Nama : Zaimah Shalsabilla

Kelas : Alpha

NIM : 04011181520071

Threatened abortion is defined by vaginal bleeding in a woman with a confirmed pregnancy.

First-trimester bleeding in a pregnant woman has an extensive differential diagnosis (Table 2)
and should be evaluated with a full history and physical examination. Laboratory tests should
include potassium hydroxide and “wet prep” microscopy of any vaginal discharge, complete
blood count, blood typing and Rh testing, and quantitative serum hCG testing. Gonorrhea and
chlamydia testing also should be considered. Ultrasonography is crucial in identifying the status
of the pregnancy and verifying that the pregnancy is intrauterine. When transvaginal
ultrasonography reveals an empty uterus and the quantitative serum hCG level is greater than
1,800 mIU per mL (1,800 IU per L), an ectopic pregnancy should be considered.5 When
transabdominal ultrasonography is performed, an empty uterus should raise suspicion of an
ectopic pregnancy if quantitative hCG levels are greater than 3,500 mIU per mL (3,500 IU per L).
A uterus found to be empty on ultrasound examination may signal a completed spontaneous
abortion, but the diagnosis is not definitive until ectopic pregnancy is excluded. If an ultrasound
examination finds an intrauterine pregnancy, ectopic pregnancy is unlikely, although heterotopic
pregnancy has been reported (i.e., simultaneous intrauterine and ectopic pregnancies).5 The risk
for spontaneous abortion decreases from 50 to 3 percent when a fetal heartbeat is identified on
ultrasound examination

Chromosomal abnormalities are a direct cause of spontaneous abortion. One meta-

analysis9 found that a chromosomal abnormality occurs in 49 percent of spontaneous abortions.
Autosomal trisomy was the most commonly identified anomaly (52 percent), followed by
polyploidy (21 percent) and monosomy X (13 percent).9 Most chromosomal abnormalities that
result in spontaneous abortion are random events, such as maternal and paternal
gametogenesis errors, dispermy, and nondisjunction. Structural abnormalities of individual
chromosomes (e.g., translocations, inversions) were reported in 6 percent of women who had
spontaneous abortions, and approximately one half of these abnormalities were
inherited.9 Chromosomal abnormalities are more likely to be associated with recurrent
spontaneous abortion, but are uncommon even in that instance (4 to 6 percent).9

Risk factors for spontaneous abortion are listed in Table 3.1,10–14 However, other factors are
notable for their lack of association with miscarriage. One study15 that examined the influence of
stress on early pregnancy loss failed to find a clear association. Marijuana use, likewise, has not
been proven to increase the risk for spontaneous abortion.11 Sexual activity also does not elevate
risk in women with uncomplicated pregnancies.

Risk Factors for Spontaneous Abortion

Advanced maternal age

Alcohol use
Anesthetic gas use (e.g., nitrous oxide)

Caffeine use (heavy)

Chronic maternal diseases: poorly controlled diabetes, celiac disease, autoimmune diseases (particularly
antiphospholipid antibody syndrome)

Cigarette smoking

Cocaine use

Conception within three to six months after delivery

Intrauterine device use

Maternal infections: bacterial vaginosis; mycoplasmosis, herpes simplex virus, toxoplasmosis, listeriosis,
chlamydia, human immunodeficiency virus, syphilis, parvovirus B19, malaria, gonorrhea, rubella,
cytomegalovirus

Medications: misoprostol (Cytotec), retinoids, methotrexate, nonsteroidal anti-inflammatory drugs

Multiple previous elective abortions

Previous spontaneous abortion

Toxins: arsenic, lead, ethylene glycol, carbon disulfide, polyurethane, heavy metals, organic solvents

Uterine abnormalities: congenital anomalies, adhesions, leiomyoma

When the clinical examination reveals a dilated cervix, spontaneous abortion is inevitable.
However, cervical evaluation is not reliable for distinguishing between complete and
incomplete abortion.6,7Transvaginal ultrasonography should be performed and is extremely
reliable for finding products of conception, with a 90 to 100 percent sensitivity and 80 to 92
percent specificity.7,8

A missed spontaneous abortion usually is diagnosed by routine ultrasonography or when an

ultrasound scan is obtained because the symptoms and physical signs of pregnancy are
regressing.Figure 1 presents an algorithm for diagnosing spontaneous abortion.

Treatment
Dilatation and curettage is the traditional treatment for spontaneous abortion; manual
vacuum aspiration is another surgical option. Prompt surgical evacuation of the uterus has
been recommended in the past because of the risk for infection and concerns about
coagulation disorders that result from retained products of conception.1,2 However, the need
for immediate surgical evacuation in all patients with a spontaneous abortion has been
questioned. Many recent studies16–24 have examined the outcomes of expectant and medical
management for women with spontaneous abortions.

Prompt surgical evacuation of the uterus is the treatment of choice when the patient is
unstable because of heavy bleeding or has evidence of a septic abortion. Patient choice is
another reason to proceed with surgical evacuation.

Some women may have already completed a spontaneous abortion by the time they present
for clinical evaluation. If the ultrasound examination shows an empty uterus and evaluation of
the expelled tissue confirms the presence of products of conception, no further action is
needed; in these instances, patients have a completed spontaneous abortion and can be
managed expectantly.16 If the products of conception are not physically confirmed when the
uterus is empty, an ectopic pregnancy must be ruled out.

Many studies17–24 have compared expectant management, medical therapy, and surgical
management for women with incomplete spontaneous abortion. Expectant management
proved to be successful, with no need for surgical intervention in 82 to 96 percent of
women.17–22,24 Most patients who had surgical intervention were followed expectantly for two
weeks before intervention was recommended.17,19,21 Medical therapy with misoprostol
(Cytotec) or mifepristone (Mifeprex) does not confer significant additional benefit.23 The
average time to completion of the miscarriage was nine days.20

Misoprostol is a synthetic prostaglandin E1 analogue. It protects the GI mucosa by inhibiting basal,

stimulated and nocturnal acid secretion and by reducing the volume of gastric secretions and increasing
bicarbonate and mucus secretion. It also induces contractions of smooth muscle fibres of the myometrium
and relaxation of the cervix uteri.

Mifepristone is a synthetic steroid which blocks the effects of progesterone by competitively binding to the
intracellular progesterone receptor. It sensitises the myometrium to the contraction-inducing action of
prostaglandin. At higher doses, it blocks the effect of cortisol at the glucocorticoid receptor while increasing
circulating cortisol concentrations

In women with missed spontaneous abortions, expectant management has a variable but
generally lower success rate than medical therapy, ranging from 16 to 76 percent.17,20,25,26 In
contrast, medical therapy for missed spontaneous abortion results in high success rates for
completion of a spontaneous abortion without surgical intervention. One study25 found that
patients had an 80 percent success rate after using 800 mcg of misoprostol, administered
intravaginally and repeated after four hours, if necessary. Intravaginal administration of
misoprostol causes less diarrhea than oral administration.27

Patient preferences should be considered when choosing a treatment for spontaneous

abortion. Physicians should discuss the available options and the evidence to support each
option with the patient. There is evidence to suggest that women who are given the
opportunity to choose a treatment option have better subsequent mental health than women
who are not allowed to choose their therapy.28 However, patients express less happiness
with the mode of treatment they receive and are less willing to have the same care again
when they begin with noninvasive management and later require surgical
intervention.29 When patients are allowed to choose their therapy, 38 to 75 percent choose
expectant management.20,26,30

An algorithm for managing women with spontaneous abortion is presented in Figure 2.1 A 50-
mcg dose of Rho (D) immune globulin (Rhogam) should be given to patients who are Rh-
negative and have a threatened abortion or have completed a spontaneous abortion
Nama : Zaimah Shalsabilla

Kelas : Alpha

NIM : 04011181520071

Klasifikasi

Klasifikasi Abortus (Sarwono, 2008)

1) Abortus Spontan

Abortus yang terjadi tanpa tindakan mekanis atau medis untuk mengosongkan uterus, maka
abortus tersebut dinamai abortus spontan. Kata lain yang luas digunakan adalah keguguran
(Miscarriage). Abortus spontan secara klinis dapat dibedakan antara abortus imminens,
abortus insipiens, abortus inkompletus, abortus kompletus. Selanjutnya, dikenal pula missed
abortion, abortus habitualis, abortus infeksiosus dan aborrtus septik.

a) Abortus Imminens (keguguran mengancam)

Peristiwa terjadinya perdarahan dari uterus pada kehamilansebelum 20 minggu, dimana hasil
konsepsi masih dalam uterus,dan tanpa adanya dilatasi serviks Diagnosis abortus imminens
ditentukan karena pada wanitahamil terjadi perdarahan melalui ostium uteri
eksternum,disertai mules sedikit atau tidak sama sekali, uterus membesarsebesar tuanya
kehamilan, serviks belum membuka, dan teskehamilan positif. Pada beberapa wanita hamil
dapat terjadiperdarahan sedikit pada saat haid yang semestinya datang jikatidak terjadi
pembuahan. Hal ini disebabkan oleh penembusanvilli koreales ke dalam desidua, pada saat
implantasi ovum.Perdarahan implantasi biasanya sedikit, warnanya merah, cepatberhenti, dan
tidak disertai mules-mules.

b) Abortus Incipiens (keguguran berlangsung)

Peristiwa perdarahan uterus pada kehamilan sebelum 20minggu dengan adanya dilatasi
serviks uteri yang meningkat,tetapi hasil konsepsi masih dalam uterus. Dalam hal ini
rasamules menjadi lebih sering dan kuat, perdarahan bertambah

c) Abortus Incomplet (keguguran tidak lengkap)

Pengeluaran sebagian hasil konsepsi pada kehamilansebelum 20minggu dengan masih ada
sisa tertinggal dalam uterus. Pada pemeriksaan vaginal, kanalis servikalis terbukadan jaringan
dapat diraba dalam kavum uteri atau kadangkadangsudah menonjol dari ostium uteri
eksternum.

d) Abortus Complet (keguguran lengkap)

Perdarahan pada kehamilan muda di mana seluruh hasilkonsepsi telah di keluarkan dari
kavum uteri. Seluruh buahkehamilan telah dilahirkan dengan lengkap. Pada
penderitaditemukan perdarahan sedikit, ostium uteri telah menutup, danuterus sudah banyak
mengecil. Diagnosis dapat di permudahapabila hasil konsepsi dapat diperiksa dan dapat
dinyatakanbahwa semuanya sudah keluar dengan lengkap

e) Abortus Infeksiosa dan Abortus Septik

Abortus infeksiosa adalah abortus yang disertai infeksi padagenitalia, sedangkan abortus
septik adalah abortus infeksiosaberat dengan penyebaran kuman atau toksinnya ke
dalamperedaran darah atau peritoneum. Infeksi dalam uterus atausekitarnya dapat terjadi
pada tiap abortus, tetapi biasanyaditemukan pada abortus inkompletus dan lebih
seringditemukan pada abortus buatan yang dikerjakan tanpamemperhatikan asepsis dan
antisepsis.

Apabila infeksi menyebar lebih jauh, terjadilahperitonitis umum atau sepsis, dengan
kemungkinan diikuti olehsyok. Diagnosis abortus infeksiosa ditentukan dengan
adanyaabortus yang disertai gejala dan tanda infeksi genitalia, sepertipanas, takikardi,
perdarahan pervaginam berbau, uterus yangmembesar, lembek, serta nyeri tekan, dan
leukositosis. Apabilaterdapat sepsis, penderita tampak sakit berat, kadangkadang menggigil,
demam tinggi dan tekanan darah menurun.

f. Missed Abortion (Retensi Janin Mati)

Kematian janin sebelum berusia 20 minggu, tetapi janin yang mati tertahan di dalam kavum
uteri tidak dikeluarkkan selama 8 minggu atau lebih. Missed abortion biasanya didahului oleh
tanda-tanda abortus imminens yang kemudian menghilang secara spontan atau setelah
pengobatan. Gejala subyektif kehamilan menghilang, mammae agak mengendor lagi, uterus
tidak membesar lagi malah mengecil, dan tes kehamilan menjadi negatif. Dengan
ultrasonografi dapat ditentukan segera apakah janin sudah mati dan besarnya sesuai dengan
usia kehamilan.

g) Abortus Habitualis

Keadaan dimana penderita mengalami keguguran berturut turut tiga kali atau lebih. Pada
umumnya penderita tidak sukar menjadi hamil, tetapi kehamilannya berakhir sebelum 28
minggu. Bishop melaporkan frekuensi 0,41% abortus habitualisp ada semua kehamilan.
Menurut Malpas dan Eastman kemungkinan terjadi abortus lagi pada seorang wanita
mengalami 15 abortus habitualis ialah 73% dan 83,6%.Sebaliknya, Warton dan Fraser dan
Llwellyn-Jones memberi prognosis lebih baik, yaitu 25,9% dan 39% (Sarwono, 2008)

2. Abortus Provokatus

Abortus terinduksi adalah terminasi kehamilan secara medis atau bedah sebelum janin
mampu hidup. Pada tahun 2000, total 857.475 abortus legal dilaporkan ke Centers for
Disease Control and Prevention (2003). Sekitar 20% dari para wanita ini berusia 19 tahun
atau kurang, dan sebagian besar berumur kurang dari 25 tahun, berkulit putih, dan belum
menikah. Hampir 60% abortus terinduksi dilakukan sebelum usia gestasi 8 minggu, dan 88%
sebelum minggu ke 12 kehamilan (Centers for Disease Control and Prevention, 2000).
Manuaba (2007), menambahkan abortus buatan adalah tindakan abortus yang sengaja
dilakukan untuk menghilangkan kehamilan sebelum umur 28 minggu atau berat janin 500
gram. Abortus ini terbagi lagi menjadi:

a) Abortus Therapeutic (Abortus medisinalis)

Abortus karena tindakan kita sendiri, dengan alasan bila kehamilan dilanjutkan, dapat
membahayakan jiwa ibu (berdasarkan indikasi medis). Biasanya perlu mendapat persetujuan
2 sampai 3 tim dokter ahli.

b) Abortus Kriminalis

Abortus yang terjadi oleh karena tindakan-tindakan yang tidak legal atau tidak berdasarkan
indikasi medis.

c) Unsafe Abortion
Upaya untuk terminasi kehamilan muda dimana pelaksana tindakan tersebut tidak
mempunyai cukup keahlian dan prosedur standar yang aman sehingga dapat membahayakan
keselamatan jiwa pasien

Tatalaksana
 k,

1. Bagaimana interpretasi dari hasil pemlab?

Indikator Lab Nilai Normal Interpretasi

Hb : 10,2 gr/dl >11g/dl Menurun

Platelet : 187.000/mm 150.000-450.000 Normal

WBC : 11.3000/ mm 5,800 to 13,200 per mm3 Normal

Plano Test : + Terdapat hormone bhCG

pada urin

2. Bagaimana dampak coitus terhadap kehamilan pada kasus?

Tidak ada. . Tetapi, bila wanita punya riwayat keguguran atau ancaman keguguran atau
menunjukan tanda-tanda ancaman keguguran, maka coitus sebaiknya dihindari.

3. Kapan dan bagaimana posisi coitus sebaiknya dilakukan pada wanita hamil?

Hubungan seksual selama hamil tetap boleh dilakukan. Waktu yang

Disarankan Untuk Membatasi Melakukan Hubungan Seksual

a. Setiap kali terjadi perdarahan yang tak diketahui sebabnya.

b. Selama trimester pertama, bila wanita punya riwayat keguguran atau
ancaman keguguran atau menunjukkan tanda-tanda ancaman keguguran.
c. Selama 8-12 minggu terakhir, bila wanita punya riwayat keguguran atau
ancaman keguguran atau menunjukkan tanda-tanda ancaman keguguran.
d. Bila membran amnion (selaput ketuban) pecah.
e. Bila terjadi plasenta previa (plasenta terletak di dekat atau di atas leher rahim), sehingga dapat
keluar terlalu dini pada hubungan seksual, menyebabkan perdarahan dan mengancam ibu
serta janinnya.
f. Selama trimester akhir pada kehamilan kembar.
4. Apa makna klinis “ she changed pads once and found blood as well as tissue from her
vagina”?

Darah dan jaringan yang ditemukan menujukkan adanya proses abortus ( pengeluaran hasil
konsepsi) yang sedang terjadi dan karena yang ditemukan baru berupa jaringan maka
jenisnya ialah abortus inkomplet.

5. Bagaimana hubungan usia ibu, usia kehamilan, dan riwayat G1 terhadap pendarahan pada
kasus?

Tidak ada hubungan. Abortus spontan biasanya terjadi pada wanita dengan usia yang lebih
tua. (> 35 tahun).