Gawat Darurat Gawat Darurat dibidang dibidang

Obstetri dan GinekologiObstetri dan Ginekologi

Agus AbadiAgus AbadiBagian Obstetri dan GinekologiBagian Obstetri dan GinekologiRSU. Dr. Soetomo / FK UnairRSU. Dr. Soetomo / FK Unair

Surabaya Surabaya

TUJUAN :

MEMAHAMI KEADAAN-KEADAAN YANG MERUPAKAN

KEGAWAT DARURATAN DIBIDANG OBSTETRI &

GINEKOLOGI

BUKU ACUAN :

1. OBSTETRIC INTENSIVE CARE MANUAL Second Edition, 2004. Michael R Foley Thomas H Strong, Jr Thomas J Garite

2. WILLIAMS OBSTETRIC’S 21ST Edition, 2001

GAWAT DARURAT

OBSTETRI GINEKOLOGI

IBU JANIN IBU

• Disseminated Intravascular Coagulopathy• Hypertension Emergencies

• Thyroid and Other Endocrine Emergencies• Diabetic Ketoacidosis In Pregnancy

• Respiratory Emergencies During Pregnancy

• Amniotic Fluids Embolism• Neurologic Emergencies During Pregnancy

• Cardiac Desease In Pregnancy• Post Partum Haemorrhage

• Others

EMERGENCIES IN OBSTETRICS AND GYNECOLOGY

DISSEMINATED INTRAVASCULAR DISSEMINATED INTRAVASCULAR COAGULOPATHY ( DIC )COAGULOPATHY ( DIC )

Suatu gejala klinis yang bersifat umum yang ditandai olehterjadinya percepatan pembekuan darah yang terjadi secara sistemik didalam pembuluh darah dan disertai

dengan pemecahan bekuan tersebut

CONSUMTIVE COAGULOPATHY

1. HPP yang masive dengan penggantian

cairan yang tidak adekuat,

2. Solusio plasenta

3. Preeklamsia Berat disertai dengan

sindroma HELLP

PENYEBAB

SERING

• Sepsis• Acute Fatty Liver in Pregnancy• Amniotic Fluids Embolism• Adult Respiratoryn Distress Syndrome• Acute Hemolytic Transfusion Reaction• Autoimmune Desease• Malignancies• Missed Abortion / IUFD

PENYEBAB

JARANG

• Kecenderungan perdarahan pada bekas tusukan jarum suntik, luka operasi dan selaput lendir ( GI Tract, Respiratory Tract)

• HPP dengan kontraksi uterus yang adekwat ( hati-hati laserasi jalan lahir )

• Shock yang tidak sesuai dengan perdarahan yang keluar

DIAGNOSIS

KLINIS

• Kadar Fibrinogen --- turun• Fibrinogen Degradation Product --- naik• Prothrombin Time --- naik• aPTT --- naik• Anti Thrombine III --- turun• Hb. Dan Hct --- turun• Bilirubin --- naik

DIAGNOSIS

LABORATORIK

PENGELOLAANPENGELOLAAN

1. HPP : - Uterotonik, repair laserasi jalan lahir

2. Solusio Plasenta : - Amniotomi, terminasi

3. PEB / HELPP : - Terminasi

4. Acute Fatty Liver : - Terminasi

5. Amniotic Fluids Embolism : - Kortikosteroid

6. Sepsis : - Antibiotika, kortikosteroid

7. ARDS : - Ventilator Support

8. IUFD : - Antibiotika, terminasi

Cardiovascular Support

PENGELOLAANPENGELOLAAN

PEMBERIAN KOMPONEN DARAH

1. Fresh frozen plasma (FFP)2. Cryoprecipitated3. Blood Platelets4. PRC

FFPFFP

• FFP ( per unit : 250 ml )• Untuk koreksi PT, aPTT, Hipofibrinogen• Dosis awal : 4 unit, ditambah bila diperlukan • Tiap unit FFP akan meningkatkan kadar

fibrinogen 5 – 10 mg / dl

CRYOPRECIPITATECRYOPRECIPITATE

• Cryoprecipitate ( per unit :35-40 ml)• Bahan kaya fibrinogen• Diberikan bila :

1. Kadar fibrinogen < 100 mg/dl

2. Kadar fibrinogen < 150 mg/dl + Perdarahan

Tiap unit Cryopr. Akan meningkatkan kadar

fibrinogen 5 – 10 mg/dl.

PLATELETS ( TROMBOSIT )PLATELETS ( TROMBOSIT )

• Diberikan bila :

1. Trombosit < 25.000 / mm3

dengan ataupun tanpa perdarahan

2. Trombosit < 50.000 / mm3 + Perdarahan

• Tiap unit Trombosit akan meningkatkan

jumlah trombosit 7000 – 10.000 / mm3

PRC ( Packed Red PRC ( Packed Red Cells )Cells )

• Meningkatkan oxygen carrying capacity• Pertahankan Hct ( Hematocrit ) ≥ 25%• Hati-hati PRC akan meningkatkan

kadar Kalium dalam darah

( bahaya hiperkalemia --- cardiac arrest )Tiap pemberian 5 unit PRC, tambahkan 1 amp.

calsium bila anticoagulan yang dipakai dalam

packed unit menyebabkan penurunan calsium darah

AMNIOTIC FLUIDS EMBOLISMAMNIOTIC FLUIDS EMBOLISM( A F E )( A F E )

Agus Abadi

Bagian Obstetri dan Ginekologi

RSU. Dr. Soetomo / FK Unair

Surabaya

AMNIOTIC FLUIDS EMBOLISMAMNIOTIC FLUIDS EMBOLISM( EMBOLI AIR KETUBAN )( EMBOLI AIR KETUBAN )

• Komplikasi obstetrik yang jarang

• Angka kejadian 1: 20.000

• Kematian ibu 60 -80%

• Gejala klinis menonjol :

1. Hypoksia

2. Hemodynamic collaps

3. DIC

SUSPECTED AFESUSPECTED AFE

• During labor, CS, Dilatation and Evacuation• Acute hipoxia (dyspneu, cyanosis, resp. arrest.)• Severe haemorrhage with no surgical caused• Acute Hypotension / Cardiac arrest• Consumptive Coagulopathy (DIC)

GEJALA KLINISGEJALA KLINIS• SIGN & SYMPTOMS N %

Hypotension 43 100 Fetal dystress 30 100 ARDS ( Pulmonary Oedema) 28 93 Cardiopulmonary arrest 40 87 Cyanosis 38 83 Coagulopathy 38 83 Dyspneu 22 49 Seizure 22 48 Atony 11 23 Bronchospasm 7 15 Transient hypertension 5 11 Cough 3 7 Headache 3 7 Chest pain 1 2

Diagnosa Diagnosa BandingBanding

• Sepsis

• Acute Myocard Infarction

• Aspration Pneumonia

• Pulmonary thromboembolism

• Solusio Plasenta

• Komplikasi Anesthesia

EVALUATION OF SUSPECTED EVALUATION OF SUSPECTED AFEAFE

Arterial Blood GasCBC & PlateletsPT & PTTFibrinogen & FDPCrossmatch & Blood typeChest X-Ray12 Lead Electrocardiogram

Maternal & Neonatal OutcomeMaternal & Neonatal Outcome

• Overall Maternal Mortality : 60 – 80% 15% Survivors --- Neurologically Intact

• Neonatal Survival Rate : 80%

50% Survivors --- Hypoxic Brain Injury

(Respiratory Acidemia )

• Cardiac arrest cases --- 8% Neuro intact

NEONATAL OUTCOME IN CARDIAC ARREST CASES

INTERVAL (MNT) SURVIVAL NEURO INTACTCARDIAC ARREST TO DELIVERY (%) (%)

< 5 100 67

5 – 15 100 67

16 – 25 40 40

26 – 35 75 25

36 – 54 0 0

PATOFISIOLOGI PATOFISIOLOGI AFEAFE

Hypertonic Ut. Contract.

Intra-ut. Pressure increase

Complete cessation of Ut. Blood Flow

Fetal to Maternal Tissue Transfer

Septic shockAnaphylactic shockPulmonary Embolisme

ANAPHYLACTOID SYNDROME OF

PREGNANCY

HEMODYNAMIC HEMODYNAMIC RESPIRATORY RESPIRATORYALTERATION ALTERATION

Profound Hypoxia

Systemic & PulmonaryVasospasme

HypotensionDepressed Ventricular Function

Suddent Cardio Respiratory Arrest

Neurologic Died Sequele

CORONARY SPASMEMYOCARD ISCHEMIC

GLOBAL HYPOXIA

MYOCARD ACTIVITY

Coagulopathy In AFECoagulopathy In AFE

• Shorten Clotting Time• Thromboplastin Like Effect• Induce Platelets Aggregation• Release Platelets Factor III• Activation Complement Cascade

DIAGNOSISDIAGNOSIS

• 1. KLINIS• 2. LABORATORIK• 3. DIAGNOSIS PASTI : Ditemukan Fetal Debris didalam pembuluh darah pulmoner

Cath. Pulm. : 50 % Otopsi : 75 %

MANAGEMENT OF AFEMANAGEMENT OF AFE

Shock Hypotension

Hypoxemia D I C

Monitor CO & BP Adequate O2 Treat Coagulopathy

CPR as Indicated Fetal Monitoring Lab. Evaluation

Vol. Expansion :Crystalloid, ColloidBlood ComponenPressor Agent :

DopamineNorepinephrine

EphedrineInotropic Agent :

Digitalis

Increase O2Keep maternal PO2

≥ 60 mmhgFace mask ; CPAP

IntubationMech. Ventilation

Pulmonary Oedema :Furosemide, morphin

Blood ComponenTherapy :

PRBCsPlatelets

FFPCryoprecipitate

Pulmonary Art. Cath.as Indicated

CORTICOSTEROIDS ( Controversial)