Staf Fetomaternal, Departemen Obstetri & Ginekologi FKUI/RSUPN Cipto Manukusumo
Pelatih Basic Surgical Skill POGI, tahun 2004‐ sekarang.
Fasilitator Advanced Labour And Risk Management (ALARM) POGI, tahun 2005‐ sekarang
Pelatih/Adva nved Trainer Jaringan Nasiona Pelatihan Klinik‐ Kesehatan Reproduksi, tahun 2005‐ sekarang.
Pelatih Resusitasi Neonatus Perinasia, tahun 2004‐ sekarang.
Anggota PokJa HIV/AIDS & Pelatih PMTCT Kementerian Kesehatan Republik Indonesia, tahun 2007‐ sekarang.
Peserta International Course Sexual Reproductive Health and Right, Swedia, Pebruari 2009
Lain‐lain 12% Kompl masa puerpureum 8% Emboli obst 3% P. lama/macet 5%
Perdarahan 30%
Abortus 5% Infeksi 12% Pre/Eklampsia 25%
RS
Rumah
FasKes
Perjalanan
Tempat lain
Tempat Kematian Maternal di RS
Qomariyah SN, Bell JS, Pambudi ES, Anggondowati T, Latief K, Achadi EL, et al. A practical approach to identifying maternal deaths missed from routine hospital reports: lessons from Indonesia: Global Health Action2009
Prakiraan Waktu menuju Kematian untuk Kasus Kegawatdaruratan Obstetri Penyebab Perdarahan Postpartum Perdarahan Antepartum Ruptur Uteri Eklampsia/PEB Persalinan Macet Infeksi
Waktu 2 jam 12 jam 1 hari 2 hari 3 hari 6 hari
Briley A, Bewley S. Management of obstetric hemorrhage: obstetric management. In: Briley A, Bewley S, editors. The Obstetric Hematology Manual. Cambridge: Cambridge University Press; 2010. p. 151‐58.
DETEKSI DINI OBSTETRI
Diagram of the outcomes of adverse events in Australian hospitals
Wilson RM, Runciman WB, Gibberd RW, et al.The Quality in Australian Health Care Study. Med J Aust. 1995;163:458–471.In : Jones D, Bellomo R, Goldsmith D. General Principles of Medical Emergency Teams. In: DeVita MA, Hillman K, Bellomo R, editors. Medical Emergency Teams Implementation and Outcome Measurement. Pittsburgh: Springer Science+Business Media; 2006 p. 80‐90.
Warning signs preceding critical event
Hemodynamic changes included systolic blood pressure <90 or >200mmHg, pulse <50 or >130 beats/min; respiratory included rate >30/min, oxygen saturation <85%; abnormal laboratory results included pH <7.2, Na+ <125 or >150mmol/L, K+ >6mmol/L; abnormal temperature <95°F or >104°F. GCS = Glasgow Coma Score Buist MD, Jarmolowski E, Burton PR, et al. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary‐care hospital. Med J Aust. 1999;171:22–25. In: DeVita MA, Hillman K, Bellomo R, editors. Medical Emergency Teams Implementation and Outcome Measurement. Pittsburgh: Springer Science+Business Media; 2006 p. 80‐90.
Risk of Mortality: Independent Predictors Event Decrease of consciousness Hypotension Loss of consciousness Bradypnea SaO2 < 90% Tachypnea
Odds ratio and 95% CI 6,4 (2,6–15,7) 2,5 (1,6–4,1) 6,4 (2,9–13,6) 14,4 (2,6–80,0) 2,4 (1,6–4,1) 7,2 (3,9–13,2)
Buist M, Campbell D. The Challenge of Predicting In‐Hospital Iatrogenic Deaths. In: DeVita MA, Hillman K, Bellomo R, editors. Medical Emergency Teams Implementation and Outcome Measurement. Pittsburgh: Springer Science+Business Media; 2006 p. 32‐48.
National Early Warning Score
Kolic I, Crane S, McCartney S, Perkins Z, Taylor A. Factors affecting response to national early warning score (NEWS). Resuscitation. 2015 May;9085‐90
A modified early obstetric warning system (MEOWS)UK, NICE
Physiologic Parameters Respiration rate Oxygen saturation Temperature Systolic blood pressure Diastolic blood pressure Heart rate Pain score Neurologic response
Yellow Alert 21–30
35–36 150–160 or 90–100 90–100 100–120 or 40–50 2–3 Voice
Red Alert <10 or >30 <95 <35 or >38 <90 or >160 >100 >120 or <40
Unresponsive, pain
Respiration rate (breaths per minute); Oxygen saturation (%); Temperature (degrees Celsius); Systolic blood pressure (mm Hg); Heart rate (beats per minute). Level of consciousness is based on the Alert Voice Pain Unresponsive scale, which assesses 4 possible outcomes to measure and record a patient’s level of consciousness. Pain scores are as follows: (0 5 no pain, 1 5 slight pain on movement, 2 5 intermittent pain at rest/moderate pain on movement). A single red score or 2 yellow scores triggers an evaluation
The MEOWS alert parameters may lead to detection of the following unrecognized conditions: hemorrhage (as demonstrated by hypotension and tachycardia), sepsis (fever, hypotension, tachycardia, hypoxia), venous thromboembolism (tachycardia, tachypnea, hypoxia), preeclampsia (hypertension, hypoxia), and cardiovascular complications (tachycardia, bradycardia, hypoxia, hypotension). Singh S, McGlennan A, England A, et al. A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS). Anaesthesia 2012;67:12–8; In : Friedman AM. Maternal early warning systems. Obstet Gynecol Clin North Am. 2015 Jun;42(2)289‐98.
National Early Warning Score & Clinical Risk Skor NEWS 0 Total skor 1‐4 Skor”MERAH” (skor parameter tunggal 3) Total skor 5‐6 Total skor 7
Risiko Klinis Rendah Sedang Tinggi
Kolic I, Crane S, McCartney S, Perkins Z, Taylor A. Factors affecting response to national early warning score (NEWS). Resuscitation. 2015 May;9085‐90
Ringkasan Aktivasi/Picu NEWS (Trigger) Skor NEWS Frekuensi Pemantauan Respon 0
Minimal setiap 12 jam
Lanjutkan pemantauan rutin NEWS
Total 1‐2
Minimal setiap 4‐6 jam
Peringatkan perawat untuk melakukan penilaian pada pasien Perawat memutuskan untuk meningkatkan frekuensi pemantauan atau perlu perawatan khusus
Tingkatkan frekuensi Total 5 atau skor 3 pemantauan menjadi pada salah setiap jam satu parameter Total 7
Perawat memanggil dokter yang kompeten dalam kasus akut untuk menilai pasien. Perawatan khusus dengan penambahan alat monitor
Pemantauan tanda vital Perawat segera memanggil tim yang secara kontinyu kompeten dalam kasus kritis (termasuk kemampuan intubasi/manajemen jalan napas) Perawatan HCU/ICU
Modified Early Obstetric Warning Scoring system (MEOWS) chart from the Liverpool Women's Hospital.
Risk management and medicolegal issues related to postpartum haemorrhage. Upadhyay, Kalpana, MRCOG, Best Practice & Research: Clinical Obstetrics & Gynaecology, Volume 22, Issue 6, 1149‐1169, 2008
1. Aktivasi Pemantauan
NEWSS Pasien Dewasa 3 Pernapasan/ menit Nadi/ menit Tekanan darah <70 Sistolik Tingkat Kesadaran Suhu Tubuh
Hijau 0‐1
2 <8
1 8
0 9‐17
1 18‐20
2 21‐29
3 >30
<40
40‐50
51‐100
101‐110
111‐129
>130
71‐80
81‐100
101‐159
160‐199
200‐220
>220
Apatis
Delirium
38.05‐ 38.5oC
>38.5oC
Coma Stupor
Somnolen Compos Mentis
<35oC 35.05‐36oC 36.05‐ 38.oC Kuning 2‐3
Orange 4‐5
Merah >6
Merah
Aktivasi Code Blue
Oranye
Perbaikan Tatalaksana
Kuning Hijau
DPJP
PJ Ruangan Perawat
Kaji Ulang Kontinu
DPJP
PJ Ruangan
Kaji Ulang tiap 1 jam
PJ Ruangan
Kaji Ulang tiap 2 Jam
Asesmen ulang
Pasien dalam keadaan stabil
Kaji ulang Setiap Shift
Peran : Team Leader Jabatan: dr. TMRC Unit/ Perawat 1 Tugas: Airway/Breathing
Skema Pertolongan Code Blue (Sebelum TMRC Pusat /Wilayah datang)
Peran: Perawat 2 Tugas: Compression
Peran: Perawat 3 Jabatan: IV line & drugs Troli Emergensi Peran:.Perawat 4 Jabatan: Dokumentasi
PREEKLAMPSIA
The revised ISSHP definition preeclampsia (2014) Hypertension developing after 20 weeks gestation and the coexistence of one or more of the following new onset conditions: 1. 2. • • • •
3. •
Proteinuria Other maternal organ dysfunction: Renal insufficiency (creatinine >90 umol/L) Liver involvement (elevated transaminases and/or severe right upper quadrant or epigastric pain) Neurological complications Haematological complications
Uteroplacental dysfunction Fetal growth restriction
The classification, diagnosis and management of the hypertensive disorders of pregnancy: A revised statement from the ISSHP. Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 4 (2014) 97–104
• • • •
Considered severely elevated: >160 mmHg systolic or >110 mmHg diastolic. Not to rely on a single reading, appropriate‐sized cuff In the case of severely elevated BP not to wait for ‘‘6 h apart’’, but in 15‐30 m Suggest mercury sphygmomanometry or sphygmomanometry using a liquid crystal device. If an automated device is to be used then it should have been validated for use in pregnancy.
Andrea L. Tranquilli, Mark A. Brown, Gerda G. Zeeman, Gustaaf Dekker, Baha M. Sibai. The definition of severe and early‐onset preeclampsia. Statements from the International Society for the Study of Hypertension in Pregnancy (ISSHP)
• Does not predict clinical outcome • A spot urine protein/creatinine ratio > 30 mg/mmol • There is no clear consensus on the amount of proteinuria to be considered ‘severe’ (between >3 and 5 g/l)
• NOT CONSIDER PROTEINURIA FOR DEFINING SEVERE PREECLAMPSIA
Andrea L. Tranquilli, Mark A. Brown, Gerda G. Zeeman, Gustaaf Dekker, Baha M. Sibai. The definition of severe and early‐onset preeclampsia. Statements from the International Society for the Study of Hypertension in Pregnancy (ISSHP)
Hipertensi bukan penyakit tapi merupakan reaksi tubuh
Implantasi yang tak sempurna
Hipertensi terjadi sebagai mekanisme kompensasi penuhi kebutuhan
Perkembangan Pre‐eklampsia
Skema sekuen kejadian sepanjang kehamilan sampai timbul gejala klinis pre‐eklampsia. EC, endothelial cell; HO‐1, haem oxygenase 1; TGF‐β, transforming growth factor β. Ramma W, Ahmed A. Is inflammation the cause of pre‐eclampsia? Biochem Soc Trans. 2011 Dec;39(6):1619‐27.
Prooxidant – antioxidant Balance
ROS dan RNS berperan penting pd PEE – Scr langsung induksi disfungsi endothelial – Induksi hipertensi dan proteinuria melalui:
• RAS • inflammasi • Insulin resistan • Pro – anti angiogenic • menurunkan NO dg meningkatkan ADMA dan menurunkan HO‐1 Failure SMC modification Aliran drh: tonik O2‐ hipertensi
Poiseuille’s+Bernoulli’s Diameter : ↑ 4 – 6 X
Syncytial knot: aptototic sincytrophoblast Exp.Physiol 1997; 82;377 - 87
Debris ke sirkulasi maternal sitokin disfungsi endotel
• Kantung elastis • Bertahanan rendah • Arus tinggi • Bebas regulasi neurovascular
Two‐stage model of development of preeclampsia
CHRISTOPHER W.G. REDMAN, IAN L. SARGENT AND ROBERT N. TAYLOR. Immunology of Normal Pregnancy and Preeclampsia. Chesley’s Hypertensive Disorder in Pregnancy
The pathophysiological processes involved in pre‐eclampsia
AT1‐AA, angiotensin II receptor 1 autoantibodies; HELLP, hemolysis, elevated liver enzymes, and low platelets; PlGF, placental growth factor; sFlt‐1, soluble Fms‐like tyrosine kinase‐1; VEGF, vascular endothelial growth factor.
Urato AC, Norwitz ER. A guide towards pre‐pregnancy management of defective implantation and placentation. Best Pract Res Clin Obstet Gynaecol. 2011 Jun;25(3):367‐87.
Genetik Immunologik Etiologic Factors
Nutrisi Infeksi Perubahan pada angiogenesis Fetoplacental
Pathophysiology Stress Oxidative
Kegagalan Invasi Trophoblast Disfungsi Endothel
Clinical Manifestation
Hypertensi & Proteinuria
PREEKLAMPSIA
Lain2: VEGF TNF dll
Overlapping role of hypertension, capillary leak, maternal symptoms, and fibrinolysis/hemolysis in the spectrum of atypical preeclampsia
Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia‐eclampsia. Am J Obstet Gynecol. 2009 May;200(5):481 e1‐7.
PREECLAMPSIA
• FIRST, delivery is always appropriate therapy for the mother but not be so for the fetus • SECOND, the signs and symptoms of preeclampsia are not pathogenetically important (lowering blood pressure do not alleviate the important pathophysiologic changes • THIRD, the pathogenic changes or preeclampsia are present long before clinical criteria for diagnosis are evident
F. Gary Cunningham. Hypertensive disorders. Williams Obstetrics ed 24th
Suggested antepartum management options for women with pre‐eclampsia at any stage of diagnosis
Optional assessment and surveillance • On admission, on day of delivery, and additional testing as indicated by changes in clinical state. Maternal • Blood: haemoglobin, platelet count, creatinine, uric acid, AST or ALT, further testing if indicated Fetal • CTG, ultrasound, AFI, umbilical artery Doppler Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre‐eclampsia. Lancet. 2010 Aug 21;376(9741):631‐44.
SEIZURE PROPHYLAXIS AND TREATMENT • In the Magpie study, 10,000 preeclamptic women were randomized to receive magnesium sulfate or placebo. • Magnesium sulfate clearly reduced the risk of eclampsia in this trial, and it was shown to be superior to other prophylactic medications, including phenytoin, and diazepam.
RCT of MgSO4 prophylaxis with placebo or active drug in women with gestational hypertension JAMES M. ALEXANDER AND F. GARY CUNNINGHAM. Clinical Management. Chesley’s Hypertensive Disorder in Pregnancy
Randomized comparative trials of Magnesium Sulfate with Another Anticonvulsant to Prevent Recurrent Eclamptic Convulsions
JAMES M. ALEXANDER AND F. GARY CUNNINGHAM. Clinical Management. Chesley’s Hypertensive Disorder in Pregnancy
• In women with normal renal function, the half‐time for excretion is about 4 hours. • Because excretion depends on delivery of a filtered load of magnesium that exceeds the Tmax, the half‐time of excretion is prolonged in women with a decreased GFR Magnesium slows or blocks neuromuscular and cardiac conducting system transmission, decreases smooth muscle contractility, and depresses central nervous system irritability
Suggested antepartum management options for women with pre‐eclampsia at any stage of diagnosis MgSO4 • Regimen: MgSO4 4 g IV loading dose over 15–20 min, followed by an infusion of 1 g/h; recurrent seizure(s) treated with additional 2–4 g IV loading dose(s); clinical monitoring by measurement of urinary output, respiratory rate, and tendon refl exes. Eclampsia prophylaxis • Yes; for severe pre‐eclampsia during initial stabilisation and peripartum (delivery +24 h) Eclampsia treatment • Yes
Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre‐eclampsia. Lancet. 2010 Aug 21;376(9741):631‐44.
• Inhibition of uterine contractility is magnesium dose dependent • Serum levels of at least 8‐10 mEq/L are necessary to inhibit uterine contractions (Watt‐Morse, 1995)
JAMES M. ALEXANDER AND F. GARY CUNNINGHAM. Clinical Management. Chesley’s Hypertensive Disorder in Pregnancy
Cerebral Blood Flow Risk of hypertensive encephalopathy
Loss of Autoregulation Normotensive Poorly controlled hypertensive
Risk of ischemia
50
100
150
200
Mean Arterial Pressure (MAP)
Adapted with permission from Varon J, Marik PE. Chest. 2000;118:214‐227.
250
JASON G. UMANS, EDGARDO J. ABALOS AND F. GARY CUNNINGHAM. Antihypertensive treatment. Chesley’s Hypertensive Disorder in Pregnancy
Randomized Placebo‐Controlled Trials of Antihypertensive Therapy for Early Mild Hypertension During Pregnancy
JASON G. UMANS, EDGARDO J. ABALOS AND F. GARY CUNNINGHAM. Antihypertensive treatment. Chesley’s Hypertensive Disorder in Pregnancy
DRUGS FOR TREATMENT OF SEVERE HYPERTENSION IN PREGNANCY Drug
Dose
Onset
Duration
Adverse Effects
Labetalol
20–40 mg IV q 10 min 1 mg/kg as needed
10–20 min
3–6 h
Scalp tingling, vomiting, heart block
Nifedipine
10–20 mg PO q 20–30 min
10–15 min
4–5 h
Headache, tachycardia, synergistic interaction with magnesium sulfate
Nicardipine
5–15 mg/h IV
5–10 min
1–4 h
Tachycardia, headache, phlebitis
No current agreement as to what level BP should be maintained when antihypertensives are instituted for non‐ urgent indications in pregnancy • The Canadian guidelines recommend 130–155/ 90–105 mmHg in the absence of co‐morbid conditions • The NICE guidelines recommend keeping BP below 150 mmHg systolic and between 80 and 100 mmHg diastolic
The classification, diagnosis and management of the hypertensive disorders of pregnancy: A revised statement from the ISSHP. Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 4 (2014) 97–104
Management of maternal fluid balance before, during and after delivery is a challenge for the clinician. • The maternal plasma volume expansion is attenuated in preeclampsia (deficits of 600‐800 ml/m2) • Recommendation 65‐125 ml/hour • because of the potential risk of pulmonary edema, caution must be taken in preeclamptic or eclamptic women simultaneously receiving magnesium sulfate for seizure prophylaxis
T.Engelhardt,F.M. MacLennan. Fluid management in preeclampsia. International Journal of Obstetric Anesthesia. 1999 Gloria T. Too, and James B. Hill. Hypertensive crisis during pregnancy and postpartum period
Fluid Management Rapid fluid infusion a significant increase in alveolar‐ arterial oxygen difference (AaDO,) and shunt fraction (Qs/Qt)
Vasodilator therapy alone appears to improve tissue oxygenation without affecting Qs/Qt F. Gary Cunningham. Hypertensive disorders. Williams Obstetrics ed 24th
• Oliguria (<15 mL/h) is common in preeclampsia, particularly postpartum. • In the absence of pre‐existing renal disease or a rising creatinine, oliguria should be tolerated over hours, to avoid volume‐dependent pulmonary oedema
Laura A. Magee, Anouk Pels, Michael Helewa, Evelyne Rey, Peter von Dadelszen, On behalf of the Canadian Hypertensive Disorders of Pregnancy (HDP) Working Group 1. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy
Suggested antepartum management options for women with pre‐eclampsia at any stage of diagnosis
Plasma volume expansion • No; because of risks of maternal mortality associated with pulmonary oedema, in women with severe pre‐eclampsia infusion of sodium‐ containing fluids might need to be restricted and balanced against urine output over 4 h or more and creatinine concentrations Thromboprophylaxis • Yes; if on bed rest for 4 days or more Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre‐eclampsia. Lancet. 2010 Aug 21;376(9741):631‐44.
Reviews and Randomized Clinical Trials for Preeclampsia Recurrence Prevention Odds Ratio (95% CI) Aspirin Coomarasamy33 High risk 12,416 0,86 (0,79‐0,94) Duley32 High risk 33,439 0,81 (0,75‐0,88) Calcium Hofmeyr34 Meta‐analysis low risk 15,206 0,48 (0,33‐0,69) Meta‐analysis high risk 587 0,22 (0,12‐0,42) Magnesium Spatling35 General low‐risk 568 NS Sibai36 Normotensive 374 NS primigravidas Fish oil Makrides37 All risk 1,683 0,86 (0,59‐1,27) Vitamins C + E Poston41 High risk 2,41 0,97 (0,80‐1,17) Rumbold42 Nulliparous women 1,877 1,20 (0,82‐1,75) Heparin Mello46 Angiotensin 80 0,26 (0,08‐0,86) converting enzyme polymorphism in nonthrombophilic women with history of preeclampsia Agent
Study
Population
N
Dildy GA, 3rd, Belfort MA, Smulian JC. Preeclampsia recurrence and prevention. Semin Perinatol. 2007 Jun;31(3):135‐41.
Long‐term health risks Hypertensive disorder Future Risk
Gestational hypertension
Pre‐eclampsia
Severe pre‐eclampsia, HELLP syndrome or eclampsia
Gestational Risk ranges from Risk ranges from about 1 in 8 hypertension in about 1 in 6 (16%) to (13%) to about 1 in 2 (53%). future pregnancy about 1 in 2 (47%). If birth was needed Risk up to about 1 in 6 (16%). before 34 weeks risk is Risk ranges from 1 in Pre‐eclampsia in No additional risk if interval about 1 in 4 (25%). 50 (2%) to about 1 in future pregnancy before next pregnancy < 10 If birth was needed before 14 (7%). years. 28 weeks risk is about 1 in 2 (55%). Cardiovascular Increased risk of hypertension and its complications. disease If no proteinuria and no hypertension at 6–8 week End‐stage postnatal review, relative risk kidney disease increased but absolute risk low. No follow‐up needed. Thrombophilia
NICE 2010 Quick Ref
Routine screening not needed.
Kontrasepsi KOK
KIK
KOP
KIP Implan
Pil AKDR‐ AKDR Tubektomi Kondar LNG
Riwayat TD tinggi selama kehamilan 2 2 1 1 1 ‐ 1 1 A (sekarang TD normal) Sistolik 140– 159 atau 3 3 1 2 1 ‐ 1 1 C diastolik 90–99 Sistolik ≥ 160 or diastolik ≥ 4 4 2 3 2 ‐ 1 2 S 100 KOK= Kontrasepsi oral kombinasi; KIK= Kontrasepsi injeksi kombinasi; KOP= Kontrasepsi oral progestin; KIP= Kontrasepsi injeksi progestin; Kondar =kontrasepsi darurat; AKDR= alat kontrasepsi dalam rahim; AKDR‐LNG= alat kontrasepsi dalam rahim Levonorgestrel.
Upaya pencegahan • Pra konsepsi optimalkan status nutrisi – Multivitamin dan mineral, protein dan mix karbohidrat – Bereskan infeksi: periodontitis, UTI, cervico vaginitis – Upayakan berat badan ideal – Olah raga teratur
• Saat hamil – Pertahankan upaya pra konsepsi
PERDARAHAN POSTPARTUM
Syok Perjalanan Syok Hipovolemik tanpa pemberian terapi Tekanan Darah
Tekanan darah (mm Hg)
Denyut Jantung
Denyut Jantung (kali/menit) 150
Perdarahan
100
50
0
Kompensasi
Dekompensasi Fase Syok
Irreversibel
(Waktu)
Prakiraan Volume darah Dewasa (70mL/kgBB) Hamil (100 mL/kgBB) Klasifikasi
0 (normal)
Prakiraan Persentasi Tanda dan Gejala Klinis Perdarahan (ml) Perdarahan (%)
< 500
< 10
Action
Tidak ada
Garis Waspada
1
500–1000
< 15
Minimal
Perlu pengawasan ketat dan Terapi cairan infus
Garis Bertindak
2
1200–1500
20–25
3
1800–2100
30–35
4
> 2400
> 40
↑ pulse rate Nadi halus ↓ diuresis ↑ prernapasan hipotensi postural hipotensi takikardia akral dingin takipnu Syok
Terapi cairan infus dan uterotonika
Manajemen aktif dan agresif Manajemen aktik kritikal (risiko 50% mortalitas bila tidak ditatalaksana aktif)
Benedetti T. Obstetric haemorrhage. In Gabbe SG, Niebyl JR, Simpson JL, eds. A Pocket Companion to Obstetrics, 4th edn. New York: Churchill Livingstone, 2002:Ch 17. In: B‐Lynch C, Keith LG, Lalonde AB, Karoshi M, editors. A Textbook Of Postpartum Hemorrhage‐A comprehensive guide to evaluation, management and surgical intervention. Dumfriesshire: Sapiens Publishing; 2007. p. 35‐44.
Singkatan HAEMOSTASIS Singkatan H A E M O S T A S I S
Help. Ask for Help (Aktivasi kode biru, Tim Respons Cepat) Akses intravena, penilaian perdarahan dan resusitasi Langkah cairan awal Etiologi cari (4 T), sedia darah Masase uterus Obat Oksitosin Uterotonika Siap ke OK/Rujuk. Singkirkan sisa plasenta dan trauma. Konservatif Kompresi bimanual , kompresi aorta abdominalis. (video) Non Bedah Tampon uterus kondom kateter (video) Aplikasi kompresi uterus B‐Lynch ataupun modifikasi Systemic pelvic devascularization : uterina, ovarika, Bedah hipogastrika, tehnik Lasso‐Budiman Konservatif Intervensi radiologi intervensi embolisasi arteri uterina Langkah Subtotal/total histerektomi Akhir
Mishra N, Chandraharan E. Postpartum haemorrhage (PPH). In: Warren R, Arulkumaran S, editors. Best Practice in Labour and Delivery. Cambridge: Cambridge University Press; 2009. p. 160‐70.
