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REFERAT ABORTUS
Disusun untuk memenuhi tugas kepaniteraan klinik SMF Obsteri dan Ginekologi RSD dr. Soebandi Jember
Oleh: Ayu Waia !rati"i #$%$###$#$#&
!embimbing: dr. 'onas (adisubroto) Sp.OG
SMF OBSTETRI DAN GINEKOLOGI RSD DR SOEBANDI 2016
DAFTAR ISI
DAFTAR DAFTAR ISI ............................................ ................................................................... .............................................. ........................................................i .................................i BAB I PENDAHULUAN ......................................................... ................................................................................ ..........................................1 ...................1 BAB II TINJAUAN PUSTAKA...... PUSTAKA............................. .............................................. .............................................. ....................................... .................2 .2 Definisi ............................................ ................................................................... .............................................. ..................................................2 ...........................2 Etiologi ............................................ ................................................................... .............................................. ..................................................2 ...........................2 Frekensi ............................................ ................................................................... .............................................. ...............................................! ........................! P"togenesis .............................................. ..................................................................... .............................................. ..........................................! ...................! Kl"sifik"si .............................................. ...................................................................... ..................................................................! ..........................................! Klinis A#orts S$ont"n ............................................ ................................................................... ................................................% .........................% Pe&eriks""n Penn'"ng .................................................... ......................................................................................... ..................................... 1! Di"gnosis B"n(ing ........................................... .................................................................. ......................................................1! ...............................1! Pe&"nt""n P"s)" A#orts ................................................ .................................................................................... .................................... 1! Ko&$lik"si A#orts............................. A#orts.................................................... ...................................................................1% ............................................1% Prognosis ............................................ ................................................................... .............................................. .............................................1* ......................1* Blig+te( ,-&.................................... ,-&........................................................... .............................................. .............................................1* ......................1* BAB III KESIPULAN ................................................................ ....................................................................................... ......................................21 ...............21 DAFTAR DAFTAR PUSTAKA PUSTAKA ............................................. .................................................................... ..............................................................22 .......................................22
i
BAB I PENDAHULUAN
A#orsi &eni&#lk"n #"n/"k $erse$si ("n #er&")"& inter$ret"si0 ti("k s"'" ("ri s(t $"n("ng kese+"t"n0 tet"$i 'g" ("ri s(t $"n("ng +k& ("n "g"&".A#orsi &er$"k"n &"s"l"+ kese+"t"n &"s/"r"k"t k"ren" &e&#eri ("&$"k $"(" kes"kit"n ("n ke&"ti"n i#. Se#"g"i&"n" (iket"+i $en/e#"# ke&"ti"n i# /"ng t"&" "("l"+ $er("r"+"n0 infeksi ("n ekl"&$si" sert" $reekl"&si".*0134 Pen("r"+"n sel"&" ke+"&il"n ("$"t (i"ngg"$ se#"g"i ke"(""n "kt /"ng ("$"t &e&#"+"/"k"n i# ("n "n"k0 ("n s"&$"i ("$"t &eni&#lk"n ke&"ti"n. Se#"n/"k 235 6"nit" +"&il $ern"+ &eng"l"&i $en("r"+"n $"(" "6"l ke+"&il"n ("n se#"gi"n &eng"l"&i "#orts. R"t"r"t" ter'"(i 117 k"ss "#orts $er'"&. Se#"gi"n #es"r st(i &eng"t"k"n k"ss "#orts s$ont"n "nt"r" 1823 5 ("ri se&" ke+"&il"n. Jik" (ik"'i le#i+ '"+ ke'"(i"n "#orts se#en"rn/" #is" &en(ek"ti 83 5. Ke'"(i"n "#orts +"#it"lis sekit"r 985. D"t" ("ri #e#er"$" st(i &enn'kk"n #"+6" setel"+ s"t k"li "#orts s$ont"n0 $"s"ng"n $n/" risiko 18 5 ntk &eng"l"&i keggr"n l"gi0 se("ngk"n #il" $ern"+ 2 k"li0 risikon/" &eningk"t 28 5. Be#er"$" st(i &er"&"lk"n #"+6" risiko "#orts setel"+ 9 k"li "#orts #errt"n "("l"+ sekit" 9378 5. Pen/e#"# "#orts sen(iri <if"ktori"l ("n &"si+ (i$er(e#"tk"n0 &&n/" ter("$"t le#i+ ("ri s"t $en/e#"#. Pen/e#"#n/" se$erti F"ktor genetik0 kel"in"n kongenit"l ters0 "toi&n0 infeksi0 (efek lte"l. Di$erkir"k"n (iselr+ (ni" seti"$ t"+n ter'"(i 23 't" k"ss "#orsi ti("k "&"n0 !3 ri# $ere&$"n &eningg"l "ki#"t "#orsi ti("k "&"n ("n 1 ("ri % ke&"ti"n i# (ise#"#k"n ole+ "#orsi ti("k "&"n. *85 1* ("ri 23 k"ss "#orsi ti("k "&"n4 (int"r"n/" #"+k"n ter'"(i (i neg"r" #erke&#"ng. *0134 Di In(onesi" seti"$ t"+nn/" ter'"(i kr"ng le#i+ 2 't" k"ss "#orsi0 "rtin/" 79 k"ss:133 kel"+ir"n +i($ senss 23334.Angk" terse#t &e&#erik"n g"&#"r"n #"+6" &"s"l"+ "#orsi (i In(onesi" &"si+ )k$ #es"r ;i'ono 23334.S"t +"l /"ng ("$"t kit" teng"r"i0 ke&"ti"n "ki#"t infeksi "#orsi ini 'str #"n/"k ter'"(i (i neg"r"neg"r" (i&"n" "#orsi (il"r"ng ker"s ole+ n("ngn("ng. *0134
#
BAB II TINJAUAN PUSTAKA DEFINISI
A#orts "("l"+ $engel"r"n +"sil konse$si se#el& '"nin #erke&#"ng se$en+n/" ("n ("$"t +i($ (i l"r k"n(ng"n ("n se#"g"i kr"n (ign"k"n ke+"&il"n kr"ng ("ri 23 &ingg "t" #er"t '"nin kr"ng ("ri 833 gr"&. 1090708
ETIOLOGI
F"ktorf"ktor /"ng &en/e#"#k"n ke&"ti"n fets "("l"+ f"ktor o-& sen(iri0 f"ktor i#0 ("n f")tor #"$"k0 "nt"r" l"in < 1. Kel"in"n ,-& enrt HERTI= (kk $ert&#+"n "#nor&"l ("ri fets sering &en/e#"#k"n "#orts s$ont"n .P"(" o-& "#nor&"l >5 (i"nt"r"n/" ter("$"t (egener"si +i("ti( -ili. A#orts s$ont"n /"ng (ise#"#k"n ole+ k"ren" kel"in"n ("ri o-& #erkr"ng ke&ngkin"n k"l" ke+"&il"n s("+ le#i+ ("ri s"t #l"n0 "rtin/" &"kin &(" ke+"&il"n s""t ter'"(in/" "#orts &"kin #es"r ke&ngkin"n (ise#"#k"n ole+ kel"in"n o-& 83%354. 2. Kel"in"n $ert&#+"n +"sil konse$si < a. Kel"in"n genetik
A(" #"n/"k se#"# genetik /"ng #er+#ng"n (eng"n "#orts. Se#"gi"n #es"r "#orts s$ont"n (ise#"#k"n ole+ kel"in"n k"rioti$ ("ri e&#rio.9D"t" ini #er("s"rk"n $"(" 835 ke'"(i"n "#orts $"(" tri&ester $ert"&" &er$"k"n kel"in"n sitogenetik /"ng #er$" "ne$loi(i /"ng #is" (ise#"#k"n ole+ ke'"(i"n non(is')tion &eiosis "t" $oli$loi(i ("ri fertil"s "#nor&"l ("n se$"r+ ("ri "#orts ker"n" kel"in"n sitogenetik $"(" tri&ester $ert"&" #er$" triso&i "toso&.9 Tri$lo(i (ite&k"n $"(" 1>5 ke'"(i"n "#orts (i &"n" ter'"(i fertilis"si o-& nor&"l ole+ 2 s$er&" (is$er&i4. 9Insi(en triso&i &eningk"t (eng"n #ert"&#"+n/" si". Triso&i 935 ("ri selr+ triso&i4 "("l"+ $en/e#"# ter#"n/"k "#orts s$ont"n (iikti (eng"n sin(ro&" Trner 232854 ("n Sin(ro&" Do6n "t" triso&i 21 /"ng se$ertig"n/" #is" #ert"+"n se+ingg" l"+ir.9 Sel"in kel"in"n sitogenetik0 kel"in"n l"in se$erti fertilis"si "#nor&"l i"it ("l"& #entk tetr"$loi(i ("n tri$loi( ("$"t (i+#ngk"n (eng"n "#orts "#solt.9 %
Kel"in"n ("ri strktr kro&oso& 'g" "("l"+ s"l"+ s"t $en/e#"# kel"in"n sitogenetik /"ng #er"ki#"t "#orsi ("n kel"in"n ini sering (itrnk"n ole+ i# &e&"n("ngk"n kel"in"n strktr kro&oson $"(" $ri" #er("&$"k $"(" ren("+n/" konsentr"si s$er&"0 infertelit"s ("n f"ktor l"inn/" /"ng #is" &engr"ngi $el"ng ke+"&il"n. 9 Sel"in it0 gen /"ng "#nor&"l "ki#"t &t"si gen #is" &engg"ngg $roses i&$l"nt"si ("n &eng"ki#"tk"n "#orts se$erti &/toti) (/stro$+/ /g #er"ki#"t $"(" ko&#in"si gen /"ng "#nor&"l ("n g"ngg"n fngsi ters. 9 ="ngg"n genetik se$erti Sin(ro&" "rf"n0 Sin(ro&" E+lersD"nlos0 +e&osistenri ("n $seso?"nto&" el"sti)& &er$"k"n g"ngg"n '"ring"n ik"t /"ng #is" #er"ki#"t "#orts.9 Kel"in"n +e&"tologik se$erti $"(" $en(erit" si)kle )ell "ne&i"0 (isfi#ronoge&i0 (efisiensi f"ktor @III &eng"ki#"tk"n "#orts (eng"n &eng"ki#"tk"n &ikroinf"k $"(" $l"sent". 9 b. F"ktor ntrisi ("n lingkng"n<
Di$erkir"k"n 1135 &"lfor&"si '"nin "("l"+ "ki#"t ("ri $"$"r"n o#"t0 #"+"n ki&i" "t" r"(i"si /"ng &&n/" "k"n #er"k+ir (eng"n "#orts. > f"ktorf"ktor /"ng ter#kti #er+#ng"n (eng"n $eningk"t"n insi(en "#orts "("l"+ &erokok0 "lko+ol ("n k"fein. erokok tel"+ (i$"stik"n ("$"t &eningk"tk"n risiko "#orts e$loi(.1 P"(" 6"nit" /"ng &erokok le#i+ ("ri 17 #"t"ng $er +"ri0 risiko "#orts "("l"+ 2 k"li li$"t ("ri risiko $"(" 6"nit" /"ng ti("k &erokok.1 Rokok &eng"n(ng r"ts"n nsr toksik "nt"r" l"in nikotin /"ng &e&$n/"i sif"t -"so"ktif se+ingg" &eng+"&#"t sirkl"si tero$l"sent".> K"r#on &onoksi(" 'g" &enrk"n $"sok"n oksigen i# ("n '"nin ("n ("$"t &"&") nerotoksin. > e&in& "lko+ol $"(" % &ingg $ert"&" ke+"&il"n ("$"t &eningk"tk"n risiko "#orts s$ont"n ("n "no&"li fets. 1 K"("r "#orts &eningk"t 2 k"li li$"t $"(" 6"nit" /"ng &engkons&si "lko+ol 2 k"li se&ingg ("n 9 k"li li$"t $"(" kons&si ti"$ti"$ +"ri (i#"n(ingk"n (eng"n 6"nit" /"ng ti("k &in&. 1 engkons&si k"fein sekr"ngn/" 8 gel"s ko$i $er+"ri "t" 833&g )"ffiene s"t +"ri ("$"t se(ikit &en"&#"+ risiko "#orts ("n $"(" &erek" /"ng &e&in& le#i+ ("ri ini0 risikon/" &eningk"t se)"r" linier (eng"n ti"$ '&l"+ t"&#"+"n gel"s ko$i.1 P"(" $eneliti"n l"in0 6"nit" +"&il /"ng
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24
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7. Pen/"kit $"(" i# < •
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FREKUENSI
Di$erkir"k"n frekensi keggr"n s$ont"n
#erkis"r
"nt"r" 13185.N"&n
(e&iki"n0 frekensi selr+ keggr"n sk"r (itentk"n k"ren" "#orts #"t"n #"t"n
-
#"n/"k /"ng ti("k (il"$ork"n0 ke)"li 'ik" ter'"(i ko&$lik"si. Jg" k"ren" se#"gi"n keggr"n s$ont"n +"n/" (isert"i ge'"l" ("n t"n(" ring"n0 se+ingg" 6"nit" ti("k ("t"ng ke (okter "t" R&"+ S"kit. ! •
"kin t" &r0 "#orts &"kin sering ter'"(i. De&iki"n 'g" (eng"n se&"kin #"n/"k "n"k0 "#orts 'g" "k"n se&"kin sering ter'"(i. Se&"kin t" &r
•
ke+"&il"n0 ke&ngkin"n "#orts &"kin ke)il ;"nit" 23 t"+n "#orts 125 ;"nit" 73 t"+n "#orts 2>5
PATOGENESIS
P"(" $er&l""n0 ter'"(i $er("r"+"n ("l"& (esi(" #"s"lis0 (iikti ole+ nekrosis '"ring"n sekit"r0 'ik" ter'"(i le#i+ "6"l0 &"k" o-& "k"n tertingg"l ("n &eng"ki#"tk"n kontr"ksi terin /"ng "k"n #er"kir (eng"n ek$lsi k"ren" (i"ngg"$ se#"g"i #en(" "sing ole+ t#+. 1 A$"#il" k"n(ng gest"si (i#k"0 #i"s"n/" (ite&k"n fets &"ser"si /"ng ke)il "t" ti("k "("n/" fets s"&" sek"li ("n +"l ini (ise#t blighted ovum.1 P"(" ke+"&il"n (i#"6"+ % &ingg +"sil konse$si (ikel"rk"n selr+n/"0 k"ren" -ili kore"lis #el& &ene&#s (esi(" terl"l ("l"& se("ngk"n $"(" ke+"&il"n %17 &inng tel"+ &"sk "g"k ("l"& se+ingg" se#"gi"n kel"r ("n se#"gi"n l"gi "k"n tertingg" k"ren" it "k"n ter'"(i #"n/"k $er("r"+"n.% P"(" "#orts /"ng ter'"(i l"&"0 #e#er"$" ke&ngkin"n #ole+ ter'"(i. Jik" fets /"ng tertingg"l &eng"l"&i &"ser"si0 /"ng &"n" tl"ng kr"ni"l kol"$s0 "#(o&en (i$en+i (eng"n )"ir"n /"ng &eng"n(ng ("r"+0 ("n (egen"r"si org"n intern"l. 1 Klit "k"n tert"ngg"l (i ("l"& ters "t" (eng"n sent+"n /"ng s"ng"t &ini&"l. 1 Bis" 'g" "$"#il" )"ir"n "&niotik (iser"$0 fets "k"n (iko&$ress
("n &eng"l"&i (esik"si0 /"ng "k"n
&e&#entk fets )o&$resss.1 K"("ngk"("ng0 fets #ole+ 'g" &en'"(i s"ng"t kering ("n (iko&$res se+ingg" &en/er$"i kert"s /"ng (ise#t fets $"$/r")eos. 1
KLASIFIKASI
A#orts ("$"t (i#"gi "t"s (" golong"n < 1.
A#orts S$ont"n 1 A("l"+ "#orts /"ng ter'"(i (eng"n ti("k (i("+li f")torf"ktor &ek"nis "t"$n &e(isin"lis0 se&"t"&"t" (ise#"#k"n ole+ f")torf"ktor "l"&i"+.
2.
A#orts Pro-"k"ts in()e( "#ortion4
A("l"+ "#orts /"ng (iseng"'"0 #"ik (eng"n &engn"k"n o#"to#"t"n "t"$n "l"t"l"t. A#orts ini ter#"gi l"gi &en'"(i < "4 A#orts e(isin"lis A("l"+ "#orts k"ren" tin("k"n kit" sen(iri0 (eng"n "l"s"n #il" ke+"&il"n #4
(il"n'tk"n ("$"t &e&#"+"/"k"n 'i6" i# #er("s"rk"n in(ik"si &e(is4. A#orts Kri&in"lis "t" ti("k "&"n A("l"+ "#orts /"ng ter'"(i ole+ k"ren" tin("k"ntin("k"n /"ng ti("k leg"l "t" ti("k #er("s"rk"n in(ik"si &e(is.
KLINIS ABORTUS SPONTAN
D"$"t (i #"gi "t"s < 7080> 1. Abor!" I##$%e%" T+re"tene( "#ortion0 A#orts &eng"n)"& 4 A("l"+ i"l"+ $eristi6" ter'"(in/" $er("r"+"n ("ri ters $"(" ke+"&il"n se#el& 23 &ingg0 (i&"n" +"sil konse$si &"si+ ("l"& ters0 ("n t"n$" "("n/" (il"t"si ser-iks. Proses "6"l ("ri s"t keggr"n0 /"ng (it"n("i (eng"n < "4 Per("r"+"n $er-"gin"&0 se&ent"r" osti& teri ekstern& &"si+ tertt$ ("n '"nin &"si+ ("l"& intr"terine ti&#l $"(" $erteng"+"n tri&ester $ert"&" #4 Per("r"+"n #i"s"n/" se(ikit0 +"l ini ("$"t ter'"(i #e#er"$" +"ri. )4 K"("ng n/eri0 ter"s" n/eri t&$l $"(" $ert #"gi"n #"6"+ &en/ert"i $er("r"+"n. (4 Ti("k (ite&k"n kel"in"n $"(" ser-iks ("n ser-iks tertt$ Pe&eriks""n $enn'"ng< "4 Pe&eriks""n +or&on += $"(" rin (eng"n )"r" &el"kk"n tes rin ke+"&il"n &enggn"k"n rin t"n$" $engen)er"n ("n $engen)er"n 1:13. Bil" +"sil tes rin &"si+ $ositif ke("n/" &"k" $rognosisn/" "("l"+ #"ik0 #il" $engen)er"n 1:13 +"siln/" neg"ti-e &"k" $rognosisn/" (#i" "( &"l"&. #4 US=< ntk &enget"+i $ert&#+"n '"nin /"ng "(" ("n &enget"+i ke"(""n $l"sent" "$"k"+ s("+ ter'"(i $ele$"s"n "t" #el&. Di$er+"tik"n 'g" kr"n #io&etri '"nin:k"ntong gest"si "$"k"+ ses"i (eng"n &r ke+"&il"n #er("s"rk"n HPHT. Den/t '"ntng '"nin ("n ger"k"n '"nin (i$er+"tik"n (is"&$ing "(" "t" ti("kn/" $e&#k""n k"n"lis ser-ik"lis. Pen"t"l"ks"n""n "4 Tir"+ #"ring #4 Ti("k $erl ter"$i +or&on"l estrogen "t" $rogestin4 "t" tokolitik s"l#t"&ol "t" in(o&et"sin4 k"ren" o#"t ini ti("k ("$"t &en)eg"+ "#orts. )4 An'rk"n ntk ti("k &el"kk"n "ktifit"s fisik se)"r" #erle#i+"n "t" &el"kk"n +#ng"n seks"l
&
(4 Bil" re"ksi ke+"&il"n 2? #ertrttrt neg"ti-e0 &"k" se#"ikn/" ters (ikosongk"n kret4 2. Abor!" I%"$&$e% Ine-it"#le "#ortion0 A#orts se("ng #erl"ngsng4 i"l"+ $eristi6" ter'"(in/" $er("r"+"n ("ri ters $"(" ke+"&il"n se#el& 23 &ingg (eng"n "("n/" (il"t"si ser-iks teri /"ng &eningk"t0 tet"$i +"sil konse$si &"si+ ("l"& ters. Dit"n("i (eng"n "("n/" < "4 ro#ekn/" sel"$t "&nion ("n "("n/" $e&#k""n ser-iks #4 ter'"(i kontr"ksi ters ntk &engel"rk"n +"sil konse$si )4 $er("r"+"n $er -"gin"& &"sif0 k"("ng k"("ng kel"r g&$"l"n ("r"+. (4 n/eri $ert #"gi"n #"6"+ se$erti ke'"ng k"ren" kontr"ksi r"+i& k"t. Pe&eriks""n $enn'"ng< "4 tes rin ke+"&il"n &"si+ $ositif #4 US=< $e&#es"r"n ters /"ng &"si+ ses"i (eng"n &r ke+"&il"n0 ger"k '"nin ("n ger"k '"ntng '"nin &"si+ 'el"s 6"l" &ngkin s("+ &l"i ti("k nor&"l. Bi"s"n/" terli+"t $eni$is"n ser-iks teri "t" $e&#k""nn/". Per+"tik"n $l" "(" ti("kn/" $ele$"s"n $l"sent" ("ri (in(ing ters. Pen"t"l"ks"n""n Bil" ke+"&il"n 1> &ingg ("$"t (il"kk"n e-"k"si ters (eng"n As$ir"si • "k& "n"l A4. Jik" e-"k"si ti("k ("$"t (il"kk"n seger" l"kk"n < - Berik"n ergo&etrin 302 &g I. /"ng (il"ngi 18 &enit ke&(i"n 'ik" $erl ATAU iso$rostol 733 &g $er or"l ("n #il" &"si+ (i$erlk"n
•
("$"t (il"ng setel"+ 7 '"& 'ik" $erl - Seger" l"kk"n $ersi"$"n ntk $engel"r"n +"sil konse$si ("ri ters. Bil" ke+"&il"n 1> &ingg tngg eks$lsi s$ont"n ke&(i"n (il"kk"n e-"k"si ters (eng"n As$ir"si "k& "n"l A4. Jik" e-"k"si ti("k ("$"t (il"kk"n seger" l"kk"n < - In(ksi o'"$o"$% 23 nit ("l"& 833 &l NS "t" RL &l"i % tetes s"&$"i 73 tetes: &enit0 ses"i kon(isi kontr"ksi ters s"&$"i ter'"(i
$engel"r"n +"sil konse$si - Seger" l"kk"n $ersi"$"n ntk $engel"r"n +"sil konse$si ("ri ters. L"kk"n Pe&"nt""n P"s)" A#orts • (. Abor!" Ko#&)e!" i"l"+ $roses "#orts (i&"n" keselr+"n +"sil konse$si (esi(" ("n fets4 tel"+ kel"r &el"li '"l"n l"+ir se+ingg" rongg" r"+i& kosong. T"n(" ("n =e'"l" "4 Ser-iks &ent$. #4 R"+i& le#i+ ke)il ("ri $erio(e /"ng (itn'kk"n "&enore". )4 =e'"l" ke+"&il"n ti("k "(". (4 U'i ke+"&il"n neg"tif.
/
e4 Bes"r ters ti("k ses"i (eng"n &r ke+"&il"n. Pe&eriks""n $enn'"ng< "4 tes rin ke+"&il"n &"si+ $ositif s"&$"i !13 +"ri setel"+ "#orts #4 US=< #i"s"n/" ti("k (i$erlk"n #il" $e&eriks""n klinis s("+ &e&"("i. Pen"t"l"ks"n""n Ti("k $erl e-"k"si l"gi ,#ser-"si ntk &eli+"t $er("r"+"n #"n/"k:ti("k. L"kk"n Pe&"nt""n P"s)" A#orts A$"#il" ter("$"t "ne&i" se("ng0 #erik"n t"#let slf"s ferross >33&g:+"ri
• • • •
sel"&" 2 &ingg0 'ik" "ne&i" #er"t #erik"n tr"nfsi ("r"+. *. Abor!" I%'o#&)e!" i"l"+ $engel"r"n se#"gi"n +"sil konse$si $"(" ke+"&il"n se#el& 23 &ingg (eng"n &"si+ "(" sis" tertingg"l ("l"& ters. =e'"l" Klinis < Di("$"ti "&enore"0 s"kit $ert0 ("n &l"s&l"s • Per("r"+"n #is" se(ikit "t" #"n/"k ("n #i"s"n/" #er$" stolsel ("r"+ • • •
#ek4. S("+ "(" kel"r fets "t" '"ring"n P"(" $e&eriks""n ("l"& .T.4 ntk "#orts /"ng #"r ter'"(i (i("$"ti k"n"lis ser-ik"lis ter#k"0 k"("ngk"("ng ("$"t (ir"#" sis" '"ring"n $"(" k"n"lis ser-ik"lis "t" k"-& teri0 sert" ters /"ng #erkr"n le#i+ ke)il ("ri se+"rsn/".
Pe&eriks""n $enn'"ng< "4 US=< +"n/" (il"kk"n #il" r"g (eng"n (i"gnosis se)"r" klinis. G"ng (i("$"tk"n ("l"& US= "("l"+ #es"r ters s("+ le#i+ ke)il ("ri &r ke+"&il"n ("n k"ntong gest"si s("+ slit (iken"li0 (i k"-& teri t"&$"k &"ss" +i$erekoik /"ng #entkn/" ti("k #er"tr"n. Pen"t"l"ks"n""n H"sil konse$si /"ng ter$er"ngk"$ $"(" ser-iks /g (isert"i $er("r"+"n0 ("$"t (ikel"rk"n se)"r" (igit"l0 "t" )n"& o-& ke&(i"n (ie-"k"si i. Bil" $er("r"+"n #er+enti (i#eri ergo&etrine 302 &g I. "t" &iso$rostol ii.
733 &g $er or"l Bil" $er("r"+"n ters #erl"ngsng0 e-"k"si sis" konse$si (eng"n kret -"k& K4 - Bil" ti("k "(" t"n("t"n(" infeksi0 "nti#iotik" $ro$+il"ksis
- Bil" ter'"(i infeksi #eri A&$i)illin 1 gr ("n etroni("Col 833 &g seti"$ % '"& - Bil" "ne&i" ter"$i (eng"n Fe k"l" $erl tr"nsfsi ("r"+. +. M$""ed Abor$o%
#$
i"l"+ #er"k+irn/" s"t ke+"&il"n se#el& 23 &ingg0 n"&n keselr+"n +"sil konse$si tert"+"n ("l"& ters % &ingg "t" le#i+ =e'"l" Klinis - Dit"n("i (eng"n ke+"&il"n /"ng nor&"l (eng"n "&enorr+e"0 ("$"t (isert"i
-
&"l ("n &nt"+ Pert&#+"n ters &enge)il (eng"n fn(s /"ng ti("k #ert"&#"+ tinggi. "&"e &en'"(i &enge)il =e'"l"ge'"l" ke+"&il"n &eng+il"ng (iiringi re"ksi ke+"&il"n &en'"(i neg"ti-e $"(" 29 &ingg setel"+ fets &"ti. P"(" $e&eriks""n ("l"& ser-iks tertt$ ("n "(" ("r"+ se(ikit P"sien &er"s" $ertn/" (ingin ("n kosong
Pe&eriks""n $enn'"ng< "4 Tes rin ke+"&il"n #i"s"n/" neg"ti-e setel"+ s"t &ingg ("ri ter+entin/" $ert&#+"n ke+"&il"n. #4 US=< (i("$"tk"n ters /"ng &enge)il0 k"ntong gest"si /"ng &enge)il0 ("n #entkn/" ti("k #er"tr"n (isert"i g"&#"r"n fets /"ng ti("k "(" t"n("t"n(" ke+i($"n. )4 Pe&eriks""n ko"gl"si $erl (il"k"kn se#el& tin("k"n e-"k"si ("n kret"se #il" &isse( "#ortion #erl"ngsng le#i+ ("ri 7 &ingg k"ren" ke&ngkin"n "k"n ter'"(i g"ngg"n $e&#ek"n ("r"+. Pen"t"l"ks"n""n i. $"(" &r ke+"&il"n kr"ng ("ri 12 &ingg tin("k"n e-"k"si ("$"t (il"kk"n se)"r" l"ngsng (eng"n &el"kk"n (il"t"si ("n kret"se #il" ii.
ser-iks ters &e&ngkink"n. Bil" &r ke+"&il"n (i "t"s 12 &ingg "t" kr"ng ("ri 23 &ingg (eng"n ke"(""n ser-iks ters /"ng &"si+ k"k0 (i"n'rk"n ntk &el"kk"n in(ksi terle#i+ ("+l ntk &engel"rk"n '"nin "t" &e&"t"ngk"n k"n"lis ser-ik"lis. "r"n/" "nt"r" l"in< - infs intr"-en" )"ir"n oksitosin (i&l"i ("ri (osis 13 nit ("l"& 833 )) (ekstrose 85 tetes"n 23 tetes $er &enit ("n ("$"t (il"ngi s"&$"i tot"l oksitosin 83 nit (eng"n tetes"n (i$ert"+"nk"n ntk &en)eg"+
-
ter'"(in/" retensi )"ir"n t#+. Jik" ti("k #er+"sil0 $en(erit" (iistir"+"tk"n 1 +"ri0 ("n ke&(i"n in(ksi
-
(il"ngi. Bi"s"n/" &"ksi&"l 9 k"li. Di#erik"n &eso$rostol se)"r" s#ling"l se#"n/"k 733 &g /"ng ("$"t (il"ngi 2 k"li (eng"n '"r"k > '"&. Deng"n o#"t ini "k"n ter'"(i $engel"r"n +"sil konse$si "t" ter'"(i $e&#k""n osti& ser-iks
##
se+ingg" tin("k"n e-"k"si ("n kret"se ("$"t (iker'"k"n ntk &engosongk"n k"-& teri. Setel"+ '"nin "t" '"ring"n konse$si #er+"sil kel"r (eng"n in(ksi ini0 (il"n'tk"n (eng"n tin("k"n kret"se se#ersi+ &ngkin. iii.
A$"#il" ter("$"t +i$ofi#rinogene&i" $erl (isi"$k"n tr"nsfsi ("r"+ seg"r
i-.
"t" fi#rinogen P"s)" tin("k"n k"l" $erl (il"kk"n $e&#eri"n infs intr"-en" )"ir"n
oksitosin ("n "nti#iotik". ,. Abor!" Hab$!a)$" i"l"+ "#orts s$ont"n /"ng ter'"(i 9 k"li "t" le#i+ #ertrttrt. Pen/e#"# "#orts +"#it"lis sel"in f"ktor "n"to&is #"n/"k /"ng &eng"itk"nn/" (eng"n re"ksi i&nologik /"it keg"g"l"n re"ksi ter+"("$ antigen lymphosite trophoblast cross reactive (TLX). Bil" re"ksi ter+"("$ "ntigen ini ren("+ "t" ti("k "("0 &"k" "k"n ter'"(i "#orts. S"l"+ s"t $en/e#"# l"in /"ng sering (i'&$"i i"l"+ inko&$etensi" ser-iks0 /"it ke"(""n (i&"n" ser-iks teri ti("k ("$"t &eneri&" #e#"n ntk tet"$ #ert"+"n &ent$ setel"+ ke+"&il"n &ele6"ti tri&ester $ert"&"0 (i&"n" osti& ser-iks "k"n &e&#k" inko&$eten4 t"n$" (isert"i r"s" &les:kontr"ksi r"+i& ("n "k+irn/" ter'"(i $engel"r"n '"nin. Kel"in"n ini sering (ise#"#k"n ole+ tr"&" ser-iks $"(" ke+"&il"n se#el&n/"0 &is"ln/" $"(" tin("k"n s"+" $e&#k""n ser-iks /"ng #erle#i+"n0 ro#ek"n ser-iks /"ng l"s se+ingg" (i"&eter k"n"lis ser-ik"lis s("+ &ele#"r. Di"gnosis< D"$"t (iteg"kk"n (eng"n "n"&nesis )er&"t. Pe&eriks""n ("l"&:ins$eklo< (inil"i (i"&eter k"n"lis ser-ik"lis ("n
-
(i("$"ti sel"$t ket#"n /"ng &l"i &enon'ol $"(" s""t &l"i &e&"ski tri&ester ke(". Di"&eter ini &ele#i+i % &&. Pe&eriks""n < ". Histeros"lfingogr"fi0 ntk &enget"+i "("n/" &io&" ters s#&kos" "t" "no&"li )ongenit"l. #. BR ("n k"("r /o(i& ("r"+ (ikr ntk &enget"+i "$"k"+ "(" "t" ti("k g"ngg"n gl"n(l" t+/roi(e" ). Psiko "n"lisis Ter"$i < •
Untk kel"in"n keg"g"l"n re"ksi "ntigen TL@0 &"k" (io#"ti (eng"n tr"nsfsi
•
lekosit "t" +e$"rinis"si. P"(" ser-iks inko&$eten0 (i"n'rk"n ntk $eriks" +"&il se"6"l &ngkin.
#%
Bil" (i)rig"i "("n/" inko&$etensi" ser-iks (i"l"kk"n tin("k"n ntk
•
&e&#erik"n fiks"si $"(" ser-iks "g"r ("$"t &eneri&" #e#"n (eng"n #erke&#"ngn/" &r ke+"&il"n. ,$er"si (il"kk"n $"(" &r ke+"&il"n 12 17 &ingg (eng"n )"r" SHIR,DKAR "t" D,NALD cervical cerlage4
(eng"n
&elingk"ri
k"n"lis
ser-ik"lis
(eng"n
#en"ng
ster":&ersilenen /"ng te#"l ("n si&$l #"r (i#k" setel"+ &r ke+"&il"n "ter& ("n #"/i si"$ (il"+irk"n. erokok ("n &in& "l)o+ol se#"ikn/" (ikr"ngi "t" (i+entik"n. Pengo#"t"n $"(" kel"in"n en(o&etri& $"(" "#orts +"#it"lis le#i+ #es"r
• •
+"siln/" 'ik" (il"kk"n se#el& "(" konse$si ("ri$"(" ses("+n/". -. Abor!" I%fe'"$o!" i"l"+ s"t "#orts /"ng tel"+ (isert"i ko&$lik"si #er$" infeksi genit"l Di"gnosis < - A("n/" "#orts < "&enore0 $er("r"+"n0 kel"r '"ring"n /"ng tel"+ (itolong
-
(i l"r r&"+ s"kit. Pe&eriks""n < K"n"lis ser-ik"lis ter#k"0 ter"#" '"ring"n0 $er("r"+"n0 ("n
-
se#"g"in/". t"n(" t"n(" infeksi /"kni ken"ik"n s+ t#+ le#i+ ("ri 9%08 (er"'"t el)is0 ken"ik"n lekosit ("n (is)+"rge #er#" $er-"gin"&0 ters #es"r ("n le&#ek (isert"i n/eri tek"n.
Pen"t"l"ks"n""n
-
Bil" $er("r"+"n #"n/"k0 #erik"n tr"nsfsi ("r"+ ("n )"ir"n /"ng )k$ Berik"n "nti#iotik" /"ng )k$ ("n te$"t #"t $e&eriks""n $e&#i"k"n (" 'i ke$ek""n o#"t4 Berik"n sntik"n $enisilin 1 't" s"t"n ti"$ > '"& o o Berik"n sntik"n stre$to&isin 833&g seti"$ 12 '"& o At" "nti#iotik" s$ektr& l"s l"inn/".
-
Bil" tet"$ ter'"(i $er("r"+"n #"n/"k setel"+ 12 +"ri l"kk"n (il"t"si ("n
kret"se ntk &engel"rk"n +"sil konse$si . Se&$c Abor$o% i"l"+ "#orts infeksioss #er"t (isert"i $en/e#"r"n k&"n "t" toksin ke ("l"& $ere("r"n ("r"+ "t" $eritone&. Di"gnosis se$ti) "#ortion (iteg"k"n 'ik" (i("$"tk"n t"n(" t"n(" se$sis0 se$erti n"(i )e$"t ("n le&"+0 s/ok ("n $enrn"n kes"("r"n. Pen"t"l"ks"n""n s"&" (eng"n "#orts infeksios0 +"n/" (osis ("n 'enis "nti#iotik" (itinggik"n ("n (i$ili+ 'enis /"ng te$"t ses"i (eng"n +"sil $e&#i"k"n ("n 'i ke$ek""n k&"n. Perl (i o#ser-"si "$"k"+ "(" t"n(" $erfor"si "t" "kt "#(o&en.
#*
#+
Ga#bar. Algorit+& for t+e &"n"ge&ent of s$ont"neos $regn"n)/ loss. += +&"n )+orioni) gon"(otro$in.4
PEMERIKSAAN PENUNJANG
Pe&eriks""n $enn'"ng ini (i$erlk"n ("l"& ke"(""n "#orts i&&inens0 "#orts +"#it"lis ("n &isse( "#ortion < 1. Pe&eriks""n ltr"sonogr"$+i "t" Do$$ler ntk &enentk"n "$"k"+ '"nin &"si+ +i($ "t" ti("k0 sert" &enentk"n $rognosis. 2. Pe&eriks""n k"("r fi#rinogen $"(" &isse( "#ortion. 9. Tes ke+"&il"n. 7. Pe&eriks""n l"in ses"i (eng"n ke"(""n ("n (i"gnosis $"sien.
DIAGNOSIS BANDING
1. KET < n/eri le#i+ +e#"t (i#"n(ingk"n "#orts. 2. ol" Hi("nti(os" < ters #i"s"n/" le#i+ #es"r ("ri$"(" l"&"n/" "n&enore ("n &nt"+ le#i+ sering. 9. Ke+"&il"n (eng"n kel"in"n ser-iks se$erti k"rsino&" ser-isi teri0 $oli$s teri0 (s#.
#,
PEMANTAUAN PAS/A ABORTUS.7
Se#el& i# (i$er#ole+k"n $l"ng0 (i#erit"+ #"+6" "#orts s$ont"n +"l /"ng #i"s" ter'"(i ("n ter'"(i $"(" $"ling se(ikit 185 ("ri selr+ ke+"&il"n /"ng (iket"+i se)"r" klinis. Ke&ngkin"n ke#er+"sil"n ntk ke+"&il"n #eriktn/" "("l"+ )er"+ ke)"li 'ik" ter("$"t se$sis "t" "("n/" $en/e#"# "#orts /"ng ("$"t &e&$n/"i efek s"&$ing $"(" ke+"&il"n #erikt. Se&" $"sien "#orts (isntik -"ksin ser"$ tet"ns 308 )) I. U&&n/" setel"+ tin("k"n kret"se $"sien "#orts ("$"t seger" $l"ng ke r&"+.Ke)"li #il" "(" ko&$lik"si se$erti $er("r"+"n #"n/"k /"ng &en/e#"#k"n "ne&i" #er"t "t" infeksi.P"sien (i"n'rk"n istir"+"t sel"&" 1 s"&$"i 2 +"ri.P"sien (i"n'rk"n ke&#"li ke (okter #il" $"sien &eng"l"&i kr"& (e&"& /"ng &e&#rk "t" n/eri setel"+ $er("r"+"n #"r /"ng ring"n "t" ge'"l" /"ng le#i+ #er"t. T'"n $er"6"t"n ntk &eng"t"si "ne&i" ("n infeksi. Se#el& (il"kk"n kret"se kel"rg" ter(ek"t $"sien &en"n("t"ng"ni sr"t $erset'"n tin("k"n.
KOMPLIKASI ABORTUS 14
Per("r"+"n.> Per("r"+"n ("$"t (i"t"si (eng"n $engosong"n ters ("ri sis"sis" +"sil konse$si ("n 'ik" $erl $e&#eri"n tr"nsfsi ("r"+.Ke&"ti"n k"ren" $er("r"+"n ("$"t ter'"(i "$"#il" $ertolong"n ti("k (i#erik"n.Per("r"+"n /"ng #erle#i+"n se6"kt "t" ses("+ "#orts #is" (ise#"#k"n ole+ "toni ters0 l"ser"si )er-ik"l0 $erfor"si ters0 ke+"&il"n ser-iks0 ("n 'g" ko"glo$"ti.
24
Perfor"si.> Perfor"si ters $"(" kerok"n ("$"t ter'"(i tert"&" $"(" ters ("l"& $osisi +i$erretrofleksi.Ter'"(i ro#ek"n $"(" r"+i&0 &is"ln/" "#orts $ro-ok"ts kri&in"lis. Deng"n "("n/" (g""n "t" ke$"sti"n ter'"(in/" $erfor"si0 l"$"r"to&i +"rs seger" (il"kk"n ntk &enentk"n l"sn/" $erlk""n $"(" ters ("n "$"k"+ "(" $erlk"n "l"t"l"t l"in. P"sien #i"s"n/" ("t"ng (eng"n s/ok +e&or"gik.
94
S/ok.>
#-
S/ok $"(" "#orts #is" ter'"(i k"ren" $er("r"+"n s/ok +e&or"gik4 ("n k"ren" infeksi #er"t."so-"g"l s/n)o$e /"ng (i"ki#"tk"n sti&l"si )"n"lis se-ik"lis se6"kt (il"t"si 'g" #ole+ ter'"(i n"&& $"sien se&#+ (eng"n seger". 74
Infeksi.> Se#en"rn/" $"(" genit"li" ekstern" ("n -"gin" (i+ni ole+ #"kteri /"ng &er$"k"n flor" nor&"l. K+ssn/" $"(" genit"li" ekstern" /"it st"$+/lo)o))i0 stre$to)o))i0 =r"& neg"tif enteri) #")illi0 /)o$l"s&"0 Tre$one&" sel"in T. $"lii(&40 Le$tos$ir"0 '"&r0 Tri)+o&on"s -"gin"lis0 se("ngk"n $"(" -"gin" "(" l")to#")ili0stre$to)o))i0 st"$+/lo)o))i0 =r"& neg"tif enteri) #")illi0 lostri(i& s$.0 B")teroi(es s$0 Listeri" ("n '"&r. U&&n/" $"(" "#orts infeksios"0 infeksi ter#"t"s $"(s" (esi(".P"(" "#orts se$tik -irlensi #"kteri tinggi ("n infeksi &en/e#"r ke $eri&etri&0 t#"0 $"r"&etri&0 ("n $eritoni&. ,rg"nis&eorg"nis&e /"ng $"ling sering #ert"nggng '"6"# ter+"("$ infeksi $"sk" "#orts "("l"+ E.)oli0 Stre$to)o))s non +e&olitiks0 Stre$to)o))i "n"ero#0 St"$+/lo)o))s "res0 Stre$to)o))s +e&olitiks0 ("n lostri(i& $erfringens. B"kteri l"in /"ng k"("ng (i'&$"i "("l"+ Neisseri" gonorr+oe"e0 Pne&o)o))s ("n lostri(i& tet"ni. Stre$to)o))s $/ogenes $otensi"l #er#"+"/" ole+ k"ren" ("$"t &e&#entk g"s.
84
Efek "nest+esi".! P"(" $enggn""n gener"l "nestesi"0 ko&$lik"si "toni ters #is" ter'"(i /"ng #er"ki#"tk"n $er("r"+"n. P"(" k"ss t+er"$eti) "#orts0 $"r")er-i)"l #lok sering (ign"k"n se#"g"i &eto(e "nestesi". Sering sntik"n intr"-"skl"r /"ng ti("k (iseng"'" $"(" $"r"ser-ik"l #lok "k"n &eng"ki#"tk"n ko&$lik"si f"t"l se$erti kon-lsi0 )"r(io$l&on"r/ "rrest ("n ke&"ti"n.
>4
Disse&in"te( Intr"-"s)l"r o"glo$"t+/ DI4.! P"sien (eng"n $ost"#orts /"ng #er"t tert"&"n/" setel"+ &i(tri&ester $erl )rig" DI.Insi(ens "("l"+ le#i+ ("ri 233 k"ss $er 1330333 "#orsi.
#
PROGNOSIS>
Prognosis
ke#er+"sil"n
ke+"&il"n
terg"ntng
("ri
etiologi
"#orsi
s$ont"n
se#el&n/".Per#"ik"n en(okrin /"ng "#nor&"l $"(" 6"nit" (eng"n "#orts /"ng rekren &e&$n/"i $rognosis /"ng #"ik sekit"r *3 5.P"(" 6"nit" keggr"n (eng"n etiologi /"ng ti("k (iket"+i0 ke&ngkin"n ke#er+"sil"n ke+"&il"n sekit"r 73%3 5. Sekit"r !! 5 "ngk" kel"+ir"n +i($ setel"+ $e&eriks""n "kti-it"s '"ntng '"nin $"(" ke+"&il"n 8 s"&$"i > &ingg $"(" 6"nit" (eng"n 2 "t" le#i+ "#orsi s$ont"n /"ng ti("k 'el"s. BLIGHTED O0UM Blig+te( o-& "("l"+ ke"(""n (i&"n" seor"ng 6"nit" &er"s" +"&il tet"$i ti("k "("
#"/i (i ("l"& k"n(ng"n. Seor"ng 6"nit" /"ng &eng"l"&in/" 'g" &er"s"k"n ge'"l" ge'"l" ke+"&il"n se$erti terl"&#"t &enstr"si0 &"l ("n &nt"+ $"(" "6"l ke+"&il"n &orning si)kness40 $"/("r" &enger"s0 sert" ter'"(i $e&#es"r"n $ert0 #"+k"n s""t (il"kk"n tes ke+"&il"n #"ik test $")k &"$n l"#or"tori& +"siln/" $n $ositif. P"(" s""t konse$si0 sel telr o-&4 /"ng &"t"ng #erte& s$er&".N"&n "ki#"t #er#"g"i f"ktor &"k" sel telr /"ng tel"+ (i#"+i s$er&" ti("k ("$"t #erke&#"ng se&$rn"0 ("n +"n/" ter#entk $l"sent" /"ng #erisi )"ir"n.eski$n (e&iki"n $l"sent" terse#t tet"$ tert"n"& (i ("l"& r"+i&. Pl"sent" &eng+"silk"n +or&on H= +&"n )+orioni) gon"(otro$in4 (i&"n" +or&on ini "k"n &e&#erik"n sin/"l $"(" in(ng telr o-"ri&4 ("n ot"k se#"g"i $e&#erit"+"n #"+6" s("+ ter("$"t +"sil konse$si (i ("l"& r"+i&. Hor&on H= /"ng &en/e#"#k"n &n)ln/" ge'"l"ge'"l" ke+"&il"n se$erti &"l0 &nt"+0 ngi("& ("n &en/e#"#k"n tes ke+"&il"n &en'"(i $ositif Hingg" s""t ini #el& "(" )"r" ntk &en(eteksi (ini ke+"&il"n #lig+te( o-&. Seor"ng 6"nit" #"r ("$"t (iin(ik"sik"n &eng"l"&i #lig+te( o-& #il" tel"+ &el"kk"n #&
$e&eriks""n US= tr"ns-"gin"l. N"&n tin("k"n terse#t #"r #is" (il"kk"n s""t ke+"&il"n &e&"ski si" >! &ingg. Se#"# s""t it (i"&eter k"ntng ke+"&il"n s("+ le#i+ #es"r ("ri 1> &ili&eter se+ingg" #is" terli+"t le#i+ 'el"s. D"ri sit 'g" "k"n t"&$"k0 "("n/" k"ntng ke+"&il"n /"ng kosong ("n ti("k #erisi '"nin. K"ren" ge'"l"n/" /"ng ti("k s$esifik0 &"k" #i"s"n/" #lig+te( o-& #"r (ite&k"n setel"+ "k"n te'"(i keggr"n s$ont"n (i&"n" &n)l kel+"n $er("r"+"n. Sel"in #lig+te( o-&0 $ert /"ng &e&#es"r se$erti +"&il0 ("$"t (ise#"#k"n +"&il "nggr &ol" +i("ti(os"40 t&or r"+i& "t" $en/"kit ss. Sekit"r >35 #lig+te( o-& (ise#"#k"n kel"in"n kro&oso& ("l"& $roses $e&#"+"n sel telr ("n s$er&". Infeksi T,RH0 r#ell" ("n stre$tokoks0 $en/"kit ken)ing &"nis (i"#etes &ellits4 /"ng ti("k terkontrol0 ren("+n/" k"("r #et" H= sert" f"ktor i&nologis se$erti "("n/" "nti#o(i ter+"("$ '"nin 'g" ("$"t &en/e#"#k"n #lig+te( o-&. Risiko 'g" &eningk"t #il" si" s"&i "t" istri se&"kin t" k"ren" k"lit"s s$er&" "t" o-& &en'"(i trn. Jik" tel"+ (i(i"gnosis #lig+te( o-&0 &"k" tin("k"n sel"n'tn/" "("l"+ &engel"rk"n +"sil konse$si ("ri r"+i& kret"se4. H"sil kret"se "k"n (i"n"lis" ntk &e&"stik"n "$" $en/e#"# #lig+te( o-& l"l &eng"t"si $en/e#"#n/". Jik" k"ren" infeksi &"k" ("$"t (io#"ti se+ingg" ke'"(i"n ini ti("k #erl"ng.Jik" $en/e#"#n/" "nti#o(i &"k" ("$"t (il"kk"n $rogr"& i¬er"$i se+ingg" kel"k ("$"t +"&il sngg+"n.
#/
BAB III KESIMPULAN
Pen/e#"# t"&" ke&"ti"n &"tern"l "("l"+ (ise#"#k"n ole+ 9 +"l0 /"it $er("r"+"n ("l"& ke+"&il"n0 $reekl"&$si":ekl"&$si" ("n infeksi. Per("r"+"n sel"&" ke+"&il"n ("$"t (i"ngg"$ se#"g"i ke"(""n "kt /"ng ("$"t &e&#"+"/"k"n i# ("n "n"k0 ("n s"&$"i ("$"t &eni&#lk"n ke&"ti"n. Se#"n/"k 235 6"nit" +"&il $ern"+ &eng"l"&i $er("r"+"n $"(" "6"l ke+"&il"n ("n se#"gi"n &eng"l"&i "#orts. P"(" k"ss $er("r"+"n $"(" &"s" ke+"&il"n0 (eng"n si" ke+"&il"n (i#"6"+ 23 &ingg sel"in (i)rig"i se#"g"i "#orts t"$i $erl 'g" (i$ikirk"n (i"gnos" #"n(ing l"inn/" se$erti "("n/" KET ("n &ol" +i("ti(os". P"(" "#orts (i$erlk"n $en"ng"n"n /"ng seger"0 ntk &eng"t"si $er("r"+"n0 &"$n ntk &en)eg"+ ter'"(in/" s/ok ("n ko&$lik"si l"inn/".
%$
DAFTAR PUSTAKA
1.
H"(i'"nto B. Per("r"+"n $"(" ke+"&il"n &(". D"l"&< S"r6ono Pr"6iro+"r('o. Il& K"n(ng"n. E(isi ke7. J"k"rt"< PT Bin" Pst"k" S"r6ono Pr"6iro+"r('o 233* < 7>3 !9.
2.
;ikn'os"stro H0 S"fi(in AB0 R")+i&"+"(+i T0 e(itor. Il& Ke#i("n"n. Bin" Pst"k" S"r6ono Pr"6i+"r('o0 J"k"rt"0 2333.
9.
o)+t"r R0 Lt"n D. Sino$sis ,#stetri. Pener#it Bk Ke(okter"n E=. J"k"rt"0 1**%.
7.
F. = nning+"&0 KJ. Le-eno0 SL. Bloo&. A#ortion in ;illi"& ,#stetri)s0 22 n( e(ition. )=r"6 Hill0 2338
8.
)P+ee S0 ,#steri)s "n( o#stretri)s (iso(ers0rrent &e(i)"l (i"gnosis "n( tre"t&ent0 233* e(ition0 ) =r"6 Hill0 233%
>.
"ns'oer A0 TORCH . E(itor
"ns'oer A0 Tri/"nti K0 S"-itri R0 ;"r(+"ni ;I0
Setio6l"n ;0 ("l"& K"$it" Selekt" Ke(okter"n e(isi ketig"0 Jili( $ert"&"0 e(i" Aes)l"$is FKUI0 J"k"rt"0 2331. !.
B"gi"n ,#stetri =inekologi F"klt"s Ke(okter"n Uni-ersit"s P"('"('"r"n B"n(ng.
%.
,#stetri Fisiologi. B"n(ng< Ele&en0 1*%9. B"gi"n ,#stetri =inekologi F"klt"s Ke(okter"n Uni-ersit"s P"('"('"r"n B"n(ng.
*.
,#stetri P"tologi. B"n(ng< Elst"r0 1*%2. Tr$in SR. A#ortion. E&e(i)ine He"lt+. E(itor< Sto$$ler . A-"il"#le "t +tt$<::666.e&e(i)ine+e"lt+.)o&:"#ortion:"rti)lee&.+t&. A))esse( on ,)to#er 91st
2318. 13. =rie#el P0 et "ll. "n"ge&ent of S$ont"neos A#ortion. Uni-ersit/ of Illinois ollege of e(i)ine. Peori". 11. ;"re Br"n)+0 .D. Re)rrent is)"rri"ge. N Engl J e( 2313 9>9< 1!731!7!. A-"il"#le "t +tt$<::666.ne'&.org:(oi:fll:13.138>:NEJ)$1338993. A))esse( on ,)to#er 91st 2318.
%#
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