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Perdarahan Obstetri
Perdarahan Pasca Persalinan 
  Respirasi

  Sirkulasi ( Kegagalan sistem sirkulasi


dalam mempertahankan aliran yang
adekuat pada organ-organ vital sehingga
timbul Anoxia)

Ali Sungkar
Divisi Fetomaternal
  Trauma
Departemen Obstetri dan Ginekologi FKUI / RSUPN - CM

  Mengancam jiwa ibu dan janin

Shock

Shock! Hemorrhagic Shock – Pathophysiology!

The most common types of shock: Stage 1: Compensated Stage


Type of shock Aetiology
Mechanism: Volume depletion due to bleeding
Hypovolaemic shock Acute loss of at least 20% of the circulating
volume
Body detects decrease in cardiac output
Cardiogenic shock Acute disease of the heart, e.g. severe
myocardial infarction

Septic shock Septic condition caused by infectious agents Sympathetic Nervous System is stimulated releasing Epinephrine and
and their toxic products Norepinehrine to stimulate Alpha and Beta Receptors

Neurogenic shock Head trauma, spinal cord injury

Anaphylactic shock Repeated contact with or injection of antigenic Alpha = Vasoconstriction Beta = Bronchodilation and
substances Cardiac Stimulation

Shock
 Shock

Hemorrhagic (Classic) shock – Pathophysiology! Hemorrhagic (Classic) shock – Pathophysiology!

Stage 2: Progressive Stage Stage 3: Irreversible Stage

Mechanism: Kidneys release anti-diuretic hormone which increases Mechanism: Compensatory mechanisms fail
vasoconstriction by closing the capillary sphincters, greatly reducing
peripheral circulation

Pre-capillary sphincters open releasing metabolic acids, micro-emboli


and other wastes into circulation
Increased hypo-perfusion causes increase in metabolic acid build up

Cell damage, organ failure and death occur

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Shock! Shock!
The Course of Hypovolaemic Shock in Absence of Therapy The Influence of Volume Replacement on Tissue Perfusion and Organ Function
Cerebral Function
Tissue
(Body Control)
Blood Pressure Heart Rate Perfusion
Blood Pressure (mm Hg) Pulmonary Function
Heart rate (min) (O2 Supply)

150 Bleeding

100

Volume Replacement
50

Liver
0 (Time) Function
Heart
Compensation Decompensation Irreversibility (metabolism)
Function
(cardiac output) Renal Function
Shock Phases
(Diuresis)

Kegagalan Sirkulasi

Perdarahan:
  Pada awal kehamilan (aborsi, kehamilan
ektopik, kehamilan mola)
  Pada akhir kehamilan atau persalinan
(plasenta previa, solusio placenta,
ruptura uteri)
  Sesudah kelahiran bayi (ruptura uteri,
atonia uteri)

Tata Laksana
Mengatasi Perdarahan Hebat Posisi Syok
ANGKAT
KEDUA
  Airway TUNGKAI

  Breathing

  Circulation and hemorrhage control


300 - 500 cc
  Shock position darah dari kaki
pindah ke
sirkulasi sentral
  Replace blood loss

  Stop / minimize the bleeding process

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Tindakan simultan Pada Syok


Perdarahan Pasca Persalinan
Tatalaksana :! •  Kehilangan darah > 500 cc
  Nilai fundus! •  10% dari persalinan
  Simultan dengan ABC !
•  Dalam 24 jam. PP H
  Atonia merupakan penyebab utama Perdarahan Post partum!
•  Jika 24 jam – 6 mg. 2nd PP H
  Jika lembek → masase bimanual !
  singkirkan inversio uteri! •  Penyebab
  mungkin terdapat trauma traktus bagian bawah! –  Atonia uteri – Trauma Genital
  evakuasi bekuan darah dari vagina dan servik! –  Retensio placentae – Placenta accreta
  membutuhkan eksplorasi manual pada saat ini! –  Iversio uterin

Tatalaksana Perdarahan pasca Persalinan

Perdarahan Post Partum

Tanda Vital & pertolongan


I.V. / Oxygen
Foley Catheter
Flow Sheet

Atony Placenta Laserasi / robekan

Kompresi Bimanual Sisa plasenta Implantasi Tatalaksana


Abnormal Bedah

Methergine / Misoprostol Ultrasound Tatalaksana bedah


Prostaglandin / Both

Tatalaksana bedah Manual


Exploration
or Curettage

Uterine Atony Uterine Atony: Treatment


•  Most common cause of pp hemorrhage •  uterine massage
•  oxytocin:
•  Contraction of uterus is 1° mechanism for
controlling blood loss at delivery –  produced by posterior pituitary
–  oxytocin and prostaglandins –  causes peripheral vasodilation, reflex tachycardia
–  administered diluted in IV fluid, not IV push
•  Risk factors
–  metabolized/excreted by liver, kidney,
–  multiple gestation – chorioamnionitis oxytocinase
–  macrosomia – precipitous labor •  ergot derivatives
–  polyhydramnios – tocolytics •  prostaglandins
–  high parity – halogenated agents •  If drugs fail, embolization of arterial supply, ligation,
–  prolonged labor or hysterectomy

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Uterine Atony: Ergot Derivatives Uterine Atony:Prostaglandins

•  ergonovine and methylergonovine


•  ↑ myometrial intracellular free Ca++, enhance
(methergine)
action of other oxytocics
– act via α-adrenergic mechanism
•  Side effects: fever, nausea/vomiting, diarrhea
– adverse effects: nausea/vomiting,
vasoconstriction (including coronary), •  15-methyl PG F2α (Carboprost, Hemabate)
HTN, –  may cause bronchospasm,↑ shunt, hypoxemia, HTN
– relative contraindications: chronic HTN, –  250 µg IM or intramyometrially q 15-30 min, up to
PIH max 2 mg.

– dose: 0.2 mg IM (not IV), last 2-3 hrs. –  contraindications: asthma, hypoxemia

Tatalaksana - Kompresi Bimanual!


Genital Trauma
•  Vaginal: associated with forceps, vacuum, prolonged
2nd stage, multiple gestation, PIH
–  Rx: I & D and packing
•  Vulvar: bleeding from branches of pudendal arteries
•  Retroperitoneal: least common, most dangerous
–  laceration of branch of hypogastric during C/S (or
uterine rupture)
–  Dx: CT
–  Rx: expl. lap., ligation of hypogastric, hyst

Retained Placenta Placenta Accreta


•  Obstetric management: •  Definitions:
–  manual removal, oxytocin –  accreta vera: adherence of placenta to myometrium
•  Anesthetic management: –  increta: invasion of placenta into myometrium
–  epidural or spinal anesthesia, if not hypovolemic –  Percreta: invasion of placenta to/thru the serosa
–  or MAC

–  or GA (ketamine, RSI, intubate, 50% nitrous, •  Risk factors:


fentanyl)

–  Uterine relaxation may be requested (NTG)


– prior uterine trauma + placenta previa

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Placenta Accreta II Uterine Inversion


•  Placenta previa + prior C/S v. accreta risk:!
•  Low mortality
Number of prior C/S Incidence of accreta
•  Risk factors:
0 5% –  Uterine atony
1 24% –  Inappropriate fundal pressure
–  Umbilical cord traction
2 47%
–  Uterine anomaly
3 40% •  Rx: replace the uterus, oxytocin,
4 67% Hemabate, methergine
•  Rx: uterine curettage, oversewing of plac. – may need uterine relaxation transiently
bed, usually hysterectomy (accreta is most • NTG (50-100 µg IV) vs. halogenated agent
common indication for C-hyst)

Invasive Treatment Options


for Obstetric Hemorrhage Menghentikan Perdarahan!
•  Uterine arteries are branches of internal iliacs (major
supply to uterus) •  Kateter Foley!
•  Ovarian arteries also contribute during preg. •  Kondom Kateter !
•  Options
•  Tampon uterus !
–  angiographic embolization
– Maier RC .Am J Obstet Gynecol 1993 Aug;169(2 pt 1):317-21!
–  bil. surgical ligation of uterine, ovarian, internal iliacs
(preserves fertility): 42% success
–  Cesarean or pp hysterectomy
– Medikamentosa: Metergin, Misoprostol, Prostaglandin!
•  EBL ≈2500 cc (emergenc), ≈1300 cc (elective)

Menghentikan Perdarahan!
 Thrombogenic uterine pack !
  Bobrowski RA, Jones TB. Obstet Gynecol 1995 May;85(5 Pt 2):836-7!

 Vaginal ligature of uterine arteries !


Menghentikan Perdarahan   Philippe HJ, d'Oreye D, Lewin D. Int J Gynaecol Obstet 1997 Mar;56(3):267-70 !
Kondom intra uterin!  Ligasi a hipogastrika!
 Histerektomi subtotal!

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Menghentikan Perdarahan! Estimasi BB : ... 60 kg


•  B-Lynch suture ! Estimasi Blood Volume : ... 70 ml/kg x 60 = 4200 ml
Estimasi Blood Loss : .... % EBV = ..... ml
–  Dacus JV, Busowski MT, Busowski JD, Smithson S, Masters K, Sibai BM. J Matern Fetal Med 2000 May-Jun;9(3):194-6 !

–  Ferguson JE, Bourgeois FJ, Underwood PB. Obstet Gynecol 2000 Jun;95(6 Pt 2):1020-2 !
Tsyst 120 100 < 90 < 60-70
Nadi 80 100 > 120 > 140 -
hangat dingin ttb
Perf pucat basah

-- 15%
NORMO -- 30% -- 50%
EBV
VOLEMIA EBV
EBV

EBL = perdarahan 600 1200 2000 ml

Infus RL 1200-2000 2500-5000 4000-8000 ml

Kristaloid vs Koloid Kristaloid vs Koloid


Sebagai Cairan Pengganti; Hasil : Sebagai Cairan Pengganti, Kesimpulan :
Kristaloid Koloid
Merembes ke komponen
ekstraselular
Mengurangi peningkatan cairan
Tetap berada di komponen
intravaskular
  Kristaloid merupakan pilihan
paru
Meningkatkan fungsi organ
volume yang diperlukan lebih
sedikit
pertama untuk digunakan, karena:
Manfaat
setelah operasi Meningkatkan transpor
Reaksi anafilaktik minimal oksigen ke jaringan, - Lebih aman
Kemungkinan dapat mengurangi kontraktilitas jantung dan
angka kematian keluarannya
Lebih murah - Lebih murah
Predisposisi untuk terjadinya
Resiko
edema pulmonal
Mahal
- Lebih mudah didapatkan

Choi et al 1999.

Alternatif Untuk Transfusi

  Larutan yang konsentrasinya


mirip dengan plasma:
- Kristaloid
- Koloid
LARUTAN DEKTROSA ADALAH CAIRAN PENGGANTI YANG BURUK. JANGAN DIGUNAKAN
KECUALI TIDAK ADA PILIHAN LAIN. JANGAN GUNAKAN CAIRAN PLASMA ATAU AIR BIASA

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Autologous Blood
•  Pre Operative Blood Donation
– Min Hb 11 gr
– 1 Unit ( 10-15% Blood vol) 5-7 days
– 35 days-2 days, iron suppl
•  Acute Normovolemic Haemodilution
– During surgery ( 4 hours )
– Monitoring, Replace fluid : crystaloid
1:3, Colloid 1:1
•  Blood Salvage
– Direct tranfusion

Transfusion Reactions Rujukan


  ACOG. Hemorrhagic shock. Educational Bulletin #235,
Immediate Delayed 1997.

  Choi PT-L et al. 1999. crystalloid vs. colloids in fluid


resuscitation: A systematic review. Critical Care Medicine
Hemolytic Non-hemolytic Infections Allergic 27( 1): 200-210.

  Scheirhout and Roberts 1998. Fluid resuscitation with


colloid or crystalloid in critically ill patients: A systematic
Febrile Allergic Hyper- Kalemia & Hypo- review of randomized trials. BMJ 316:961-964.
Acidosis calcemia
Hemolytic   MNH Post Partum Hemorrage.
Transfusion Acute Lung Injury
Reaction   The Clinical Use of Blood, WHO 2002.

Terima Kasih

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