gawat darurat obgyn
DESCRIPTION
emergencyTRANSCRIPT
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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
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TUJUAN :
MEMAHAMI KEADAAN-KEADAAN YANG MERUPAKAN
KEGAWAT DARURATAN DIBIDANG OBSTETRI &
GINEKOLOGI
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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
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GAWAT DARURAT
OBSTETRI GINEKOLOGI
IBU JANIN IBU
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• 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
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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
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1. HPP yang masive dengan penggantian
cairan yang tidak adekuat,
2. Solusio plasenta
3. Preeklamsia Berat disertai dengan
sindroma HELLP
PENYEBAB
SERING
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• 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
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• 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
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• Kadar Fibrinogen --- turun• Fibrinogen Degradation Product --- naik• Prothrombin Time --- naik• aPTT --- naik• Anti Thrombine III --- turun• Hb. Dan Hct --- turun• Bilirubin --- naik
DIAGNOSIS
LABORATORIK
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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
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PENGELOLAANPENGELOLAAN
PEMBERIAN KOMPONEN DARAH
1. Fresh frozen plasma (FFP)2. Cryoprecipitated3. Blood Platelets4. PRC
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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
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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.
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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
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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
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AMNIOTIC FLUIDS EMBOLISMAMNIOTIC FLUIDS EMBOLISM( A F E )( A F E )
Agus Abadi
Bagian Obstetri dan Ginekologi
RSU. Dr. Soetomo / FK Unair
Surabaya
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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
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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)
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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
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Diagnosa Diagnosa BandingBanding
• Sepsis
• Acute Myocard Infarction
• Aspration Pneumonia
• Pulmonary thromboembolism
• Solusio Plasenta
• Komplikasi Anesthesia
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EVALUATION OF SUSPECTED EVALUATION OF SUSPECTED AFEAFE
Arterial Blood GasCBC & PlateletsPT & PTTFibrinogen & FDPCrossmatch & Blood typeChest X-Ray12 Lead Electrocardiogram
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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
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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
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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
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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
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Coagulopathy In AFECoagulopathy In AFE
• Shorten Clotting Time• Thromboplastin Like Effect• Induce Platelets Aggregation• Release Platelets Factor III• Activation Complement Cascade
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DIAGNOSISDIAGNOSIS
• 1. KLINIS• 2. LABORATORIK• 3. DIAGNOSIS PASTI : Ditemukan Fetal Debris didalam pembuluh darah pulmoner
Cath. Pulm. : 50 % Otopsi : 75 %
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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)
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