5/27/2018

GYNECOLOGY

dr. Nashria
dr. Reagan Resadita
BATCH AGUSTUS 2018 dr. Sekar Laras

1
 5/27/2018

Siklus
Infeksi
Neoplasma Menstruasi Infertilitas
Kongenital
Abnormal
Vulva Menstruasi
Toxoplasmosis
Analisis Sperma
Perdarahan Uterus
Vagina Abnormal
Rubella
Endometriosis
Serviks Tes Fertilitas Wanita
Amenorrhea
CMV
Korpus Uteri
Menopause
Policystic Ovarian
Pelvic Inflammatory Syndrome Varicella
Ovarium
Disease

2
 5/27/2018

Neoplasma
Pertumbuhan jaringan yang berlebihan dan abnormal
Gejala Utama : Perdarahan abnormal, massa pelvis, gejala vulvovaginal
Benigna VS Maligna Lokasi Tersering
Benigna vs Maligna

Tidak invasif, terlokalisasi Sifat Invasif, destruktif,

lambat Pertumbuhan cepat

Gejala penekanan massa Gejala Sindrom Para neoplastik

(nyeri punggung, obstipasi, (endokrinopati), cachexia
retensi urin)
Perdarahan, ulserasi, Komplikasi Metastasis
infeksi sekunder

SOLID KISTIK
Massa padat Kantong tertutup berisi cairan, gas, atau substansi semisolid

Kista ovarium, kista dermoid, kista bartholini

3
 5/27/2018

Neoplasma Vulva
Kista Bartholini Fibroma Vulva
Lokasi 1/3 posterior labium mayus, posisi jam 4 Lokasi Area vulva, labium mayus
dan 8 Asal Proliferasi fibroblast labium
Asal sumbatan pada ductus/ kelenjar mayus
bartholini (rekurensi 68-75%) S&S massa, penekanan urethra,
S&S massa, nyeri, dyspareunia, demam nyeri, dyspareunia

Tx - Word Catheter (kambuh 3-17%) Tx Eksisi

- Marsupialisasi (kambuh 10-24%)
- Insisi drainase
Jika infeksi -> abses (tersering N.gonorrhoeae)

4
 5/27/2018

Treatment Kista Bartholini

word CATHETER MARSUPIALISASI
• Pembuatan 5 mm incisi pada kista atau abses • Membuka rongga tertutup menjadi kantong
terbuka.
• Masukkan kateter Word dan dikembangkan
dengan 2-3 ml saline  selama 3-4 minggu • Pembuatan insisi vertikal elips 1,5-3 cm (sesuai
garis Langer)
• Pengeluaran isi kista dg sendok kuret kecil
sampai bersih
• Dinding kista dijahit ke kulit vertibular dengan
jahitan interupted

5
 5/27/2018

Neoplasma vagina
Kista Gartner Endometriosis Vagina Fibroma Vagina

• Lokasi: dinding • Lokasi: Fornix posterior • Lokasi: tidak khas

anterolateral vagina
• Asal: sisa kanalis Wolfii
(duktus gartner)
• S&S: massa
• Tx: Insisi dan eksisi
• Asal: Endometrium
• S&S: nodul subepitel
dengan perdarahan
ireguler
• Tx: sesuai tx endometriosis
• Asal: proliferasi fibroblast
jaringan ikat dan otot
vagina
• S&S: massa, dyspareunia
• Tx: eksisi

6
 5/27/2018

Neoplasma serviks uteri

Kista Nabothian (Retensi) Polip serviks Mioma Serviks

• Lokasi: Area endoserviks • Lokasi: Endo-ektoserviks • Lokasi: 1/3 inferior

• Asal: Retensi muara • Asal: Lapisan Stroma uterus
kelenjar endoserviks  endo-ektoserviks • Asal: proliferasi jaringan
retensi cairan musin • S&S: Massa bertangkai, otot uterus
• S&S: asimptomatik, rapuh, merah/pucat, • S&S: massa,
vesicle lesion bleeding, dyspareunia dyspareunia
• Tx: tidak ada terapi • Tx: Ekstirpasi  • Tx: ekstirpasi, eksisi,
kuretase , kauterisasi histerektomi

7

Tumor Maligna Serviks Uteri
Klasifikasi
A. Karsinoma serviks
 Squamous cell carcinoma 91 %
 Adenocarcinoma
 Adenosquamous carcinoma
 Adenoacanthoma
B. Sarcoma (sangat jarang)
5/27/2018
Faktor Resiko
 Infeksi HPV tipe16, 18, 45 dan 56
 Status sosial ekonomi
 Menikah/ memulai aktivitas seksual pada usia muda (kurang 18
tahun)
 Berganti ganti pasangan seksual.
 Berhubungan seks dengan laki laki yang berganti ganti pasangan
 Riwayat infeksi di daerah kelamin atau radang panggul
 Perempuan yang melahirkan banyak anak
 Perempuan perokok(2,5x lebih tinggi)
 Perokok pasif (1,4x lebih tinggi)
8
 5/27/2018

Zona
Transformasi

 Displasia adalah hilangnya diferensiasi normal dari epitel serviks

 Tempat paling sering terjadinya displasia adalah junctio epitelium skuamosum dan kolumnar
(zona transformasi)
 Daerah ini paling rentan terhadap infeksi virus, perubahan pH vagina dan fluktuasi level estrogen

 Peningkatan estrogen menstimulus epitel kolumnar bergerak keluar menuju vagina (kehamilan,
konsumsi pil kontrasepsi, bayi baru lahir).
 Penurunan estrogen menstimulus epitel kolumnar untuk masuk kembali ke kanalis endoserviks

9
 5/27/2018

Patogenesis
Carcinoma Serviks

10
 5/27/2018

Spektrum Klinis ca. serviks

11
 5/27/2018

GEJALA & TANDA KLINIS

GEJALA
• Pre invasive stage: asimtomatik
• Early invasive stage: perdarahan vagina abnormal, nyeri (dispareunia) dan perdarahan
post coitus, vaginal discharge
• Advanced stage: nyeri panggul (pelvic pain), weight loss, anorexia, anemia

TANDA KLINIS
• Nodul, ulkus, erosi serviks (tahap lanjut: crater-shaped ulcer dengan massa rapuh),
massa eksofitik
• Perdarahan
• Mobilitas serviks tergantung derajat keganasan (lunak  keras)

MANAJEMEN PREVENTIF
Primer:
• Gaya hidup sehat
• Vaksinasi HPV (kuadrivalen- genotipe 6, 11, 16 &18 ; bivalen- genotipe 16
&18)  usia > 10 th
Sekunder:
• Skrining untuk lesi pra kanker & diagnosis awal diikuti dengan terapi
Tersier:
• Diagnosis Dini dan terapi dari kanker yang terbukti

12
 5/27/2018

Screening Kanker Serviks

Recommendation for screening
Keluhan Lesi anatomis Rekomendasi
skrining
- - IVA
+ - PAP SMEAR

+ + Biopsi
(diagnostic)

IVA PAP’S SMEAR

13
 5/27/2018

Inspeksi Visual dengan Asam Asetat (IVA)

• Perempuan berusia 30-50 tahun

• Pasien klinik IMS dengan discharge
dan nyeri abdomen bawah (semua
usia)
• Perempuan yang tidak hamil
• Perempuan yang mendatangi
puskesmas, klinik IMS< dan klinik
KB yang meminta screening
• Jika hasil tes IVA negatif,  ulangi
3-5 tahun sekali.
• Jika hasil tes IVA positif 
rekomendasi krioterapi  ulangi 1
bulan post krioterapi  ulangi 6
bulan post krioterapi
Pedoman teknis Ca Payudara dan Ca Serviks,
kemenkes 2015

14
 5/27/2018

PAP SMEAR

PAP’S SMEAR
•Mendeteksi perubahan
pada morfologi sel
(dysplasia) yang merupakan
prekursors dari keganasan
Syarat:
•Lakukan Paps smear pada
fase proliferasi (1 minggu
setealah mens berakhir)
•Tidak melakukan
hubungan sexual 24-48 jam
sebelum paps smear
•Tidak menggunakan Exception:
Women at increased risk of CIN : ACOG
lubrikan vagina. 1. in utero DES (diethylstilbestrol) exposure  annually guideline
2. Immunocompromise  2x in first year then annually
3. History of cervical cancer
2012
should continue to be screened at least annually (2008)  More frequent screening (2012)

15
 5/27/2018

HASIL PAP SMEAR

ACOG guideline 2012

16
 5/27/2018

Interpretasi Pap Smear

Cervical dysplasia:
Perubahan abnormal pada sel di permukaan cervix, dilihat menggunakan miscroscope

©2015
UpToDate®

17
 5/27/2018

COLPOSCOPY -BIOPSY

Kolposkopi adalah pemeriksaan visual

bertenaga tinggi (pembesaran) untuk
melihat leher rahim, bagian luar dan kanal
bagian dalam leher rahim. Biasanya
disertai biopsi jaringan.

Merupakan GOLD STANDARD DIAGNOSIS

18
 5/27/2018

TERAPI PRE-CANCER/CA CERVIX

Terapi Penjelasan
Krioterapi Perusakan sel sel prakanker
dengan cara dibekukan
(dengan membentuk bola es
pada permukaan serviks)
elektrokauter Perusakan sel sel prakanker
dengan cara dibakar dengan
alat kauter, dilakukan leh
SpOG dengan anestesi
Loop ElectroSutgican Pengambilan jaringan yang
Excision Procedure (LEEP) mengandung sel prakanker
dengan menggunakan alat
LEEP
Konikasi Pengangkatan jaringan yang
megandung sel prakanker
dengan operasi
Histerektomi Pengangkatan seluruh rahim
termasuk leher rahim

19
 5/27/2018

Neoplasma Uteri
Leiomyoma
Benign /Uterine Fibroid

Neoplasma Uteri
Sarcoma Uteri

Malignant
Ca
Endometrium

Uterine Wall Anatomy

20
 5/27/2018

Leiomyoma/Uterine Fibroid
Tumor pelvis paling sering ditemukan pada wanita. Merupakan
tumor monoklonal yang berasal dari jaringan otot polos
myometrium. Etiologi: estrogen, negroid, nullipara

Type of Leiomyoma SIGN & SYMPTOMS

1. Submucous : beneath • Menorrhagia – heavy &
endometrium, if prolonged menstruation
pedunculated  geburt (common)
myoma • Pelvic pressure：urinary frequency,
2. Intramural/interstitial constipation
: within uterine wall • Spontaneous abortion, Infertility
3. Subserous/subperitone PHYSICAL EXAMINATION
al: at the serosal surface • Palpasi Abdomen: Teraba tumor
or bulge outward from pelvis, batas tegas, konsistensi
myometrium; if padat, permukaan rata, mobile.
pedunculated  satelite • Pelvic exam：Uterus —membesar,
myoma teraba keras dan irregular

21

Leiomyoma/Uterine Fibroid
DIAGNOSIS
Bimanual exam, USG (transabdominal
and transvaginal) hysteroscopy,
Laparacospy, CT, MRI
Whorl like pattern / Pusaran air
5/27/2018
Management
• Observation: for small myoma, premenopause
• Operation : myomectomy or hysterectomy
MEDICATION
1. NSAID (contoh: Ibuprofen, Naproxen)
Untuk mengurangi menstrual cramp dan menstrual flow
2. Kontrasepsi Hormonal (contoh: Pil KB, IUD hormonal, dll)
Mengurangi nyeri, perdarahan dan mengkoreksi anemia
3. Antifibrinolitik (contoh: Asam Tranexamat)
Indikasi: menorrhagia. Hati-hati co-therapy antifibrinolitik dan
KB hormonal karena meningkatkan risiko stroke, blood clotting
dan heart attack.
4. GNRH-agonist.
Diberikan secara injeksi tiap 1-3 bulan sekali untuk
memperkecil fibroid dan menghentikan perdarahan secara
sementara.
Terdapat gejala “flare” dalam minggu2 pertama pemakaian,
sehingga harus hati2 pada pasien dengan anemia
22

Neoplasma Uteri Malignant
Sarkoma Uteri
• Myoma uteri yang menjadi
leiomyosarkoma hanya 0,32 – 0,6%
dari seluruh myoma
• Leiomyosarkoma merupakan 50-75%
dari semua jenis sarkoma uteri
• Kecurigaan malignansi:
• Perdarahan pascamenopause
• Myoma uteri cepat membesar
• Pembesaran myoma pada
menopause
• Muncul jaringan nekrotik
5/27/2018
Kanker endometrium
• Insidensi keganasan ini 4,8% (ke-4
terbanyak) pada organ ginekologik
• Faktor risiko: obesitas, rangsangan
estrogen, menopause terlambat,
nulipara, siklus anovulasi, hiperplasi
endometrium, HRT
• Kecurigaan malignansi:
• Perdarahan uterus abnormal
• Perdarahan pascamenopause
• Diagnosis: kuretase diagnostic, biopsy
endometrium
23
 5/27/2018

Neoplasma Ovarium
Follicle Cyst

Functional Corpus Luteum

Cyst Cyst

Theca Lutein Cyst

Benign Non-Functional
Cyst
PCOS

Neoplasma Malignant Others

Ovarium e.g: Brenner Tumor,
Benign teratoma etc.

Tubo Ovarian
Inflammatory
Abscess

24
 5/27/2018

Neoplasma Ovarium Origin:No Type Subtype Note

1. Epithelium Serous Most

-Benign common
-Malignant 60% benign
-Borderline Can be
(low malignant bilateral
potential) (25%)
Malignant
type highly
associated
Mucinous with BRCA
Endometrioid gene
Clear-cell mutation
Brenner
Cystadenofibroma
2. Germ Cell Teratoma Most
Dysgerminoma common in
Endodermal sinus young
tumor women
Choriocarcinoma Majority are
benign.
3. Sex-Cord Fibroma May produce
Granulosa-theca cell estrogen or
Stroma
Robins Basic Pathology 9th edition Sertolli Leydig androgen

25
 5/27/2018

Kanker Ovarium
Malignant Ovarian Neoplasm
Etiology Sign & Symptoms
• inactivation of tumor suppressor genes Known as silent lady killer  high mortality
(PTEN, p16, p53)
• Low abdominal discomfort
• activation of oncogenes (HER-2, c-myc, (fullness, bowel symptom) 
K-ras, Akt) Pressure symptom
• mutations in BRCA1, BRCA2
• Loss of weight, malaise, anorexia
Risk Factor • Pain due to torsion, hemorage or
• Age  mostly found in older age; rupture.
>50% cases found >63 y.o patients
• Vaginal Bleeding
• Family history of ovarian cancer,
breast cancer, or colorectal cancer
Diagnosis
• Obesity
• Reproductive history (increasing • USG
menstrual cycle) • CT An enlarged ovary with a papillary serous carcinoma
on the surface
• Fertility drugs (clomiphene citrate)
• MRI
• Estrogen therapy and hormone
therapy • Tumor marker Ca-125
• Personal history of breast cancer

26
 5/27/2018

Teratoma Ovarium (Dermoid cyst of ovary)

• Bizzare Tumour

• Insidensi: 15-20% tumor ovarium

• Sering terjadi pada wanita usia decade 2

 semakin muda, semakin maligna

• Asal: totipotential germ cell (ektodem,

mesoderm, endoderm)  membentuk
rambut, kelenjar keringat, tulang, gigi,
sel saraf
Robins Basic Pathology 9th edition
• Gejala: infertilitas, torsio (10-15%
kejadian)  operasi emergensi

• Terapi: Laparotomi, kistektomi

27
 5/27/2018

SIKLUS MENSTRUASI

28
 5/27/2018

Normal Menstrual Cycle

GnRH/Gonadotropin Releasing Hormone

Bila kadar estrogen tinggi, maka estrogen akan

memberikan umpan balik ke hipotalamus sehingga
kadar GnRH akan menjadi rendah

FSH/Follicle Stimulating Hormone

•FSH akan menyebabkan pematangan dari folikel.

•Dari folikel yang matang akan dikeluarkan ovum.
Kemudian folikel ini akan menjadi korpus luteum

LH/Luteinizing Hormone

•LH berfungsi untuk mempertahankan korpus

luteum.
•Dibawah pengaruh LH, korpus luteum
mengeluarkan estrogen dan progesteron, dengan
jumlah progesteron jauh lebih besar.
•Walaupun estrogen kadar tinggi merangsang
sekresi LH, progesteron dengan kuat akan
menghambat sekresi LH dan FSH.

29
 5/27/2018

Normal Menstrual cycle

30
 5/27/2018

Normal Menstrual Bleeding

• Occurs approximately once a
month (every 21 to 35 days).
• Lasts a limited period of time (3 to
7 days).
• May be heavy for part of the
period, but usually does not
involve passage of clots.
• Often is preceded by menstrual
cramps, bloating and breast
tenderness, although not all
women experience these
premenstrual symptoms.
• Average : 35-50 cc

31
 5/27/2018

Ovulasi
• Terjadi 14 hari sebelum mens • >> kadar progesterone 2ng/ml
berikutnya • LH surge (dg Radioimunoassay)
• Tanda dan tes : • USG  folikel >1,7 cm
– Rasa sakit di perut bawah (mid
cycle pain/mittleschmerz) Ferning test Result:
– Perubahan temperatur basal 
efek termogenik progesteron
– Ferning test
Menggunakan sampel mukus serviks
atau dengan saliva, akan tampak
gambaran daun pakis pada mikroskop
– Perubahan lendir serviks
• Uji membenang (spinnbarkeit):
Fase folikular : lendir kental,
opak; menjelang ovulasi  MENGHITUNG FERTILE WINDOW PADA SIKLUS
encer, jernih, mulur MENSTRUASI YANG IREGULER:
- Siklus terpendek – 18 hari
- Siklus terpanjang – 11 hari Americanpregnancy.org

32
 5/27/2018

Abnormal Uterine Bleeding

Term (Previous) Definition Pattern
Amenorrhea No uterine bleeding for moments
Menorrhagia Excessive amount (>8omL/cycle) or Occurs at irregular interval
prolonged duration > 7 days, also
called “hypermenorrhea”
Metrorrhagia Uterine bleeding occurring at Irregular
irregular but frequent interval,
amount varies
Menometrorrhagia Irregular, heavy, and prolonged Irregular
menstrual bleeding
Oligomenorrhea Decreased, scanty flow, the term Interval >36-40 days
“hypomenorrhea” is used for regular
timing with scanty amount
Polymenorrhea Regular, frequent menstruation Interval < 21 days
Intermenstrual Bleeding or spotting between Between periods (usually light flow)
normal periode

33
 5/27/2018

Etiologi Abnormal Uterine Bleeding

Polip Coagulopathy
• Endocervical polip - Von Willebrand
• Endometrial polip disease
- Gangguan agregasi
platelet

Ovulatory disturbance
Adenomyosis
- Endocrinopatie
• Part of endometrial (PCOS, Hypotiroid,
that penetrate to obesity, anorexia)
myometrium -Extreme exercise,
stress

Leiomyoma Endometrial
• Submucosal -Endometrial
inflammation infection
• Subserosal -Defisiensi endothelin-1,
• intramural Prostaglandin F2-alpha

Iatrogenic
Malignancy and
Drugs : rifampicin,
hyperplasia defined as bleeding from the uterine corpus that is abnormal in griseofulvin, trisiklik,
- Endometrial cancer regularity, volume, frequency, or duration and occurs in the absence of phenothiazine,
anticoagulant, antiplatelet,
pregnancy

34
 5/27/2018

Medical Management for Acute AUB

Hormonal management is considered the first line of medical therapy for patients with
acute AUB without known or suspected bleeding disorders.
Drug Dosage Schedule Contraindication

Conjugated 25 mg IV Every 4-6 hours Breast canver.

equine estrogen for 24 hour PAD, Venous
thrombosis, liver
dysfunction
Combined oral Combined oral 3x/day for 7 days Cigeratte smoking
contraceptive contraceptive (aged > 35 years),
contain 35 hypertension,
microgram ethinyl DVT, CVD,
estradiol migraine, breast
cancer, liver
dysfunction
Medroxyprogeste 20 mg PO 3x/day for 7 days DT, breast cancer,
rone acetate liver dysfunction
Tranexamic acid 1,3 gram PO or 10 3x/day for 5 days Trombosis,
mg/kg IV (max. impaired color
600 mg/dose) vision,
thromboembolic
ACOG 2013, COMMITTEE OPINION, Management of disease
Acute AUB in nonpregnant Reproductive Aged For longterm therapy: Levonorgestrel intrauterine, Oral contraceptive,progestin therapy,
Women
tranexamic acid,NSAID

35
 5/27/2018

Dysmenorrhea
Dysmenorrhea: painful cramp during menstruation. Divided into 2 broad categories: primary (occurring in
the absence of pelvic pathology) and secondary (resulting from identifiable organic diseases).
Primary
• Onset 6-12 months after menarche
• Usual duration of 48-72 hours (often starting several hours before or just after the menstrual flow)
• Cramping or laborlike pain
• Background of constant lower abdominal pain, radiating to the back or thigh
• Often unremarkable pelvic examination findings (including rectal)
Current evidence suggests that the pathogenesis of primary dysmenorrhea is due to prostaglandin F2α
(PGF2α), a potent myometrial stimulant and vasoconstrictor, in the secretory endometrium.
Treatment:
NSAID  celecoxib, Ibuprofen, Naproxen, mefenamic acid
Hormonal  COC, Levonorgestrel-releasing intrauterine system Medroxyprogesterone injection
Secondary
• Dysmenorrhea beginning in the 20s or 30s, after previous relatively painless cycles
• Heavy menstrual flow or irregular bleeding
• Most ethiologies: Endometriosis, adenomyosis, PID, infection
• Poor response to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptives (OCs)
• Often with Infertility, Dyspareunia, Vaginal discharge
Diagnosis and Initial Management of Dysmenorrhea, Am Fam Physician. 2014;89(5):341-346.

36
 5/27/2018

Endometriosis
Kondisi ditemukannya jaringan endometrium diluar korpus uteri
merespon estrogen  perdarahan  inflamasi

Patofisiologi: mullerian duct remnants theory, menstruasi retrograde,

coelomic metaplasia, Sampson’s theory, Iron-induced oxidative stress

Lokasi tersering: peritoneum, ovarium, tuba falopi

Lokasi lain: vesical urinaria, ureter, usus halus, fornix posterior, SIGN and SYMPTOM
rectum, diafragma
• Dismenorea
• Menorhagia
TRIAS klasik: dismenorhea berat, dyspareunia/ nyeri panggul kronis,
• Nyeri goyang panggul
infertil
• Nyeri perut bawah
• Dyschezia
Penunjang: Transvaginal/endorectal USG, MRI (deteksi implantasi • Dysuria
endometrial) • Dyspareunia
• Mual, muntah, rasa penuh perut

37
 5/27/2018

Endometriosis Therapy
Women with endometriosis are confronted with one or both of two major problems:
endometriosis-associated pain and infertility.
Endometriosis Pain EBM If Unresolved Pain  Surgical Intervention
• Laparoscopy
Analgetik GPP* • Hysterectomy/Oophorectomy/Salpingo-
oophorectomy
Kontrasepsi Hormonal (Cth: Pil KB)
Works by  GnRH   LH& FSH B
Infertility
Progestagen
suppress the hypothalamus through negative feedback  A clinicians should not prescribe
hypoestrogenic state hormonal treatment for suppression of ovarian
function to improve fertility.
Anti-Progestagen (Gestrinone)
mechanism of action of gestrinone is complex and multifaceted, has A Operative Laparoscopy
functional antiestrogenic activity in the endometrium. A
GnRH Agonist
 LH& FSH melalui mekanisme down regulation. Efek samping: bone AA
loss. Tidak utk usia <16th dan long term therapy.

Aromatase Inhibitor GPP : expert opinion

suppress the conversion of androstenedione and testosterone to B
estrogen. Dipilih jika obat lain tdk efektif dan sebaiknya dgn kombinasi • ESHRE guideline: management of women with endometriosis
obat lain karena efek samping yg severe

38
 5/27/2018

Amenorrhea
Amenorrhea is the absence of menstruation.
• Primary
– Absence of menses by age 13 without or age 15 with secondary sexual development
• Secondary
– Absence of menses for 3 month in regular or 6 month in iregular cycle menstruation

Amenorrhea: An Approach to
Diagnosis and Management
Am Fam Physician.
2013;87(11):781-788

39
 5/27/2018

Amenorrhea: An Approach to
Diagnosis and Management
Am Fam Physician.
2013;87(11):781-788

40
 5/27/2018

Amenorrhea: An Approach to
Diagnosis and Management
Am Fam Physician.
2013;87(11):781-788

41
 5/27/2018

Amenorrhea

Example:
Prolactinoma
Prolactinomas are the most common
hormone-secreting pituitary tumors
Symptoms
- Menstrual disturbance
- Galactorrhea
- Hypoestrogenism
Vaginal dryness,dyspareunia
- Space Occupying effect
Headache, diplopia
(kompresi kiasma optik),
vision loss (kompresi
NC III, IV, VI

42
 5/27/2018

Functional Hypothalamic Amenorrhea

(Hypogonadotropic hypogonadism)
the hypothalamic-pituitary-ovarian axis is
suppressed due to an energy deficit stemming
from stress, weight loss (independent of
original weight), excessive exercise, or
disordered eating.
• It is characterized by a low estrogen state
without other organic or structural disease
• Menses typically return after correction of the
underlying nutritional deficit.

43
 5/27/2018

Menopause
Perimenopause
Periode 3-5 tahun sebelum menopause yang ditandai
dengan peningkatan frekuensi irregular anovulatory
bleeding yang selanjutnya diikuti periode amenorrhea
dan gejala-gejala menopause lainnya

Menopause
Periode dimana siklus menstruasi secara permanen
berhenti. Diagnosis secara retrospektif sejak 12 bulan
paska amenorrhea. (Rerata usia 51 tahun).

Postmenopause
Periode setelah menopause, gejala menopause sudah
mulai berkurang, tetapi berisiko terhadap beberapa
penyakit seperti osteoporosis dan penyakit jantung akibat
estrogen yang rendah.

44
 5/27/2018

Menopause
PATOFISIOLOGIS GEJALA AKIBAT PENURUNAN ESTRADIOL
• pada usia sekitar 50 tahun fungsi ovarium VASOMOTOR INSTABILITY
menjadi sangat menurun. Folikel mencapai Hot Flashes
jumlah yang kritis, maka akan terjadi gangguan Gangguan tidur
sistem pengaturan hormon Night Sweat
• insufisiensi korpus luteum, siklus haid Gangguan mental: depresi/cemas
anovulatorik dan pada akhirnya terjadi
oligomenore UROGENITAL CHANGES  akibat  kolagen & blood flow
• Masa perimenopause aktivitas folikel Stress incontinence VAGINA:
dalam ovarium mulai berkurang. Pelvic organ prolapse - dryness, irritation, infectio
• Ketika ovarium tidak menghasilkan ovum dan - dyspareunia
berhenti memproduksi estradiol, kelenjar
hipofise berusaha merangsang ovarium untuk CARDIOVASCULAR CHANGES
menghasilkan estrogen, sehingga terjadi  Total Kolesterol  Aterosklerosis  risiko Infark
peningkatan produksi FSH. Vasokontriksi
• Pada pascamenopause kadar LH dan FSH akan
meningkat, FSH biasanya akan lebih tinggi BONE CHANGES
dari LH sehingga rasio FSH/ LH menjadi lebih Bone resorption > bone formation  Osteoporosis
besar dari satu.
• Hal ini disebabkan oleh hilangnya mekanisme
umpan balik negatif dari steroid ovarium dan
inhibin terhadap pelepasan gonadotropin.

45
 5/27/2018

Menopause
DIAGNOSIS
• Retrospective diagnose, FSH > 30 mIU/ml and E2 < 30pg/ml (Rogerio, 2000; Baziad, 2003).

TERAPI
• Estrogen – a minimum of 2mg of oestradiol is needed to mantain bone mass and relief symptoms of
menopause.
• Women with uterus – add progestin at last 10 days to prevent endometrial Hyperplastic
• Sequential Regimens - used in patient close to menopause.
o Oestrogen – in the first ½ of 28 day per pack
o Oestrogen & Progetin in 2nd 1/12 of 28 day pack

• Benefit for HRT (Hormone Replacement Therapy)

o Vagina-↑ vaginal thickness of epithelium →↓ dyspareunia & vaginitis.
o Urinary tract – enhancing normal bladder function.
o Osteoporosis – decrease fractures by more than 50%
o CVS – decrease by 30% by observation studies but recent studies shows no benefits.
o Colon Cancer decrease up to 50%

46
 5/27/2018

Premenstrual Syndrome
PMS PMS PMM
Diagnostic Tenth Revision of the Diagnostic and
the cyclic recurrence in the luteal criteria International Statistical Manual of
phase of the menstrual cycle of a Classification of Mental Disorders, 4th
Disease (ICD-10) ed. (DSM-IV)
combination of distressing
physical, psychological, and/or Providers using Obstetrician/gynec Psychiatrists, other
these criteria ologists, primary mental health care
behavioral changes of sufficient care physicians providers
severity to result in deterioration
Number of One 5 of 11 symptoms
of interpersonal relationships symptoms
and/or interference with normal required
activities..
Functional Not required Interference

PMM impairment with social or

role functioning
required
Many patients with psychiatric
Prospective Not required Prospective daily
disorders also complain of
charting of charting of
worsening of their symptoms symptoms symptoms
around the premenstrual phase, required for two
called “premenstrual cycles
magnification”. ACOG 2008

47
 5/27/2018

ACOG 2008

48
 5/27/2018

Pelvic Inflammatory Disease

Infeksi polimikrobial yang melibatkan traktus genital atas
Terutama menyerang wanita usia muda yang aktif secara seksual
Chlamydia trachomatis dan Neisseria gonorrhoeae adalah patogen tersering

Kriteria minimum Kriteria tambahan Pemeriksaan Penunjang

(satu atau lebih harus - Temperatur oral > 38.3 C - Biopsi endometrial
ada untuk PID) - Discharge serviks atau vagina yang - Transvaginal sonografi
- Cervical motion mukopurulen dan abnormal atau MRI
tenderness/nyeri - Terdapat sel darah putih pada - Laparoskopi
goyang serviks pemeriksaan mikroskopis cairan vagina
- Uterine tenderness - Peningkatan laju sedimentasi eritrosit
- Adnexal tenderness - Peningkatan CRP
- Bukti lab adanya gonorrhea atau
klamidia

49
 5/27/2018

Suggested Criteria for Hospitalization of Patients with Pelvic Inflammatory Disease

• Inability to follow or tolerate an outpatient oral medication regimen
• No clinical response to oral antimicrobial therapy
• Pregnancy
• Severe illness, nausea and vomiting, or high fever
• Surgical emergencies (e.g., appendicitis) cannot be excluded
• Tubo-ovarian abscess

DRUG DOSAGE
ORAL Option 1
Ceftriaxone (Rocephin) 250 mg IM in a single dose
plus
Doxycycline 100 mg orally twice per day for 14 days
with or without
Metronidazole (Flagyl) 500 mg orally twice per day for 14 days

DRUG DOSAGE
PARENTERAL Regimen A
Cefotetan (Cefotan) 2 g IV every 12 hours
or
Cefoxitin 2 g IV every six hours
plus
Doxycycline 100 mg orally or IV every 12 hours

50
5/27/2018

51
 5/27/2018

Infertilitas
Kegagalan dalam konsepsi, mempertahankan kehamilan, atau melahirkan bayi hidup bagi pasangan suami-istri yang
telah melakukan hubungan seksual secara regular tanpa kontrasepsi setelah:
1. Usia wanita < 35 tahun  melewati durasi 12 bulan
2. Usia wanita > 35 tahun  melewati durasi 6 bulan

Prevalensi: Klasifikasi:
a. 40% faktor istri Primary infertility
a. Infeksi: Servisitis  Inflamasi uterus  salfingitis  perituba adesi  When a woman is unable to ever bear a
stenosis tuba  oklusi tuba child, either due to the inability to become
b. Gangguan ovulasi: Penuaan (usia), Polikistik Ovarii (PCOS), Kelainan
pregnant or the inability to carry a
pada hipotalamus-hipofisis, Hiperprolaktin
c. Gangguan anatomi: Kelainan kongenital
pregnancy to a live birth she would be
classified as having primary infertility.
b. 40% faktor suami
a. Kelainan sperma Secondary infertility
b. Gangguan transportasi: Varikokel, Prostatitis, Epididimitis, Orkhitis, When a woman is unable to bear a child,
c. Kelainan kongenital (Hipospadia, agenesis vas deferens, klinefelters either due to the inability to become
syndrome), pregnant or the inability to carry a
d. Kelainan hipotalamus-hipofisis
pregnancy to a live birth following either a
e. Autoimunitas, Impotensi
previous pregnancy or a previous ability to
c. 20% pada keduanya carry a pregnancy to a live birth.

52
 5/27/2018

Fertility Test for Male

WHO 2010 sperm analysis

53

Terminologi analisa sperma
Normozoospermia
Oligozoospermia
Astenozoospermia
Teratozoospermia
OligoAstenoTeratozoospermia
Azoopermia
Aspermia
5/27/2018
Jumlah sperma ≥ 15 juta/ml
Jumlah sperma < 15 juta/ml
Motilitas sperma A < 32 % atau A+B <40%
A : bergerak cepat dan lurus
B : Bergerak lambat dan tidak lurus
C : bergerak ditempat
D : tidak bergerak
Morfologi sperma normal < 4%
(sindroma OAT)
0 sperma + plasma semen
0 sperma + 0 plasma semen
54
 5/27/2018

Fertility Test for Female

HSG

55
 5/27/2018

LH : FSH Test
• LH-FSH Ratio : the relative value of 2 gonadotropin hormone
produce by the pituitary gland in women
• Luteinizing hormone (LH) and Follicle stimulating hormone
(FSH) stimulate ovulation by working in different ways.
• in premenopusal women, the normal LH-FSH ration is 1:1 as
measured on day three of the menstrual cycle
• Variation from this ratio used to diagnose PCOS or other
disorders, explain infertility or verify that woman has entered
menopause
• FSH stimulates the ovarian follicle to mature. Then a large
surge of LH stimulates the follicle to release an egg to
fertilization
• On day 3 of the cycle, LH should be low. If LH is elevated on
this day, possible even as high as FSH, then it suggest
problem with ovulation. Ovulation requires an LH surge, and
if LH is already elevated, it may not surge and ovulated

56
5/27/2018

57
 5/27/2018

Policystic Ovarian Syndrome (PCOS)

Kelainan endokrin
 wanita usia reproduktif

Definisi klinis
Terdapatnya hiperandrogenemia
yang berhubungan dengan
anovulasi kronik pada wanita
tanpa adanya kelainan dasar spesifik
pada adrenal atau kelenjar hipofisa

Syarat PCOS menurut Rotterdam Consensus (2003) yaitu 2 dari berikut:

1. Hiperandrogenisme klinis dan/atau hiperandrogenemia: hirsutisme, jerawat,
alopesia
2. Oligoanovulasi: oligomenorhea dan/atau amenorhea
3. USG: polikistik ovari

58
 5/27/2018

Pathophysiology of
PCOS
Lifestyle modification as
First line of PCOS
management

Source: http://www.pathophys.org/pcos/

59
 5/27/2018

Therapy of PCOS

Keluhan
Utama :

Terapi:

OVULATION INDUCTION. Approach to

ovulation induction in women with
polycystic ovarian syndrome. IVF: In
vitro fertilization
Guzick. Polycystic Ovary Syndrome. Obstet Gynecol. 2004

60
 5/27/2018

TORCH
Toxoplasmosis
Other (sifilis, varicella-zoster, parvovirus B19)
Rubella
Cytomegalovirus (CMV)
Herpes Infection

INFEKSI KONGENITAL

61
 5/27/2018

IgM is too large to cross placenta

and does not confer maternal
immunity

IgG crosses placenta and confers

passive immunity on the fetus

62
 5/27/2018

Toxoplasmosis

Toxoplasma gondii trophozoites are

typically crescent shaped, with a
In pregnancy, the most prominent central nuclei
common mechanisms of acquiring infection:
1. consuming raw or very undercooked meats
or contaminated water,
2. exposure to soil (gardening without gloves)
or
3. Exposure to cat litter

63
 5/27/2018

Toxoplasmosis Diagnosis
Serologic Testing

- IgG (-) dan IgM (-)  tidak ada infeksi ATAU

extremely recent acute infection
- IgG (+) dan IgM (-)  infeksi lama (lebih dari 1
tahun)
- IgG (+) dan IgM (+)  Recent infection atau
False (+). Jika suspek infeksi akut lakukan tes
ulang 2-3 minggu kemudian. Peningkatan IgG
sebesar 4x lipat menandakan infeksi akut.
Sumber: SOGC

64
 5/27/2018

Toxoplasmosis Diagnosis
Amniocentesis
Amniocentesis should be offered to identify Toxoplasma gondii in the amniotic fluid by polymerase chain
reaction IF
(a)maternal primary infection is diagnosed
(b)serologic testing cannot confirm or exclude acute infection
(c) in the presence of abnormal ultrasound findings (intracranial calcification, microcephaly,
hydrocephalus, ascites, hepatosplenomegaly, or severe intrauterine growth restriction).
Amniocentesis should not be offered at less than 18 weeks’ gestation because of the high rate of false-positive
results.

Therapy
Spiramycin: fetal prophylaxis
• <18 minggu (hingga terbukti tidak ada infeksi pada janin):
– Spiramicin: 1g per 8 jam bersama makan Pyrimethamine  folic acid
antagonist. Should not be used in the
• >18 minggu (diberikan sampai lahir): first trimester because it is
– Pirimetamin 50 mg 2x sehari, selama 2 hari, dilanjutkan 50 potentially teratogenic.
mg/hari
– Sulfadiazine loading 75 mg/kg, dilanjutkan 50 mg/kg 2x sehari Folinic acid: to counteract bone
marrow depression by
– Asam folat : 10-20 mg/hari hingga 1 minggu bebas pirimetamin pyrimethamine

65
 5/27/2018

Ultrasonographic
findings
- Fetal
hydrocephalus
- Fetal intracranial
calcification
- IUGR
Classic tetrad of
congenital
toxoplasmosis:
1. Hydrocephalus
2. Chorioretinitis
3. Intracranial
calcification
4. Convulsion
Sabin

66
 5/27/2018

Rubella (German Measles)

Congenital rubella syndrome

67
 5/27/2018

Algorithm for serologic evaluation of pregnant women

exposed to rubella

www.cdc.gov

68
 5/27/2018

Congenital rubella syndrome

Diagnosis of congenital
rubella

Risk of congenital defects:

• Before 11 weeks of gestation  90%
• 13 -14 weeks  11%
• 15-16 weeks  24%
• After 16 weeks  0%

Women should be counselled about the possible risk of vertical transmission and offered
THERAPY pregnancy termination, especially if primary infection occurs prior to 16 weeks’ gestation.
Unfortunately, there is no in utero treatment available for infected fetuses. Thus, prevention
remains the best strategy to eliminate all cases of CRS. SOGC, 2008

69
 5/27/2018

CITOMEGALOVIRUS (CMV)

70
 5/27/2018

CMV
Identification of Primary CMV in Pregnancy
Mother
Serologic testing:
•CMV – IgG positive with low IgG avidity
•CMV-IgM positive
Fetus
Amniocentesis:
•Viral/antigen detection CMV-PCR
•Viral load = severe infection
Ultrasound
Newborn
•CMV-IgM positive
•Virus/PCR positive in body fluid
•CMV IgG positive at 1 year

71
5/27/2018

72
 5/27/2018

CMV: Ultrasonographic findings

Diagnostic clue:
Calcification
- Intracranial
- Hepatic
-- Hepatosplenomegaly
-- Amnniotic fluid volume disorder

73
 5/27/2018

Symptomatic CMV infection

• Petechiae (54 to 76 percent)
• Jaundice at birth (38 to 67 percent)
• Hepatosplenomegaly (39 to 60
percent)
• Small size for gestational age (39 to
50 percent)
• Microcephaly (36 to 53 percent)
• Sensorineural hearing loss (SNHL,
present at birth in 34 percent)
• Lethargy and/or hypotonia (27
percent)
• Poor suck (19 percent)
• Chorioretinitis (11 to 14 percent)
• Seizures (4 to 11 percent)
• Hemolytic anemia (11 percent)
• Pneumonia (8 percent)

74
 5/27/2018

Treatment
• Once the diagnosis of congenital CMV infection is confirmed,
one option is pregnancy termination.
• A second proposed option: treatment of the mother with
antiviral agents (ganciclovir, foscarnet, and cidofovir.)
– These drugs are of moderate effectiveness in treating CMV infection in
the adult
– No proven value in preventing or treating congenital CMV infection.
• The most promising therapy for congenital CMV infection
appears to be hyperimmune globulin.

Source;
http://www.perinatology.com/exposures/I
nfection/CMV/Cytomegalovirus.htm#DXM
OTHER

75
 5/27/2018

Varicella

76
 5/27/2018

Radioulnar hipoplasia
Hepatic calcification and missing hand
USG Findings:
• Calcification
o intrahepatic
o Intracranial : may also see liver, heart, and renal
• Poly hydramnion : due to neurologic impairment of swallowing
• Limb Hipoplasia
• Microcephaly

77
 5/27/2018

Management
• Fetal Infection  Amniocentesis (culture or
PCR of virus) or Fetal MRI : CNS
• Maternal infection symptomatic
– Hospitalization in severe case, esp in
varicella pneumonia (emergency case)
– Acyclovir 800 mg P.O 5 times a day, for 7
days
• Maternal zooster outbreak in pregnancy is
not associated with risk of fetal malformation
Zooster Lesion

78
5/27/2018

79