Pemicu 4

Blok Sistem Reproduksi

Andreas Natan
405140099
 Distosia
• Distosia adalah Waktu persalinan yang memanjang karena
kemajuan persalinan yang terhambat. Persalinan lama
memiliki definisi berbeda sesuai fase kehamilan, seperti
klasifikasi berikut ini
– Distosia pada kala I fase aktif: grafik pembukaan serviks pada
partograf berada di antara garis waspada dan garis bertindak,
atau sudah memotong garis bertindak, ATAU
– Fase ekspulsi (kala II) memanjang: tidak ada kemajuan
penurunan bagian terendah janin pada persalinan kala II.
Dengan batasan waktu:
• Maksimal 2 jam untuk nulipara dan 1 jam untuk multipara,
ATAU
• Maksimal 3 jam untuk nulipara dan 2 jam untuk multipara
bila pasien menggunakan analgesia epidural
 Epidemiologi
• 1-2 per1000 kelahiran
• 16 per 1000 kelahiran bayi>4000 gram
 Diagnosis
• Tentukan kondisi dan kekuatan kontraksi
• Tentukan kemampuan ibu dalam menghasilkan tenaga
ekspulsi
• Tentukan kondisi janin
– Didalam atau di luar rahim
– Jumlah
– Letak
– Presentasi dan penuruan bagian terbawah janin
– Posisi, moulase dan kaput susedaneum
– Bagian kecil janin disamping presentasi (tangan, tali pusat, dll)
– Anomali congenital yang dapat menghalangi proses ekspulsi bayi
– Taksiran berat janin
– Janin mati atau hidup, gawat janin atau tidak
• Tentukan ukuran panggul dan imbangan feto-pelvik
• Tentukan ada/tidaknya tumor pada jalan lahir yang dapat
menghalangi persalinan pervaginam
 Faktor Predisposisi
• 1.Bayi:
– Kepala janin yang besar
– Hidrosefalus
– Presentasi wajah, bahu, alis
– Malposisi persisten
– Kembar yang terkunci (terkunci pada daerah leher)
– Kembar siam

• 2.Jalan lahir:
– Panggul kecil karena malnutrisi
– Deformitas panggul karena trauma atau polio
– Tumpor daerah panggul
– Infeksi virus di perut atau uterus
– Jaringan parut (dari sirkumsisi wanita)
 Tatalaksana
• Tatalaksana Umum: Segera rujuk ibu ke rumah
sakit yang memiliki pelayanan seksio sesarea.
• Tatalaksana Khusus: Tentukan penyebab
persalinan lama.
– Power: His tidak adekuat (his dengan frekuensi <3x/10
menit dan durasi setiap kontraksinya <40 detik).
– Passenger: malpresentasi, malposisi, janin besar
– Passage: panggul sempit, kelainan serviks atau
vagina, tumor jalan lahir
– Gabungan dari faktor-faktor di atas
 Tatalaksana
• Sesuaikan tatalaksana dengan penyebab dan situasi.
• Prinsip umum:
– Lakukan augmentasi persalinan dengan oksitosin dan/atau
amniotomi bila terdapat gangguan Power. Pastikan tidak ada
gangguan passenger atau passage.
– Lakukan tindakan operatif (forsep, vakum, atau seksio sesarea)
untuk gangguan Passenger dan/atau Passage, serta untuk
gangguan Power yang tidak dapat diatasi oleh augmentasi
• Jika ditemukan obstruksi atau CPD, tatalaksananya adalah
seksio sesarea.
– Pantau tanda-tanda gawat janin.
– Catat hasil analisis dan seluruh tindakan dalam rekam medis lalu
jelaskan pada ibu dan keluarga hasil analisis serta rencana
tindakan selanjutnya.
 Prognosis
• Komplikasi dari distosia dapat dibagi pada :
• A. Komplikasi ibu
– Perdarahan
– Trauma / cedera jalan lahir
– Infeksi
• B. Komplikasi janin
– Asfiksia berat
– Ekskoriasi kepala
– Sefalhematoma
– Perdarahan subgaleal dan ikterus neonatorum berat
– Nekrosis kulit kepala yang dapat menimbulkan alopesia
dikemudian hari
 Endometritis
• Endometritis is an inflammation or irritation of the lining of
the uterus (the endometrium)
• Endometritis is caused by an infection in the uterus. It can be
due to chlamydia, gonorrhea, tuberculosis, or a mix of normal
vaginal bacteria. It is more likely to occur after miscarriage or
childbirth. It is also more common after a long labor or C-
section.
• The risk of endometritis is higher after having a pelvic
procedure that is done through the cervix. Such procedures
include:
– D and C (dilation and curettage)
– Endometrial biopsy
– Hysteroscopy
– Placement of an intrauterine device (IUD)
• Endometritis can occur at the same time as other pelvic
infections
 Epidemiology
• The incidence of postpartum endometritis in the
United States varies depending on the route of
delivery and the patient population. After a
vaginal delivery, incidence is 1-3%. Following
cesarean delivery, the incidence ranges from 13-
90%, depending on the risk factors present and
whether perioperative antibiotic prophylaxis had
been given. In the nonobstetric population,
concomitant endometritis may occur in up to 70-
90% of documented cases of salpingitis
 Risk Factors
• Women are particularly vulnerable to endometritis after birth or
abortion. In both the postpartum and postabortal state, risk is increased
because of the open cervical os, presence of large amounts of blood and
debris, and uterine instrumentation.
• Major risk factors for obstetric endometritis include the following:
– Cesarean delivery (especially if before 28 weeks' gestation)
– Prolonged rupture of membranes
– Long labor with multiple vaginal examinations
– Severely meconium-stained amniotic fluid
– Manual placental removal [10]
– Extremes of patient age
– Low socioeconomic status
• A study by Tuuli et al indicated that the risk of endometritis is
significantly higher in cesarean deliveries performed during the second
stage of labor (10 cm cervical dilation) than in those performed during
the first stage (less than 10 cm dilation). Comparing 400 second-stage
deliveries with 2105 first-stage procedures, the investigators found
endometritis rates of 4.25% and 1.52%, respectively. A study by Asicioglu
et al also found a higher endometritis rate, along with greater risk of
other complications, in second-stage cesarean deliveries. [11, 12]
 Risk Factors
• Minor risk factors include the following:
– Absence of the normal cervical mucus plug
– Administration of multiple courses of corticosteroids for prevention of premature delivery
– Prolonged internal fetal monitoring
– Prolonged surgery
– General anesthesia
– Postpartum anemia

• The following factors increase the risk for endometritis in general:

– Presence of an intrauterine device: the vaginal part of the device may serve as a track for the
organisms to ascend into the uterusThe intrauterine device as a factor in the etiology of pelvic
inflammatory disease was associated with early forms of the device, in particular, the Dalkon
Shield. The incidence of pelvic inflammatory disease is not higher in users of
modern intrauterine devices than in non-users. [3, 4, 5]
– Presence of menstrual fluid in the uterus
– Associated cervicitis secondary to gonorrhea or Chlamydia infection
– Associated bacterial vaginosis [13, 14]
– Frequent douching
– Unprotected sexual activity
– Multiple sexual partners
– Cervical ectopy
 Pathophysiology
• Infection of the endometrium, or decidua, usually results from an
ascending infection from the lower genital tract. From a pathologic
perspective, endometritis can be classified as acute versus chronic.
Acute endometritis is characterized by the presence of neutrophils
within the endometrial glands. Chronic endometritis is characterized by
the presence of plasma cells and lymphocytes within the endometrial
stroma.
• In the nonobstetric population, pelvic inflammatory disease and
invasive gynecologic procedures are the most common precursors to
acute endometritis. In the obstetric population, postpartum infection is
the most common predecessor.
• Chronic endometritis in the obstetric population is usually associated
with retained products of conception after delivery or elective
abortion. In the nonobstetric population, chronic endometritis has
been seen with infections (eg, chlamydia, tuberculosis, bacterial
vaginosis) and the presence of an intrauterine device.
 Diagnosis usually is based on clinical
findings, as follows:
• Fever
• Lower abdominal pain
• Foul-smelling lochia in the obstetric population
• Abnormal vaginal bleeding
• Abnormal vaginal discharge
• Dyspareunia (may be present in patients with pelvic inflammatory disease
[PID])
• Dysuria (may be present in patients with PID)
• Malaise
• In postpartum cases, patients present with fever, chills, lower abdominal
pain, and foul-smelling lochia. Patients with PID present with lower
abdominal pain, vaginal discharge, dyspareunia, dysuria, fever, and other
systemic signs. However, PID caused by Chlamydia tends to be indolent,
with no significant constitutional symptoms.
 Physical Examination
• Physical examination findings include the following:
• Fever, usually occurring within 36 hours of delivery, in the obstetric
population
• Lower abdominal pain
• Uterine tenderness
• Adnexal tenderness if there is an associated salpingitis
• Foul-smelling lochia
• Tachycardia
• Uterine tenderness is the hallmark of the disease.
• An oral temperature of 38°C or higher within the first 10 days postpartum
or 38.7°C within the first 24 hours postpartum is required to make the
diagnosis of postpartum endometritis. For PID, the minimum diagnostic
criteria are lower abdominal tenderness, cervical motion tenderness, or
adnexal tenderness. In severe cases, the patient may appear septic.
 Antibiotic Therapy
• The combination of clindamycin and gentamicin administered intravenously every 8
hours has been considered the criterion standard treatment. Some studies have
revealed adequate efficacy with once-daily dosing, as well. [17, 18, 19, 20] The
combination of a second- or third-generation cephalosporin with metronidazole is
another popular choice.
• In teenagers, postabortion endometritis may be caused by organisms that
cause pelvic inflammatory disease (PID). The initial treatment regimen in these
patients usually includes intravenous cefoxitin and doxycycline, in the same doses as
for PID.
• A trend toward the use of broad-spectrum monotherapy has emerged; these agents
are generally effective in 80-90% of patients. Cephalosporins, extended-spectrum
penicillins, and fluoroquinolones are used as monotherapy. [21]
• Improvement is noted within 48-72 hours in nearly 90% of women. Parenteral
therapy is continued until the patient has been afebrile for longer than 24 hours. If
the physical examination findings are benign, the patient may be discharged at that
time. Further outpatient antibiotic therapy has proved to be unnecessary. If the
patient does not improve in the expected 48- to 72-hour period, reevaluate for
complications such as abscess.
 Potential Complications
• Potential complications of endometritis include the following:
– Wound infection
– Peritonitis
– Adnexal infection
– Parametrial phlegmon
– Pelvic abscess
– Pelvic hematoma
– Septic pelvic thrombophlebitis
• Spread of infection from the endometrium to the fallopian tubes,
ovaries, or the peritoneal cavity may result in salpingitis, oophoritis,
localized peritonitis, or tubo-ovarian abscesses. Salpingitis
subsequently leads to tubal dysmotility and adhesions that result in
infertility, higher incidence of ectopic pregnancy, and chronic pelvic
pain.
 Prognosis
• Nearly 90% of women treated with an approved
regimen note improvement in 48-72 hours. Delay in
initiation of antibiotic therapy can result in systemic
toxicity.
• Endometritis is associated with increased maternal
mortality due to septic shock. However, mortality is
rare in the United States because of aggressive
antimicrobial management.
• In the PID Evaluation and Clinical Health (PEACH) study,
endometritis was not found to be associated with
subsequent pregnancy-related complications, chronic
pelvic pain, or infertility.