Kehamilan di Bekas Seksio

Sesarea dan Tatalaksana

Yudianto Budi Saroyo
Divisi Fetomaternal Departemen Obstetri dan Ginekologi
RSUPN Cipto Mangunkusumo
Fakultas Kedokteran Universitas Indonesia
 Tatalaksana & Pencegahan Spektrum Plasenta Akreta

TERSIER
SEKUNDER PRIMER
LANJUT DINI

Teknik Usaha
Tatalaksana pembedahan menurunkan
Diagnosis Dini
Komprehensif uterus yang angka SC &
& Tatalaksana
Spektrum baik & pencegahan-
Kehamilan
Plasenta optimalisasi
Luka SC tatalaksana
Akreta penyembuhan
luka uterus faktor risiko
 CITA – CITA: Deteksi dan Tatalaksana Dini
Plasenta Akreta (CSP)
90

82
80

70

60 60

50 50

40 40

30 30

20 20
16
10
8

0
2021 2025 2030 2035

Akreta CSP
 Placenta Accreta, Increta, and Percreta
PAS disorders were first defined by Luke et al. to include both
abnormally adherent and invasive placentas. Three categories
are now considered:
(1) adherent placenta accreta, also described by pathologists as
“placenta creta, vera or adherenta” when the villi simply adhere
to the myometrium; Placenta accreta (attachment of the
placenta to myometrium without intervening decidua),
(2) placenta increta, when the villi invade the myometrium; and
(3) placenta percreta, when villi invade the full thickness of the
myometrium including the uterine serosa and sometimes
adjacent pelvic organs.
Variations in the lateral extension of myometrial invasion also
divide PAS disorders into the focal, partial, or total categories,
depending on the number of placental cotyledons involved.

Silver RM, Branch DW. Placenta Accreta Spectrum. N Engl J Med. 2018;378(16):1529-36
Jauniaux E, Ayres-de-Campos D, Diagnosis FPA, Management Expert Consensus P. FIGO consensus guidelines on placenta accreta spectrum
disorders: Introduction. Int J Gynaecol Obstet. 2018;140(3):261-4.
 Peningkatan kejadian Spektrum Plasenta Akreta di
RSUPN Dr. Cipto Mangunkusumo, Jakarta
(Jan 2015 – Sep 2021, n: 288), CSP 28/288 : 9.7%
90

81 82
80

70

60

50
45
40
38

30
24
20

10 10
8 8 7 8
3
0 0 1 1
2015 2016 2017 2018 2019 2020 2021
Akreta CSP
 Angka Kematian Spektrum Plasenta Akreta di
RSUPN Dr. Cipto Mangunkusumo (2015 – 2021)

Maternal Mortality

50%
Kematian pada CSP:
TIDAK ADA Critical
30% COVID

4% 4%
3%
0% 0%
2015 2016 2017 2018 2019 2020 2021
Persentase Perawatan ICU
 Proporsi Perawatan Intensif Pasca Pembedahan
Kasus Spektrum Plasenta Akreta di RSCM (n: 288)

Ruang ICU
120%

100% 100%
90% 28 kasus CSP tidak ada
80%
yang dirawat di ICU
60%
53%

40%
36%
29%
23% 22%
20%
TIM AKRETA

0%
2015 2016 2017 2018 2019 2020 2021
Persentase Perawatan ICU
 Rerata Jumlah Perdarahan Spektrum
Plasenta Akreta (dan CSP) di RSUPN Dr.
Cipto Mangunkusumo (n: 288)
4000

3500 3500

3000

2500 2500 2500

2200 2200
2000
1800
1500 1500

1000

500 500 500 500

300 300 300
0 0
2015 2016 2017 2018 2019 2020 2021
Akreta CSP
 CS Scar Pregnancy /CSP
(Kehamilan Luka Seksio Sesaria)
• Kehamilan ektopik dimana terjadi implantasi embrio pada skar/ bekas
seksio sesarea
• Apakah Spektrum Plasenta Akreta dapat dicegah?
• Patofisiologi: Complex – Abnormal desidua dan Trofoblas ekstravili
• Kontrol Faktor risiko !?

Defek
Peningkatan
penyembuhan luka
Sifat Invasif
uterus & Kelainan
Trofoblas
Desidua
 Patofisiologi CSP

Desidua basalis absen dan terjadi berbagai derajat invasi

AKRETA
miometrium oleh jaringan trofoblas. Kehamilan DALAM
KAVUM UTERI

Kantung kehamilan secara sempurna menempel pada

Kehamilan miometrium dan jaringan skar, dan terpisah dari
Bekas SC endometrium. Kehamilan BUKAN DI KAVUM UTERI

Traktus mikrotubular (gap) /

dehisens dapat terjadi karena
Invasi trofoblas pada miometrium
kerusakan desidua basalis karena
melalui traktus mikrotubular di
intervensi pada miometrium
antara jaringan parut seksio
(bedah uterus) seksio sesarea,
dengan kanalis endometrialis
kuretase, miomektomi,
hysteroskopi, manual plasenta

Ash A, Smith. Cesarean scar pregnancy. BJOG 2006.

 The two implantation modes of CSP

(A) “On the scar” with measurable (usually 2–3 mm) myometrial thickness between placenta/gestational sac and bladder.
(B) “In the niche” with <2 mm or no measurable myometrium between placenta/gestational sac and bladder.

Timor-Tritsch IE, Monteagudo A, Cali G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.
Obstet Gynecol Clin North Am. 2019;46(4):797-811.
 Klasifikasi CSP

Tipe 1
(endogen)

Tipe 2
(eksogen)
Via et al, 2000

15/10/21
 Sonographic criteria for the diagnosis of CSP.
(A)Low, anterior position of the
placenta/gestational sac; empty
uterine cavity; empty cervical
canal.
(B)Thin or no detectable
myometrium between the
placenta/gestational sac and the
bladder.
(C)Unusually increased vascularity
between the placenta/sac and
the bladder or internal cervical
os.

Timor-Tritsch IE, Monteagudo A, Cali G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.
Obstet Gynecol Clin North Am. 2019;46(4):797-811.
 Schematic demonstration of the gradual increase in size
of the gestational sac in a continuing pregnancy.

The sac with the fetus is moving up into the uterine cavity leaving behind the placenta with its vascularity. This may lead to
misdiagnosing a CSP as a normal intrauterine pregnancy leading to complications

Timor-Tritsch IE, Monteagudo A, Cali G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.
Obstet Gynecol Clin North Am. 2019;46(4):797-811.
 Diagnosis and differential diagnosis of CSP

IUP, intrauterine pregnancy.

Easy protocol for the diagnosis and differential diagnosis of CSP, intrauterine pregnancy, and cervical pregnancy on a sagittal,
longitudinal US image of the uterus.
(A) The center of the sac (plus sign) is below the plotted half line (ie, closer to the cervix), hence a CSP.
(B) On this heterotopic, intrauterine, and CSP, the center of the upper sac is above the half line and marks an intrauterine
pregnancy, whereas the center of the other lower sac is below that line indicating a CSP.
(C) Although the center of this sac is below the half line, the sac is within the posterior lip of the cervix and is, therefore, a
cervical pregnancy.
Timor-Tritsch IE, Monteagudo A, Cali G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.
Obstet Gynecol Clin North Am. 2019;46(4):797-811.
 Sonographic criteria of CSP
Partial or complete placenta previa.

In this image, the placenta is covering the Close proximity of the deeply implanted pregnancy in the
internal os at 8 weeks, 2 days. It is also a good niche of the previous CD with no measurable myometrium
example of lacunae in the placenta. or clear space between the gestational sac and bladder
(arrows).
Timor-Tritsch IE, Monteagudo A, Cali G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.
Obstet Gynecol Clin North Am. 2019;46(4):797-811.
 Sonographic criteria of CSP

Close proximity of the deeply implanted

pregnancy in the niche of the previous CD with The myometrium under the bladder is extremely thin and
no measurable myometrium or clear space there is increased vascularity at the site of implantation.
between the gestational sac and bladder
(arrows).
Timor-Tritsch IE, Monteagudo A, Cali G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.
Obstet Gynecol Clin North Am. 2019;46(4):797-811.
 Sonographic criteria of CSP
Interrupted or deformed bladder line

(A) Six weeks, 6 days CSP bulging (arrow) into the comfortably full bladder (cca 300 mL) disturbing the otherwise smooth
bladder line. (B) Ten weeks CSP causing more distortion of the bladder line.

Timor-Tritsch IE, Monteagudo A, Cali G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.
Obstet Gynecol Clin North Am. 2019;46(4):797-811.
 Sonographic criteria of CSP
Interrupted or deformed bladder line
(A, B) Side by side gray scale and
power Doppler images of a CSP at
10 weeks and 1 day and
(C, D) as a full blown placenta
accreta at 36 weeks and 3 days

Timor-Tritsch IE, Monteagudo A, Cali G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.
Obstet Gynecol Clin North Am. 2019;46(4):797-811.
Gambaran Ultrasonografi pada Kehamilan pada Skar Seksio Sesarea

Transvaginal ultrasonografi pada trimester pertama merupakan baku emas untuk diagnosis kehamilan
pada skar seksio sesarea

Kantong gestasi tidak berada di cavum Lapisan myometrium yang tipis di antara
uterus vesica urinaria dan kantong gestasi

Satgas Plasenta Akreta POGI

Gambaran Triangular dari kantong Kantong gestasi berada didekat vesica urinaria dan 2
berada di dinding anterior uterus 0
gestasi
Kriteria USG TV untuk Diagnosis Kehamilan pada Skar SC

Timor-Tritsch IE et al. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol 2012;207:44-47 2
1
Niche pada lokasi SC dan suatu kehamilan pada skar SC

Timor-Tritsch. Early placenta accreta and cesarean section scar pregnancy: a review. Am J Obstet Gynecol 2012.
2
2
GAMBARAN USG

Kantong kehamilan pada area bekas skar SC, termasuk yolk sac Reaksi desidua dengan ekogenisitas di sekitarnya dan sebuah
GS pada area skar bekas SC

Uysal, Fatma, Ahmed Uysal, Gurhan Adam. Cesarean Scar Pregnancy. J Ultrasound Med 2013; 32:1295–1300
2
 Heterotopic cesarean scar and intrauterine
pregnancies at 5 weeks, 2 days.

The pregnancy was continued until 30 weeks at which time a CD resulted in the live birth of both fetuses. One had severe
intrauterine growth restriction and a hysterectomy was performed for placenta accreta. (A) CSP on grey-scale image. (B) CSP
with increased vascularity on Color Doppler
Timor-Tritsch IE, Monteagudo A, Cali G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis.
Obstet Gynecol Clin North Am. 2019;46(4):797-811.
 Diagnosis CSP

Test pack positif,

Kavum uteri kosong Desidualisasi (+)
median serum bHCG

GS dan plasenta pada

Miometrium tipis / absen Serviks tertutup
pada batas miometrium
anterior ismus pada bekas
bekas skar dan kandung dan kanalis
skar SC servikalis kosong
kemih

Peningkatan pola
vaskularisasi sekitar
GS dan plasenta
 Diagnosis USG

First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign
Calì et al., UOG 2018

Dibawah dividing line dari axis longitudinal dan

garis khayal yang membagi 2 uterus

15/10/21
 Diagnosis MRI
Sagital transverse T1-T2 weighted MRI menunjukkan GS menempel pada segmen anterior bawah uterus

Endogen Eksogen
Pendekatan Tatalaksana

Kehamilan pada
Bekas SC

Intervensi
Ekspektatif Medikamentosa
Pembedahan
Pendekatan Tatalaksana
Evakuasi jaringan

Preservasi fertilitas
Kehamilan pada
Bekas SC

Derajat I Derajat II Derajat 3 Derajat 4

Kuretase USG Laparoskopi / Laparoskopi /

Kuretase USG
guided, Baloon laparotomi laparotomi
guided, MTX
tamponade, UAE reseksi Wedge reseksi Wedge
Pendekatan Tatalaksana (Take Home Message)

**Syarat & Prasyarat untuk pemberian MTX pada kehamilan ektopik terpenuhi & Siap beralih modalitas
Pendekatan Tatalaksana (Injeksi MTX)
Angka keberhasilan
43%
Methotrexate
(MTX)

Ultrasound- Systemic uterine

Local
guided gestational artery perfusion
intramuscular
MTX injection MTX

3-6 mL of concentrated MTX 2 25 mg MTX combined with UAE like gelatin

mEq/mL in potassium IM sponge embolization, given
chloride injected to fetus 60-200 mg MTX through both
sides of uterine artery
Pendekatan Tatalaksana (Kuretase USG guided)
CSP tipe endogen
Tidak memiliki AV fistula
Tidak dalam kegawatdaruratan (tidak ada
perdarahan aktif)
Kuretase Backup transfusi darah dan fasilitas operasi
(histerektomi)

Dimulai dengan evakuasi kavum uteri

dan dinding posterior dengan 400-
Kuretase Kuretase Histeroskopi 600 mmHg dilanjutkan dengan
hisap dengan tajam dengan dilanjutkan evakuasi kehamilan pada dinding
anterior ismus dengan 200-300
USG-guided USG-guided kuretase mmHg
Kuret Hisap dalam bantuan USG
Pemasangan balon intrauterine untuk kompresi konsepsi pada kehamilan bekas sesar
Pendekatan Tatalaksana (Reseksi)
CSP tipe eksogen
Histeroskopi / Suspek terdapat AV fistula
Laparoskopi / Terdapat kegawatdaruratan
Backup transfusi darah
Laparotomi
Reseksi

Histeroskopi
Laparoskopi Laparotomi
dilanjutkan Bigati
reseksi Wedge reseksi Wedge
shaver

Dilanjutkan dengan repair niche pada bekas sesar

Laparotomi Reseksi Cranial

Seen mass of Vesicouterine pouch was

pregnancy Caudal disected into caudal and vesica
urinaria pushed downward
Laparotomi Reseksi Cranial

Caudal
Ny. 38 tahun datang ke IGD RSCM dirujuk dari RSUD Tipe B dengan kecurigaan mola hidatidosa, diferensial
diagnosa penyakit trofoblas ganas
Pasien mengeluhkan perdarahan dari jalan lahir sejak 3 hari sebelum masuk RS.
Ny. 38 tahun datang ke IGD RSCM dirujuk dari RSUD Tipe B dengan kecurigaan mola hidatidosa, diferensial
diagnosa penyakit trofoblas ganas
Pasien mengeluhkan perdarahan dari jalan lahir sejak 3 hari sebelum masuk RS.
Intra - Pembedahan
LAPROSKOPI RESEKSI pada gr III-IV
Pendekatan Tatalaksana (Histeroskopi – Bigati Shaver)
 Tatalaksana 28 kasus di RSUPN Dr. Cipto
Mangunkusumo thn 2015 - 2021

Laparotomi KURETASE HISAP

Reseksi

Kuretase Hisap Kuretase + Balon Laparotomi Reseksi

Laparoskopi Reseksi Histeroskopi + Shaving Histerektomi
Follow-up Pasca Evakuasi

bHCG per minggu

USG TV : evaluasi
hingga tidak
reduksi dari sisa
terdeteksi ( < 25
konsepsi
mIU/mL )

Rata-rata 9 minggu Rata-rata 3 bulan

hingga tidak mencapai tidak ada
terdeteksi GS dan EL <10 mm
Prognosis dan Rekurensi

Angka Kehamilan
rekurensi: 5% spontan : 88%

Kehamilan
Abortus
intrauterin :
spontan : 35%
96%
Pendekatan Tatalaksana (Take Home Message)

**Syarat & Prasyarat untuk pemberian MTX pada kehamilan ektopik terpenuhi & Siap beralih modalitas
Terima Kasih