BAB I PENDAHULUAN
Perdarahan pascapersalinan adalah kehilangan darah lebih dari 500 ml melalui jalan lahir yang terjadi selama atau setelah persalinan kala III. Sebagian besar perdarahan pada masa nifas (75-80%) adalah akibat adanya atonia uteri. Sebagaimana kita ketahui bahwa aliran darah uteroplasenta selama masa kehamilan adalah 500-800 ml/menit, sehingga bisa kita bayangkan ketika uterus itu tidak berkontraksi selama beberapa menit me nit saja, maka akan menyebabkan kehilangan darah da rah yang sangat banyak. Sedangkan volume darah manusia hanya berkisar 5 - 6 liter saja.1,2,3 Dalam persalinan, sukar untuk menentukan jumlah darah akurat karena (1)
tercampur dengan air ketuban dan terserap pada pakaian atau kain alas .. Darah tersebut tercampur dengan cairan amnion atau dengan urin. Darah juga tersebar pada spons, handuk, dan kain, di dalam ember dan di lantai. Volume darah yang hilang juga bervariasi akibatnya sesuai dengan kadar hemoglobin he moglobin ibu. Seseorang ibu dengan kadar hemoglobin normal akan dapat menyesuaikan diri terhadap kehilangan darah, dan akan berakibat fatal pada ibu yang menderita anemia.3 Perdarahan postpartum ini merupakan penyebab utama kematian maternal. Semua wanita yang usia kehamilannya lebih dari 20 minggu beresiko untuk mengalami perdarahan postpartum. Meskipun angka kematian maternal akibat perdarahan postpartum telah berkurang drastis di negara-negara maju, jumlahnya masih tetap tinggi di negara lainnya terutama negara berkembang termasuk di Indonesia.2
1
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Diperkirakan ada 14 juta kasus perdarahan pada kehamilan, setiap tahunnya paling sedikit 128.000 wanita mengalami perdarahan sampai meninggal. Sebagian besar kematian tersebut terjadi dalam waktu 4 jam setelah melahirkan dan kebanyakan terjadi pada wanita dengan usia kurang dari 20 tahun atau lebih dari 35 tahun serta wanita dengan jarak persalinan yang berdekatan yaitu kurang dari 2 tahun. Perdarahan pascapersalinan dibagi menjadi perdarahan pascapersalinan primer dan sekunder. 1. Perdarahan pascapersalinan primer ( Early Early Postpartum Haemorrhage, Haemorrhage, atau perdarahan
pascapersalinan segera). Perdarahan pascapersalinan primer terjadi
dalam 24 jam pertama setelah bayi lahir. Penyebab utama Perdarahan pascapersalinan primer adalah atonia uteri, retensio plasenta, sisa plasenta, dan robekan jalan lahir. Terbanyak dalam 2 jam pertama. 2. Perdarahan pascapersalinan sekunder ( Late Late Postpartum Haemorrhage, Haemorrhage, atau perdarahan masa nifas, atau perdarahan pascapersalinan lambat, atau PPP kasep). Pascapersalinan sekunder terjadi setelah 24 jam setelah persalinan. Penyebab utama Perdarahan pascapersalinan sekunder adalah robekan jalan lahir dan sisa plasenta.1,2,3
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BAB II ATONIA UTERI
2.1. DEFINISI
Atonia Uteri adalah keadaan lemahnya atau gagalnya tonus/kontraksi otot rahim yang menyebabkan uterus tidak mampu menutup perdarahan terbuka dari tempat implantasi plasenta setelah bayi dan plasenta lahir. 2,6 Perdarahan postpartum bisa dikendalikan melalui kontraksi dan retraksi seratserat miometrium. Kontraksi-kontraksi ini menyebabkan terlipatnya pembuluh pembuluh darah sehingga aliran darah ke tempat plasenta terhenti. Kegagalan mekanisme akibat gangguan fungsi miometrium dinamakan atonia uteri. (1,2,3)
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2.2.
ANATOMI UTERUS
2
Uterus terbentuk seperti buah avokad/ pir sedikit gepeng, ke arah antefleksi (depan belakang). Ukurannya sebesar telur ayam dan mempunyai rongga. Dindingnya terdiri atas otot-otot polos. Ukuran panjang uterus 7-7,5 cm, lebar sekitar 5,25 cm, tebal 2,5 cm, dan tebal dinding 1,25 cm. Letak uterus dalam keadaan fisiologis adalah anteversiofleksio (serviks kedepan dan membentuk sudut dengan vagina, demikian pula korpus uteri ke depan dan membentuk sudut dengan serviks uteri).
Gambar 2 : Anatomi Uteri Uterus terdiri dari fundus, korpus, dan serviks uteri. Fundus adalah bagian proksimal uterus. Korpus merupakan bagian terbesar sebagai tempat janin
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serviks uteri yang dinamakan porsio dan pars supravaginalis serviks uteri yaitu bagian serviks yang berada diatas vagina. Saluran yang terdapat pada serviks disebut kanalis servikalis berbentuk sebagai saluran dengan panjang 2,5 cm. Pintu saluran serviks sebelah dalam disebut ostium uteri internum dan pintu divagina disebut ostium uteri eksternum. Secara histologik uterus terdiri atas (dari dalam ke luar), endometrium dikorpus uteri dan endoserviks di serviks uteri, myometrium (otot- otot polos), dan lapisan serosa, yakni peritoneum viserale. Endometrium terdiri atas epitel kubik, kelenjar- kelenjar dan jaringan dengan banyak pembuluh p embuluh darah d arah yang berlekuk-lekuk. Endometrium melapisi seluruh kavum uteri dan mempunyai arti penting dalam siklus haid pada seorang wanita dalam masa reproduksi. Pada masa haid, endometrium sebagian besar dilepaskan, untuk kemudian tumbuh lagi pada fase proliferasi dan selanjutnya ke fase sekretorik. Lapisan otot- otot polos dibagian dalam berbentuk sirkuler, dan dibagian luar berbentuk logitudinal. Diantara kedua lapisan itu terdapat lapisan otot oblik, berbentuk anyaman, dan lapisan ini paling penting pada persalinan oleh karena sesudah plasenta lahir, uterus berkontraksi kuat dan menjepit pembuluh- pembuluh darah yang terbuka. Uterus dalam rongga pelviks disokong oleh jaringan ikat dan ligamen yang menyokongnya, sehingga terfiksasi dengan baik. Adapun Ligamen yang memfiksasi uterus adalah : 1.
Ligamentum kardinale sinistrum et dekstrum (Mackenrodt), yakni ligamentum yang terpenting, mencegah supaya uterus tidak turun, terdiri atas jaringan ikat
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2.
Ligamentum sakro-uterinum sinistrum et dekstrum, yakni yakni ligamntum yang menahan uterus supaya tidak banyak bergerak, berjalan dari serviks
bagian
belakang, kiri, kanan, kearah ke arah os sacrum kiri dan kanan. 3.
Ligamentum rotundum sinistrum et dekstrum, yakni ligamentum yang menahan uterus dalam antefleksi dan berjalan dari sudut fundus uteri kiri dan kanan, ke daerah inguinal kiri kiri dan kanan. Pada kehamilan kadang- kadang terasa sakit di daerah ligamentum rotundum menjadi kencang serta mengadakan tarikan pada daerah inguinal.
4.
Ligamentum rotundum sinistrum et dekstrum, yakni ligamentum yang meliputi tuba, berjalan dari uterus ke arah sisi, tidak banyak mengandung jaringan ikat.
5.
Ligamentum infundibulo pelvikum, yakni ligamentum yang menahan tuba falloppii berjalan dari arah infundibulum ke dinding pelvis. Isthmus adalah bagian uterus antara serviks dan korpus uteri, yang diliputi oleh
peritoneum viserale. Di tempat inilah dinding uterus dibuka saat seksio sesarea transperitonealis profunda. Dinding belakang uterus seluruhnya diliputi oleh peritoneum viserale yang membentuk suatu rongga yang disebut kavum Douglasi yang menonjol jika ada cairan (darah atau asites) atau ada tumor di daerah tersebut. Vaskularisasi uterus yang lain ialah arteri ovarika sinistra et dekstra. Vaskularisasi ini berjalan dari lateral dinding pelvis, melalui ligamentum infundibulo-pelvikum mengikuti tuba Falloppii, beranastomosis dengan ramus ascendens arteri uterine disebelah lateral, kanan dan kiri uterus. Bersama-sama dengan arteri-arteri tersebut diatas terdapat vena-vena yang kembali melalui pleksus vena ke vena hipogastrika.
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Gambar 3 : Vaskularisasi Uterus.
2.3.
EPIDEMIOLOGI
Atonia uteri merupakan penyebab tersering perdarahan postpartum. Sekurangkurangnya 2/3 dari semua perdarahan postpartum disebabkan oleh atonia uteri. Upaya penanganan perdarahan postpartum akibat atonia uteri harus dimulai dengan mengenal ibu yang memiliki kondisi yang berisiko terjadinya atonia uteri. Jika seorang wanita memiliki salah satu dari kondisi-kondisi yang berisiko tersebut, maka penting bagi penolong untuk mengantisipasi kemungkinan terjadinya atoni uteri postpartum. Meskipun demikian, sekitar 20% atoni uteri postpartum dapat terjadi 3
pada ibu tanpa faktor resiko tersebut.
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2.
Kelelahan uterus akibat persalinan lama, persalinan buatan, induksi atau augmentasi persalinan, mengakibatkan uterus tidak mampu berkontraksi segera setelah plasenta lahir.
3.
Kehamilan grande-multipara mengakibatkan uterus berulang kali teregang, sehingga menurunkan kemampuan berkontraksi uterus segera setelah plasenta lahir.
4.
Ibu dengan keadaan umum yang jelek, anemia, atau menderita penyakit menahun.
5.
Mioma uteri mengganggu kontraksi rahim disebabkan mioma yang paling sering menjadi penyebab perdarahan postpartum adalah mioma intramural, dimana mioma berada di dalam miometrium sehingga akan menghalangi uterus berkontraksi.
6.
Infeksi intrauterine (korioamnionitis), Korioamnionitis adalah infeksi dari korion saat intrapartum yang potensial akan menjalar pada otot uterus sehingga menjadi infeksi dan menyebabkan gangguan untuk melakukan kontraksi.
7.
Ada riwayat pernah mengalami atonia uteri sebelumnya.
2.5. PATOFISIOLOGI
7
Pada awal persalinan estrogen akan meningkat dalam darah, hal ini
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oksitosin, dan peregangan uterus pada akhir kehamilan juga dapat meningkatkan pembentukan reseptor tersebut. Pada awal kehamilan konsentrasi oksitosin dalam plasma ibu tidak lebih tinggi dari kadar prapersalinan yaitu sekitar 25pg/mL. Peningkatan mencolok reseptor oksitosin dapat menyebabkan uterus berespon terhadap konsentrasi oksitosin plasma yang normal. Begitu persalinan dimulai, kontraksi uterus menyebabkan dilatasi serviks, dilatasi ini selanjutnya menimbulkan sinyal pada saraf aferen yang dipancarkan ke nukleus supraoptik dan paraventrikel meningkatkan sekresi oksitosin. Kadar oksitosin plasma meningkat dan lebih banyak oksitosin tersedia untuk bekerja pada uterus. Dengan demikian, terjadi umpan balik positif yang membantu persalinan dan berakhir setelah hasil konsepsi dikeluarkan. Oksitosin meningkatkan uterus dengan dua cara:1) bekerja langsung pada sel otot polos uterus untuk membuatnya berkontraksi, dan 2) merangsang pembentukan prostaglandin di desidua. Dalam persalinan pembuluh darah yang ada di uterus melebar untuk meningkatkan sirkulasi ke sana. Setelah persalinan, kontraksi uterus merupakan mekanisme utama untuk mengontrol perdarahan setelah melahirkan.
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Adanya peregangan yang berlebih atau berkurangnya kerja reseptor oksitosin di miometrium pasca persalinan menyebabkan kontraksi uterus menurun atau disebut hipotonia uteri yang jika tidak tertangani akan jatuh menjadi atonia uteri. Atonia uteri terjadi karena kegagalan mekanisme ini. Perdarahan pospartum secara fisiologis dikontrol oleh kontraksi serabut-serabut miometrium yang mengelilingi pembuluh darah yang memvaskularisasi daerah implantasi plasenta. Atonia uteri terjadi apabila serabut-serabut miometrium tersebut tidak berkontraksi.(5-8)
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2.6. GAMBARAN KLINIS
2
Atonia uteri ditandai dengan adanya perdarahan masif pervaginam yang (9)
diakibatkan kurangnya tonus miometrium tanpa disertai akibat lainnya. Pada palpasi uterus ditemukan fundus uterus lembek atau mengembang tanpa adanya kontraksi. Tanda dan gejala atonia uteri adalah: 1) Perdarahan pervaginam Perdarahan yang terjadi pada kasus atonia uteri sangat banyak dan darah tidak merembes. Yang sering terjadi adalah darah keluar disertai gumpalan, hal ini terjadi karena tromboplastin sudah tidak mampu lagi sebagai anti pembeku darah. 2) Konsistensi rahim lunak Gejala ini merupakan gejala terpenting/khas atonia dan yang membedakan atonia dengan penyebab perdarahan yang lainnya. 3) Fundus uteri naik Disebabkan
adanya
darah
menggumpal 4) Terdapat tanda-tanda syok
yang
terperangkap
dalam
cavum
uteri
dan
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2.7. PENATALAKSANAAN
8
Banyaknya darah yang keluar mempengaruhi keadaan pasien. Pasien bisa masih dalam keadaan sadar, sedikit anemis, atau sampai menjadi syok hipovolemik berat. Perdarahan yang lebih dari 1000 cc atau 1500 cc (20-25% volume darah) akan menimbulkan gangguan vascular hingga terjadi syok hemoragik sehingga transfuse darah diperlukan segera. Tindakan pertama yang dilakukan tergantung pada keadaan klinisnya. Pada umumnya dilakukan secara simultan. No.
1.
Langkah
Lakukan
masase
Keterangan
fundus
uteri Massase merangsang kontraksi uterus.
segera setelah plasenta dilahirkan Sambil melakukan masase sekaligus selama 15 detik.
dapat dilakukan penilaian kontraksi uterus.
2.
Bersihkan
kavum
uteri
dari Selaput ketuban atau gumpalan darah
selaput ketuban dan gumpalan dalam kavum uteri akan dapat mengdarah.
halangi kontraksi uterus secara baik.
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uterus. Pemberian intravena bila sudah terpasang infus sebelumnya. 6.
Berikan
infus
cairan
larutan Anda telah memberikan oksitosin pada
ringger laktat dan oksitosin 20
waktu penatalaksanaan aktif kala tiga
unit dalam 500cc RL
dan metergin intramuskuler. Oksitosin intravena akan bekerja segera untuk menyebabkan Ringger
laktat
uterus
berkontraksi.
akan
membantu
memulihkan volume cairan yang hilang selama atoni. Jika uterus wanita belum berkontraksi selama 6 langkah l angkah pertama, sangat mungkin bahwa ia mengalami perdarahan postpartum dan memerlukan penggantian darah yang hilang secara cepat. 7.
Mulai lagi kompresi bimanual interna
atau
uterovagina.
pasang
tampon
Jika atoni tidak teratasi setelah 7 langkah
pertama,
mungkin
ibu
mengalami masalah serius lainnya.
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persediaan cairan intravena, berikan cairan 500 cc yang ketiga tersebut secara perlahan, hingga cukup untuk sampai di tempat rujukan. Berikan ibu minum untuk tambahan rehidrasi. 10.
Lakukan pertimbangan
laparotomi antara
: Pertimbangan
antara
lain
paritas,
tindakan kondisi ibu, jumlah perdarahan.
mempertahankan uterus dengan ligasi arteri uterin/ hipogastrika dengan histerektomi.(3)
2.7.1. Manajemen Atonia Uteri 1. Resusitasi
Apabila terjadi perdarahan postpartum banyak, maka penanganan awal yaitu resusitasi dengan oksigenasi dan pemberian cairan intravena cepat, monitoring tanda-tanda vital, monitoring jumlah urin, dan monitoring
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b. Jika uterus tidak berkontraksi maka :
Bersihkanlah bekuan darah atau selaput ketuban dari vagina dan lubang serviks. Pastikan
bahwa
kandung
kemih
telah
kosong.Lakukan
kompresi bimanual internal (KBI) selama 5 menit.
Jika uterus berkontraksi, teruskan KBI selama 2 menit, keluarkan tangan perlahan-lahan dan pantau kala empat dengan ketat.
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3. Uterotonika
Oksitosin merupakan hormon sintetik yang diproduksi oleh lobus posterior hipofisis. Obat ini menimbulkan kontraksi uterus yang efeknya meningkat seiring dengan meningkatnya umur kehamilan dan timbulnya reseptor oksitosin. Pada dosis rendah oksitosin menguatkan kontraksi dan meningkatkan frekuensi, tetapi pada dosis tinggi dapat menyebabkan tetani. Oksitosin dapat diberikan secara IM atau IV, untuk perdarahan aktif diberikan lewat infus RL, sebanyak 20 IU, jika sirkulasi kolaps bisa diberikan oksitosin 10 IU intramiometrikal (IM). Efek samping pemberian oksitosin sangat sedikit, biasa ditemukan nausea dan vomitus. Jika oksitosin tidak mampu untuk menghasilkan tonus uterus yang adekuat maka terapi lini kedua harus diberikan. Pilihan terapi lini kedua bergantung pada efek samping dan kontraindikasi agen uterotonik tersebut. Methylergonovine
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Uterotonika prostaglandin merupakan sintetik analog 15 metil prostaglandin intraservikal,
F2alfa.
Dapat
transvaginal,
diberikan
intravenous,
secara
intramiometrikal,
intramuscular,
dan
rectal.
Pemberian secara IM 0,25 mg, yang dapat diulang setiap 15 menit sampai dosis maksimum 2 mg. Pemberian secara rektal dapat dipakai untuk mengatasi perdarahan pospartum (5 tablet 200 µg = 1 g). Prostaglandin ini merupakan uterotonika yang efektif tetapi dapat menimbulkan efek samping prostaglandin seperti: nausea, vomitus, diare, sakit kepala, hipertensi dan bronkospasme yang disebabkan kontraksi otot halus, bekerja
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kontraindikasi terhadap penggunaannya. Beberapa efek samping yang (10)
dapat ditimbulakan misoprostol adalah takikardi dan demam.
Jika atonia uteri disebabkan oleh terapi tokolitik seperti magnesium sulfat dan nifedipin, yang mencegah masuknya kalsium kedalam sel, maka kalsium glukanoat dapat diberikan sebagai terapi adjuvan. Dosis 1 gram (1ampul) kalsium glukanoat dapat meningkatkan tonus uterus dan mengurangi perdarahan akibat atonia uteri. (10) Tabel 1. Jenis uterotonika dan cara pemberiannya (DepKes RI 2007) JENIS DAN CARA
OKSITOSIN
ERGOMETRIN
MISOPROSTOL
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4. Pemasangan tampon (packing) kassa uterovaginal
Tamponade uterus sangatlah aman, sederhana, dan efektif untuk mengontrol perdarahan post partum dengan menggunakan tampon pada permukaan uterus yang perdarahan. Meskipun tampon ini mempunyai banyak variasi teknik, beberapa beb erapa prinsip dasar dasa r harus diikuti. d iikuti. Letakkan kain kasa diantara plastik bag steril ataupun sarung tangan yang dapat memindahkan tampon. Balutan kain kasa seharusnya diletakkan diatas fundus untuk mencegah adanya spasi yang tertinggal yang dapat menyebabkan adanya akumulasi dari darah.12
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keluar dari introitus vagina. Kontraktilitas uterus dijaga dengan pemberian drip oksitosin sampai dengan 6 jam kemudian. Diberikan kateter lepas 24-48 jam kemudian, pada kasus dengan perdarahan berat kondom dapat dipertahankan lebih lama
10
5. Operatif a.
Ligasi Arteri Uterina
Beberapa penelitian tentang ligasi arteri uterina menghasilkan angka keberhasilan 80-90%. Pada teknik ini dilakukan ligasi arteri uterina yang berjalan disamping uterus setinggi batas atas segmen bawah
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masih terus berlangsung perlu dilakukan bilateral atau unilateral ligasi (11)
vasa ovarian.
b. Ligasi Arteri Iliaka Interna
Identiffikasi bifurkasiol arteri iliaka, tempat ureter menyilang, untuk melakukannya harus dilakukan insisi 5-8 cm pada peritoneum lateral paralel dengan garis ureter. Setelah peritoneum dibuka, ureter ditarik ke medial kemudian dilakukan ligasi arteri 2,5 cm distal bifurkasio iliaka interna dan eksterna. Klem dilewatkan dibelakang arteri, dan dengan menggunakan benang non absobable dilakukan dua ligasi
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semua kasus tanpa komplikasi, dan 4 dari 5 pasien dapat hamil kembali. Dua.
Pemeriksaan
uterus
pada
bekas seksio
sesarea
tidak
menunjukkan kelainan. Dalam review yang dilakukan Christopher B Lynch, Lynch, dinyatakan bahwa
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Masase fundu uteri segera setelah plasenta lahir (maksimal 15 detik) Tidak Uterus kontraksi ?
Ya
Evaluasi rutin
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2.8.
PROGNOSIS Prognosis bergantung pada jumlah darah yang hilang (sesuai dengan rasio (3)
berat badan pasien), komplikasi yang terjadi, dan keberhasilan terapi.
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