Kehamilan dengan Besar Ukuran

yang Tidak Sesuai Usia

Kehamilan:
Kelainan Jumlah Air Ketuban
dan Fetal Growth Abnormalities
Nadya Anindita
Kelompok 7
Kelainan Jumlah Air Ketuban
Amniotic Fluid
• Peran
• Menyediakan ruang untuk pergerakan janin  musculoskeletal development
• Fetal swallowing  GI tract development
• Fetal breathing  lung development
• Melindungi janin dari kompresi tali pusat dan trauma
• Masalah: produksi atau sirkulasi
Amniotic Fluid Volume
• 98% water
• Volume
• 10 wga: 30 mL
• 16 wga: 200 mL
• Mid-third trimester: 800 mL
• Full term: ~2800 mL
• Masalah
• Oligohydramnios
• Hydramnios/polyhydramnios
Physiology

Early pregnancy Mid-to-late pregnancy

• Amniotic cavity is filled with
fluid that is similar in
composition to ECF
• Transfer of water and small
molecules
• Transmembranous flow (amnion)
• Intramembranous flow (fetal
vessels on placental surface) Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, et al. Williams obstetrics.
24th ed.New York: McGraw-Hill Education; 2014

• Across fetal skin ~22-25wga

Amniotic Fluid Measurement
• Dye-dilution methods: biasa digunakan untuk keperluan riset
• Sonographic assessment (semi-quantitative)
• Single deepest pocket (SDP)
• Mengukur kedalaman maksimum dari cairan amnion yang tidak terdapat bagian dari
fetus maupun tali pusat
• Normal range: 2 – 8 cm (maximum vertical pocket)
• Amniotic fluid index (AFI)
• Total SDP dari empat kuadran uterus
• Normal range: 5 – 24 cm
1. Hydramnios/Polyhydramnios
• Peningkatan volume cairan amnion
• Bisa dicurigai ketika ukuran uterus lebih besar dari usia kehamilan
• Dibagi berdasarkan derajat volume
• Mild (>50% of cases): AFI 25 – 29.9 cm; SDP 9 – 9.9 cm
• Moderate (~20%): 30 – 34.9 cm; SDP 10 – 11.9 cm
• Severe (~15%): ≥35 cm; SDP ≥12 cm
• Biasanya karena ada underlying etiology
• Etiology
• Fetal congenital anomalies
• Anensefali, hydranencephaly, holoprosencephaly: Impaired fetal swallowing
• Obstructions or atresia
• Diabetes mellitus
• Fetal osmotic diuresis
• Congenital infection: CMV, toxoplasmosis, sifilis, parvovirus
• Alloimunization
• Multifetal gestation
• Idiopathic
• Dapat menyebabkan: hydrops fetalis
• Anamnesis
• Tidak nyaman: distensi abdomen berlebih
• Dyspnea dan orthopnea: bernapas lega saat duduk
• Oliguria
• PF
• Uterus teraba tegang, sulit meraba bagian kecil janin, sulit auskultasi DJJ
• TFU lebih besar dari usia kehamilan
• Edema pada ekstremitas, vulva, dinding abdomen: major venous compression
• Komplikasi
• Preterm labor
• PROM
• Abruptio placenta
• Atony  PPH, uterine dysfunction
• Outcomes
• SC
• Fetal birthweight >4000g
• Increase perinatal mortality rate
• Management
• Penanganan berdasarkan penyebab
• Amnioreduction
• Amniocentesis
2. Oligohydramnios
• Penurunan volume cairan amnion yang abnormal
• Anhydramnios: tidak ada amniotic fluid pocket
• Diagnosis
• AFI ≤ 5cm, atau
• SDP≤ 2 cm, atau
• AFI di bawah p5 atau p2.5
• Etiology
• Early onset (sejak awal trimester 2)
• Fetal abnormalities  menghambat urinasi normal
• Placental abnormalities  perfusi buruk
• After midpregnancy (sejak akhir trimester dua atau pada trimester tiga)
• Fetal-growth restriction
• Placental abnormality
• Maternal complications: pre-eclampsia, vascular disease
• Congenital anomalies: renal agenesis, multicystic dysplastic kidney, etc
• Post-term pregnancies: reduced by 8% per week beyond 40 wga
• Medications: ACE-inhibitor, NSAIDs, angiotensin-receptor blockers
• Outcomes • Management
• Stillbirth • Evaluation of fetal anomalies and
• Malformations growth
• Growth restriction • Amnioinfusion dilakukan bila
• Nonreassuring heart rate pattern terdapat FHR variable
decelerations
• Meconium aspiration syndrome
• Pulmonary hypoplasia
• Fetal distress
• Umbilical cord compression
Fetal Growth Abnormalities
Fetal Growth
• Characterized by
• Tissue and organ growth, differentiation,
maturation
• Three phases
• First 16w: rapid increase in cell number
• ~32w: cellular hyperplasia and hypertrophy
• >32w: cellular hypertrophy, accumulation of
fetal fat and glycogen
• Growth rates
• 5g/d at 15w
• 15 – 20g/d at 24w
• 30 – 35g/d at 34w
• Normal birth weight: 2,500 – 4,000 g
(term) Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, et al. Williams obstetrics.
24th ed.New York: McGraw-Hill Education; 2014
1. Macrosomia
• “appropriate appellation for newborns who weigh 4500 g or more at
birth” (ACOG)
• Large for gestational age (LGA): >p90
• Risk Factors • Outcomes
• Obesity • Increase SC delivery rates by 50%
• DMG • Shoulder dystocia
• Type 2 DM • PPH
• Multiparity • Perineal lacerations
• Advanced maternal age • Maternal infection
• Previous macrosomic infants
• Racial and ethnic factors
• Diagnosis
• Belum ada yang pasti
• Baru bisa identifikasi dengan tepat
saat bayi sudah lahir
• Alternatif
• USG (sensitivity 60%)
• Management
• Prophylatic labor induction
• For non-diabetic patients
• Elective caesarean delivery
• Avoid difficult delivery and shoulder
dystocia
• Not recommended for non-diabetic
patients with FW <5000 g (ACOG)
2. Fetal-growth Restriction (FGR)
• Small for gestational age (SGA): weights below p10 for the gestational
age (using Lubchenco curve)
• FGR: berat janin <10% berat yang harus dicapai pada usia kehamilan
• Symmetrical or asymmetrical
• Symmetrical: proportionally small
• Faktor janin (kelainan genetic), lingkungan uterus yang kronik (diabetes, hipertensi)
• Asymmetrical: disproportionately lagging abdominal growth
• AC < HC
• Kurang O2 dan nutrisi pada trimester akhir
• Keadaan parah: kerusakan tingkat seluler (kelainan nukelus dan mitokondria)
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, et al. Williams obstetrics.
24th ed.New York: McGraw-Hill Education; 2014
• Outcomes • Diagnosis
• Stillbirth • TFU (sen <35%, spe >90%)
• Birth asphyxia • USG: biometri, TBJ
• Meconium aspiration • Amniotic fluid volume
• Neonatal hypoglycemia and (oligohydramnios)
hypothermia • Doppler velocimetry
• Abnormal neurological • Detect placenta-based GR
development
• Cardiac structural changes and
functions
• Postnatal structural and functional
renal changes
Cunningham FG, Leveno KJ,
Bloom SL, Spong CY, Dashe
JS, et al. Williams obstetrics.
24th ed.New York: McGraw-
Hill Education; 2014
References
1. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, et al.
Williams obstetrics. 24th ed.New York: McGraw-Hill Education; 2014
2. Saifuddin AB, Rachimhadhi T, Wiknjosastro GH, editors. Ilmu
kebidanan sarwono prawirohardjo. Jakarta: Bina Pustaka Sarwono
Prawairohardjo; 2008
3. Moegni EM, Ocviyanti D, editors. Buku Saku Pelayanan Kesehatan
Ibu di Fasilitas Kesehatan Dasar dan Rujukan. Jakarta: Kementerian
Kesehatan RI; 2013