee?in- 6460 ron"hi 646

*,'o%en

: *,'o%en ce%,un-0 na%pa" "eha%ilan

sesuai

u%ur "eha%ilann&a0 striae li@i'e0 linea n'-ra0 ta" ta%pa" ,e"as lu"a se=io saecaria 5ati 1i%Aa Gin+al Kan'un- "e%ih : Ti'a" 'apat 'inilai : ti'a" 'apat 'inilai : ',n0n&eri "eto" su'ut costophrenicus ti'a" a'a : ',n

Ke%aluan

: @ul@a B /arna "e%erahan0 lu"a parut ti'a" a'a0

Aluor al,us se'i"it0 @arices ti'a" a'a0 e'e%a ti'a" a'a0 na%pa" 'arah len'er "eluar 'ari "e%aluan# Pun--unRectu% 4 anus E"stre%itas ReAle"s Sensi,ilitas : S"oliosis 8690 "iAosis 8690 lor'osis 869 : ;arices 8690 he%oroi' 869 : e'e%a 8690 sianosis 869 : reAle"s Aisiolo-is 'an patolo-is ti'a" 'ila"u"an : ',n

2# Pe%eri"saan O,stetri" a# Pe%eri"saan u%u% Inspe"si : *,'o%en ce%,un-0 na%pa" u"uran "eha%ilan

sesuasi 'en-an usia "eha%ilann&a0 ,e"as lu"a operasi ti'a" a'a0 pa'a "ontur a,'o%en na%pa" -a%,aran uterus &an- %enon+ol#

<

Palpasi 1eopol' I

: : TD( 3 +ari 'i ,a/ah procesus =ipoi'heus0 pa'a Aun'us i,u tera,a luna"0"uran- %elentin-0 "uran,un'ar0 'iper"ira"an a'alah ,o"on- +anin#

1eopol' II

: leta" %e%an+an-0 pa'a perut ,a-ian "iri tera,a "eras %e%an+an- 'iper"ira"an pu--un- +anin 'an 'ise,elah "anan perut i,u tera,a ,a-ian "ecil > "ecil +anin &an- 'iper"ira"an tan-an 'an "a"i +anin#

1eopol' III

: pa'a perut ,a-ian ter,a/ah terasa ,un'ar0 "eras 'an ti'a" 'apat 'i-o&an-"an0 'iper"iira"an "epala +anin su'ah %asu" P*P

1eopol' I;

: Ke'ua tan-an 'i@er-en0 "epala su'ah %asu" P*P !45 8tera,a ! +ari 'iatas s&%phisis9

TD( 5is T2. Per"usi *us"ultasi

: 3 +,p= atau 32 c% : 2410420E : 8326119= 155F 3255 -r# : Pe"a"0 na%pa" %asa pa'at : 3.. 13 =4%0 re-ular

,# Pe%eri"saan 'ala% ;a-inal taucher Porsio Pen'ataran : 1una" : 25G

Pe%,u"aan Ketu,an 2a-ian teren'ah Penurunan Penun+u" Posisi

: 3 c% : selaput "etu,an 8690 +ernih0 ti'a" ,er,au : "epala : 5o'-e I : ((K lintan: Me'ial

Inspe"ulo Portio O(E Dlu"sus Dluor Erosi4polip4laserasi Tes 1a"%us : 1i@i'e : Ter,u"a : PositiA : Ne-atiA : Ti'a" a'a : positiA 8C9

c# Pe%eri"saan pan--ul *r"us pu,is 3in'in- sa%pinSpina ischia'i"a 1inea ino%inata Pro%ontoriu% : $00 : lurus : ti'a" tera,a : 143 > 143 : ti'a" tera,a

:on+u-ata 'ia-onalis : H13 c% :on+u-ata @era (+un- sacru% : H1005 c% : "on"aA

Kesan pan--ul S"or Pel@ic 6 6 6 6 6 3ilatasi Pen'ataran Konsistensi Posisi

: 1uas : : 36! c% : 25G : luna" : Me'ial 1 1 2 0 2

Turunn&a "epala : 62 c% .u%lah : )

1%3 P-+-(IKSAA/ P-/0/JA/G 1# 1a,oratoriu% a# 5, ,# Proteinuria c# Pe%eri"saan 1a, lainn&a 6 6 6 6 6 6 6 1eu"osit G3S Tro%,osit (rea Kreatinin Masa per'arahan Masa pe%,e"uan : 110 -r4'l : Ne-atiA 869 : : $#!004ul : <$ %-4'l : 13$#0004%%3 : 11%-4'l : 00! %-4'l : 3 %enit : 12 %enit

2# Pe%eri"saan (SG lainn&a

: ti'a" 'ila"u"an

10

1%4 (-S0+7 3 hari SMRS pasien %en-eluh "eluar air6air 'ari "e%aluann&a0 /arnan&a ,enin-0 ,au ti'a" a'a0 'an ,an&a"n&a 1 sa%pai 3 "ali -anti celana 'ala%# OS +u-a %en-eluh perut terasa %ules &an- %en+alar "e pin--an-0 perut %ules hilan- ti%,ul0 +aran-0 'an 'irasa"an se%a"in la%a se%a"in "uat# Ri/a&at "eluar 'arah len'ir a'a 0 ri/a&at 'e%a% ti'a" a'a0 ri/a&at sa"it -i-i ti'a" a'a0 ri/a&at trau%a ti'a" a'a0 ri/a&at post coitus ti'a" a'a0 ri/a&at "eputihan ti'a" a'a0 ri/a&at %inu% +a%u atau o,at6o,atan ti'a" a'a# Os "e%u'ian per-i "e ,i'an0 'i"ata"an "etu,an su'ah pecah# Os %en-a"u ha%il cu"up ,ulan 'an -era"an ana" %asih 'irasa"an# 1alu os 'iru+u" untu" ,ero,at "e RS*M#

1%5 .IAG/*SIS a# 3ia-nosis "er+a : G2P1*0 ha%il ater% inpartu "ala I Aase laten

'en-an KPSI 3 hari .T5 pres"ep ,# 3ia-nosis ,an'in-: 6

1%# P-/ATALAKSA/AA/ Th4 O,ser@asi tan'a6tan'a @ital0 3..0'an tan'a6tan'a inpartu :hec" la,oratoriu% 'arah rutin0 urin rutin0 'an cross%atch I;D3 R1 JJ-tt4%enit In+e"si anti,ioti" proAila"sis 8 a%picilin 1-r 9 3''1 R4 *"selerasi

11

R4 partus per@a-ina% R4 e@aluasi sesuai parto-raA I5O %o'iAi"asi

1%" P(*G/*SIS 2 1# I,u 2# *na" : 'u,ia : 'u,ia

12

1%! F*LL*W 0P
1% 13%0!%2013 Partus Sp6ntan dengan KPSW /7% Isralinda835832"433 0"%34 WI, 3.. 13 =4% T3 : 1204 0 %%5Tes la"%us 8C9 2ishop score ) G2P1*0 ha%il ater% inpartu "ala I Aase laten 'en-an R4 pecah "etu,an 3 hari .T5 pres"ep Th4 O,ser@asi tan'a6tan'a @ital0 3..0'an tan'a6tan'a inpartu :hec" la,oratoriu% 'arah rutin0 urin rutin0 'an cross%atch I;D3 R1 JJ-tt4%enit In+e"si anti,ioti" proAia"sis 8 a%picilin 1-r 9 3=1 R4 a"selerasi 5 I( o=&toc&n R4 partus per@a-ina% R4 e@aluasi sesuai parto-raA I5O %o'iAi"asi G2P1*0 ha%il ater% inpartu "ala I Aase a"tiA 'en-an R4 pecah "etu,an 3 hari .T5 pres"ep Th4 O,ser@asi tan'a6tan'a @ital0 3..0'an tan'a6tan'a inpartu ID;3 R1 JJ-tt4%enit R4 partus per@a-ina% R e@aluasi sesuai parto-raA I5O %o'iAi"asi 15%34 WI, 3.. : 1!3 =4% G2P1*0 ha%il ater% inpartu "ala II Aase a"tiA 'en-an R4 pecah "etu,an 3 hari .T5 pres"ep OS -elisah in-in %en-e'an0 ;T K : len-"ap Th4 pi%pin persalinan 1ahir spontan neonates hi'up la"i6la"i 22 3500 -r0 P2 50c%0 *4S 4$0 *nus 8C90 cacat 869 DT *G* Plasenta lahir len-"ap spontan 'en-an 2P 500-r0 PTP ! c%0 K 1<=1 c% Perineu% utuh Kontra"si uterus ,ai" Per'arahan "ala III4I; 7300 cc Pasien 'ala% "ea'aan ,ai" 'ipin'ah"an "e ruan-an 'an %en+alani ra/at -a,unP6st partum sp6ntan /7% Isralinda835832"433 05%00 WI, (uangan$ P2*0 post partu% spontan

2%3 WI, 3.. 1!5 =4%

15%34 WI, 15%40 WI,

1"%30 WI, 2% 13%0!%13

13

Status Present K( Na'i Suhu P1 : Ta%pa" sa"it se'anT3 : 1104 0 %%5RR : 20 =4%nt : 0 =4%nt : 3)0<L: : tiAut 2 +, pusat0 "ontra"si ,ai"0 per'arahan a"tiA 8690 lo"ia ru,ra 8C9 Th4 Oser@asi tan'a6tan'a @ital I;D3 R1 JJ-tt4%enit *%o=icillin 500 %- ta, 3 '' 1 Paraceta%ol 500 %- ta, 3 '' 1 Neuro'e" ta, 1''1 Ks'rn : :M

Status O,stetri"us

13%0!%013 12%30 WI,

Pasien su'ah pulan- 'ala% "ea'aan u%u% ,ai"

1!

II% P-(+ASALAHA/

1# *pa"ah 'ia-nosis pa'a "asus ini su'ah tepatM 2# *pa"ah penatala"sanaan pa'a "asus ini tepatM 3# *pa"ah pen&e,a, KPSI pa'a "asus iniM

A/ALISA KAS0S

1#

*pa"ah 'ia-nosis pa'a "asus ini tepatM Seoran- pere%puan ,erusia 3) tahun 'atan- "e ru%ah sa"it 'en-an "eluhan ha%il cu"up ,ulan 'en-an su'ah "eluar air6air 7 3 hari &an- lalu# 3ari ana%nesis 'i"etahui ,ah/a pen'erita %en-eluh perut terasa %ules &an%en+alar "e pin--an- 'an "eluar air6air se+a" 7 3 hari se,elu% %asu" ru%ah sa"it0 ,enin-0 ti'a" a'a ,au0 ,an&a"n&a 1 sa%pai 'en-an 3 "ali -anti celana 'ala% sela%a 3 hari # Os %en-a"u "eluar 'arah len'ir 'ari "e%aluan 'an %asih %erasa"an a'a -era"an +aninn&a# 3ari ana%nesa0 ri/a&at sa"it -i-i ti'a" a'a0 ri/a&at "eputihan ti'a" a'a0 ri/a&at trau%a ti'a" a'a0 ri/a&at postcoitus ti'a" a'a0 ri/a&at %inu% +a%u 'an o,at6o,atan ti'a" a'a# Ke%u'ian os per-i "e ,i'an 'an 'iru+u" "e RS*M#

15

Pa'a pe%eri"saan Aisi" 'i'apat"an tan'a @ital i,u 'ala% "ea'aan ,ai" 'en-an te"anan 'arah 1204 0 %%5-0 na'i 2 "ali per%enit0 pernaAasan 20 "ali

per%enit0 'an suhu 3)0<N:# Pa'a pe%eri"saan luar 'i'apat"an tin--i Aun'us uteri 3 +ari 'i ,a/ah proccessus =iphoi'eus0 leta" +anin %e%an+an-0 pun--un- "iri0 ,a-ian ter,a/ah a'alah "epala 'an penurunan !450 'en&ut +antun- +anin 13 "ali per%enit0 his a'a 2=410E420EE# Pe%eri"saan 'ala%

'ila"u"an 'i'apat"an hasil Pe%eri"saan 'ala% portio luna"0 pen'ataran 25G0 pe%,u"aan 3c%0 selaput "etu,an utuh0 ,a-ian teren'ah a'alah "epala0 penurunan 5o'-e I0 'an penun+u" ,elu% 'apat 'itentu"an# Pa'a saat inspe"ulo 'i'apat"an hasil portio li@i'e0 O(E ter,u"a0 Alu"us positiA0 Aluor ne-ati@e0 'an tes la"%us positiA#

3ari se%ua ana%nesa 'an pe%eri"saan Aisi" &an- telah 'ila"u"an 'apat 'ite-a""an 'ia-nosa pasien ini a'alah G2P1*0 ha%il ater% inpartu "ala I Aase laten 'en-an KPSI 3 hari0 +anin tun--al hi'up presentasi "epala#

2%

Apa9ah penatala9sanaan pada 9asus ini sudah tepat: Pa'a "asus ini pen'erita %asu" ru%ah sa"it 'en-an 'ia-nosis G2P1*0 ha%il ater% inpartu "ala I Aase laten 'en-an KPSI 3 hari0 +anin tun--al hi'up presentasi "epala# Penatala"sanaan pa'a pasien ini su'ah tepat#

Pasien ini 'itatala"sana secara a"tiA 'en-an rencana persalinan per@a-ina%# 5al terse,ut 'ila"u"an "arena pasien 'en-an ha%il ater% O3< %in---u 'an ri/a&at KPSI le,ih 'ari 12 +a%# Pe%ilihan persalinan per@a-ina% pa'a

1)

pasien ini 'en-an "eha%ilan presentasi "epala# Pe%,erian anti,ioti" 'i,eri"an untu" %ence-ah inAe"si intrauterin a"i,at terhu,un-n&a ca@u% intrauterine 'en-an 'unia luar a"i,at pecahn&a selaput "etu,an# 3ila"u"an o,ser@asi terha'ap 3..0 tan'a @ital i,u0 'an tan'a6tan'a inpartu# 5al ini 'ila"u"an -una untu" %en-etahui "ea'aan +anin 'an +u-a "ea'aan i,u# 3.. 'i pantau untu" %en-etahui +i"a 'ite%u"an a'an&a -a/at +anin &an- 'apat %en-anca% +anin0 'an +u-a tan'a @ital i,u untu" %en-etahui "on'isi i,u atau "ea'aan &an- 'apat %en-anca% n&a/a i,u seperti ter+a'in&a inAe"si0 "arena %or,i'itas 'an %ortilitas pa'a KPSI %enca"up -a/at +anin &an- 'apat ter+a'i "arena a'an&a pene"anan pa'a plasenta 'i"arena"an oli-ohi'ra%nion0 intra uterin Aetal 'eath 8162 G "asus90 'an +u-a a'an&a inAe"si i,u &an'itan'ai 'en-an te%peratur H3 o:0 2 atau le,ih 'ari tan'a6tan'a n&eri uterus0 "ontra"si0 "etu,an ,au0 leu"osit %enin-"at 'an "ultur %enun+u""an nilai positiA#

3%

Apa9ah pen7e;a; tim;uln7a KPSW pada 9asus ini: 2er'asar"an etiolo-in&a0 ter+a'in&a KPSI se,a-ian ,esar 'ite%u"an pa'a /anita ,eru%ur 'iatas 35 tahun# 5al ini %un-"in +u-a 'apat 'ise,a,"an Aa"tor6Aa"tor etiolo-i lain &an- %e%pen-aruhin&a0 seperti:

1# 2er"uran-n&a "e"uatan %e%,ran "etu,an a"i,at inAe"si0 teruta%a inAe"si ascen'en 'ari @a-ina atau ser@i"s# 2# *'an&a penin-"atan te"anan intra uterine pa'a O(I seperti ser@i"s in"o%peten0 "eha%ilan "e%,ar0 hi'ra%nion0 "ontra"si %&o%etriu%

1<

%enin-"at0 3KP0 5*P0 'an %alposisi# 3# *'an&a 'e-ra'asi "ola-en pa'a selaput "etu,an &an- 'i%e'iasi oleh %atri"s %etalloproteinase 8MMP9# 3i%ana se/a"tu %asa persalinan0 "esei%,an-an antara MMP 'an TIMP61 %en-arah pa'a 'e-ra'asi proteoliti" 'ari %atri"s e"straseluler 'an %e%,ran +anin# *"ti@itas 'e-ra'asi proteoliti" ini %enin-"at saat proses "eha%ilan sehin--a %en-a"i,at"an ter+a'in&a "etu,an pecah 'ini# !# 1ain6lain0 %eliputi: sosial e"ono%i ren'ah0 'eAisiensi -i?i 'an @ita%in c0 %ero"o"0 "eturunan0 'an anta-onis -olon-an 'arah *2#

Pa'a "asus 'iatas KPSI &an- ter+a'i "e%un-"inan "arena a'an&a proses penin-"atan 'e-ra'asi %atri"s e"straseluler %e%,ran selaput "etu,an oleh %atri"s %etalloproteinase 8MMP9#

III%

Tin<auan Pusta9a

Masa "eha%ilan 'i%ulai 'ari "onsepsi sa%pai lahirn&a +anin# 1a%an&a ha%il nor%al a'alah 2 0 hari 8 !0 %in--u atau $ ,ulan < hari 9 'ihitun- 'ari hari perta%a hai' tera"hir#Keha%ilan 'i,a-i 'ala% 3 tri/ulan &aitu tri/ulan perta%a 'ari "onsepsi sa%pai 3 ,ulan tri/ulan "e'ua 'ari ,ulan "ee%pat sa%pai ) ,ulan0 tri/ulan "eti-a 'ari ,ulan "etu+uh sa%pai $ ,ulan# Menurut :unin-ha%0 200) tahap per"e%,a-an %anusia &an- 'ia%,il 'ari Moore &aitu : 1# Pi-ot &aitu sel &an- ter,entu" se,a-ai hasi Aertilisasi o@u% 'an sper%ato?oa 2# 2lasto%er# Pe%,elahan %itotic 8 clea@a-e9 ?i-ot %en-hasilsel aana" 'ise,ut ,lasto%er 3# Morula &aitu sel ,er,entu" ,ola pa'at &an- ter,entu" 'ari 1) atu le,ih ,lasto%er !# 2lasto"ista# Setelah %orula %encapai uterus0 ter,entu" suatu ron--a ,erisi cairan &anA %en-u,ah %orula %en+a'i ,lasto"ista

1$

5# Mu'i-ah 8e%,rio9# Sel6sel pe%,entu" %u'i-ah0 &an- ,er"elo%po" se,a-ai suatu %asa sel 'ala% 8inner cell %ast90 en-hasil"an %u'i-ah &an,iasan&a 'ise,ut 'e%i"ian apa,ila su'ah ter,entu" le%pen- e%,rioni" ,ila%inar# Perio'e %u'i-ah %e%an+an- sa%pai a"hir %in--u "e > < saat stru"tur6stru"tur uta%a %ulai 'ite%u"an# )# .anin 8Aetus9 &aitu setelah perio'e %u'i-ah "onseptus &an- tu%,uh 'ise,ut +anin# <# Konseptus &aitu "ata &an- 'i-una"an untu" %en&e%,ut se%ua pro'u" +arin-an hasil "onsepsi6%u'i-ah0 +anin0 %e%,ran +anin0 'an plasenta# Konseptus %enca"up se%ua +arin-an0 ,ai" e%,rioni" %aupun

e"strae%,rioni"0 &an- ,er"e%,an- 'ari ?i-ot#

2%1 .e&inisi Partus Partus a'alah suatu proses pen-eluaran hasil "onsepsi &an- 'apat hi'up 'ari 'ala% uterus %elalui @a-ina "e 'uia luar# Se,a, ter+a'in&a partus sa%pai "ini %asih %erupa"an &an- "o%ple"s# Da"tor6Aa"tor hu%oral0 pen-aruh prostat-lan'in0 stru"tur uterus0 sir"ulasi uterus0 pen-aruh saraA 'an nutrisi 'ise,ut se,a-ai Aa"tor6Aa"tr &an- %en-a"i,at"an partus %ulai#Peru,ahan6 peru,han 'ala% ,io"i%ia 'an ,ioAisi"a telah ,an&a" %en-un-"ap"an %ulai 'ari ,erlan-sun-n&a partus0 antara lain penurunan "a'ar hor%one estro-en 'an pro-esterone# Seperti 'i"etahui pro-esterone %erupa"an penenan- ,a-i otot uterus# Menurunn&a "a'ar "e'ua hor%one ini ter+a'i "ira6"ira 162 %in--u se,elu% partus 'i%ulai 8Pra/irohar'+o0 200<9#

20

2%2 +e9anisme Persalinan Partus 'i,a-i %en+a'i ! "ala# Pa'a "ala I ser@i"s %e%,u"a sa%pai ter+a'i pe%,u"aan 10 c%# Kala I 'ina%a"an pula "ala pe%,u"aan0 Kala II 'ise,ut pula "ala pen-eluaran0 oleh "arena ,a"at "e"uatan is 'an "e"uatan %en-e'an +anin 'i'oron- "e luar sa%pai lahir# 3ala% "ala III atau "ala uri plasenta terlepas 'ari 'in'in- uterus 'an 'ilahir"an# Kala I; 'i%ulai 'ari lahirn&a plasenta 'an la%an&a 1 +a% 8 Pra/ihar'+o0 200<9# a% Kala I Klinis 'apat 'in&ata"an partus 'i%ulai ,ila ti%,ul his 'an /anita terse,ut %en-eluar"an len'er &an- ,erse%u 'arah 8,loo'& sho/9# 1en'ir &an,erse%u 'arah ini ,erasal 'ari len'er "analis ser@i"alis "arena ser@i"s %ulai %e%,u"a atau %en'atar# Se'an-"an 'arahn&a ,erasal 'ari pe%,uluh6pe%,ulh "apiler &an- ,era'a 'i se"itar "analis ser@i"alis itu pecah "arena per-eseran6per-eseran "eti"a ser@i"s %e%,u"a# Proses %e%,u"an&a ser@i"s se,a-ai a"i,at his 'i,a-i 'ala% 2 Aase# Dase laten &an- ,erlan-sun- sela%a +a%# Pe%,u"aan ter+a'i san-at la%,at

sa%pai %encapai u"uran 'ia%eter 3 c%# Selan+utn&a &aitu Aase a"tiA &an'i,a-i 'ala% 3 Aase la-i0 &a"ni Aase a"selerasi0 'ala% /a"tu 2 +a% pe%,u"aan 3 c% ta'i %en+a'i ! c%# Dase 'ilatasi %a"si%al0 'ala /a"tu 2 +a pe%,u"aan ,erlan-sun- san-at cepat0 'ari ! c% %en+a'i $ c%# Dase 'eselerasi pe%,u"aan %en+a'i la%,at "e%,ali# 3ala% /a"tu 2 +a% pe%,u"aan 'ari $ c% %en+a'i len-"ap#

21

Dase6Aase terse,ut 'i+u%pai pa'a pri%i-ra@i'a# Pa'a %ulti-ra@i'a pun ter+a'i 'e%i"ian0 a"an tetapi Aase laten0 Aase a"tiA0 'an Aase 'eselerasi ter+a'i le,ih pen'e"# Kala I selesai apa,ila pe%,u"aan ser@i"s uteri telah len-"ap# Pa'a pri%i-ra@i'a "ala I ,erlan-sun- "ira6"ira 13 +a%0 se'an-"an pa'a %ultipara "ira6"ira < +a%# Ketu,an a"an pecah 'en-an sen'iri&a "eti"a pe%,u"aan ha%pir atau telah len-"ap# Ti'a" +aran- "etu,an harus 'ipecah"an "eti"a pe%,u"aan ha%pir len-"ap atau telah len-"ap# 2ila "etu,an telah pecah se,elu% %encapai pe%,u"aan 5 c%0 'ise,ut "etu,an pecah 'ini 8KP39

8Pra/irohar'+o0200<9# ;% Kala II Pa'a "ala II his %en+a'i le,ih "uat 'an le,ih cepat0 "ira6"ira 2 sa%pai 3 %enit se"ali# Karena ,iasan&a 'ala% hal ini "epala .anis su'h %asu" 'i ruan- pan--ul %a"a pa'a his 'irasa"an te"anan pa'a otot6otot 'asarpan--ul &a- secara reAle"toris %eni%,ul"an rasa%en-e'an# Iaita %erasa pula te"anan "epa'a rectu% 'an hen'a" ,uan- air ,esar# Ke%u'ian perineu% %ulai %enon+ol'an %en+a'i le,ar 'en-an anus %e%,u"a# 1a,ia %ulai %e%,u"a 'an ti'a" la%a "e%u'ian "epala +anian ta%pa" 'ala% @ul@a pa'a /a"tu his0 'en-an his 'an "e"uatan %en-e'an a"si%al "epala +anin'ilahir"an 'en-an su,o"siut 'i,a/ah si%phisis 'an 'ahi0 %u"a 'an 'a-u %ele/ati perineu%# Setelah istirahat se,entar0 his %ulai la-i untu" %en-eluar"an ,a'an 'an an--ota ,a&i#

22

=% Kala III Setelah ,a&i lahir0 uterus tera,a "eras 'en-an Aun'us uteri a-a" 'iatas pusat# 2e,erapa %enit "e%u'ia uterus ,er"ontra"si la-i untu" %elepas"an plasenta 'ari 'in'in-n&a# 2iasan&a plasenta lepas 'ala% )615 %enit setelah ,a& lahir 'an "eluar spontan atau 'en-an te"anan pa'a Aun'us uteri# Pen-eluaran plasenta 'isertai 'en-an pen-eluaran 'arah# d% Kala I> Seperti 'iteran-"an 'iatas "ala ini 'ian--ap perlu untu" %en-a%ati apa"ah a'a per'arahan post partu%# Setelah plasenta lahir %asih a'a %asa "ritis &an- 'iha'api oleh i,u 'ala% %asa terse,ut 'apat ter+a'i per'arahan# Pen&e,a, uta%a 'ari per'arahan ialah "ontra"si uterus &an- "uran- ,ai"# Oleh "arena itu se,elu% 1 +a ,erlalu0 pen'erita ,elu% ,oleh 'ipin'ah"an "e "a%arna 'an %asih %e%erlu"an pen-a/asan &an- se"sa%a#

III%2

Selaput Ketu;an dan ?airan Amni6n

Selaput "etu,an 8selaput +anin9 ter'iri 'ari a%nion 'an "orion# *%nion a'alah %e%,ran +anin %e%,rane +anin palin- 'la% 'an ,er'a%pin-an 'en-an cairan %anion# Stru"tur a@as"ular "husus ini %e%ili"i peran pentin'ala% "eha%ilan pa'a %anusia# *%nion a'alah +arin-an &an- %enentu"an ha%pir se%ua "e"uatan re-an%e%,rane +anin#3en-an 'e%i"ian0

pe%,entu"an "o%ponen6"o%ponen a%nion &an- %ence-ah rupture atau ro,e"an san-atlah pentin- ,a-i "e,erhasilan "eha%ilan#

23

Menurut 5elen0 a%nion 8selput "etu,an9 %erupa"an %e%,rane internal &an%e%,un-"us +anin 'an cairan "etu,an# Selaput ini licin0 tipis0 ulet 'an transparan# Selaput a%nion %ele"at pa'a "orion 8se"alipun 'pat 'i"upas 'en-an %u'ah9# Selaput ini %enutupi peru"aan Aetal plasenta sapai pa'a insersio tali pusat 'an "e%u'ian ,erlan+ut se,a-ai pe%,un-"us tali pusat &an- te-a" lurus hin--a u%,ilicus +anin# Se'an-"an "orion %erupa"an %e%,ran e"sternal &an- ,er/arna putih 'an ter,entu" 'ari @ili6@ili sel telur &an- ,erh,un-an 'en-an 'esi'ua "apsularis# Selaput ini ,erlan+ut 'en-an tepi plasenta 'an %ele"at pa'a lapisan uterus#

>6lume =airan amni6n 2 :airan &an- nor%aln&a +ernih 'an %enu%pu" 'i 'ala% ron--a a%nion ini a"an %enin-"at +u%lahn&a seirin- 'en-an per"e%,an-an "eha%ilan sa%pai %en+elan- ater%0 saat ter+a'i penurunan @olu%e cairan a%nion pa'a ,an&a" "eha%ilan nor%al#
Min--u Gestasi 1) 2 3) !0 .anin 8-9 100 1000 2500 3300 Plasenta 8-9 100 200 !00 500 :airan a%nion 8%l9 200 1000 $00 00 Persen cairan 50 !5 2! 1<

Ta;el 1% ;olu%e cairan a%nion &an- la?i%

;olu%e cairan a%nion pa'a ha%il ater% se"itar 100061500 %l0/arna putih0 a-a" "eruh0 serta %e%pun&ai ,au "has0 a-a" a%is 'an %anis# :airan ini 'en-an ,erat +enis0 1000 ter'iri atas $ G air#Sisan&a ter'iri atas -ra% anor-ani serta ,ahan or-anic 'an ,ila 'iteliti ,enar0 ter'apat ra%,ut lanu-o0 sel6sel epitel

2!

'an @erni"s "aseosa# Protein 'ite%u"an rata6rata 20)G -ra% per liter0se,a-ian ,esar se,a-ai al,u%in# Kea'aan nor%al cairan a%nion %enurut Qulai"hah 200$ antaralain pa'a usia "eha%ilan cu"up ,ulan @olu%e 100061500 cc0 "ea'aan +ernih a-a" "eruh0steril ,au "has a-a" %anis 'an a%is ter'iri 'ari $ 6$$G air 'an 162G -ara%6-ara% anor-ani" 'an ,ahan or-anic 8protein teruta%a al,uin90 runtuhan ra%,ut lanu-o0 @erni"s "aseosa0 'an sel6sel epitel sir"ulasi se"itar 500 cc4+a%#

Fungsi =airan amni6n 2 1# Prote"si 2# Mo,ilisas : %elin'un-i +anin terha'ap trau%a 'ari luar : %e%un-"in"an ruan- -era" ,a-i +anin

3# 5o%eostasis : %en+a-a "esei%,an-an suhu 'an lin-"un-an asa% ,asa 8p59 'ala% ron--a a%nion untu" suasan lin-"un-an &an- opti%al ,a-i +anin# !# Me"ani" intrauterine 5# Pa'a persalinan0 %e%,ersih"an atau %elicin"an +alan lahir 'en-an cairan steril sehin--a %elin'un-i ,a&i 'ari "e%un-"inan inAe"si +alan lahir : %en+ah-a "esei%,an-an te"anan 'ala%seluruh uan-

3%3 -pidemi6l6gi 3ala% "ea'aan nor%al0 hin--a 10G pere%puan ha%il ater% a"an

%en-ala%i Ketu,an Pecah 3ini# Ketu,an Pecah 3ini Pre%atur pula ter+a'i pa'a 1G "eha%ilan#5Men-i"ut reAerensi Il%u Ke,i'anan0 "e+a'ian Ketu,an

25

Pecah 3ini pa'a u%ur "eha%ilan se,elu% 3! %in--u0 "e+a'iann&a se"itar !G#33i"e%u"an ,ah/a "e+a'ian "etu,an pecah 'ini0 5 G 'iantaran&a se-era 'ii"uti oleh persalinan 'ala% 56) +a%0 se"itar $5 G 'ii"uti oleh persalinan 'ala% <6$5 +a%0 'an sele,ihn&a %e%erlu"an tin'a"an "onser@atiA atau a"tiA 'en-an %en-in'u"si persalinan atau operatiA#$Menurut +urnal Acta Medice Iranica 20030 ,erla"u per,e'aan insi'en %en-i"ut ras &aitu0 ,erla"u penin-"atan 'rastic pa'a /anita "ulit hita% &aitu 'ari 5#1G "e 12#5G 'an pa'a /anita "ulit putih 'ari 1#5G %en+a'i 2#2G# Sosioe"ono%i ren'ah ,elu% 'apat 'i+a'i"an para%eter &an- %e%pen-aruhi Ketu,an Pecah 3ini# 13 2er'asar"an Sur@ei 3e%o-raAi 'an Kesehatan In'onesia 8S3KI9 2002420030 an-"a "e%atian i,u 8*KI9 'i In'onesia %asih ,era'a pa'a an-"a 30< per 100#000 "elahiran hi'up atau setiap +a% ter'apat 2 oran- i,u ,ersalin %enin--al "arena ,er,a-ai se,a,# *ntaran&a0 )5G a'alah 'ise,a,"an "o%pli"asi 'ari Ketu,an Pecah 3ini#

3%4 .e&inisi Ketu;an Pe=ah .ini Ketu,an pecah 'ini a'alah pecahn&a "eu,an se,elu% ter'apat tan'a persalinan %ulai 'an 'itun--u satu +a% se,elu% ter+a'i inpartu# Se,a-ian ,esar "etu,an pecaha 'ini a'alah ha%il ater% 'i atas 3< %in--u0 se'an-"an 3) %in--u ti'a" terlalu ,an&a" 8Manua,a0200$9#

Se'an-"an %enurut Qu"hi"ah0 200$ "etu,an pecah 'ini a'alah pecahn&a "etu,an se,elu% ter'apat tan'a persalinan 'an setelah 'itun--u satu +a%0 ,elu% a'a tan'a persalinan# Ia"tu se+a" "etu,an pecah sa%apai ter+a'i

2)

"ontra"si rahi% 'ise,ut "e+a'ian "etu,an pecah 'ini 8 perio'e laten9# Kon'isi ini %erupa"an pen&e,a, terse,ar persalinan pre%ature 'en-an se-ala a"i,atn&a# Ketu,an pecah 'ini a'alah pecah&a "etu,an se,elu% inpartu0&aitu ,ila pe%,u"aan pa'a pri%i "uran- 'ari 3 c% 'an pa'a %ultipara "uran- 'ari 5 c% 8Mochtar0 200 9

2e,erapa penulis %en&aran"an istilah RKP3 la%aS untu" %en+elas"an perio'e laten &an- le,ih 'ari 2! +a%0 na%un +aran- 'i-una"an# *"i,at 'ari KP3 ter-antun- "epa'a usia "eha%ilan# Karenan&a0 "on'isi terse,ut 'i"lasiAi"asi"an "epa'a 010:

Ketu,an pecah pre%atur &aitu pecahn&a %e%,ran "horio6a%nioti" se,elu% onset persalinan atau 'ise,ut +u-a Premature Rupture Of Membrane = Prelabour Rupture Of Membrane = PROM # Insi'en PROM a'alah )61$G "eha%ilan# Ketu,an pecah pre%atur pa'a preter% &aitu pecahn&a %e%,ran :horio6 a%nioti" se,elu% onset persalinan pa'a usia "eha%ilan "uran- 'ari 3< %in--u atau 'ise,ut +u-a Preterm Premature Rupture Of Membrane = Preterm Prelabour Rupture Of Membrane = PPROM # Insi'en PPROM a'alah 2G "eha%ilan#
010

2<

Gam;ar 1# Ketu,an pecah 'ini

Arti 9linis 9etu;an pe=ah 2 1# 2ila ,a-ian teren'ah +anin ,elu% %asu" pintu atas pan--ul prolapsus tali %a"a "e%un-"inan ter+a'in&a prolapsus tali pusat atau "o%presi tali pusat %en+a'i ,esar 2# Peristi/a KP3 &an- ter+a'i pa'a pri%i-ra@i'a ha%il ater% 'en-an ,a-ian teren'ah &an- asih ,elu% %asu" pintu atas pan--ul serin-"ali %erupa"an tan'a a'an&a -an--uan "esei%,an-an Aeto pel@i" 3# KP3 serin-"ali 'ii"uti 'en-an a'a&a tan'a6tan'a persalinan 'apat e%icu ter+a'in&a persalinan preter% 'en-an se-ala a"i,atn&a !# Peristi/a KP3 &an- ,erlan-sun- le,ih 'ari 2! +a% 8prolon-e' rupture oA the %e%,rane9 serin-"ali 'isertai 'en-an inAe"si intrauterine 'en-n se-ala a"i,atn&a

5# Peristi/a KP3 'apat %en&e,a,"an oli-ohi'ra%nion 'an 'ala% +an-"a pan+an- "e+a'ian ini a"an 'apat %en&e,a,"an hilan-n&a Aun-si a%nion ,a-i pertu%,uhan 'an per"e%,an-an +anin

Gam;ar 2% 1apisan selaput "etu,an 3%5 -ti6l6gi Ketu;an Pe=ah .ini Ialaupun ,an&a" pu,li"asi tentan- KP30 na%un pen&e,a,n&a %asih ,elu% 'i"etahui 'an ti'a" 'apat 'itentu"an secara pasti#2e,erapa laporan %en&e,ut"an Aa"tor6Aa"tor &an- ,erhu,un-an erat 'en-an KP30 na%un Aa"tor6Aa"tor %ana &an- le,ih ,erperan sulit 'i"etahui# Ke%un-"inan &an%en+a'i Aa"tor pre'isposisi a'alah:20$

2$

a% Fa9t6r 0mum InAe"si &an- ter+a'i secara lan-sun- pa'a selaput "etu,an %aupun ascen'en 'ari @a-ina atau inAe"si pa'a cairan "etu,an ,isa %en&e,a,"an ter+a'in&a KP3#Penelitian %enun+u""an inAe"si se,a-ai pen&e,a, uta%a "etu,an pecah 'ini#Me%,rana "horioa%nioti" ter'iri 'ari +arin-an @is"oelasti"# *pa,ila +arin-an ini 'ipacu oleh persalinan atau inAe"si %a"a +arin-an a"an %enipis 'an san-at rentan untu" pecah 'ise,a,"an a'an&a a"ti@itas en?i% "ola-enoliti"#InAe"si %erupa"an Aa"tor &an- cu"up ,erperan pa'a persalinan preter% 'en-an"etu,an pecah 'ini# Grup 2 streptococcus %i"roor-anis%e &an- serin- %en&e,a,"an a%nionitis#

Selain itu 2acteroi'es Ara-ilis0 1acto,acilli 'anStaph&lococcus epi'er%i'is a'alah ,a"teri6,a"teri &an- serin- 'ite%u"an pa'a cairan "etu,an pa'a "eha%ilan preter%#2a"teri6,a"teri terse,ut 'apat %elepas"an %e'iator inAla%asi &an- %en&e,a,"an "ontra"si uterus#5al ini %en&e,a,"an a'an&a peru,ahan 'an pe%,u"aan ser@i"s0 'an pecahn&a selaput "etu,an# Da"tor u%u% &an- lain a'alah "ea'aan sosial e"ono%i &an- ,erhu,un-an 'en-an ren'ahn&a "ualitas pera/atan antenatal0 pen&a"it %enular se"sual %isaln&a 'ise,a,"an oleh :hla%&'ia tracho%atis 'an Neischeria -onorhoe#

;% Fa9t6r 6;stetri9 Ser@i" &an- in"o%petensia0 ser@i"s "onisiasi0 ser@i"s %en+a'i pen'e"# Kelainan pa'a ser@i"s &an- 'ise,a,"an oleh pe%a"aian alat6alat seperti a,orsi terapeuti"0 loop electrosur-ical e=cision proce'ure 81EEP9 &an30

tu+uann&a untu" %en-o,ati 'isplasia ser@i"s serta 'ia-nose 'ini "an"er ser@i"s 'an se,a-ain&a#11 Kanalis se@i"alis &an- selalu ter,u"a oleh "arena "elainan pa'a ser@i" uteri 8a"i,at persalinan0 "uretase9# Te"anan intra uterin &an- %enin-"at secara ,erle,ihan 8o@er'istensi uterus9 %isaln&a tu%or0 hi'ra%nion0 -e%elli#Kelainan leta" %isaln&a lintan-0 sehin--a ti'a" a'a ,a-ian teren'ah &an-%enutupi pintu atas pan--ul 8P*P9 &an'apat %en-halan-i te"anan terha'ap %e%,ran ,a-ian ,a/ah#

=% Fa9t6r 9eturunan Da"tor "eturunan ,erla"u +i"a a'a "elainan -eneti" 'an ,erla"u 'eAisiensi @ita%in : 'an ion :upru% 8:u9 'ala% seru%#

d% Fa9t6r lain Trau%a oleh ,e,erapa ahli 'isepa"ati se,a-ai Aa"tor pre'isisi atau pen&e,a, ter+a'in&a KP3#Trau%a &an'i'apat %isaln&a a%nosintesis

hu,un-anse"sual0

pe%eri"saan

'ala%0

%aupun

%en&e,a,"anter+a'in&a KP3 "arena ,iasan&a 'isertai inAe"si#Da"tor -olon-an 'arah &aitu0 a"i,at -olon-an 'arah i,u 'an ana" &an- ti'a" sesuai 'apat %eni%,ul"an "ele%ahan ,a/aan ter%asu" "ele%ahan +arinn-an "ulit "etu,an#Da"tor lain &aitu: Da"tor 'isproporsi antar "epala +anin 'an pan--ul i,u# Da"tor %ulti -ra@i'itas0 %ero"o" 'an per'arahan antepartu%# 3eAisiensi -i?i 'ari te%,a-a 'an @ita%in :#

31

 Prose'ur %e'is# (sia i,u ha%il &an- le,ih tua %un-"in %en&e,a,"an "etu,an "uran- "uat 'ari i,u &an- le,ih %u'a# Kele,ihan ,erat ,a'an se,elu% "eha%ilan 'an penin-"atan ,erat ,a'an &an- se'i"it se/a"tu "eha%ilan +u-a %erupa"an antara etiolo-i KP3#11 Da"tor risi"o "etu,an pecah 'ini persalinan preter%: "eha%ilan %ultipel : "e%,ar 'ua 850G90 "e%,ar ti-a 8$0G9 ri/a&at persalinan preter% se,elu%n&a per'arahan per@a-ina% p5 @a-ina 'i atas !#5 Kelainan atau "erusa"an selaput "etu,an# Alora @a-ina a,nor%al Ai,ronectin H 50 n-4%l "a'ar :R5 8corticotropin releasin- hor%one9 %aternal tin--i %isaln&a pa'a stress psi"olo-is In"o%petensi ser@i"s 8leher rahi%9 Polihi'ra%nion 8cairan "etu,an ,erle,ih9 Ri/a&at KP3 se,elu%n&a Trau%a 32

 ser@i= tipis 4 "uran- 'ari 3$ %%0 Ser@i"s 8leher rahi%9 &an- pen'e" 8T25%%9 pa'a usia "eha%ilan 23 %in--u InAe"si pa'a "eha%ilan seperti ,a"terial @a-inosis

Da"tor6Aa"tor &an- 'ihu,un-"an 'en-an partus preter%$: iatro-eni" : h&-iene "uran- 8teruta%a90 tin'a"an trau%ati" %aternal : pen&a"it siste%i"0 patolo-i or-an repro'u"si atau pel@is0 pre6e"la%psia0 trau%a0 "onsu%si al"ohol atau o,at2 terlaran-0 inAe"si intraa%nion su,"lini"0 "orioa%nionitis "lini"0 in"o%petensia ser@i"s0 ser@isitis4@a-initis a"ut0 Ketu,an Pecah pa'a usia "eha%ilan preter%# Aetal : %alAor%asi +anin0 "eha%ilan %ultipel0 hi'rops Aetalis0 pertu%,uhan +anin terha%,at0 -a/at +anin0 "e%atian +anin# cairan a%nion : oli-ohi'ra%nion 'en-an selaput "etu,an utuh0 "etu,an pecah pa'a preter%0 inAe"si intraa%nion0 "orioa%nionitis "lini"# placenta : solutio placenta0 placenta prae@ia 8"eha%ilan 35 %in--u atau le,ih90 sinus %a-inalis0 chorioan-io%a0 @asa prae@ia#

33

 uterus : %alAor%asi uterus0 o@er'istensi a"ut0 %io%a ,esar0 'esi'uositis0 a"tiAitas uterus i'iopati"

2e,erapa Aactor &an- ,erhu,un-an 'en-an "etu,an pecah 'ini12: *'an&a hiper%otilitas rahi% &an- su'ah la%a ter+a'i se,elu% "etu,an pecah# Pen&a"it6pen&a"it seperti pieloneAritis0 sistitis0 se@isitis 'an @a-initis ter'apat ,ersa%a6sa%a 'en-an hiper%otilitas rahi% ini# Selaput "etu,an terlalu tipis 8 "elainan "etu,an 9 InAe"si 8 a%nionitis atau "orioa%nionitis 9 Dactor6Aa"tor lain &an- %erupa"an pre'isposisi ialah : %ultipara0 %alposisi0 'isproporsi0 cer@i= inco%petent 'an lain6lain# Ketu,an pecah 'ini artiAicial 8 a%nioto%i 90 'i%ana "etu,an 'ipecah"an terlalu 'ini#

Pen&e,a, KP3 %enurut Manua,a0 200$ 'an Mor-an 200$ %eliputi : 1# Ser@i"s in"o%peten %en&e,a,"an 'in'in- "etu,an palin- ,a/ah %en'apat"an te"anan &an- se%a"in tin--i 2# Da"tor "eturunan 8 ion :u seru% ren'ah0 @ita%in : ren'ah0 "elainan -enetic 9

3!

3# Pen-aruh 'ari luar &an- %ele%ah"an "etu,an seperti inAe"si -enitalia 'an %enin-"atn&a en?i% proteoliti"# Masa inter@al se+a" "etu,an pecah sa%pai ter+a'i "ontra"si 'ise,ut Aase laten0 %a"in tin--i "e%un-"inan inAe"si# Ma"in %u'a "eha%ilan0 %a"in sulit upa&a pe%ecahann&a tanpa %eni%,ul"an %or,i'itas +anin 'an "o%pli"asi "etu,an pecah 'ini %a"in %enin-"at# !# Multipara0 -ran'e%ultipara# Pa'a "eha%ilan &an- terlalu serin- a"an %e%pen-aruhi proses e%,r&o-enesis sehin--a selaput "etu,an &anter,entu" a"an le,ih tipis &an- a"an %en&e,a,"an selaput "etu,an pecah se,elu% tan'a6tan'a inpartu# 5# O@er'istensi uterus pa'a h'ra%nion0 "eha%ilan -an'a 'an seAalopel@i" 'isproporsi# 5i'ra%nion atau "a'an-6"a'an- 'ise,it polii'ra%nion a'alah "ea'aan 'i%ana ,an&a"n&a air "etu,an %ele,ihi 2000 cc# 5i'ra%nion 'apat ter+a'i pa'a "asus anenseAalus0 atresia esopha-us0 -e%eli0 'an i,u &an- %en-ala%i 'ia,etes %elits -estasional 83MG9# I,u 'en-an 3MG a"an %elahir"an ,a&i 'en-a ,erat ,a'an ,erle,ihan pa'a se%ua usia "eha%ilan sehi--a "a'ar cairan a%nion +u-a a"an ,erle,ih# Keha%ilan -an'a a'alah "eha%ilan 'en-an 'ua +anin atau le,ih sehin--a "e%un-"inan ter+a'in&a hi'ra%nion ,erta%,ah 10 "ali le,ih ,esar# )# Kelainan leta" &aitu leta" lintan- sun-san<# Pen'ular a,'o%en 8perut -antun-9 # (sia i,u &an- le,ih tua %un-"in %en&e,a,"an "etu,an "uran- "uat 'aripa'a i,u %u'a# 35

$# Ri/a&at KP3 se,elu%n&a se,an&a" 'ua"ali atau le,ih 10# Mero"o" sela%a "eha%ilan#

3%# +e9anisme ter<adin7a 9etu;an pe=ah dini 2 a# Ter+a'i pe%,u"aan pre%atur ser@i"s ,# Me%,ran ter"ait 'en-an pe%,u"aan ter+a'i : 1# 3e@as"ularisasi 2# Ne"rosis 'an 'apat 'ii"uti pecah spontan 3# .arin-an i"at &an- %en&an--a %e%,ran "etu,an %a"in ,er"uran!# Mele%ahn&a 'a&a tahan "etu,an 'ipercepat 'en-an inAe"s &an%en-eluar"an en?i% proteoliti" 'an en?i% "ola-enase

3%" Pat6genesis 2 ;olu%e air "etu,an pa'a "eha%ilan cu"up ,ulan a'alah 1000 > 1500 cc# *ir "etu,an ,er/arna putih "e"eruhan0 ,er,au "has a%is0 'an ,erasa %anis0 rea"sin&a a-a" al"alis atau netral0 ,erat +enis 1000 # Ko%posisin&a ter'iri atas $ G air0 sisan&a al,u%in0 urea0 asa% uri"0 "reatinin0 sel6sel epitel0 ra%,ut lanu-o0 @erni"s "aseosa 'an -ara% anor-ani"# Ka'ar protein "ira6"ira 20) -r G per liter teruta%a se,a-ai al,u%in#

3)

3i+u%pai lecitin spin-o%&elin 'ala% air "etu,an a%at ,er-una untu" %en-etahui apa"ah +anin su'ah pun&ai paru6paru &an- %atan-# Se,a, penin-"atan "a'ar lecitin pertan'a ,ah/a per%u"aan paru6paru 'iliputi ?at surAa"tan# Ini %erupa"an s&arat ,a-i paru6paru untu" ,er"e%,an- 'an ,ernapas# 2ila persalinan ,er+alan la%a atau a'a -a/at +anin atau pa'a leta" sun-san- a"an "ita +u%pai /arna "etu,an "eruh "ehi+au6hi+auan0 "arena telah ,erca%pur 'en-an %e"oniu%#*sal air "etu,an 'ari 819 "encin- +anin 8Aetal urin90 829 transu'asi 'ari 'arah i,u0 839 se"resi 'ari epitel a%nion 'an 8!9 asal ca%puran 8mixed origin9#

Dun-si air "etu,an a'alah: (ntu" prote"si +anin# (ntu" %ence-ah perlen-"etan +anin 'en-an a%nion# *-ar +anin 'apat ,er-era" 'en-an ,e,as# Re-ulasi terha'ap panas 'an peru,ahan suhu# Mun-"in untu" %ena%,ah suplai cairan +anin0 'en-an cara 'itelan atau 'i%inu% &an- "e%u'ian 'i"eluar"an %elalui "encin- +anin# Merata"an te"anan intra > uterin 'an %e%,ersih"an +alan lahir ,ila "etu,an pecah# Pere'aran air "etu,an 'en-an 'arah cu"up lancar 'an perputarann&a cepat0 "ira6"ira 3506500 cc# 3<

Ketu,an pecah 'ala% persalinan secara u%u% 'ise,a,"an oleh "ontra"si uterus 'an pere-an-an ,erulan-#Selaput "etu,an pecah "arena pa'a 'aerah tertentu ter+a'i peru,ahan ,io"i%ia &an- %en&e,a,"an selaput "etu,an inAerior rapuh#

Penelitian ter,aru %en-ata"an KP3 ter+a'i "arena %enin-"atn&a apoptosis 'ari "o%ponen sel 'ari%e%,ran Aetal 'an +u-a penin-"atan 'ari en?i% protease tertentu# Ke"uatan %e%,rane Aetal a'alah 'ari %atri"s e"straselule a%nion# Kola-en a%nion interstitial teruta%a tie I 'an III &an- 'ihasil"an oleh sel %esen"i%+u-a pentin- 'ala% %e%pertahan"an "e"uatan %e%,rane Aetal#

Matri"s %etalloproteinase 8MMP9 a'alah "u%pulan proteinase &an- terli,at 'ala% re%o'elin- tissue 'an 'e-ra'asi 'ari "ola-en MMP620 MMP630 'an MMP6$ 'ite%u"an 'en-an "onsentrasi &an- tin--i pa'a "eha%ilan 'en-an "etu,an pecah 'ini# *"ti@itas MMP ini 'ire-ulasi oleh tissue inhi,itor oA %atri"s %etalloproteinase 8TIMPs9# TIMPs ini pula 'ite%u"an ren'ah 'ala% cairan a%nion pa'a /anita 'en-an "etu,an pecah 'ini# Penin-"atan en?i% protease 'an penurunan 'ari inhi,itor %n'u"un- teori ,ah/a en?i%6en?i% ini %e%pen-aruhi "e"uatan 'ari %er%an Aetal#

Ter'apat

"esei%,an-an

antara

sintesis sel0

'an 'an

'e-ra'asi

e"straseluler "ola-en 3

%atri"s#Peru,ahan

stru"tur0

+u%lah

"ata,olis%e

%en&e,a,"an a"ti@itas "ola-en ,eru,ah 'an %en&e,a,"an selaput "etu,an pecah#Da"tro resi"o untu" ter+a'in&a "etu,an pecah 'ini a'alah ,er"uran-n&a asa% as"or,i" se,a-ai "o%ponen "ola-en serta "e"uran-an te%,a-a 'an asa% as"or,i" &an- ,era"i,at pertu%,uhan stru"tur a,nor%al "arena antara lain %ero"o"# 3e-ra'asi "ola-en 'i%e'iasi oleh %atri"s %etalloproteinase 8MMP9 &an- 'iha%,at oleh inhi,itor +arin-an spesiAi" 'an inhi,itor protease 8TIMP619#Men'e"ati /a"tu persalinan0 "esei%,an-an antara MMP 'an TIMP61 %en-arah pa'a 'e-ra'asi proteoliti"'ari %atri"s e"straseluler 'an %e%,rane +anin#*"ti@itas 'e-ra'asi proteoliti" ini %enin-"at %en+elanpersalinan# Pa'a pen&a"it perio'ontitis 'i%ana ter'apat penin-"atan MMP0 cen'erun- ter+a'i "etu,an pecah 'ini#5 Selaput "etu,an san-at "uat pa'a "eha%ilan %u'a#Pa'a tri%ester "eti-a0 selaput "etu,an %u'ah pecah#Mele%ahn&a "e"uatan selaput "etu,an a'a hu,un-ann&a 'en-an pe%,esaran uterus0 "ontra"si rahi% 'an -ea"an +anin#Pa'a trise%ster ter"hir ter+a'i peru,ahan ,io"i%ia pa'a selaput "etu,an#Pecahn&a "etu,an pa'a "eha%ilan ater% %erupa"an hal

Aisiolo-is#Ketu,an pecah 'ini pre%ature serin- ter+a'i pa'a polihira%nion0 in"o%petens ser@i"s0 'an solusio plasenta# Selain itu0 Aa"tor &an- palinserin- %en&e,a,"an "etu,an pecah 'ini a'alah Aactor e"sternal %isaln&a inAe"si#5

3$

Pecahn&a selaput "etu,an ,er"aitan 'en-an proses ,io"i%ia &an- ter+a'i 'ala% "ola-en %atri"s e"traseluler a%nion0 "otion0 'an apoptosis %e%,rane +anin# Me%,rane +anin 'an 'esi'ua ,erea"si terha'ap sti%uli seperti inAe"si0 'an pere-an-an selaput "etu,an 'en-an %e%pro'u"si %e'iator seperti prosta-lan'in0 sito"inin0 'an protein hor%one &an- %eran-san- a"ti@itas R%atri"s 'e-ra'in- en?&%eS#5

Kola-en ter'apat pa'a lapisan "o%pa"ta a%nion0 Ai,ro,las0 +arin-an reti"uler "orion 'an troAo,las#Sintesis %aupun 'e-ra'asi +arin-an "ola-en 'i"ontrol oleh siste% a"tiAitas 'an inhi,isi interleu"in61 8I1619 'an prosta-lan'in# .i"a a'a inAe"si 'an inAla%asi0 ter+a'i penin-"atan a"tiAitas prosta-lan'in0 %en-hasil"an "ola-enase +arin-an0 I161 'an ter+a'i

sehin--a

'epoli%erisasi "ola-en pa'a selaput "orion 4 a%nion0 %en&e,a,"an selaput "etu,an tipis0 le%ah 'an %u'ah pecah spontan#

!0

Selain itu ter'apat teori &an- %en-ata"an %enin-"atn&a %ar"er6%ar"er apoptosis 'i %e%,rane Aetal pa'a "etu,an pecah 'ini ,er,an'in- 'en-an %e%,ran pa'a "eha%ilan &an- nor%al# 2an&a" penelitian &an- %en-ata"an ,ah/a "etu,an pecah 'ini ter+a'i "arena -a,un-an a"ti@asi a"ti@itas 'e-ra'asi "ola-en 'an "e%atian sel &an- %e%,a/a "ele%ahan 'in'in%e%,rane Aetal#

PatoAisiolo-i pa'a inAe"si intrapartu% : *scen'in- inAection0 pecahn&a "etu,an %en&e,a,"an a'a hu,un-an lan-sun- antara ruan- intraa%nion 'en-an 'unia luar# InAe"si intraa%nion ,isa ter+a'i lan-sun- pa'a ruan- a%nion0 atau 'en-an pen+alaran inAe"si %elalui 'in'in- uterus0 selaput +anin0 "e%u'ian "e ruan- intraa%nion# Mun-"in +u-a +i"a i,u %en-ala%i inAe"si siste%i"0 inAe"si intrauterin %en+alar %elalui plasenta 8sir"ulasi Aeto%aternal9# Tin'a"an iatro-eni" trau%ati" atau hi-iene ,uru"0 %isaln&a pe%eri"saan 'ala% &an- terlalu serin-0 'an se,a-ain&a0 pre'isposisi inAe"si#

3%! Penatala9sanaan Penatala"sanaan "eha%ilan 'en-an "o%pli"asi "etu,an pecah 'ini perlu %e%perti%,an-"an %or,i'itas 'an %ortalitas i%%aturitas neonatal &an,erhu,un-an 'en-an persalinan 'an risi"o inAe"si terha'ap i,u 'an +anin#

!1

5al &an- se-era harus 'ila"u"an 'ala% penan-anan "etu,an pecah 'ini a'alah 5 B Pasti"an 'ia-nosis Tentu"an u%ur "eha%ilan E@aluasi a'a ti'a"n&a inAe"si %aternal 'an +anin *pa"ah 'ala% "ea'aan inpartu0 ter'apat "e-a/atan +anin#

3ala% %en-ha'api "etu,an pecah 'ini0 harus 'iperti%,an-"an ,e,erapa hal ,eri"ut $B 19 Dase laten : 1a%an&a se+a" "etu,an pecah sa%pai ter+a'in&a proses persalinan# Se%a"in pan+an- Aase laten0 se%a"in ,esar "e%un-"inan ter+a'in&a inAe"si# Mata rantai inAe"si %erupa"an ascen'ens inAe"si0 antara lain B 6 Korioa%nionitis: *,'o%en terasa te-an Pe%eri"saan la,oratoriu% ter+a'i leu"ositosis Protein c rea"tiA %enin-"at Kultur cairan a%nion positiA#

!2

6 3esi'uitis : inAe"si &an- ter+a'i pa'a lapisan 'esi'ua# 29 Per"iraan 22 +anin 'apat 'itentu"an 'en-an pe%eri"saan (SG &an%e%pun&ai pro-ra% untu" %en-u"ur 22 +anin# Se%a"in 22 +anin se%a"in ,esar "e%un-"inan "e%atian 'an "esa"itan sehin--a tin'a"an ter%inasi %e%erlu"an perti%,an-an "eluar-a# 39 Presentasi +anin intrauteri Presentasi +anin %erupa"an penun+u"untu" %ela"u"an ter%inasi

"eha%ilan#Pa'a leta" lintan- atau ,o"on-0 harus 'ila"u"an 'en-an +alan se"sio sesarea#Perti%,an-an "o%pli"asi 'an resi"o &an- a"an 'iha'api +anin 'an %aternal terha'ap tin'a"an ter%inasi# !9 (sia "eha%ilan Ma"in %u'a "eha%ilan antar ter%inasi "eha%ilan ,an&a" 'iperlu"an /a"tu untu" %e%pertahan"an +anin hin--a le,ih %atur# Se%a"in la%a %enun--u0 "e%un-"inan inAe"si a"an se%a"in ,esar 'an %e%,aha&a"an +anin serta situasi %aternal#

1% .iagn6sis (ntu" %ene-a""an 'ia-nosis KP30 'apat 'i peroleh 'ari :10203 1# *na%nesis Pa'a u%u%n&a pen'erita %en&ata"an telah %en-eluar"an cairan 'ari

"e%aluann&a # :airan ,er,au "has 'an %ere%,es se,elu% proses persalinan ter+a'i#

!3

2# Pe%eri"saan luar 3en-an pen-a%atan %ata ,iasa a"an ta%pa" "eluarn&a cairan 'ari @a-ina # Pe%eri"saan ini a"an le,ih +elas la-i ,ila "ulit "etu,an ,aru sa+a pecah 'an +u%lahn&a cu"up ,an&a"0 'an ,a-ian ,a/ah ana" ,elu% ,e-itu turun "e'ala% +alan lahir# 3# Pe%eri"saan 'en-an spe"ulu% 3en-an %en--una"an spe"ulu% @a-ina 'apat 'iperhati"an "eluarn&a 'ari ostiu% uteri e"sterna# !# Pe%eri"saan la,oratoriu% a# Kertas Nitra?ine : /arna ,eru,ah ,iru "arena p5 al"ali 8<016<0!9 'ari air "etu,an ,# Pen-ecatan -lo,uli le%a" Aetus c# Dernin- test4*r,orisation test '# Pen-u"uran 'ia%in o=i'ase 83*O90 alAa Aetoprotein atau Ai,rone"tin +anin 5# Pe%eri"saan Dlouresensi )# Pe%eri"saan ultrasono-raAi

2% +edi9a +ent6sa1! Korti"osteroi' Pe%,erian "orti"osteroi' 'apat %ene"an %or,i'itas 'an %ortalitas perinatal pasca "etu,an pecah 'ini preter%# Korti"osteroi' +u-a %ene"an risi"o ter+a'in&a sin'ro% 'istress pernaAasan 8 20 > 350!G 90 he%ora-i intra@entri"ular 8 <05 > 150$G 90 entero"olitis ne"roti"ans 8 00 > !0)G 9#

!!

Re"o%en'asi se,a-ian ,esar %en--una"an ,eta%ethason 8 celestone 9 intra%uscular 12 %- setiap 2! +a% sela%a 2 hari# National Institute oA 5ealth %ere"o%en'asi"an pe%,erian "orti"osteroi' se,elu% %asa -estasi 30 > 23 %in--u0 'en-an asu%si @ia,ilitas Aetus 'an ti'a" a'a inAe"si intra a%nioti"#Pe%,erian "orti"osteroi' setelah %asa -estasi 3! %in--u %asih contro@ersial 'an ti'a" 'ire"o%en'asi"an "ecuali a'a ,u"ti i%%aturitas paru %elalui pe%eri"saan a%niosentesis#

*nti,ioti" Pe%,erian anti,iotic pa'a pasien "etu,an pecah 'ini 'apat %ene"an inAe"si neonatal 'an %e%perpan+an- perio'e latensi# Se+u%lah anti,ioti" &an- 'i-una"an %eliputi a%pisilin 2 -ra% 'en-an "o%,inasi eritro%isin 250 %- setiap ) +a% sela%a ! +a%0 'ii"uti pe%,erian a%o"sisilin 250 %'an eritro%isin 333 %- setiap +a% untu" li%a hari# Pasien &an-

%en'apat "o%,inasi ini 'i%un-"in"an 'apat %e%pertahan"na "an'un-an sela%a 3 %in--u setelah pen-hentian pe%,erian anti,ioti" setelah < hari#

!5

K-T0,A/ P-?AH I/F-KSI /*/A I/F-KSI Penisilin *%o"silin C Genta%isin Eritro%isin Metroni'a?ol untu" < 1ahir"an ,a&i hari

P(*FILAKSIS Stop anti,iotic

Steroi' untu" pe%atan-a n paru Anti;i6ti9 setelah persalinan I/F-KSI 1an+ut"an untu" 2!6! +a% setelah ,e,as panas

@ 3# +I/GG0 I/F-KSI /*/A I/F-KSI Penisilin 1ahir"an ,a&i Genta%isin 2eri"an Metroni'a?ol penisilin 1ahir"an ,a&i atau a%pisilin

/*/AI/F-KSI Ti'a" perlu anti,ioti"

Ta;el 3% Pen--unaan *nti,ioti" 2a-i Menan-ani Ketu,an Pecah 3ini#

*-en To"oliti" Pe%,erian a-ent to"oliti" 'iharap"an 'apat %e%perpan+an- perio'e latensi na%un ti'a" %e%per,ai"i luaran neonatal#Ti'a" ,an&a" 'ata &an- terse'ia %en-enai pe%a"aian a-en to"oliti" untu" "etu,an pecah 'ini#Pe%,erian a-en to"oliti" +an-"a pan+an- ti'a" 'iper"enan"an 'an hin--a "ini %asih %enun--u hasil penelitian le,ih +auh#

Tatala9sana Ketu;an Pe=ah .ini Ke%un-"inan tin'a"an &an- 'apat 'ila"u"an pa'a "etu,an pecah 'ini 50$015: Konser@atiA Tirah ,arin- untu" %en-uran-i "eluarn&a air "etu,an sehin--a %asa "eha%ilan 'apat 'iperpan+an-# Tirah ,arin- ini +u-a 'apat 'i"o%,inasi"an 'en-an pe%,erian anti,iotic se,a-ai proAila"sis 8%ence-ah inAe"si9#$ *nti,iotic &an- 'ian+ur"an5 :

!)

 *%picillin 8untu" inAe"si Streptococcus U 9 : ! = 500 %- atau eritro%icin ,ila ti'a" tahan a%picillin 'an %etroni'a?ol 2 = 500 %- sela%a < hari# Eritrosin 'osis tin--i 8untu" inAe"si :la%&'ia tracho%atis0 ureoplas%a0 'an lainn&a9 # 2aha&a %enun--u terlalu la%a a'alah "e%un-"inan inAe"si se%a"in %enin-"at sehin--a terpa"sa harus 'ila"u"an ter%inasi# Tatala"sana a"tiA$ 3ila"u"an untu" %e%perpan+an- usia "eha%ilan 'en-an pe%,erian "o%,inasi : Korti"osteroi' untu" pe%atan-an paru 82eta%eta?on IM 12 %- 2! +a% atau 'e"sa%eta?on IM ) %- 12 +a% sela%a 2 hari9 To"oliti" untu" %en-uran-i atau %en-ha%,at "ontra"si uterus0 'apat 'i,eri"an : 6 V > S&%patho%i%etic : Rito'rine 6 Ma-nesiu% sulAat 6 In'o%etacin 6 NiAe'ipine : Epilate 6 *tosi,an : Tractocile *nti,iotic untu" proAila"sis inAe"si 8%en-uran-i peranan inAe"si se,a-ai pe%icu ter+a'in&a proses persalinan9

!<

Tin'a"an tatala"sana a"tiA +u-a ti'a" terlalu ,an&a" %enin-"at"an %aturitas +anin 'an paru#3ala% "ea'aan terpa"sa harus 'ila"u"an ter%inasi "eha%ilan untu" %en&ela%at"an +anin 'an %aternal# 3ala% %enun'a persalinan ini0 a'a li%a criteria &an- 'apat 'iperti%,an-"an : (sia "eha%ilan T 2) %in--u# Sulit %e%pertahan"an "eha%ilan sa%pai ater% atau sa%pai usia "eha%ilan se"itar 3! %in--u# 2aha&a inAe"si 'an oli-ohira%nion a"an %eni%,ul"an %asalah pa'a +anin# 2a&i 'en-an usia "eha%ilan "uran- 'ari 2) %in--u sulit untu" hi'up 'an ,era'aptasi 'i luar "an'un-an# (sia "eha%ilan 2) 6 31 %in--u % Persoalan tentan- si"ap 'an "o%pli"asi %asih sa%a 'en-an usia "an'un-an T 2) %in--u# Na%un pa'a ru%ah sa"it &an- su'ah %a+u0 'i%un-"in"an a'an&a pera/atan intensiA neonatus# Pertolon-an ,a&i 'en-an ,erat T 2#000 -ra% 'ian+ur"an 'en-an se"sio sesarea# (sia "eha%ilan 31 6 33 %in--u# 3ila"u"an a%niosintesis untu" %enetu"an "e%atan-an paru0 atau test ,usa 8,u,,le test9# Me%perhati"an "e%un-"inan inAe"si intrauteri# 2a&i 'en-an ,erat H 2#000 -ra% san-at %un-"in 'itolon-# (sia "eha%ilan 3! 6 3) %in--u# 22 +anin san-at ,ai" sehin--a 'apat 'ila"u"an in'u"si persalinan atau se"sio sesarea# (sia "eha%ilan H 3) %in--u# Su'ah 'ian--ap ater% sehin--a 'apat hi'up 'iluar "an'un-an 'an sela%at#Keha%ilan pa'a usia ini 'apat 'i in'u"si 'en-an o"sitosin# 2ila -a-al se"sio sesarea# 3apat pula 'i,eri"an !

%isoprostol 25 > 50 W- intra@a-inal setiap ) +a% %a"si%al ! "ali# 2ila a'a tan'a6tan'a inAe"si0 ,eri"an anti,iotic 'osis tin--i 'an persalinan 'ia"hiri# 6 2ila pe%,u"aan 4 s"or pel@i"s T 50 la"u"an pe%atan-an ser@i"s0 "e%u'ian in'u"si# .i"a ti'a" ,erhasil a"hiri persalinan 'en-an se"sio sesarea# 6 2ila pe%,u"aan 4 s"or pel@i"s H 50 in'u"si persalinan5# Tatala"sana a-resiA $ Ti'a"an a-resiA 'ila"u"an ,ila a'a in'i"asi @ital sehin--a ti'a" 'apat 'itun'a "arena %en-anca% "ehi'upan +anin atau %aternal# In'i"asi @ital &an'i%a"su'"an &aitu : InAe"si intrauteri Solution plasenta Ga/at +anin Prolaps tali pusat E@aluasi 'eta" +anin 'en-an KTG %enun+u""an hasil -a/at +anin atau re'up 22 +anin cu"up @ia,le untu" ,era'aptasi 'i luar "an'un-an# Pe%ilihan "eti-a si"ap 'iatas san-at sulit ,ila pa'a "etu,an pecah 'ini0 +anin %asih pre%ature# Kea'aan +anin &an- pre%ature a"an %en-ha'api ,er,a-ai "en'ala u%u% a"i,at "eti'a"%a%puann&a ,era'aptasi 'en-an "ehi'upan 'iluar "an'un-an# 5al ini 'ia"i,at"an or-an @ital &an- ,elu% siap untu" %en-ha'pi !$

situasi &an- san-at ,er,e'a 'en-an "ea'aan intrauteri sehin--a %eni%,ul"an %or,i'itas 'an %ortalitas &an- tin--i# Penanganan Ketu;an Pe=ah di (umah *pa,ila ter'apat re%,esan atau aliran cairan 'ari @a-ina0 se-era hu,un-i 'o"ter atau petu-as "esehatan 'an ,ersiaplah untu" "e Ru%ah Sa"it Guna"an pe%,alut /anita 8+an-an ta%pon9 untu" pen&erapan air &an"eluar 3aerah @a-ina se,ai"n&a se,ersih %un-"in untu" %ence-ah inAe"si0 +an-an ,erhu,un-an se"sual atau %an'i ,eren'a% Selalu %e%,ersih"an 'ari arah 'epan "e ,ela"an- untu" %en-hin'ari inAe"si 'ari 'u,ur .an-an co,a %ela"u"an pe%eri"saan 'ala% sen'iri S"e%a 'i ,a/ah %enun+u""an tatala"sana untu" Ketu,an Pecah 3ini Pre%atur 'an *ter%#$

50

Hamil dengan KPD

AB profilaksis NST / Profil Biofisik Tanda infeksi/ korioamnionitis

Hamil preterm (< 37 mgg)

5a%il 'en-an KP3

Hamil aterm ( 37 mgg)

!" < 3# mgg

!" 3# mgg

SB < '
(-el%m matang)

SB ' - .
(/%k%p matang)

SB , (matang)

konser$atif
Infeksi (-) Infeksi ( ) Infeksi ( ) Infeksi (-) Infeksi (-) Infeksi ( )

ind%ksi Bel%m inpart%

"onser$atif & "ortikosteroid

inpart%

T%ngg% *# + 7# (am

T%ngg% , + *# (am

ind%ksi

"onser$atif #' (am & "ortikosteroid Tokolitik

inpart%

Bel%m inpart%

inpart%

ind%ksi Terminasi !" 37 mgg Ind%ksi setela) #' (am 51

Algoritma pengelolaan kehamilan dengan KPD

52

53

3%10 K6mpli9asi Ko%pli"asi ti%,ul pa'a Ketu,an Pecah 3ini ini ter-antun- pa'a usia "eha%ilan# Ia 'apat ter+a'i inAe"si %aternal ataupon neonatal0 persalinan pre%ature0 hipo"sia "arena "o%presi tali pusat0 'eAor%itas +anin0 %enin-"atn&a insi'en se"sio sesarea atau -a-aln&a persalinan nor%al#5 Persalinan Prematur5 Setelah "etu,an pecah ,iasan&a se-era 'isusul oleh persalinan# Perio'e laten ter-antun- u%ur "eha%ilan# Pa'a "eha%ilan ater% $0G ter+a'i 'ala% 2! +a% setelah "etu,an pecah# Pa'a "eha%ilan antara 2 63! %in--u persalinan 'ala% 2! +a%# Pa'a "eha%ilan "uran- 'ari 2) %in--u persalinan ter+a'i 'ala% 1 %in--u# In&e9si5 Resi"o inAe"si i,u 'an ana" %enin-"at pa'a Ketu,an Pecah 3ini#Pa'a i,u ter+a'i "orioa%nionitis#Pa'a ,a&i 'apat ter+a'i septice%ia0 pneu%onia0 o%Aalitis#(%u%n&a ter+a'i "orioa%nionitis se,elu% +anin terinAe"si#Pa'a Ketu,an Pecah 3ini pre%atur0 inAe"si le,ih serin- 'aripa'a ater%# Secara u%u% insi'en inAe"si se"un'er pa'a Ketu,an Pecah 3ini %enin-"at se,an'in- 'en-an la%an&a perio'e laten# Ko%pli"asi I,u: 6 En'o%etritis 6 Penurunan a"tiAitas %io%etriu% 8'istonia0 atonia9

5!

6 Sepsis 8'aerah uterus 'an intra%nion %e%ili"i @as"ularisasi san-at ,an&a"9 6 S&o" septi" sa%pai "e%atian i,u# Ko%pli"asi .anin 6 *sAi"sia +anin 6 Sepsis perinatal sa%pai "e%atian +anin# Hip69sia dan As&i9sia5 3en-an pecahn&a "etu,an ter+a'i oli-ohi'ra%nion &an- %ene"an tali pusat hin--a ter+a'i asAi"sia atau hipo"sia#Ter'apat hu,un-an antara ter+a'in&a -a/at +anin 'an oli-ohi'ra%nion0 se%a"in se'i"it air "etu,an0 +anin se%a"in -a/at# Pene9anan tali pusat Pr6lapsus$ Ga/at +anin0 "e%atian +anin a"i,at hipo"sia 8serin- ter+a'i pa'a presentasi ,o"on- atau leta" lintan-90 trau%a pa'a /a"tu lahir 'an pre%atur#

Ga%,ar 3#Prolapsus Tali Pusat# Sindr6m .e&6rmitas Janin

55

Ketu,an Pecah 3ini &an- ter+a'i terlalu 'ini %en&e,a,"an pertu%,uhan +anin terha%,at0 "elainan 'ise,a,"an oelh "o%presi %u"a 'an an--ota ,a'an +anin serta hipoplasi pul%onar&#5

K6mpli9asi +aternal

,entu9 X*ntepartu% 6Korioa%nionitis 306)0G 6Solusio plasenta XIntrapartu% 6Trau%a persalinan a"i,at in'u"si4operatiA# XKe%un-"inan retensio 'ari plasenta XPostpartu% 6Trau%a tin'a"an operatiA 6InAe"si %asa niAas 6Per'arahan postpartu%# XSe%a"in %u'a usia "eha%ilan 'an se%a"in ren'ah ,erat ,a'an +anin0 %a"a "o%pli"asi %a"in ,erat# XK6mpli9asi a9i;at prematuritasB 6%u'ah inAe"si 6%u'ah ter+a'i trau%a a"i,at tin'a"an persalinan 6%u'ah ter+a'i aspirasi air "etu,an 'an %eni%,ul"an asAi"sia sehin--a %en&e,a,"an "e%atian# XK6mpli9asi p6stpartumB 6Pen&a"it Respirator& 3istress S&n'ro%e 8R3S9 atau hialin %e%,rane 65ipoplasia paru 'en-an a"i,atn&a 6Ti'a" tahan terha'ap hipoter%ia# 6Serin- ter+a'i hipo-li"e%ia 6Gan--uan Aun-si alat @ital# XK6mpli9asi a9i;at 6lig6hidramni6nB 6Gan--uan tu%,uh "e%,an- &an%en&e,a,"an 'eAor%itas# 6Gan--uan sir"ulasi retroplasenta &an%eni%,ul"an asi'osis 'an asAi"sia#

Keterangan XSepsis +aran- ter+a'i "arena pe%,erian anti,iotic 'an resusitasi XTrau%a tin'a"an operasi 6Trias "o%pli"asi : Y InAe"si Y Trau%a tin'a"an Y Per'arahan XKe+a'ian "o%pli"asi &an- 'iin'i"asi"an untu" ter%inasi "eha%ilanB 6Prolaps tali pusat 6InAe"si intrauteri 6Solusio plasenta X(ntu" %e%,u"ti"an ter+a'i inAe"si intrauteri 'apat 'ila"u"an a%niosentesis 'en-an tu+uan untu"B 6"ultur cairan a%nion 6pe%eri"saan -lu"osa 6alAa Aetoprotein 6Ai,rone"tin

/e6natus

X(pa&a untu" tirah ,arin- 'an pe%,erian anti,iotic 'apat %e%perpan+an- usia "eha%ilan supa&a ,erat

5)

6Retra"si otot uterus &an- %eni%,ul"an solusio plasenta# XK6mpli9asi a9i;at 9etu;an pe=ahB 6Prolaps ,a-ian +anin teruta%a tali pusat 'en-an a"i,atn&a# 6Mu'ah ter+a'i inAe"si intrauteri 'an neonatus#
Ta;el 2% Ko%pli"asi Maternal 'an Perinatal#

,a'an +aninn&a le,ih ,esar 'an le,ih %a%put untu" hi'up 'i luar "an'un-an#

3%11 Pen=egahan a% Pen=egahan primer (ntu" %en-uran-i ter+a'in&a pecah "etu,an 'ini0 'ian+ur"an ,a-i i,u ha%il untu" %en-uran-i a"ti@itas pa'a a"hir tri%ester "e'ua 'an a/al tri%ester "e ti-a0 serta ti'a" %ela"u"an "e-iatan &an- %e%,aha&a"an "an'un-an sela%a "eha%ilan#I,u ha%il +u-a harus 'inasihat"an supa&a ,erhenti %ero"o" 'an %en-a%,il al"ohol#2erat ,a'an i,u se,elu% "eha%ilan +u-a harus cu"up %en-i"ut In'e"s Massa Tu,uh 8IMT9 supa&a ti'a" ,erla"u %ana6%ana "o%pli"asi#Selain itu0 pasan-an +u-a 'inasihat"an supa&a %en-henti"an "oitus pa'a tri%ester a"hir "eha%ilan ,ila a'a Aa"tor pre'isposisi#1)

=% Pen=egahan se9under Mence-ah inAe"si intrapartu% 'en-anB *nti,ioti"a spe"tru% luas : -enta%icin i@ 2 = 0 %-0 a%picillin i@ ! = 1 %-0 a%o=icillin i@ 3 = 1 %-0 penicillin i@ 3 = 1#2 +uta I(0 %etroni'a?ol 'rip# Pe%,erian "orti"osteroi' : "ontro@ersi# 3i satu piha" 'apat

%e%per,uru" "ea'aan i,u "arena %enurun"an i%unitas0 'i lain piha" 5<

'apat %ensti%ulasi pe%atan-an paru +anin 8surAa"tan9# 3i RS:M 'i,eri"an0 ,ersa%a 'en-an anti,ioti"a spe"tru% luas#5asil cu"up ,ai"

3%12 Pr6gn6sis Pro-nosis pa'a "etu,an pecah 'ini san-at @ariatiA ter-antun- pa'a : (sia "eha%ilan *'an&a inAe"si 4 sepsis Dactor resi"o 4 pen&e,a, Ketepatan 3ia-nosis a/al 'an penatala"sanaan

Pro-nosis 'ari KP3 ter-antun- pa'a /a"tu ter+a'in&a0 le,ih cepat "eha%ilan0 le,ih se'i"it ,a&i &an- 'apat ,ertahan# 2a-ai%anapun0 u%u%n&a ,a&i &an- lahir antara 3! 'an 3< %in--u %e%pun&ai "o%pli"asi &an- ti'a" serius 'ari "elahiran pre%ature#105

I>%

P-/0T0P

Persalinan %erupa"an suatu proses pen-eluaran hasil "onsepsi &an- 'apat hi'up "e'unia luar 'ari rahi% %elalui +alan lahir atau 'en-an +alan lain# ("uran "e,erhasilan suatu pela&anan "esehatan tercer%in 'ari penurunan an-"a "e%atian i,u 8Maternit& Mortalit& Rate9 sa%pai pa'a ,atas an-"a teren'ah &an- 'apat 'icapai sesuai 'en-an "on'isi 'an situasi sete%pat serta /a"tu#

Ketu,an pecah 'ini a'alah pecahn&a "etu,an se,elu% ter'apat tan'a6tan'a persalinan 'an 'itun--u satu +a% se,elu% 'i%ulain&a tan'a6tan'a persalinan# Ketu,an pecah 'ini %erupa"an %asalah pentin- 'ala% ,i'an- "esehatan &an,er"aitan 'en-an pen&ulit "elahiran pre%atur 'an ter+a'in&a inAe"si

"orioa%nionitis sa%pai sepsis0 serta %en&e,a,"an inAe"si pa'a i,u &an%en&e,a,"an %enin-"atn&a %or,i'itas 'an %ortalitas i,u 'an ,a&i#Ketu,an

5$

pecah 'ini "e%un-"inan ,esar %eni%,ul"an risi"o tin--i inAe"si 'an ,aha&a "o%presi tali pusat0 %a"a 'ala% penatala"sanaan pera/atann&a 'ian+ur"an untu" pe%antauan i,u %aupun +anin 'en-an "etat#

KP3 serin- "ali %eni%,ul"an "onse"uensi &an- 'apat %eni%,ul"an %or,i'itas 'an %ortalitas pa'a i,u %aupun ,a&i teruta%a "e%atian perinatal &an- cu"up tin--i# Ke%atian perinatal &an- cu"up tin--i ini antara lain 'ise,a,"an "arena "e%atian a"i,at "uran- ,ulan0 'an "e+a'ian inAe"si &an- %enin-"at "arena partus ta" %a+u0 partus la%a0 'an partus ,uatan &an- serin- 'i+u%pai pa'a pen-elolaan "asus KP3 teruta%a pa'a pen-elolaan "onser@atiA # 3ile%a serin- ter+a'i pa'a pen-elolaan KP3 'i%ana harus se-era ,ersi"ap a"tiA teruta%a pa'a "eha%ilan &an- cu"up ,ulan0 atau harus %enun--u sa%pai ter+a'in&a proses persalinan0 sehin--a %asa tun--u a"an %e%an+an- ,eri"utn&a a"an %enin-"at"an "e%un-"inan ter+a'in&a inAe"si# Se'an-"an si"ap "onser@atiA ini se,ai"n&a 'ila"u"an pa'a KP3 "eha%ilan "uran- ,ulan 'en-an harapan tercapain&a pe%atan-an paru 'an ,erat ,a'an +anin &an- cu"up#

*'a 2 "o%pli"asi &an- serin- ter+a'i pa'a KP30 &aitu : perta%a0 inAe"si0 "arena "etu,an &an- utuh %erupa"an ,arier atau pen-halan- terha'ap %asu"n&a pen&e,a, inAe"si# 3en-an ti'a" a'an&a selaput "etu,an seperti pa'a KP30 Alora @a-ina &an- nor%al a'a ,isa %en+a'i pato-en &an- a"an %e%,aha&a"an ,ai" pa'a i,u %aupun pa'a +aninn&a# Oleh "arena itu %e%,utuh"an pen-elolaan &ana-resiA seperti 'iin'u"si untu" %e%percepat persalinan 'en-an %a"su' untu" %en-uran-i "e%un-"inan resi"o ter+a'in&a inAe"si B "e'ua0 a'alah "uran- ,ulan

)0

atau pre%aturitas0 "arena KP3 serin- ter+a'i pa'a "eha%ilan "uran- ,ulan# Masalah &an- serin- ti%,ul pa'a ,a&i &an- "uran- ,ulan a'alah -e+ala sesa" naAas atau respirator& 3istress S&n'ro% 8R3S9 &an- 'ise,a,"an "arena ,elu% %asa"n&a paru#

Penatala"sanaan &an- opti%al harus %e%perti%,an-"an 2 hal terse,ut 'i atas 'an Aa"tor6Aa"tor lain seperti Aasilitas serta "e%a%puan untu" %era/at ,a&i &an"uran- ,ulan#Mes"ipun ti'a" a'a satu proto"ol pen-elolaan &an- 'apat untu" se%ua "asus KP30 tetapi harus a'a pan'uan pen-elolaan &an- strate-is0 &an'apat %en-uran-i %ortalitas perinatal 'an 'apat %en-hilan-"an "o%pli"asi &an,erat ,ai" pa'a ana" %aupun pa'a i,u#

)1

.AFTA( P0STAKA

1#

Mochtar R# Ketu,an Pecah 3ini# 3ala%: Sinopsis O,stetri0 O,stetri OperatiA 'an O,stetri Sosial# .ili' I# E'# II# .a"arta# EG:# 1$$ #p# 2556 #

2#

Ko%ite Me'i" RS(P 3R#Sar'+ito0 Ketu,an Pecah 3ini 'ala% Stan'ar Pela&anan %e'is RS(P 3R# Sar'+ito0 2u"u I0 Me'i"a Da"ultas Ke'o"teran (ni@ersitas Ga+ah Ma'a0 Qo-&a"arta0 1$$$0 hal : 32 > 33

3#

Manua,a#I#2#G# Ketu,an Pecah 3ini 'ala% Kapita Sele"ta Penatala"sanaan O,stetri Gine"olo-i 'an K20 EG:0 .a"arta0 20010 hal : 221 > 225#

!#

.onathan G# *na%nesis 'an Pe%eri"saan O,stetri" 'an Gine"olo-is# *t a Glance *na%nesis 'an Pe%eri"saan Disi"B alih ,ahasa0 *rtsi&anti 3#B e'itor0 *%alia S#0 Rina *## .a"arta: Pener,it Erlan--a0 200<# Pp 3265#

5#

Soe/arto S# Ketu,an Pecah 3ini# In Pra/irohar'+o S#8e'#9 Il%u Ke,i'anan# 2a-ian Keti-a: Patolo-i Keha%ilan0 Persalinan0 NiAas 'an 2a&i 2aru 1ahir#

)2

E'isi Kee%pat# :eta"an Ke'ua# .a"arta# PT 2ina Pusta"a Sar/ono Pra/irohar'+o# 200$# Pp )<<6 2# )# *%erican :olle-e oA O,stetricians an' G&necolo-ists# Pre%ature rupture oA %e%,ranes# :linical %ana-e%ent -ui'elines Aor o,stetrician6-&necolo-ists# *:OG practice ,ulletin no# 1# Int . G&naecol O,stet# 200 B)3:<5> !# <# Reece0 E#* M3 at alB :linical O,stetric The Detus Z Mother 3r' e'ition : RPrela,or rupture oA the %a%,ranesSB 2lac"/ell Pu,lishin- 200<B 1130 > 11<3 # 3e:herne&0 *5# M3 et alB 1*NGE :urrent 3ia-nosis Z Treat%ent O,stetrics Z G&necolo-& 10the'ition : RPre%ature Rupture oA Me%,ranesSB McGra/65ill 200<B 2<$ > 2 1# $# Manua,a I#2#G0 :han'ranita Manua,a I#*0 Da+ar Manua,a I#2#G#8e's9 Pen-antar Kuliah O,stertri# 2a, ): Ko%pli"asi (%u% Pa'a Keha%ilan# Ketu,an Pecah 3ini# :eta"an Perta%a# .a"arta# Pener,it EG:# 200<# Pp !5)6 )0# 10# Kenneth .# 1e@eno0D# Gar& :unnin-ha%0 Nor%an D# Gant0 .a%es M# *le=an'er0 Ste@en 1# 2loo%0 2rian M# :ase&0 .o'i S# 3ashe0 .eanne S# SheAAiel'0 Nicole P# Qost# O,stetri Iillia%s Pan'uan Rin-"as# E'isi 21# .a"arta E:G0 200$ Bh !)$ 11# Mor-an G#0 5a%ilton :# O,stetri 'an Gine"olo-i Pan'uan Pra"ti"# Trans S&a%si R#M#0 Ketu,an Pecah 3ini 8KP39# Kapoh R#P# .a"arta# Pener,it EG:# 200$# Pp 3$16!# 12# Pre%ature Rupture oA Me%,rane# http:44Scri,#co%4 'iun'uh tan--al 1 .uni 2011# 13# Nili D#0 *nsaari *#*#S# Neonatal :o%plications OA Pre%ature Rupture OA Me%,ranes# *cta Me'ica Iranica# [Online\ 2003# ;ol !1# No#3# 3iun'uh 'ari http:44+ournals#tu%s#ac#ir4uploa']Ailes4p'A45$#p'A# 3iun'uh pa'a 02 .uni 2011#

)3

1!# 2en?ion Ta,er# Kapita Sele"ta Ke'aruratan O,stetri 'an Gine"olo-i# Pener,it 2u"u Ke'o"teran EG:# 2001B h# 3) 6<3# 15# Dortner0 Ki%,erl& 2#B S?&%ans"i0 1in'a M#B Do=0 5arol' E#B Iallach0 E'/ar' E# Preter% 1a,or an' Pre%ature Rupture oA Me%,ranes# .ohns 5op"ins Manual oA G&necolo-& an' O,stetrics e,oo"s# 3r' E'ition# 1ippincott Iillia%s Z Iil"ins# 200<# 1)# Mor-an G#0 5a%ilton :# O,stetri 'an Gine"olo-i Pan'uan Pra"ti"# Trans S&a%si R#M#0 Ketu,an Pecah 3ini 8KP39# Kapoh R#P# .a"arta# Pener,it EG:# 200$# Pp 3$16!# 1<# Michael K#Qance&0M3# Prela,or rupture oA %e%,ranes at ter% : In'uce or IaitM# http:44///#%e'scape#co%4%e'scape4/o%ens5ealth4+ournal41$$)4@01#n114/ 133#&ance&#&ance&#ht%l# 1 # Ro%ero R0 Ghi'ini *0 Sin-h R2# Pre%ature rupture oA the %e%,ranes# In : Reece E*0 5o,,ins .:0 Mahone& M.0 Petrie R5 8e'9# Me'icine oA Aetus an' %other# .#2# 1ippincott :o%pan&#1$$2 p# 1!30 > )3# 1$# SaiAu'in *20 *'riaan? G0 Ii"n+osastro G50 Iaspo'o 3# 2u"u *cuan Nasional Pela&anan Kesehatan Maternal 'an Neonatal#Qa&asan 2inapusta"a0 2000# 20# Gre-- *R0 Intro'uction to pre%ature rupture oA %e%,ranes# In : Ienstro% K30 Ieiner :P 8e'9 : Pre%ature rupture oA %e%,ranes# O,stetrics an' G&necolo-& :linics oA North *%erica0 @ol 1$# 1$$2: 21# Shu,ert P.0 3iss E0 Ia%s .3# Etiolo-& oA pre%ature rupture oA %e%,ranes# In : Ienstro% K30 Ieiner :P 8e'9 : Pre%ature rupture oA %e%,ranes# O,stetrics an' G&necolo-& :linics oA North *%erica0 @ol 1$# 1$$2: 22# Malee MP# E=pectan an' acti@e %ana-e%ent oA preter% Pre%ature rupture oA %e%,ranes# In : Ienstro% K30 Ieiner :P 8e'9 : Pre%ature rupture oA

)!

%e%,ranes# O,stetrics an' G&necolo-& :linics oA North *%erica0 @ol 1$# 1$$2:

)5

))