Kuliah obsgin

Dr Frizar Irmansyah SpOG(K)

Departemen Obstetri Ginekologi

 ANTAntenatEN
ATAL CARE :
Menuju suksesnya
kehamilan dan
Antenatal Care
persalinan

Yuyun Lisnawati
 Definisi :

Suatu program berupa

Sejarah : observasi, edukasi, dan
Paris (1788) : penanganan medik
pasien rawat inap usia 36 minggu – lahir.
pada ibu hamil.
Ballantyne (1901) :
asuhan antenatal pada pasien rawat jalan.
Tujuan :
Program “Safe Motherhood“
(World congress FIGO, 1988) :
menjadikan kehamilan dan
Upaya dunia untuk menurunkan persalinan sebagai suatu
morbiditas dan mortalitas maternal. pengalaman yang aman dan
memuaskan.

(ACOG)
 Konsep :

Focused antenatal care

Focused antenatal care
Asuhan antenatal (FANC) :
Asuhan antenatal (FANC) :
tradisional : suatu metode pendekatan
tradisional : suatu metode pendekatan
- Jumlah kunjungan asuhan antenatal yang
- Jumlah kunjungan asuhan antenatal yang
- Risiko rendah dan risiko berorientasi tujuan.
- Risiko rendah dan risiko berorientasi tujuan.
tinggi, berdasarkan
tinggi, berdasarkan
komplikasi yang akan Rekomendasi para peneliti
komplikasi yang akan Rekomendasi para peneliti
terjadi (2001), diadaptasi WHO
terjadi (2001), diadaptasi WHO
tahun 2002.
tahun 2002.
 Metode Pemeriksaan
Metode Manfaat
Anamnesis Identitas, riwayat haid,
perkawinan, kehamilan- Skrining risiko / penyulit
persalinan sebelumnya, kehamilan dan persalinan
riwayat penyakit, keluhan
ibu hamil.

Pemeriksaan fisik : TB, BB, IMT Skrining hipertensi dalam

Pemeriksaan fisik umum kehamilan
dan pemeriksaan khusus Skrining risiko DMG
(vagina, serviks) Deteksi infeksi genitalia
(risiko preterm)

Ultrasonografi
 Pemeriksaan Ultrasonografi
Trimester I Trimester II Trimester III

Dasar
Menentukan lokasi dan Pertumbuhan dan Pertumbuhan dan
usia kehamilan perkembangan janin perkembangan janin
Deteksi kehamilan Skrining dasar kelainan Indeks cairan amnion
multipel, korionisitas kongenital
Menentukan kehidupan Kelamin janin Lokasi plasenta
mudigah/janin
Evaluasi tumor Indeks cairan amnion
ginekologi
Mengukur panjang Lokasi plasenta
serviks

Tambahan
 7T
1. Timbang BB ibu
2. Tekanan Darah
3. Tinggi fundus uteri
4. Tablet Fe
5. Toxoid Tetanus
6. Tes penyakit menular sexual
7. Temu wicara
8. Status gizi/ukur linkar lengan atas
9. Tentukan presentasi janin dan djj
10.Tatalaksana kasus
Masalah Kesehatan Ibu di Indonesia
● Penyebab kematian ibu :
● 1. perdarahan (30%)
● 2. eklampsia (25%)
● 3. infeksi (12%)
● WHO : insiden 7 x lebih tinggi di negara berkembang
● Negara maju : 1,3% - 6%, negara berkembang : 1,8% - 18%
● Indonesia : 128.273/ tahun atau 5,3%
● 5-6% pada primigravida dan 3% akan berkembang
menjadi eklampsia
 Hypertension in Pregnancy
(Report of the ACOG Task Force on Hypertension in Pregnancy)
Obstetrics & Gynecology, Vol. 122, No. 5, November 2013
Etiologi
● ? Diseases of theori
● Karena kehamilan terjadi vasospasme arteriol dan
kerusakan sel endotel pembuluh darah
● Akibatnya terjadi ekstravasasi cairan dari intrasel ke
ekstra sel dengan manifestasi oedema, terjadi kerusakan
glomerulus akibatnya terjadi pengeluaran protein di urin.
● Akibat spasme arteriol terjadi hipertensi.
● Akibat spasme arteri terjadi hipoksia jaringan dengan
akibat kerusakan multi organ.
 PREEKLAMSIA

DAMPAK
Anak:
Jangka Pendek: Jangka Panjang: Cerebral Palsy
HELLP, Gagal Ginjal Kronik, DM tipe 2
CVD Peny. Kardio Penyakit Kardio Vaskular
Edema pulmonum, Vaskular, Obesitas
Eklamsia DM tipe 2 PCO
Teratozoospermia

Preeclampsia: No longer solely a pregnancy disease

Hypertension 2007;49(5):1056-62, J Clin Endocrinol Metab 2006;91(4):1233-8

REVIEW
Preeclampsia: No longer solely a pregnancy disease
Andrea L. Tranquillia, Beatrice Landia, Stefano R. Giannubiloa,*, Baha M. Sibaib

Risk of developing disease after preeclampsia

Relative risk
Chronic hypertension 2.5 [23]-3.7 [2]
Cardiovascular disease, if preeclampsia associated with IUGR 3.9 [6]
Ischemic heart disease (overall) 2.16 [2]
Ischemic heart disease mild preeclampsia 2.0 [24]
Ischemia heart disease severe preeclampsia 5.36 [24]
Mortality from ischemic heart disease 1.38 [26]
Death from circulatory diasease 1.30 [26]
Death from cardiovascular disease ; preeclampsia > 34 wks HR 2.08 [25]
Death from cardiovascular disease ; preeclampsia < 34 wks HR 9.54 [25]
Premature death (within 25 yrs) 2.71 [20]
Non-fatal stroke 1.76 [2]
Fatal stroke 2.98 [2]
Stroke preeclampsia > 37 wks 0.98 [2]
Stroke preeclampsia < 37 wks 5.98 [2]
Venous thromboembolism 1.19 [2]
End-stage renal disease 4.7 [41]
Type 2 diabetes mellitus 1.40 [8]-3.8 [3]
Hypothyroidism 1.7 [49]
Cancer HR 0.92 [15]-0.86 [26]

In brackets: reference cited in the text.

HR: Hazard ratio

Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 2 (2012) 350-357

 Poor ability to Predict Pre-Eclampsia
Test No of studies No of women Sn (95% CI) Sp (95% CI)
BMI>34 2 16200 18 (15 - 21) 93 (87 - 97)
BMI>29 8 410823 23 (15 - 33) 88 (80 - 93)
BMI>24.2 9 440214 41 (29 - 53) 75 (62 - 84)
BMI<19.8 7 152720 11 (8 - 16) 80 (73 - 86)
AFP 12 137097 9 (5 - 16) 96 (94 - 98)
Fibronectin cellular 2 135 50 (30 - 70) 96 (79 - 99)
Fibronectin total 3 373 65 (42 - 83) 94 (86 - 98)
Foetal DNA 3 351 50 (31 - 69) 88 (80 - 93)
HCG 16 72732 24 (16 - 35) 89 (86 - 92)
Oestriol 3 26811 26 (9 - 56) 82 (61 - 93)
Serum uric acid 5 514 36 (22 - 53) 83 (73 - 90)
Urinary calcium excretion 4 705 57 (24 - 84) 74 (69 - 79)
Urinary calcium/creatinine ratio 6 1345 50 (36 - 64) 80 (66 - 89)
Total proteinuria 4 2228 35 (13 - 68) 89 (79 - 94)
Total albuminuria 2 88 70 (45 - 87) 89 (79 - 94)
Microalbuminuria 2 190 62 (23 - 90) 68 (57 - 77)
Microalbumin/creatinine ratio 1 1422 19 (12 - 28) 75 (73 - 77)
Kallikreinuria 1 307 83 (52 - 98) 98 (98 - 100)
SDS Page proteinuria 1 153 100 (88 - 100) 69 (60 - 77)
Doppler any/unilateral notching 19 14345 63 (51 - 74) 82 (74 - 87)
Doppler bilateral notching 21 29331 48 (34 - 62) 92 (87 - 95)
Doppler other ratios 8 2619 55 (37 - 72) 80 (73 - 86)
Doppler pulsatility index 8 14697 48 (29 - 69) 87 (75 - 94)
Doppler resistance index 29 7982 66 (54 - 76) 80 (74 - 85)
Doppler combinations of FVW 25 22896 64 (54 - 74) 86 (82 - 90)

0 20 40 60 80 100 0 20 40 60 80 100

Sensitivity Specificity
Source: Meads CA, 2008.
• Cochrane: Doppler utero-plasenta tidak menunjukkan
perbedaan kejadian hipertensi pada ibu (RR 1,08; 95% CI
0,87 – 1,93)

Doppler
 Primary Prevention of PE
Intervention No of RCTs No of women RR (95% CI)
Ambulatory BP 0 0
Bed rest for high BP 1 228 0.98 (0.80, 1.20)
Exercise 2 45 0.31 (0.01, 7.09)
Rest alone for normal BP 1 32 0.05 (0.00, 0.83)
Altered dietary salt 2 631 1.11 (0.46, 2.66)
Antioxidants 7 6082 0.61 (0.50, 0.75)
Calcium 12 15206 0.48 (0.33, 0.69)
Nutritional advice 1 136 0.98 (0.42, 1.88)
Balanced protein/energy intake 3 512 1.20 (0.77, 1.89)
Isocaloric balanced protein supplementation1 782 1.00 (0.57, 1.75)
Energy/protein restriction 2 284 1.13 (0.59, 2.18)
Garlic 1 100 0.78 (0.31, 1.93)
Magnesium 2 474 0.87 (0.57, 1.32)
Marine oils 4 1683 0.86 (0.59, 1.27)
Antihypertensives v none 19 2402 0.99 (0.84, 1.18)
Antiplatelets 43 33439 0.81 (0.75, 0.88)
Diuretics 4 1391 0.68 (0.45, 1.03)
Nitric oxide donors and precursors 4 170 0.83 (0.49, 1.41)
Progesterone 1 128 0.21 (0.03, 1.77)

0.01 0.1 0.2 0.5 1 2 5 10

Relative Risk (95% Confidence Interval)
 Prevention of Preeclampsia

• Antioxidants: vitamins C and E are not effective.

• Calcium: may be useful in populations with low
calcium intake (not in the USA).
• Low-dose aspirin (60 to 80 mg): beginning in the late
first trimester may have slight effect to reduce
preeclampsia and adverse perinatal outcomes.
• Bed rest or salt restriction: no evidence of benefit
 Daily Calcium Intake

Minimum daily calcium intake, Pregnant Women (1300−1500 mg/day)

Minimum daily calcium intake, Adult WRA (1000−1200 mg/day)

Source: Calcium and Prevention of Pre-Eclampsia: Summary of Current Evidence, Monitoring, Evaluation and Research Task Force of the PE/E working
group 2010
• Pemberian kalsium (1,5 – 2 g kalsium elemental/hari)
berhubungan dengan penurunan hipertensi dalam
kehamilan dan preeklampsia terutama pada wanita dengan
asupan rendah kalsium dan risiko tinggi preeklampsia.
 
Rekomendasi:
• Pemberian kalsium dapat diberikan pada wanita yang
memiliki risiko tinggi preeklampsia dan rendah asupan
kalsium untuk mencegah terjadinya preeklampsia.
Level of evidence I a, Rekomendasi A

Pencegahan-Kalsium
• Istirahat di rumah 4 jam/hari di rekomendasikan untuk
pencegahan primer maupun sekunder preeklampsia
Level evidence I a, Rekomendasi A

• Pembatasan garam untuk mencegah preeklampsia dan

komplikasinya tidak direkomendasikan.
Level evidence I a, Rekomendasi A

Pencegahan
Classification of Hypertensive Disorders of Pregnancy

Four categories
• Preeclampsia-eclampsia (BP elevation after 20 weeks of gestation with
proteinuria or any of the severe features of preeclampsia listed below)
• Chronic hypertension (of any cause that predates pregnancy)
• Chronic hypertension with superimposed preeclampsia (chronic
hypertension in association with preeclampsia)
• Gestational hypertension (BP elevation after 20 weeks of gestation in the
absence of proteinuria or any of the severe features of preeclampsia listed
below)
 Severe Features of Preeclampsia
(Any of these findings):
• Hypertension: systolic >160 or diastolic >110 on two occasions at least 4 hours
apart while the patient is on bed rest (unless antihypertensive therapy is
initiated before this time).
• Thrombocytopenia (platelet count <100,000).
• Impaired liver function (elevated blood levels of liver transaminases to twice the
normal concentration), severe persistent RUQ or epigastric pain unresponsive to
medication and not accounted for by alternative diagnoses, or both.
• New development of renal insufficiency (elevated serum creatinine greater than
1.1 mg/dL, or doubling of serum creatinine in the absence of other renal
disease).
• Pulmonary edema.
• New-onset cerebral or visual disturbances.
 Proteinuria

• Defined as the excretion of > 300 mg of protein in a 24-hour

urine collection. The dipstick method is discouraged for
diagnostic use unless other approaches are not readily
available. 1+ is considered as the cutoff for the diagnosis of
proteinuria.
• The diagnosis of severe preeclampsia is no longer dependent
on the presence of proteinuria. Do not delay management of
preeclampsia in the absence of proteinuria.
• Massive proteinuria (> 5 g) has been eliminated from
consideration of preeclampsia as severe.
Fetal growth restriction has been removed as a
finding indicative of severe preeclampsia.
 Management of Preeclampsia

Recent changes in management:

– Timing of delivery: In women with preeclampsia without

severe features is 37 0/7 weeks of gestation.

– Postpartum management : Nonsteriodal antiinflammatory

agents may contribute to increased BP and should be
replaced by other analgesics in women with hypertension
that persists for more than 1 day postpartum.
 TASK FORCE RECOMMENDATIONS
MONITORING

• Close monitoring of women with gestational hypertension or

preeclampsia without severe features, with serial assessment
of maternal symptoms and fetal movement (daily by the
woman), serial measurements of BP (twice weekly), and
assessment of platelet counts and liver enzymes (weekly) is
suggested.

• For women with gestational hypertension, monitoring BP at

least once weekly with proteinuria assessment in the office
and with an additional weekly measurement of BP at home or
in the office is suggested.
 TASK FORCE RECOMMENDATIONS
ANTIHYPERTENSIVE

• For women with mild gestational hypertension or

preeclampsia with a persistent BP of less than 160
systolic or 110 diastolic, it is suggested that
antihypertensive medications not be
administered.
• For women with preeclampsia with severe
hypertension during pregnancy (sustained systolic
BP of at least 160 or diastolic of at least 110), the
use of antihypertensive therapy is recommended.
 TASK FORCE RECOMMENDATIONS
EXPECTANT / DELIVERY ?

• For women with mild gestational hypertension or

preeclampsia without severe features and no indication for
delivery at less than 37 0/7 weeks of gestation, expectant
management with maternal and fetal monitoring is suggested.

• For women with mild gestational hypertension or

preeclampsia without severe features at or beyond 37 0/7
weeks of gestation, delivery rather than continued
observation is suggested.
 TASK FORCE RECOMMENDATIONS
EXPECTANT / DELIVERY ?

For women with severe preeclampsia at or beyond

34 0/7 weeks of gestation, and in those with
unstable maternal or fetal conditions irrespective of
gestational age, delivery soon after maternal
stabilization is recommended.
 TASK FORCE RECOMMENDATIONS
MAGNESIUM SULFATE

For women with preeclampsia with systolic BP of less

than 160 and a diastolic BP less than 110 and no
maternal symptoms, it is suggested that magnesium
sulfate not be administered universally for the
prevention of eclampsia.
 TASK FORCE RECOMMENDATIONS
MAGNESIUM SULFAT

• For women with eclampsia, the administration of

parental magnesium sulfate is recommended.
• For women with severe preeclampsia, the
administration of intrapartum-postpartum magnesium
sulfate to prevent eclampsia is recommended.

• For women with preeclampsia undergoing cesarean

delivery, the continued intraoperative administration of
parenteral magnesium sulfate to prevent eclampsia is
recommended.
 TASK FORCE RECOMMENDATIONS

For women with severe preeclampsia at less than

34 0/7 weeks of gestation with stable maternal
and fetal conditions, it is recommended that
continued pregnancy be undertaken only at
facilities with adequate maternal and neonatal
intensive care resources.
 TASK FORCE RECOMMENDATIONS

• For women with preeclampsia, it is suggested that a

delivery decision should not be based on the amount
of proteinuria or change in the amount of
proteinuria.

• For women with severe preeclampsia and before

fetal viability, delivery after maternal stabilization is
recommended. Expectant management is not
recommended.
 TASK FORCE RECOMMENDATIONS

It is suggested that corticosteroids be administered and

delivery deferred for 48 hours if maternal and fetal
conditions remain stable for women with severe
preeclampsia and a viable fetus at 33 6/7 weeks or
less .
 TASK FORCE RECOMMENDATIONS
MODE OF DELIVERY

• For women with preeclampsia, it is suggested that

the mode of delivery need not be cesarean
delivery.

• The mode of delivery should be determined by fetal

gestational age, fetal presentation, cervical status,
and maternal and fetal conditions.
 TASK FORCE RECOMMENDATIONS

• For women with HELLP syndrome and before the

gestational age of fetal viability, it is recommended that
delivery be undertaken shortly after initial maternal
stabilization.
• For women with HELLP syndrome at 34 0/7 weeks or more
of gestation, it is recommended that delivery be
undertaken soon after initial maternal stabilization.
• For women with HELLP syndrome from the gestational age
of fetal viability to 33 6/7 weeks of gestation, it is suggested
that delivery be delayed for 24-48 hours if maternal and
fetal conditions remain stable to complete a course of
corticosteroids for fetal benefit.
 Chronic Hypertension

For women with chronic hypertension and NO

additional maternal or fetal complications, delivery
before 38 0/7 weeks of gestation is not
recommended.
 Preeclampsia Definitions - OLD

• Preeclampsia (mild)
– BP >140/90 mmHg
– Proteinuria >0.3 g/24hr

• Severe Preeclampsia
– BP >160/110 mmHg
– Proteinuria >5 g/24hr
– HELLP syndrome
– CNS symptoms

ACOG Practice Bulletin 33, 2002

 Preeclampsia Definitions - NEW

• Preeclampsia without severe features (new term)

– BP >140/90
– Proteinuria >300 mg/24hr OR dipstick 1+ OR
protein/creatinine ratio >0.3
• Absence of proteinuria with any:
– Platelets <100k
– Creatinine >1.1
– LFT elevation
– CNS symptoms

ACOG Task Force HTN Pregnancy Nov 2013

 Post-Partum Preeclampsia

• Occurs up to 6 weeks postpartum

– De novo increase of BP
– First diagnosis post-partum

• Physiology:
– BP rises again 3-6 days postpartum
– BP usually decreases 1-2 days postpartum

CMQCC Preeclampsia Toolkit 5-2014

Preeclampsia Foundation
 Preeclampsia Definitions NEW

• Severe Preeclampsia = ANY ONE of:

– BP >160/110 – must TREAT within 1hr
– Platelets <100k
– LFT elevation
– Creatinine >1.1
– Pulmonary edema
– CNS symptoms

ACOG Task Force HTN Pregnancy Nov 2013

Manajemen PEB:
• Atasi TD: target MAP Ideal 90 – 110 mmHg.
• Cegah Kejang: MgSO4 4 – 7 meq/ml
• Atasi Disfungsi Endotel
• Redakan inflamasi berlebih
• Redakan ROS berlebih
• Kembalikan Resistensi Insulin fisiologis
• Cukupi protein high quality
• Cukupi cairan
• Bertahap lakukan pelatihan otot lurik
• 6 – 12 bulan post partum:
- Tidak hipertensi
- Fs GFR N
- Tidak resistensi Insulin, tidak dislipidemia
- Tidak Inflamasi kronis
 DRUGS FOR TREATMENT OF SEVERE HYPERTENSION IN PREGNANCY

Drug Dose Onset Duration Adverse Effects

Hydralazine 5–10 mg IV q 20 min 10–20 min 3–6 h Tachycardia, headache, flushing,

aggravation of angina

Labetalol 20–40 mg IV q 10 min 1 10–20 min 3–6 h Scalp tingling, vomiting, heart block
mg/kg as needed

Nifedipine 10–20 mg PO q 20–30 min 10–15 min 4–5 h Headache, tachycardia, synergistic
interaction with magnesium sulfate

Nicardipine 5–15 mg/h IV   5–10 min 1–4 h Tachycardia, headache, phlebitis

Sodium 0.25–5 μg/kg/min IV Immediate 1–2 min Nausea, vomiting, muscle twitching,
nitroprusside thiocyanate and cyanide intoxication

Nitroglycerin 5–100 μg/min IV   2–5 min 3–5 min Headache, methemoglobinemia,

tachyphylaxis
 Management of
Hypertensive Emergency

• Patients should be admitted to an Intensive Care Unit for

continuous monitoring of BP and parenteral
administration of an appropriate agent
• The initial goal therapy is to reduce mean arterial BP by
no more than 25% (within minutes to 1 hour).
• Then if stable, to 160/100 to 110 mmHg within the next 2
to 6 hours.
• Excessive falls in pressure that may precipitate renal,
cerebral, or coronary ischemia should be avoided.

Chobanian AV et al, The JNC 7 report, JAMA 2003;389-2560-70

 Nifedipine

• Formerly given sublingually or as bite-and-swallow (in fact,

there is only negligible absorption sublingually)

• Erratic and unpredictable effect on BP

• Many documented cases of CVA and even death from rapid

↓ BP

Rynn et al, J Pharm Pract 2005;18:363-76

• Belum ada kesepakatan waktu yang optimal untuk memulai
magnesium sulfat, dosis (loading dan pemeliharaan), rute
administrasi (intramuskular atau intravena) serta lama terapi.
• RCOG: loading 4g, pemeliharaan 1-2 g/jam
• Mortalitas maternal ditemukan lebih tinggi pada penggunaan
diazepam dibandingkan magnesium sulfat.

Magnesium sulfat
 MgSO4 pada preeklampsia berat dan eklampsia

4 to 6 gram IV loading dose selama 15 - 20 minute

2 grams IV tambahan untuk kejang berulang

2 grams per jam IV hingga 24 jam post partum

Monitor:
Magnesium levels (therapeutic ranges 4 to 8 mg/dl)
Reflexes
Mental status
Respiratory status
Urine outputs
 Eklampsia
 38% antepartum

 18% intrapartum

 44% postpartum

 Airway
 Breathing
 Circulation
 Magnesium sulphate pilihan antikonvulsan
 Upaya pencegahan
• Pra konsepsi  optimalkan status nutrisi
– Multivitamin dan mineral, protein dan mix karbohidrat
– Bereskan infeksi: periodontitis, UTI, cervico vaginitis
– Upayakan berat badan ideal
– Olah raga teratur

• Saat hamil
– Pertahankan upaya pra konsepsi
 Hiperemesis Gravidarum
Dr Frizar Irmansyah SpOG(K)

Departemen Obstetri Ginekologi

 Hiperemesis Gravidarum

• Etiologi ?
• Batas dengan emesis tidak jelas
• Dapat menyebabkan dehidasi dan alkalosis hipokloremik
• Derajat ringan ; lidah kering, mata cekung, nyeri epigastrium
• Derajat berat, penurunan kesadaran, nistagmus, bau aseton
• Penanganan ;
• 1. rehidrasi cairan
• 2. koreksi elektrolit
• 3. sedativa, phenobarbital
• 4. anti mual
• 5.terapi psikologik

Kuliah mahasiswa
 Kontrasepsi
Dr Frizar Irmansyah SpOG(K)

Departemen Obstetri Ginekologi

 Faktor yang Berpengaruh dalam
Pemilihan Kontrasepsi

• Usia
• Lama Pernikahan
• Riwayat kehamilan
• Riwayat kesehatan
• Jumlah atau jarak anak
• Pendidikan
• Pengetahuan
 Kontrasepsi Rasional
• Masa MenundaKehamilan/kesuburan
1.reversibilitas tinggi
2.efektivitas tinggi
contoh: Pil, AKDR
Masa Mengatur Kehamilan/Kesuburan
1. Efektivitas cukup tinggi
2. Reversibilitas cukup tinggi
3. Dapat dipakai 3-4 tahun
4. Tidak menghambat produksi ASI
cth : pil, suntik, susuk, IUD
 Kontrasepsi Rasional
• Masa mengakhiri kesuburan
1. efektivitas sangat tinggi
2. reversibilitas rendah
contoh : kontap, susuk, pil, IUD
 METODE KONTRASEPSI P.I.
(Pearl Index)

1. Pil Kombinasi 0.1

Pearl Index : H
KONTRASEPSI (Estrogen+ Progesteron)
Angka kegagalan O ORAL 2. Pil Sequential 2.0

metode R (Estrogen + Progesteron bertahap)

3. POP = Progesterone Only Pill 2.3
M
kontrasepsi yaitu : O
(Progesteron saja)

jumlah kehamilan N SUNTIKAN 1 bulan (estrogen + progesteron) 0.7 - 1.0

yang terjadi pada A 3 bulan (depot progesteron) 0.7 - 1.1

100 wanita yang L SUSUK / IMPLAN Depot Progesteron 0.7 - 1.0

menggunakan
suatu metode M
E 1. Spiral (IUD = Intra Uterine Device 1.0 - 2.0 (tembaga)
AKDR = Alat Kontrasepsi Dalam Rahim) 1.0 - 5.0 (plastik)
kontrasepsi K
A ALAT - ALAT 2. Kondom 10
selama 1 tahun N
I
MEKANIK 3. Diafragma 20
4. Spermatisida 20
K 5. Diafragma +Spermatisida 12

TEKNIK TEKNIK 1. Sanggama terputus (Coitus Interruptus) 17

2. Kalender / Pantang berkala 23

NON- TANPA KONTRASEPSI 80

KONTR.
 Kontrasepsi Ideal ?
100%
efektif
100% 100%
reversible aman

Kontrasepsi
Ideal
100% Manfaat
acceptable non-kontrase
100%
nyaman
 Kondisi Medis Penyerta Akseptor

• Penyakit hati
• Kanker Payudara
• Tromboemboli Vena
• Penyakit Kardiovaskular
• Hipertensi
• Obesitas
• Diabetes
• Merokok
• Sakit Kepala
• Interaksi Obat obatan lain
• HIV
• PID
• Infeksi menular seksual
• Postpartum dan menyusui
• Mioma uteri

Pekan Ilmiah Dokter 2019

 Vaksinasi Ca Serviks
Dr Frizar Irmansyah SpOG(K)

Departemen Obstetri Ginekologi

 Beban Kanker Serviks di Dunia

Di dunia, setiap 2 menit seorang wanita

meninggal akibat kanker serviks.1

CRV/PRN/17/23/02/11
Ferlay J et al. Globocan 2002. IARC 2004.
 Beban Kanker Serviks di Indonesia

Setiap satu jam, 1 wanita meninggal karena

Kanker Serviks

CRV/PRN/17/23/02/11
Ferlay J et al. Globocan 2002. IARC 2004.
Apa KANKER SERVIKS?

 Kanker Serviks adalah

penyakit yang diderita
wanita
 Keganasan terjadi pada
leher rahim (serviks), yang
merupakan bagian terendah
dari rahim yang menonjol ke
puncak liang senggama
(vagina)

CRV/PRN/17/23/02/11
 Apa KANKER SERVIKS?

 Kanker Serviks terjadi

saat sel normal di serviks
berubah menjadi sel
kanker.

 Perubahan ini biasanya memakan waktu 10-15 tahun sampai terjadi kanker
 Maka dari itu sebenarnya terdapat kesempatan yang cukup lama untuk mendeteksi

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melalui skrining dan menanganinya sebelum menjadi kanker serviks
 Apakah Penyebab Kanker Serviks?

Kanker Serviks disebabkan oleh

virus Human Papilloma (HPV).

CRV/PRN/17/23/02/11
1. Munoz N. et al. N Engl J Med 2003; 348:518-27
Faktor pendukung Kanker Serviks 1,2

 Menikah muda
 Kehamilan yang sering
 Merokok
 Infeksi Menular Seksual

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1. Burd EM. Clin Microbiol Rev 2003; 16:1–17; 2. Baseman JG & Koutsky LA. J Clin Virol 2005; 2S:S16–S24.
Dampak Kanker Serviks Pada Wanita
 Puncak usia reproduktif wanita adalah 30-50
tahun
 Gangguan Kualitas Hidup : psikis, fisik, dan
kesehatan seksual 1,2
 Dampak sosial dan ekonomi (finansial)3
 Pengaruh pada perawatan, pendidikan anak, dan
suasana kehidupan keluarga4

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1. Basen-Enquist K et al. Cancer 2003; 98:2009-14; 2. Greimel E et al. Gynecol Oncol 2002; 85: 140-7; 3. Schiller JT et al. Nat Rev Microbiol 2004; 2: 343-347;
4. Yang BH, et al. Int J Cancer 2004; 109: 418-424.
 Siapa yang berisiko?

 Hingga 80% wanita akan

terinfeksi oleh HPV sepanjang
masa hidupnya. 1,2,3

 Hingga 50% dari mereka akan

terinfeksi oleh virus HPV yang
dapat menyebabkan kanker
sepanjang masa hidupnya.3,4
Setiap wanita berisiko

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.
1. Baseman JG et al. J Clin Virol 2005; 32 Suppl 1; S1624; 2. Ho GY et al. N Engl J Med 1998; 338: 423–8; 3. Brown DR et al. J Infect Dis 2005; 191: 182–92;
4. Bosch FX et al. J Natl Cancer Inst Monogr 2003; 313;
 Mengapa setiap wanita berisiko?

 Biasanya sebagian besar infeksi akan sembuh dengan

sendirinya. Mereka yang mengalami infeksi persisten
jarang menunjukkan gejala pada stadium awal, dan
biasanya berkembang menjadi kanker serviks
beberapa tahun kemudian.1-3

 Setelah infeksi HPV, tubuh kita tidak selalu dapat

membentuk kekebalan, maka kita tidak terlindungi
dari infeksi berikutnya.4

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References:
1). Moscicki AB. Journal of Adol Health 2005; 37: S3-S9. 2). Guiliano AR et al. J Infect Dis 2007; 196: 1153-62.
3). Franco EL et al. J Infect Dis 1999; 180 1415 – 23. 4). Viscidi RP et al. Ca Epid Biom Prev 2004; 13: 324-7
 Bagaimana mencegah kanker serviks?

Pencegahan Primer
 Edukasi & Promosi
 Vaksinasi

Pencegahan Sekunder
 Pap smear atau IVA

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 Pencegahan

SEKUNDER
PRIMER

• Pemberian vaksin (antigen) yang dapat • Deteksi dini dapat mendeteksi sel
merangsang pembentukan antibodi1 abnormal, lesi pra-kanker dan kanker
• Vaksinasi dapat mencegah terjadinya serviks namun tidak dapat mencegah
infeksi HPV 16 dan 18 yang terjadinya infeksi HPV3
menyebabkan 71% kasus kanker • Kanker serviks yang ditemukan pada
serviks2 stadium dini dan diobati dengan cepat

CRV/PRN/17/23/02/11
dan tepat dapat disembuhkan. Oleh
sebab itu lakukan deteksi dini secara
DAI: Buku Pedoman Imunisasi di Indonesia. Edisi III. Jakarta. Page 7. berkala!
Paavonen J et al. Lancet 2008: 369: 2161-70
Sankaranarayanan et al Int J Gynaecol Obstet 2005; 89 Suppl 2: S4-S12
 Rekomendasi Pemberian Vaksin
 Rekomendasi pemberian vaksin:
 Panduan HOGI – wanita berusia 10-55 tahun
(Andrijono. Kanker Serviks Edisi I. Divisi Onkolologi, Dept. Obstetri-Ginekologi FKUI, Jakarta. Balai Penerbit FKUI: 2007: 67)

 Panduan IDAI – wanita berusia > 10 tahun

(Ikatan Dokter Anak Indonesia (IDAI): Buku Pedoman Imunisasi Di Indonesia, Edisi III, Jakarta; 2008)

 Panduan PAPDI – wanita berusia 12-55 tahun

(PAPDI, Buku Konsesus Imunisasi Dewasa 2008)

• Jadwal Pemberian bulan 0, 1 atau 2, dan 61

Contoh: Penyuntikan 1: Januari
Penyuntikan 2: Februari/Maret

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Penyuntikan 3: Juli

1. (Ikatan Dokter Anak Indonesia (IDAI): Buku Pedoman Imunisasi Di Indonesia, Edisi III, Jakarta; 2008)
 Infeksi Saluran Kemih

• Bila pada pemeriksaan urin, ditemukan bakteri yang jumlahnya

> 10.000/ml.
• Urin pancar tengah
• Pada wanita hamil sering tanpa gejala
• Predisposisi;uretra wanita yg pendek, sistokrl, adanya rest urin,
penggunaan kateter, pemeriksaan ginekologik.
• Penyebab Utama : E. coli
• Gejala Klinis: disuria terutama pada akhir berkemih, frekuensi
berkemih meningkat, nyeri diatas simfisis, air kemih terasa
panas, hersitansi, suhu badan pada umumnya tidak meningkat.

Kuliah mahasiswa
 Pengobatan

• Alkalinisasi urin, banyak minum

• Edukasi kesehatan
• Pengobatan harus pikirkan efek ke janin
• Antibiotika : golongan ampisilin, makrolid
• Komplikasi pada kehamilan :ketuban pecah dini.