KURET Kanadi Sumapradja
[email protected]
PENATALAKSANAAN ABORTUS INKOMPLIT
• Prinsip : Pembersihan sisa konsepsi. • Caranya tergantung : – Usia kehamilan, besar uterus dan hasil penghitungan HPHT – Ketersediaan peralatan, pasokan dan tenaga kesehatan yg terampil → tidak ada : RUJUK !
Table 1. Impact of Unsafe Abortion by Region
Region
Number of unsafe abortions (1000s)††
Unsafe abortions per 1000 women 1549
Mortality from unsafe abortion per 100,000 live births
Number of deaths from unsafe abortion††
Case fatality per 100 unsafe abortions
Risk of death
More developed countries
2340
8
600
4
0.03
1 in 3700
Less developed countries†
17620
17
69000
55
0.4
1 in 250
Africa
3740
26
23000
83
0.6
1 in 150
Asia†
9240
12
40000
47
0.4
1 in 250
260
2
100
2
0.04
1 in 2600
Latin America
4620
41
6000
48
0.1
1 in 800
USSR (former)
2080
30
500
10
0.03
1 in 3900
Europe
Table 2. Provision of Postabortion Care by Level of Healthcare Facility and Staff Level
Staff May Include
Emergency Postabortion Care Provided
Postabortion Family Planning
Community
Community residents with basic health training Traditional birth attendants Traditional healers
•Recognition of signs and symptoms of abortion and serious post abortion complications •Referral to facilities where treatment is available
Provision of pills, condoms, diaphragms and spermicides Referral and follow up for these and other methods
Primary (Primary health clinics, Family planning clinics or Polyclinics)
Health workers Nurses Trained midwives General practitioners
All primary care facilities. Above activities, plus: •Diagnosis based on medical history and physical and pelvic examination •Resuscitation/preparation for treatment or transfer •Haematocrit/hemoglobin testing •Referral, if needed
Provision of above methods plus IUDs, injectables and Norplant® implants Referral for voluntary sterilization
If trained staff and appropriate equipment are available. Above activities, plus: •Initiation of emergency treatments •antibiotic therapy •intravenous fluid replacement •oxytocics •Uterine evacuation during first trimester for uncomplicated cases of incomplete abortion •Pain control •simple analgesia and sedation •local anesthesia (paracervical block) First Referral Level (District hospital)
Nurses Trained midwives General practitioners Ob/Gyn specialists
Above activities, plus: •Emergency uterine evacuation through second trimester •Treatment of most postabortion complications •Local and general anesthesia •Diagnosis and referral for severe complications (septicemia, peritonitis, renal failure) •Laparotomy and indicated surgery (including for ectopic pregnancy) •Blood crossmatch and transfusion
Provision of above methods plus voluntary sterilization Followup
Secondary and Tertiary Level (Regional or Referral hospital)
Nurses Trained midwives General practitioners Ob/Gyn specialists
Above activities, plus: •Uterine evacuation as indicated for all incomplete abortions •Treatment of severe complications (including bowel injury, severe sepsis, renal failure) •Treatment of bleeding/clotting disorders
All above activities
AVM
KEUNGGULAN AVM
– Sampai usia 12-14 mgg – Risiko lebih rendah drpd kuret tajam – Anestesi umum (-) – Ruang khusus (-)
ASPIRASI VAKUM MANUAL
→ Dgn tek. negatif • Masukkan kanula, hubungkan dg tabung pengisap melalui adaptor • Buka katup pengatur sampai tek. negatif • Kanula digerakkan maju-mundur sambil rotasi ke kanan-kiri
PERLENGKAPAN ALAT AVM • Tabung vol.60 ml, dengan : – 1 atau 2 katup pengatur – Toraks & tangkai penarik/pendorong – Penahan toraks – Silikon pelumas cincin karet • Kanula steril
PEMILIHAN ALAT AVM
UKURAN KANUL
KATUP
USIA KEHAMILAN
5 – 6 mm
1 atau 2
0-8 minggu
2 katup
Trimester I - II awal (< 14 mgg)
6-10 mm 12 mm
KEWASPADAAN SEBELUM TINDAKAN AVM
Yg menjadi perhatian, bila : • Besar uterus tdk sesuai dgn usia kehamilan (HPHT) • Usia kehamilan > trimester pertama
PERSIAPAN PROSEDUR AVM
1. Mengurangi Risiko Infeksi – – – –
Cuci tangan dg sabun & air mengalir Peralatan yg steril atau DTT Bersihkan vagina & serviks dg lar. antiseptik Teknik tanpa sentuh
2. Menyiapkan Instrumen AVM – Periksa fungsi isap tabung AVM – Kesiapan tindakan gawat darurat – Buat tekanan negatif dengan : • Kunci katup pengatur • Tarik tangkai toraks
3. Pemeriksaan Panggul – Besar & arah uterus (bimanual) – Kondisi vagina & serviks
4. Persiapan Pasien – Kosongkan kandung kemih – Bersihkan perut bawah, lipat paha, genitalia eksterna dengan sabun & air. – Siapkan vagina & serviks dgn antiseptik 2-3 kali (bila dengan iodofor tunggu 2’)
LANGKAH-LANGKAH PROSEDUR AVM
Langkah 1 • Masukkan spekulum • Keluarkan jaringan atau bekuan darah • Cabut AKDR bila ada.
Langkah 2 • Bersihkan servik & vagina dgn larutan antiseptik
Langkah 3 • Blok paraservikal (bila perlu)
Langkah 4 • Pegang bibir atas serviks dengan tenakulum/klem ovum (jam 1 dan jam 11) • Ukur bukaan ostium dengan kanul Anestesi verbal G
Langkah 5
• Masukkan kanula dengan adaptor • Dorongan ringan dan putar kiri-kanan
Langkah 6 • Perhatikan ukuran bila kanula telah mencapai fundus • Titik terdekat 6 sm • Tarik sedikit ujung kanula dari fundus
Langkah 7
• Hubungkan pangkal kanula dengan tabung AVM
Langkah 8
• Buka katup pengatur • Bila bekerja : cairan darah & busa
Langkah 9 • Gerakkan kanula majumundur + rotasi jam 102 • Jangan sampai tertarik keluar • Bila tek. negatif hilang tutup pengatur + lepaskan kanula • Siapkan tek. negatif kembali & pasang kembali • Jangan pegang pada tangkai pendorong !
Langkah 10 • Periksa kebersihan kavum uteri • Tanda : – Busa-busa merah – Jaringan tak terlihat – Terasa kasar – Uterus kontraksi – Kanul seperti terjepit
Langkah 11 • Keluarkan kanula • Lepaskan sambungan • Masukkan ke wadah dekontaminasi
Langkah 12
Periksa jaringan : • Jumlah & massa kehamilan • Pastikan kebersihan evakuasi • Adanya kelainan seperti mola
Cara Pemeriksaan • Isi mangkok + air bersih + kassa saringan • Hasil evakuasi + mangkok angkat • Jaringan : – Vili korialis : • Putih keabuan, memanjang, mengambang – Endometrium : • Massa lunak, licin, butiran putih tanpa juluran halus, tenggelam
Bila Tak Tampak Jaringan Kehamilan
Kemungkinan : • Abortus komplit • Kurang terampil tidak terambil • Bukan abortus inkomplit • Uterus abnormal Bila Tak Tampak Jaringan Kehamilan + Tanda Kehamilan KEHAMILAN EKTOPIK !!!
Langkah 13-16
• Lepaskan tenakulum & spekulum • Dekontaminasi alat : klorin 0,5% 10’ : – 2 tempat : logam + non logam – Alat tidak terkunci • Bersihkan sarung tangan balikkan • Cuci tangan dgn sabun & air mengalir
Langkah-langkah kuret dengan kuret tajam
Check the cervix for tears or protruding products of conception. If products of conception are present in the vagina or cervix, remove them using ring (or sponge) forceps. Gently grasp the anterior lip of the cervix with a vulsellum or single-toothed tenaculum Note: With incomplete abortion, a ring (sponge) forceps is preferable as it is less likely than the tenaculum to tear the cervix with traction and does not require the use of lignocaine for placement. If using a tenaculum to grasp the cervix, first inject 1 mL of 0.5% lignocaine solution into the anterior or posterior lip of the cervix which has been exposed by the speculum (the 10 o’clock or 12 o’clock position is usually used).
Dilatation is needed only in cases of missed abortion or when some retained products of conception have remained in the uterus for several days: - Gently introduce the widest gauge cannula or curette; - Use graduated dilators only if the cannula or curette will not pass. Begin with the smallest dilator and end with the largest dilator that ensures adequate dilatation (usually 10–12 mm) (Fig P-33); - Take care not to tear the cervix or to create a false opening.
Gently pass a uterine sound through the cervix to assess the length and direction of the uterus. The uterus is very soft in pregnancy and can be easily injured during this procedure. Evacuate the contents of the uterus with ring forceps or a large curette Gently curette the walls of the uterus until a grating sensation is felt.
Give paracetamol 500 mg by mouth as needed. Encourage the woman to eat, drink and walk about as she wishes. Offer other health services, if possible, including tetanus prophylaxis, counselling or a family planning method. Discharge uncomplicated cases in 1–2 hours. Advise the woman to watch for symptoms and signs requiring immediate attention: - prolonged cramping (more than a few days); - prolonged bleeding (more than 2 weeks); - bleeding more than normal menstrual bleeding; - severe or increased pain; - fever, chills or malaise; - fainting.
KURET HISAP
