dr. Nashria
BATCH NOVEMBER 2020 dr. Reagan Resadita
dr. Sekar Laras
Siklus
Infeksi
Neoplasma Menstruasi Infertilitas
Kongenital
Abnormal
Vulva Menstruasi
Analisis Sperma Toxoplasmosis
Perdarahan Uterus
Vagina Abnormal
Tes Fertilitas Wanita Rubella
Endometriosis
Serviks
Amenorrhea Policystic Ovarian
CMV
Syndrome
Korpus Uteri
Menopause
Uterine
Ovarium Pelvic Inflammatory Varicella
Abnormalities
Disease
Neoplasma
Pertumbuhan jaringan yang berlebihan dan abnormal
Gejala Utama : Perdarahan abnormal, massa pelvis, gejala vulvovaginal
Benigna VS Maligna Lokasi Tersering
Benigna vs Maligna
SOLID KISTIK
Massa padat Kantong tertutup berisi cairan, gas, atau substansi semisolid
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
Spektrum Klinis ca. serviks
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; 9vHPV- 9
valen HPV vaccine)
Sekunder:
• Skrining (IVA, Pap smear, HPV DNA) untuk lesi pra kanker & diagnosis awal diikuti dengan
terapi
Tersier:
• Diagnosis Dini dan terapi dari kanker yang terbukti
Screening Kanker Serviks
Recommendation for screening
Keluhan Lesi anatomis Rekomendasi
skrining
- - IVA
+ - PAP SMEAR
+ + Biopsi
(diagnostic)
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)
HASIL PAP SMEAR
•Atypical squamous cells of undetermined significance (ASC-US)—ASC-US
means that changes in the cervical cells have been found. The changes are
almost always a sign of an HPV infection.
Atypical glandular cells (AGC)—Glandular cells are another type of cell that
make up the thin layer of tissue that covers the inner canal of the cervix. An
AGC result means that changes have been found in glandular cells that raise
concern for the presence of precancer or cancer.
Interpretasi Pap Smear
Cervical dysplasia:
Perubahan abnormal pada sel di permukaan cervix, dilihat menggunakan miscroscope
Neoplasma Uteri
Sarcoma Uteri
Malignant
Ca
Endometrium
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
Neoplasma Ovarium
Benign Functional Cyst
Follicle Cyst
Terbentuk saat sac pada
ovarium tidak
mengeluarkan ovum dan
sac terisi oleh cairan.
Tersusun dari sel theca dan
sel granulosa
Corpus Luteum
A functional ovarian cyst
Neoplasma is a sac that forms on the
Cyst
surface of a woman's
Ovarium ovary during or after
ovulation
Terjadi setelah sac
mengeluarkan ovum,
kemudian menutup
kembali dan terisi carian
e.g: PCOS,
Non-Functional endometriosis,
Cyst dermoid cyst
Not part of normal
menstruation cycle
LH/Luteinizing Hormone
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
Medical Management for Acute AUB
Acute AUB refers to an episode of heavy bleeding that, in the opinion of the clinician, is of sufficient
quantity to require immediate intervention to prevent further blood loss
Akses IV 2 jalur
1. Determine patient’s acuity Hemodynamic instability
Assesment: Transfusi
4. As. tranexamat
Lokasi lain: vesical urinaria, ureter, usus halus, fornix posterior, rectum, SIGN and SYMPTOM
diafragma
• Dismenorea
• Menorhagia
TRIAS klasik: dismenorhea berat, dyspareunia/ nyeri panggul kronis, infertil • Nyeri goyang panggul
• Nyeri perut bawah
• Dyschezia
Penunjang: Gold Standard Laparoscopy. • Dysuria
Transvaginal/endorectal USG, MRI (deteksi implantasi endometrial) • Dyspareunia
• Mual, muntah, rasa penuh perut
Endometrioma ovary/Chocolate cyst
Endometrioma adalah adanya
jaringan endometirum pada Transvaginal
ultrasonography showing
ovarium. Ini merupakan jenis a 67 x 40 mm
endometriosis yang paling sering. endometrioma as
distinguished from other
Pembentukan endometriosis types of ovarian cysts by a
somewhat grainy and not
dapat menyebabkan scar tissue, completely anechoic
content.
perlengketan dan reaksi inflamasi.
Amenorrhea: An Approach to
Diagnosis and Management
Am Fam Physician.
2013;87(11):781-788
Amenorrhea: An Approach to Diagnosis and Management
Diagnosis of Primary Amenorrhea Am Fam Physician. 2013;87(11):781-788
Diagnosis of Secondary Amenorrhea
Amenorrhea: An Approach to
Diagnosis and Management
Am Fam Physician.
2013;87(11):781-788
Anovulasi
Example:
Prolactinoma Symptoms
Prolactinomas are the most common - Menstrual disturbance - Space Occupying effect
hormone-secreting pituitary tumors - Galactorrhea Headache, diplopia
- Hypoestrogenism (kompresi kiasma optik),
Vaginal dryness,dyspareunia vision loss (kompresi
NC III, IV, VI
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.
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.
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, infection
• 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. Diagnosis dengan penghitungan Bone Mineral Density
DIAGNOSIS TERAPI
- FSH > 40 mIU/ml Estrogen – a minimum of 2mg of oestradiol is needed to
- E2 < 20pg/ml mantain bone mass and relief symptoms of menopause.
Faktor Risiko
Prolaps Uteri
Terapi
Multiparitas, genital atrofi, hipoestrogenisme Stage1 : diet and exercise (Kegel)
Tanda dan Gejala Stage 2 keatas atau
• Sensasi benda asing yang turun kontraindikasi terhadap surgery:
• Nyeri punggung Pessary (Ring, donut, Gelhorn)
• Frekuensi miksi meningkat Jika Tx konservatif gagal
• Stress incontinence dan gangguan voiding pertimbangkan surgical
• Gangguan defekasi approach
Grading
Pelvic Organ Prolapse Quantification System (POP-Q)
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
DRUG DOSAGE
RAWAT JALAN 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
RAWAT INAP 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
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.
Fertility Test for Male
Analisa sperma
Normozoospermia Jumlah sperma ≥ 15 juta/ml
Oligozoospermia Jumlah sperma < 15 juta/ml
Astenozoospermia 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
HSG
LH : FSH Test
• LH-FSH Ratio : the relative value of 2 gonadotropin hormone produce by the pituitary gland in women
• 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
• 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
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
Source: http://www.pathophys.org/pcos/
Therapy of PCOS
Keluhan
Utama :
Terapi:
INFEKSI KONGENITAL
IgM is too large to cross placenta
and does not confer maternal
immunity
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
Ultrasonographic
findings
- Fetal
hydrocephalus
- Fetal intracranial
calcification
- IUGR
Classic Triad of
congenital
toxoplasmosis:
1. Hydrocephalus
2. Chorioretinitis
3. Intracranial
calcification
Rubella (German Measles)
www.cdc.gov
Congenital rubella syndrome
Diagnosis of congenital
rubella
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
CITOMEGALOVIRUS (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
CMV: Ultrasonographic findings
Diagnostic clue:
Calcification
- Intracranial
- Hepatic
-- Hepatosplenomegaly
-- Amnniotic fluid volume disorder
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.
Varicella
Congenital Varicella
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
Note: Jika ibu terkena varicella dekat dengan hari persalinan maka mortalitas pada bayi akan meningkat karena virus dapat menular secara transplasental dan belum terbentuk
protective antibody pada bayi