Konferensi Kasus Sulit

Selasa, 4 April 2023

Annisa Fitriani

Departemen Obstetri dan Ginekologi

Fakultas Kedokteran, Kesehatan Masyarakat, dan Keperawatan
Universitas Gadjah Mada
 Fetomaternal Ny. I.F.N, 28 tahun, G2P1A0 hamil 39 minggu 1hari
UPD HOM-Anesthesi No. RM 01877314

ITP Refrakter, G2P1A0 hamil 39 minggu 1hari,

Diagnosis :
Riwayat SC 4 tahun yll

Topik Diskusi : Manajemen Persiapan Operasi

DPJP : dr. Irwan Taufiqur Rachman, Sp.O.G, Subsp. K.Fm

RIWAYAT SINGKAT
2019
Pasien riwayat ITP dan diketahui sejak 2019 saat hamil anak pertama.
Keluhan perdarahan seperti mimisan, lebam di tubuh disangkal.
Riw. Menstruasi : menarche 13 tahun, durasi 7-10 hari, siklus 30 hari,
teratur
Riw menikah : 1x menikah, usia menikah selama 4 tahun Pasien direncanakan Re-
Riw ANC : >4x di puskesmas SC elektif pada 3 April
Riw Obstetri : I. 2019/aterm/SC a.i ITP/RS sardjito/dokter/laki-laki/2600 gr 2023, target AT pre-
II. Hamil ini RPD : ITP (+) HT (-), DM (-), jantung (-), asma (-), alergi (-) operasi : 75rb
Riwayat penyakit keluarga : HT (+) ibu, DM (+) ibu, sakit jantung (+) ayah,
asma (-), alergi (-)
Operasi ditunda
Perbaikan KU dan
kelayakan operasi

Maret 2023 Persiapan operasi :

Pasien dirujuk dari RSUD Tjitrowardojo dengan diagnosis Transfusi 1 TA dan 10 TC
G2P1A0 UK 38+4 minggu, awalnya pasien datang sendiri ke + Inj Metilprednisolon
IGD RSUD Tjitrowardojo dengan keluhan kenceng-kenceng 125 mg/8 jam (mulai
(+) sejak pagi pukul 09.00 WIB. 22.00 2/4/23)
Keluhan LD (-), AK rembes (-) gerak janin aktif (+) pusing (-),
mual (-), muntah (-), pandangan kabur (-), nyeri ulu hati (-) Evaluasi lab pre op:
Keluhan gusi berdarah (-), mimisan (-) AT 35 rb
 Pemeriksaan Fisik

G1P0A0, 27 th Kepala : CA-/-, SI-/-

HPHT 3/7/22
HPL 10/4/23 Thorax : Simetris
UK 39 minggu 1 hari
- Pulmo : SN vesikuler, Rh (-/-), Whee (-/-)
O: KU: baik, sadar
TD 94/62 mmHg - Cor : S1S2 tunggal, bising (-)
HR 74 kpm
RR 18 kpm Abdomen : janin tunggal memanjang preskep, DJJ 144 kpm,
T 36 C gerak janin aktif, TFU 29 cm, His(+)1x/10’/10”/L
SpO2 98% RA
PD : VU tenang, dinding vagina licin, cervix agak lunak di
BB saat ini : 52 kg depan, eff 30%, pembukaan (-), selket sdn, AK (-),
BB sebelum hamil : 39 STLD (+), BS :
Kenaikan BB : 13 kg
TB : 152 cm
Ekstremitas : Edema (-)
IMT 22.5 kg/m2
 USG 01/04/2023
Lubchenco Curve

USG 01/04/23
Janin tunggal memanjang preskep, DJJ (+), gerak janin (+),
plasenta di corpus lateral kiri, AK kesan cukup (SDP 3.37 cm),
Myometrial thickness 0.83cm, 0.62 cm, 0.41 cm
BPD 8.81 cm, HC 31.1 cm, AC 31.7 cm, FL 6.04 cm
EFW 2544 gram
CTG 01/04/2023

CTG 01/04/2023
FHR 145 kpm
Variabilitas>5
Akselerasi +
Deselerasi –
Gerak +
HIS -
Kesan kategori 1
 Laboratory
Nama 01/04/23 03/04/23 Nilai Nama 01/04/23 02/04/23 Nilai Rujukan
Pemeriksaan Rujukan Pemeriksaan
Hb 11.9 10.0 12.0 - 15.0 HBsAg NR NR
Hmt 39.4 33.5 35.0 - 49.0 Swab antigen Negatif Negatif
AL 13.2 12.5 4.50 - 11.50 SARS COV-2
AT 16 35 150 - 450
PPT 9.3 9.4 - 12.5
INR 0.85 0.90 - 1.10
APTT 28.4 25.1 - 36.5
Alb 3.60 3.97 - 4.94
OT 21 10- 35
PT 12 10 - 35
BUN 7 6 - 20
Cr 0.50 0.51 - 0.95
GDS 94 74 - 106
Na 132 136 - 145
K 3.3 3.5 - 5.1
Cl 101 98 - 107
Analisis Kasus

Ny. IFN, 28 tahun

Idiopathic thrombocytopenic
purpura (ITP) sejak 2019
G2P1A0 hamil 39 minggu 1 hari
Riwayat SC 4 tahun yll
Belum dalam persalinan
VBAC score :
Myommetrial thickness <1cm

Time of delivery Mode Of delivery Labor preparation Postnatal

Resiko Perdarahan Target AT Strategi Medikasi

Diskusi
 Idiopathic Thrombocytopenic Purpura (ITP)
• Penyebab ITP: primer dan sekunder

• ITP primer, yang terjadi pada 1% sampai 4% pasien hamil dengan trombositopenia, ditandai dengan
penghancuran trombosit yang diperantarai imunoglobulin G autoimun.

• Kehamilan tidak meningkatkan risiko kambuh atau memperburuk penyakit aktif.

• Perkiraan kejadian ITP penyulit kehamilan kira-kira 1 kasus dalam 10.000 kelahiran (Care, 2018).
Namun, bukan hal yang aneh bagi wanita yang telah mengalami remisi klinis selama beberapa tahun
untuk mengalami trombositopenia berulang selama kehamilan.

• Semua penyebab trombositopenia pada kehamilan berisiko tinggi mengalami solusio plasenta

• Perdarahan postpartum juga terjadi pada tingkat yang lebih tinggi pada wanita dengan trombositopenia
prapersalinan yang diketahui berkisar antara 3,6% dan 7,1%
William Obstetrics, 26th Ed
Baucom, Amanda M. BS ; Kuller, Jeffrey A. MD ; Dotters-Katz, Sarah MD, MMHPE . Immune Thrombocytopenic Purpura in Pregnancy. Obstetrical & Gynecological Survey 74(8):p
∗ † ‡

490-496, August 2019. | DOI: 10.1097/OGX.0000000000000697

 Management of ITP in Pregnancy

• Close collaboration between haematologist, obstetrician, neonatologist and anaesthetist is needed to

ensure a good pregnancy outcome.

• The schedule of follow-up laboratory tests should be based on clinical reasoning, however a platelet
count advised to be checked at each routine prenatal visit

• The goal of medical therapy during pregnancy in women with ITP is to minimize the risk of bleeding
complications that can occur with regional anesthesia and delivery associated with thrombocytopenia

• Treatment should be initiated when the patient :

- Has symptomatic bleeding
- A platelet count below 10,000/μl at any time during pregnancy
- A platelet count below 30,000/μl at second or third trimester
- To increase platelet counts to a level considered safe for procedures (70,000/μl for epidural
placement and 50,000/μl for cesarean delivery)
William Obstetrics, 26th Ed
ACOG Practice Bulletin No. 207: Thrombocytopenia in Pregnancy. Obstet Gynecol. 2019 Mar;133(3):e181-e193. doi: 10.1097/AOG.0000000000003100. PMID:
30801473.
 Modalities of treatment of ITP in pregnancy

• Corticosteroids and IVIG are effective and safe in pregnancy and are used as first line therapy. (Grade B)

• Splenectomy is considered only if above measures fail to elevate the platelet counts and patient has
serious bleeding. This is best deferred until the second trimester to prevent miscarriage.
• Refractory ITP: does not respond to or relapses after splenectomy and that requires treatment to
reduce the risk of clinically significant bleeding
• Second line of treatment for refractory ITP, includes:
− The immunosuppressants azathioprine and cyclosporin should be considered for women who
require treatment for refractory ITP in the first and second trimesters.
− Platelet transfusions may be used in the setting of significant bleeding, and may be considered if
emergency Caesarean section is required with a platelet count below 50x109/L despite other
treatment measures

Eslick, R., & McLintock, C. (2019). Managing ITP and thrombocytopenia in pregnancy. Platelets, 1–7.  doi:10.1080/09537104.2019.1640870 
 Management of ITP in Pregnancy

First
Trimester

Second
Trimester

Third
Trimester

Eslick, R., & McLintock, C. (2019). Managing ITP and thrombocytopenia in pregnancy. Platelets, 1–7.  doi:10.1080/09537104.2019.1640870 
 Management During Labor
 The mode of delivery in a mother with ITP is based on obstetric indications.
 Vaginal delivery is considered to be the safer option for both mother and fetus, and cesarean delivery
should be reserved for the usual obstetric indications according to ACOG
 Operative vaginal deliveries such as vacuum or forceps should also be generally avoided if possible.
However, if assistance at the time of delivery is required, forceps-assisted delivery poses less of a risk to the
fetus compared with vacuum-assisted delivery.
 Platelet count >30 x 109/L: safe for normal vaginal delivery in patients with otherwise normal coagulation
 Platelet count <30 x 109/L: admit for pulsed IVIG and close monitoring
 Platelet count above 50 x 109/L is safe for caesarian section under general anaesthesia but not epidural
anaesthesia.
 Epidural anaesthesia is best avoided because of the risk of epidural haematoma and cord compression.
 If platelet counts are less than 50 x 109/L and patient requires immediate caesarian delivery, administer
IVIG and methylprednisolone.
ACOG Practice Bulletin No. 207
 Give platelet transfusion just prior to surgery.
 ITP effect on Fetus
• Pregnancy complications that are increased with ITP include stillbirth, fetal loss,
and preterm birth (Wyszynski, 2016)
• Maternal IgG is actively transported to the fetal circulation subsequent to its
binding to Fcγ receptors on the syncytiotrophoblast cells of the placenta 
development of fetal thrombocytopenia
• Risk of intracranial hemorrhage during delivery by <1 % (American College of
Obstetricians and Gynecologists, 2019). Hemorrhage was not associated with
route of delivery.
 Usulan

• Mode of delivery : re-SC elektif

• Time of delivery : aterm (39 minggu)
• Perbaikan KU sesuai dengan TS UPD HOM (steroid dengan Inj MP 125mg/8jam/iv)
• Persiapan Operasi sesuai TS Anesthesi (target AT 50rb untuk SC dengan GA)
• Transfusi dengan 1 TA atau 7 TC pre operasi dan persiapan operasi dengan 2 PRC 7TC
• KIE pasien dan keluarga terkait perburukan kondisi sd kemungkinan DOT apabila
target operasi belum terpenuhi namun terjadi kondisi gawat obstetrik yang
mengharuskan tindakan operasi emergency
Terima Kasih