PLENARY

TUTORIAL 1
GROUP 10 B
AMALIA SAVIRA
AISYAH MARWA BILQIS
M FADILA ARIE NOVARD
MIRZA NURING TYAS
NABILA JASMINE
NUGRA DAARY RAZSKY G
REZKY FAJRIANI ANUGRA
RIRIN LAUSARINA
SRIKITTA DANIELLA
YENI NOVI YANTI

Learning Objective
1
MATERNAL THE INFANT MORTALITY

Maternal the Infant

Mortality

Maternal Mortality
DIRECT OBSTETRIC DEATHS

INDIRECT OBSTETRIC DEATHS

ETIOLOGY
DIRECT
45.2 % Bleeding
11.1% Complications of Abortion
12.9% Eklampsia
9.6% Postpartum Sepsis
6.5% Obstructed Labor
1.6% Anemia

INDIRECT
3 Lates Factor
Late to recognize danger
signs of labor and decisions
making
Late referenced
Late
handled
by
skilled
medical personnel

4 Too Factors
Too young
Too old
Too many children
Birth spacing is too tight

Infant Mortality Rate

Live Birth

Death

Fetal Death

INCIDENCES
WORLD
3 million of neonatal death a
year
3 million of fetal death a year
90% occur in developing
countries

INDONESIA
45,7/1000 of live birth
47% of IMR is neonatal death
50%
of
neonatal
death
occured in the first week of
life

ETIOLOGY
50% Neonatal Asphyxia
25% BBLR
25% Infection
10% Birth Trauma

The problems
Lack of pregnant womens knowledge
about the importance of maintaining
their health
Error of comunications between health
personnel during labor
Lack of facilities and infrastructures for
labor
People arent concerned about the
importance of considering the safety of
pregnant women

The efforts to reduce

MM & IMR
Educate pregnancy mothers that prenatal
care is really important
Improve the quality of medical personnel
in labor
Improve the facilities and infrastructures
of labor
Change societys view about the
importance of maternal health

Learning Objective
2
ANATOMY AND PHYSIOLOGY OF
PREGNANCY

Learning Objective
3
INTRA UTERINE GROWTH RESTRICTION

INTRA UTERINE
GROWTH
RESTRICTION

WHO: Fetuses that have failed to achieve the

standard weight or size of a standard ageappropriate pregnancy.
Definition that often used are fetuses that have
weight below the 10th percentile of the normal
fetuss weight curve
Also often defined as small for gestational
age/SGA (Kecil untuk Masa Kehamilan/KMK).
Generally will be born preterm (<37 weeks) or
can be born aterm (> 37 weeks)

Etiology
1. Maternal Factors
.Malnutrition
.Hypertension >> Retroplasenter
Ischemic
.Abnormality of uterus
.Multiple fetuses
.Altitude area >> Hypoxic
. Smoking >> epinefrine >>
vasoconstriction

2. Fetal Factors
Congenital abnormalities
Genetic disorders
Fetal infection, diseases such as TORCH
and AIDS (30% incidency)
>> increases fetal metabolism without
increasing substrate transportation
through placenta

3. Placental Factors (Placental Insuficiency)

Three stages of fetal growth (Cunningham, 2006):

a. Hyperplasia:
At 4-20 weeks of pregnancy
Occurs very fast mitosis and increase the amount of DNA.
b. Hyperplasia and hypertrophy
At 20-28 weeks
Decreased mitotic activity, but an increase in cell size .
c. Hypertrophy
At 28-40 weeks to a maximum cell growth, especially at
week 33
Increasing the amount of fat, muscle and connective tissue
of the body.

Types of IUGR
Renfield (1975):
1. Proportionate Fetal Growth Restriction
- Long distress (weeks to months before
born)
- Weight, length and head circumference
in balanced proportions, all below normal

2. Disproportionate Fetal Growth Restriction

- Subacute distress (days to weeks
before born)
- Normal length and head circumference,
weight below normal
>> Less fatty tissue under the skin, dry
skin wrinkles, the baby looks thinner and
longer.

Cunningham (2006):
1. Type I (Symmetric type)
- Until 20 weeks of pregnancy
- Disruption to reproduce cells
(hyperplasia)
- Usually caused by chromosomal
abnormalities or fetal infection
- Bad prognosis

2. Type II (Asymmetric type)

- Occur at 28-40 weeks of pregnancy
- Disruption of cells enlarge (hypertrophy)
- Usually caused by hypertension in
pregnancies with placental insufficiency
- Better prognosis

3. Type III
- Occur at 20-28 weeks of pregnancy
- Disruption combination of hyperplasia
and hypertrophy cell disorders
- May occur in maternal malnutrition,
drug addiction, or poisoning

Comparison between normal

neonatus (L) and neonatus with IUGR
(R)

Babies born with IUGR will undergo the

following circumstances (Cunningham,
2006):
Decrease in oxygenation level
Low APGAR value
Meconium aspiration
Hypoglycemia
Difficulty at maintaining body temperature
Polycythemia

Risk factors of IUGR

Low socio-economic environment
History of IUGR in the family
Bad obstetric history
Low body weight before pregnancy and
during pregnancy
Obstetric complications in pregnancy
Medical complications in pregnancy.

Prevention
Provide adequate nutrition
Maintaining sanitary >> prevention of
infection
Prenatal care

Learning Objective
4
HYPEREMESIS GRAVIDARUM

Hyperemesis
Gravidarum

 Hyperemesis gravidarum is the most

severe form of nausea and vomiting in
pregnancy, characterized by persistent
nausea and vomiting associated with
ketosis and weight loss (>5% of
prepregnancy weight). This condition
may cause volume depletion, electrolytes
and acid-base imbalances, nutritional
deficiencies, and even death.

Phatophysiology
The physiologic basis of hyperemesis
gravidarum is controversial. Hyperemesis
gravidarum appears to occur as a complex
interaction of biological, psychological, and
sociocultural factors. The following
theories have been proposed:
Hormonal changes : high levels of hCG &
estrogen during pregnancy
Metabolic theory :vitamin B6 deficiency
Psychological theory : Psychological stress
increase the symptoms

Exam and Tests

asking the client about the onset, duration, and
course of her nausea and vomiting
Ask her about any medication or treatments she
used and how effective they were in relieving her
nausea and vomiting
Weight the client
Inspect the mucous membranes for dryness &
check skin turgor for.
Assess blood pressure for changes
Note any complaints of weakness ,fatigue, activity
intolerance ,dizziness, or sleep disturbance

 The following laboratory tests will be

done to check for signs of dehydration:

Complete blood count

Electrolytes
Urine ketones

A pregnancy ultrasound will be done to

see if you are carrying twins or more
babies and also checks for a
hydatidiform mole.

Treatment
Eating small, frequent meals and dry foods such as
crackers may help relieve uncomplicated nausea
Avoid fatty and spicy foods and emetogenic foods or
smells
Drink plenty of fluids
Decreased activity and increased rest.
Antihistamines, antiemetics of the phenothiazine class,
and promotility agents (eg, metoclopramide) have been
used in the treatment of nausea and vomiting during
pregnancy.
Vitamin B-6 (pyridoxine) has also been studied in the
treatment of nausea and vomiting during pregnancy and
reduced nausea and vomiting when compared with
placebo. (vitamin B-6 10-25 mg 3-4 times daily)
Doxylamine 12.5 mg 3-4 times daily can be used in

Complications
the following maternal complications of
hyperemesis gravidarum:

Esophageal rupture or perforation

Pneumothorax and pneumomediastinum
Wernicke encephalopathy or blindness
Hepatic disease
Seizures, coma, or death

Prognosis
Hyperemesis gravidarum is self-limited
and, in most cases, improves by the end
of the first trimester. However, symptoms
may persist through 20-22 weeks of
gestation and, in some cases, until
delivery.

Learning Objective
5
VAGINAL BLEEDING TRIMESTER 1,2 AND 3

st
e
m
Tri r 1
e

Trimest
er 2

st
e
m
Tri 3
er

VAGINAL BLEEDING

Bleeding in early
pregnancy
(Trimester 1)

ABORTI
ON

MOLA
HIDATID
OSA

ECTOPIC
PREGNA
NCY

ABORTIO
N

Spending the products of conception

before less than 20 weeks gestation
and less than 500 gram.

Type of Abortion:
Spontaneous
Abortion

Abortion without action

A. P. Medisinalis

Provokatus
Abortion
A. P. Kriminalis

Deliberate

Continue ..
...

Abortion:
A. Iminens
A. Insipiens
A. Kompletus
A. Inkompletus
Missed Abortion
A. Habitualis
A. Infeksiosus, A.
Septik

Continue.
..
Genetic
Factor

Kelainan
Kongenital Usus

Autoimmun
e

Environmental
Factor

Causes
Infection

ECTOPIC
PREGNA
NCY

Implantation is not in its proper

place

Continue.
..

Type of Ectopic Pregnancy:

1. Pars Interstitial Tubal Pregnancy (95%)
2. Ovarial Pregnancy
3. Servical Pregnancy

Causes:
1.
2.
3.
4.

A factor of tubal
Abnormal factor of the zygote
Ovarian factor
Hormonal factor

MOLA
HIDATID
OSA

No fetuse, only white bubbles filled with

fluid

Symptom:
1. Pregnant signs with more
severe
complaints
2. Rapid development
3. Bleeding

The bleeding since 2nd and

3rd Trimester of Gestation

1. Placenta Previa
placenta is located below the mouth of
the womb and blocking the canal fetus
the main sign is blood discharge
without a pain.

2. Solutio Placenta
some or all of the placenta separates
from the uterine wall.
blood came out a little or a lot but with
severe pain.

3. Partus Prematur
4. Infection in vagina or servix
5. Abortus

Learning Objective
6
IRON DEFICIENCY ANEMIA AND
MALNUTRITION IN PREGNANCY

Iron Deficiency Anemia

Changes in the Maternal

Circulatory
System During Pregnancy

O2 consumption
BMR
erythropoietin production
Hidremia or hipervolemia
plasma
volume (1000 ml); RBC volume (500
ml)
blood viscosity decreases &
hemodilution
Which helps the heart to work more
easily

Anemia during pregnancy

Hb < 11 g/dL
Ht < 33%
10 - 20 % in developed countries
25 - 75 % in developing countries
Food intake has an important role

Iron deficiency anemia

Microcytosis and hypochromia
Worst stage of iron deficiency
apprx. 62.3 % of cases during pregnancy
Blood loss, lack of iron in diet, inability to
absorb, increase of requirement during
pregnancy

Malnutrition in
Pregnancy

Learning Objective
7
MEDICOLEGAL ASPECT

Medicolegal aspect
Definition:
Procedure in healthy care related to law in
each country.
Lex generale : Kitab UU Hukum Pidana
( KUHP)
Lex Speciale : UU No. 36 tahun 2009

Illegal Abortus provocatus

according to KUHP
Chapter XIV KUHP :
Sec. 229
1) Barang siapa dgn sengaja mengobati wanita atau
menyuruhnya supaya diobati, dengan diberitahukan atau
ditimbulkan harapan, bahwa karena pengobatan itu
hamilnya dapat digugurkan , diancam pidana penjara
paling lama 4 tahun atau denda paling banyak 3 juta rupiah
2) Jika yang bersalah, berbuat demikian untuk mencari
keuntungan, atau menjadikan perbuatan tersebut sebagai
pencarian atau kebiasaan, atau jika dia seorang dokter,
bidan atau juru obat, pidananya dapat ditambah sepertiga
3) Jika yg bersalah melakukan kejahatan tersebut, dalam
menjalankan pencarian, maka dapat dicabut haknya dalam
melakukan pencarian itu.

Chapter XIV KUHP

Sec. 346
Seorang wanita yang sengaja menggugurkan atau
mematikan kandungannya atau menyuruh orang lain
untuk itu, diancam dengan pidana penjara paling lama
empat tahun
Sec. 347
1) Barang siapa dengan sengaja menggugurkan atau
mematikan kandungan seorang wanita tanpa
persetujuannya, diancam dengan pidana penjara
paling lama 12 tahun
2) Jika perbuatan itu mengakibatkan matinya wanita
tersebut, dincam dengan pidana penjara paling
lama 15 tahun

 Sec. 348
1) Barang siapa dengan sengaja menggugurkan atau
mematikan kandungan seorang wanita dengan
persetujuannya, diancam pidana penjara paling lama 5
tahun 6 bulan
2) Jika perbuatan itu mengakibatkan matinya wanita
tersebut, diancam dengan pidana penjara paling lama 7
tahun
)Sec. 349
Jika seorang dokter, bidan atau juru obat membantu
melakukan kejahatan dlaam pasa 347 dan 348 , maka
pidana yang ditentukan dalam pasal itu dapat ditambah
dengan sepertiga dan dapat dicabut hak untuk
menjalankan pencaharian dalam mana kejahatan
dilakukan

Legal Abortus provocatus

according to KUHP & UU
Chapter III KUHP
Sec. 48
Barang siapa melakukan perbuatan
karena pengaruh daya paksa tidak
dipidana
This section is reference for UU No. 36
tahun 2009.

UU No. 36 tahun 2009

Sec. 75
1) Setiap orang dilarang melakukan aborsi
2) Larangan di ayat (1) dapat dikecualikan berdasarkan :
Indikasi kedaruratan medis yg dideteksi sejak usia dini kehamilan, baik yg
mengancam nyawa ibu dan/ janin, yg menderita penyakit genetik berat dan/
cacat bawaan, maupun yang tidak dapat diperbaiki sehingga menyulitkan
bayi tersebut hidup di luar kandungan; atau
Kehamilan akibat perkosaan yang dapat menyebabkan trauma psikologis
bagi korban perkosaan

3) Tindakan di ayat (2) hanya dapat dilakukan setelah melalui

konseling dan/ atau penasehatan pra tindakan dan diakhiri dgn
konseling pasca tindakan yang dilakukan konselor yg kompeten
dan berwenang.
4) Ketentuan lebih lanjut mengenai indikasi kedaruratan medis dan
perkosaan, sebagimana dimaksud pada ayat (2) dan ayat (3) dgn
Peraturan Pemerintah

 Sec. 76
Aborsi sebagaimana dimaksud dalam Pasal 75 hanya dapat
dilakukan :
Sebelum kehamilan berumur 6 minggu dihitung dari HPHT,
kecusli dalam kedaruratan medis.
Oleh tenaga kesehatan yg memiliki keterampilan dan
kewenangan yg memiliki sertifikat yg ditetapkan oleh Menteri
Dengan persetujuan ibu hamil yg bersangkutan
Dengan izin suami, kecuali korban perkosaan
Penyedia layanan kesehatan yang memenuhi syarat yg
ditetapkan Menteri
Sec. 77
Pemerintah wajib melindungi dan mencegah perempuan dari
aborsi sebagaimana dimaksud dalam Pasal 75 ayat (2) dan
ayat (3) yg tidak bermutu, tidak aman, dan tidak bertanggung
jawab serta bertentangan dgn norma agama dan UU

 Sec. 194
Setiap orang yg dengan sengaja
melakukan aborsi tidak sesuai dgn ketentuan
sebagaimana dimaksud dalam Pasal 75 ayat
(2) dipidana dengan pidana penjara paling
lama 10 tahun dan denda paling banyak 1
miliar rupiah.

According to Kusumo in Book of Ekotama,

the principle of Lex posteriori derogate legi
priori is apply between KUHP and UU No.
36/2009.
According to this principle, UU No.
36/2009 absolutely can be used while
incompatible with KUHP, because when there
is new law ( UU No. 36 ), the old law ( KUHP )
undeleted.