Kehamilan Ektopik Terganggu

Kehamilan Ektopik Terganggu

dr. Refinaldi, SpOG

Kehamilan Ektopik• Implantasi di tempat selain endometrium di kavum uteri• 40% etiologi tidak diketahui

ACOG (USA):• 200415% penyebab kematian maternal• 20082% dari kehamilan trimester pertama • 95% segmen tuba fallopiampula• 5% ovarium, kavitas peritoneum, serviks

1. Chan PD, Johnson SM. New ACOG Treatment Guidelines, Current Clinical Strategies, Gynecology and Obstetrics, 2004 Edition. California: Current Clinical Strategies Publishing.p. 21-4.

2. Pitkin J, Peattie AB, Magowan BA. Obstetrics and Gynaecology, An Illustrated Colour Text. United Kingdom: Churchill Livingstone. p. 98-9.3. Yates M, King J. Ectopic Pregnancy. In: Fortner KB, Szymanski LM, Fox HE, Wallach EE. The Johns Hopkins Manual of Gynecology and Obstetrics. Third Edition. Maryland:

Lippincot Williams & Wilkins.

Epidemiologi• UK1:200 kehamilan• Angka kematian1:1000 KE

Faktor Risiko• Riwayat kehamilan ektopik• Operasi korektif tuba• Sterilisasi tuba• Alat intrauterus• Patologi dokumentasi tuba• Infertilitas• Assisted reproductive technology• Infeksi genital sebelumnya

– Chlamydia– Salfingitis

• Merokok• Aborsi sebelumnya• Pasangan multiseksual• Riwayat sesar


2. Pitkin J, Peattie AB, Magowan BA. Obstetrics and Gynaecology, An Illustrated Colour Text. United Kingdom: Churchill Livingstone. p. 98-9.

Kehamilan Tuba• Implantasi terseringampula• Lapisan submukosa (-)ovum

melekat di lapisan epiteliumzigot di lapisan muskularis

• Ismusdaerah paling sempitruptur tuba pada trimester pertama

• Ampulaaborsi tubahematosalpinx


2. Pitkin J, Peattie AB, Magowan BA. Obstetrics and Gynaecology, An Illustrated Colour Text. United Kingdom: Churchill Livingstone. p. 98-9.

3. Seeber BE, Barnhart KT. Ectopic Pregnancy. In: Gibbs RS, Karlan BY, Haney AF, Nygaard. Danforth’s Obstetrics and Gynecology. Tenth Edition. Lippincott Williams & Wilkins; 2008. p. 72-87.

Chorionic villi

Tubal muscularis layer

Kehamilan Abdomen• Worley dkk, 2008:• hasil konsepsi keluar dan menempel

pada kavitas peritoneum• Berada di Kavum Douglas untuk

beberapa tahunmassa tidak berkapsul

• Kalsifikasilithopedion


Classic Triad (<50% pasien):• Amenorea• Abdominal pain• Vaginal bleeding

Tanda dan Gejala

Pemeriksaan Fisis

• Tanda vitalsyok hipovolemik• Nyeri adneksa dan abdomen– 45%generalis– 35%kuadran bawah unilateral– 25%kuadran bawah bilateral

• Massa adneksa (40%)• Pembesaran uterus


Diagnosis• β-hCG• Serum Progesteron• Kuldosintesis• USGTVUS/ TAUS

Gold standard:• laparoskopi


Peningkatan:<50%nonviable pregnancy

<15%(Plateau)KE>aborsi spontan<1,500 mIU/mL+nyeri+perdarahanKE 2,5x

70% kasuspeningkatan normal

>25 ng/mLIUP<5 ng/mLnonviable pregnancykuretase

Unclotted blood(+) di kavitas peritoneal

Jarang dilakukan

Radiologic Signs:Empty uterus

Cystic/solid adnexal massesDilated and thick-walled fallopian tubes

Free echogenic fluid in pelvisHematosalpinx

Extrauterine gestational sacyolk sac

Diagnosis Banding

Tatalaksana:Metotreksat

Antagonis Asam Folat

Inaktivasi dihydrofolate reductase

Tetrahydrofolate↓

Sintesis DNA dan RNA↓

Inhibisi pertumbuhan sel trofoblas KE


Tatalaksana:Surgical Management

LaparoskopiIndikasi:• Hemodinamik stabil

Kontraindikasi:• Adhesi pelvis• Hematoperitoneum• Ukuran >4 cm• Hemodinamik tidak stabil

Teknik:• Linear salpingostomy• Salpingectomy

1. Chan PD, Johnson SM. New ACOG Treatment Guidelines, Current Clinical Strategies, Gynecology and Obstetrics, 2004 Edition. California: Current Clinical Strategies Publishing.p. 21-4.2. Pitkin J, Peattie AB, Magowan BA. Obstetrics and Gynaecology, An Illustrated Colour Text. United Kingdom: Churchill Livingstone. p. 98-9.3. Yates M, King J. Ectopic Pregnancy. In: Fortner KB, Szymanski LM, Fox HE, Wallach EE. The Johns Hopkins Manual of Gynecology and Obstetrics. Third Edition. Maryland: Lippincot Williams & Wilkins.


LaparotomiIndikasi:• Perdarahan↑• Hemodinamik tidak stabil• Adhesi

Teknik:• Salpingectomycomplete/

partial

1. Chan PD, Johnson SM. New ACOG Treatment Guidelines, Current Clinical Strategies, Gynecology and Obstetrics, 2004 Edition. California: Current Clinical Strategies Publishing.p. 21-4.2. Pitkin J, Peattie AB, Magowan BA. Obstetrics and Gynaecology, An Illustrated Colour Text. United Kingdom: Churchill Livingstone. p. 98-9.3. Yates M, King J. Ectopic Pregnancy. In: Fortner KB, Szymanski LM, Fox HE, Wallach EE. The Johns Hopkins Manual of Gynecology and Obstetrics. Third Edition. Maryland: Lippincot Williams & Wilkins.


Surgical TechniquesSalpingostomy

Salpingectomy

Segmental Resection


2. Pitkin J, Peattie AB, Magowan BA. Obstetrics and Gynaecology, An Illustrated Colour Text. United Kingdom: Churchill Livingstone. p. 98-9.3. Yates M, King J. Ectopic Pregnancy. In: Fortner KB, Szymanski LM, Fox HE, Wallach EE. The Johns Hopkins Manual of Gynecology and Obstetrics. Third Edition. Maryland:

Lippincot Williams & Wilkins.

Kandidat idealAmpullaInsisi tuba fallopistoma baruInsisisecondary intention

Membuang bagian tuba yang ruptur

End-to-end anastomosisIndikasiIsmus

Terima Kasih

Documents

Kehamilan Ektopik Terganggu