KURET. Kanadi Sumapradja.

Transkripsi

1 KURET Kanadi Sumapradja

2 PENATALAKSANAAN ABORTUS INKOMPLIT Prinsip : Pembersihan sisa konsepsi. Caranya tergantung : Usia kehamilan, besar uterus dan hasil penghitungan HPHT Ketersediaan peralatan, pasokan dan tenaga kesehatan yg terampil tidak ada : RUJUK!

3 Table 1. Impact of Unsafe Abortion by Region Region Number of unsafe abortions (1000s) Unsafe abortions per 1000 women Number of deaths from unsafe abortion Mortality from unsafe abortion per 100,000 live births Case fatality per 100 unsafe abortions Risk of death More developed in 3700 countries Less developed in 250 countries Africa in 150 Asia in 250 Europe in 2600 Latin America in 800 USSR (former) in 3900

4 Level Community Primary (Primary health clinics, Family planning clinics or Polyclinics) First Referral Level (District hospital) Secondary and Tertiary Level (Regional or Referral hospital) Table 2. Provision of Postabortion Care by Level of Healthcare Facility and Staff Staff May Include Community residents with basic health training Traditional birth attendants Traditional healers Health workers Nurses Trained midwives General practitioners Nurses Trained midwives General practitioners Ob/Gyn specialists Nurses Trained midwives General practitioners Ob/Gyn specialists Emergency Postabortion Care Provided Recognition of signs and symptoms of abortion and serious post abortion complications Referral to facilities where treatment is available All primary care facilities. Above activities, plus: Diagnosis based on medical history and physical and pelvic examination Resuscitation/preparation for treatment or transfer Haematocrit/hemoglobin testing Referral, if needed If trained staff and appropriate equipment are available. Above activities, plus: Initiation of emergency treatments antibiotic therapy intravenous fluid replacement oxytocics Uterine evacuation during first trimester for uncomplicated cases of incomplete abortion Pain control simple analgesia and sedation local anesthesia (paracervical block) Above activities, plus: Emergency uterine evacuation through second trimester Treatment of most postabortion complications Local and general anesthesia Diagnosis and referral for severe complications (septicemia, peritonitis, renal failure) Laparotomy and indicated surgery (including for ectopic pregnancy) Blood crossmatch and transfusion Above activities, plus: Uterine evacuation as indicated for all incomplete abortions Treatment of severe complications (including bowel injury, severe sepsis, renal failure) Treatment of bleeding/clotting disorders Postabortion Family Planning Provision of pills, condoms, diaphragms and spermicides Referral and follow up for these and other methods Provision of above methods plus IUDs, injectables and Norplant implants Referral for voluntary sterilization Provision of above methods plus voluntary sterilization Followup All above activities

5 AVM

6 KEUNGGULAN AVM Sampai usia mgg Risiko lebih rendah drpd kuret tajam Anestesi umum (-) Ruang khusus (-)

7 ASPIRASI VAKUM MANUAL Dgn tek. negatif Masukkan kanula, hubungkan dg tabung pengisap melalui adaptor Buka katup pengatur sampai tek. negatif Kanula digerakkan maju-mundur sambil rotasi ke kanan-kiri

8 PERLENGKAPAN ALAT AVM Tabung vol.60 ml, dengan : 1 atau 2 katup pengatur Toraks & tangkai penarik/pendorong Penahan toraks Silikon pelumas cincin karet Kanula steril

9 PEMILIHAN ALAT AVM UKURAN KANUL KATUP USIA KEHAMILAN 5 6 mm 1 atau minggu 6-10 mm 12 mm 2 katup Trimester I - II awal (< 14 mgg)

10 KEWASPADAAN SEBELUM TINDAKAN AVM Yg menjadi perhatian, bila : Besar uterus tdk sesuai dgn usia kehamilan (HPHT) Usia kehamilan > trimester pertama

11 PERSIAPAN PROSEDUR AVM 1. Mengurangi Risiko Infeksi Cuci tangan dg sabun & air mengalir Peralatan yg steril atau DTT Bersihkan vagina & serviks dg lar. antiseptik Teknik tanpa sentuh

12 2. Menyiapkan Instrumen AVM Periksa fungsi isap tabung AVM Kesiapan tindakan gawat darurat Buat tekanan negatif dengan : Kunci katup pengatur Tarik tangkai toraks 3. Pemeriksaan Panggul Besar & arah uterus (bimanual) Kondisi vagina & serviks

13 4. Persiapan Pasien Kosongkan kandung kemih Bersihkan perut bawah, lipat paha, genitalia eksterna dengan sabun & air. Siapkan vagina & serviks dgn antiseptik 2-3 kali (bila dengan iodofor tunggu 2 )

14 LANGKAH-LANGKAH PROSEDUR AVM

15 Langkah 1 Masukkan spekulum Keluarkan jaringan atau bekuan darah Cabut AKDR bila ada. Langkah 2 Bersihkan servik & vagina dgn larutan antiseptik

16 Langkah 3 Blok paraservikal (bila perlu) Langkah 4 Pegang bibir atas serviks dengan tenakulum/klem ovum (jam 1 dan jam 11) Ukur bukaan ostium dengan kanul Anestesi verbal

17 Langkah 5 Masukkan kanula dengan adaptor Dorongan ringan dan putar kiri-kanan

18 Langkah 6 Perhatikan ukuran bila kanula telah mencapai fundus Titik terdekat 6 sm Tarik sedikit ujung kanula dari fundus

19 Langkah 7 Hubungkan pangkal kanula dengan tabung AVM

20 Langkah 8 Buka katup pengatur Bila bekerja : cairan darah & busa

21 Langkah 9 Gerakkan kanula majumundur + rotasi jam 10-2 Jangan sampai tertarik keluar Bila tek. negatif hilang tutup pengatur + lepaskan kanula Siapkan tek. negatif kembali & pasang kembali Jangan pegang pada tangkai pendorong!

22 Langkah 10 Periksa kebersihan kavum uteri Tanda : Busa-busa merah Jaringan tak terlihat Terasa kasar Uterus kontraksi Kanul seperti terjepit Langkah 11 Keluarkan kanula Lepaskan sambungan Masukkan ke wadah dekontaminasi

23 Langkah 12 Periksa jaringan : Jumlah & massa kehamilan Pastikan kebersihan evakuasi Adanya kelainan seperti mola

24 Cara Pemeriksaan Isi mangkok + air bersih + kassa saringan Hasil evakuasi + mangkok angkat Jaringan : Vili korialis : Putih keabuan, memanjang, mengambang Endometrium : Massa lunak, licin, butiran putih tanpa juluran halus, tenggelam

25 Bila Tak Tampak Jaringan Kehamilan Kemungkinan : Abortus komplit Kurang terampil tidak terambil Bukan abortus inkomplit Uterus abnormal Bila Tak Tampak Jaringan Kehamilan + Tanda Kehamilan KEHAMILAN EKTOPIK!!!

26 Langkah Lepaskan tenakulum & spekulum Dekontaminasi alat : klorin 0,5% 10 : 2 tempat : logam + non logam Alat tidak terkunci Bersihkan sarung tangan balikkan Cuci tangan dgn sabun & air mengalir

27 Langkah-langkah kuret dengan kuret tajam

28

29 Check the cervix for tears or protruding products of conception. If products of conception are present in the vagina or cervix, remove them using ring (or sponge) forceps. Gently grasp the anterior lip of the cervix with a vulsellum or single-toothed tenaculum Note: With incomplete abortion, a ring (sponge) forceps is preferable as it is less likely than the tenaculum to tear the cervix with traction and does not require the use of lignocaine for placement. If using a tenaculum to grasp the cervix, first inject 1 ml of 0.5% lignocaine solution into the anterior or posterior lip of the cervix which has been exposed by the speculum (the 10 o clock or 12 o clock position is usually used).

30 Dilatation is needed only in cases of missed abortion or when some retained products of conception have remained in the uterus for several days: - Gently introduce the widest gauge cannula or curette; - Use graduated dilators only if the cannula or curette will not pass. Begin with the smallest dilator and end with the largest dilator that ensures adequate dilatation (usually mm) (Fig P-33); - Take care not to tear the cervix or to create a false opening.

31 Gently pass a uterine sound through the cervix to assess the length and direction of the uterus. The uterus is very soft in pregnancy and can be easily injured during this procedure. Evacuate the contents of the uterus with ring forceps or a large curette Gently curette the walls of the uterus until a grating sensation is felt.

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33 Give paracetamol 500 mg by mouth as needed. Encourage the woman to eat, drink and walk about as she wishes. Offer other health services, if possible, including tetanus prophylaxis, counselling or a family planning method. Discharge uncomplicated cases in 1 2 hours. Advise the woman to watch for symptoms and signs requiring immediate attention: - prolonged cramping (more than a few days); - prolonged bleeding (more than 2 weeks); - bleeding more than normal menstrual bleeding; - severe or increased pain; - fever, chills or malaise; - fainting.

34 KURET HISAP