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PRETES 4

SYAH RINI WISDAYANTI DR. SP.OG,M.KES

1. Which is not an indication for

transfer of a pregnant patient to

an intensive care unit?

a. Need for invasive monitoring

b. Impending respiratory failure

c. Thyrotoxicosis with

normotensive tachycardia

d. Refractory hypotension

despite adequate resuscitation

2.

a.

b.

c.

d.

3.

a.

b.

c.

d.

4. Why does ventricle

performance, measured

with the use of pulmonary

artery catheters, remain

within normal range in

term pregnant women?

a. Increased pulse rate

b. Decreased vascular

resistance

c. Increased blood

volume and cardiac

output

d. All of the above

5. Which of the following changes

would cause an increase in stroke

volume?

a. Increase in heart rate

b. Increase in cardiac output

c. Increase in systemic vascular

resistance

d. Decrease in pulmonary

vascular resistance

6. What is the most common cause

of pulmonary edema in a pregnant

patient?

a. Sepsis

b. Cardiac failure

c. Iatrogenic fluid overload

d. Hypertensive disorders

7. When diagnosing acute

respiratory distress syndrome,

which criteria is necessary?

a. PaO2:FiO2 <300

b. Evidence of heart failure

c. Chest radiograph with

pulmonary infiltrates

d. All these criteria are

necessary

8. When managing pregnant

women with severe acute lung

injury, which intervention is most

effective for improving oxygen

delivery?

a. Maximizing FiO2

b. Antibiotic therapy

c. Delivery of the fetus

d. Transfusion to correct

anemia

9. In order to maintain placental

perfusion during pregnancy a

hemoglobin oxygen saturation of

at least 90% is preferred. What is

the goal PaO2 in the management

of acute respiratory distress

syndrome in pregnancy?

a. >40 mm Hg

b. >60 mm Hg

c. >80 mm Hg

d. >100 mm Hg

10. Positive end-expiratory

pressure is sometimes increased

to 5–15 mm Hg to accomplish

adequate ventilation in cases of

severe lung injury. Which is a

possible complication of using

high levels of positive end-

expiratory pressure in pregnancy?

a. Barotrauma

b. Decreased cardiac output

c. Decreased uteroplacental

perfusion

d. All of the above

11. Obesity increases the risk for

maternal death by how much?

a. 2-fold

b. 4-fold

c. 10-fold

d. It does not increase the risk

12. Which of the following is not

associated with nonalcoholic fatty

liver disease?

a. Preeclampsia

b. Preterm birth

c. Hypoglycemia

d. Low birthweight

13. What is the prevalence of

wound infection in obese (body

mass index >30 kg/m2) pregnant

women?

a. 0.1%

b. 0.5%

c. 1.0%

d. 5.0%

14. What is the odds ratio for

preeclampsia in obese (body mass

index >30 kg/m2) pregnant

women?

a. 1

b. 2

c. 3

d. 5

15. What is the highest ranking

modifiable risk factor for stillbirth?

a. Obesity

b. Cocaine use

c. Mental illness

d. Vitamin deficiencies

16. Which of the following is more

common in obese pregnant

women?

a. Macrosomia

b. Neural tube defect

c. Congenital heart defect

d. All of the above

17. A 25-year-old primigravida at 20 weeks’ gestation

presents for her anatomy ultrasound. The patient has a

body mass index of 45 kg/m2. Which of the following

statements should be part of this patient’s

counseling?

a. Obesity limits the accuracy of the ultrasound, but

obesity does not increase the risk for birth defects.

b. Obesity does not limit the accuracy of the

ultrasound nor does it increase the risk for birth

defects.

c. Obesity increases the risk for certain birth

defects, but ultrasound remains excellent at

identifying these problems.

d. Obesity increases the risk for certain birth

defects, and obesity limits the accuracy of the

ultrasound done to identify those problems.

18. A 30-year-old primigravida at

12 weeks’ gestation presents for

prenatal care. She has a body

mass index of 35 kg/m2. How

much weight should she gain this

pregnancy?

a. 5–10 pounds

b. 11–20 pounds

c. 15–25 pounds

d. 25–40 pounds

19. A 26-year-old primigravida at

10 weeks’ gestation presents for

prenatal care. She is 5 feet 7

inches tall and 170 pounds. How

much weight should she gain this

pregnancy?

a. 5–10 pounds

b. 11–20 pounds

c. 15–25 pounds

d. 25–40 pounds

20. Why have lifestyle interventions such as

exercise in obese pregnant women not been

shown to significantly improve neonatal

outcomes?

a. Endorphin release with exercise increases

insulin resistance

b. Early gene expression within the placenta

has already been programmed

c. Patients are not capable of changing as

dramatically as needed to make a significant

difference

d. Increased physical activity increases

hunger disproportionately, which results in

increasedweight gain

DEFINISI INTERNATIONAL CONTINENCE SOCIETY (ICS)

adalah keluarnya urin yang tidak dapat

dikontrol/dikendalikan, yang dapat dibuktikan secara

objektif, merupakan masalah higiene dan sosial

Sosial: tidak berhubungan dengan orang sekitarnya

atau menghambat aktivitas yang sebelumnya pernah

dilakukan, ex pengajian, olah raga

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ADA 2 MACAM

True inkontinensia:

o Stress incontinence

o OAB

o Overflow incontinence

o Continue incontinence / fistula

Untrue incontinence: Transient incontinence

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FAKTOR RISIKO

A. Faktor intrinsik

Usia

Genetik

Ras

Kelainan bawaan

Hormonal

B. Faktor ekstrinsik

Kehamilan, persalinan (paritas)

Kebiasaan buruk: peminum, perokok, konstipasi

Olah raga angkat berat

Riwayat operasi, trauma, radiasi, kemoterapi

Batuk kronis, asma, diabetes

Obat-obatan

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KLASIFIKASI A. True incontinence

Yang terbanyak di bidang uroginekologi:

1. Inkontinensia Stres

Terjadi bila tekanan intravesika melebihi tekanan maksiumum intraveksika tanpa adanya tekanan dari detrusor

- Intrinsic Sphincter Deficiency

- Urethral hypermobility

2. Over Active Bladder

Overactive hyperreflexia

- Detrussor instability / Idiopathic

3. Overflow incontinence

Urinary retension

4. Continue incontinence

Urogenital fistula

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B. UNTRUE INCONTINENCE

Transient incontinence DIAPPERS

o Delirium

o Infection

o Atrophi vaginitis

o Psichys

o Pharmacy

o Endocrine

o Restricted mobility

o Stool impaction

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Etiologi dan Patofisiologi

Inkompetensi mekanisme penutupan urethra

I. Intrinsic Sphincter Deficiency (ISD) 5-10%

loss of the urethral resistance

urethral closure pressure decrease

stress incontinence

II. Urethral Hypermobility 90-95%

descent of the bladder neck and proximal urethra

pressure transmission decrease

stress incontinence

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panjang N urethra pada wanita 3-5 cm, lumen 0,6 cm.

Menurut Petros, kelemahan ada di mid urethra

Penyebab hipermobilitas:

Persalinan (Kehamilan juga ada, tapi kecil)

Usia

Menopause (hormonal atrofi p.d)

Tekanan intraabdominal khronik (batuk kronik, konstipasi, obesitas)

Denervasi pelvic

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PENYEBAB ISD:

Operasi berulang sebelumnya (skene, divertikel, polip)

Trauma

Radiasi

Neurogenik disorders termasuk DM

Atropic changes lack of estrogen,

Myelodisplasia, menyebabkan kerusakan pada onuf

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PEMERIKSAAN KHUSUS INKONTINENSIA STRES

Tes batuk/bonney test/spoon test/pesarium test/pad test

Penjelasan:

1. Tes batuk positif bila keluar urin saat pasien diminta batuk

syarat :VU terisi minimal 150-200 cc.

Posisi: litotomi, berdiri

2. Bonney test jari telunjuk dan jari tengah pemeriksa diletakkan periurethra melalui dinding

vagina anterior. Bonney test positif bila tanpa penekanan keluar urin pada peningkatan tekanan

intraabdomen, tetapi bila jari ditekan ke arah urethra tidak keluar urin pada peningkatan tekanan

intraabdomen.

3. Q-tip test/spoon test dengan cotton bud yang dimasukkan ke lumen urethra, pasien diminta

batuk, dinilai perubahan sudut yang terjadi. Normal bila sudut 20-300, meskipun hasil ini tidak

valid oleh karena banyak penyimpangan. Abnormal (hipermobilitas) bila sudut >30 derajat ok

berarti bladder neck-nya sudah melebar.

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4. Pesarium test

Tanpa pesarium maka urin akan keluar saat peningkatan tekanan intraabdomen. Dengan pesarium, maka urin

tidak keluar lagi saat peningkatan tekanan intraabdomen.

5. Pad test (tes pembalut)

ukur berat pad sebelum mulai tes, pasien diminta berkemih

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Klinis beratnya inkontinensia stres: bila keluarnya urin saat:

o Batuk kuat inkontinensia stres ringan

o Batuk ringan inkontinensia stres sedang

o Lompat-lompat inkontinensia stres berat

o Berdiri inkontinensia stres sangat berat

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TERAPI/TATA LAKSANA

di bidang uroginekologi kalau tidak ada keluhan tidak perlu terapi

Pencegahan kenali dan atasi faktor risiko

pembatasan hamil dan partus keluarga berencana

pencegahan sakit batuk kronis, diabetes, asma dll

Kegel exercise (murah, meriah tapi kurang efisien)

Konservatif

Indikasi:

inkontinensia stres ringan

menunda operasi

inkontinensia stres dengan kombinasi instabilitas detrusor

ada komplikasi bila dilakukan operasi/anestesi

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Macamnya:

1. Kegel exercise minimal 3 bulan (murah, meriah, tapi kurang efisien)

Tujuan: melatih otot levator ani (sehingga sudut vagina menjadi 450 di distal dan 1200 di

proksimal),

Keberhasilan kegel exercise tergantung:

Pasien tahu otot mana yang dikontraksikan

Tahu bagaimana cara mengkontraksikannya

Menyediakan waktu khusus untuk melakukannya

2. Vaginal cone

diameter 20-24mm terbuat dari kayu, beban bervariasi

diberi tali dengan beban 10-60gram

tiap minggu diameter diturunkan, beban dinaikkan

lamanya 3 bulan

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3. Positive feedback/perineometri

menggunakan rangsangan listrik

tujuan: melatih otot supaya otot hipertropi

4. Electro stimulation

5. Obat-obatan:

• estrogen

• alfa adrenergik agents contoh: propil propanolamin

Kombinasi kedua obat ini tidak digunakan bersama-sama lagi karena mengakibatkan perdarahan subdural

Estrogen boleh diberikan pada kasus yang sangat ringan

6. Akupuntur

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Terapi konservatif pada inkontinensia stres

ringan keberhasilan mencapai 90%

sedang 40-80%

berat 20-40% (hanya untuk menunggu operasi)

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OPERATIF

Kolporafi anterior:

Kelly plication paraurethra dijahit (dilipatkan) rekurensi 35%

Kelly Kennedy Kelly plication+kolporafi anterior rekurensi 60%

Suburethral bulging/bulking agent (transvaginal needle bladder neck suspension):

• Bahan:

a. koloid

b. silikon

• Jangan terlalu banyak, bisa retensio urin

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Retropubic suspension:

MMK (Marshall Marchetti Krantz)/ Eropa buka cavum Retzii, pisahkan

vesica urinaria dari simfisis pubis secara tumpul sampai mendapatkan urethra. Jaringan paraurethra dijahitkan ke

perios pubis (tulang) dengan prolene. Keberhasilan 70-80%. Yang jadi masalah adalah perdarahan pada tulang

yang sulit diatasi. Juga risiko terjadi infeksi yang bisa menjadi kronis.

Burch colposuspension/ Amerika jaringan paravaginal/paraurethra dijahit ke ligamen iliopektinea/ Cooper/jalan

dari simpisis ke spina ishiadika (80% berhasil baik). Lig Cooper merupakan penebalan perios yang berjalan antara

pubis dan spina ischiadika. Hasilnya cukup bagus. Tapi bisa rekurensi oleh karena ligamentum Cooper makin lama

makin lemah juga.

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Sling procedure

o Tujuan:menggantung urethra

o Materi:

fasia gracilis, tahun 1912, oleh Gooble

fasia rectus, tahun 1914, oleh franklin

fasia lata

prolene

mesh, 10 tahun terakhir:

TVT (Tension free Vaginal Tape)/ menggantung urethra kearah anterior supra simpisis

(risiko trauma kandung kemih atau usus atau robeka arteri iliaka eksterna dan

TVT-O (pain, reject, infeksi) risiko cedera buli dan nervus ishiadika

TOT (Trans Obturator Tape) bisa cedera pembuluh darah dan saraf

o Cara: Cavum Retzii dibuka, sling diletakkan di bawah urethra.

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21. A 45-year-old multipara

presents with involuntary loss of

urine with coughing or sneezing

that has become progressively

more frequent during the past 2

years. This complaint typically

reflects which of the following

incontinence forms?

a. Stress incontinence

b. Urgency incontinence

c. Over ow incontinence

d. Functional incontinence

22. If the symptoms of overactive

bladder or urgency incontinence

are objectively demonstrated

during urodynamic testing, which

of the following terms is used?

a. Detrusor overactivity

b. Functional incontinence

c. Genuine urgency

incontinence

d. Verified urgency

incontinence

23. If stress incontinence is documented during urodynamic

testing, which of the following terms is used?

a. Detrusor overactivity

b. Functional incontinence

c. Veri ed urge incontinence

d. Urodynamic stress incontinence

24. Which age-related physiologic change

predisposes to incontinence or voiding

dificulties?

a. Increase in urinary flow rate

b. Increase in total bladder capacity

c. Increase in involuntary detrusor

contractions

d. Diurnal-predominant (daytime) fluid

excretion

25. Hypoestrogenism is linked to a greater risk of

incontinence through which of the following mechanisms?

a. Increased urethral collagen volume

b. Atrophy of the urethral mucosal seal

c. Increased compliance o urethral sphincter

musculature

d. All of the above