Perdarahan dalam

kehamilan

ARIO DANIANTO
06 Maret 2020

Dept Obsgyn FK Universitas Mataram

RSUD Prov NTB – RS Universitas Mataram
Maternal death
KASUS I
● Ny A/ 23 thn hamil usia kehamilan 30 mgg
tiba2 setelah bangun tidur merasakan ada
darah yang keluar dari kemaluan, tidak
nyeri dan membasahi kain yang dipakainya
diagnosis????
KASUS II
● Ny B/25 thn, haid terakhir 3 bln yang lalu,
mengeluhkan nyeri perut bawah yang hebat.
Pusing (+), perdarahan pervaginam (+)
minimal. Pasien tampak pucat dan dilakukan
pemeriksaan tensi : 80/50 , Nadi 100x/mnt
diagnosis????
Hemorrhage in Pregnancy
● Earlypregnancy (<20 weeks)
-related to the pregnant state :
abortion, ectopic pregnancy, hydatidiform mole,
implantation bleeding
-associated with the pregnant state :
cervical lession such as vascular erosion, polyp,
ruptured varicos veins and malignancy

● Latepregnancy (> 20 weeks)

-antepartum haemorrhage :
placenta previa, abruption placenta
Abortus..... (1)
● Definition

Abortion is the expulsion or extraction from its

mother of an embryo or fetus weighing 500 g
or less when it is not capable of independent
survival (WHO)
● Incidence

probably 10–20% of all clinical pregnancies.

75% abortions occur before the 16th week
and of these, about 75% occur before the 8th
week of pregnancy
Abortus.....(2)
● Etiology

is often complex and

obscure - genetic
- endocrine and
metabolic - anatomic
- Infection
- Immunological
- antifetal antibodies
- Trombophilias
- others
Abortus.....(3)
● classification
 Threatened
miscarriage Inevitable miscarriage Incomplete miscarriage

Abortus.....(4)
● emergency management
 - vital sign 🡪 stabilization (A-B-C)
- vaginal toucher 🡪 digitalization 🡪 curettage -
give oxytocin 10 IU iv
- septic 🡪give antibiotics 🡪 curettage 6 hours
after inj antibiotics
- stable condition 🡪 curettage or refer to
hospital
Abortus.....(5)
● definitif management
- Depend on type of abortion
- Uterus is less than 12 weeks:
*expectant
 *medical
*suction evacuation / dilatation +
curretage - Uterus more than 12 weeks:
*prostaglandin E1 analog
(misoprostol) *oxytocin
* dilatation evacuation
Ectopic pregnancy .....(1)
● Definition : Fertilized ovum is implanted and
develops outside the normal endometrial
cavity ● Sites of implantation
Ectopic pregnancy .....(2)
Ectopic pregnancy .....(3)
Ectopic pregnancy .....(4)

Risk factor :
- History of PID
- History of tubal ligation
- Contraception failure
- Previous ectopic pregnancy
- Tubal reconstructive surgery
- History of infertility
- ART particularly if the tubes are patent
but damaged
- big zygote
Ectopic pregnancy .....(5)

Clinical Features: (acute- unruptured-subacute/chronic)

- The
classic triad
abdominal pain - amenorrhea – vaginal
bleeding - Vomiting , fainting attack
- Features of shock
- Abdominal examination 🡪 tense
- Pelvic examination 🡪 cavum douglas bulge 🡪
slinger pain
Ectopic pregnancy .....(6)

Investigations for the

diagnosis - Blood examination
- Culdocentesis
- Estimation of β-hCG
- Sonography

Diffrential diagnosis
- Incomplete abortion
- Salphingitis
- Appendicitis
- Twisted ovarial cyst
- Rupture ovarial cyst
Ectopic pregnancy .....(7)

emergency management
- Vital sign 🡪 shock 🡪 stabilization (A-B-C) -
Double iv line
- Refers to hospital (accompanied by family with
same blood type 🡪 for donation)

definitif management
- Medical
- Surgical 🡪 laparotomy/ laparoscopy
🡪 salpingectomy/ salpingostomy/
curnuectomy
GESTATIONAL TROPHOBLASTIC
DISEASES (GTD)

Definition : a spectrum of proliferative

abnormalities of
trophoblasts associated with pregnancy

Classification GTD :
- Hydatidiform mole: – Complete – Partial -
Invasive mole
- Placental site trophoblastic tumor -
Choriocarcinoma
Hydatidiform mole …..(1)

Definition: an abnormal condition of the

placenta where there are partly degenerative and
partly proliferative changes in the young chorionic
villi

Incidence :
wide range of geographical and ethnic variation of
the prevalence of the condition. Common in
Oriental countries—Philippines, China, Indonesia,
Japan, India, Central and Latin America and Africa
Hydatidiform mole …..(2)

Etiology : The cause is not definitely known,

but it appears to be related to the ovular defect as
it sometimes affects one ovum of a twin
pregnancy

- Nutrition (inadequate intake protein)

- Cytogenetic abnormality—In general, complete
moles have a 46, XX karyotype - Disturbed
maternal immune mechanisms suggested by—(a)
Rise in gammaglobulin level in absence of hepatic
disease (b) Increased association with AB blood
group which
 possesses no ABO antibody
Hydatidiform mole …..(3)

Clinical features :
- Abnormal vaginal bleeding
- Uterus > dates
- Lower abdominal pain
- Hyperemesis gravidarum
- Features of early onset pre-eclampsia < 20 weeks -
Absent fetal parts and FHB
- Expulsion of vesicular tissues
- Thecalutein cyst of ovaries (25%) > 6 cm -
Hyperthyroidism
- Serum hCG > 100,000 mIU/mL
- USG: snowstorm/honeycomb appearance
Hydatidiform mole …..(4)

Sonography:
- snowstorm/honeycomb appearance
Hydatidiform mole …..(5)

Clinical features :
- Expulsion of vesicular tissues

Hydatidiform mole …..(6)

emergency management
- Vital sign 🡪 shock 🡪 stabilization (A-B-C) -
Double iv line
- Refers to hospital (bring family with same blood type)

definitif management
- Suction evacuation 🡪 pathology examination -
Regular follow up β-hCG + USG
- β-hCG persistent 🡪 ???
Antepartum hemorrhage

Definition : bleeding from or into the genital tract

after the 28th week of pregnancy but before the
birth of the baby

Diagnosis procedure
● History taking and physical examination
● Ultrasound

● Electronic Fetal Monitoring

● Speculum
Placenta previa .....(1)
● Definition : the placenta is implanted partially or
completely over the lower uterine segment (over
and adjacent to the internal os)
● Etiology

- Dropping down theory

- Persistence of chorionic activity
- Defective decidua
- Big surface area of the placenta
Placenta previa .....(2)
● Risk factors :
 - previous C-section or operation in
uterine - history pregnant with placenta
previa - multiparity
- advance maternal age
- smoking
- multifetus pregnancy
Placenta previa .....(3)
Type or degrees
 Low-lying Marginal Central/ total

Incomplete/partial

Placenta previa .....(4)

● Clinicalfeatures:
- vaginal bleeding 🡪 bright red (sudden onset,
 painless, apparently causeless, recurrent) -
persistence of malpresentation
- the head is floating
- hemodynamic 🡪 depent on blood loss
- Vaginal examination 🡪 not be done
Placenta previa .....(5)
● Confirmation of
diagnosis : -
Double set-up
- Sonography
- MRI
Placenta
previa .....(6)
● emergency management
- Vital sign 🡪 shock 🡪 stabilization (A-B-C) -

Double iv line
- Refers to hospital (accompanied by family with
same blood type 🡪 for donation)
- BAKSOKU

Placenta previa .....(7)

● definitif
management (active, conservative)
- depends on the gestational age
- depends on blood loss /
hemodynamics - depends on fetus
condition
Placenta previa .....(8)
Abruptio Placentae .....(1)
● Definition: the bleeding occurs due to premature
separation of normally situated placenta ● Varieties
:

Concealed Revealed

Marginal/subchorionic preplacental

Abruptio Placenta .....(2)

● Risk factor :
- history pregnancy with abruptio placenta
- PPROM
- Preeclampsia
- Trauma
- Polyhidramnion
- previous C-section
- placental anomaly
Abruptio Placenta .....(3)
● Clinical features :
Abruptio Placenta .....(4)
● Emergency management :
- Vital sign 🡪 shock 🡪 stabilization (A-B-C) -
Double iv line
- VT 🡪 amniotomy
- Refers to hospital (accompanied by family with
same blood type 🡪 for donation)
- BAKSOKU

Abruptio Placenta .....(5)

Abruptio Placenta .....(6)
● Complication:

- Hemorrhage

- Shock

- Blood coagulation disorder 🡪 DIC -

Oligouria and anuria

- Postpartum hemorrhage

- Puerperal Sepsis

Abruptio Placenta .....(7)

KASUS I
● Ny A/ 23 thn hamil usia kehamilan 30 mgg
tiba2 setelah bangun tidur merasakan ada
darah yang keluar dari kemaluan, tidak
nyeri dan membasahi kain yang dipakainya
diagnosis????
KASUS II
● Ny
B/25 thn, haid terakhir 3 bln yang lalu,
mengeluhkan nyeri perut bawah yang hebat.
Pusing (+), perdarahan pervaginam (+)
minimal. Pasien tampak pucat dan dilakukan
pemeriksaan tensi : 80/50 , Nadi 100x/mnt
diagnosis????
● Rangkuman
● nilaistatus kesehatan dan
stabilitas ibu ● nilai kesejahteraan
bayi
● lakukan resusitasi yang sesuai
● tentukan penyebab perdarahan – jangan

lakukan periksa dalam ( trimester 2)

● terapiekspektatif bila memungkinkan
● Terminasi atas dasar kondisi ibu dan/atau janin
No woman should die
while giving life…!