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Penatalaksanaan Kegawatdaruratan Obstetri
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Penatalaksanaan Kegawatdaruratan Obstetri
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` PENATALAKSANAAN KEGAWATDARURATAN OBSTETRI
1. Prinsi Prinsip p Umum Umum Penilai Penilaian an Dan Penan Penangan ganan an Preer Preerm m Sampai saa ini m!ralias "anm!r#!"ias ne!naus pa"a #an$i preerm%premaur masi& sanga inggi. 'al ini #er(aian "engan maurias !rgan pa"a #a$i la&ir) seperi paru) !a() "an gasr!inesinal. Pen$e#a# persalinan preerm "apa "i(enali "engan *elas. Namun pen$e#a# pasi i"a( "apa "i(ea&ui. Be#erapa +a(!r mempun$ai an"il "alam er*a"in$a persalinan preerm seperi +a(!r pa"a i#u) +a(!r *anin "an plasena) aaupun +a(!r lain seperi s!si s!si!e !e(! (!n! n!mi mi(. (. Pen" Pen"e( e(a aan an !#se !#see eri( ri( $ang $ang #ai( #ai( er& er&a" a"ap ap pers persal alin inan an pre preer erm m a(an a(an mem#eri(an &arapan er&a"ap (ea&an &i!"up "an (,alias &i"up #a$i preerm. DE-INISI Persalinan preerm a"ala& persalinan $ang #erlangsung pa"a umur (e&amilan /02 minggu "i&iung "ari &ari perama &ai" era(&ir. Dan pa"a a&un //3 &impunan (e"!(erana +e!maernal +e!maernal pagi "isemarang "isemarang meneap(an #a&,a persalinan persalinan preerm preerm a"ala& persalinan $ang er*a"i pa"a usia (e&amilan 02 minggu. 4ASALA' PERSALINAN PRETER4 Perm Permasa asala la&a &an n $ang $ang er* er*a" a"ii pa"a pa"a persa persali lina nan n pre preerm erm #u(a #u(an n sa*a sa*a pa"a pa"a (ema (emai ian an perinaal) melain(an #a$i premaur ini sering pula "iserai "engan (elainan) (elainan *ang(a pen"e( maupun *ang(a pan*ang. Kelainan *ang(a pen"e( $ang sering er*a"i a"ala& RDS) pen"ara&an inra%peri5enri(uler) "isplasi Br!n6!0Pulm!nar) Br!n6!0Pulm!nar) sepsi "an paen "u(us areri!sus. Dan a"apun (elainan *ang(a pan*ang sering #erupa (elainan neur!l!gi( seperi sere#ral palsi) rein!pai) rear"asi menal) "apa er*a"i "is+ungsi neur!#e&a5i!ral "an presasi se(!la& $ang (urang #ai(. Dan #ila meli&a permasala&an $ang "apa er*a"i pa"a #a$i preerm) ma(a menun"a persalinan preerm) #ila mung(in) masi& eap mem#eri suau (eunungan. ETIOLOGI DAN -AKTOR PREDISPOSISI Ban$a( Ban$a(
(asus (asus persali persalinan nan premaur premaur se#agai se#agai a(i#a a(i#a pr!ses pr!ses pa!!g pa!!gani ani( ( $ang $ang 4PK
me"ia! me"ia!rr #i!(im #i!(imia ia $ang $ang mempun mempun$ai $ai "ampa( "ampa( er*a"i er*a"in$a n$a (!nra (!nra(si (si ra&im ra&im "an peru#a peru#a&an &an ser5i(s $aiu 7
1. A(i5ias a(sis (alen*er '$p!alamus0'$p!+isis0a"5ernal #ai( pa"a i#u maupun pa"a *anin) a(i#a seress pa"a i#u aau *anin. . In+lamasi "esi"ua0(!ri!amni!n aau sisemai( a(i#a in+e(si asen"en "an ra(us geni!unaria aau in+e(si sisemi(. . Per"ara&an "esi"ua. 8. Peregangan uerus pa!l!gi(. 3. Kelainan pa"a uerus aau ser5i(s. K!n"isi selama (e&amilan $ang #eresi(! er*a"i persalinan preerm a"ala& 7 9 :anin "an plasena 0
Per"ara&an rimeser a,al.
0
Per"ara&an aneparem ;plasena pre5ia) s!lusi! plasena) 5asa pre5ia<
0
KPD.
0
Perum#u&an *anin er&am#a.
0
=a6a #a,aan *anin.
0
Ke&amilan gan"a%gemeli.
0
P!li&i"ramni!n.
0
Pen$a(i #era pa"a i#u.
0
Dia#eusmellius%D4.
0
Pre(lamsi%'iperensi.
0
In+e(si seluru& (emi&%genial%inra uerin.
0
Pen$a(i in+e(si "engan "emam.
0
Seres pesi(!l!gi(.
0
Kelainan #enu( uerus%ser5i(s
0
Ri,a$a persalinan preerm%a#!rus #erulang.
0
In(!mpeensi ser5i(s ;pan*ang ser5i(s (urang "ari 1 6m<
0
Pema(aian !#a nar(!i(.
0
Trauma.
0
Per!(!( #era.
0
Kelainan imun!l!gi%(elainan resus.
9 I#u
Disamping +a(!r resi(! "iaas) +a(!r lain $ang perlu "iper&ai(an a"ala& ing(a S!si!0e(!n!mi) ri,a$a la&ir mai) "an (e&amilan "iliuar ni(a&) merupa(an lang(a& pening "alam pen6ega&an persalinan preerm) a"ala& #agaimana mengi"eni+i(asi(an +a(!r resi(!
"an (emu"ian mem#eri(an pera,a aueraal sera pen$ulu&an agar i#u "apa mengurangi resi(! am#a&an.
DIAKNOSIS Dia(n!sis an6aman persalinan preem) $aiu 7 0
K!nra(si $ang #erulang se"i(in$a seiap 20> meni se(ali) aau 0 (ali "alam ,a(u 1/ meni.
0
A"a$a n$eri pa"a punggung #a&,a ;l!, #a6( pain<
0
Pen"ara&an mene(an "aera& ser5i(s.
0
Pemeri(saan ser5i(s menun*u(an ela& er*a"i pem#u(aan se"i(in$a 6m) "an penipisan 3/0>/?.
0
Presenasi *anin ren"a&) sampai men6apai spina isia"i(a.
0
Selapu (eu#an pe6a& "apa merupa(an an"a a,al er*a"in$a persalinan preerm.
0
Ter*a"i pa"a usia (e&amilan 02 minggu.
Be#erapa lang(a& $ang "apa "ila(u(an unu( men6ega& persalinan preerm anara lain s## 7 0 'in"ari (e&amilan pa"a i#u erlalu mu"a ;(urang "ari 12&<. 0 'in"ari *ara( (e&amilan erlalu "e(a. 0 4engguna(an (esempaan peri(sa &amil "an memper!le& pela$anan auenanal $ang #ai(. 0 An*uran i"a( unu( mer!(!( "an meng(!nsumsi !#a erlarang ;nar(!i(a<. 0 'in"ari (er*a #era "an 6u(up isira&a. 0 O#ai pen$a(i $ang "apa men$e#a#(an persalinan preerm. 0 Kenali "an !#ai in+e(si genial%saluran (en6ing. 0 Dee(si "an pengamanan +a(!r resi(! er&a"ap persalinan preerm. PENGELOLAAN Pengel!laan persalinan preerm a"ala& apa(a& memamg persalinan preerm. 4en6ari pen$e#a# n$a "an menilai (ese*a&eraan *anin $ang "apa "ila(u(an se6ara (linis) la#!ra!ries) aau pun USG. 4elipui perum#u&an%#era *anin) *umla& "an (ea"aan 6airan amni!n) presenasi "an (ea"aan *anin aau (elainan (!ngenial. Dan #ila pr!ses ersalinan (urang #ulan masi& eap #erlangsung aau mengan6am) mes(i ela& "ila(u(an segala upa$a pen6ega&an) ma(a perlu "i perim#angan 7 0 Se#erapa #esar (emampuan (lini( unu( men*aga (e&i"upan #a$i preerm aau #erapa persen $ang a(an &i"up menuru #era "an usia gesasi 0 Bagaimana se#ai(n$a persalinan #era(&ir) per5aginaan aau #e"a& sesar 0 K!mpli(asi apa $ang a(an im#ul) misaln$a per"ara&an !a( aau sin"r!ma ga,a na+as 0 Bagaimana pen"apa pasien "an (eluarga mengenai (!nse(uensi pera,aan #a$i preerm "an (emung(inan &i"up aau 6a6a 0 Se#erapa #esar "ana $ang "iperlu(an unu( mera,a #a$i preerm) "engan ren6ana pera,aan inensi+ Ne!naus.
I#u &amil $ang mempun$ai resi(! er*a"i persalinan preerm "an % aau menun*u(an an"a @ an"a persalinan preerm peru "ila(u(an iner5ensi unu( mening(a(an Ne!naal Ou6!mes.
4ana*emen persalinan preerm #erganung pa"a #e#erapa +a(!r 7 Kea"aan selapu (eu#an. Persalinan i"a( "i&am#a #ilamana selapu (eu#an su"a& pe6a& Pem#u(aan ser5i . Persalinan a(an suli "i6ega& #ila pem#u(aan men6apai 86m. Umur (e&amilan. 4a(in mu"a usia (e&amilan) upa$a men6ega& persalinan ma(in "iperlu(an. Persalinan "apa "iperim#ang(an #erlangsung #ila #era *anin le#i& "ari /// gram aau (e&amilan le#i& "ari 8 mg. Pen$a#a#%(!mpli(asi persalinan preerm Kemampuan Ne!naal Inensi5e =are -a6iliies.
Be#erapa lang(a& $ang "apa "ila(u(an pa"a persalinan preerm) eruama men6ega& 4!r#i"ias "an 4!ralias Ne!naus Preerm a"ala& 7 0 4eng&am#a pr!ses persalinan preerm "engan pem#erian !(!lisis. 0 Pemaangan sur+a(an paru *anin "engan K!ri(!seer!i" 0 Pen6ega&an er&a"ap in+e(si T!(!lisis Aasan pem#erian !(!isis pa"a persalinan preerm a"ala& 7 0 4en6ega& 4!ralias "an 4!r#i"ias pa"a #a$i premaure 0 4em#eri (esempaan #agi erapi K!ri(!seer!i" unu( menseimulir Sur+a(an Paru *anin 0 4em#eri (esempaan rans+er Inrauerin pa"a +asilias $ang le#i& leng(ap 0 Opimalisasi pers!nel. O#a $ang "apa "iguna(an se#agai T!(!lisis a"ala& 7 0 Kalsium Anag!nis 7 Ni+e"ipine 1/mg%Oral 0 (ali%*am. Dian*ur(an iap > *am sampai K!nra(si &ilang. 0 O#a B @ mimei( 7 Seperi Ter#ualin) Rir!"ine) Is!(suprin) "an Sal#uam!l. 0 Sul+as 4agnesi(us "an Ani Pr!aglan"in. 0 4em#aasi a(i+ias aau ira& #aring. K!ri(!ser!i" Unu( pemaangan sur+a(an paru *anin) menurun(an insi"ensi RDS) men6ega& per"ara&an Inra5eni(uler $ang a(&irn$a menurun(an (emaian Ne!naus. O#a $ang "i#eri(an a"ala& 7 Deame&as!n aau Beameas!n -> Dan i"a( "iulang (arena resi(! er*a"in$a perum#u&an *anin er&am#a. D!sis unggal K!ri(!ser!i" a"ala& 7 0 Beameas!n 1 mg. im. "engan *ara( pem#erian 8*am 0 Deameas!n 8C mg. im. "engan *ara( pem#erian 1*am Ani#i!i(a Di#eri(an #ilamana (e&amilan mengan"ung resi(! er*a"in$a in+e(si seperi (asus KPD. O#a Oral $ang "ian*ur(an a"ala& 7 Erir!misin 3// mg selama &ari. O#a lain a"ala& Ampisilin 3// mg selama &ari. ang perlu "iper&ai(an pa"a pemeri(saan pasien "engan KPD pa"a preerm 7 0 Semua ala unu( peri(sa 5agina &arus seril. 0 PD 5agina i"a( "ian*ur(an) eapi "ila(u(an "engan Spe(ulum.
Pen"eria "engan KPD "ila(u(an penga(&iran persalinan pa"a usia (e&amilan Cmg. Bila "iemu(an a"an$a #u(i in+e(si ma(a penga(&iran persalinan "iper6epa%"i in"u(si) anpa meli&a usia (e&amilan. Persiapan persalinan preerm perlu "iperim#ang(an #er"asar 7 o Usia Gesasi 0 Usia Gesasi 8mg aau le#i&. Dapa mela&ir(an "iing(a "asar%primer menginga Pr!gn!sis relai+ #ai( 0 Usia Gesasi (urang "ari 8mg &arus "iru*u( "i Ruma& Sa(i "engan +asilias pera,aan Ne!naus $ang mema"ai. o Kea"aan selapu (eu#an 0 Bila "i"apa KPD pa"a usia (e&amilan (urang "ari >mg) ma(a (eluarga "ipersila&(an unu( memili& 6ara pengel!laan seela& "i#eri pen*elasan. =ara Persalinan Bila *anin presenasi (epala) ma(a "iper#!le&(an parus per5aginaan "an "engan meli&a #era *anin. S= i"a( mem#eri Pr!gn!sis $ang le#i& #ai( #agi #a$i) #a&(an merugi(an i#u. Premaurias *angan "ipa(ai unu( in"i(asi mela(u(an S=. S= "ila(u(an aas in"i(asi O#seri. Pa"a (e&amilan lea( sungsang /08mg. S= "apa "iperim#ag(an seela& (e&amilan le#i& "ari 8mg) persalinan "i#iar(an er*a"i (arena 4!r#i"ias "ianggap sama "engan (e&amilan Aerm. Pera,aan Ne!naus Pera,aan #a$i preerm #aru la&ir perlu "iper&ai(an (ea"aan umum) Bi!meri (emampuan #erna+as) (elainan +isi() "an (emampuan minum. Kea"aan (riis pa"a #a$i preerm a"ala& (e"inginan) perna+asan $ang i"a( A"e(,a) aau Trauma. Suasana &anga "iperlu(an unu( men6ega& 'ip!ermia pa"a Ne!naus ;su&u #a"an "i#a,a& C)3 "era*a =<. Ba$i "ira,a se6ara KANGURU unu( meng&in"ari 'ip!ermia. Di#ua peren6anaan peng!#aan "an asupan 6airan. ASI "i#eri(an le#i& sering #ila memung(in(an "i#eri(an S!n"e aau "ipasang In+us. Ba$i #aru la&ir &arus men"apa nurisi sesuai "engan (emampuan "an (!n"isi #a$i. Se#ai(n$a persalinan #a$i erlalu mu"a aau erlalu (e6il #erlangsung pa"a +asilias $ang mema"ai) seperi pela$anan Perinaal "engan pers!nel "an +asilias $ang A"e(,a ermasu( pera,aan Perinaal Inensi+.
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