Perdarahan antepartum adalah perdarahan
pada jalan lahir setelah kehamilan 28 minggu.
Insiden : 2-5% seluruh persalinan
Klasifikasi perdarahan antepartum yaitu :
1. plasenta previa (20% APB)
2. Solusio plasenta (40% APB)
3. Vasa previa / Insersio velamentosa
4.Ruptur sinus marginalis
5. Plasenta sirkumvalata
6. Tak terklasifikasi (35% APB)
Plasenta previa
merupakan plasenta yang letaknya abnormal
yaitu pada segmen bawah rahim, sehingga
menutupi sebagian atau seluruh pembukaan
jalan lahir.
Klasifikasi
1. Plasenta previa totalis
2. Plasenta previa lateralis/parsialis
3. Plasenta previa marginalis
4. Plasenta previa letak rendah
Etiologi
Etiologi plasenta previa belum jelas
Faktor resiko terjadinya plasenta previa:
1. Merokok
2. Pertambahan usia (>35 tahun)
3. Riwayat seksio sesaria sebelumnya
4. Defek Vaskularisasi pada desidua
5. Plasenta yang besar dan luas
6.riwayat plasenta previa sebelumnya
7. multipara
Diagnosis
plasenta previa :
- Adanya perdarahan pervaginam pada hamil
28 minggu, tanpa sebab, berwarna merah
segar dan tidak nyeri.
• Perdarahan tanpa nyeri
• Perdarahan terutama terjadi pd saat inpartu.
• Perdarahan diperparah krn ketidakmampuan
miometrium di segmen bawah berkontraksi
untuk menjempit pembuluh darah yang
robek dibanding korpus uteri.
• Diagnosis ditegakkan dg USG, pemeriksaan
klinis dg pemeriksaan serviks tidak dianjurkan
Pemeriksaan Fisik
Pemeriksaan Luar :
- Bagian terbawah janin belum masuk PAP ,
sering terdapat kelainan letak janin.
• Pemeriksaan Inspekulo
Untuk mengetahui asal perdarahan
• Perabaan Fornices
Pemeriksaan ini bermakna bila janin letak
kepala.
• Pemeriksaan dalam : tidak dianjurkan
• Pemeriksaan anjuran : USG
• USG: transabdominal akurasi 96%, false positif
tjd bila VU distensi.
• USG transvaginal lebih baik dibanding
transabdominal. USG transabdominal
diperlukan konfirmasi dg USG transvaginal.
• MRI: Kay dan Spritzer (1991) diskusikan aspek
positif teknik ini.
• Placenta yang terletak dekat os interna tetapi
tidak menutupi selama trimester kedua atau
awal trimester ketiga kecil untuk tetap tjd plac
previa.
• Penatalaksanaan plasenta previa
1. Terapi Ekspektatif
- Rawat inap dan tirah baring
- Pemeriksaan USG
- Berikan tokolitik
- Uji pematangan paru janin
2. Terapi aktif
Untuk perdarahan yang aktif dan
banyak
3. Seksio sesaria
1. Janin preterm tetapi belum ada indikasi
untuk pelahiran.
2. Janin sudah matur.
3. Sudah inpartu.
4. Perdarahan yang parah sehingga janin
harus dilahirkan walaupun masih
imatur.
• Pelahiran: hampir semua kasus dg SC.
-Lakukan ligasi pembuluh darah bila
perlu (a. uterina atau a. iliaka interna.
HEPATITIS B
pada ibu hamil
• Sembuh ( 90 %)
• Infeksi Akut-Hepatitis Fulminan
• Pengidap kronik
* Pengidap sehat ( healthy carrier) :
- HBsAg (+), SGOT/SGPT Normal
- No Liver Defect
- Transmisi (+)  Vertical & Horizontal Trans.
* Pengidap kronik (chronic hepatitis) - KHP/SH
- HBsAg (+), SGPT/SGOT 
- Liver defect (+)
- Transmit HBV (+)
- HBV-DNA integrasi dg sel hati  KHP/ SH
hepatitis fulminan
• Terjadi sebesar 1% dari pengidap
• Mortalitas 70% (O Grady et al.,1988)
• Gejala:
*Sangat ikterik, nyeri perut ka. atas,
uro.& bilirubin positif,ALT & AST tinggi
diatas 1000, samnolensia dll.
*Bayi, tgt dari derajat kerusakan hepar
*Kemungkinan HPP sangat besar
TRANSMISI IBU KE JANIN
intrauteri, perinatal, post natal
PREDISPOSISI FACTOR
• Titer DNA ( > 3,5 pg/ml)
• HBeAg (+)
• Infeksi VHB Akut pd trimester 3rd
(75%,Tong,1981)
• Vaccine escaped mutations :
 Bayi dg HBsAg & Anti HBs positif (10 - 20%) The RBC indices has three parts:
• Partus lama ( lebih dari 16 jam ?)  mean corpuscular volume (MCV),
which is the average red blood cell size
Ibu Bayi hari 0 Bayi 1 bl Bayi 6 bl
 mean corpuscular hemoglobin (MCH),
Vaksinasi which is the amount of hemoglobin per
Titer DNA-VHB Plasenta red blood cell
PCR 0
<3,5 pg/ml (-) Infeksi -  mean corpuscular hemoglobin
PCR (-) concentration (MCHC), which is the
³ 3,5 pg/ml
(+)
Infeksi
Intra Uterin
amount of hemoglobin relative to the
(PCR +,HBsAg - )
size of the cell or hemoglobin
Penularan
³ 12,5 – 22,5 pg/ml (+)
Infeksi vertikal +
concentration per red blood cell
Intra Uterin
(PCR +, HBsAg +)
According to the American Association for
³ 37,5 pg/ml
(+)
Clinical Chemistry, normal values for RBC indices
Infeksi +
are:
Persalinan
Bagan: Terjadinya Inf. VHB menurut titer virus ( Surya , 1997)
 The MCV should be 80 to 96 femtoliters.
 The MCH should be 27 to 33 picograms
H.B. Immunization by HBV Prevalence per cell.
 The MCHC should be 33.4 to 35.5 grams
Endemicity per deciliter.
* Low : - Before exposure
High risk : medical, patient, drug adict., homosex. High MCV
- After exposure The MCV is higher than normal when red blood
babies born by HBsAg (+) mothers cells are larger than normal. This is called
macrocytic anemia.
HBV (+) couple
Macrocytic anemia can be caused by:
needle stick in juries
 Vitamin B-12 deficiency
* Moderate / High :  folate deficiency
- Before exposure : all babies  chemotherapy
- After exposure : babies of HBsAg (+) mother  preleukemias
1. Pasive Immunization  HBIG Low MCV
2. Active Immunization The MCV will be lower than normal when red
- Plasm vaccine blood cells are too small. This condition is called
- Recombinant vaccine microcytic anemia.
- Containing vaccine Pre S2 (+Pre S1) Microcytic anemia may be caused by:
- Inprogess / developed :  iron deficiency, which can be caused
- Recombinan Vaccine at Vaccinia virus by poor dietary intake of iron, menstrual
- Therapeutic Vaccine : bleeding, or gastrointestinal bleeding
TH + Epitop Sel TC (HBcAg 18 – 27)  thalassemia
+ Ajuvan (Tetanus Toksoid) )  lead poisoning
3. Pasive - Active immunization  chronic diseases
Normal MCV
Mother to Infant HBV transmission start by If you have a normal MCV, it means that your red
screening HBsAg to pregnant women than blood cells are normal in size. You can have a
followed by normal MCV and still be anemic if there are too
selective Immunization. few red blood cells or if other RBC indices are
HBV prevention mean , primary prevention to abnormal. This is called normocytic anemia.
HCC and Normocytic anemia occurs when the red blood
HC and increasing the quality of life of the next cells are normal in size and hemoglobin content,
generation. but there are too few of them. This can be
Universal precaution should be done intensively caused by:
especially
 a sudden and significant blood loss
to whom with highly contact to blood.
Obsterician and pediatrician should be work  a prosthetic heart valve
hand in hand in  a tumor
the prevention of mother to infant HBV  a chronic disease, such as a kidney
transmission. disorder or endocrine disorder
 aplastic anemia
 a blood infection
High MCHC
If you have a high MCHC, this means that the
relative hemoglobin concentration per red
blood cell is high. MCHC can be elevated in
diseases such as:
 hereditary spherocytosis
 sickle cell disease
 homozygous hemoglobin C disease
Low MCHC
If you have a low MCHC, it means that the
relative hemoglobin concentration per red
blood cell is low. The red blood cells will take on
a lighter color when viewed under the
microscope. Individuals with anemia and a
corresponding low MCHC are said to be
hypochromic. Conditions that can cause low
MCHC include the same conditions that cause
low MCV, including:
 iron deficiency
 chronic diseases
 thalassemia
 lead poisoning
Generally, a low MCV and a MCHC will be found
together. Anemias in which both MCV and
MCHC are low are called microcytic,
hypochromic anemia