PERDARAHAN

POST PARTUM

DISUSUN OLEH:

Dr.Mohammad Haekal
Objektif

Perdarahan Postpartum (HPP)

Mengenal tanda, gejala,
penegakan diagnosis perdarahan postpartum
dan manajemen aktif kala III
Normal hemodynamic changes during pregnancy

Physiologic
Term Pregnancy Labor and Delivery Postpartum
Variable
Cardiac output Increases 3050% Increases 50% Increases 6080%
within 1520 min
Additional 300500
Decreases to
Blood volume Increases 3050% mL with each
baseline
contraction
Increases by 1520 Increases depend on
Decreases to
Heart rate
beats/min stress and pain relief
baseline
Decreases to
Blood pressure Decreases by 510 mm Increase depends on
baseline
Hg in midpregnancy stress and pain relief
Systemic vascular Decreases to
Decreases Increases
resistance baseline
Oxygen Increases with stress Decreases to
Increases by 20%
consumption of labor and delivery baseline
Red blood cell
Increases by 1520%
mass

Fujitani S, Baldisseri MR. Hemodynamic assessment in a pregnant and peripartum patient. Crit Care Med. 2005;33:S354-61.
Normal hemodynamic changes during pregnancy

Change From
Measurement Nonpregnant Pregnant
Nonpregnant

Cardiac output, L/min 4,3 0,9 6,2 10 43%

Heart rate, beats/min 71 10 83 10 17%
Systemic vascular resistance, dyne . cm .
1530 520 1210 266 -21%
sec-5
Mean arterial pressure, mm Hg 86,4 7,5 90,3 5,8 NS
Pulmonary artery occlusion pressure, mm
6,3 2,1 7,5 1,8 NS
Hg
Central venous pressure, mm Hg 3,7 2,6 3,6 2,5 NS
Colloid oncotic pressure, mm Hg 20,8 1,0 18,0 1,5 -14%

Fujitani S, Baldisseri MR. Hemodynamic assessment in a pregnant and peripartum patient. Crit Care Med. 2005;33:S354-61.
 Iron
Supplements,
Oxytocin and Malaria
Manual Intermittent
Compression treatment and
Antiretroviral
for HIV

Magnesium
Sulfate

Patogram
Family
Planning and
Antibiot
Postabortion
ics
Care
Tetanus Toxoid
Immunization Clean
Delivery

Adapted from: Maternal Health Around the World World Health

*Other direct causes include: ectopic pregnancy, Organization, Geneva, 1997
embolism, anesthesia-related
Lebih dari separuh jumlah seluruh kematian ibu
terjadi dalam waktu 24 jam setelah melahirkan,
sebagian besar karena terlalu banyak
mengeluarkan darah
 Definisi
Perdarahan pascapartum didefinisikan
sebagai hilangnya 500 ml atau lebih darah
setelah kala tiga persalinan selesai.

Hal ini setara dengan pengeluaran darah

1000 ml pada seksio sesarea, 1400 ml pada
histerektomi elektif, dan 3000 sampai 3500 ml
untuk histerektomi darurat (Chestnut et al., 1985;
Clark et al., 1984).
Gejala
 The Four T s Mnemonic Device
for Causes of Postpartum
Hemorrhage

Anderson JM, Etches D. Prevention and Management of Postpartum Hemorrhage. Am Fam Physician. 2007;75:875-82.
 Faktor Risiko
Pathophysiology Clinical Risk Factors
Multiple gestation
Overdistended uterus Polyhydramnios
Macrosomia
Abnormal uterine Prolonged labor Augmentation of labor
Uterine muscle fatigue
contractility (TONE) Prior PPH
Chorioamnionitis Prolonged ROM
Uterine distortion/abnormality Fibroids, Placenta previa
Uterine-relaxing drug Beta mimetics, MgSO4, anesthetic drugs
Prior uterine surgery
Retained products of Accreta/Increta/Percreta Placenta previa
conception (TISSUE) Multiparity
Manual placenta removal,
Retained placenta/membranes
Succinturiate/accessory lobe
Precipitous delivery
Macrosomia
Laceration of the cervix, vagina or perineum
Shoulder dystocia
Operative delivery
Genital tract trauma Episiotomy (esp. mediolateral)
(TRAUMA) Deep engagement,
Extension/laceration at cesarean section
Malposition, malpresentation
Uterine rupture Prior uterine surgery
Fundal placenta Grand multiparity
Uterine inversion
Excessive traction on umbilical cord
Preexisting clotting abnormalities, eg,
hemophilia, von Willebrands disease, History of coagulopathy or liver disease
hypofibrinogenemia
Abnormalities of coagulation Acquired in pregnancy Sepsis
(THROMBIN)
DIC Intrauterine demise
HELLP Hemorrhage
Anticoagulation
Devine PC. Obstetric Hemorrhage. Semin Perinatol. 2009;33:76-81.
 Risk Factors for Uterine Atony
Factors associated with uterine Use of uterine relaxants
overdistension Deep anesthesia (especially
Multiple pregnancy halogenated anesthetic agents)
Polyhydramnios Magnesium sulfate
Fetal macrosomia

Labor-related factors Intrinsic factors

Induction of labor Previous postpartum hemorrhage
Prolonged labor Antepartum hemorrhage (placental
Precipitate labor abruption or previa)
Oxytocin augmentation Obesity
Manual removal of placenta Age > 35 year
Adapted from Breathnach F, Geary M: in A Textbook on Postpartum Hemorrhage. B-Lynch C, Louis K (eds): Sapiens Publishing, 2004. In :
Breathnach F, Geary M. Uterine Atony: Definition, Prevention, Nonsurgical Management, and Uterine Tamponade. Semin Perinatol. 2009;33:82-
7.
PENYEBAB PERDARAHAN POSTPARTUM PRIMER (4T)

Tonus
Uterine overdistention: multipariti, polyhidroamnion, makrosomia; uterine relaxant: nipedipin, magnesium, beta-mimetics,
indometacin, nitric oxide donor; rapid or prolong labor, induksi persalinan dengan oksitosin,chorioamnionitis, anastesi
dengan halogen, uterus fibroid.

Tissue/jaringan
Multiple fibroid, sisa plasenta; plasenta akreta, lobs suksenteriatum; riwayat operasi sebelumnya miomektomi, insisi
klasik atau SC segmen bawah rahim; obstructed labor; prolonged third stage of labor; traksi tali pusat yang terlalu kuat

Trauma
Vulvo vaginal injury, episiotomi, makrosomia, partus presipitatus.

Thrombin
Trombositopeni karena hellp syndrome, DIC (eklamsi, intrauterine fetal death, septisemia, placenta abruption, emboli air
ketuban), Hipertensi dalam kehamilan, sepsis, Von Willebrands
Willebrands disease, terapi antikoagulan (penggantian valve, pasien
dengan tirah baring total.

Adapted from Wac et al. Female Patient 2005;30:19

PENYEBAB PERDARAHAN POSTPARTUM SEKUNDER

Infeksi uterus
Sisa plasenta
Involusi yang abnormal dari placental side

Adapted from Wac et al. Female Patient 2005;30:19

 Faktor Risiko HPP ( Antepartum )

Riwayat HAP sebelumnya atau plasenta manual

Solusio plasenta, terutama jika tidak terdeteksi
IUFD
Plasenta previa
Hipertensi dalam kehamilan dengan proteinuria
Regangan berlebihan pada uterus (mis. gemelli,
polihidramnion)
Kelainan perdarahan sebelum kehamilan (mis. ITP)
Faktor Risiko HPP ( Intrapartum )
Persalinan operatif s.c atau pervaginam dengan alat
Persalinan lama
Persalinan cepat
induksi atau augmentasi
Korioamnionitis
Distosia bahu
Versi podalik internal dan ekstraksi bayi kembar yang
kedua
Koagulopati yang didapat (mis. HELLP, DIC)
 Faktor Risiko HPP
( Postpartum )
Laserasi atau episiotomi
retensi plasenta/plasenta abnormal
Ruptura uteri
Inversi uteri
Koagulopati yang didapat (mis. DIC)
Apakah penyebabnya?
Lakukan pemeriksaan fundus
Inspeksi traktus genital bawah
Eksplorasi uterus
sisa plasenta
ruptura uteri
inversi uteri
Lakukan pemeriksaan koagulasi
 HEMOSTASIS Mnemonic
Mnemonic
H Help. Ask for Help
A Assess (vital sign, blood loss) and resucitate
Establish aetilogy, ensure aviabioity of blood, Initial
E acbolic (oxytocin, ergometrine, or syntometrine Management
bolus IV/IM)
M Massage uterus
Oxytocin infusion, ergometrine bolus IV/IM, Medical
O
prostaglandins per rectal Treatment
Shift to the theatre. Exclude retain products
Conservative
S and trauma, bimanual compression, abdominal
Non Surgical
aorta compression
Management
T Tamponade ballon and uterine packing
Apply compression uterus, B-Lynch technique or
A
modified, Lasso-Budiman technique
Conservative
Systemic pelvic devascularization : uterine,
S Surgical
ovarian, quadriple, internal iliaca
Management
Interventional radiologist, if appropriate,
I
uterine artery embolization
Last Effort-
M. Nurhadi Rahman*, Gulardi H.Wiknjosastro*, Ali Sungkar*, Novan NonSatya
-
S Subtotal/total
Pamungkas*, hysterectomy
Budiman**, Iswan Conservative
Syarif**, Agung Suhadi. The use of B-Iynch
technique and Lasso Budiman technique to control post partum Surgical
hemorrhage
 TATALAKSANA
ABC s
Minta PERTOLONGAN!

Bicara dan observasi pasien

Jalur IV besar (No 16 gauge)
Kristaloid- jumlah banyak!
Hitung Darah lengkap (DPL)
Golongan darah dan Cross-matched
Pasang abocath intravena kaliber besar
kedua sehingga kristaloid dan oksitosin dapat
diberikan bersama dengan transfusi darah

Pasang kateter Foley untuk memantau

pengeluaran urin, yang merupakan parameter
yang baik untuk perfusi ginjal.
 PENATALAKSANAAN
PERDARAHAN POSTPARTUM
LANGKAH I
PENILAIAN DAN PENATALAKSANAAN AWAL
Resusitasi Cari Etiologi Laboratorium
Akses Intravena Eksplorasi uterus Darah perifer
Oksigen Eksplorasi jalan lahir Faktor pembekuan
Monitor tanda vital Anamnesis Kelainan darah Golongan darah
LANGKAH 2
PENATALAKSANAAN LANGSUNG
Tone Thrombin
Tissue Trauma
Masase uterus Antikoagulasi
Manual plasenta Penjahitan laserasi
Kompresi bimanual Tim multidisplin
Kuretase Identifikasi rupture uteri
Uterotonika (hematology)

LANGKAH 3
KONTROL LOKAL

Kompresi manual Resusitasi cairan

Tamponade uterus, Vasopresin, embolisasi Kristaloid, Transfusi

LANGKAH 4
OPERASI

Ligasi pembuluh darah

Histerektomi
Uterina, Arteri iliaka interna,ovarika

LANGKAH 5
PERDARAHAN POST HISTEREKTOMI

Abdominal packing Embolisasi angiografi

Kompresi Bimanual
 Oxytocin segera setelah bayi lahir
Tarikan tali pusat terkendali
Masase rahim pasca kelahiran plasenta

Risiko perdarahan
Perdarahan > 500 ml
TD turun
Nadi meningkat Perdarahan post partum

Bimanual kompresi Eksplorasi Periksa plasenta Perhatikan bekuan

Oksitosin 20 IU per L jalan lahir darah
NaCl 9% Pertimbangkan Siapkan transfusi
Infus 500 ml dlm 10 eksplorasi dan periksa sistem
menit uterus pembekuan

Resisutasi
Lajur IV besar 4T reminder
Berikan oksigen
Monitor TD,
Nadi, jumlah Uterus lembek Laserasi jalan lahir Plasenta belum lahir Darah tidak beku
urin
Team TONUS Iversio uteri Tissue Thrombin
TRAUMA

Oksitosin 20 IU Jahit Manual plasenta Ganti kekurangan faktor pembek

Ergotamin 0.4 mg IV Hemostasis Kuret FFP, TC dsb
Misoprostol 1000 mcg rectal hematoma dan Methrotrexate
pasang drain
Kembalikan
uterus jika
inversi

Kehilangan darah > 1000 ml

Perdarahan masif

Resusitasi cairan,
Transfusi,
siapkanHemorrhage.
Anderson JM, Etches D. Prevention and Management of Postpartum operasi, Am
pasang
Fam Physician. 2007;75:875-82.
Anderson JM, Etches D. Prevention and Management of Postpartum Hemorrhage. Am Fam Physician. 2007;75:875-82.
UTEROTONIKA
 Tampon Balon Kateter
Dilakukan setelah terapi gagal dan sebelum dilakukan intervensi bedah dan
direncanakannya hysterectomy.

Setelah perdarahan terkontrol balon tanponade dibiarkan 24 sampai 48 jam

tergantung dari berat kehilangan darah. Diberikan juga drip oksitosin selama
6 jam setelah dilakukan prosedur tersebut.
Metode ini digunakan oleh penulis di RS Dhaka Medical College untuk menangani
22 kasus perdarahan postpartum yang disebabkan atonia uteri atau placenta
acreta karena perdarahan tidak dapat dikontrol dengan uterotonika atau yang
lainnya. Digunakan kondom yang dihubungkan dengan katheter no 16 dan di isi
dengan 250 sampai 300 ml larutan normal salin sampai perdarahan dapat
dikontrol.
 HAEMOSTASIS
Tamponade ballon and uterine packing
 HAEMOSTASIS
Tamponade ballon and uterine packing
Penatalaksanaan Syok
Tujuan Sesi
Praktek terbaik untuk penatalaksanaan syok
Bukti penelitian mengenai penggantian cairan
Praktek terbaik dalam penggunaan darah/produk-produk
darah
Definisi Syok

Kegagalan sistem sirkulasi dalam mempertahankan

aliran yang memadai (adekuat) pada organ-organ vital
sehingga timbul anoxia
Mengancam Jiwa
Memerlukan perawatan yang segera dan intensif
 Classification of hemorrhagic shock
Class 1
Class 3 Class 4
(Compensat Class 2 (Mild)
(Moderate) (Severe)
ed)
Bloodloss (% 1500 2000
750 ml 800 1500 ml > 2000 ml
Circulating blood ml (30%40%)
( <15%) (15%30%) (>40%)
volume)
Systolic blood Orthostatic Fall
No change Low Very low
pressure
Diastolic blood
No change Raised Reduced Very low
pressure
> 140 (very
Pulse rate <100 >100 > 120 (weak)
weak)
Prolonged (>
Capillary refill Normal Slow ( < 2s) Slow (> 2s)
5s)
Raised Raised
Respiratory rate Normal Normal
(>20/min) (>20/min)
Urine output > 30 ml/h 20 30 ml/h 10 20 ml/h 0 10 ml/h
Extremities Normal Pale Pale Pale and cold
Complexion Normal Pale Pale Ashen
Intensive Care Society. Guidelines for the Introduction of Outreach Services. Intensive Care Society; 2002. In :Kakar V, OSullivan G.
Anxious, Drowsy,
Management of obstetric hemorrhage: anesthetic management. In: Briley A, Bewley S, editors. The Obstetric Hematology Manual. Cambridge:
 Classification
Blood
Estimated Clinical signs and
Hemorrhage class volume loss Action
blood loss (ml) symptoms
(%)

0 (normal loss) < 500 < 10 none

ALERT LINE
Need observation replacement
1 5001000 < 15 minimal
therapy
ACTION
LINE
urine output
pulse rate
2 12001500 2025
respiratory rate Replacement therapy and
postural hypotension oxytocics
narrow pulse
pressure
hypotension
tachycardia
3 18002100 3035 Urgent active management
cold clammy
tachypnea
Critical active management (50%
4 > 2400 > 40 profound shock
mortality if not managed actively)

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.
 Derajat Syok

Kompensasi Ringan Sedang Berat

500-1000ml 1000-1500 ml 1500-2000 ml 2000-3000 ml

10-15% 15-25% 25-35% 35-45%
Kehilangan darah

Tidak ada Sedikit turun Turun bermakna Sangat turun

Perubahan tekanan (80-100 mmHg) (70-80 mmHg) (50-70 mmHg)
darah
(sistolik)

Palpitasi Lemas Lemah Kolaps

Takikardia Berkeringat Demam Haus
Gejala dan tanda Mengantuk Takikardia Oliguria anuria
 Shock
Hemorrhagic Shock Pathophysiology

Stage 1: Compensated Stage

Mechanism: Volume depletion due to bleeding

Body detects decrease in cardiac output

Sympathetic Nervous System is stimulated releasing Epinephrine and

Norepinehrine to stimulate Alpha and Beta Receptors

Alpha = Vasoconstriction Beta = Bronchodilation and

Cardiac Stimulation
 Shock
Hemorrhagic (Classic) shock Pathophysiology

Stage 2: Progressive Stage

Mechanism: Kidneys release anti-diuretic hormone which increases

vasoconstriction by closing the capillary sphincters, greatly reducing
peripheral circulation

Increased hypo-perfusion causes increase in metabolic acid build up

 Shock
Hemorrhagic (Classic) shock Pathophysiology

Stage 3: Irreversible Stage

Mechanism: Compensatory mechanisms fail

Pre-capillary sphincters open releasing metabolic acids, micro-emboli

and other wastes into circulation

Cell damage, organ failure and death occur

 Shock
The Course of Hypovolaemic Shock in Absence of Therapy

Blood Pressure Heart Rate

Blood Pressure (mm Hg)
Heart rate (min)

150 Bleeding

100

50

0 (Time)
Compensation Decompensation Irreversibility

Shock Phases
 Shock
The Influence of Volume Replacement on Tissue Perfusion and Organ Function
Cerebral Function
Tissue
(Body Control)
Perfusion
Pulmonary Function
(O2 Supply)

Text

Volume Replacement

Liver
Function
Heart (metabolism)
Function
(cardiac output) Renal Function
(Diuresis)
 Tata Laksana
Mengatasi Perdarahan Hebat
Airway
Breathing
Circulation and hemorrhage control
Shock position
Replace blood loss
Stop / minimize the bleeding process
Posisi Syok
ANGKAT
KEDUA
TUNGKAI

300 - 500 cc
darah dari kaki
pindah ke
sirkulasi sentral
Flow rates through intravenous
cannulae
Gauge Colour code Flow rate
number* mL/min**
20G Pink 40-80
18G Green 75-120
16G Grey 130-220
14G Orange 250-360
* G refers to a wire gauge classification of the size of the internal
diameter of the cannula. It is slightly different to the American and
Standard Wire Gauges.
** The British standard for determining flow rate: involves in-vitro
testing using distilled water at 22 C, kept at constant pressure. The flow
rates are therefore not the same as those achievable clinically.
 General Goals for Support of Shock
Patients

Papadakos PJ. Approach to Shock. In: Apostolakos MJ, Papadakos PJ, editors. The Intensive Care Manual. New York: McGraw-Hill; 2001. p.
 Non-pneumatic Anti-Shock
Garment (NASG)
Konversi celama
anti G militer.
Untuk mengatasi
syok, resusitasi
& stabilisasi.
Penting saat
merujuk dari
daerah yang jauh.
Mudah digunakan.
Celana Anti Syok & Penekan
Infus