Laporan Kasus

ibu hamil dengan hBsAG +, inkompatibilitas

rhesus, dan plasenta previa parsialis
Pembimbing: dr. Miko Susanto, SpOG

Sharon/406172040
Identitas Pasien
Nama : Ny. N
Umur : 36 tahun
Alamat : Jl. Duku Srengseng, Kembangan
Pendidikan : SMP
Status : Menikah
Pekerjaan : Ibu rumah tangga
Tanggal masuk RS: 28 Maret 2019
Keluhan Utama

Rujukan RS Bhakti Mulya

Rencana SC karena ari-ari menutupi jalan lahir
curiga ketidakcocokan golongan darah ibu dan janin
Riwayat Penyakit Sekarang
• Pasien G4P1A2 hamil 37-38 minggu dirujuk dari RS Bhakti Mulya. Pasien mengatakan
berdasarkan hasil pemeriksaan di RS tersebut, ia direncanakan untuk SC karena ari-ari
menutupi jalan lahir. Selama hamil ini, pasien tidak pernah mengalami keluhan
perdarahan. HPHT pasien 5 Juli 2018 dan perkiraan lahir 10 April 2019. Pasien rutin
control kehamilan di RS Harapan Kita sebanyak 4x. Selama hamil, keluhan yang dirasakan
hanya mual-muntah (saat hamil muda). Tidak ada keluhan sakit kepala, lemas, bengkak
pada tangan dan kaki. Gerakan janin dirasakan aktif. Pasien hamil dari suami pertama dan
sudah menikah selama 7 tahun.
• Pasien mengatakan saat hamil anak pertama, ia melakukan cek darah dan dikatakan
menderita hepatitis B. Tidak ada keluhan terkait dengan hepatitisnya dan ia tidak minum
obat apapun. Ia juga tidak tahu bagaimana bisa terkena hepatitis B.
• Pasien memiliki golongan darah A- sedangkan suaminya B+. Karena itu dokter
mengatakan kemungkinan akan timbul ketidakcocokan golongan darah antara ibu dan
janin.
Riwayat Penyakit Dahulu
• Pasien pernah dioperasi SC di tahun 2013 (melahirkan anak pertama)
• Riwayat hipertensi, diabetes melitus, asma, alergi obat-obatan
disangkal.
• Riwayat HBsAG (+), pertama kali didiagnosis tahun 2013
• Tidak ada obat-obatan yang rutin dikonsumsi pasien setiap hari
• Pasien tidak pernah merokok, menggunakan obat terlarang, tidak
minum minuman beralkohol, tidak berganti-ganti pasangan seksual
Riwayat Penyakit Keluarga

• Pasien mengatakan tidak ada anggota keluarganya yang menderita Hepatitis B

• Riwayat penyakit jantung, hipertensi, diabetes mellitus, asma, dan alergi disangkal.

Riwayat Menstruasi
• Menarche usia 12 tahun
• Lama haid 6 hari, jumlah perdarahan +/- 60cc
• Teratur, siklus 30 hari

Riwayat penggunaan KB (-)

Riwayat kehamilan, persalinan, nifas
1. 2013  hamil 8 bulan, persalinan SC di RS, ditolong dokter  bayi
perempuan, BB 2,5kg. Meninggal 3 hari setelah lahir (dx: anensefali)
2. 2016  abortus, hamil 3 bulan
3. 2017  abortus, hamil 1 bulan
4. 2019  hamil ini.

Riwayat asupan nutrisi

• Makan 3x sehari dengan nasi, lauk bervariasi (daging, sayur) dan buah.
• Minum cukup 8 gelas/hari
• Konsumsi asam folat selama hamil ini. Pasien menolak pemberian tablet
besi karena mual.
Pemeriksaan Fisik
27 Maret 2019
• Keadaan Umum : Baik, compos mentis (GCS 15)
• Kesadaran : Compos mentis
• Tanda Vital:
• Tekanan darah : 110/62 mmHg
• Nadi : 82x/menit, reguler, isi cukup
• Suhu : 36,5ºC
• Laju Nafas : 18x/menit
Pemeriksaan Fisik
Kepala: Konjungtiva anemis +/+ ringan, sclera ikterik -/-, kloasma
gravidarum (+), epulis (-), edema wajah (-)
• Leher : trakea di tengah, pembesaran KGB (-), pembesaran tiroid
(-)
• Thoraks: payudara menggantung, putting tampak tumpul, retraksi
(-/-), hiperpigmentasi areola (+/+), kolostrum (-/-)
Pulmo: suara napas vesikuler +/+, rh -/-, wh -/-
Cor: BJ I-II regular, murmur (-), gallop (-)
Pemeriksaan Fisik
• Abdomen :
I: Tampak perut membuncit sesuai usia kehamilan, pusat tampak datar
dengan perut, linea nigra (+), striae gravidarum (+), jaringan parut BSC (+)
A: BU (+) normal, DJJ 145x/menit, regular
P: supel, TFU 31 cm, his (-), TBJ 2945gr
Leopold I: lunak, bulat, tidak melenting  bokong
Leopold II : bagian besar di kanan  punggung kanan
Leopold III: keras, bulat, melenting  kepala
Leopold IV: konvergen  belum masuk PAP
• Ekstremitas : Akral hangat, CRT <2 detik, edema (-/-), luka (-/-)
• Kulit : Linea nigra (+), striae gravidarum (+), kloasma gravidarum (+),
hiperpigmentasi areola (+/+), jaringan parut bekas SC (+)
• Anus dan Genitalia :
Anus tampak normal, perineum tidak menonjol, fissure ani (-), benjolan (-
)
Genitalia, I  tampak normal, vulva tertutup, hiperemis (-), pembesaran
kelenjar (-), tumor (-)

• Pemeriksaan neurologis tidak dilakukan

Pemeriksaan Penunjang
Hasil Nilai Acuan Satuan
Hematologi
Eritrosit 4.21 4.00 – 5.20 Juta/µL
Hemoglobin 10.5 12 – 16 g/dL
Hematokrit 32.0 36.0 – 46.0 %
Trombosit 268 150 – 440 Ribu/µL
Leukosit 9.9 4.0 – 11.0 Ribu/µL
MCV 76 80 – 100 /fL
MCH 24.9 26-34 pg
MCHC 32,8 31-37 %
Goldar A-
Imunologi HBsAG +
USG Trimester 3

Janin tunggal hidup, presentasi kepala

Implantasi plasenta di corpus uteri segmen posterior, maturasi derajat II, menutupi jalan lahir
Ketuban cukup
Biometri sesuai usia kehamilan 35 minggu dengan TBJ 2616 gram
DJJ 136bpm
EDD 18/4/2019

Pertumbuhan janin baik, sesuai HPHT

Rencana SC tanggal 27/3/2019
Resume
Telah diperiksa perempuan 36 tahun, G4P1A2 rujukan dari RS Bhakti Mulya
pro SC atas indikasi plasenta previa parsialis segmen posterior, HBsAG +,
susp inkompatibilitas rhesus. HPL USG 18/4/2019. Hamil dari suami
pertama, sudah menikah selama 7 tahun.
Tahun 2013, hasil pemeriksaan imunologi: HBsAg +
Riwayat BSC 1x di tahun 2013. Haid teratur, siklus 30 hari.
Anak pertama (2013) meninggal 3 hari setelah lahir karena anensefali.
Riwayat abortus 2x (2016 dan 2017)
Dari PF didapatkan konjungtiva anemis ringan, kloasma gravidarum (+),
payudara kesan multipara, hiperpigmentasi areola, linea nigra, striae
gravidarum, jaringan parut bekas SC. TFU 31 cm, DJJ 145x/menit regular, TBJ
2945gr, presentasi kepala, belum masuk PAP.
Pemeriksaan penunjang didapatkan anemia, HBsAg +, golongan darah A-.
USG: implantasi plasenta di corpus uteri segmen posterior.
Diagnosa Kerja
• G4P1A2 HbsAg+ hamil 37-38 minggu pro SC a/I plasenta previa parsialis segmen
posterior uteri dan BSC 1x
• Susp inkompatibilitas golongan darah

Diagnosa Banding
-
Rencana Terapi Farmakologis
• Ketorolac 3 x 30mg IV
• Oxytocin 1 amp intraoperatif
• Cefotaxime 3 x 1g
• Cefadroxil 2 x 500mg
• Asam mefenamat 3 x 500 mg
• RhoGam inj 1x max 72 jam postpartum
Rencana Terapi Non-Farmakologis
• Pro re-SC
• Puasa asupan oral 8 jam sebelum operasi
• Indwelling catheter pre op
• Pubic hair shave
• Ambulasi dini
Edukasi
• Menjelaskan tindakan SC, tujuan, alasan dilakukan serta risiko tindakan kepada pasien
• Menjelaskan tentang masase fundus uteri untuk mempercepat pemulihan uterus pasca
operasi kepada pasien
• Menyarankan penyuntikan HBIG dan imunisasi HepB untuk bayi
• Menjelaskan pemberian ASI eksklusif untuk bayi selama 6 bulan jika sudah divaksin HepB
saat lahir
• Menjelaskan mobilisasi aktif pasca operasi
• Menjelaskan pasien untuk makan makanan bergizi selama menyusui
• Menjelaskan tentang penyuntikan RhoGam, indikasi, dan kemungkinan reaksi yang timbul
setelah penyuntikan
Prognosis
• Ad vitam: ad bonam
• Ad sanationam: dubia ad bonam
• Ad functionam: ad bonam
Tinjauan Pustaka
Placenta Previa
• a placenta that is implanted somewhere in the lower uterine segment,
either over or very near the internal cervical os
• “placenta migration” theory  no apparent movement of placenta from
the internal os

• Classification:
• Low-lying placenta (marginal previa)—implantation in the lower uterine
segment is such that the placental edge does not reach the internal os and
remains outside a 2-cm wide perimeter around the os.
• Placenta previa—the internal os is covered partially or completely by
placenta.
• Risk factors:
• Maternal age  older, more frequent
• Multiparity
• Prior caesarean delivery
• Cigarette smoking
• Elevated prenatal maternal serum alfa-fetoprotein level

• Clinical features
• Painless bleeding  usually does not appear until near the end of the
second trimester or later, but it can begin even before midpregnancy.
• begins without warning and without pain or contractions
• Could be complicated with abnormally implanted placenta (placenta
accrete)
• Diagnosis
• Whenever there is uterine bleeding after
midpregnancy, placenta previa or abruption
should always be considered.
• Physical exam  double set-up technique
• Transabdominal sonographic evaluation
• MRI  could be used to diagnose placenta
accrete

• Management:
• Factors  fetal age (maturity); labor; and
bleeding and its severity
• Preterm, no persistent active bleeding 
close observation in obstetrical unit
• near term, no bleeding,  scheduled
cesarean delivery.
Hepatitis B in Pregnancy
• HBV  double-stranded DNA virus of the Hepadnaviridae family
• endemic in Africa, Central and Southeast Asia, China, Eastern Europe, the Middle
East
• transmitted by exposure to blood or body fluids from infected individuals
(sexual/sharing contaminated needles), vertical transmission (mother to fetus)
• Acute hepatitis B develops after an incubation period of 30 to 180 days with a
mean of 8 to 12 weeks.
• At least half of acute infections are asymptomatic.
• If symptoms are present, they are usually mild and include anorexia, nausea,
vomiting, fever, abdominal pain, and jaundice.
• Complete resolution of symptoms occurs within 3 to 4 months in more than 90
percent of patients
• Hepatitis B infection is not a cause of excessive maternal morbidity and
mortality.
• It is often asymptomatic and found only on routine prenatal screening
• Infants born to seropositive mothers are given HBIG very soon after
birth. This is accompanied by the first of a three dose hepatitis B
recombinant vaccine.
• For high-risk mothers who are seronegative, hepatitis B vaccine can be
given during pregnancy.
• To decrease vertical transmission in women at highest risk because of
high HBV DNA levels, some have recommended antiviral therapy.
Lamivudine, a cytidine nucleoside analogue, has been found to
significantly decrease the risk of fetal HBV infection in women with high
HBV viral loads (Dusheiko, 2012; Giles, 2011; Han, 2011; Shi, 2010; Xu,
2009)
Inkompatibilitas rhesus
• The rhesus system includes five red cell proteins or antigens: C, c, D, E, and
e.
• Rh D-negativity is defined as the absence of the D antigen.
• Rh D-negative individuals may become sensitized after a single exposure to
as little as 0.1 mL of fetal erythrocytes
• Without anti-D immune globulin prophylaxis, an Rh D-negative woman
delivered of an Rh D-positive, ABO-compatible infant has a 16-percent
likelihood of developing alloimmunization.
• Initial evaluation of alloimmunization begins with determining the paternal
erythrocyte antigen status  amniocentesis, PCR testing of uncultured
amniocytes, cell-free fetal DNA from maternal plasma
• There are two potential indications in Rh D negative pregnant
women:
• (1) in women with Rh D alloimmunization, testing can identify
fetuses who are also Rh D negative and do not require anemia
surveillance, and
• (2) in women without Rh D alloimmunization, anti-D immune
globulin might be withheld if the fetus is Rh D negative.
• Factors that influence an Rh-negative pregnant female's chances
of developing Rh incompatibility include the following:
• Ectopic pregnancy
• Placenta previa
• Placental abruption
• Abdominal/pelvic trauma
• In utero fetal death
• Any invasive obstetric procedure (eg, amniocentesis)
• Lack of prenatal care
• Spontaneous abortion
• Obtain the following history:
• History of prior blood transfusion
• Rh blood type of the mother
• Rh blood type of the father
• Previous pregnancies, including spontaneous and elective
abortions
• Previous administration of Rh IgG (RhoGAM)
• Mechanism of injury in cases of maternal trauma during
pregnancy
• Presence of vaginal bleeding and/or amniotic discharge
• Previous invasive obstetric procedures, such as amniocentesis,
cordocentesis, chorionic villous sampling, or ectopic pregnancy
• Physical examination:
• Evaluation of the vital signs and primary survey of the airway and
cardiovascular system are indicated to ensure maternal stability.
• A thorough pelvic examination is required  pelvic/abdominal
trauma? Fetomaternal hemorrhage
• a thorough physical examination of the newborn  Physical
findings may vary from mild jaundice to extreme pallor and
anemia with hydrops fetalis.
• Workup:
• Determination of Rh blood type in pregnant mothers
• Rosette screening test
• Kleihauer-Betke acid elution test
• maternal Rh antibody titers

• Postnatal:
• blood from the umbilical cord of the infant for ABO blood group and Rh
type
• measure hematocrit and hemoglobin levels,
• perform a serum bilirubin analysis,
• obtain a blood smear,
• perform a direct Coombs test.
• Other testing:
• fetal monitoring in cases of suspected fetal distress
• pelvic ultrasonography  hydrops fetalis
• scalp edema
• cardiomegaly
• Hepatomegaly
• pleural effusion
• ascites.