Bad Obstetrical History

BAD
OBSTETRICAL
HISTORY
SAG-OBG
PENDAHULUAN
A woman is said to have 'bad obstetric history (BOH)' if she has
experienced any of the following events on two or more occasions
in the past:
• Spontaneous abortions or recurrent pregnancy loss
• Early neonatal deaths.
• Stillbirths.
• Intrauterine fetal deaths.
• Intrauterine growth retardation.
• Congenital anomalies in the fetus.
WHO : three consecutive pregnancy losses that constitutes the

classic definition of BOH. This condition is seen in 1-2% of couples.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 1/Issue 16/Dec 22, 2014
APA YANG HARUS
DILAKUKAN ?
• IDENTIFIKASI RIWAYAT KEHAMILAN SEBELUMNYA DENGAN
SEKSAMA.
•  MENJADI MASALAH KARENA SISTEM PENCATATAN
REKAMAN MEDIS BELUM BAIK
•  KURANGNYA PENCARIAN SUMBER MASALAH PENYEBAB
BOH
•  KETERBATASAN FASILITAS DAN DANA
Recurrent Pregnancy Loss. Causes, Controversies and Treatment.Howard JA Carp. 2007

Etiology
1. Hypertensive Disorders
• Gestational hypertension
• Chronic hypertension
• Preeclampsia/Eclampsia imbalance angiogenic regulator 
disfungsi endotel insufisiensi plasenta  outcome : IUGR,
IUFD, Stillbirth
Emilija Jasovic-Siveska and Vladimir Jasovic “Obstetric History and Risk for Mild and Severe Preeclampsia”. EC
Gynaecology
1.2 (2015): 73-80.
Calcium
High dose 2gr/day
Starting since 16W of
pregnancy
2. Thrombophilia
Penelitian yang dilakukan tidak
menemukan hubungan yang kuat antara
defisiensi protein dan protrombin mutasi
HEREDITARY dengan kejadian RPL (Protein C: OR 1.57;
• PROTEIN C/S DEFICIENCY
95% CI 0.23-10.54; 2 studies; n=633 - Protein
• FACTOR V LEIDEN MUTATION
S: 14.72; 95%CI 0.99-217.01; 2 studies; n=624
• PROTHROMBIN MUTATION
– Antithrombin: OR 0.88; 95% CI 0.17-4.48; 1
study; n=204) (Rey et al., 2003)
• APS didiagnosis dengan adanya

antibodi antiphospolipid,
ACQUIRED
APS (ANTIPHOSPOLIPID SYNDROME)
trombosis vaskular dan atau
komplikasi kehamilan.
Kapan dicurigai sebagai
suatu thrombofilia/APS?
• Riwayat keluarga yang jelas dan hasil pemeriksaan antibodi APS
(Antikoagulan lupus, Anti-cardiolipin, Beta-2 Glikoprotein I) atau :
• > 3x keguguran berturut2 <10 minggu UK
• > 1x kematian janin > 10 minggu UK
• Kelahiran Preterm < 34 minggu karena kelainan plasenta (PE, DM
gestasional, IUGR)
Heija, AA. “Thrombophilia and Reccurent Pregnancy Loss, Is Heparin Still the Drug of Choice?”-2014
Treatment
• Low Molecular weight heparin 3000 IU SC 2x/hari  mahal
• Unfractionated Heparin  better option
• Low dose aspirin
• Steroid ? Masih kontroversial
• Kolaborasi dengan TS IPD mungkin perlu  terapi secara
holistik
-Champa Koppad, Lakshmi K. IMMUNOLOGICAL CAUSES OF BAD OBSTETRIC HISTORY, REVIEW

ARTICLE. 2014-
3. Parental Genetic
Disorders
• Salah satu orang tua membawa anomali kromosom

• Yang terbanyak : Balanced Resiprocal atau translokasi
Robertsonian
• Outcome :
- Miscarriage
- Lahir hidup dengan kelainan kongenital multipel atau mental
disabilitas karena ketidakseimbangan pada kromosom
4. Faktor Anatomis
Congenital Acquired
• Mullerian abnormalities  • Fibroid  congestion and &
early pregnancy loss ec dilatation of endometrial venous
plexus  atrophy and ulceration
decreased of blood supply on endometrium  poor
• Incompetent cervix  endometrial receptivity 
recurrent abortion degeneration and increasing
cytokine  disturbing fetal
growth
• Endometrial polyp
• Intrauterine adhesion
Treatment
• Mullerian abnormalities  • Fibroid  myomectomy,
surgical hysteroscopy resection
• Incompetent cervix  • Endometrial polyp  polyp
cerclage (UK 10-14 mgg) resection
(electrocoagulation)
• Intrauterine adhesion 
dilatation and curretage +
IUD intrauterine
5. Faktor Endokrin
1. Disfungsi Tiroid B. Hipotiroid
• Sebuah studi pada 163 wanita (tidak
Hormon tiroid sangat penting untuk
sedang hamil) dengan riwayat keguguran
perkembangan janin. gangguan hormon
berulang dan 170 kontrol, didapatkan
tiroid dan peningkatan kadar Tiroid
prevalensi hipotiroid lebih tinggi pada
Peroksidase (TPO) Antibodies (TPOAb)
wanita dengan keguguran berulang
berhubungan dengan gangguan (4.29%) dibandingkan dengan 25
folikulogenesis, spermatogenesis, fertilisasi kelompok kontrol (0.61%).
dan embriogenesis. • Penyebab tersering autoimun hipotiroid
(Hashimoto disease)
A. Hipertiroid
• Paling sering adalah penyakit Graves,
ditemukan pada 0.1-0.4% pada wanita
hamil.
• Wanita hamil dengan hipertiroidisme
memiliki peningkatan risiko terhadap
komplikasi kehamilan termasuk
keguguran, pre-eklampsia, kelahiran
prematur, dan gagal jantung kongestif.
(Level of Evidence IV)
HIFERI“Konsensus Keguguran Berulang” . 2018

Treatment
Hipertiroid : Hipotiroid :
• PTU 300-450 mg/ hr • Sering pada daerah endemis
• Carbimazole 10-40 mg/hr defisiensi yodium.
• Surgical : subtotal • PO : levothyroxine 0,1
thyroidectomy mg/day
• Pemantauan kadar TSH
dapat diulangi 6-8 mgg
• Terapi OAT dipertahankan
s/d dosis maintenance.
Diabetes Mellitus
Diabetes gestational  diabetes yang muncul pada masa
kehamilan, dan hanya berlangsung hingga proses melahirkan
(onset tersering 24-28 weeks)
DM type 2 on pregnancy
- DM yang tidak terkontrol menyebabkan peningkatan resiko
outcome :
•IUGR
•IUFD
•Preterm labor
•Congenital malformation
- DM terkontrol mengurangi resiko
Skrining untuk DM
Gestasional
• Glucose Tolerance Test
1. Two Step Testing.
• 50 mg glukosa diberikan peroral tanpa PUASA, pada UK 24-
28 mgg  plasma glukosa diukur dari darah vena. Diukur
dalam 1 jam setelah pemberian
• Bila > 140 mg/dL  lanjutkan GTT  lanjut pemberian
glukosa 100 mg
• Bila > 200 mg/dL  Diabetes  C/ IPD
>
>
>
2. One Test Testing
- Pasien diminta puasa 8-14 jam sebelum test
- Pasien diminta minum glukosa per oral 75 mg
- Kadar glukosa darah di ambil 2 jam setelah pemberian glukosa
6. Infeksi
Mekanisme infeksi yang diduga berperan dalam pregnancy loss :
1. Infeksi langsung pada uterus, fetus atau plasenta
2. Chronic endometriosis/ endocervicitis
3. Amnionitis
4. Infected intrauterine device
Nigro, G et al. Role of the Infection in Reccurent spontaneous Abortion. 2011

Patomekanisme
1. Production of toxin or cytokines  induce uterine
contraction or damage feto-placental unit
2. Fetal infection  fetal death or life threatening malformation
3. Placental infection  placental insufficiency  fetal death
4. Endometrial chronic infection  interfering with embryo
implantation
5. Amnionitis  which causes abortion in the first TM/ preterm
labor in the third TM

Etiologi
1. Ascending Infection of genital : Bacterial vaginosis,
Chlamydia, Mycoplasma, Ureoplasma
2. Bacterial : Brucellosis, Listeriosis
3. Virological : CMV, HSV, Parvovirus

Treatment

Mode of Delivery???
• Kontroversial
• ACOG  with medical indication vs without medical indication (CDMR)
• BOH bukan indikasi mutlak cesarean delivery  sesuai indikasi obstetrik
 kembali ke etiologi BOH.
• Indikasi sesuai etiologi yang mendasari/penyakit penyerta.
Ruibin deng, et al. “Cesarean delivery on maternal request and its influencing factors in Chongqing, China.”
BMC Pregnancy and Childbirth. 2021.

Indikasi sosial
Bagaimana pada
kasus IVF ???
Williams Obstetric Ed.25. Cesarean Delivery and Peripartum Hysterectomy. P: 584-607.

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BAD

WHO : three consecutive pregnancy losses that constitutes the

Recurrent Pregnancy Loss. Causes, Controversies and Treatment.Howard JA Carp. 2007

• APS didiagnosis dengan adanya

-Champa Koppad, Lakshmi K. IMMUNOLOGICAL CAUSES OF BAD OBSTETRIC HISTORY, REVIEW

• Salah satu orang tua membawa anomali kromosom

HIFERI“Konsensus Keguguran Berulang” . 2018

Nigro, G et al. Role of the Infection in Reccurent spontaneous Abortion. 2011

Nigro, G et al. Role of the Infection in Reccurent spontaneous Abortion. 2011

Nigro, G et al. Role of the Infection in Reccurent spontaneous Abortion. 2011

Nigro, G et al. Role of the Infection in Reccurent spontaneous Abortion. 2011

Williams Obstetric Ed.25. Cesarean Delivery and Peripartum Hysterectomy. P: 584-607.

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