Bleeding ANTEPARTUM

Bleeding ANTEPARTUM
Antepartum hemorrhage is bleeding in the street were born after 20 weeks of pregnancy. (1)
Classification of antepartum haemorrhage
1. Placenta previa
2. Solusio placenta
3. Antepartum bleeding source unknown (idiopathic)

The characteristics of placenta previa: (2)
1. Bleeding without pain
2. Recurrent bleeding
3. Fantastic fresh red bleeding
4. The presence of anemia and in accordance with Schok bleeding
5. Slow emergence
6. The timing of when pregnant
7. His usually no
8. Flavor not tense (regular) during palpation
9. Fetal heart rate was
10. Placental tissue palpable in the vagina in check
11. Decrease in the head does not enter the door above the pelvis
12. Presentations may be abnormal.

Solusio characteristics of the placenta: (2)
1. Bleeding with pain
2. Bleeding does not repeat
3. Red-brown color bleeding
4. The presence of anemia and Schok inconsistent with bleeding
5. Sudden emergence
6. The timing of when pregnant inpartu
7. His is
8. Sense of anticipation as palpation
9. Fetal heart rate usually does not have
10. Amniotic palpable tension in check in the vagina
11. The decrease can head into the door of the pelvis
12. Not related to presentation

Placenta Previa
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Placenta previa is an abnormal placenta that is situated on the lower uterine segment that covers part or all of the opening of the birth canal (os uteri internum). (2)

Classification of placenta previa based terabanya placental tissue through the opening of the birth at a particular time: (2)
1. Placenta previa totalis: if the opening of roads covered by the placenta is born.
2. Lateral placenta previa: if only partially covered the opening of the birth canal
by the placenta.
3. Placenta previa marginalis: if the edge of the placenta was right on the edge of the
opening of the birth canal.
4. Placenta previa low position: if the placenta is 3-4 cm above the edge
opening of the birth canal.

Aetiology of placenta previa is not clear. (2)

Diagnosis of placenta previa: (2)
1. Anamnesis: the existence of vaginal bleeding in pregnancy over 20 weeks
and lasted for no reason.
2. External examination: frequently found abnormalities location. If the location of the head of the
head does not enter the door of the pelvis.
3. Inspekulo: the blood of the os uteri eksternum.
4. Ultrasound to determine the location of the placenta.
5. Determining the location of the placenta directly with the touch directly via
examination of the cervical canal but this is very dangerous because it can
cause bleeding a lot. Therefore this method is only done
above the operating table.

Management of placenta previa: (2)
1. Conservative if:
a. Less than 37 weeks of pregnancy.
b. Bleeding does not exist or is not much (Hb still in the normal range).
c. Patient residence near the hospital (can take
travel for 15 minutes).
2. Handling active when:
a. Bleeding a lot of pregnancy regardless of age.
b. Age pregnancy 37 weeks or more.
c. Child dies

Conservative treatment in the form:
- Rest.
- Provide hematinik and spasmolitik unntuk overcome anemia.
- Give antibiotics if there indikasii.
- Ultrasound, hemoglobin, and hematocrit.

If for 3 days did not bleed after conservative treatment then do a gradual mobilization. Patients discharged if still no bleeding. If bleeding occur immediately brought to the hospital and should not perform intercourse.

Active handling of:
- Labor per vaginal.
- Labor per abdominal.

The patient is prepared for examination on the operating table (double set-up) that is in a state ready for operation. If the examination obtained:
1. Placenta previa marginalis
2. Placenta previa low position
3. Lateral Marginal placenta or fetal death and in which the cervix is ripe,
head had entered the door of the pelvis and there was no bleeding or only
then do a little bleeding amniotomi followed by oxytocin drips
on partus per vaginal if fail drips (in accordance with the termination protap
pregnancy). If there is bleeding a lot, do seksio fault.

Indications do seksio fault:
- Placenta previa totalis
- Bleeding a lot without stopping.
- Percentage abnormal.
- Narrow pelvis.
- State of the cervix is not favorable (beelum mature).
- Emergency fetus

In circumstances where possible do not fault the seksio do Willet installation pliers or Braxton Hicks version.

Solusio Placenta
________________

Separation of the placenta is Solusio some or all of the normal implantation of the placenta on the fetus before birth. (2)

Solusio classification based on clinical signs of the placenta and the degree of release of the placenta, namely:
1. Light: Bleeding less 100-200 cc, the uterus is not tense, there is no sign of
renjatan (Schok ), fetal life, the release of the placenta is less 1 / 6 of the surface, the levels
more plasma fibrinogen 120 mg%.
2. Medium: 200 cc more bleeding, uterine tension, there is a sign of pre renjatan,
severe fetal or fetus has died, the release of the placenta 1/4-2/3
surface, plasma fibrinogen levels of 120-150 mg%.
3. Weight: Uterus tetanik tense and contract, there are signs renjatan, fetal
death, the release of the placenta may occur over 2 / 3 part or whole.

Etiology unclear solusio placenta. (2)

Management of placenta solusio: (2)

Depending on the severity of the case. In light of the placenta is solusio break, giving sedatives and then determine whether the symptoms of the more progressive or it will stop. When the process stops gradually, the patient mobilized. During examination treatment Hb, fibrinogen, hematocrit and platelets.

In solusio placenta and the weight it was intended to overcome the handling renjatan, improving anemia, stop bleeding and to empty the uterus as quickly as possible. Rx include:
1. Provision of blood transfusion
2. Solving membranes (amniotomi)
3. Oxytocin infusion
4. If necessary seksio fault.

If the diagnosis is clinically placenta solusio already be enforced, there is minimal bleeding which 1000 cc of blood transfusion should be given a minimum of 1000 cc. Amniotic solved soon in order to reduce the strain of the uterine wall and to accelerate the delivery of oxytocin infusion was given 5 UI dekstrose in 500 cc 5%.

Fault Seksio done when:
1. Labor is not completed or not expected to be completed in 6 hours.
2. Bleeding a lot.
3. No opening of 4 cm or less.
4. Narrow pelvis.
5. Location of latitude.
6. Severe pre eclampsia.
7. Pelvic score less than 5.

Vasa Previa

Vasa previa is a condition in which the fetal umbilical blood vessels are inserted with the vilamentosa ie membranes. (2)

Etiology unclear vasa previa. (2)

Diagnosis of vasa previa: (2)

On examination of the vagina on palpable vascular membranes. Screening also can be done with inspekulo or amnioskopi. When you are bleeding it will be followed by fetal heart rate irregular, deceleration or bradikardi, especially when perdahan occurs when or shortly after the membranes rupture. This blood comes from the fetus and to know it can be done with the test Apt and Kleihauer-Betke tests and peripheral blood removal.

Management of vasa previa: (2)

Highly dependent on the status of the fetus. If there is doubt about the viability of the fetus, determine the age of first pregnancy, fetal size, lung maturity and fetal well-being monitoring by ultrasound and kardiotokografi. If the fetus is mature enough to live and can be done immediately seksio fault but if the fetus is dead or immature, performed vaginal delivery.

HELLP SYNDROME

HELLP syndrome is a pre eclampsia and eclampsia are accompanied by the hemolysis, increased liver enzymes, liver dysfunction and thrombocytopenia. (H = haemolysis; EL = Elevated Liver Enzymes; LP = low platelets count)

The diagnosis of HELLP syndrome:
1. Signs and symptoms are not typical: nausea, vomiting, headache, malaise,
weaknesses. (All signs and symptoms similar to viral infection).
2. Signs and symptoms of pre eclampsia: hypertension, proteinuria, epigastric pain,
edema, and increased uric acid.
3. The signs of hemolysis intravaskuler:
a. The increase in LDH, AST and bilirubin indirect.
b. Decrease in haptoglobin.
c. Peripheral blood swabs: the fragmentation of erythrocytes.
d. Increased urobilinogen in the urine.
4. Signs of damage / dysfunction hepatosit cells: Increase in ALT, AST, LDH.
5. Thrombocytopenia: Platelets 150.000/ml or less.

All pregnant women with complaints of pain in the quadrant of the abdomen without regard to presence or absence of signs and symptoms of pre eclampsia HELLP syndrome should be considered.

HELLP syndrome classification:
1. Classification Mississippi
Class I: Platelets 50.000/ml or less; serum LDH 600,000 IU / l or more;
AST and / or ALT 40 IU / l or more.
Class II: Platelets over 50,000 to 100.000/ml; serum LDH 600,000 IU / l
or more; AST and / or ALT 40 IU / l or more.
Class III: Platelets over 100,000 to 150.000/ml; serum LDH 600,000 IU / l
or more; AST and / or ALT 40 IU / l or more.
2. Classification Tennessee
Complete class: Platelets less 100.000/ml; 600,000 LDH IU / l or more;
AST 70 IU / l or more.
Class is incomplete: If found 1 or 2 of the signs above.

Diagnosis versus pre-eclampsia HELLP syndrome:
1. Trombotik angiopati
2. Fibrinogen consumptive disorders, such as:
- Acute fatty liver of pregnancy.
- Hypovolaemia heavy / heavy bleeding.
- Sepsis.
3. Connective tissue disorders: SLE.
4. Primary renal disease.

Medical Therapy:
1. Following medical therapy: pre eclampsia and eclampsia.
2. Laboratory for examination and LDH platelets every 12 hours.
3. When platelets less 50.000/ml or any sign of the consumptive coagulopathy
should be checked:
- Left protombin
- Partial thromboplastin time
- Fibrinogen.
4. Giving dexamethasone rescue:
a. Antepartum: double strength given dexamethasone (double dose). If
obtained:
- Platelets less 100.000/cc or
- Platelets 100.000-150.000/cc and with eclampsia, severe hypertension, pain
epigastrium, symptoms of fulminant then given dexamethasone 10 mg IV
every 12 hours.
b. Postpartum: Dexamehasone given 10 mg intravenously every 12 hours 2 times
then followed by 5 mg intravenously every 12 hours 2 times.
c. Dexamethasone therapy was stopped if there is:
1. Improvements laboratory: Platelets more 100.000/ml and decreased LDH.
2. Repair clinic signs and symptoms of pre eclampsia - eclampsia.
5. Can be considered providing:
a. Platelet transfusions when platelets less 50.000/cc.
b. Antioxidants.

Attitude: The management of obstetric

Attitudes toward pregnancy in HELLP syndrome, which is active the pregnancy terminated (termination) without regard to age pregnancy. Vaginal delivery can be done or perabdomen.

Pre eclampsia LIGHTER
Mild pre eclampsia is a pregnancy specific syndrome with decreased perfusion to the organs due to activation vasospasme and endothel.

Diagnostic criteria mild pre eclampsia:
1. Blood Pressure 140/90 - 160/110 mmHg; increase in systolic blood 30 mmHg or
more and an increase in diastolic blood 15 mmHg or more, not included
in the diagnostic criteria for pre eclampsia but need careful observation.
2. Proteinuria 300 mg/24 hours or more the amount of urine or dipstick +1 or more.
3. Edema: local in the legs were not included in the diagnostic criteria except
anasarka.

Management of mild pre eclampsia can be:
1. Outpatient (ambulatoir)
2. Inpatient (hospitalisasi)

Management of outpatient (ambulatoir):
1. No absolute must tirah lie, recommended ambulasi wanted. In
Indonesia tirah lying still needed.
2. Regular diet: do not need a special diet.
3. Pre natal vitamins.
4. No need to salt intake restriction.
5. There is no need granting diuretic, antihypertensive and sedativum.
6. Visits to the hospital every week.

Management of inpatient care (hospitalisasi):
1. Indications of mild pre eclampsia hospitalized (hospitalisasi)
a. Hypertension that persist for over 2 weeks.
b. Proteinuria in a settlement for over 2 weeks.
c. The results of abnormal laboratory tests.
d. The presence of symptoms or signs 1 or more severe pre eclampsia.
2. Inspection and monitoring of the mother
a. Measurement of blood pressure every 4 hours unless you sleep.
b. A careful observation of edema in the face and abdomen.
c. Weighing heavily on the mother's body in the hospital and
weighing done every day.
d. Observation with symptoms of pre eclampsia closely with the impending
eclampsia:
- Pain or occipital frontal head.
- Disturbance visus
- Upper right quadrant pain stomach
- Epigastric pain
3. The laboratory
a. Dipstick proteinuria at the time of entry and followed at least 2 days later.
b. Hematocrit and platelet 2 times a week.
c. Liver function tests 2 times a week.
d. Kidney function tests with measurement of serum creatinine, uric acid and BUN.
e. Measurement of the production of urine every 3 hours (not necessarily with the catheter fixed).
4. Fetal welfare checks
a. Observations fetal movements every day
b. NST 2 times a week
c. Fetal biophysical profile, if the non-reactive NST.
d. Evaluation of fetal growth with ultrasound every 3-4 weeks.
e. Umbilical artery Doppler ultrasound, uterine artery.

Medical treatment:
1. Basically the same as ambulatoar therapy.
2. If there is improvement of symptoms and signs of pre eclampsia and age
pregnancy 37 weeks or more, you still need to be observed for 2-3 days
then be discharged.

Management of obstetric

Depending on the age of pregnancy:
a. If the patient does not inpartu
- Age less than 37 weeks of pregnancy
If signs and symptoms did not worsen, pregnancy can be maintained until
term.
- Age 37 weeks of pregnancy or more
1. Maintained pregnancy until the onset partus arise.
2. If the cervix is ripe on the estimated date of delivery can be considered
performed labor induction.
b. If the patient has inpartu
The journey can be followed by delivery Friedman graphics or partograf WHO.

During hospitalization conducted consultations on:
1. Part of eye disease
2. Part of heart disease
3. Other parts of indications.


Bleeding IN PREGNANCY YOUNG
Bleeding in pregnancy is vaginal bleeding in pregnancy is less than 22 weeks.

General handling young bleeding in pregnancy:
- Make a quick assessment of the general state mengenaii patients, including
vital signs (pulse, blood pressure, respiration, and temperature).
- Check for signs of shock (pale, berkerringat many, fainting, systolic pressure
less than 90 mm Hg, pulse over 112 beats per minute).
- If suspected happens shock, shock treatment mullai soon. If no visible signs of
signs of shock, still consider this possibility when helpers do
evaluation of the condition of women because the condition may worsen with
fast. In the event of shock, it is important to start treatment of shock with
soon.
- If the patient is in a state of shock, the possibility of ectopic pregnancy pikirkaan
upset.
- Install an IV infusion with a large ((16 G or more), given saline solution
physiological or Ringer's lactate with a rapid drop (500 cc in the first 2 hours).

Diagnosis of bleeding in pregnancy:
1. Think about the possibility of ectopic pregnancy in women with anemia, a disease
pelvic inflammation (pelvic inflammatory disease-PID), symptoms or complaints abortion
unusual pain.
Note: If suspected ectopic pregnancy, do the inspection
bimanual carefully for early ectopic pregnancy can be reached easily
rupture.
2. Think about the possibility of abortion in women of reproductive age who have
missed a period (over 1 month since the last menstruation) and have 1 or more
the following signs: bleeding, rigid abdomen, spending some product of conception,
a dilated cervix or uterus that is smaller than it should.
3. If abortion is a possible diagnosis, identify and quickly handle
there are complications.

1. Diagnosis abortion imminens:
- Spots of bleeding until bleeding is. Mild bleeding
It took about 5 minutes to wet gauze or cloth
clear.
- The cervix is closed.
- Uterus in accordance with gestational age.
- Symptoms / signs: lower abdominal cramps and uterine software.
2. The diagnosis of disturbed ectopic pregnancy:
- Spots of bleeding until bleeding is.
- The cervix is closed.
- Uterus slightly larger than the normal gestation
- Symptoms / signs: unsteady or faint, lower abdominal pain, pain porsio rocking,
adneksa mass, and intra-abdominal free fluid.
3. The diagnosis of complete abortion:
- Spots of bleeding until bleeding is.
- The cervix is closed or open.
- The uterus is smaller than the normal gestation
- Symptoms / signs: little or no lower abdominal pain, and history ekspulsi results
conception.
4. Diagnosis abortion insipiens:
- The bleeding was so massive (many). Heavy bleeding requires
less 5 minutes to wet gauze or clean cloth.
- The cervix is open.
- Uterus with age pregnancy.
- Symptoms / signs: cramping / lower abdominal pain, and has not happened ekspulsi results
conception.
5. Diagnosis abortion inkomplit:
- The bleeding was so massive (many).
- The cervix is open.
- Uterus with age pregnancy.
- Symptoms / signs: cramping / lower abdominal pain, and some of the results ekspulsi conception.
6. Molar abortion diagnosis:
- The bleeding was so massive (many).
- The cervix is open.
- Uterus soft and larger than the age of pregnancy
- Symptoms / signs: nausea / vomiting, abdominal cramps down, syndrome-like pre
eclampsia, there is no fetus, and out of networks like wine.

Signs and symptoms include abortion under the abdominal pain, pain free, the uterus felt weak, continue bleeding, weakness, lethargy, fever, smelly vaginal secretions, secretions & pus from the cervix, and cervical pain rocking. Complications were infection / sepsis. Handling is starting to give antibiotics as soon as possible before doing the manual vacuum aspiration. Of antibiotic ampicillin 2 g IV every 6 hours plus gentamicin 5 mg / kgbb IV every 24 hours plus metronidazole 500 mg IV every 8 hours until the mother's fever-free 48 hours.

Other signs and symptoms are pain / stiff in the abdomen, pain free, abdominal distension, abdominal feel tight & hard, shoulder pain, nausea, vomiting, and fever. Complication is injury of the uterus, vagina or bowel. Handling is done laparotomy to repair injury and do manual vacuum aspiration, respectively. Ask for further assistance if needed.

Types of Abortion

The types of abortion:
1. Spontaneous abortion
2. Deliberate abortion
3. Unsafe abortion
4. Septic abortion

Spontaneous abortion is the termination of pregnancy before the fetus reaches viability (22 weeks of gestation). Stages of spontaneous abortion include:
1. Imminens abortion (pregnancy may continue).
2. Insipiens abortion (the pregnancy will not continue and will grow to
inkomplit abortion or abortion complete).
3. Inkomplit abortion (some of the conceptus has been issued).
4. Complete abortion (all the conceptus has been issued).

Deliberate abortion is a process of termination of pregnancy before the fetus reaches viability.

Unsafe abortion is a procedure performed by someone who is inexperienced, or in environments that do not meet minimal medical standards or both.

Septic abortion is that abortion complications of infection, sepsis can be derived from organisms causing infection if the rise of lower urinary tract after a spontaneous abortion or abortion is not safe. Sepsis is likely to occur if there is a remainder of conception or delays in spending the conceptus. Sepsis is a common complication of unsafe abortion by using the equipment.

Handling

If you suspect an unsafe abortion occurs, check for signs of infection or injury of the uterus, vagina and intestinal, vaginal irrigation done to remove vegetation, the local drugs or other substances.

Handling abortion imminens:
1. Do not need special treatment or a total lie tirah.
2. Do not do excessive physical activity or sexual intercourse.
3. If the bleeding:
- Stop: do ante-natal care as usual, do the assessment if
bleeding occurs again.
- Keep going: the value of fetal condition (pregnancy test or ultrasound). Do
confirm the possibility of other causes. The bleeding continues,
especially if the uterus is found larger than expected,
may indicate multiple or molar pregnancy.
4. No need hormonal therapy (estrogen or progestin) or tokolitik (eg
Salbutamol or indomethacin) because these drugs can not prevent
abortion.

Handling abortion insipiens:
1. If age less than 16 weeks of pregnancy, do an evaluation of the uterus by aspiration
manual vacuum. If the evaluation can not, do immediately:
- Give ergometrin 0.2 mg intramuscular (can be repeated after 15 minutes when
necessary) or 400 mcg of misoprostol orally (may be repeated after 4 hours if
necessary).
- Immediately make preparations for spending the conceptus from the uterus.
2. If age over 16 weeks of pregnancy:
- Wait ekspulsi spontaneous conception and evaluation of the remnants of conception.
- If necessary, take 20 units of oxytocin infusion in 500 ml of intravenous fluids
(physiological salt solution or Ringer's lactate) at 40 drops per
minutes to help ekspulsi the conceptus.
3. Be sure to keep monitoring the condition of women after treatment.

Handling abortion inkomplit:
1. If the bleeding is not how much, and less 16 weeks of pregnancy,
evaluation can be done digitally or with pliers ova for
out the conceptus is out through the cervix. If bleeding
stopped, give 0.2 mg of intramuscular ergometrin or 400 mcg misoprostol per
oral.
2. If bleeding a lot or continue and gestational age less than 16
weeks, the rest of the conceptus evaluation with:
- Manual vacuum aspiration is the chosen method of evaluation. Evacuation
with a sharp curette should only be done if the manual vacuum aspiration
not available.
- If evacuation can not be done immediately, give 0.2 mg ergometrin
intramuscular (repeated after 15 minutes if necessary) or 400 mcg misoprostol
per oral (may be repeated after 4 hours if necessary).
3. If pregnancy over 16 weeks:
- Give 20 units of oxytocin infusion in 500 ml of intravenous fluids (physiological salt
or Ringer's lactate) at 40 drops per minute until there is
ekspulsi the conceptus.
- If you need to give misoprostol 200 mcg per vaginal every 4 hours until
occurs ekspulsi the conceptus (maximum 800 mcg).
- Evaluate the rest of the conceptus is left in the uterus.
4. Be sure to keep monitoring the condition of women after treatment.

Handling of complete abortion:
1. No need to evaluate again.
2. Observations to see a lot of bleeding.
3. Be sure to keep monitoring the condition of women after treatment.
4. If there is anemia, sulfas ferrosus tablets provide 600 mg per day
for 2 weeks. If severe anemia, blood transfusions given.
5. Post-abortion care counseling and monitoring information.

Monitoring Post-Abortion
__________________________

Incidence of spontaneous abortion approximately 15% (1 of 7 pregnancies) of all pregnancies.

The requirements begin contraceptive methods within 7 days of an unwanted pregnancy:
1. There were no severe complications that require further treatment.
2. Mothers receive counseling and assistance in choosing a method sufficiently
most appropriate contraception.

Post-abortion contraceptive methods:
1. Condoms
- When the application immediately.
- Effectiveness depends on the level of client discipline.
- Can prevent sexually transmitted diseases.
2. Contraceptive pill
- When the application immediately.
- Self-effective but needs obedience clients to take a pill regularly.
3. Injections
- When the application immediately.
- Counseling for the choice of single or combination of hormones.
4. Implant
- When the application immediately.
- If the couple had 1 child or more and wanted to contraception
long-term.
5. Intrauterine device
- When the application immediately and after the patient recovered.
- Postpone the insert if hemoglobin less than 7 g / dl (anemia) or if the suspected
infection.
6. Tubectomy
- When the application immediately.
- For couples who want to stop fertility.
- If you suspect an infection, delay the procedure until the situation clearly. If
hemoglobin less than 7 g / dL, delay until the anemia has improved.
- Provide an alternative method (such as condoms).

Some women may require:
1. If the client never immunized, give a booster tetanus toxoid 0.5 ml or if
wall of the vagina or cervical canal was contaminated wounds.
2. If the immunization history is not clear, given anti-tetanus serum 1500 units
intramuscular followed by 0.5 ml of tetanus toxoid after 4 weeks.
3. Treatment for sexually transmitted diseases.
4. Cervical cancer screening.

Pregnancy Ektopik Bothered
___________________________

Ectopic pregnancy is a pregnancy with implantation occurs outside the uterine cavity. Fallopian tube is the most common place of implantation of ectopic pregnancy (over 90%).

Signs and symptoms of ectopic pregnancy vary greatly depending on whether the pregnancy broke. Important tool that can be used to diagnose ectopic pregnancies that rupture is of the serum pregnancy test combined with an ultrasound examination. If you obtained the day! Not frozen blood begin treatment.

Signs and symptoms of ectopic pregnancy:
1. Symptoms of early pregnancy in the form of spots or irregular bleeding, nausea, enlarged
breast, discoloration of the vagina & cervix, cervical perlunakan,
enlargement of the uterus, frequency of urination increases.
2. Pain in the abdomen and pelvis.

Signs and symptoms of disturbed ectopic pregnancy:
1. Collapse and fatigue.
2. Pulse rapid and weak (110 times per minute or more).
3. Hypotension.
4. Hypovolemia.
5. Acute abdominal and pelvic pain.
6. Abdominal distension. Abdominal distension with shifting dullness is
evidence of free blood.
7. Pain free.
8. Pale.

Differential diagnosis of ectopic pregnancy is linked imminens abortion. Another appeal diagnosis is pelvic inflammatory disease acute & chronic, ovarian cysts (twist or rupture) and acute Appendisitis. Ultrasound can distinguish between an ectopic pregnancy, abortion and imminens twisted ovarian cyst.

Initial handling of ectopic pregnancy:
1. Immediately do blood tests and laparatomi cross. Do not wait for the blood
before performing surgery.
2. If there are no facilities, immediately refer to the more complete facilities and do
initial assessment.
3. In laparatomi, exploring both ovaries and fallopian tubes:
- Severe tubal damage: do salpingektomi (the conceptus and the tuba
both released). This is the treatment of choice in most
case.
- Damage to the small tube: do salpingostomi (the conceptus issued
and fallopian maintained). This is done by considering
conservation of fertility because of the risk of subsequent ectopic pregnancy is high.

If there is bleeding a lot can be done autotransfusi if intraabdominal blood still fresh and not infected or contaminated (by the end of pregnancy, the blood can be contaminated with amniotic fluid and others that should not be used for autotransfusi). Blood can be collected before surgery or after abdominal opening:
1. As the mother lay on the operating table before surgery and abdominal
looked tense due to the blood gathering, as it allows for
insert the needle through the abdominal wall and the blood collected is set
donors.
2. Alternatively, open the abdomen:
- Take the blood into a place and using the blood filter
screen to separate the blood clot.
- Clean the top of the blood bag with an antiseptic and open
with a sterile knife.
- Pour the blood of these women into the bag and re-enter
through a set of filters in the normal way.
- If there is no donor bag with anticoagulant, add sodium
citrate 10 ml for every 90 ml of blood.

Further handling:
1. Before allowing the mother came home, doing counseling and advice on
fertility prognosis. Given the increased risk of ectopic pregnancy
next, counseling and provision of contraceptive methods contraceptive methods,
if desired, is essential.
2. Fix sulfas anemia with ferrous 600 mg / hr per orally for 2 weeks.
3. Schedule the next visit to monitoring within 4 weeks.

Hydatidiform mole
_______________

Molar pregnancy is an abnormal proliferation of the villi khorialis.

Initial handling of molar pregnancy:
If the diagnosis of molar pregnancy has been established, evaluate the uterus:
- If required dilatation of the cervix, gunakkan block paraservikal.
- Discharging with manuaal vacuum aspiration is safer than kuretase
sharp. Risk of perforation by using a sharp curette is high enough.
- If the source is a vacuum tube manual, prepare a vacuum aspiration equipment
manual at least 3 sets to be used interchangeably to
uteri finished pouch emptying. The contents of the uterus, but significant enough to
quickly emptied.

Subsequent handling of molar pregnancy:
- Patients are encouraged to use hormonal konntrasepsi (if still want to
children) or tubectomy if you want to stop fertility.
- Conduct monitoring every 8 weeks selaama least 1 year post-evacuation
by using a urine pregnancy test because of the risk
trophoblast disease persist or khoriokarsinoma. If test
urine pregnancy with no negative after 8 weeks or becomes positive
back in the first 2 years, refer to a tertiary medical center for
monitoring and further treatment.