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KURETKanadi Sumapradja

[email protected]

PENATALAKSANAAN

ABORTUS INKOMPLIT

• Prinsip : Pembersihan sisa konsepsi.

• Caranya tergantung :

– Usia kehamilan, besar uterus dan hasil – Usia kehamilan, besar uterus dan hasil penghitungan HPHT

– Ketersediaan peralatan, pasokan dan tenaga kesehatan yg terampil

→ tidak ada : RUJUK !

Table 1. Impact of Unsafe Abortion by Region

Region

Number

of unsafe

abortions

(1000s)††

Unsafe

abortions

per 1000

women 15-

49

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 2340 8 600 4 0.03 1 in 3700More developed

countries

2340 8 600 4 0.03 1 in 3700

Less developed

countries†17620 17 69000 55 0.4 1 in 250

Africa 3740 26 23000 83 0.6 1 in 150

Asia† 9240 12 40000 47 0.4 1 in 250

Europe 260 2 100 2 0.04 1 in 2600

Latin America 4620 41 6000 48 0.1 1 in 800

USSR (former) 2080 30 500 10 0.03 1 in 3900

Table 2. Provision of Postabortion Care by Level of Healthcare Facility and Staff

LevelStaff May Include Emergency Postabortion Care Provided

Postabortion Family

Planning

Community Community residents with

basic health training

Traditional birth attendants

Traditional healers

•Recognition of signs and symptoms of abortion and serious post

abortion complications

•Referral to facilities where treatment is available

Provision of pills,

condoms, diaphragms and

spermicides

Referral and follow up for

these and other methods

Primary

(Primary health

clinics, Family

planning clinics

or Polyclinics)

Health workers

Nurses

Trained midwives

General practitioners

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

Provision of above

methods plus IUDs,

injectables and Norplant®

implants

Referral for voluntary

sterilization

If trained staff and appropriate equipment are available.

Above activities, plus:

•Initiation of emergency treatments

•antibiotic therapy

•intravenous fluid replacement •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)

First Referral

Level

(District hospital)

Nurses

Trained midwives


Ob/Gyn specialists


•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

Provision of above

methods plus voluntary

sterilization

Followup

Secondary and

Tertiary Level

(Regional or

Referral

hospital)

Nurses

Trained midwives


Ob/Gyn specialists


•Uterine evacuation as indicated for all incomplete abortions

•Treatment of severe complications (including bowel injury,

severe sepsis, renal failure)

•Treatment of bleeding/clotting disorders

All above activities

AVM

KEUNGGULAN AVM

– Sampai usia 12-14 mgg

– Risiko lebih rendah drpd kuret

tajamtajam

– Anestesi umum (-)

– Ruang khusus (-)

ASPIRASI VAKUM MANUAL

→→→→ Dgn tek. negatif

• Masukkan kanula, hubungkan dg tabung

pengisap melalui adaptorpengisap melalui adaptor

• Buka katup pengatur sampai tek. negatif

• Kanula digerakkan maju-mundur sambil

rotasi ke kanan-kiri

PERLENGKAPAN ALAT AVM

• Tabung vol.60 ml, dengan :

– 1 atau 2 katup pengatur

– Toraks & tangkai

penarik/pendorongpenarik/pendorong

– Penahan toraks

– Silikon pelumas cincin karet

• Kanula steril

PEMILIHAN ALAT AVM

UKURAN

KANULKATUP USIA KEHAMILAN

5 – 6 mm 1 atau 2 0-8 minggu

6-10 mm

12 mm2 katup

Trimester I - II awal

(< 14 mgg)

KEWASPADAAN SEBELUM

TINDAKAN AVM

Yg menjadi perhatian, bila :

• Besar uterus tdk sesuai dgn usia • Besar uterus tdk sesuai dgn usia

kehamilan (HPHT)

• Usia kehamilan > trimester pertama

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

2. Menyiapkan Instrumen AVM

– Periksa fungsi isap tabung AVM

– Kesiapan tindakan gawat darurat

– Buat tekanan negatif dengan :

• Kunci katup pengatur• Kunci katup pengatur

• Tarik tangkai toraks

3. Pemeriksaan Panggul

– Besar & arah uterus (bimanual)

– Kondisi vagina & serviks

4. Persiapan Pasien

– Kosongkan kandung kemih

– Bersihkan perut bawah, lipat paha, genitalia

eksterna dengan sabun & air.eksterna dengan sabun & air.

– Siapkan vagina & serviks dgn antiseptik 2-3 kali

(bila dengan iodofor tunggu 2’)

LANGKAH-LANGKAH PROSEDUR AVMLANGKAH-LANGKAH PROSEDUR AVM

Langkah 1

• Masukkan spekulum

• Keluarkan jaringan atau bekuan darah

• Cabut AKDR bila ada.

Langkah 2

• Bersihkan servik & vagina dgn larutan

antiseptik

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 G

Langkah 5

• Masukkan kanula

dengan adaptordengan adaptor

• Dorongan ringan dan

putar kiri-kanan

Langkah 6

• Perhatikan ukuran bila

kanula telah mencapai

fundusfundus

• Titik terdekat 6 sm

• Tarik sedikit ujung

kanula dari fundus

Langkah 7

• Hubungkan pangkal

kanula dengan

tabung AVMtabung AVM

Langkah 8

• Buka katup pengatur

• Bila bekerja : cairan • Bila bekerja : cairan

darah & busa

Langkah 9

• Gerakkan kanula maju-mundur + rotasi jam 10-2

• Jangan sampai tertarik keluar

• Bila tek. negatif hilang • Bila tek. negatif hilang � tutup pengatur + lepaskan kanula

• Siapkan tek. negatif kembali & pasang kembali

• Jangan pegang pada tangkai pendorong !

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

– Kanul seperti terjepit

Langkah 12

Periksa jaringan :

• Jumlah & massa kehamilan• Jumlah & massa kehamilan

• Pastikan kebersihan evakuasi

• Adanya kelainan seperti mola

Cara Pemeriksaan

• Isi mangkok + air bersih + kassa saringan

• Hasil evakuasi + mangkok �angkat

• Jaringan :

– Vili korialis :– Vili korialis :

• Putih keabuan, memanjang, mengambang

– Endometrium :

• Massa lunak, licin, butiran putih tanpa juluran halus, tenggelam

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 !!!

Langkah 13-16

• 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

Langkah-langkah kuret dengan

kuret tajamkuret tajam

Check the cervix for tears or protruding products of conception. If 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).

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 10–12 mm) (Fig P-33);

- Take care not to tear the cervix or to create a false opening.

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.

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 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.

KURET HISAP

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