P4P REPRO 2.

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#1 PREGNANCY COMPLICATION
● Early pregnancy complication
● Third trimester complication
● Hypertension in pregnancy
● Postpartum hemorrhage
EARLY PREGNANCY COMPLICATION
ECTOPIC PREGNANCY
Intinya: blastocyst implants anywhere other than endometrium
Approach nya gimana?
Semua woman in reproductive age + abdominal pain / vaginal bleeding diluar siklus mens → HARUS cek
pregnancy (ga peduli kalo dia blg dia lg pake kontrasepsi pun)

Gejala khas dari ectopic pregnancy:

- Gejala kehamilan pasti: amenorrhea, nausea, breast tenderness, sering kencing

- Lower abdominal pain and guarding (mirip peritonitis, makanya dari awal harus cek b-hCG)
- Vaginal bleeding
- Kalo dari PF:
- Cervical motion tenderness, closed cervix
- Enlarged uterus
- Kalo udah tubal rupture → signs of hemorrhagic shock
Step to diagnose
1. Ketemu wanita usia muda dengan abdominal pain / vaginal bleeding / telat mens (SYARAT kalo
hemodynamically stable) → tes b-hCG
2. Kalo negatif → least likely ectopic pregnancy
3. Kapan b-hCG terdeteksi?
- Min 14 days after conception
- Normalnya akan naik sampe 60-80 days after last mens → lalu plateau → during this period, coba
cek serial serum b-hCG dlm 48 jam
- Kalo ada perubahan pattern → curiga abnormal pregnancy
- Kalo ectopic ada doubling times
4. Kalo ada peningkatan b-hCG → TVUS paling sensitif
- Empty uterine cavity in combination with a thickened endometrial lining
- Possible free fluid within the pouch of Douglas (unspecific)
- Possible extraovarian adnexal mass
- Tubal ring sign (blob sign): an echogenic ring that surrounds an unruptured ectopic pregnancy
5. Kalo hemodynamic unstable → exploratory laparoscopy langsung
Treatment
1. Unstable : stabilisasi hemodinamik dulu, konsul
2. Stable: bisa medical, surgical, or expectant
a. Medical therapy
i. Methotrexate (inhibit sintesis folat → no DNA synthesis → terminate ectopic pregnancy
b. Surgical
i. Laparoscopy → salpingostomy (removal of ectopic pregnancy w/o removing the affected
fallopian tube)

Semuanya harus dapat supportive care:

- Pain management
- Anti D immunoglobulin kalo ibu rhesus negatif
SPONTANEOUS ABORTION
Expulsion of the fetus prior to 20 weeks of gestation
- hrus in the absence of intervention.
Inget !
- Kalo early spontaneous abortion in the first
trimester → MOSTLY penyebabnya adalah
chromosomal abnormalities - paling sering
trisomy
- Kalo second trimester → maternal systemic
disease, abnormal placentation
Cervical ectropoin
Squamous cell epithelium of the ectocervix →
jadi columnar cell epithelium of endocervix

- Karena estrogen exposure (pregnancy,

certain oral contraceptives)
- Colposcopy: sharply demarcated bright
red area with papillary structures
- Clinical features: mostly asymptomatic;
occasional postcoital bleeding and
vaginal discharge
THIRD SEMESTER BLEEDING
PLACENTA PREVIA

Kalo complete gabisa resolves spontaneously.

Partial and low lying placenta previa bisa resolve by 32-35 weeks of gestation, how?
- Bukan upward migration of the placenta, tapi stretching and thinning of the lower
uterine segment → jd kek narik dan moves the placenta away from the os
Symptoms:

- Ga khas (seringnya bleeding2 aja)

- At least pasti pernah bleeding 1 kali (biasanya around 29-30 weeks)
- Bleeding biasanya berhenti dalam 1-2 jam
- Painless

Diagnosis:

- Paling akurat: transvaginal USG

Management:

- Observation
- Fluid
- Bed rest
- Steroid → utk fetal lung maturity
- Delivery biasanya by cesarian birth
- Kalo kondisi pasien stable : caesarean delivery can be undertaken at 36 to 37 weeks of gestation →
amniocentesis to confirm fetal lung maturity
- Kalo lungs blm mature → patient hrus delivered at 37 to 38 weeks gestation
PLACENTA ACCRETA, INCRETA, PERCRETA

Hipotesis knp bisa terjadi?

● Defective decidua:
complete or partial lack of
decidua in an area of
previous scarring within the
endometrial-myometrial
interface
● Excessive trophoblastic
invasion: abnormal growth
→ uncontrolled invasion of
Cara mudah ingatnya:
villi through the
1. Accreta : adhered to uterine wall
2. Increta : invade into myometrium myometrium, including its
3. Percreta: penetrate through myometrium vascular system
PLACENTA ABRUPTION
Diagnosis
● Clinical
● External bleeding can be profuse
● Sonography
○ Bisa transvaginal and/or transabdominal
○ Assess placental position and fetal biophysical profile
○ Bisa terlihat retroplacental hematoma
● Fetal heart rate tracing: cek signs of fetal distress
Placental abruption is a clinical diagnosis. Ultrasound is indicated in all patients to rule
out placenta previa but is not diagnostic for abruption.
Management
Cek hemodinamik dulu
- Unstable: langsung emergency cesarean
- Stable with mild bleeding
- Reassuring fetal status dulu
- Kalo <34 weeks
- Expectant management and observation
- Consider tocolytics (nifedipine, B2 adrenergic agonist) → buying time utk
maturation of lung dulu
- Kalo 34-36 weeks
- Active uterine contraction: vaginal delivery
- Gak ada contraction: expectant management and observation
- Kalo >36 weeks: deliver
- Non reassuring fetal status: emergency cesarean
POST-PARTUM HEMORRHAGE
● Uterine atony
● Retained placenta
● Perineum laceration
Uterine Atony
Clinical diagnosis:

- Tonus of uterus : softer, more pliable,

boggy
- Cervix is open
- Profuse vaginal bleeding

Diagnostics:

- Bimanual pelvic exam after emptying

bladder
- Speculum examination of vagina and
cervix
Management:
● Active management of third stage of labor
a. Uterotonic agent (IV/IM oxytocin)
b. Controlled umbilical cord traction
c. External compression of uterus
● Uterotonic agents:
○ IV oxytocin
○ IM methergine
○ Prostaglandin (misoprostol)
● Tranexamic acid
● Surgical procedures
○ Uterine balloon tamponade → kalo
masih severe bleeding padahal udah di
treat, sambil rujuk
○ Surgical ligation of uterine or internal
iliac arteries
○ Last: hysterectomy
Retained placenta

Normal: separation of placenta from uterus → due to uterine contraction →

causing cleavage between zona basalis and zona spongiosa → separated →
expulsion

● After expulsion → placenta should be inspected → to detect missing

cotyledons

Retained placenta: inability to completely separate the placenta during the

third stage of labor

● No adequate contraction → atony and excessive bleeding

Management:
1. General measures
- Monitor vital signs and urine output
- Oxygenation
- 2 large bore IV access kalo ada signs of hypovolemic shock → resus with
crystalloid
- Blood transfusion if necessary
2. Active management of third stage labor :
- Uterotonic agent
- Controlled umbilical cord traction
- External compression of uterus and bimanual uterine massage
3. Manual removal of placenta
- Administer nitroglycerin: relaxes the uterine smooth muscle and facilitates the
retained placental extraction
4. Surgical procedures
- Dilation and curettage (D&C) or vacuum removal of RPOC under
anesthesia/regional anesthesia
- Cesarean hysterectomy (generally, mode of delivery and treatment for placenta
accreta spectrum)
Perineum Laceration
● 1st degree = cutaneous - subcutaneous
tissue tear (skin)
● 2nd degree = involvement of perineal
muscle without involvement of anal
sphincter
● 3rd degree = involvement of external
anal sphincter
○ A = <50% of EAS is torn
○ B = >50% of EAS is torn
○ C = external and internal anal
sphincter is torn
● 4rd degree = ada laceration of the
anterior wall of the anal canal or
rectum
Treatment:
● First and second degree
○ Conservative: NSAIDs
○ Suture: local anesthesia and laceration closure using surgical glue or continuous suture
● Third and fourth degree
○ Regional or general anesthesia
○ Reconstructive surgery
HYPERTENSION IN PREGNANCY
Pathophysiology

● Failure to cytotrophoblast to adequately invade uterine spiral arteries → high resistance of uteroplacental
circulation → inadequate perfusion → ischemia → oxidative and inflammative stress → endothelial
dysfunction, vasospasm, and activation of coagulation system
Diagnosis
Treatment
Preeclampsia without severe features

● Twice weekly BP monitoring

● Weekly lab test (CBC, creatinine levels, alanine
transaminase, aspartate transaminase levels)
● Twice weekly fetal nonstress testing
● Fetal growth USG every 3 weeks
● Seizure prophylaxis (MgSO4) dikasih kalo ada
severe features aja
● Delivery: at 37 weeks gestation
Preeclampsia with severe features
Eclampsia
Magnesium sulfate (MgSO4) utk seizure prophylaxis
● Prevent eclamptic seizure and placental abruption
● Kalo muncul absent reflexes, elevated creatinine, decreased urine output
→ cek serum magnesium every 6 hours
● Magnesium toxicity: bikin respiratory paralysis, central nervous system
depression, and cardiac arrest.
Kapan harus stop kasih?
● Kalo udah ada tanda lost of deep tendon reflexes, RR decrease <12, urine
output <30 ml/hour
● Antidote: 1 gr calcium gluconate IV over 2 mins
● Excessive magnesium : slow IV 10% calcium gluconate + O2
supplementation + cardiorespiratory support (if needed)
● Kalo severe preeclampsia and eclampsia → bisa kasih magnesium sulfate parenterally sbg anticonvulsants → avoid
producing CNS depression in mother or infant
● Bisa IV by continuous infusion or IM by intermittent injection
● Dosis utk preeclampsia sm eclampsia sama aja
● Dikasihnya during labor and for 24 hours postpartum
Delivery
● Assess for indication for immediate delivery
○ If present (eclampsia, pulmo edema, DIC, placental abruption, refractory severe htn, signs of
fetal distress): urgent delivery after maternal hemodynamic stabilization
○ If absent: depends on disease severity and gestational age
■ ≥34 weeks : deliver
■ 24-34 weeks: kasih corticosteroid dulu baru deliver
● Attempted vaginal delivery = recommended kalo preeclampsia with severe
features karena less blood loss
● Eclampsia
○ Indication utk langsung immediate delivery
○ Delivery only after mother is stable and seizure have stopped
○ C-sec mode
#DYSTOCIA - ABNORMAL LABOR PROGRESS
● Factor yang contribute to normal labor
● Abnormal labor pattern
Dystocia
Difficult labor = slow labor progress
Factor contributes to normal labor
● Power
○ Uterine contraction
○ Monitored by: palpation, external tocodynamometry, intrauterine pressure catheters
○ Optimal frequency: minimum of 3 contractions in 10 minute interval
● Passenger
○ Fetal presentation
■ Brow = c sec
■ Face = c sec
● Kalo mento-anterior → kepala bayi nnti bs fleksi jadinya bisa lahiran normal
→ bakal fleksi trus jadi keluar dngn suboccipitobregma
● Mento posterior → kepalanya hyperextension → susah keluar karena
hitungannya dia pake diameter occipitomental
● Passage
○ Maternal skeletal or soft tissue anomalies → obstruct birth canal
○ Cephalopelvic disproportion → size pelvis ga muat buat dilewatin fetus
○ Soft tissue – abnormal di cervix (tumor, lesi colon / adnexa, distended bladder,
uterine fibroids, accessory uterine horn, morbid obesity)
Abnormal labor patterns
● Protraction disorder – slow to progress
○ Can occur during both the latent and active
phases of labor
● Arrest disorder – labor ceases to progress
○ Only in active phase
First stage disorders
Kala 1 = pembukaan cervix

● Prolonged latent phase

○ Banyakan terlihat prolonged latent phase padahal false labor
○ Bisa 2 case:
■ Pasien stop kontraksi → berarti emg ga lagi in labor
■ Lanjut ke active labor → perlu intervensi
● First stage
○ Once in active labor
○ Prolonged if:
■ Cervix dilates <1 cm per hour in nulliparous women and <1.2-1.5 cm per hour in
multiparous women
○ Management: observation, augmentation by amniotomy or oxytocin, continuous support
AUGMENTATION

● Amniotomy (artificial rupture of membranes)

○ Stimulate prostaglandin release → memperkuat contraction
○ Risks: fetal heart rate decelerations due to cord compression and an increased incidence of
chorioamnionitis.
● Oxytocin administration
○ Goal: membuat uterine activity cukup supaya cervix membesar dan fetus bisa turun
○ Respon adekuat: max. 5 contractions in 10 mins dengan penambahan dilatasi cervix
● Kapan augmentation?
○ Frequency of contractions is <3 contractions per 10 minutes
○ The intensity of contractions is <25 mm Hg above the baseline
○ Both
Second stage disorders
Protraction disorders:
● When the second stage exceeds 3 hours if regional anesthesia has been administered
● or 2 hours if no regional anesthesia is used
● or if the fetus descends at a rate of less than 1 cm per hour if no regional anesthesia is used.

Second stage arrest: no descent after 1 hour of pushing

Treatment: cesarean delivery

Child development