Gynecology

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 Materi
Screening for Cervical Cancer TB on pregnancy
Cervicitis Orchitis
Diagnosis kehamilan
Menstrual abnormality TORCH
Family planning KB vs lipid profile
Infertilitas Hiperemesis gravidarum
Kista, abses bartholini Mola hidatidosa
Kista Ovarium
Demam post partus
Thyroid and pregnancy
Abortus Analisa sperma
Kehamilan ektopik Drugs for pregnancy
IUFD Delirium krn organik

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Normal uterine hystology

http://instruction.cvhs.okstate.edu/histology/
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HistologyReference/HRFemaleRS.htm
 http://instruction.cvhs.okstate.edu/histology/
HistologyReference/HRFemaleRS.htm

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 Tumor of the Uterine Cervix
Risk Factors
Benign tumor HVP infection, particularly
Leiomyoma (myoma)
type 16, 18, 45 and 56
Malignant tumor Sexual factor: early
A. Carcinoma of the cervix marriage, young age of
1. Squameus cell carcinoma
(epidermoid ca.) 91 %
first coitus, multiple sexual
2. Adenocarcinoma partners, promiscuity
3. Adenosquameus carcinoma Female factor
4. Adenoacanthoma
B. Sarcoma ( very rare)
Cigarette smoking
Ca. of the Cervix is the most Socio economic status,
common female malignancy
in developing countries
Parity, Race

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 Early detection
Cytology examination
(Pap smear)
Visual Inspection with
Acetic acid application
(VIA)
Colposcopy examination
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Clinical Aspects
Symptoms
Bleeding: vaginal, rectal, urethral
Exert pressure: obstipasi, anuria
hydronephrosis --> renal failure
--> uremia
Infection --> odor watery vaginal discharges
Physical signs
discover follow cytology examination
nodule, ulcer, exuberant erosion of the
cervix
at advanced as crater-shaped ulcer with
high or friable warty mass
freely bleeding on examination
mobility of the cervix depend on the stage
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Cervical dysplasia:
abnormal changes in the cells on the
surface of the cervix that are seen
underneath a microscope
Histology
cervical intraepithelial neoplasia (CIN) I
(mild) a benign viral infection
CIN II (moderate),
CIN III (severe).
Cytology
low-grade SIL (squamous intraepithelial
lesion) low-grade lesions
high-grade SIL (HSIL) high-grade dysplasia

http://www.sh.lsuhsc.edu/fammed/Images/PAP-fig1.jpg
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Clinical staging of Cervical Cancer
Stage 0 Carcinoma in situ, cervical intraepithelial neoplasia Grade III
Stage I The carcinoma is strictly confined to the cervix
Ia. Invasive carcinoma which can be diagnosed only by microscopy.
Ib. All macroscopically visible lesions- even with superficial invasion
Stage II Cervical carcinoma invades beyond the uterus, but not to the pelvic wall
or to the lower third of the vagina
IIa No obvious parametrial involvement
IIb Obvious parametrial involvement
Stage III The carcinoma has extended to the perlvic wall. On rectal examination,
there is no cancer-free space between the tumour and the pelvic wall. The tumor
involves the lower-third or the vagina. All cases with ydronephtosis or nonfunctioning
kidney are included, unless they are known to be due to other cause.
IIIa Tumour involves lower third of the vagina , with no extension to the
pelvic wall
IIIb Extension to the pelvic wall and / or hydronephrosis or nonfuctioning
kidney
Stage IVThe carcinoma has extended beyond the true pelvis, or has involved
(biopsy-proven) the mucosa of the bladder or rectum. A bullous oedema, as such, does
not permit a case to be allotted to Stage IV
IVa Spread of the growth to adjacent organs
IVb Spread to distant organs
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 Solitary pulmonary nodule
In radiology, SPN/ coin lession is a mass in the lung, < 3 cm in diameter.
80% : benign tumor such as granulom or hamartoma
20% : malignant cancer or metastasis of malignant cancer.

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 Screening for Cervical Cancer
started three years after the onset of sexual activity, but no later than age
21.
High grade cervical intraepithelial lesions (HSIL) are almost entirely related
to human papillomavirus (HPV)
HSIL is a precursor to cervical cancer
Infection through genital skin to skin contact
lesions usually do not occur until three to five years after exposure to HPV.
INTERVAL ACOG guideline 2008
annual screening for women younger than 30 years of age regardless of
testing method (conventional or liquid-based cytology).
Women aged 30 and over :
performed annually if conventional cervical cytology smears (Pap) are used OR
every two years with liquid based cytology tests
Women aged 30 and over who have had :
three negative smears,
no history of CIN II/III, and
are not immunocompromised
interval between tests to two - three years.
Women aged 30 and over : consider a combined cervical cytology and HPV test.
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Women who test negative by both tests should be screened every three years.
 Exceptions: Women at increased risk of CIN :
in utero DES (diethylstilbestrol) exposure,
immunocompromise,
a history of CIN II/III or
Cancer
should continue to be screened at least annually.
DISCONTINUE
The United States Preventive Services Task Force stated screening may stop at age 65
if :
recent normal smears
not at high risk for cervical cancer.
The American Cancer Society guideline stated that women age 70 or older may elect
to stop cervical cancer screening if :
had three consecutive satisfactory, normal/negative test results and no
abnormal test results within the prior 10 years.
Not recommended in women who have had total hysterectomies for benign
indications (presence of CIN II or III excludes benign categorization).
Screening of women with CIN II/III who undergo hysterectomy may be discontinued
after three consecutive negative results have been obtained.
However, screening should be performed if the woman acquires risk factors for
intraepithelial neoplasia, such as new sexual partners or immunosuppression.
ACOG
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 Pap Smear
to detect changes in cellular morphology (dysplasia) that are precursors to
carcinoma.
The false-negative rate of the Pap smear is at least 20%. This means that biopsy is
imperative for visible cervical lesions.
The use of serial Pap smear screening decreases the false-negative rate; with
repeated smears
False-negative Pap smears may result from inadequate sampling because of the
location of the lesion (i.e., endocervix), artifacts or poor preparation of slides, or
from reading (interpretive) errors.
Dysplasia : loss of the normal cytoplasmic differentiation or maturation of
cervical epithelium.
The area of development of dysplasia and squamous cell cervical cancers is at
the junction of the squamous and columnar epithelia (transformation zone)
This area is evidently most susceptible to viral infection.
Responds to changes in vaginal pH in response to fluctuating estrogen levels.
Increases in estrogen stimulation result in advancement of the columnar
epithelium toward the vagina (during pregnancy, in women taking oral
contraceptives, and in newborns).
Decreases in estrogen stimulation are followed by "retreat" of columnar
epithelium into the endocervical canal.
Columnar epithelium extending onto the ectocervix is called ectropion
In contrast, it is unusual to see columnar epithelium on the ectocervix of a
postmenopausal or premenarchal patient.
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Emedicine
Unreliable Pap smear due to inflammation:
If severe inflammation is present, its cause(s) must be
investigated. The physician's goals are to identify the cause of
inflammation and to treat and resolve the condition, if possible.
Untreated inflammation can have consequences for the woman
as well as her sexual partner(s).
Physician should repeat the test after the condition resolve to
diminish the false positive result.

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Emedicine
Methods to Improve Accuracy of Pap Smears
Perform a Pap smear when the patient is in the proliferative phase
(in the week following cessation of menses).
The patient should avoid intercourse or intravaginal
products/douches for 24-48 hours before the examination.
Use no lubricant prior to performing the Pap smear.
Have cytobrush, spatula, slide, and other supplies on hand before
starting the pelvic exam.
Rotate the Ayers spatula through a 360-degree arc over the
squamocolumnar junction if visible. Gently brush the spatula over
the entire slide, taking care to avoid a thick smear or shearing of
cells by excessive pressure.
Collect the endocervical specimen using a cytobrush (about one full
turn with the brush mostly inside the cervix), or use a saline-
moistened cotton swab for pregnant women. Apply this to the same
slide using a rolling motion as noted in step 5.
Rapidly apply fixative to the slide. If using a spray, hold it about 10
inches from the slide to avoid dispersing the cells.
Provide the cytologist with complete clinical information about the
patient including age, menopausal status, hormone use, history of
radiation, dysplasia, malignancy, etc.

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Emedicine
ASC-H: atypical squamous cells cannot exclude high grade
ASC-US: atypical squamous cells of undetermined significance

Accuracy of the Papanicolaou Test in Screening for and Follow-up of Cervical Cytologic
Abnormalities: A Systematic Review
Kavita Nanda, MD, MHS; Douglas C. McCrory, MD, MHSc; Evan R. Myers, MD, MPH; Lori A.
Bastian, MD, MPH; Vic Hasselblad, PhD; Jason
BimbelD. Hickey;
UKDI MANTAP and David B. Matchar, MD
 ACOG guideline 2008
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Visual Inspection with Acetic Acid (VIA) or PAP SMEAR ?

Pap smear has been shown to effectively lower the risk for developing invasive cervical
cancer, by detecting precancerous changes.
In developing countries, only 5% of eligible women undergocytology-based screening in a
5-year period. This is because :
too few trained and skilled professionals
Healthcare resources are not available to sustain such a programme
Delays in reporting cytology results and less follow-up.
Recent studies have demonstrated that visual inspection with acetic acid (VIA) is an
alternative sensitive screening method.
Cheap and non-invasive
Can be done in a lowlevel health facility like a primary health centre
Provides instant results.
Cryotherapy as a method of treatment for precancerous lesions has some advantages :
Effective and easier to implement than loop electrosurgical excision procedure
(LEEP), loop excision of the transformation zone (LETZ) and cone biopsy.
Affordable
No need for complicated equipment
It can be done by less specialized personnel
can be implemented in a primary health-care
Bimbel UKDI MANTAP(PHC) setting (4 ).
VIA procedure

Positive VIA test

any aceto-white lesion
at the squamo-columnar
junction of the cervix.

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 Side effects of cryotherapy : cramping, vaginal
discharge, spotting, or light bleeding.
abstain from sexual intercourse for four weeks
following cryotherapy, or use female condoms to reduce
the risk of cervical infection
Reasons for referral included:
suspicion of cervical cancer
the presence of a cauliflower fungating lesion
a positive VIA test, but ineligibility for cryotherapy
aceto-white lesions occupying more than 75% of the cervix or
extending more than 2 mm beyond the outer limit of the standard
cryotherapy probe.
a lesion extending onto the vaginal wall or more than 2 mm
into the cervical canal
a positive VIA test 12 months after treatment with
cryotherapy. Bimbel UKDI MANTAP
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 Cervicitis
*Tidak mudah membedakan
servisitis dari vaginitis Servisitis menular seksual = Servisitis
4 faktor risiko u/ prediksi
servisitis: mukopurulenta
1. umur < 21 th
2. Lajang Biasanya asimtomatis
3. CS > 1 org dlm 3 bln
terakhir Datang karena mitra menderita
4. CS dg pasangan baru dlm 3
bln terakhir UMS

Penyebab: GO; Non-GO

(C.trachomatis)

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Lect. By dr. Retno Satiti, Sp.KK
 CERVICITIS GO
peradangan serviks o/k N. gonorrhoeae
Diagnosis:
Penyebab: N. gonorrhoeae: diplokokus Gram
neg Gram: pmn > 30; DGNI (+)
Klinis: asimtomatis; keputihan warna kuning
Px: Kultur: Media Thayer Marthin
- vulva tenang
- inspeculo: dd vagina eritem/tenang PCR
- ektoserviks: eritem/normal
- endoserviks: eritem, edem,
ektopi, bleeding,
discar mukopurulen

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Lect. By dr. Retno Satiti, Sp.KK
CERVISITIS NON GO

Peradangan serviks bukan o/k GO

Penyebab: C. trachomatis (terbanyak)
Klinis: asimtomatis; keputihan kuning
Px: vulva tenang
inspeculo: dd vagina eritem/normal
ektoserviks: eritem/normal
endoserviks: eritem, edem, ektopi, swab bleeding, discar
mukopurulen

C. Trachomatis

immunofluoresence
dg antibodi
monoklonal

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Lect. By dr. Retno Satiti, Sp.KK
 Vaginitis
Penyebab umumnya: Trikomonas, Kandida, bakteri anaerob
keputihan tdk selalu ditularkan secara seksual
Gejala: abnormalitas volume, warna, bau dari discar vagina
Gejala yg menyertai: gatal, edem, disuri, sakit perut/
punggung bawah

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Lect. By dr. Retno Satiti, Sp.KK
 TRIKOMONIASIS/Vaginitis Trikomonal
Definisi: peny. Infeksi protozoa yg disebabkan oleh T. vaginalis

Etiologi: T. vaginalis

inkubasi: 3-28 hr
Dx: 1. Discar vagina kuning kehijauan,atau
berbuih dan bau busuk, strawberry cervix (+)
2. Peradangan pd dinding vagina
3. Lab: NaCl 0,9% : T. vaginalis motil

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Lect. By dr. Retno Satiti, Sp.KK
Bimbel UKDI MANTAP
 KANDIDOSIS VULVOVAGINAL/
Vulvovaginitis kandidal
Definisi: infeksi vagina dan/atau vulva oleh kandida
khususnya C. albicans
Etiologi: Genus candida t/u C. albicans (80%)
kandida: kuman oportunis: di seluruh badan
Predisposisi: hormonal, DM, antibiotik, imunosupresi, iritasi

* keluhan gatal/panas/iritasi, keputihan tak bau/masam

* Dinding vagina &/vulva eritem/erosif
* Discar putih kadang disertai semacam sariawan
(thrush) berupa pseudomembran yg melekat pd
daerah erosif
Discar putih kental spt susu/keju, bisa banyak, masam
Dinding vagina dijumpai gumpalan keju
* pH <= 4,5 Lect. By dr. Retno
Lab KOH 10% : pseudohifa Satiti, Sp.KK
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 Vaginosis bakterial (VB)

Definisi: * gangguan pada vagina tanpa peradangan

* sindroma klinik akibat perubahan lingkungan lokal
* pergantian flora normal Lactobasilus sp. oleh bakteri
anaerob: terutama G.vaginalis dll
Etiologi: bukan organisme tunggal
perubahan situasi dlm vagina --> anaerob

Inkubasi: bbrp hr-4 mgg

Dx: 3 dari 4 gejala:
1. Discar vagina, homogen, putih keabuan, melekat
pd dinding vagina
2. PH vagina > 4,5
3. Discar bau spt ikan --> tes amin
4. Clue cells --> Gram -

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Lect. By dr. Retno Satiti, Sp.KK
DUH TUBUH VAGINA DENGAN PENDEKATAN SINDROM

Bimbel UKDI MANTAP Lect. By dr. Retno Satiti, Sp.KK

DUH TUBUH VAGINA DENGAN PEMERIKSAAN INSPEKULO

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Lect. By dr. Retno Satiti, Sp.KK
 DUH TUBUH VAGINA DENGAN PEMERIKSAAN
INSPEKULO & MIKROSKOP

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Lect. By dr. Retno Satiti, Sp.KK
Pengobatan sindrom duh tubuh vagina karena vaginitis
Pengobatan untuk trikomoniasis
DITAMBAH
Pengobatan untuk vaginosis bakterial .
BILA ADA INDIKASI,
Pengobatan untuk kandidiasis vaginalis

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Lect. By dr. Retno Satiti, Sp.KK
Pengobatan sindrom duh tubuh vagina karena infeksi serviks
Pengobatan untuk gonore tanpa komplikasi
DITAMBAH
Pengobatan untuk klamidiosis

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Lect. By dr. Retno Satiti, Sp.KK
Pelvic Inflammatory Disease

Acute infection of the upper genital tract

structures in women, involving any or all of
the uterus, oviducts, and ovaries
Microbiology
N. gonorrhea 1/3 of cases
Chlamydia 1/3 of cases Clinical symptoms
Mixed infection strep, e.coli, klebsiella, Abdominal pain
anaerobes Vaginal bleeding
Vaginal discharge
Risk factors Urethritis
Number of sexual partners PE
Age Abdominal pain
15-25 years old w/ highest frequency Fever
Symptomatic male partner Bimanual exam with CMT or
Previous PID adnexal tenderness
African American women Cervical discharge

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Lect. By dr. Retno Satiti, Sp.KK
 Diagnosis
Pregnancy test
Cervical sample for GC/ Chlamydia
Pelvic ultrasound

Treatment
Outpatient
Ceftriaxone 250 mg IM x 1 + doxycycline 100 mg po BID x
14 days
Add metronidazole if concern for pelvic abscess, suspected
infection with Trichomonas, or recent instrumentation
Inpatient
Cefoxitin 2 G IV q 6 + doxycycline 100 mg po/IV Q12
Amp/Sulbactam 3 G IV q 6 + doxycycline po/IV
Oral administration of doxyxycline preferred due to pain
associated with drug administration when infused
bioavailability of oral AND IV preparation equivalent

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Lect. By dr. Retno Satiti, Sp.KK
 Complications
Perihepatitis: Fitz-Hugh Curtis Syndrome
RUQ pain with pleuritic component
Tubo-ovarian abscess
Chronic pelvic pain seen in 1/3 of patients
Infertility
Ectopic pregnancy

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Lect. By dr. Retno Satiti, Sp.KK
 Diagnosis Kehamilan

Tanda Kehamilam tidak pasti (probable sign)

Tanda kehamilan pasti

Obstetri Fisiologi, 2008.

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 Probable sign

Amenorrhea Quickening
Persepsi gerakan janin I
Penyebab lain : ketidakseimbangan 18-20 mg (primigravida), 16 mg
ovarium hipofisis, stres, obat-obatan, (multigravida)
penyakit kronis Ditemukan jg pada Pseudocyesis
Mual dan muntah Keluhan kencing
Morning sickness >> estrogen dan Urinasi >>, kencing malam >>
Desakan uterus yg membesar
beta HCG, << motilitas gaster pagi hari dan tarikan ke kranial
>> dg bau menusuk, emosi tidak stabil Konstipasi
Beri makanan ringan mudah dicerna Efek relaksasi profesteron pd
tonus otot usus
Mastodinia Perubahan pola makan
Rasa kencang dan nyeri pada payudara Perubahan BB
Pembesaran payudara, vaskularisasi>>, Kehamilan 2-3 bl << BB
proliferasi asinus dan duktus Selanjutnya >>

Pengaruh estrogen dan progesteron

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Obstetri Fisiologi, 2008.
 Peningkatan
BB
Minggu kg
Normal: 9-14 kg 6 0,2
8 0,5
Janin 3,5 kg 10 0,8
Plasenta 0,5 kg 12 1,1
Amnion 1 kg 14 1,7
Uterus 1 kg 16 2,4
Darah 2 kg 18 3,1
Mammae 1 kg 20 3,9
22 4,7
24 5,5
26 6,2
28 7
30 7,7
32 8,4
34 9,1
36 9,8
38 10,4
Obstetri Fisiologi, 2008. Bimbel UKDI MANTAP
40 10,9
 >> temperatur basal > 3 mg
Warna kulit :
Kloasma, setelah 16 mg
Warna areola menggelap
Striae gravidarum
Linea nigra
Teleangiektasis
Stimulasi MSH krn estrogen yang tinggi
kortikosteroid >>
Perubahan Payudara :
Tuberkel montgomery menonjol (UK 6-8 mg)
Stimulasi prolaktin dan Human Placental Lactogen
Sekresi kolostrum (UK > 16 mg)
Perubahan pelvis
Chadwick sign (+)
Serviks livid
Cairan vagina putih, encer, sel eksfoliasi vagina >>
Estrogen >>
Hegar sign (+) (UK 6-8 mg)
Pembesaran uterus (stlh UK 10 mg)

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Obstetri Fisiologi, 2008.
 Pembesaran perut (stlh UK 16 mg)
Kontraksi uterus
Balotemen
UK 16-20 mg
Dd : asites dg kista ovarium, mioma uteri.

Bimbel UKDI MANTAP Obstetri Fisiologi, 2008.

 Tanda
Kehamilan Pasti
DJJ Laboratorium
Laenec (17-18 mg)
Doppler (12 mg) Tes inhibisi
Palpasi 22 mg koagulasi/PP test
Rontgenografi Inhibisi koagulasi
anti HcG
Tulang tampak mg 12-14
Jk terdapat keragu-raguan dan Mendeteksi HcG
mendesak di urin
USG Kepekaan pada
Mg 6 : gestational sac 500-1000 mU/ml
6-7 : polus embrional Positif mg ke 6
8-9 : gerak janin
9-10 : plasenta, dst
2 gestational sac di mg 6 gmeli
Fetal ECG : 12 mg, dg fetalkardiografi Obstetri Fisiologi, 2008.

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Menstrual cycle

Lect.
Bimbel UKDI MANTAP By dr. Hasto Wardoyo, Sp. OG
 Lect.
Bimbel UKDI MANTAP By dr. Hasto Wardoyo, Sp. OG
 Ovulasi
Terjadi 14 hari sebelum mens >> kadar progesterone
berikutnya
2ng/ml
Tanda dan tes :
Rasa sakit di perut bawah LH surge (dg
(mid cycle Radioimunoassay)
pain/mittleschmerz)
Perubahan temperatur basal USG folikel >1,7 cm
efek termogenik
progesteron
Perubahan lendir serviks
Uji membenang (spinnbarkeit):
Fase folikular : lendir kental,
opak, menjelang ovulasi
encer, jernih, mulur
Fern test : gambaran daun
pakis

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 Normal Menstrual Bleeding

Occurs approximately once a

month (every 26 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

Lect.
Bimbel UKDI MANTAP By dr. Hasto Wardoyo, Sp. OG
 Lect.
Bimbel UKDI MANTAP By dr. Hasto Wardoyo, Sp. OG
FIGO Classification

FIGO (International Federation of Gynecology and

Obstetrics) classification system for causes of abnormal uterine
bleeding in nongravid women of reproductive age
Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia

Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrofenic
Not yet classified

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Munro, M.G., 2011
Polyp Uterine

Usually benign but a small minority may have atypical or malignant features.
These epithelial proliferations comprise a variable vascular, glandular, and
fibromuscular and connective tissue
Guidelines for Recognizing the Presence of Endometrial Polyps
1. Increasing age is the most common risk factor for the presentation of an endometrial
polyp
2. For women with symptoms with a polyp, abnormal uterine bleeding is the most
common presenting symptom
3. Infertile women are more likely to be diagnosed with an endometrial polyp
4. Polyps may naturally regress in up to 25% of patients, with small polyps more likely to
resolve spontaneously
5. Medications such as tamoxifen may predispose to the formation of endometrial polyps

ADVANCING MINIMALLY INVASIVE

GYNECOLOGY WORLDWIDE, 2012

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GUIDELINES FOR THE MANAGEMENT OF ENDOMETRIAL POLYPS

1. Conservative management is reasonable, particularly for small polyps and if

asymptomatic.
2. Medical management of polyps cannot be recommended at this time
3. Hysteroscopic polypectomy remains the gold standard for treatment
4. There does not appear to be differences in clinical outcomes with different
hysteroscopic polypectomy techniques
5. Removal for histologic assessment is appropriate in postmenopausal
women with symptoms
6. Hysteroscopic removal is to be preferred to hysterectomy because of its less-invasive
nature, lower cost, and reduced risk to the patient

For the infertile patient with a polyp, surgical removal is recommended to allow natural
conception or assisted reproductive technology a greater opportunity to be successful

ADVANCING MINIMALLY INVASIVE GYNECOLOGY WORLDWIDE, 2012

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ENDOMETRIOSIS

Definisi
Terdapatnya Jaringan endometrium diluar rahim

Symptoms
Pelvic Pain (acute or chronic)
Dyspareunia (painful intercourse)
Painful bowel movements
Premenstrual staining and abnormal bleeding
Difficult urination and/or blood present in the urine
Infertility

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 TREATMENT
1. Surgical

2. Non-Surgical
Gonadotropin-releasing hormone agonists, Danazol,
Norethindrone, Gestrinone
All acyclic, some high androgen, others high progesterone, all low
estrogen
Negative side effects such as accelerated bone loss, weight gain,
nausea, breakthrough bleeding
Pain killers (aspirin, morphine, and codeine

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Adenomyosis

Benign condition
Presence of ectopic endometrial glands and stroma within the myometrium.
It frequently occurs coincidentally with fibroids.
May cause no symptoms but some women with adenomyosis experience heavy,
prolonged menstrual bleeding with severe cramps, pelvic pain and discomfort.
Treatment for symptomatic adenomyosis includes anti-inflammatory medications,
hormone therapy and endometrial ablation.
For severe symptoms that do not respond adequately, hysterectomy has been the
conventional surgical treatment.
Uterine artery embolisation may be an alternative option for women who do not
wish to have hysterectomy and/or who wish to preserve their fertility.

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 Myoma Uteri

Benign, uterine neoplasms, arises from the

myometrium, primarily
composed of smooth muscle
Also called leiomyomas , fibroids or
fibromyomas.
Generally benign and found in up to 20% of
women in the reproductive
age group.
30-50 years old
Classification based on anatomic
location:
Submucous : beneath endometrium
Intramural/interstitial: within uterine wall
Subserous/subperitoneal: at the serosal surface
or bulge outward from
myometrium Bimbel UKDI MANTAP
Bimbel UKDI MANTAP
 SYMPTOMS
Menorrhagia and prolonged
menstrual period (common)
Pelvic pain : occurs in
pregnancy if undergoing
degeneration or torsion of
a pedunculated myoma
Pelvic pressureurinary
frequency, bowel difficulty
(constipation)
Spontaneous abortion
Infertility
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SIGN
A palpable abdominal tumor :
Abdominal lump arising from
pelvis , well defined margins , firm
in consistency and having smooth
surface, tumor is mobile from side
to side .
Pelvic examinationUterus
enlarged and irregular, hard
Diagnosis : Bimanual exam, USG,
hysteroscopy, Laparacospy
Treatment:
Observation: for small myoma,
premenopause
Operation : myomectomy or
hysterectomy
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 Perubahan Sekunder
Myoma
Atrofi : Setelah menopause ataupunb sesudah mioma uteri menjadi kecil.
Degenerasi hyalin >> lansia.
Tumor kehilangan struktu aslinya menjadi homogen.
Jaringan ikat bertambah, berwarna putih keras
Degenerasi kistik
Sebagian mioma menjadi cair terbentuk ruangan-ruangan yang tidak teratur
berisi seperti agar-agar.
Sukar dibedakan dari kista ovarium atau suatu kehamilan.

Degenerasi merah (Caineous Degeneration)

>> Kehamilan dan nifas.
Gangguan vaskularisasi nekrosis subakut
Sarang mioma seperti daging mentah berwarna merah disebabkan oleh
pigmen hemosiderin dan hemodifusi.

1. Estrogen merangsang tumbuh kembang mioma. 2. Aliran darah tidak

seimbang 3. Edema sekitar tungkai 4. Tekanan hamil

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 Degenarasi Lemak Kelanjutan degenerasi hialin.
Degenerasi Sarcomateus
Infeksi dan Suppurasi >> L. submukosa krn ulserasi
Gangguan vaskularisasi
1. Nekrosis 2. Pembentukan Trombus 3. Bendungan darah dalam mioma 4. Warna
merah hemosiderin/hemofuksin (Manuaba, 2001)

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Histerektomi merupakan tindakan yang paling ideal karena mioma sering multipel dan
mencegah residif.
Pada wanita masa reproduksi, sebaiknya ditinggalkan 1 atau kedua ovarium untuk
menjaga
jangan menopause sebelum waktunya
Sebaiknya histerektomi totalis, kecuali bila keadaan tidak memungkinkan dapat
dilakukan
histerektomi supravaginalis lalu dilakukan rutin pap smear pada tumpul serviks
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 AUB-P : endometrial/endocervical polyp
AUB-Lsm : Leiomyoma submucosal
AUB-A : adenomyosis
AUB-E : endometrial
AUB-O : ovulatory dysfunction
AUB-M : malignancy and hyperplasia
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 Disfungsional Uterine Bleeding
Diagnosis has to be confirmed by a process of exclusion
of pathological causes.

DUB anovulasi (~90% kasus)

Disfungsi aksis hipothalamus-thalamus-ovarium ?anovulasi
?progesteron tidak dihasilkan ?proliferasi endometrium
?perubahan vaskular endometrium & penurunan prostaglandin
?perdarahan

DUB ovulasi
Akibat dilatasi vaskular endometrium

Lect.
Bimbel UKDI MANTAP By dr. Hasto Wardoyo, Sp. OG
 Treatment of uterine
bleeding

Treatment of infrequent bleeding

1. Therapy should be directed at the underlying cause when possible.
2. If the CBC and other initial laboratory tests are normal and the history and
physical examination are normal reassurance
3. Ferrous gluconate, 325 mg bid-tid,

ACOG 2008
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Treatment of frequent or heavy bleeding

1. NSAID
improves platelet aggregation
increases uterine vasoconstriction.
NSAIDs are the first choice in the treatment of menorrhagia because they are well
tolerated and do not have the hormonal effects of oral contraceptives.
a. Mefenamic acid (Ponstel) 500 mg tid during the menstrual period.
b. Naproxen (Anaprox, Naprosyn) 500 mg loading dose, then 250 mg tid during the
menstrual period.
c. Ibuprofen (Motrin, Nuprin) 400 mg tid during the menstrual period.

2. Ferrous gluconate 325 mg tid.

3. Patients with hypovolemia or a hemoglobin level below 7 g/dL should be

hospitalized for hormonal therapy and iron replacement.
Hormonal therapy: estrogen (Premarin) 25 mg IV q6h until bleeding stops.
Thereafter, oral contraceptive pills should be administered q6h x 7 days, then taper
slowly to one pill qd.
If bleeding continues, IV vasopressin (DDAVP) should be administered.
ACOG 2008
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 Hysteroscopy may be necessary, and dilation and curettage is a last
resort. Transfusion may be indicated in severe hemorrhage.
Ferrous gluconate 325 mg tid.

4. Primary childbearing years ages 16 to early 40s

A. Contraceptive complications and pregnancy are the most common causes of
abnormal bleeding in this age group. Anovulation accounts for 20% of
cases.
B. Adenomyosis, endometriosis, and fibroids increase in frequency as a woman ages,
as do endometrial hyperplasia and endometrial polyps. Pelvic inflammatory
disease and endocrine dysfunction may also occur.

ACOG 2008
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 PMS
the cyclic recurrence in the luteal phase of
the menstrual cycle of a combination of
distressing physical, psychological, and/or
behavioral changes of sufficient severity to
result in deterioration of interpersonal
relationships and/or interference with
normal activities..

PMM
Many patients with psychiatric disorders
also complain of worsening of their
symptoms around the premenstrual phase,
called premenstrual magnification.

Lect. By dr. Hasto Wardoyo, Sp. OG Bimbel UKDI MANTAP ACOG 2008
Bimbel UKDI MANTAP ACOG 2008
 PMS PMM
Diagnostic criteria Tenth Revision of Diagnostic and
the International Statistical Manual
Classification of of Mental
th
Disease (ICD-10) Disorders, 4 ed.
(DSM-IV)

Providers using Obstetrician/gynec Psychiatrists, other

these criteria ologists, primary mental health care
care physicians providers
Number of One 5 of 11 symptoms
symptoms
required
Functional Not required Interference with
impairment social or role
functioning
required

Prospective Not required Prospective

charting of daily charting of
symptoms symptoms
required for two
cycles

Lect.
Bimbel UKDI MANTAP By dr. Hasto Wardoyo, Sp. OG
Bimbel UKDI MANTAP ACOG 2008
ACOG 2008
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 Dysmenorrhea
Dysmenorrhea refers to the symptom of painful menstruation. It can be divided into 2
broad categories: primary (occurring in the absence of pelvic pathology) and
secondary (resulting from identifiable organic diseases).
Primary
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 F2 (PGF2), a potent myometrial stimulant and vasoconstrictor,
in the secretory endometrium.The response to prostaglandin inhibitors in patients
with dysmenorrhea supports the assertion that dysmenorrhea is prostaglandin-
mediated. Substantial evidence attributes dysmenorrhea to prolonged uterine
contractions and decreased blood flow to the myometrium.
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Secondary
Dysmenorrhea beginning in the 20s or 30s, after previous relatively painless cycles
Heavy menstrual flow or irregular bleeding
Dysmenorrhea occurring during the first or second cycles after menarche
Pelvic abnormality with physical examination
Poor response to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral
contraceptives (OCs)
Infertility
Dyspareunia
Vaginal discharge

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Drug therapy:
Dysmenorrhoea can be effectively treated by drugs that inhibit
prostaglandin synthesis and hence uterine contractility.
These drugs include aspirin, mefenamic acid, naproxen or ibuprofen. As
dysmenorrhoea is often associated with vomiting, headache and
dizziness, it may be advisable to start therapy either on the day before the
period is expected, or as soon as the menstrual flow commences
Mefenamic acid is given in a dose of 250 mg 6-hourly. This drug also
reduces menstrual flow in some women with menorrhagia.

If these drugs are inadequate, suppression of ovulation with the

contraceptive pill is highly effective in reducing the severity of
dysmenorrhoea. Where it is ineffective, then careful consideration should
be given to the possibility of underlying pathology.
If all conservative medical therapy fails, then relief may sometimes be
achieved by mechanical dilatation of the cervix or by the surgical removal of
the pain fibers to the uterus in an operation known as presacral
neurectomy, but these methods of treatment should be approached with
considerable caution.
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Amenorrhea

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 Amenorrhea
primer
I. GADIS USIA 14 TH TANDA SEKS SEKUNDER (-) & BLM MENARKE
II. GADIS USIA 16 TH TANDA SEKS SEKUNDER (+) TETAPI BELUM
MENARKE

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Sheehan Syndrome

Hypopituitarism, caused by necrosis due to blood loss and hypovolemic shock

during and after childbirth
Most common initial symptoms of Sheehan's syndrome are agalactorrhea
and/or difficulties with lactation.
Many women also report amenorrhea or oligomenorrhea after delivery

Secondly, the anterior pituitary is supplied by a low pressure portal venous

system.
These vulnerabilities, when affected by major hemorrhage or hypotension
during the peripartum period, can result in ischemia of the affected pituitary
regions leading to necrosis.
The posterior pituitary is usually not affected due to its direct arterial
supply.

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 Menopause
Climacteric : The phase in the aging
process of women marking the transition
from the reproductive stage of life to
the non-reproductive stage

The final menstrual period and occurs

during the climacteric. The average
age of menopause is 51.
Symptoms Hot flushes
(early) Insomnia
Irritability
Mood disturbances

Physical changes Vaginal atrophy

(intermediate) Stress (urinary) incontinence
Skin atrophy

Diseases Osteoporosis
(late) Cardiovascular disease
Dementia of the Alzheimers type
Cancers
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 ACOG 2008
Menopausal transition :
begins with variation in menstrual cycle length and an elevated FSH
concentration
and ends with the final menstrual period (12 months of amenorrhea).
Stage -2 (early) is characterized by variable cycle length (>7 days
different from normal menstrual cycle length, which is 21 to 35 days).
Stage -1 (late) is characterized by >2 skipped cycles and an interval of
amenorrhea >60 days; women at this stage often have hot flashes as
well.
Perimenopause begins in stage -2 of the menopausal transition and ends 12
months after the last menstrual period.
Menopause is defined by 12 months of amenorrhea after the final menstrual
period.
It results from complete, or near complete, ovarian follicular depletion and
absence of ovarian estrogen secretion.
Postmenopause.
Stage +1 (early) is defined as the first five years after the final menstrual
period. It is characterized by further and complete decline in ovarian function
and accelerated bone loss; many women in this stage continue to have hot
flashes.
Stage +2 (late) begins five years after the final menstrual period and ends with
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death.
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ACOG 2008 Bimbel UKDI MANTAP
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FAMILY PLANNING

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Metode KB
Barier KB
Coitus interuptus
Kondom, vaginal pouch
Diafragma
spermicida
Hormonal KB
Implant
KB suntik
AKDR
Lain-lain

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Metode Kelebihan Kekurangan Indikasi kontraindikasi

Vaginal Mengganggu ASI (-) << sensasi Butuh KB Alergi lateks

pouch/kondo Pengaruh sistemik (-) Not practical pendukung,
m Murah, mudah didapat PMS, menunda
Mencegah PMS, ejakulasi dini hamil jangka
pendek

diafragma Mengganggu ASI (-) Sulit memasang Tdk bs memakai ISK

Dipasang 6 jam pre coitus tdk Didiamkan di KB lain Alergi lateks
mengganggu sex vagina - 6 jam post Menyusui
Pengaruh sistemik (-) coitus PMS
Mencegah PMS >> infeksi uretra

spermicida Langsung efektif (busa dan krim) Efektivitas rendah Tidak bs ISK
Mengganggu ASI (-) Ketergantungan memakai KB
Metode pendukung pengguna hormonal
Pengaruh sistemik (-) Harus menunggu Tidak mau AKDR
Mudah dipakai, mudah didapat, 15 menit sebelum Menyusui
kapanpun hubungan (tablet,
>> lubrikasi supositoria)
Efektifitas 1x pakai
Coitus Mengganggu ASI (-) << sensasi Tdk bs Ejakulasi dini
interuptus KB pendukung Gagal >> menggunakan Ketaatan rendah
Efek samping (-), gratis, KB lain High risk mother
kapanpun

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Metode Kelebihan Kekurangan Indikasi Kontraindikasi

Pil Kombinasi Sangat Efektif, Harus diminum tiap Heavy bleeding, Pregnancy
(estrogen dan reversibel hari Severe cramping, Cardiovascular and
progesterone) Tidak perlu px pelvis Efek samping : mual, irregular menstrual cerebro-vascular
Mengganggu coitus (- bercak perdarahan, period diseases
) nyeri kepala History of benign Breast lump or
Mudah Mengganggu ASI ovarian cyst cancer
Mencegah PID Mahal History of ectopic Malignant diseases
Interaksi dg pregnancy of genital tract
beberapa obat History of breast Abnormal vaginal
Tidak melindungi diseases bleeding
PMS Family history of Liver diseases and
ovarian cancer benign or malignant
liver tumors

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 - Monofasik :
21 tablet hormon aktif dlm dosis sama,
dan 7 tablet iron/plcbo
- Bifasik :
21 tablet hormon aktif dlm 2 dosis
berbeda dan 7 tablet iron/plcbo
- Trifasik :
21 tablet hormon aktif dg 3 dosis
berbeda dan 7 tablet iron/plcbo

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Bimbel UKDI MANTAP
Waktu menggunakan Pil Special attention

- Setiap saat, selagi haid - Pil pertama diminum hari 1

- Hari pertama siklus haid mens
setelah berhenti kb - Pil non hormonal diminum 7 hr
suntik, bs langsung sebelum haid berikutnya
menggunakan kb pil. - Paket 28 pil habis ganti
- Paket 21 pil habis tunggu 7
hari ganti
- Setelah melahirkan :
1. Setelah 6 bulan ASI
eksklusif - Lupa minum 1 hari
2. Setelah 3 bulan dan hari berikut minum 2
tidak ASI - Lupa 2 hari minum 2
3. Pasca aborsi (segera- 7 saat ingat, besoknya
hari post aborsi minum 2 kembali ke
jadwal + kb pendukung
- kec. placebo

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 Pil Progestin (Mini Pill)
Kelebihan Kekurangan Indikasi Kontraindikasi
- Tdk mengganggu - Gangguan mens- - Wanita menyusui Hamil
ASI amenorrhea - Perokok segala Pedarahan per
- Dosis rendah - Spotting usia vaginam
- Tdk memberi efek - Mens tdk teratus - TD tinggi (< Menggunakan obat
samping estrogen - Mahal 180/110) atau TB, fenitoin,
- KB darurat - Tdk mencegah PMS, masalah barbiturat
HIV pembekuan darah Riw. Kanker payudara
- Nyeri kepala, mual Mioma uteri
- Perubahan mood Riw. stroke
- Gemuk
- Jerawat, hirsutisme

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Waktu menggunakan Pil Special attention

- Mulai hari 1-5 mens

Menyusui 6 mg- 6 bulan, - Muntah 2 jam setelah minum
dan tidak haid minum pil lagi, pakai kondom
- Bl > 6 mg menyusui, saat coitus dlm 48 jam
haid, minipil dimulai hr 1 - Lupa minum 3 jam lgsg
mens minum saat ingat pakai
- kondom saat coitus dlm 48 jam

- KB sebelumnya
hormonal bs lgsg
diganti minipil - Lupa minum 1 hari
hari berikut minum 2
- KB sebelumnya KB
suntik minipil diberi di - Lupa 2 hari minum 2
jadwal selanjutnya saat ingat, besoknya
minum 2 kembali ke
- KB lain dpt lgsg ganti jadwal + kb pendukung

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 PIL KOMBINASI DAN PROGESTIN
Keadaan Saran
DM Tanpa komplikasi Pil dapat diberikan
Migrain Tanpa defisit neurologi fokal Pil dapat diberikan
Menggunakan fenitoin, Dosis etinilestridiol 50 mcg
barbiturat, rifampisin
Sickle cell anemia Pil tdk boleh digunakan

Efek samping penanganan

Amenorrhea PP test tdk hamil lanjutkan KB dg dosis estrogen 50 mcg

atau turunkan dosis progesteron.
Hamil stop pil

Mual, pusing, Tes kehamilan, px ginekologi tdk hamil minum pil saat
muntah makan malam/sebelum tidur

Perdarahan per Pp tes, px ginekologi

vaginam/ spotting Biasa pada 3 bulan pertama, akan berhenti sendiri
> 3 bulan naikkan dosis estrogen (50 mcg) perdarahan
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stop kembali dosis awal.
 Metode Keuntungan Kerugian Indikasi Kontraindikasi

Injeksi - Efektif - Fertilitas dapat - Menunda hamil - Hamil

Kombinasi - Dapat digunakan tertunda jangka panajang - Ikterik
dan Injeksi - Gangguan hepar
usia > 35 - Invasif - Punya anak cukup
Progestin - Gangguan
- Tidak mengganggu - Dpt - Tidak mau minum pil tromboemboli
ASI menyebabkan tiap hari - DUB
- Tidak mengganggu infeksi - Takut sterilisasi - Tumor payudara
coitus - Mens lebih - Menyusui - DM dg komplikasi, HT
> 180/110 atau st II dg
banyak
komplikasi
- Tidak mencegah - Migrain berat
PMS
- Efek samping
estrogen
(kombinasi)
Jenis suntikan :
- 25 mg Depo Medroksiprogesterone Asetat
(Depo provera) + 5 mg Estradiol Sipionat (1 - Menekan Ovulasi
bulan sekali - Mengentalkan lendir serviks
- 50 mg Noretindron Enantat + 5 mg Estradiol - Atrofi endometrium
Valerat (sebulan sekali) mengganggu implantasi
- Depoprovera (150 mg DMPA) tiap 3 bln - Menghambat gerakan tuba
- Depo Noretisteron Enantat 200 mg, tiap 2
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bln (4 injeksi ) tiap 3 bln
 Keadaan Penanganan
Waktu injeksi Td tinggi < 180/110 dpt diberikan dg
pengawasan

-hari 1 mens** DM Dapat diberikan jk tanpa

- Setelah hari 7 mens dg KB kompikasi
pendukung 7 hari** Migrain Dpt diberikan jk tdk ada
- Post partus 6 bulan, tdk haid, defisit neurologis dan nyeri
ASI asal tdk hamil kepala
Obat TB dan Ditambah pil etinilestradiol
epilepsi 50 mcg / ganti KB
- Post partus > 6 bl, ASI, haid ** Sickle cell Tidak boleh diberikan
- Post partus 3 minggus, tidak ASI tdk anemia
boleh suntik
Amenorrhea Singkirkan kehamilan, KB
- Post aborsi ** dapat dilanjutkan
- Ganti dari KB non hormonal **
Mual, pusing, Jk tidak hamil, akan hilang
Ganti dari KB hormonal sesuai jadwal muntah dalam 2-3 bulan
- Boleh maju 2 mg dari jadwal
Spotting Bl tidak hamil, akan hilang
- Boleh mundur 2 mg dari jadwal asal tdk dalam 2-3 bl.
hamil pakai KB pendukung 7 hr
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 IMPLANT
Keuntungan
Highly effective, first year
preg. rate 0.2-0.5/100
women
Rapidly effective, less than
24 hours
Longterm protection, up to
five years
Immediate return of fertility
after removal
Inexpensive and convenient
Kerugian
Does not protect against
STDs, HIV, HBV
Requires minor surgical
procedur for insertion and
removal
Client can not discontinue
on her own
Implant may be visible
under the skin
Menstrual problems may
happen
Other side effects are similar
to injectables
Indikasi
Wants to have longterm
birth spacing
Has got enough children
Does not want to take dailly
pills
Has contraindication to
estrogen
Does not accept sterilization
Is breastfeeding
Kontraindikasi
Pregnancy
Jaundice, active liver
disesaes or tumors
Active thromboembolic
disorder
Undiagnosed vaginal
bleeding
Breast lump or cancer
Diabetes mellitus and
hypertension
Severe migrain headache
Depression

- Norplant : 6 batang, 36 mg levonogestrel, 5 tahun

- Implanon : 1 batang, 68 mg 3-keto-desogestrel, 3 tahun
- Jadena dan Indoplant : 2 batang, 75 mg levonogestrel, 3
tahun
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Gangguan hati, stroke, penyakit jantung,
terapi TB dan epilepsi, tumor jinak atau
ganas pada hati jangan menggunakan
implant
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 AKDR (ALAT KONTRASEPSI DALAM RAHIM)
Keuntungan
Immediate, highly effective
and longterm (up to 8
years for the Tcu 380A)
Immediate return to
fertility upon removal
No hormonal side efeects
(local only)
Cost effective
Suitable for lactating
women
Practical, not user
dependent
Efek Samping :
- Siklu haid terganggu dlm 3 bulan
pertama
- Haid >>
- Spotting antar siklus
Kerugian
Requires pelvic examination
May increase risk of PID
and subsequent infertility
Requires minor surgical
prosedure either on
insertion or removal
May increase menstrual
bleeding and cramping
No protection against STDs,
HIV or HBV
May spontaneously expel
Requires checking the string
Bimbel UKDI MANTAP
Indikasi
Prefers a longterm and
effective method but no
sterilization
Has one or more children
Is breastfeeding
Does want to take
hormonal contraception
because of side effects or
contraindications
Is at low risk of contracting
STDs
Has sucessfully used an IUD
in the past
Kontraindikasi
Pregnancy
Current, recent or recurrent
PID
Acute purulent discharge
from the cervical canal
(gonorrheal or chlamydial
cervicitis)
Undiagnosed vaginal
bleeding
High risk for GTIs or STDs
Available mainly in three types
Innert IUDs, plastic (Lippes Loop) or Mevhanism of action :
Preventing fertilization, by blocking the
stainless steel (the chiness ring)
migration of the sperms to the ovum,
Coper bearing IUDs which include the TCu
decreasing the number of sperm and
200, TCu 380A, MLCu 250, MLCu 375, Nova T
inactivating them
and the Medusa Pessar
Less likely a local inflamation may prevent
Steroid medicated IUDs such as implantation of the fertilized egg
ProgestasertR, and LevoNovaR

Relative Contraindication
Leukemia, diabetes and immunocompromised
women
Severe anemia
Rheumatic or Valvular heart disease
Severe painful menstrual period (dismenorrhea)
History of an ectopic pregnancy
Uterine fibromyomas, uterine abormality and
cervical stenosis
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 Metode Laktasi Amenore
MLA merupakan metode kontrasepsi Wanita yang:
alamiah yang mengandalkan
pemberian ASI pada bayinya Menyusukan bayinya secara eksklusif
Akan tetap mempunyai efek (memberikan ASI secara penuh tanpa
kontrasepstif apabila
Menyusukan secara penuh suplementasi lainnya)
(eksklusif) Belum mendapat haid sejak
Belum haid melahirkan bayinya
Usia bayi kurang dari 6 Menyusukan secara eksklusif sejak
bulan
Efektif hingga 6 bulan
bayi lahir hingga bayi berusia 6 bulan
1
Bila ingin tetap belum ingin hamil,
kombinasikan dengan metode
kontrasepsi lain setelah bayi berusia 6
bulan TIDAK DILANJUTKAN JIKA
Setelah beberapa bulan amenorea,
klien mulai mendapat haid
Tidak menyusukan secara eksklusif
Bayi telah berusia diatas 6 bulan
Ibu bekerja dan terpisah dari
bayinya lebih dari 6 jam dalam
sehari
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 Metode KBA
Metode Kalendar
Suhu Tubuh Basal (STB)
Metoda Mukosa Servik (Billings)
Simptotermal (STB + Mukosa Servik)

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 KBA: Pemanfaatan
Untuk Kontrasepsi:
Menghindari sanggama dalam periode subur
dalam siklus menstruasi untuk menghindarkan
terjadinya kehamilan
Untuk Kehamilan:
Melakukan sanggama dalam periode subur
(disekitar pertengahan siklus menstruasi)
dimana peluang terjadinya kehamilan cukup
besar.

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Grafik menstruasi

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 JENIS TUBEKTOMI

Pascapersalinan
Minilaparotomi Subumbilikus
Interval
Minilaparotomi Suprapubik
Laparoskopi

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 Tubektomi:
Mekanisme Kerja

Mencegah pertemuan
sperma dengan sel telur
(fertilisasi) dengan jalan
menutup atau oklusi
saluran telur (tuba
fallopii)

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 Kontrasepsi Metode Operatif

Oklusi Tuba secara Laparoskopik teknik (1):

Pengangkatan dinding abdomen dengan insuflasi CO2

menyediakan ruang untuk memposisikan Elektrokoagulasi atau aplikasi

instrumen bedah. Bimbel cincin titanium
UKDI MANTAP
 Kontrasepsi Metode Operatif

Oklusi Tuba secara Laparoskopik teknik (2):

menyediakan ruang untuk memposisikan Elektrokoagulasi atau aplikasi

instrumen bedah. cincin titanium
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 Tubektomi: Petunjuk Untuk Klien

Jaga luka insisi bersih dan kering selama 2 hari.

Lakukan kegiatan harian secara bertahap.
Sebaiknya hindari sanggama selama 1 minggu atau
klien siap untuk itu
Jangan melakukan kerja berat/mengangkat benda
berat selama 1 minggu.
Untuk nyeri pasca-tubektomi gunakan 1 - 2 tablet
analgesik setiap 4 sampai 6 jam.
Jadwalkan kunjungan ulangan antara hari ke 714.
Pesankan untuk kembali setelah 1 minggu jika
menggunakan benang jahit yang tidak dapat diserap
(non-adsorbable)
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 MOP

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 Jenis Vasektomi

Vasektomi Tanpa Pisau

(VTP atau No-scalpel
Vasectomy) lebih
disukai
Vasektomi dengan insisi
skrotum (tradisional)

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 Vasektomi dengan Insisi
1 atau 2 insisi pada skrotum
99% prosedur vasektomi dilakukan dengan
anestesia lokal
Jenis oklusi yang umum dipakai:
Ligasi
Kauterisasi
Gabungan (kombinasi)

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 Vasektomi Tanpa Pisau
Dikembangkan di Cina oleh Profesor Lee dan mulai
diperkenalkan di Amerika Serikat pada tahun 1988
Menggunakan anestesia lokal
Petugas memfiksasi vasa diferensia di bawah
skrotum dan raphe mediana
Kemudian vasa diambil dengan klem diseksi dan
dioklusi, baik yang kiri maupun yang kanan (hanya
melalui satu lubang)
Luka diseksi tidak perlu dijahit, cukup ditutup plester

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Kontrasepsi Metode Operatif

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 Vasektomi: Mekanisme Kerja

Oklusi vasa deferensia

membuat sperma tidak dapat
mencapai vesikula seminalis
sehingga tidak ada di dalam
cairan ejakulat saat terjadi
emisi ke dalam vagina

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 Vasektomi: Petunjuk Untuk Klien

Pastikan area luka diseksi/insisi tetap bersih, kering

dan terbalut selama 3 hari.
Jangan mengorek atau menggaruk luka insisi atau
diseksi sebelum sembuh.
Klien boleh mandi setelah 24 jam tetapi luka harus
tetap kering. Setelah 3 hari, klien boleh membersihkan
luka dengan sabun dan air bersih
Gunakan penyangga skrotum, jaga agar area operasi
tetap kering dan istirahatlah selama 2 hari.

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 Vasektomi: Petunjuk Untuk Klien
Untuk mengatasi nyeri, minum 2 - 3 tablet analgesik
setiap 4 - 6 jam dan pakai kompres es (jangan basah)
Jangan mengangkat benda berat atau bekerja keras
selama 3 hari.
Hindari sanggama selama 2 - 3 hari atau hingga klien
terasa nyaman atau siap untuk itu.
Untuk mengosongkan depot sperma dalam vesikula seminalis,
gunakan kondom/kontrasepsi lain hingga 20 kali ejakulasi.
Bila menggunakan benang jahit yang tidak diserap, klien
diminta kembalilah setelah 1 minggu vasektomi
Untuk memastikan tidak ada sperma dalam cairan mani,
lakukan uji air mani setelah 3 bulan operasi.

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 Vasektomi:
Barier Medik dalam Pelayanan

Menerapkan batasan usia (muda dan tua) dan paritas

(kurang dari dua anak yang lahir hidup, tidak ada anak
laki-laki)
Status perkawinan/persetujuan dari pasangan
Kurangnya tingkat pemahaman klinik dan program dari
pemberi layanan
Penerapan kriteria atau aturan ketat
Ketentuan ketat tentang pemberi pelayanan:
Dokter Spesialis
Dokter terlatih

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 Emergency post coital contraception
Digunakan setelah unprotected coitus, gagal KB
Morning after pill
Progestin only
Mekanisme : mukosa cerviks lebih kental, menunda
ovulasi
Levonogestrel 1,5 mg single dose atau 0,75 mg tiap 12
jam (satu hari) , dalam 5 hari dari unprotected coitus
Copre bearing IUD (>> efektif)
Hanya dipasang pada yang sudah menikah
www.nhs.uk
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ACOG, FAQ, 2013 Bimbel UKDI MANTAP
 Infertilitas
Selama 1 tahun, 2-3 x hub sex/minggu, tanpa kontrasepsi, tidak hamil

40% faktor istri

40% faktor suami
20% pada keduanya
wanita: 35-60% faktor tuba & peritonium
10-25% kasus: Unexplained infertility

Faktor Suami

a. 35% : faktor sperma

-b. Gangguan transfortasi: Varikokel, prostatitis, Epididimitis, Orkhitis, kelainan
kongenital (Hipospadia, agenesis vas deferens, klinefelters syndrome,
Myotonic distrophy), kelainan hipotalamus-hipofisa
-c. Autoimunitas, Impotensi dan yang tak diketahui sebabnya.
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 Faktor Istri :
Infeksi
Gangguan ovulasi
Gangguan anatomi
Gangguan Ovulasi

Penuaan (usia)
POF
Polikistik Ovarii (PCOS)
Kelainan pada
hipotalamus-hipofisis
Hiperprolaktin
Kelainan kongenital

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 Sindroma Ovarium Polikistik
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

Gejala :
Siklus menstruasi yang iregular: oligomenore dan amenore
Hiperandrogen: hirsutisme, jerawat dan alopesia

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Obesitas
> 65% wanita SOPK IMT > 27
Distribusi lemak = kelainan metabolik
( hipertensi, dislipidemia, resistensi insulin / intoleransi glukosa )
Mulai belasan tahun
BB resistensi insulin, penyembuhan siklus menstruasi
pengurangan 10-15 % BB 75% konsepsi spontan

Akantosis nigrikan
Stimulasi insulin lapisan basal epidermis

Ovarium polikistik
Terdapat pada 16-25% wanita normal & wanita amenora etiologi lain
Kista folikular kecil multipel (< 10mm), mengelilingi stroma.
80% wanita hiperandrogenemia mempunyai ovarium polikistik
(tidak pada wanita yang menggunakan OC, agen sensisitasi insulin, atau
bentuk lain supresi ovarium)

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Px penunjang infertilitas

Fisik diagnostik-ginekologik
Foto HSG
Suhu badan basal (ovulasi)
Penunjang USG-TV
Analisa sperma
Penunjang hormonal (bila diperlulkan)
Laparoskopi-histeroskopi

Terapi Induksi Ovulasi

Senggama Terencana Clomiphene Citrate (CC) 50-150 mg

IUI diberikan pada hari ke 5, 6, 7, 8, 9
Induksi Ovulasi dari siklus menstruasi
Laparoskopi operatif hMG 2-3 Ampl/hari diberikan pada
Drilling hari ke 5,6,7,8,9,10,11,12,13,14,15
IVF dari siklus menstruasi
FSH murni (Metrodin) 75 IU cara
pemberian sama dengan hMG
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 Kista dan Abses Bartholini
Umum pada wanita umur
reproduksi
Lokasi pada labia mayora
Abses 3 kali lebih umum dari
pada kista
Obstruksi pada distal duktus
dapat karena retensi sekret
dan pembentukan kista

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 Patologi
Abses Bartholini Isolates from Bartholin's Gland
Abscesses
merupakan Aerobic organisms
polymikrobal infeksi Neisseria gonorrhoeae
Neisseria gonorrhoeaea Staphylococcus aureus
Streptococcus faecalis
yang paling umum Escherichia coli
Jika tidak inflamasi Pseudomonas aeruginos
Chlamydia trachomatis
asimtomatik Anaerobic organisms Bacteroides
Simtom: nyeri vulva, fragilis
Clostridium perfringens
dispareunia, kesulitan Peptostreptococcus species
berjalan/olah raga Fusobacterium species

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 Penatalaksanaan
Asimtomatik tidak perlu terapi
Incisi dan drainase tx cepat & mudah
kemungkinan rekuren
WORD CATHETER
MARSUPIALIZATION
INCISI & DRAINASE

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 WORD CATHETER
Pembuatan 5 mm incisi
pada kista atau abses
Masukkan kateter Word
dan dikembangkan
dengan 2-3 ml saline
selama 3-4 minggu
Jika tidak ada bukti
infeksi tidak perlu
antibiotik

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 Marsupialisasi
Membuka rongga tertutup mjd kantong
terbuka.
Untuk cegah kista berulang
Dengan lokal anestesi
Pembuatan insisi vertikal elips 1,5-3 cm
(sesuai garis Langer)
Cukup dalam sampai kulit vestibular
dinding kista
Pengeluaran isi kista dg sendok kuret kecil
sampai bersih
Dinding kista dijahit ke kulit vertibular
dengan jahitan interupted
 Incisi dan drainase
Dilakukan pada pasien yang tidak respon pada
terapi konservatif tidak ada infeksi aktif
Kekambuhan
Pemasangan balon kateter Word
(Kambuh 3-17%)
Marsupialisasi (Kambuh 10-24%)
Eksisi risiko perdarahan

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 Patofisiologi
GO cepat menjadi abses keluar lewat
duktus tersumbat: abses membesar
Radang bisa berulang (68-75%)
Jika menahun terbentuk kista

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 Kista folikel :
Kista fungsional ovarium
Tipe kista ovarium tersering
Dinding kista tipis, dikelilingi lapisan sel granulosa, berisi
cairan jernih
Jika ovulasi tdk terjadi folikel graafian tidak ruptur
tumbuh menjadi kista
Kista teka lutein:
Kista ovarium fungsional bilateral, berisi cairan.
Cairan : serous, seorus sanguine, clear straw colour fluid
Terjadi karena >> beta HCG (mola, multiple pregnancy)

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 Kista coklat :
Disebabkan oleh endometriosis
Dibentuk ketika jaringan endometrium mengelupas
tumbuh dan membesar di dalam ovarium
Jaringan endometrium berdarah seiring waktu
menjadi coklat
Ruptur materi kista keluar ke permukaan uterus,
vesica, intestinal, dan rongga di antaranya.
Gejala : Heavy bleeding, menorrhagia, dyspareunia
Kista nabothian: kista di cervix
Kista berisi mukus
>> di permukaan cervix
Terjadi krn metaplasi epitel squamous stratifikatum
ektoserviks menjadi epitel columnar seperti di
endoserviks.
Pertumbuhan jaringan mengeblok kripta cervix
trapping cervival mucus inside crypts
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 Kista Gartner / vaginal inclusion cyst :
Lesi kistik vagina jinak, tumbuh dari sisa duktus
mesonefrikus/ Gartners duct.
Asimtomatik
>> di dinding lateral vagina
Kejadian ureter ektopik dan hipoplasia renal ipsilateral
sering menyertai kisa Gartner.

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Demam postpartus

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 Abortus
Perdarahan + hasil konsepsi, UK < 22 mg atau berat < 500
gr
Early abortion < 12 weeks
Late abortion 12-20 weeks

Abortus imminens Spontaneous abortion: abortion

Abortus Insipiens
Abortus Inkomplit
Abortus Komplit
Missed Abortion
Septic abortion
Habitual abortion
happens by nature, no
intervention
Induced abortion (artificial
abortion): abortion made for
certain purposes
Medical or therapeutic abortion
Criminal abortion: other than
therapeutic abortion (illegal
abortion)

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 ETIOLOGY
EARLY ABORTION
Abnormal product of
conception
Infections (CMV)
Autoimmun disorders (SLE)
Endocrine abnormalities
(luteal phase defect)
Uterine abnormalities
(septus, arcuatus, bicornual,
didelphys etc)
Many is still unknown
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LATE ABORTION
Infection (malaria, syphylis,
typhoid)
Circumvallate placenta
Metabolic disorders (DM,
Thyroid)
Physiologic impairment (renal,
cardiac, hepatic diseases,
hypertension)
Severe dietary insufficiency:
anemia, avitaminosis
Isoimmunisation
Poisoning (lead, drugs abuse)
Trauma to the womb
Cervical incompetence
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 Ab imminens
Penanganan :
Bedrest total
Hindari aktivitas fisik berlebihan dan hub seksual
Antibiotik mencegah infeksi
tokolitik
Progesterone VS placebo
Wahabi HA, Abed Althagafi NF, Elawad M. Progestogen for treating threatened
miscarriage. Cochrane Database of Systematic Reviews 2007, Issue 3.

Jika perdarahan :
Berhenti lakukan ANC seperti biasa
Berlanjut Pptes, USG
Rawat inap :
Untuk menunjang bedrest
Observasi jika berlanjut menjadi Ab insipiens, inkomplit, atau komplit.

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 Abortus insipiens
UK < 16 mg :
Evakuasi konsepsi dg aspirasi vakum manual
Jk tdk bisa : ergometrin 0,2 mg IM (dpt diulang tiap 15
menit jk perlu)
Atau misoprostol 400 mcg per oral (dapat diulang tiap
4 jam jk perlu)
Lanjutkan dg kuretase
UK > 16 mg :
Tunggu ekspulsi spontan evakuasi sisa konsepsi
Jk perlu, berikan oksitosin 20U dalam 500cc RL 40 tpm
untuk mempercepat ekspulsi

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 Abortus inkomplit
UK < 16 mg
Evakuasi jaringan secara digital
Perdarahan berhenti ergometrin 0,2 mg IM atau misoprostol 400
mcg PO
UK < 16 mg, perdarahan banyak, terus menerus
Aspirasi vakum manual untuk evakuasi jaringan
Jk tidak ada : kuretase dg sendok kuret tajam
Jk perlu ergometrin 0,2 mgIM (dpt diulang stlh 15 menit) atau
misoprostol 400 mcg PO (dpt diulang setelah 4 jam)
UK > 16 mg :
Oksitosin 20 U dlm 500 cc RL, drip 40 tpm sampai tjd ekspulsi
Jk perlu : misoprostol 200 mcg pervag tiap 4 jam smp ekspulsi (maks
800 mcg)
Jk perlu : kuretase untuk membersihkan sisa jaringan di uterus.

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 Abortus Komplit
Tidak perlu evakuasi jaringan
Observasi KU, VS, dan perdarahan
Cek Hb post abortus anemia ringan SF
600 mg/hari 2 mingggu
Jk anemia berat (<7 gr/dl) transfusi darah
sampai Hb mencapai 10 mg/dl

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 Abortus rekuren/habituasi
Abortus spontan berturut-turut selama tiga
kali atau lebih
Penyebab : >> anomali kromosom

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 Abortus septik

>> komplikasi pada abortus kriminalis

Tanda dan gejala :
demam,
Sekret vagina berbau
AL > 11 rb atau < 4 rb
Dapat terjadi syok septik
metritis, parametritis, hingga peritonitis
Penyebab : bakteri anaerob (>>), H. influenzae,
Campylobacter jejuni, streptokokus grup A
Terapi : evakuasi segera produk konsepsi, spektrum
luas parenteral, tangani syok jk terjadi

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 Missed abortion
perdarahan dari jalan lahir 8 mg
Perdarahan sedikit, hitam.
Nyeri perut <<
OUE menutup
PPTest (-)
Ukuran uterus < UK
USG : blood clot dalam uterus
Tx : dilatasi dan kuretase

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 Complication
Hemorrhage
Infection
Choriocarcinoma
Infertility
Rh senstization: avoided by Rh immune globulin
Psychological effect: grief, dysphoria, anxiety,
depression etc.

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 Kontrasepsi Post Abortus
Metode Waktu aplikasi Keterangan
Kondom Segera Membantu mencegah PMS
Pil hormonal Segera Butuh ketaatan tinggi
Suntikan Segera
Implan Segera Jk sudah punya anak 1 atau
lebih dan ingin KB jangka
panjang
AKDR Segera atau setelah pasien Tunda insersi jk Hb < 7
pulih gr/dl atau curiga infeksi
Tubektomi Segera Tunda jk curiga infeksi dan
Hb < 7 gr/dl

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Safe pregnancy after medical abortion
Dont have sex until 2-4 weeks after abortion.
Patient can get pregnant as soon as two weeks
after an abortion.
Menstrual cycle will go back to its regular
cycle and ovulation at 2 weeks post abortion.

http://www.afterabortion.com/physical.html
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 Kehamilan Ektopik
Definisi

Kehamilan yang implantasi blastosisnya

terjadi di luar mukosa endometrium

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 INSIDENSI
>1 dalam 100 kehamilan.
Bukti terakhir menunjukkan kehamilan ektopik
meningkat di beberapa negara.
USA-5 kali lipat
UK-2 kali lipat
France 15/1000 kehamilan
India-1 dalam 100 kehamilan
Recurrence rate - 15% sesudah kejadian ke-1,
25% sesudah kejadian ke-2

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 ETIOLOGI
Beberapa faktor yang menyebabkan
terhambatnya transport zygote dari tuba ke
uterus
Keadaan tuba sendiri yang menyokong
terjadinya implantasi di mukosanya sendiri
Kongenital atau Acquired.

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 ETIOLOGI
KONGENITAL - Tubal Hypoplasia , Tortuosity ,
Congenital diverticuli , Accessory ostia , Partial
stenosis
ACQUIRED -
Inflamasi: PID, Septic Abortion, Puerperal Sepsis, adhesi
intraluminal
Pembedahan: Pembedahan rekonstruksi tuba, Recanalisasi
tuba
Neoplastic: mioma intraligamenter, tumor ovarium
Kasus Miscellaneous : IUD , Endometriosis, ART (IVF & &
GIFT

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Tempat-tempat kehamilan ektopik
Abdomen (< 2%)
Ampulla (>85%)
Isthmus (8%)

Cornual (< 2%)

Ovary (< 2%)

Cervix (< 2%)

1)Fimbria 2)Ampulla 3)Isthemus 4)Interstitial 5)Ovarium

6)Cervic 7)Cornual 8) Secondary abdominal 9) ligamentum
latum 10)Primary abdominal
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 Gambaran Klinis
Kehamilan ektopik ada yang asimptomatik
hingga ruptur
Ada dalam 2 variasi: akut dan kronik
Gejala-gejala:
Amenorrhea
Nyeri abdomen
Syncope
Perdarahan pervaginam
Massa pelvis

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 DIAGNOSIS DINI
Dapat didiagnosis sebelum umur kehamilan 6
minggu, paling awal 4,5 minggu, dan sebelum
adanya gejala-gejala
Pengukuran hCG kehamilan normal
meningkat 2 kali lipat tiap 2 hari pada minggu
4-8. KE tidak ada peningkatan
Kadar progesteron serum (8-10 minggu)
USG transvaginal: 4-5 mg; hCG 2000 IU/L
Laparoskopi gold standard
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 PENATALAKSANAAN

Tergantung stage penyakit dan kondisi pasien

Pilihan terapi:
Ekspektatif
Medikamentosa
Pembedahan
Pilihan terapi berdasarkan penilaian luaran jangka
pendek (menurunnya hCG, trofoblast persisten,
keutuhan tuba) dan luaran jangka panjang (patensi
tuba dan fertilitas berikutnya)
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 PENATALAKSANAAN

Ekspektatif:
Bila titer hCG < 2000 IU/L, mengalami
penurunan progresif
USG: ukuran massa < 2 cm, tidak ditemukan
bagian janin
Hemoperitoneum < 50 ml
Tidak ada gejala-gejala klinis yang semakin
memburuk
Efikasi jelek, rawat inap lama, evaluasi lama

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 PENATALAKSANAAN
Medikamentosa
Sistemik atau lokal
Agen: MTX, glukosa hiperosmolar, prostaglandin.
Yang paling banyak digunakan MTX
Singgle dose 50 mg/m3
Syarat:
Titer hCG < 2000 IU/L
Ukuran massa KE < 3,5 cm

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 Pembedahan
Perdebatan:

LAPAROTOMY?
VS.
LAPAROSCOPY?
SALPINGECTOMY?
VS
SALPINGOSTOMY / SALPINGOTOMY?
Tergantung stabilitas hemodinamik, ukuran
dan lokasi KE, keahlian
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Kecenderungan Laparoskopi:
Perdarahan sedikit
Kebutuhan analgesi
Lama rawat inap
Cepatnya penyembuhan
Biaya
Terjadinya kehamilan intrauterin berikutnya:
Laparoskopi (70%) vs Laparotomi (55%)
Terjadinya kehamilan ektopik rekuren:
Laparoskopi (5%) vs Laparotomi (16,6%)
Angka trofoblas persisten:
Laparoskopi (12,2%) vs Laparotomi (1,7%)
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 SALPINGECTOMY
VS
SALPINGOSTOMY / SALPINGOTOMY
Kehamilan ektopik rekuren:
Salpingostomi lebih tinggi (15%) dibandingkan
salpingektomi (10%)
Kegagalan pengambilan produk kehamilan secara
komplit:
Salpingostomi 4,8-11%, salpingektomi hampir tidak
ada
Salpingektomi lebih dipilih bila tuba kontralateral
masih baik

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management

6 : Induksi dg oksitosin
Terminasi kehamilan < 5 : matangkan serviks dg
prostaglandin dan kateter
Foley

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 TB on pregnancy and lactation
Efek pada kehamilan :
- Gangguan
pertumbuhan janin Rifampicin
- BBLR INH
- Persalinan Preterm
- >> kematian perinatal
Ethambutol

KONTRA INDIKASI :
STREPTOMYCIN
- OTOTOKSIK pd janin
- Nefrotoksik Efek teratogenik tidak terbukti
- Neurotoksik pd n 8
Semua jenis OAT aman untuk ibu menyusui
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 ORCHITIS
Orchitis is an inflammatory condition of one or both testicles in males, generally caused by
a viral or bacterial infection.
Most cases of orchitis are caused by infection with the mumps virus.
Orchitis caused by a bacterial infection most commonly develops from the progression of
epididymitis, an infection of the tube that carries semen out of the testicles. This is called
epididymo-orchitis.
The majority of cases of mumps orchitis occur in prepubertal (less than 10 years old) males,
while most cases of bacterial orchitis occur in sexually active men, or in men older than 50
years of age with benign prostatic hypertrophy.

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The symptoms associated with orchitis may range from mild to severe, and the
inflammation may involve one or both testicles. Patients may experience the rapid onset
of pain and swelling, or the symptoms may appear more gradually. Symptoms of orchitis
may include the following:
Testicular swelling
Testicular redness
Testicular pain and tenderness
Fever and chills
Nausea
Malaise and fatigue
Headache
Body aches
Pain with urination

Tuberculous epididymitis and mumps orchitis can cause testicular atrophy (shrinkage),
which may reduce testosterone production in the affected testicle. Testosterone levels
are not affected in other cases. Severe cases may lead to an abscess (collection of pus),
death of a testicle, or continuous draining through the skin, any of which may require
surgery.

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People with bacterial orchitis or bacterial epididymo-orchitis require antibiotic
treatment. Antibiotic therapy is necessary to cure the infection.
Most men can be treated with antibiotics at home for 10-14 days. Longer courses may
be required if the prostate gland is also involved.
If a patient has high fever, is vomiting, if he is very ill, or if he develops serious
complications, the patient may require admission to a hospital for IV antibiotics.
Young, sexually active men need to make sure that all of their sexual partners are
treated if the cause is determined to be a STD. They should either use condoms or
abstain from sexual relations until all partners have completed their full course of
antibiotics and are symptom-free.
Antibiotics prescribed will depend on the patient age and underlying cause of the
bacterial infection. Antibiotics commonly used may include ceftriaxone (Rocephin),
doxycycline (Vibramycin, Doryx), azithromycin (Zithromax) or ciprofloxacin (Cipro).
If the cause of orchitis is determined to be viral in origin, antibiotics will not be
prescribed. Mumps orchitis will generally improve over a 1-2 week period. Patients
should treat symptoms with the home care treatments outlined above.

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Rubella

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 CMV

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 TOXOPLASMOSIS

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 Hormonal Contraception and Lipid Metabolism

Hormonal contraceptives produce >> cortisol

Cortisol increase the mobilization of free fatty acids from
adipose.
Excessive cortisol is linked to weight gain in some women.
Older generations of hormonal contraceptives increase
insulin
secretion and the insulin resistance of cells
Serum glucose levels are likely to increase in users of these
hormonal contraceptives, generally by 10 milligrams
(mg)/deciliter (dL).
Newer progestogens do not seem to change fasting or
nonfasting insulin or glucose levels over the long term.
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 Older generation forms of hormonal
contraceptives (>> estrogen ) increase total
cholesterol and LDL cholesterol, while HDL
cholesterol is decreased.
Newer forms increasing HDL and keeping LDL
steady.
Coagulation proteins, including fibrinogen, are
produced by the liver at a greater rate in women
who are taking hormonal contraceptives. This
increases the risk of thrombosis of all types.

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Hiperemesis Gravidarum

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 MOLA HIDATIDOSA

Kelainan vili korionik :

gangguan
proliferasi trofoblas
dg derajat
bervariasi
edema stroma vilus
Letak : rongga uterus
(>>), tuba falopii,
ovarium

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 Gambaran Mola Parsial Mola komplit
Kariotipe Umumnya 69, 46, XX atau 46,
XXX atau 69, XXY XY
Patologi :
- Janin Sering dijumpai Tidak ada
- Amnion, RBC Sering dijumpai Tidak ada
janin Bervariasi, fokal Difus
- Edema vilus Bervariasi, fokal, Bervariasi, ringn-
- Proliferasi ringan-sedang berat
Honey comb appearance trofoblas
Gambaran Klinis :
- Diagnosis Missed abortion Gestasi mola
- Ukuran uterus Kecil untuk masa 50% besar untuk
kehamilan masa kehamilan
- USG Honey comb Snow storm/
appearance granular
appearance
- Penyulit medis Jarang Sering
- Penyakit
pascamola < 5-10% 20%
- Kista teka
Snow storm appearance lutein >> <<
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 Perdarahan uterus
Ukuran uterus berubah
tidak sesuai UK
Aktivitas janin (-), DJJ (-)
Hipertensi, tjd < 24 mg
kehamilan
Hiperemesis
Tirotoksikosis
>> kadar tiroksin plasma
o.k estrogen dan
gonadotropin korionik yg
susunannya mirip tirotropin
>< di resseptor tiroid
Embolisasi akibat deportasi
trofoblas ke venula
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Evakuasi jaringan mola segera
Aspirasi vakum, dilatasi
(oksitosin, prostaglandin) dan
kuret tajam, histerektomi
menghilangkan
hipertiroidisme
menyebabkan kegawatan
hipertiroid (krisis tiroid atau
gagal jantung tiroid)
Deteksi dini koriokarsinoma
(deteksi hCG)
PTU 3x 100mg/hari, menjelang
kuretase + Sol. Lugol 10
tetes/8jam
Pada kasus berat: PTU vs
metimazol
Krisis tiroid: sol. Lugol + PTU +
propanolol
 Cegah kehamilan min 1 tahun
Ukur kadar hCG tiap 2 minggu
Tunda terapi selama kadar hCG berkurang
Setelah kadar normal cek hCG tiap bulan
selama 6 bulan tiap 2 bulan selama 1 tahun

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THYROID DISORDER AND PREGNANCY

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ANALISA SPERMA

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 Drugs for pregnancy
Chloramphenicol

Ciprofloxacin

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Gentamycin

Ceftriaxon

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 Gangguan mental Organik- Delirium
Gangguan kesadaran dan perhatian : kesadaran
berkabut-koma, 3P terganggu
Gangguan kognitif secara umum : distorsi persepsi
(ilusi, halusinasi (visual)), disorientasi, hendaya daya
ingat segera dan pendek
Gangguan psikomotor : hipo/hiperaktivitas
Gangguan siklus tidur-bangun : insomnia, gejala
memburuk di malam hari
Gangguan emosional : depresi, anxietas/takut, mudah
marah, apatis, kehilangan akal
Onset cepat, hilang timbul sepanjang hari kurang dari
6 bulan

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