3.fisiologi kehamilan

FISIOLOGI KEHAMILAN, FISIOLOGI JANIN,

PERTUMBUHAN DAN PERKEMBANGAN JANIN

Efendi Lukas, dr, Sp.OG

Syarat ?

Kapan ?

Bagaimana ?

Dimana ?

Syarat ?

Kapan ?

Bagaimana ?

Dimana ?

Ada sperma & sel telur yang matang

Sekitar ovulasi

Pertemuan dan persenyawaan

ovum & sperma

Di ampula

Gametogenesis

Gametogenesis

A. Two-cell stageB. Three-cell

stageC. Four-cell stageD. Five-cell stageE. Six-cell stageF. Eight-cell

stage

5 hari setelah fertilisasi

5 hari setelah fertilisasi

Pembentukan Ruang Amnion & Kuning Telur

Pembentukan Ruang Amnion & Kuning Telur

Zigot

Zigot

Pembelahan

Pembelahan

Morula (32 sel)

Morula (32 sel) exocoelomexocoelom

Blastokist

Blastokist trofoblast

bintik benih trofoblast bintik benih

Nidasi

Nidasi

Nodus embryonale : ruang amnion ruang kuning telur

Nodus embryonale : ruang amnion ruang kuning telur

Ectodermkulit, rambut, kuku, gigi, saraf

Entodermusus, hati, saluran nafas, kandung kencing

Mesodermotot, tulang, jaringan ikat, jantung & pembuluh darah

Bintik Benih

Bintik Benih

Ectodermmesoder

mentoderm

Ectodermmesoder

mentoderm

Discusembryonale

(D.e)

Discusembryonale

(D.e)

JaninJanin

D.e menonjol ke Ruang AmnionHubungan D.e dengan

Trofoblast

D.e menonjol ke Ruang AmnionHubungan D.e dengan

Trofoblast

Tangkai penghubung

(Tali Pusat)

Tangkai penghubung

(Tali Pusat)

Decidua : Str. Compactum Str. Spongiosum Str. Basale

Decidua : Str. Compactum Str. Spongiosum Str. Basale

Decidua : basalis capsularis vera

Decidua : basalis capsularis vera

Perubahan Endometrium

Perubahan Endometrium

Chorion frondosum pembuluh darah ibu decidua (Haftzote)

Chorion frondosum pembuluh darah ibu decidua (Haftzote)

Membran plasenta : Amnion Khorion

Membran plasenta : Amnion Khorion

16 minggu : sel Langhans hilang terbentuk lapisan Nitabuchl

16 minggu : sel Langhans hilang terbentuk lapisan Nitabuchl

Chorion Frondosum (chorionic villi)

TrofoblastTrofoblast

1. Lapisan Langhans (cytotrophoblast) mesoderm2. Lapisan luar (syncytium/syncytio

trophoblast) decidua

1. Lapisan Langhans (cytotrophoblast) mesoderm2. Lapisan luar (syncytium/syncytio

trophoblast) decidua

KhorionKhorion

Vilichorion laevechorion frondosum

Vilichorion laevechorion frondosum

PERKEMBANGAN

TROFOBLAST

PERKEMBANGAN

TROFOBLAST

Berbentuk cakramØ 15-20 cm, tebal 2-3 cm+ 500 gram

2 bagian (bagian ibu dan bagian anak)

16 - 20 kotiledon 2 arteri umbilikalis

1 vena umbilikalis

Berbentuk cakramØ 15-20 cm, tebal 2-3 cm+ 500 gram

2 bagian (bagian ibu dan bagian anak)

16 - 20 kotiledon 2 arteri umbilikalis

1 vena umbilikalis

Skematik aliran darah dalam plasenta manusia

The umbilical cord inserts into the fetal surface of the placenta.Note the vessels radiating out from the cord over the fetal surface in this normal term placenta.

The maternal surface of a normal term placenta is seen here.Note that the cotyledons that form the placenta are reddish brown and indistinct.

kotiledon

I. Pertukaran Zat - difusi pasif - transpor aktif - difusi yang

difasilitasi - pinositosis

I. Pertukaran Zat - difusi pasif - transpor aktif - difusi yang

difasilitasi - pinositosis

II. Kelenjar Endokrin 1. Steroid Hormon (Estrogen dan Progesteron) 2. Protein Hormon (HCG, HPL, HCT, HCCT) 3. Releasing Hormon (TSHRF, FSHRH, CHR) 4. Enzim : HSAPase Oksitosinose “Pregnancy spesific

Protein”

II. Kelenjar Endokrin 1. Steroid Hormon (Estrogen dan Progesteron) 2. Protein Hormon (HCG, HPL, HCT, HCCT) 3. Releasing Hormon (TSHRF, FSHRH, CHR) 4. Enzim : HSAPase Oksitosinose “Pregnancy spesific

Protein”

III. Sebagai barier mekanis kimiawi

III. Sebagai barier mekanis kimiawi

Mekanisme transpor

• Transpor aktif butuh energi (ATP) melawan konsentrasi tinggi pompa. Contoh: Vit B12, kreatinin, sejumlah asam amino.

• Difusi yang difasilitasi >> difusi pasif. Yang berperan adalah carrier. Contoh : glukosa

• Pinositosis vesikel kecil dari membran sel yang melingkupi zat. Contoh: imunoglobulin

Antara pusat janin - permukaan fetal plasenta

30-100 cm; Ø 1-1,5 cm

Antara pusat janin - permukaan fetal plasenta

30-100 cm; Ø 1-1,5 cm

Wharton’s jelly insersi

sentral / parasentral / lateral / marginalis

Wharton’s jelly insersi

sentral / parasentral / lateral / marginalis

diliputi amnion 2 arteri umbilicales

1 vena umbilicalis

diliputi amnion 2 arteri umbilicales

1 vena umbilicalis

Seen here is a "velamentous" insertion of the umbilical cord in which the major umbilical vessels break up in the fetal membranes before reaching the placental disk.Such a condition is of no major consequence in utero, but could lead to a greater chance for cord trauma with bleeding during delivery.Dividing membranes are see at the left in this twin placenta.

Berisi cairan amnion Banyaknya ~ umur kehamilan alkalis lanugo vernix caseosa

Berisi cairan amnion Banyaknya ~ umur kehamilan alkalis lanugo vernix caseosa

Oligohidramnion < 500 cc

Polihidramnion > 2000 cc

Oligohidramnion < 500 cc

Polihidramnion > 2000 cc

1. Pergerakan anak2. Barier fisik3. Pertahanan suhu4. Membuka serviks

(persalinan)

1. Pergerakan anak2. Barier fisik3. Pertahanan suhu4. Membuka serviks

(persalinan)Asalnya : kencing janin transudat dari ibu sekret epitel amnion campuran

Asalnya : kencing janin transudat dari ibu sekret epitel amnion campuran

Lama hamil = 280 hari 266 hari dari

ovulasiTaksiran Persalinan = NAEGELE(siklus 28 hari)

Haid terakhir : Hari +7 Bulan -3 Tahun +1

Lama hamil = 280 hari 266 hari dari

ovulasiTaksiran Persalinan = NAEGELE(siklus 28 hari)

Haid terakhir : Hari +7 Bulan -3 Tahun +1

Abortus : < 500 gr < 22

minggu

Abortus : < 500 gr < 22

minggu

Partus Prematurus : 500- 2500 gr

22 - 37 minggu

Partus Prematurus : 500- 2500 gr

22 - 37 mingguPartus Maturus : > 2500 gr

37 - 42 minggu

Partus Serotinus : > 42 minggu

Partus Maturus : > 2500 gr 37 - 42 minggu

Partus Serotinus : > 42 minggu

1 bulan = 1 cm 2 bulan = 4 cm = 1 gr 3 bulan = 9 cm = 14,2 gr 4 bulan = 16 cm = 108 gr 5 bulan = 25 cm = 316 gr 6 bulan = 30 cm = 630 gr 7 bulan = 35 cm = 1045 gr 8 bulan = 40 cm = 1680 gr 9 bulan = 45 cm = 2478 gr10 bulan = 50 cm = 3400 gr

1 bulan = 1 cm 2 bulan = 4 cm = 1 gr 3 bulan = 9 cm = 14,2 gr 4 bulan = 16 cm = 108 gr 5 bulan = 25 cm = 316 gr 6 bulan = 30 cm = 630 gr 7 bulan = 35 cm = 1045 gr 8 bulan = 40 cm = 1680 gr 9 bulan = 45 cm = 2478 gr10 bulan = 50 cm = 3400 gr

Implantation is beginning. Trophoblast cells proliferate and begin to invade the uterine epithelium. Invasion is effected through digestion of the uterine cells by secretions of the trophoblast cells. Upon contact with the endometrium the cytotrophoblast forms the syncytiotrophoblast and HCG (human chorionic gonadotropin) production begins.

7th day

Syncytiotrophoblast cells further invade the Endometrium by secreting hydrolytic enzymes.

8th day

Implantation continues. The synctiotrophoblast nearly completely surrounds the cytotrophoblast cells of the blastocyst. The primary yolk sac is (probably) formed as the hypoblast cells move around the blastocyst cavity.

10th day

Gastrulation begins when the primitive pit forms, though it can not be seen in this picture. Gastrulation is the process by which the third germ layer, the intraembryonic mesoderm, is formed. It involves ingression and migration of cells from the epiblast through the primitive pit and primitive streak. This results in a trilaminar embryo with the three basic germ layers; ectoderm, mesoderm, and endoderm.

2nd week

A very significant week for the embryo. It has changed from a flat trilaminar disc into a tubular embryo and has now acquired a three-dimensional form. The embryo and amnion have grown vigorously, but the yolk sac has not. The lateral edges fold under and become the ventral surface of the embryo. Neurulation is almost completed and the anterior (rostal) and posterior (caudal) neuropores are closing. Sometimes are still forming. Two pairs of branchial (pharyngeal) arches have formed (beginning about day 22).Upper limb buds appear around day 25. The primordia of the eye and ear are present. The heart bulge is present.

4th week

5th week

The size of the embryo is now (approximately) 10mm CRL (Crown-Rump Length). The embryo trunk is elongating and the cervical region is straightening, raising the head. Genital ridges are ambisexual gonads.

7th week

8th week

The head is now erect and the eyes face anteriorly. The ears are still lowset, but very close to their definitive position. The lower limbs are now well developed. Early toenail development.

15th week

Head and body hair (lanugo) are visible. External ears stand out from the head. At this point the mother has felt movements of the fetus.

20th week

The fetus has now been viable since 20-22 weeks, i.e., survival is possible in the outside world without extraordinary measures. Fingernails, toenails, and eyelashes are present. The fetus may now have a good head of hair. The body is filling out. Testes are descending. The eyelids have parted and the eyes are open.

30th week

11 12 16 20 24 28 32 36 38KEHAMILAN

ATERM

11 12 16 20 24 28 32 36 38KEHAMILAN

ATERM

Fetus : + 2 cm

Fetus : + 2 cm

Kehamilan

Enam Minggu

Kehamilan

Enam Minggu

Fetus : + 7 cm

Fetus : + 7 cm

KehamilanDuabelas

Minggu

KehamilanDuabelas

Minggu

Fetus : + 18-27 cmBerat : + 300 grm

Fetus : + 18-27 cmBerat : + 300 grm

KehamilanDuapuluh

Minggu

KehamilanDuapuluh

Minggu

Fetus : + 25 - 38 cmBerat : + 1000 grm

Fetus : + 25 - 38 cmBerat : + 1000 grm

KehamilanDuapuluh

DelapanMinggu

KehamilanDuapuluh

DelapanMinggu

Berat : + 3000 grm

Berat : + 3000 grm

KehamilanAterm

KehamilanAterm

> 37 minggu> 37 minggu

Setelah lahir : Ductus Botali menutup lig. Arteriosum Foramen ovale menutup Duct. Venosus aranti lig teres hepatis Aa umbilicales lig vesico umbilicale

laterale

Setelah lahir : Ductus Botali menutup lig. Arteriosum Foramen ovale menutup Duct. Venosus aranti lig teres hepatis Aa umbilicales lig vesico umbilicale

laterale

2 arteri 1 vena “darah campuran” isi vena cava inferior lebih bersih dari

aorta

2 arteri 1 vena “darah campuran” isi vena cava inferior lebih bersih dari

aorta

Sirkulasi Darah Janin

Sirkulasi Darah Janin

Cardiovascular

system of fetus

Cardiovascular

system of fetus

HB janin ‡ Hb dewasa Dibuat terutama di hepar

Transport O2 lebih mudah

Menjadi Hb biasa 4 bulan

HB janin ‡ Hb dewasa Dibuat terutama di hepar

Transport O2 lebih mudah

Menjadi Hb biasa 4 bulan

Peredaran darah lebih cepat

Kadar Hb lebih tinggi eritrosit lebih banyak

Peredaran darah lebih cepat

Kadar Hb lebih tinggi eritrosit lebih banyak

O2 darah janin lebih rendah

O2 darah janin lebih rendah

1. Faktor Ibu : tinggi badan gizi

Penyakit ibu (hipertensi, asthma, anemia, penyakit

jantung, diabetes, dll) kehamilan ganda

kelainan uterus

1. Faktor Ibu : tinggi badan gizi

Penyakit ibu (hipertensi, asthma, anemia, penyakit

jantung, diabetes, dll) kehamilan ganda

kelainan uterus2. Faktor Anak : jenis kelamin kelainan genetis

infeksi intrauterin kelainan

kongenital

2. Faktor Anak : jenis kelamin kelainan genetis

infeksi intrauterin kelainan

kongenital 3. Faktor Plasenta : insufisiensi plasenta3. Faktor Plasenta : insufisiensi plasenta

1. UTERUS Uterus membesar hiperplasi, hipertrofi otot pertumbuhan aktif (estrogen) pertumbuhan pasif : segmen bawah

rahim lingkaran retraksi

1. UTERUS Uterus membesar hiperplasi, hipertrofi otot pertumbuhan aktif (estrogen) pertumbuhan pasif : segmen bawah

rahim lingkaran retraksi

Tanda Piskacek Kontraksi Braxton Hicks Perubahan serviks

Tanda Piskacek Kontraksi Braxton Hicks Perubahan serviks

Pembentukan rahim dan perubahan sikap tubuh ibu selama kehamilan

Minggu 6 12 16 20 24

Minggu 28 32 36 40

2. VAGINA Elastisitas bertambah Tanda Chadwick Keasaman bertambah

2. VAGINA Elastisitas bertambah Tanda Chadwick Keasaman bertambah

3. OVARIUM Corpus luteum graviditatum

3. OVARIUM Corpus luteum graviditatum

4. DINDING PERUT Striae gravidarum lividae albicans

4. DINDING PERUT Striae gravidarum lividae albicans O.K. hiperfungsi gl.

suprarenalisO.K. hiperfungsi gl. suprarenalis

5. KULIT hiperpigmentasi : linea nigra chloasma

5. KULIT hiperpigmentasi : linea nigra chloasma

6. PAYUDARA Membesar, nyeri ( hipertrofi alveoli ) Colostrum Hiperpigmentasi

6. PAYUDARA Membesar, nyeri ( hipertrofi alveoli ) Colostrum Hiperpigmentasi

7. Berat Badan Triwulan 1 : 1 kg Triwulan 2 : 5 kg Triwulan 3 : 5,5 kg

7. Berat Badan Triwulan 1 : 1 kg Triwulan 2 : 5 kg Triwulan 3 : 5,5 kg Janin : 3 kg Plasenta : 0,5

kg Air ketuban : 1 kg

Janin : 3 kg Plasenta : 0,5

kg Air ketuban : 1 kg Rahim : 1 kg Lemak : 0,5

kg Protein : 2 kg Air : 1,5 kg

Rahim : 1 kg Lemak : 0,5

kg Protein : 2 kg Air : 1,5 kg

Kebutuhan Fe, Ca dan P bertambah

Kebutuhan Fe, Ca dan P bertambah

8. Darah• Kadar hemoglobin dan hematokrit menurun

(anemia fisiologis)• Viskositas darah menurun• Saat aterm kadar Hb rata-rata 12,5 gr/dL• WHO : anemia < 11 gr/dL• Hb < 9 gr/dL rasio plasenta : berat badan

bayi meningkat dan berat badan lahir menurun

• Kehamilan lekositosis

• PMN dan monosit meningkat, limfosit (sel-sel T), eosinofil dan basofil menurun

• Aterm : 5000 – 12.000/mm3

• Persalinan dan post partum : 25.000 – 30.000 mm3

• Kehamilan penekanan imunitas humoral dan seluler

• Kehamilan mekanisme koagulasi aktif• Semua faktor pembekuan meningkat kecuali

faktor XI, XIII dan antitrombin III• Kadar fibrinogen meningkat mencapai rata-rata

450 mg/dL LED meningkat• Peningkatan fibrinogen + Stasis vena tungkai

bawah hiperkoagubilitas risiko tromboemboli

9. Lain-lain beban jantung bertambah kerja paru-paru bertambah sekresi HCl & gerakan lambung

berkurang

9. Lain-lain beban jantung bertambah kerja paru-paru bertambah sekresi HCl & gerakan lambung

berkurang kerja ginjal bertambah ureter melebar polakisuri perubahan mental

kerja ginjal bertambah ureter melebar polakisuri perubahan mental