PRE TES 2. dr. Syah Rini Wisdayanti Sp.OG,M.Kes

PRE TES 2

Pendahuluan

Intrauterine Growth Restriction (IUGR)

Kegagalan janin untuk mencapai perkembangan yang sesuai

potensinya

Saat ini, diagnosis berdasarkan EFW (Estimated Fetal Weight) di bawah

persentil 10



Sensitivitas kurang

(gagal terdiagnosis bila ada hambatan perkembangan, namun

EFW janin tidak kurang dari persentil 10)

Luaran perinatal buruk



Penegakan diagnosis merupakan hal yang penting



Mencegah Intrauterine Fetal Death (IUFD), cedera otak perinatal dan fetal distress intrapartum yang berat

Managemen untuk monitoring dan rekomendasi usia saat

persalinan

Fase Pertumbuhan

Hiperplasia

•

0-16 minggu

•

Mitosis cepat

•

Jumlah DNA



Hiperplasia

& Hipertrofi

•

17-32 minggu

•

Mitosis



•

Ukuran sel



Hipertrofi

•

>32 minggu

•

Ukuran sel



,

deposisi lemak,

massa otot dan

jaringan ikat

15 minggu

5 gram/hari

24 minggu

10-20

gram/hari

34 minggu

30- 35

gram/hari

Fase Pertumbuhan

Peningkatan berat

janin (gram/hari)

berdasarkan usia

kehamilan

garis hitam: rata-rata garis biru: ± standar deviasi

Faktor Risiko dan

Etiologi

Faktor Risiko yang

mempengaruhi

pertumbuhan janin

terhambat meliputi

potensi abnormalitas

pada ibu, janin, dan

plasenta

Identifikasi

perkembangan

janin

↓

Sonography

Paling umum dilakukan

Femur Length

Biparietal diameter

Head circumference

Abdominal

circumference

Estimated

Fetal Weight

(EFW)

IUGR vs SGA

Janin Kecil

IUGR

Intrauterine Growth Restriction

SGA

Small for Gestational Age

Janin yang kecil, dengan risiko luaran perinatal lebih buruk

dibandingkan janin yang tumbuh normal

Terdapat redistribusi

hemodinamik sebagai respon adaptasi janin terhadap kondisi

undernutrition, hipoksia atau

gangguan (insufiseiensi) plasenta

Janin yang kecil, dengan luaran perinatal yang sama baik seperti janin yang tumbuh

normal

Tidak terdapat tanda-tanda respon adaptasi janin terhadap perubahan pada lingkungannya juga mempunyai risiko kelainan

perinatal dan neurodevelopmental

1. Which of the following is not true regarding intrauterine growth restriction?

• A. It is associated with premature labour

• B. It may be associated with a low socio-economic status

• C. These babies are at an increased risk of developing respiratory distress syndrome

• D. It may be associated with raised serum AFP at 16 weeks followed by normal scan

at18 weeks

Kehamilan multifetal meningkat sebanyak 3% pada populasi dunia. Persalinan preterm merupakan masalah utama dari kehamilan multifetal, global survey dari WHO menyatakan 35.2 % kehamilan multifetal berakhir

dengan persalinan preterm (Fallis, 2013; Wei, 2016)

PENDAHULUAN

Kehamilan multifetal merupakan hasil dari 2 atau lebih kejadian fertilisasi, fertilisasi tunggal diikuti

pembelahan ”erroneous´ dari zigot, atau kombinasi dari keduanya (Cunningham, 2018)

FAKTOR RISIKO

• 3,5% pada wanita kulit hitam, 3 % pada wanita kulit putih. Wanita Hispanik, Asia dan Amerika kemungkinanya lebih rendah daripada wanita kulit putih.

Ras

• Kejadian kembar dizigot meningkat pada usia 15-37 tahun

Usia saat kehamilan

• Kemungkinan meningkat 8x lipat saat paritas ≤4 dan 20x lipat saat paritas ≥5 (Olusanya,2012)

Jumlah paritas

• Riwayat kembar dari ibu lebih berpengaruh daripada riwayat kembar dari ayah

Hereditas

• Beberapa penelitian menunjukkan wanita yang mendapat asam folat memiliki prevalensi yang lebih tinggi. Pada World

War II di eropa saat pemenuhan nutrisi bagi wanita hamil

lebih sulit tercatat penurunan angka kehamilan kembar

Nutrisi

• Peningkatan kelahiran kembar berkaitan dengan pelepasan FSH hipofisis yang berlebihan sebagai respons terhadap penurunan umpan balik negatif dari kegagalan impending ovarium

Gonadotropin Pituari

• Induksi ovulasi dengan FSH plus human chorionic

gonadotropin (hCG) atau klomifen sitrat meningkatkan

kemungkinan ovulasi bersamaan.

Terapi Infertilitas

DIZIGOTIK VS

MONOZIGOTIK

Dizigotik

Lebih sering Dipengaruhi kadar FSH (geografi, ras, multipara, usia, kontrasepsi) Selalu dikorionik

Monozigotik

Jarang (3.5-4/1000 kelahiran) Paling dipengaruhi genetik Korionisitas tergantung kapan membelah (Cunningham et al, 2018) (Basiri et al, 2019)

KLASIFIKASI

DICHORIO

N

19

DIAGNOSIS MULTIFETAL

Evaluasi Klinis

Sonograf

• Pengukuran TFU. Memantau

pertumbuhan janin & volume cairan amnion. Pada uk 20-30 minggu dapat > 5 cm daripada kehamilan tunggal

• Palpasi. Menentukan bagian

janin pada trimester ketiga, penyulit : posisi janin saling tumpang tindih, ibu dengan obesitas dan hidramnion.

• Pemeriksaan DJJ, dengan

alat Doppler dapat dibedakan jika letak jantung janin cukup berjauhan

• Tidak disarankan diagnosa

multifetal hanya

menggunakan 1 kriteria

Gambar 2 A. Sonografi “puncakkembar”/”tandal lambda” B. Sonografi dengan “tanda T”

Pemeriksaan sonografi pada trimester pertama, sering terjadi deteksi dini kehamilan kembar Sonografi juga dapat digunakan untuk menentukan jumlah janin, perkiraan usia kehamilan, korionisitas, dan amnionisitas. Dengan pemeriksaan yang cermat, jika ada kantung kehamilan yang terpisah, dapat diidentifikasi pada awal kehamilan kembar.

Alat Bantu Diagnostik lainnya:

• Radiografi abdominal  sulit saat janin bergerak dan uk <18minggu • Magnetic Resonannce Imaging  patologi kembar yang lebih detail

• Kadar β-hCG dan maternal serum levels of alpha-fetoprotein (MSAFP)  meningkat

• Evaluasi USG  perkiraan usia kehamilan, menentukan korionisitas dan screening Down’s syndrome

Menentukan usia kehamilan dan korionisitas

• Lebih beresiko anemia  rutin evaluasi  as folat/zat besi

Diet and Nutrisi

Perawatan spesialistik

• Skrining down syndrome saat CRL : 45 mm - 84 mm (pada usia kehamilan : 11 – 13+6 minggu)

• Screening kombinasi : nuchal translucency, β hCG , pregnancy

associated plasma protein A)

• Monitoring untuk IUGR

SKRINING

Usia kehamilan 16-17, 19-20, dan 21-22 minggu

untuk skrining TTTS dan TAPS serta skrining jantung sebagai bagian dari skrining anatomi

lengkap pada minggu ke 18-19 minggu atau pada minggu ke 21-22.

USG pada usia kehamilan 11+0 _minggu

hingga 13+6 _{minggu (CRL 45-84 mm)}

berfungsi untuk menilai viabilitas janin, usia kehamilan dan korionisitas, serta melihat

adanya malformasi kongenital mayor

Jika tidak terdapat kelainan dilanjutkan pemeriksaan pertumbuhan pada

PILIHAN PERSALINAN

 Direncanakan sejak UK 24 - 28 minggu (tempat, waktu, metode, dan

resiko persalinan)

- Tanpa komplikasi uncomplicated triplet pregnancies elektif UK 35 minggu (setelah + kortikosteroid)

 Persiapan standar untuk pelaksanaan persalinan + pertimbangan

khusus untuk wanita dengan kehamilan multifetal

 Posisi dan presentasi janin paling baik dikonfirmasi secara sonografi

Gambar 3. Macam-macam presentasi janin pada kehamilan

kembar

Sumber: https://obgynkey.com/multiple-pregnancy-and-other-antenatal-complications/

2016 Royal College of Obstetricians and Gynaecologists

Christopher D, Robinson BK, Peaceman AM. An evidence-based approach to determining route of delivery for twin gestations. Rev Obstet Gynecol. 2011;4(3-4):109-116.

Gambar 4. Alur pemilihan persalinan pada kehamilan kembar

(Christoper, 2011)

MATERNAL

Persalinan preterm (35.2%) ( Jun Wei, 2016) Hipertensi dalam kehamilan 2.5 -2.8 kali (Devine and Malone, 2004) Diabetes dalam kehamilan 2.2 kali (Rauh-Hain et al., 2009). AFLP 7.1% hingga 28.6% (Minakami et al., 2014). Anemia (multifetal triplet, 70%)

(Devine and Malone, 2004). Cholelitiasis 0.4% - 5.5% (Rissanen et al., 2019)

KOMPLIKASI

(ACOG, 2016)

KOMPLIKASI

Preterm Delivery

Deteksi

• Pada pasien asimptomatik tidak dianjurkan melakukan tindakan intervensi yang bertujuan untuk skrining risiko preterm

• Pada pasien simtomatik dapat dilakukan pengukuran panjang serviks dan skrining fetal fibronectin sebagai bantuan untuk prediksi risiko kelahiran preterm. Panjang serviks 25mm adalah cut-off paling sering digunakan pada trimester kedua

Pencegahan

• Belum ada Tindakan intervensi yang direkomendasikan _{untuk memprolong masa kehamilan}

Manajemen

• Tokolitik dapat diberikan untuk memperpanjang masa kehamilan jangka pendek

• Pemberian kortikosteroid antenatal untuk wanita hamil usia 24-34 minggu mengurangi insiden kematian neonatal karena distres pernapasan

• Pemberian magnesium sulfat prenatal dapat dilakukan untuk mengurangi terjadinya cerebral palsy

FETAL

Gambar 2. Overview insidensi komplikasi kehamilan ganda (Cunningham, 2014)

KOMPLIKASI

Dichorion

Diamnion Monochorion Diamnion Monochorion Monoamnion

TTTS Rare 15% 2-6%

TAPS - Up to 5 % -

TRAP - 1% 1%

sIUGR 11.6% 12% -

Tabel 1. Insidensi komplikasi fetal pada kehamilan Multifetal (Rauh-Hain et al., 2009; Anca et al.,

2015; Buyukkaya, Tekbas and Buyukkaya, 2015; Johnson, 2015; K.Behavkova, 2016; Lanna et al., 2019; Antonakopoulos et al., 2020; Gleeson et al., 2020)

KOMPLIKASI

Twin to Twin Trnasfussion syndrome

Mempengaruhi 15% dari kehamilan multifetal monochorionic.

FETAL

• Treament of choice adalah ablasi laser

pada quintero stage II

(Rekomendasi: A)

• Konservatif management dilakukan

pada quintero stage I (Rekomendasi B)

• Amnioreduction bertahan sebelum

usia kehamilan 26 minggu

(Rekomedasi A) (Khalil et al., 2016)

KOMPLIKASI

Twin Anemia – Polycyteamia Sequence (TAPS)

Mempengaruhi 2% dari kehamilan multifetal dan 13% setelah mendapatkan terapi ablasi laser

FETAL

Pilihan terapi pada TAPS bergantung kasus per kasus. Terapi paling umum adalah konservatif, early delivery, ablasi

laser, transfusi intrauterine, partial

exchange transfusion (Evidence Level 3)

(Khalil et al., 2016).

KOMPLIKASI

Twin Reversed Arterial PerfusionSequence (TRAPS)

FETAL

Terapi utama dari TRAPS

adalah discontinuation

transfusion dari janin

acardiac, dengan cara

ligasi tali pusat dari janin acardiac (Evidence Level 3).

(Khalil et al., 2016)

Twin Reverse Arterial Perfussion (TRAP) terjadi pada 1% kehamilan multifetal dengan

janin kedua acardiac.

KOMPLIKASI

Selective Intra Uterine Growth Restriction

FETAL

Terminasi merupakan pilihan utama dimana bila termasuk dalam tipe I direkomendasikan pada usia kehamilan 34-36 minggu, sedangkan pada tipe II dan III disarankan dilakukan terminasi pada usia kehamilan 32 minggu

MANAGEMENT

• sFGR, secara konvensional, didefinisikan sebagai suatu kondisi di mana satu janin memiliki EFW <10 percentile dan diskrepansi EFW dengan kembarannya > 25%

• Terjadi pada 10-15% kehamilan multifetal

• Tipe I, waveform doppler arteri umbilikalis terdapat positive end-diastolic flow

• Tipe II, terdapat absent or reversed end-diastolic flow (AREDF).

• Tipe III, terdapat pola AREDF yang memebntuk siklus/intermittent

2. Which of the following is true regarding the monozygotic twins?

• A. Are more common than dizygotic twins

• B. Are commonly familial

• C. May be reliably distinguished from dizygotic twins by the naked-eye examination

of the foetal membranes and placentae

• D. Have a higher incidence of placenta praevia than singleton pregnancies

3. Which of the following complication is associated with multiple births?

• A. Increased incidence of congenital abnormalities

• B. Increased incidence of growth retardation

• C. Increased incidence of postpartum haemorrhage

• D. Increased incidence of preterm labour

4. Second trimester bleeding may be due to which of the following cause? • A. Missed abortion • B. Premature labour • C. Erythroblastosis fetalis • D. Threatened abortion • E. Monilial infection

5. Which of the following is not true regarding ABO blood group incompatibility between mother and foetus?

• A. It is associated with a strongly positive direct Coombs’ test

• B. Its severity does not vary between the first and subsequent pregnancies

• C. It is usually detected in the antenatal period

• D. Manifests itself on the first or second day of life

6. Which of the following is not true regarding preimplantation genetic diagnosis?

• A. Disorders caused by a single gene defect can be detected

• B. It should be used to exclude Down syndrome in a couple undergoing IVF using a

donor ovum from a 23-year-old, into a 46-year-old recipient

• C. Foetal sex can be determined

• D. HLA status can be determined

7. Which of the following is true regarding a 37 yearold-woman at 16 weeks’ gestation?

• A. Has a risk of Down syndrome of 1:100

• B. Should be advised to have screening for Down syndrome

• C. Should be advised to have amniocentesis, not the ‘triple’ test

• D. Is at increased risk of Edward’s syndrome

8. Regarding ‘HELLP’ syndrome which of the following statement is not true?

• A. It is related to preeclampsia

• B. It may occur in non-pregnant patients

• C. Upper abdominal quadrant pain is a characteristic feature

• D. Patients may have low platelets

9. Which of the following statement is correct regarding the foetal scalp ph?

• A. A result of 7.28 is normal

• B. Accurately determines the condition of the baby

• C. Carries no risk

• D. Cannot be performed in cases of breech presentation

• E. Increases the Caesarean section rate in patients having continuous electronic

10. Which of the following is not true regarding the epidural space?

• A. Commences at the foramen magnum

• B. Contains Batson’s plexus

• C. Ends at the level of S2 in the adult

• D. Negative pressure within the space is greatest in the lumbar and sacral regions

11. Which of the following is true regarding classical caesarean section?

• A. Is Caesarean section performed through a mid-line abdominal incision

• B. Is never done nowadays

• C. Carries an increased risk of dehiscence of the abdominal wound

• D. Is a ground for elective repeat caesarean section

12. Which of the following is not true regarding the ventouse method of delivery?

• A. May employ a metal cup

• B. Has increased in popularity with electronic pumps

• C. Can be used safely in the absence of criteria necessary for a forceps delivery

• D. Requires the patient to be in the lithotomy position

13. Which of the following steps must be taken at the time of massive post-partum haemorrhage?

• A. An anaesthetist is essential to assist in the management of the patient

• B. Initial cross-matching of three units of blood is sufficient

• C. Bimanual uterine compression has no role in these cases

• D. Uncross-matched O rhesus-positive blood may be given in an emergency

14. Which of the following is true regarding breastfeeding?

• A. Human milk contains more protein than cow milk.

• B. Human milk has a higher energy content and more fat than cow milk

• C. Breast feeding does not protect against infection in the baby.

• D. Breast milk is of uniform composition throughout a feed.

15. Hydramnios is not associated with which of the following conditions?

• A. Twin-twin transfusion syndrome

• B. Diabetes

• C. Potter’s syndrome

• D. Hydrops fetalis

16. Which of the following is not true regarding the routine ultrasound scan at 18– 20+6

weeks?

• A. The National Screening Committee has recommended 6 basic measurements that should be taken

• B. The National Screening Committee has identified 11 foetal anomalies to be looked for • C. Screening for placenta praevia is at the top of the list

• D. Choroid plexus cysts no longer need any response • E. Presence of echogenic bowel requires a response

17. Epidural bupivacaine administered during labour may cause which of the following?

• A. An increased rate of caesarean delivery

• B. Decreased uterine contractility

• C. Pruritus

• D. Tinnitus

18. Which of the following statement is not correct regarding external cephalic version?

• A. Anti-D should be given to rhesus negative mothers.

• B. Is best done at 32 weeks

• C. Reduces the incidence of breech presentation at term

• D. Is more successful if a beta-sympathomimetic is used

19. Which of the following is not true regarding a newborn term infant?

• A. Anaemia may be caused by a cephalhaematoma

• B. Ballotable kidneys may not always be abnormal

• C. Oedema of the feet and hands suggest Turner’s syndrome

• D. The Apgar score at 5 minutes is more predictive of later neurodevelopment

prognosis than Apgar score at 1 minute

• E. The findings of bilateral single palmar creases in an otherwise normal-appearing

20. Which of the following is true regarding haemoglobin values of less 10g/dl during pregnancy?

• A. Is a recognised side-effect of anti-convulsant therapy

• B. Is associated with urinary tract infection

• C. Is a complication of multiple pregnancy

• D. Increases the risk of post-partum haemorrhage

21. Which of the following is true regarding thyrotoxicosis in pregnancy?

• A. It is usually due to a solitary adenoma

• B. The major maternal risk is congestive cardiac failure

• C. Beta-blocking drugs are contra-indicated

• D. May be treated with radioactive iodine as the drug does not cross the placenta

22. Which of the following is true regarding hypertension in pregnancy?

• A. It is of little significance unless accompanied by proteinuria

• B. It causes foetal growth restriction in more than half of affected women

• C. It is not associated with an increased incidence of bleeding from placental

praevia

• D. It should be assessed by admission to hospital

23. Which of the following is not true concerning the blood pressure regulation?

• A. Adrenaline acts primarily upon the vasomotor centre

• B. Angiotensinogen is inactive without modification

• C. Bradykinin decreases blood pressure

• D. Prostacyclin lowers blood pressure

24. Which of the following is not true regarding placental abruption?

• A. May have no associated vaginal bleeding

• B. Is an indication for delivery

• C. Has a higher incidence with maternal cocaine abuse

• D. May be identified using ultrasound to demonstrate retroplacental clot

• E. The diagnosis of concealed abruption can be easily confused with that of acute

25. Which of the following is true regarding the Kleihauer test?

• A. It may be used to confirm the presence of Rhesus antibodies

• B. It should be performed routinely at 28 and 36 weeks in the woman who is rhesus

negative

• C. It is no longer required after delivery in the Rhesus negative woman

• D. It is based on the relative resistance of foetal haemoglobin to denaturation using

an acid solution