pretes 1 mei · 2021. 6. 10. · kejadian keguguran recurrent miscarriage tiga kali atau lebih...

PRETES 1 MEI

dr. Syah Rini Wisdayanti Sp.OG,M.Kes

ABORTUS2

Definisi

Umum

• Terminasi kehamilan secara spontan atau diinduksi sebelum fetus viabel/ mampu hidup

Definisi CDC

dan WHO

• Terminasi kehamilan pada usia kehamilan < 20 minggu atau dengan BB fetus < 500 gram

Silver M, Branch DW, Goldenberg R, et al: Nomenclature for pregnancy outcomes. Obstet GynecoI 118 (6) : 1 402, 2011

TERMINOLOGI BARU ABORTUS

American College of Obstetricians and Gynecologists 2017

• kehamilan intrauterin yang nonviable dengan saccus gestasional yang kosong atau saccus gestasional yang mengandung embrio atau janin tanpa aktivitas jantung janin dalam 12 minggu pertama kehamilan.

Istilah klinis

• Abortus spontan: Abortus imminens, insipiens, inkomplit, komplit, dan missed abortion.• Abortus septik: kaitannya dengan infeksi

3

American College of Obstetricians and Gynecologists: Early pregnancy loss. Practice Bulletin No. 150, May 2015 , Reairmed 2017c

INSIDENSI ABORTUS

Pada UK 5-20 minggu mencapai 11-22%

Sering pada UK < 5 minggu

4

Ammon Avalos L, Galindo C, Li OK: A systematic review to calculate background miscarriage rates using life table analysis. Birth Defects Res A Clin Mol TeratoI 94(6) :417, 2012

ABORTUS SPONTAN PADA TRIMESTER PERTAMAPATOFISIOLOGI

Kematian fetus/ embrio diikuti perdarahan ke desidua basal

Nekrosis jaringan yang

merangsang kontraksi uterus

Ekspulsi spontan

5

Silver M, Branch DW, Goldenberg R, et al: Nomenclature for pregnancy outcomes. Obstet GynecoI 118 (6) : 1 402, 2011

FAKTOR FETUS

½ kasus merupakan euploid abortion dan ½ lainnya karena kelainan kromosom

Tingkat aborsi dan anomali kromosom menurun dengan bertambahnya usia kehamilan sering pada UK 8 minggu

Kelainan kromosom terjadi karena 95% kesalahan gametogenesis maternal dan 5% dari ayah.

Kelainan tersering: trisomi (50-60%), monosomiX (9-13%), triploidy

6

Jenderny J : Chromosome aberrations in a large series of spontaneous miscarriages in the German population and review of the literature. Mol Cytogenet 7:38, 2014

FAKTOR MATERNAL7

Wilcox, A., Branch, E., & Weinberg, C. (2018). The role of maternal age and pregnancy history in risk of miscarriage.

Kalagiri RR, Carder T, Choudhuty S, et al: Inlammation in complicated pregnancy and its outcome. Am J Perinatol 33 (14) : 1337, 2016

FAKTOR MATERNAL8

Gaskins AJ, Toth TL, Chavarro JE: Prepregnancy nutrition and early pregnancy outcomes. Curr Nutr Rep 4(3) :265, 2015

Centers for Disease Control and Prevention : Tobacco use and pregnancy. 2016. Available at: https://www.cdc.govlreproductivehealth/maternalinfanthealth/tobaccousepregnancy./ Accessed May 2, 20 16

FAKTOR PATERNAL/ AYAH

Faktor usia ayah (>45 tahun) risiko abortus >>

Kelainan kromosom pada spermatozoa

9

Sartorius GA, Nieschlag E: Paternal age and reproduction. Hum Reprod Update 16 (1) :65, 2010

KLASIFIKASI KLINIS ABORTUS SPONTAN

Abortus Iminens/

Threatened

Abortus Insipien/

Inevitable

Abortus Inkomplit

Abortus komplit

Missed abortion

Septic Abortion

10

Buzad, P., & McCoy, T. W. (2016). Spontaneous abortion and recurrent pregnancy loss. Ob/Gyn secrets E-book, 113.

ABORTUS IMINENS

Bloody discharge dari vagina berhari-

hari/ minggu

Telat menstr

uasi

Kram perut, nyeri

suprapubik,

tekanan di

pelvik, nyeri

punggung

persisten

11

Mouri, M., & Rupp, T. J. (2019). Threatened Abortion. In StatPearls [Internet]. StatPearls Publishing.

ABORTUS IMINENS12

Risiko dari abortus iminen yang tidak mengalami abortus akan meningkatkan risiko dari maternal

maupun perinatal. Risiko tertinggi adalah kelahiran prematur.

EVALUASI DIAGNOTIKPEMERIKSAAN FISIK:• Inspekulo : perdarahan

(+) + oue tertutup

ANAMNESISKehamilan trimester

pertama + perdarahan

pervaginal + nyeri

13

Tujuan: agar dapat mendiagnosis/ menyingkirkan segera kehamilan

ektopik

Mouri, M., & Rupp, T. J. (2019). Threatened Abortion. In StatPearls [Internet]. StatPearls Publishing.

PENUNJANG:• ß-hCG• USG transvaginal

mengetahui lokasi kehamilan dan janin viabel/ tidak

MANAGEMEN ABORTUS IMINENS

Pertahankan

kehamilan

1. Progester

on alamiah2. NSAID

Bed rest

Cek lab: Hb, Ht,

Golongan darah

evaluasi nilai ulang

kondisi janin

14

Mouri, M., & Rupp, T. J. (2019). Threatened Abortion. In StatPearls [Internet]. StatPearls Publishing.

ABORTUS INSIPIEN

Abortus insipien

Terjadi karena spontan, Prosedur

invasive, atau kecelakaan

perdarahan prevaginal,

nyeri

Terdapat Dilatasi Servix

Pada pemeriksaan speculum terdapat genangan cairan

15

Wasson, C., Kelly, A., Ninan, D., & Tran, Q. (2019). Spontaneous abortion. In Absolute Obstetric Anesthesia Review (pp. 89-89). Springer, Cham.

KOMPLIKASI

- Perdarahan sampai dengan syok

- Sepsis

16

TATALAKSANA

Evakuasi hasil

konsepsi

Antibiotik sesuai indikasi

Kuretase

17

ABORTUS INKOMPLIT

Plasenta

lepas sebagi

an

Serviks

dilatasi

Perdarahan

18

Kim C, Barnard 5 , Neilson JP, et al: Medical treatments for incomplete miscarriage. Cochrane Database Syst Rev 1 : CD007223, 20 17

TATALAKSANA

Kuretase

Managemen ekspektatif

Misoprostol/ prostaglandin EI

19

Kim C, Barnard 5 , Neilson JP, et al: Medical treatments for incomplete miscarriage. Cochrane Database Syst Rev 1 : CD007223, 20 17

ABORTUS KOMPLIT

Pengeluaran seluruh hasil konsepsi dari rahim pada kehamilan sebelum 20 minggu dan berat

janin < 500gr.

20

ABORTUS KOMPLITTerdapat riwayat

keluarnya jaringan utuh

(fetus), perdarahan berat, dan

kram

Serviks menutup

Gestasional sac lengkap

yang dikeluarkan

tidak teridentifikasi

USG transvaginal

Hasil abortus komplit:

endometrium menebal

minimal tanpa gestasional

sac

Tidak jelas hasil USG

cek HCG

20

KLASIFIKASI

Pada abortus komplit, terjadi penurunan nilai ß-hCG yang sangat cepat

21

MISSED ABORTIONKematian konsepsi yang telah

dipertahankan selama berhari-hari atau berminggu-minggu di dalam rahim dengan

serviks yang tertutup

USG Transvaginal lebih dipilih dari pada USG Transabdominal

22

TATALAKSANA MISSED ABORTION

Pembedahan Non-Bedah

Misoprostol 800 μg, bisa diulang 1-2 hari

setelahnya

Aspirasi Vakum Manual atau Kuret

25

American College of Obstetricians and Gynecologists: Medical management of first-trimester abortion. Practice Bulletin No. 143, March 20 14, Reairmed 2016c

Tatalaksana Khusus Missed Abortion

◦ Lakukan konseling.

◦  Jika usia kehamilan <12 minggu:◦ evakuasi dengan sendok kuret.

◦ Rekomendasi FIGO: Misoprostol 800μg pervaginam setiap 3 jam (maksimal x2) atau 600μg sublingual setiap 3 jam (maksimal 2x)

◦  Jika usia kehamilan ≥12 minggu namun <16 minggu:◦ pastikan serviks terbuka, bila perlu lakukan pematangan serviks sebelum dilakukan

dilatasi dan kuretase. Lakukan evakuasi dengan tang abortus dan sendok kuret.

◦ Jika usia kehamilan 16-20 minggu:◦ lakukan pematangan serviks.

◦ Lakukan evakuasi dengan infus oksitosin 20 unit dalam 500 ml NaCl 0,9%/Ringer laktat dengan kecepatan 40 tetes/menit hingga terjadi ekspulsi hasil konsepsi.

◦ Bila dalam 24 jam evakuasi tidak terjadi, evaluasi kembali sebelum merencanakan evakuasi lebih lanjut.

SEPTIC ABORTIONAbortus

yang disebabka

n oleh infeksi

Bakteri flora normal vagina adalah

penyebab paling banyakMenyeran

g Miometriu

mParametriti

s(Infeksi pelvic)

Peritonitis

Septicemia

26

DaifJL, Levie M, Chudnof S, e t al: Group A streptococcus causing necrotizing fasciitis and toxic shock syndrome after medical termination of pregnancy.Obstet Gynecol 113 (2 Pt 2): 504, 2009

TANDA DAN GEJALA SEPTIC ABORTION

DemamHypotension

Severe endothelial

injury

Capillary leakage

Hemoconcentration

Leukocytosis

27

TATALAKSANA SEPTIC ABORTION

Ada sisa hasil konsepsi

Peritonitis

Pemberian Antibiotik spektrum luas

Kuretase Laparotomi

Necrotizing Uterus

Histerektomi

Perbaiki KU

28

28

Udoh, A., Effa, E. E., Oduwole, O., Okusanya, B. O., & Okafo, O. (2016). Antibiotics for treating septic abortion. Cochrane Database of Systematic Reviews, (7).

KEGUGURAN BERULANG / RECURRENT MISCARRIAGEKejadian keguguran

tiga kali atau lebih secara berturut-turut dgn UK <20 mg atau

BJ <500 g

Terjadi pada 1% pasangan

subur

34

American Society for Reproductive Medicine: Definitions of infertility and recurrent pregnancy loss. Fertil Steril 99:63, 2013

Faktor Risiko

Hubungan

dengan

risiko

Meningkatnya usia dan paritas

1.3–1.5

Preeklampsia

2.1–4.0

Hipertensi kronik

1.8–3.0

Ketuban pecah dini

2.4–4.9

Kehamilan ganda

2.1

Hidroamnion

2.0

Wanita perokok

1.4–1.9

Trombofilia

3–7

Penggunaan kokain

NA

Riwayat solusio plasenta

10–25

Mioma dibelakang plasenta

8 dari 14

Trauma abdomen dalam kehamilan

Jarang

Prediksi Keberhasilan Kehamilan

Hebatnya, peluang keberhasilan kehamilan mencapai >50% bahkan

setelah lima kali keguguran

35

ETIOLOGI RPL

kelainan kromosom, sindrom

antiphospolipid, dan abnormalitas anatomi

uterus

Kapan terjadinya RPL dapat menjadi petunjuk penting

Faktor genetik → pada kehilangan embryo awal

Kelainan anatomi uterus dan autoimun →

pada TII

40-50% wanita dengan idiopatik RPL

36

El Hachem, H., Crepaux, V., May-Panloup, P., Descamps, P., Legendre, G., & Bouet, P. E. (2017). Recurrent pregnancy loss: current perspectives. International journal of women's health, 9, 331.

ABNORMALITAS KROMOSOM PARENTAL

Hanya 2-4% dari kasus RPL, namun esensial

Kelainan translokasi resiprokal (paling umum) dan translokasi robertsonian

Tx : fertilisasi in vitro diikuti diagnosis genetik preimplantasi

37

El Hachem, H., Crepaux, V., May-Panloup, P., Descamps, P., Legendre, G., & Bouet, P. E. (2017). Recurrent pregnancy loss: current perspectives. International journal of women's health, 9, 331.

FAKTOR ANATOMI

15% wanita RPL memiliki anomali rahim bawaan atau didapat

Ex: Sindrom Asherman, Leiomioma, anomali saluran genital kongenital (unikornu, bikornu, septate uterine)

38

El Hachem, H., Crepaux, V., May-Panloup, P., Descamps, P., Legendre, G., & Bouet, P. E. (2017). Recurrent pregnancy loss: current perspectives. International journal of women's health, 9, 331.

FAKTOR IMUNOLOGIS

RPL lebih sering pd wanita dgn SLE maupun sindrom antifosfolipid dan memiliki antibodi lebih tinggi

Kehamilan normal membutuhkan faktor penghambat antigen janin yg diturunkan dari ayah

39

El Hachem, H., Crepaux, V., May-Panloup, P., Descamps, P., Legendre, G., & Bouet, P. E. (2017). Recurrent pregnancy loss: current perspectives. International journal of women's health, 9, 331.

FAKTOR IMUNOLOGIS

40

FAKTOR ENDOKRIN

Arrendondo dan Noble (2006), terjadi 8-12% pada RPL

Ex: defisiensi progesteron fase luteal , PCOS, diabetes, hipotiroidisme, defisiensi yodium berat

Tx: kontrol glikemik, suplementasi hormon tiroid

41

El Hachem, H., Crepaux, V., May-Panloup, P., Descamps, P., Legendre, G., & Bouet, P. E. (2017). Recurrent pregnancy loss: current perspectives. International journal of women's health, 9, 331.

KONTRASEPSI POST ABORTUS

43

Setelah manajemen medis atau pembedahan untuk terminasi kehamilan, ovulasi dapat dimulai paling cepat 8 hari, tetapi waktu rata-rata adalah 3 minggu

AKDR dapat diinsersikan setelah prosedur atau aborsi medis selesai

Atau, kontrasepsi hormonal dapat dimulai pada saat yang samaStoddard A, Eisenberg DL: Controversies in family planning: timing of ovulation after

abortion and the conundrum of postabortion intrauterine device insertion. Contraception 84(2) : 119, 2011

1. Which of the following sonogram findings is consistent with the American College of Obstetricians and Gynecologists definition of early pregnancy loss?

◦ a. An anembryonic pregnancy

◦ b. A crown-rump length of 7 mm with no cardiac motion

◦ c. A fetus measuring 13 weeks’ gestation with no cardiac motion

◦ d. All of the above

2. What percent of spontaneous abortions occur within the first 12 weeks of gestation?

◦ a. 60%

◦ b. 70%

◦ c. 80%

◦ d. 90%

3. A 22-year-old G1P0 presents for a follow-up visit after receiving care for a spontaneous abortion at 8 weeks’ gestation. She has many questions regarding the possible cause of her miscarriage, and the risk of recurrence. You counsel her that approximately what percentage of pregnancies end in miscarriage?

◦ a. 3–5%

◦ b. 5–10%

◦ c. 10–25%

◦ d. 40%

4. For the patient in Question 18–3, you also counsel her regarding the rate of aneuploidy in first-trimester miscarriages. What is the approximate rate of aneuploidy in pregnancies that end in a clinically apparent first trimester spontaneous abortion?

◦ a. 10%

◦ b. 20%

◦ c. 33%

◦ d. 50%

5. Which of the following chromosomal abnormalities is most common in the setting of first-trimester spontaneous abortion?

◦ a. Trisomy 18

◦ b. Trisomy 21

◦ c. Tetraploidy

◦ d. Monosomy X (Turner syndrome)

6. Consumption of which of the following legal substances in large quantities is most clearly associated with an increased risk of miscarriage?

◦ a. Alcohol

◦ b. Tobacco

◦ c. Caffeine

◦ d. Phthalates

7. A 20-year-old G2P0A2 presents for follow-up after a spontaneous miscarriage at 7 weeks’ gestation. She demands that you “do something” to prevent miscarriages in her future pregnancies. You offer evaluation for recurrent pregnancy loss, but provide reassurance that her likelihood of a successful next pregnancy is approximately what percent?

◦ a. 74%

◦ b. 82%

◦ c. 86%

◦ d. 92%

8. Which of the following is not a widely accepted cause of recurrent pregnancy loss?

◦ a. Uterine structural abnormalities

◦ b. Parental chromosomal abnormalities

◦ c. Antiphospholipid antibody syndrome

◦ d. Progesterone deficiency (luteal phase defect)

9. What percentage of recurrent pregnancy loss is due to parental chromosomal abnormalities?

◦ a. 2–4%

◦ b. 6–8%

◦ c. 10%

◦ d. 15%

10. Which of the following clinical scenarios is not an indication for antiphospholipid antibody testing?

◦ a. History of three embryonic losses

◦ b. History of fetal loss at 16 weeks’ gestation

◦ c. History of unexplained thromboembolism

◦ d. History of severe preeclampsia requiring delivery at 38 weeks’ gestation

11 A 22-year-old G1 undergoes a routine sonogram to survey fetal anatomy at 20 weeks’ gestation. The cervix is noted to appear short on transabdominal imaging and a transvaginal cervical length is performed, measuring 19 mm. According to the American College of Obstetricians and Gynecologists, what is the recommended therapy?

◦ a. Cerclage placement

◦ b. Daily vaginal progesterone

◦ c. 17-Hydroxyprogesterone acetate injections weekly

◦ d. Expectant management with repeat cervical

◦ length in 1 week

12. Among women who become pregnant while using contraception, the relative number of ectopic pregnancies is increased with which of the following contraceptives?

◦ a. Condoms

◦ b. NuvaRing

◦ c. Progestin-releasing intrauterine device

◦ d. Estrogen-containing birth control pills

13. In ectopic pregnancies, the absence of which tubal tissue layer facilitates rapid invasion of proliferating trophoblasts into the muscularis?

◦ a. Serosa

◦ b. Epithelium

◦ c. Submucosa

◦ d. Connective tissue

14. What is the classic triad of clinical symptoms of an ectopic pregnancy?

◦ a. Nausea, pain, and vaginal bleeding

◦ b. Delayed menstruation, pain, and vaginal bleeding

◦ c. Dizziness, delayed menstruation, and vaginal bleeding

◦ d. Shoulder pain, delayed menstruation, and vaginal bleeding

15. A 38-year-old G4P3 presents with a positive pregnancy test, vaginal bleeding, palpitations, and intense neck and shoulder pain, which is worse with inspiration. She is found to be tachycardic and hypotensive. Her ultrasound reveals a likely right ectopic pregnancy. What is the most likely cause of her neck and shoulder pain?

◦ a. A pulled back muscle

◦ b. Referred pain from her right fallopian tube

◦ c. Diaphragmatic irritation due to hemoperitoneum

◦ d. None of the above

16. Which clinical or laboratory finding is least consistent with the diagnosis of a ruptured ectopic pregnancy?

◦ a. Fever of 39.8°C

◦ b. Heart rate of 137 bpm

◦ c. Hematocrit of 21.2%

◦ d. Leukocytosis of 28,000 μL

17. A 30-year-old G2P1 presents at 6 weeks’ gestation by last menstrual period complaining of pelvic pain and nausea. Her β-hCG is 3010 mIU/mL, and no intrauterine pregnancy is seen on ultrasound. Noadnexal masses or free fluid are visualized. What is the best management strategy?

◦ a. No intervention

◦ b. Surgical therapy

◦ c. Methotrexate injection

◦ d. Expectant management with 48-hour follow-up

18. What is the discriminatory β-hCG level above which failure to visualize an intrauterine pregnancy likely indicates that a pregnancy either is not alive or is ectopically located?

◦ a. ≥100 mIU/mL

◦ b. ≥500 mIU/mL

◦ c. ≥1000 mIU/mL

◦ d. ≥1500 mIU/m

19. What is the minimum rise of β-hCG you expect in 48 hours from an early progressing intrauterine pregnancy?

◦ a. 12%

◦ b. 23%

◦ c. 53%

◦ d. 67%

20. What percentage of ectopic pregnancies demonstrate appropriately rising β-hCG levels?

◦ a. 15%

◦ b. 33%

◦ c. 42%

◦ d. 50%

◦ 21. Which of the following statements regarding steroidogenesis is FALSE?

◦ a. Steroid production primarily occurs in the Golgi apparatus.

◦ b. The primary building block of sex steroid hormones is cholesterol.

◦ c. The enzymes involved in steroid production are members of the cytochrome P450 super family.

◦ d. The placenta is the only steroid-producing tissue that cannot synthesize cholesterol rom its precursor, acetate.

◦Steroidogenesis is the multistep process for biosynthesis of steroid hormones from cholesterol.

◦ 22. The last step in estrogen synthesis requires which of the following enzymes?

◦ a. Aromatase

◦ b. 21-hydroxylase

◦ c. 5α-reductase

◦ d. 11β-hydroxylase

◦ 23. All of the following tissues express significant levels of aromatase EXCEPT:

◦ a. Skin

◦ b. Brain

◦ c. Ovary

◦ d. Muscle

24. What is the predominant estrogen during menopause?

◦ a. Estriol

◦ b. Estrone

◦ c. Estradiol

◦ d. None of the above

25. Which of the following androgens is NOT produced by the ovary?

◦ a. Testosterone

◦ b. Androstenedione

◦ c. Dihydrotestosterone (DHT)

◦ d. Dehydroepiandrosterone (DHEA)