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GYNECOLOGY

dr. Nashria
dr. Reagan Resadita
Abnormal
Congenital
Neoplasm
2 Menstrual Infertility Infection
infection
Cycle

Gonorrhea
Menstruation
Toxoplasmosis
Cervix Sperm Analysis
Trichomoniasis

Abnormal uterine
bleeding Candidiasis
Rubella
Bacterial Vaginosis
Polycystic ovarian
Uterine Corpus Endometriosis
syndrome
PID
CMV
Amenorrhea Syphilis

Condiloma
Woman Fertility acuminata
Ovarium
Test Varicella
menopause
Bartholin abscess
3
NEOPLASM
Neoplasma
Abnormal, excessive growth of tissue

Common
4
Malignant symptoms:
Vs Solid Abnormal
Benign Vs bleeding
(myoma,ovarian Cystic Pelvic mass
cyst) Vulvovaginal
symptoms
5
Clinical Aspects : Benign vs Malignant Tumor

enign Tumor Malignant tumor


May cause significant clinical Clinical significant much greater :
disease invasive, rapid growing more
often cause bleeding, ulceration,
Exert pressure : uterine myoma
infection
low back pain, obstipation, urine
retention Para neoplastic syndrome
(endocrinopathies)
Superimposed complication :
abnormal bleeding, ulceration, cachexia
secondary infection
Undergo malignant
transformation
Common Location of tumors
Tumor of the Uterine Cervix
7
Cervix: Classification Risk Factors
lower
1/3 of Benign tumor HPV infection:
uterus; Leiomyoma (myoma) type 16, 18, 45 and 56
at and Malignant tumor
below A. Carcinoma of the Sexual factor:
cervix early marriage,
level of
young age of first
internal 1. Squamous cell
coitus
cervical carcinoma 91 % multiple sexual
os 2. Adenocarcinoma partners
3. Adenosquamous
carcinoma Cigarette smoking
4. Adenoacanthoma
B. Sarcoma ( very Socio economic
rare) status, Parity, Race
8 FAKTOR RISIKO
a. Menikah/ memulai aktivitas seksual pada usia muda (kurang
20 tahun)
b. Berganti ganti pasanan seksual.
c. Berhubungan seks dengan laki laki yang berganti ganti
pasangan
d. Riwayat infeksi di daerah kelamin atau radang panggul
e. Perempuan yang melahirkan banyak anak
f. Perempuan perkokok(2,5x lebih tinggi)
g. Perokok pasif (1,4x lebih tinggi)
HPV and human immunodeficiency virus (HIV)
co -infection accelerates progression towards cancer.
Pedoman teknis Ca Payudara dan Ca
Serviks, kemenkes
HPV and Uterine Cervix - Pathogenesis
9

Infection through genital skin to skin contact


lesions usually do not occur until 3-5 years
after HPV exposure.
Why in transformation zone?
10
Dysplasia : loss of the normal
cytoplasmic differentiation or
maturation of cervical epithelium.
The area of development of
dysplasia and SCC is at the junction
of the squamous and columnar
epithelia (transformation zone)
This area is most susceptible to viral
infection.
Responds to changes in vaginal pH
due to fluctuating estrogen levels.

Increases in estrogen stimulation result in advancement of columnar epithelium


toward the vagina (during pregnancy, in women taking oral contraceptives, in
newborns).
Decreases in estrogen stimulation are followed by "retreat" of columnar epithelium
into the endocervical canal.
12
13
15 Clinical sign & symptoms
Symptoms
Bleeding : vaginal, rectal, urethral
Exert pressure : obstipasi, anuria
hydronephrosis renal failure uremia
Infection : odor watery vaginal discharges
Physical signs
Nodule, ulcer, exuberant erosion of the cervix
Advanced: crater-shaped ulcer with high or friable warty
mass
Freely bleeding on examination
Mobility of the cervix depend on the stage
16
Prevention
Primary prevention: healthy lifestyles and vaccination
against HPV(quadrivalent vaccine - genotypes 6, 11, 16
&18 ; bivalent vaccine - genotypes 16 &18)

Secondary prevention: screening for precancer lesions


& early diagnosis followed by adequate treatment.

Tertiary prevention: diagnosis and treatment of confirmed


cancer. Treatment: surgery, radiotherapy and sometimes
chemotherapy. Palliative if incurable
18 Kelompok Sasaran Screening

Perempuan berusia 30-50 tahun


Pasien klinik IMS dengan discharge dan nyeri abdomen
bawah (semua usia)
Perempuan yang tidak hamil
Perempuan yang mendartangi puskesmas, klinik IMS<
dan klinik KB yang meminta screening

Pedoman teknis Ca Payudara dan Ca


Serviks, kemenkes
Screening for cervical cancer Visual Inspection Test
19
Aceto White Sign Pre Cancerous Lession

Pedoman teknis Ca Payudara dan Ca


Serviks, kemenkes
Screening for cervical cancer Visual Inspection Test
20
Aceto White Sign Pre Cancerous Lession

Pedoman teknis Ca Payudara dan Ca


Serviks, kemenkes
Screening for Cervical Cancer
21
23 Exception....

Women at increased risk of CIN :


1. in utero DES (diethylstilbestrol) exposure,
2. immunocompromise,
3. a history of CIN II/III or
4. Cancer
should continue to be screened at least annually.
The United States Preventive Services Task Force
stated screening may stop at age 65 if :
24
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 DISCONTINUE
consecutive negative results have been obtained.
However, screening should be performed if the
ACOG guideline 2008
woman acquires risk factors for intraepithelial
neoplasia, such as new sexual partners or
immunosuppression.
27 Summary Recommendation
Keluhan Lesi anatomis Rekomendasi
skrining
- - IVA

+ - PAP SMEAR

+ + Biopsi
Methods to Improve Accuracy of Pap Smears

Perform a Pap smear when the patient is in the proliferative phase (in the
28
week following cessation of menses).
The patient should avoid intercourse or intravaginal products for 24-48 hours
before the examination.
Use no lubricant prior to performing the Pap smear.

Technique:
1. Rotate the Ayers spatula through a 360-degree arc over the
squamocolumnar junction if visible.
2. Gently brush the spatula over the entire slide, taking care to avoid a thick
smear or shearing of cells by excessive pressure.
3. 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.
4. Apply this to the same slide using a rolling motion as noted in step 5.
5. Rapidly apply fixative to the slide. If using a spray, hold it about 10 inches
from the slide to avoid dispersing the cells.
6. Provide the cytologist with complete clinical information about the patient
including age, menopausal status, hormone use, history of radiation,
dysplasia, malignancy, etc.
Terminology Precancerous Lesion Squamous Cell Carcinoma

Cervical dysplasia:
Abnormal changes in the cells on the surface of the cervix, seen
underneath a miscroscope
LSIL: low-grade squamous intraepithelial neoplasia; HSIL: high-grade squamous
intraepithelial neoplasia; CIN: cervical intraepithelial neoplasia.

2015 UpToDate
33

AAFP Guideline
34
Terapi Penjelasan
36 Krioterapi Perusakan sel sel prakanker
dengan cara dibekukan
(dengan membentuk bola es
pada permukaan serviks)
elektrokauter Perusakan sel sel prakanker
dengan cara dibakar dengan
alat kauter, dilakukan leh
SpOG dengan anestesi
Loop ElectroSutgican Excision Pengambilan jaringan yang
Procedure (LEEP) mengandung sel prakanker
dengan menggunakan alat
LEEP
Konikasi Pengangkatan jaringan yang
megandung sel prakanker
dengan operasi
Histerektomi Pengangkatan seluruh rahim
termasuk leher rahim
37
Tumor of the Uterine Corpus
40
Benign tumor
Leiomyoma (myoma): most common tumor in the body (smooth
muscle cells)
Etiological factors: related to estrogen, three times more in black
often found in nulliparous

Type of Leiomyoma
1. Submucous : beneath
endometrium, if pedunculated
geburt myoma
2. Intramural/interstitial: within
uterine wall
3. Subserous/subperitoneal: at the
serosal surface or bulge outward
from myometriuml ; if
pedunculated : satelite myoma
41
Influencing factors of
Myoma Uterine
SYMPTOMS SIGN
42
Menorrhagia heavy & A palpable abdominal tumor :
prolonged menstruation arising from pelvis, well defined
(common) margins , firm consistency, smooth
Pelvic pain : occurs in surface, mobile from side to side.
pregnancy if undergoing
degeneration or torsion Pelvic examinationUterus
Pelvic pressureurinary enlarged and irregular, hard
frequency, constipation
Spontaneous abortion Diagnosis : Bimanual exam, USG,
Infertility hysteroscopy, Laparacospy

TREATMENT
Observation: for small myoma,
premenopause
Operation : myomectomy or
hysterectomy

Whorl like pattern / Pusaran air


Perubahan Sekunder Myoma
44
Jenis Degenerasi Ganas
Myoma uteri yang menjadi leiomyosarkoma hanya 0,32 0,6% dari
seluruh myoma

Leiomyosarkoma merupakan 50-75% dari semua jenis sarkoma uteri

Kecurigaan malignansi: apabila myoma uteri cepat membesar dan


terjadi pembesaran myoma pada menopause.
45 Tumor of the Uterine Corpus
Malignant Tumors
46 Tumor of the Ovary
47

Tumor of the Ovary


Ovarian cancer has highest mortality of Benign Tumor
all gynecological tumor
Small can be felt by bimanual, moile
Called as silent lady killer
Medium may have long pedicle and
Symptom (many ovarian tumor cause rise out of pelvis
no symptom only discover during routine Benign mucinous cyst may be vary in
examinatiion. sixe
Low abdominal discomfort (fullness, Benign teratoma cyst the commonest
bowel symptom) undergo torsion
Loss of weight, malaise, anorexia Benign solid tumor are less common
Pain due to torsion, hemorage or Meig syndrome : solid tumor, ascites,
rupture pleural effusion
Pressure symptom Malignant Tumor
Endocrinopaties Early detection would improve
Abnominal gross swelling prognosis, bimanual, USG or tumor
marker
Also called a dermoid cyst of the ovary,
48 this is a bizarre tumor, usually benign, in the
ovary that typically contains a diversity of
tissues including hair, teeth, bone, thyroid,
Ovarian
etc.
teratoma
A dermoid cyst develops from a
totipotential germ cell (a primary oocyte)
that is retained within the egg sac (ovary).
Being totipotential, that cell can give rise to
all orders of cells necessary to form mature
tissues and often recognizable structures
such as hair, bone and sebaceous (oily)
material, neural tissue and teeth.

Dermoid cysts may occur at any age but


the prime age of detection is in the
childbearing years. The average age is 30.
Up to 15% of women with ovarian teratomas
have them in both ovaries. Dermoid cysts
can range in size from a centimeter (less
than a half inch) up to 45 cm (about 17
inches) in diameter.
49
Menstrual cycle abnormalities
Menstrual cycle
50

Image source:https://embryology.med.unsw.edu.au/
51
Normal Menstrual Bleeding

52 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. By dr. Hasto Wardoyo, Sp. OG


FSH LH
53 In sexually-mature females, FSH In sexually-mature females, a surge of LH
(assisted by LH) acts on the follicle triggers the completion of meiosis I of the
to stimulate it to release estrogens. egg and its release (ovulation) in the
FSH produced by recombinant middle of the menstrual cycle;
DNA technology (Gonal-f) is stimulates the now-empty follicle to
available to promote ovulation in develop into the corpus luteum, which
women planning to undergo in secretes progesterone during the latter half
vitro fertilization (IVF) and other of the menstrual cycle.
forms of assisted reproductive
technology.
54 Ovulasi
Terjadi 14 hari sebelum mens >> kadar
berikutnya progesterone 2ng/ml
Tanda dan tes : LH surge (dg
Rasa sakit di perut bawah (mid cycle
Radioimunoassay)
pain/mittleschmerz) USG folikel >1,7 cm
Perubahan temperatur basal efek
termogenik progesteron
Perubahan lendir serviks
Uji membenang (spinnbarkeit): Fase
folikular : lendir kental, opak,
menjelang ovulasi encer, jernih,
mulur
Fern test : gambaran daun pakis
57 Fertility Test
LH-FSH Ratio : the relative value of 2 gonadotropin hormone produce by
the pituitary gland in women
Luteinizing hormone (LH) and Follicle stimulating hormone (FSH) stimulate
ovulation by working in different ways.
in premenopusal women, the normal LH-FSH ration is 1:1 as measured on
day three of the menstrual cycle
Variation from this ratio used to diagnose PCOS or other disorders, explain
infertility or verify that woman has entered menopause
FSH stimulates the ovarian follicle to mature. Then a large surge of LH
stimulates the follicle to release an egg to fertilization
On day 3 of the cycle, LH should be low. If LH is elevated on this day,
possible even as high as FSH, then it suggest problem with ovulation.
Ovulation requires an LH surge, and if LH is already elevated, it may not
surge and ovulated
58
59

Abnormal Uterine Bleeding


60

Malignancy and
Polyp Adenomyosis leiomyoma
hyperplasia

Coagulopathy Ovulatory disorder Endometrial iatrogenic Not Yet Classified


Polip
61 Endocervical polip
Endometrial polip

Adenomyosis
Part of endometrial that penetrate to myometrium

Leiomyoma
Submucosal
SUbserosal
intramural

Malignancy and hyperplasia


- Endometrial cancer
Coagulopathy
Von Willebrand disease
62
Gangguan agregasi platelet

Ovulatory disurbance
Endocrinopatie (PCOS, Hypotiroid, obesity, anorexia)
Extreme exercise, stress

endometrial
Endometrial inflammation
Endometrial infecton
Defisiensi endothelin-1, defisiensi Prostaglandin F2-alpha

Iatrogenic
Drugs : rifampicin, griseofulvin, trisiklik,
phenothiazine, anticoagulant, antiplatelet,
Treatment of uterine bleeding
63

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

ACOG 2008
Treatment of frequent or heavy bleeding
64
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
65 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
Dysmenorrhea
66
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.
Secondary
Dysmenorrhea beginning in the 20s or 30s, after previous
67
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

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.
68 Endometriosis
An estrogen-dependent disease frequently resulting in substantial morbidity, severe pelvic
pain, multiple surgeries, and impaired fertility

Clinically defined as presence of endometrial-like tissue found outside uterus, resulting in


sustained inflammatory reaction

Most common location: GI tract

Other locations: urinary tract, soft tissues & diaphragm


Pathophysiology
69 In situ from wolffian or mullerian duct remnants (metaplastic theory)
Coelemic metaplasia
Sampsons theory
Iron-induced oxidative stress
Stem cells

Sign Symptom
Classic signs: Dysmenorrhea
severe dysmenorrhea, dyspareunia, Heavy or irregular bleeding
chronic pelvic pain, Cylical/noncylical pelvic pain
infertility Lower abdominal or back pain
Dyschezia, often with cycles of
diarrhea/constipation
Bloating, nausea, and vomiting
Inguinal pain
Dysuria
Dyspareunia with or without penetration
Nodules may be felt upon pelvic exam
Imaging may indicate pelvic mass/endometriomas
70 Physical exam and imaging
Physical examination has poor Imaging studies
sensitivity, specificity, and Predictive
value in diagnosis endometriosis. Transvaginal or endorectal USG may reveal US feature
varying from simple cyst to complex cyst with internal
Combination of History, Physical echoes to solid masses, usually devoid of vascularity
exam and laboratory and diagnostic
studies is indicated to determine CT may reveal endometrioma appearing as cystic
cause of pelvic pain and rule out non masses; however, apperance are non specific and
endometriosis concerns imaging modalities should not be relied upon on for
diagnosis
Pain mapping may help isolate
location spesific disease such as MRI : may detect even smallest lesion and distinguish
nodulas masses in posterior hemorragic signal of endometrial implant
rectovaginal septum MRI demonstrated to accurately detect rectovaginal
Absence of evidence during exam is disease and obliteration in more than 90% of cases
not evidence of disease absence when USG gel was inserted in the vaginal and rectum
71 Endometriosis therapy

Medical Therapies Indications for surgical management:


Gonadotropin-releasing
hormone agonists (GnRH), diagnosis of unresolved pelvic pain
oral contraceptives, severe, incapacitating pain with
Danazol, significant functional impairment
aromatase inhibitors,
Progestins and reduced quality of life
advanced disease with anatomic
impairment
Surgical Intervention
(distortion of pelvic organs,
Laparoscopy endometriomas, bowel or bladder
Hysterectomy/Oophorecto dysfunction)
my/Salpingo- failure of expectant/medical
oophorectomy management
endometriosis-related emergencies,
Nonsurgical Therapies ie, rupture or torsion of
Medical Therapies endometrioma, bowel obstruction,
Alternative Therapies or obstructive uropathy
72 Endometriosis therapy
Mild Moderate Pain Moderate-Severe Pain
NSAID GnRH agonis
Oral contraceptive Danazole
progestin Aromatase inhibitor
73 Endometriosis therapy

Oral contraceptive Non Steroidal Anti Inflamatory


Generally well tolerated, fewer Proven efficacy fot treatment of
metabolic and hormonal side primary dismenorhea
effect than similar therapies
Acceptable side effects
Relieve dismenorrhea throuh
Reasonable cost
ovarian supresion and continous
progestin administration Ready availability
Often simple, effective choice to
manage endometriosis through
avoidance or delay menses for
upwards of 2 years
74 Endometriosis therapy
Progestins Aromatase Inhibitor
Inhibit growth of lesion by infucing Endometriotic implan express
ecidualization followed by athropy aromatase and consequently
uterine type tissue generate esterogen, maintaining
own viability
Compared to GnRH therapy, both
modalities show comparable Inhibit local esterogen production in
effectiveness endometrioticimplant
Medroxyprogesterone acetat Significantly reduce pain,
proven for pain suppresion both compared with GnRH agonit alone.
oral and injectable
Adverse effect : weight gain, fluid
retention, depresion, breakhrough
bleeding
75 Endometriosis therapy

GnRH agonist Danazol


Produced hypogonadic state Among oldest f medical therapy
through down regulation of pituitary for endometriosis
gland
Inhibit midcycle FSH and LH surge
Efective as other therapies in relieving and prevent steroidogenesis in
pain and reduce progression corpus luteum
No fertility improvement Higher incidence of adverse
effect more recent therapy
High cost, bone density loss,
intolerable hypoesterogeninc side Androgenic manifestation (oily
effect skin, ane, weight gain, deepening
voice, hirsutism) maybe
Preoperative therapy reported to
intolerable
reduce pelvic vascularity and size of
lesion, reduce intraoperative blood
loss
77
Amenorrhea

Amenorrhea is the absence of menstruation.


Primary
Absence of menses by age 14 without secondary sexual
development
Absence of menses by age 16 with normal secondary sexual
characteristic
Secondary
Absence of menses for 6 month in a previous menstruating
female
78

Lect. By dr. Hasto Wardoyo, Sp. OG


79
80 Definisi heavy
Prolonged menstrual
bleeding
menstrual
Menstrual period exceeding 8 days inbleeding dkk
duration on regular basis

Shortened menstrual Uncommon, define as bleeding of no longer than 2 days


bleeding
Irregular menstrual bleeding Bleeding of 20 days In individual cycle length over period of one year

Absent menstrual bleeding No bleeding in a 90 days period


(amenorhea)
Infrequent menstrual One or two episode in a 90 day period
bleeding
Frequent menstrual bleeding More than four time episode in a 90 day period

Heavy menstrual bleeding Excessive menstrual blood loss that interferences with the woman
physical, emotional, social, and material quality of life and can occur
alone or in combination with other symptom

Heavy and prolonged Less common than HMB, its important to make a distinction from HMB
menstrual bleeding given they may have different etiologies and respond to different
therapies
Light Menstrual Bleeding Based on patient complaint, rarely related to pathology
81
term
Acute Abnormal Uterine Episode of bleeding in a woman of reproductive age, who is not
Bleeding pregnant, of sufficient quantity to require immediate intervention to
prevent further blood loss

Chronic Abnormal uterine Bleeding from the uterine corpus hat is abnormal in duration,
bleeding volume, and/or frequency and has been present for the majority of
the last 6 month
Irregular Non Menstrual Irregular episode of bleeding, often light and short, occurring
Bleeding between normal menstrual period. Mostly associated with benign
or malignant structure lesion, may occur during or following sexual
intercourse
Post menopausal bleeding Bleeding occurring >1 year after the acknowledge menopause
Precocious menstruation Usually associated with other sign of precocious puberty, occur
before 9 years of age
83
Diagnosis of
primary
amenorrhea
84

Diagnosis of
secondary
amenorrhea
85
Functional
86 hypothalamic
amenorrhea:
the hypothalamic-
pituitary-ovarian axis is
suppressed due to an
energy deficit stemming
from stress, weight loss
(independent of original
weight), excessive
exercise, or disordered
eating.
It is characterized by a
low estrogen state without
other organic or structural
disease
Menses typically return
after correction of the
underlying nutritional
deficit.
87 Menopause

I. Definition
permanent cessation of menstrual periods, determined
retrospectively after a woman has experienced 12 months of
amenorrhea without any other obvious pathological or
physiological cause ; mean age 51,4 y.o
89 II. Pathophysiology

The number of primordial follicle decline even before birth but


dramatic just before menopause.
Increase FSH, LH from about 10 years before menopause.
Close to menopause: There will be
-anovulation
-inadequate Leuteal phase decrease progesterone but not
estrogen level lead to DUB and endometrial Hyperplasia
- at menopause dramatic decrease of estrogenmenstruation
ceases and symptoms of menopause started.
But still ovarian stroma produce small androstenedione and
testosterone but, main postmenopausal astrogen is estrone
produced by Peripheral fat from adrenal androgen.
90
91 III. Symptoms of Menopause:
1. Hot flushes - cutaneous 3. Psychological changes
vasodilation decreased level of
- occurs in 75% of central
women neurotransmitters
- more severe after - Depression
surgical menopause - Irritability
- continue for 1 year - Anxiety
- 25% continue more - Insomia
than 5 years - lose of concentration

2. Urinary Symptoms
- urgency
- frequency
- nocturia
4. Atrophic Changes
92 Vagina
*vaginitis due to thinning of epithelium, PH and lubrication.
*dysparnuedue to decrease vascularity and dryness
Decrease size of cervix and mucus with retract of segumocolumnar (SC)
junction into the endocervical canal.
Decrease size of the uterus, shrinking of myoma & adenomyosis.
Decrease size of ovaries, become non palpable.
Pelvic floor - relaxation prolapse.
Urinary tract atrophy lose of urethral tone caruncle
Hypertonic Bladder - detrusor instability
Decrease size of breast and benign cysts.
5. Skin Collagen collagen & thickness elasticity of the skin.
6. Reversal of premenstrual syndrome
93 Diagnosis and Investigations:
The Triad of:
-Hot flushes
-Amenorrhea
-increase FSH > 15 i.u./L
Before starting treatment: You should perform
-breast self examination
-mammogram
-pelvic exam (Pap Smear)
-weight, Blood pressure
No indication to perform
-bone density
-Endometrial Biopsy but any bleeding should be
investigated before starting and treatment.
94 Treatment:
Estrogen a minimum of 2mg of oestradiol is needed to
mantain bone mass and relief symptoms of menopause.
Women with uterus add progestin at last 10 days to
prevent endometrial Hyperplastic
Sequential Regimens - used in patient close to
menopause.
Oestrogen in the first of 28 day per pack
& Oestrogen & Progetin in 2nd 1/12 of 28 day pack.
Combined continuous therapy who has Progesterone
everyday is useful for women who are few years past
the menopause and who do not to have vaginal
bleeding.
There is evidence that increase risk of endometrial
cancer with sequential regimens for > 5 years while on
combined continuous regimens decrease risk of Cancer.
95 Benefits of HRT:
Vagina- vaginal thickness of epithelium
dyspareunia & vaginitis.
Urinary tract enhancing normal bladder
function.
Osteoporosis decrease fractures by
more than 50%
CVS decrease by 30% by observation
studies but recent studies shows no
benefits.
Colon Cancer decrease up to 50%
104
INFERTILITAS
105
Infertility
Infertilitas
106

failure of a couple to conceive after 12 months of regular intercourse


without use of contraception in women less than 35 years of age; and
after six months of regular intercourse without use of contraception in
women 35 years and older

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.
107
Faktor Istri:
108 Infeksi
Gangguan ovulasi
Gangguan anatomi Gangguan Ovulasi

Penuaan (usia)
POF
Polikistik Ovarii (PCOS)
Kelainan pada hipotalamus-
hipofisis
Hiperprolaktin
Kelainan kongenital
109
110

Analisa Sperma
111 ANALISA SPERMA
Fertilitas seorang pria ditentukan A: bergerak cepat dan lurus
oleh jumlah dan kualitas B: Bergerak lambat dan tidak lurus
spermanya
C : bergerak ditempat
Normozoospermia
D : tidak bergerak
Jumlah sperma 20 juta/ml
Teratozoospermia
Oligozoospermia
Morfologi sperma normal < <30%
Jumlah sperma < 20 juta/ml
oligoAstenoTeratozoospermia sindroma
Astenozoospermia OAT
Motilitas sperma a<25% atau Azoopermia 0 sperma + plasma semen
a+b <50%
Aspermia 0 sperma + 0 plasma semen
112 Motilitas spermatozoa dan viabilitas
Digunakan untuk kriteria D tidak bergerak uji viabilitas
Pewarnaan supravital menggunakan Eosin Y dengan prinsip sperma hidup
tidak dapat menyerap zat warna dan sebaliknya denan sperma mati
(disintegrasi membran sel)
Dilihat dibawah mikroskop
Sperma hidup kepala bening
Sperma mati kepala ungu
Dari 100 sperma yang dihitung
80 sperma kepala bening
20 sperma kepala ungu
Uji Viabilitas 80%
Sindroma Ovarium Polikistik
113

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
114

Source: http://www.pathophys.org/pcos/
Therapy
Lifestyle modification: may help First line of PCOS management.
115 all symptoms of PCOS
attenuate Increased exercise, improved diet, and weight loss can help to reduce the
and reduce the long-term risk of metabolic abnormalities associated with PCOS.
infertility, CVD and T2DM. Weight loss 5-10% correct oligoanovulation & improve conception.

Estrogen and progestin oral Can be used to normalize androgen levels and attenuate the signs of
contraceptive (OCP) hyperandrogenism as well as to regulate menstrual cycles. This also helps to
therapy: treatment of acne, reduce the risk of heavy and irregular menstrual bleeding associated with the loss
hirsutism and irregular menstrual of normal estrogen and progestrone levels.
cycles.
Anti-androgens (e.g. Spironolactone and flutamide competitively inhibits DHT and testosterone by
spironolactone,finasteride, binding to their receptors in peripheral cells (e.g. hair follicles).
flutamide): treatment of acne and Finasteride is a 5a-reductase inhibitor that inhibits conversion of testosterone to the
hirsutism. more potent DHT in peripheral cells.
Anti-androgens can be used synergistically with OCPs, which act centrally to
suppress androgen release.

Metformin: treatment of glucose Metformin reduces glucose intolerance and hyperinsulinemia by increasing insulin
intolerance, hyperinsulinemia, and sensitivity and decreasing hepatic gluconeogenesis and lipogenesis; it can
anovulation. Reducing circulating therefore be used to help prevent and treat T2DM. Treating these factors can also
insulin levels may secondarily induce ovulation.
reduce ovarian androgen synthesis. Combined treatment with metformin and clomiphene citrate (see below) more
effective than either agent alone in inducing ovulation.
Source: http://www.pathophys.org/pcos/
Clomiphene Clomiphene citrate is a selective estrogen receptor modulator (SERM). It
induces ovulation by interfering with estrogen feedback to the brain and
thus increasing FSH release. There is increased risk of multigestational
116 pregnancy (e.g. twins or triplets) because of the large number of antral
follicles in polycystic ovaries. Clomiphene citrate treatment should be
limited to 12 cycles because longer-term treatment is associated with
increased risk of ovarian cancer due to ovarian hyperstimulation.

Gonadotropin therapy: recombinant FSH and Exogenous gonadoptropins can be administered to mimic physiological
hCG can be used to induce ovulation in mechanisms of follicle development. FSH is given to promote growth of a
cases where treatment with clomiphene dominant follicle to a particular size, and then human chorionic
citrate and metformin has been unsuccessful. gonadotropin is used to induce ovulation.

Ovarian drilling: a laparoscopic surgical Ovarian drilling involves the creation of ~10 perforations in the ovary using
procedure that may be used to treat either cautery or laser. The ablation of some of the ovarian theca is thought
clomiphene citrate-resistant anovulation. to help induce ovulation by decreasing androgen production.

IVF: used for the treatment of infertility in IVF involves the retrieval of oocytes from the ovaries and in vitro
women who have not responded to other combination with sperm to produce embryos. Viable embryos are then
therapies to induce ovulation. transferred into the uterus. Women with PCOS have similar success and live
birth rates compared to women without PCOS.
117 Fertility Test
LH-FSH Ratio : the relative value of 2 gonadotropin hormone produce by
the pituitary gland in women
Luteinizing hormone (LH) and Follicle stimulating hormone (FSH) stimulate
ovulation by working in different ways.
in premenopusal women, the normal LH-FSH ration is 1:1 as measured on
day three of the menstrual cycle
Variation from this ratio used to diagnose PCOS or other disorders, explain
infertility or verify that woman has entered menopause
FSH stimulates the ovarian follicle to mature. Then a large surge of LH
stimulates the follicle to release an egg to fertilization
On day 3 of the cycle, LH should be low. If LH is elevated on this day,
possible even as high as FSH, then it suggest problem with ovulation.
Ovulation requires an LH surge, and if LH is already elevated, it may not
surge and ovulated
118
122
GYNECOLOGIC INFECTIONS
Cervicitis
123
*Tidak mudah
Servisitis menular seksual =
membedakan servisitis
Servisitis mukopurulenta
dari vaginitis
4 faktor risiko u/ prediksi
Biasanya asimtomatis
servisitis:
1. umur < 21 th Datang karena mitra
2. Lajang menderita IMS
3. CS > 1 org dlm 3 bln terakhir Penyebab:
4. CS dg pasangan baru dlm GO; Non-GO (C.trachomatis)
3 bln terakhir

Lect. By dr. Retno Satiti, Sp.KK


CERVICITIS GO
124 Definisi: peradangan serviks o/k N. Diagnosis:
Gonorrhoeae (diplokokus Gram negatif, Gram: pmn > 30; DGNI (+)
terlihat di luar dan di dalam leukosit) Kultur: Media Thayer Marthin
PCR
Klinis: asimtomatis; keputihan warna kuning
Px:
- vulva tenang
- inspeculo: dd vagina eritem/tenang
- ektoserviks: eritem/normal
- endoserviks: eritem, edem,
ektopi, bleeding,
discar mukopurulen

Lect. By dr. Retno Satiti, Sp.KK


Komplikasi Gonorhea Pada Pria Komplikasi Gonorhea pada
125 Wanita

Infeksi Komplikasi Lokal: Infeksi Komplikasi Lokal:


Pertama: pertama:
-Tysonitis -Parauretritis
Uretritis -Parauretritis -Uretritis -Bartholinitis
-Littritis -Servisitis
-Cowperitis
Komplikasi asenden : Komplikasi
asenden :
-Prostatitis
-Vesikulitis -Salphingitis
-Funikulitis -PID
-Epididimitis
-Trigonitis
Ilmu Penyakit Kulit dan Kelamin FKUI
CERVISITIS NON GO
126 Peradangan serviks bukan o/k GO
Penyebab: C. trachomatis (terbanyak)
Klinis: asimtomatis; keputihan kuning
Px: vulva tenang
inspeculo: dd vagina eritem/normal C. Trachomatis
ektoserviks: eritem/normal immunofluoresence
endoserviks: eritem, edem, ektopi, swab bleeding, dg antibodi
monoklonal
discar mukopurulen

Lect. By dr. Retno Satiti, Sp.KK


127 Vaginitis

Penyebab umumnya: Trikomonas, Kandida, bakteri


anaerob keputihan tidak selalu ditularkan secara
seksual
Tanda : abnormalitas volume, warna, bau dari discar
vagina
Gejala: gatal, edem, disuri, sakit perut/punggung bawah

Lecture by dr. Retno Satiti, Sp.KK


128
TRIKOMONIASIS/Vaginitis Trikomonal
129
Definisi: Diagnosa :
peny. Infeksi protozoa yg 1. Discar vagina kuning kehijauan,atau
disebabkan oleh T. vaginalis berbuih dan bau busuk, strawberry cervix
(+)
inkubasi: 3-28 hr 2. Peradangan pd dinding vagina
3. Lab: NaCl 0,9% : T. vaginalis motil

Lect. By dr. Retno Satiti, Sp.KK


130
KANDIDOSIS VULVOVAGINAL/
131
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
Diagnosa :
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 Satiti, Sp.KK
Lab KOH 10% : pseudohifa
Vaginosis bakterial (VB)
132
Definisi: * gangguan pada vagina tanpa peradangan
* sindroma klinik akibat perubahan lingkungan lokal
* pergantian flora normal Lactobasilus sp. oleh bakteri
anaerob: terutama G.vaginalis dll

Inkubasi: bbrp hr-4 mgg


Diagnosa 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 -

Lect. By dr. Retno Satiti, Sp.KK


Pengobatan sindrom duh tubuh vagina karena vaginitis
Pengobatan untuk trikomoniasis
133 DITAMBAH
Pengobatan untuk vaginosis bakterial .
BILA ADA INDIKASI,
Pengobatan untuk kandidiasis vaginalis

Lect. By dr. Retno Satiti, Sp.KK


Pengobatan sindrom duh tubuh vagina karena infeksi
serviks
134 Pengobatan untuk gonore tanpa komplikasi
DITAMBAH
Pengobatan untuk klamidiosis

Lect. By dr. Retno Satiti, Sp.KK


Pelvic Inflammatory Disease
135
Acute infection of the upper genital Clinical symptoms
tract structures in women, involving any or Abdominal pain
all of the uterus, oviducts, and ovaries Vaginal bleeding
Microbiology Vaginal discharge
N. gonorrhea 1/3 of cases Dispareunia
Chlamydia 1/3 of cases Disuria/ureteritis
Mixed infection strep, e.coli, klebsiella, Physical exam:
anaerobes Abdominal pain
Fever
Bimanual exam with CMT
Risk factors or adnexal tenderness
Number of sexual partners Cervical discharge
Age Diagnosis
15-25 years old w/ highest frequency Pregnancy test
Symptomatic male partner Cervical sample for GC/
Previous PID Chlamydia
African American women Pelvic ultrasound
Indikasi Rawat Inap Pada pasien Penyakit Radang
Panggul
136
Diagnosis tidak dapat dipastikan
Indikasi bedah darurat : appendisitis, KET
Dugaan abses panggul
Pasien sedang hamil
Kegagalan pengobatan saat rawat jalan
Kemungkinan semakin parah jika rawat jalan
Pasien tidak mau atau tidak menaati rejimen
pengobatan bila dilakukan rawat jalan

Complication of Pelvic Inflammatory Disease


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

Pedoman penanggulangan IMS, 2011


Pengobatan Penyakit Radang Panggul (Rawat Jalan)
137

Pedoman penanggulangan IMS, 2011


Indikasi Rawat Inap Pada pasien Penyakit Radang
Panggul
138

Keterangan
- Dilakukan hingga 2 hari
menunjukan perbaikan
klinis, lalu dilanjutkan oleh
salah satu obat
- Doksisiklin 2x100 mg PO 12
hari
- Tetrasiklin 4x500 mg PO 14
hari

Pedoman penanggulangan IMS, 2011


Sindroma Ulkus Genital
139

* Sifilis
* Chancroid = ulkus mole
* Herpes genitalis
* Limfogranuloma venereum
* Granuloma inguinale
Ulkus Durum vs Ulkus Mole
140

Ulkus Durum Ulkus Mole


Terkait dengan Sifilis Chancroid / H. Ducreyi
Cenderung tunggal Cenderung multiple
Dasar bersih Dasar kotor, tampak
Tempat tersering : sulcus kemerahan hingga
coronarius (pria), wanita nekrotik
(labia mayora)
141
Sifilis

Peny. Infeksi sistemik & kronis


Etiologi: T. pallidum (Spirochaeta,
spiral, Gram neg., Bergerak
berputar, atau maju spt
pembuka tutup botol)

Transmisi: Perjalanan sifilis tanpa Tx:


* Kontak seksual 1. Sifilis primer
* Trans-Plasenta
2. Sifilis sekunder
Patogenesis: kontak langsung dari 3. Laten dini
lesi infeksius
4. Laten lanjut tertier benign,
treponema selaput lendir
kelenjar limfe pemb.darah kardiovaskuler, neurosifilis
seluruh tubuh
Sifilis Primer
142

ulkus di genital eksterna, 3


mgg setelak CS
tunggal/multipel, uk 1-2 cm
Papula erosi permukaan
tertutup krusta ulserasi
tepi meninggi & keras
ulkus durum
pembesaran lln. Inguinal
bilateral
sembuh spontan 4-6 mgg
Sifilis sekunder
143 (3-4 mgg setelah ulkus durum)

lesi kulit, selaput lendir, organ tubuh


demam, malaise
lesi kulit simetris, makula, papula
folikulitis, papuloskuamosa,pustula
moth-eaten alopecia - oksipital
papula basah daerah lembab: kondilomata lata
lesi pd mukosa mulut, kerongkongan, serviks:
plakat
pembesaran kel. Limfe multipel
splenomegali
Sifilis Laten Sifilis Tersier
144

Sifilis Laten Dini : Muncul beberapa lesi kulit, distribusi


stadium sifilis tanpa asimetris
Sulit menemukan TP dlm lesi kurang
gejala klinis
infeksius
tes serologis reaktif < Terjadi kerusakan jaringan/organ
1 th Lesi spesifik: Gumma
- endarteritis obliterans peradangan
Sifilis laten lanjut sifilis nekrosis
- neurosifilis, kardiosifilis
tersier
Muncul 2-20 tahun
sesudah infeksi
primer
Terjadi pada 30%
kasus sifilis
145 Sifilis Kongenital

Didapat dari Ibu dg Sifilis awal

Terjadi saat kehamilan > 4 bl (10 bl) < 4 bl sisitem imun blm berkembang penuh

Tidak pernah terjadi ulkus

Manifestasi klinis awal lebih berat dibanding sifilis dapatan

Sistem kardiovaskular sering terlibat

Dapat mengenai mata, telinga, hidung

Sering juga merusak sistem skeletal


146

Sifilis kongenital dini: < 2 th


lesi kulit: terjadi segera,
vesikobulosa, erosi,
papuloskuamosa,
mukosa: hidung, pharing:
perdarahan
tulang: osteokondritis tl
panjang
anemia hemolitik
hepatosplenomegali
SSP
147 Sifilis
kongenital
lanjut: > 2 th

Sklerosis Keratitis
sabre interstisialis,

Bilateral gigi
Neurosifilis hutschinson

Gangguan Gigi Mulberry


saraf pusat VIII
tuli
Diagnosis: klinis + lab
148 1. Lab : medan gelap (dark field) sifilis primer
2. Antibodi serum : VDRL (1/16), TPHA S sekunder & tersier
Terapi
sifilis primer & sekunder
Benzatin penisilin G 2,4 juta IU, IM, ds tunggal
anak: 50.000 IU/kg , IM, ds tunggal

sifilis laten:
laten dini: Benzatin penisilin G 2,4 juta IU. IM, ds tunggal
laten lanjut: Benzatin penisilin G 2,4 juta IU, IM/mgg, 3 mgg
anak: 50.000 IU/kg,IM,ds tunggal
50.000 IU/kg,IM/mgg, 3 mgg

Sifilis terstier: Benzatin penisilin G 2,4 juta IU/mgg, 3 mgg


Tindak lanjut: ulang serologi, 6, 12, 24 bl
Tx. Berhasil jika titer turun 4 x
149

Lakukan pemeriksaan serologi tiap 3 bln pd tahun I

Ulang serologi setiap 6 bln pd tahun II

* Amati kembali pada tahun ke 3


Kondiloma Akuminata
150

Termasuk dalam STD


Predileksi :
Pria = Wanita Pria : perineum, sekitar anus,
Penularan : kontak kulit sulkus koronarius, glans penis,
langsung muara uretra eksterna, korpus
penis
Etiologi : Human Papilloma
Virus (HPV) tipe 6,11,16,18, Wanita : vulva, introitus vagina,
30, 31, dsb porsio uteri (<<), disertai fluor
albus, pada wanita hamil
Virus DNA pertumbuhan lebih cepat
Keluarga Papova
Vegetasi bertangkai, merah-
hitam, papilomatosa
Giant condyloma (Buschke)
biopsi!
Terapi
151
Sebagai first line bisa dipilih podofilin atau TCA
Podofilin
Tingtur podofilin 25%, 0,3 cc, dapat diulang setelah 3 hari
Gejala toksisitas : mual, muntah, nyeri abdomen, gangguan pernafasan, supresi
sumsum tulang, trimbositopenia, leukopenia
Teratogenik : kematian fetus
Tidak Dapat untuk mengobati condiloma acuminata yang lokasinya berada pada
vagina dan cerviks (risiko chemical burn)
Asam trikloroasetat 50% :
Dioleskan seminggu sekali
Efek samping : ulkus, sehingga perlu hati hati dalam pemberian
Dapat diberikan pada ibu hamil dan lesi internal
5-Fluorourasil 1-5% cr :
Berbentuk gel, lebih baik digabung dengan epinefrin
Setiap hari sampai lesi hilang, Os tidak miksi sampai 2 jam post pengolesan
Elektrokauterisasi
152 Hanya untuk kondiloma acuminata yang berada di labia / kulit
Beresiko terjadinya jaringan parut
Bedah beku/cryotherapy (N2, N2O cair)
Bedah skalpel lebih baik pada kondiloma yang besar
dan menutupi jalan lahir
Laser karbondioksida
Lebih cepat sembuh, sedikit jaringan parut dibandingkan
elektrokauterisasi
Interferon
Injeksi IM atau intralesi atau topikal (cr)
Dosis : 4-6mU IM 3 kali seminggu, 6 mg atau 1-5mU IM, 6 mg
153 Kondiloma akuminata vs kondiloma lata

Kondiloma akuminata
Etiologi : HPV virus
Kondiloma lata
Etiologi : triponema
palidum (sifilis
sekunder)
Kista dan Abses Bartholini
154
Kista bartholini adalah kista yang
terbentuk akibat sumbatan pada
ductus/ kelenjar bartolini & retensi
sekret
Umum pada wanita umur
reproduksi
Lokasi pada labia mayora.
apabila terinfeksi abses
Abses 3 kali lebih umum dari pada
kista
155 Patologi
Abses Bartholini merupakan Isolates from Bartholin's Gland
polymikrobal infeksi Abscesses
Neisseria gonorrhoeaea Aerobic organisms
yang paling umum Neisseria gonorrhoeae
Jika tidak inflamasi Staphylococcus aureus
asimtomatik Streptococcus faecalis
Simtom: nyeri vulva, Escherichia coli
dispareunia, kesulitan Pseudomonas aeruginos
berjalan/olah raga Chlamydia trachomatis
Anaerobic organisms
Bacteroides fragilis
Clostridium perfringens
Peptostreptococcus
species
Fusobacterium species
156 Penatalaksanaan

Asimtomatik tidak perlu terapi


Incisi dan drainase tx cepat & mudah
kemungkinan rekuren
WORD CATHETER
MARSUPIALIZATION
INCISI & DRAINASE
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

157
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
159 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
160 Patofisiologi

GO cepat menjadi abses keluar lewat


duktus tersumbat: abses membesar
Radang bisa berulang (68-75%)
Jika menahun terbentuk kista
161
INFEKSI KONGENITAL
162
Teratogen: TORCH
163
164
165
TOXOPLASMOSIS

In pregnancy, the most


common mechanisms of
acquiring infection:
1. consuming raw or very
undercooked meats or
contaminated water,
2. exposure to soil
(gardening without
gloves) or
3. Exposure to cat litter
166
167
168
Amniocentesis should not
be offered at less than 18
weeks gestation
172 because of the high rate of
false-positive results.

Spiramycin: fetal
prophylaxis

Pyrimethamine folic
acid antagonist. Should
not be used in the first
trimester because it is
potentially teratogenic.

Folinic acid: to
counteract bone
marrow depression by
pyrimethamine
173 Congenital Toxoplasmosis
maternal infection 3 month before conception or during pregnancy

<18 minggu (hingga terbukti tidak ada infeksi pada janin):


Spiramicin: 1g per 8 jam bersama makan
>18 minggu (diberikan sampai lahir):
Pirimetamin 50 mg 2x sehari, selama 2 hari, dilanjutkan 50 mg/hari
Sulfadiazine loading 75 mg/kg, dilanjutkan 50 mg/kg 2x sehari
Asam folat : 10-20 mg/hari hingga 1 minggu bebas pirimetamin

Uptodate.com, medscape
175
176 Rubella
178
Risk of congenital defects:

Before 11 weeks of gestation 90%


13 -14 weeks 11%
15-16 weeks 24%
After 16 weeks 0%
180
181
183 CMV
184
185 Symptomatic CMV
infection
Petechiae (54 to 76 percent)
Jaundice at birth (38 to 67 percent)
Hepatosplenomegaly (39 to 60 percent)
Small size for gestational age (39 to 50 percent)
Microcephaly (36 to 53 percent)
Sensorineural hearing loss (SNHL, present at birth in
34 percent)
Lethargy and/or hypotonia (27 percent)
Poor suck (19 percent)
Chorioretinitis (11 to 14 percent)
Seizures (4 to 11 percent)
Hemolytic anemia (11 percent)
Pneumonia (8 percent)
186
187
Treatment
188

Once the diagnosis of congenital CMV infection


is confirmed, one option is pregnancy
termination.
A second proposed option: treatment of the
mother with antiviral agents (ganciclovir,
foscarnet, and cidofovir.)
These drugs are of moderate effectiveness in treating
CMV infection in the adult
Source; No proven value in preventing or treating congenital
http://www.peri
natology.com/e CMV infection.
xposures/Infecti
on/CMV/Cytom
egalovirus.htm#
The most promising therapy for congenital CMV
DXMOTHER infection appears to be hyperimmune globulin.
189 Varicella Syndrome : USG findings

Calcification
o intrahepatic
o Intracranial : may also see liver, heart, and renal
Poly hydramnion : due to neurologic impairment of swallowing
Limb Hipoplasia
Microcephaly
190

Zooster Lesion

Hepatic calcification Radioulnar hipoplasia and


missing hand
191 Management

Fetal Infection
Amniocentesis (culture or PCR of virus)
Fetal MRI : CNS

Maternal infection symptomatic


Hospitalization in severe case, esp in varicella pneumonia (emergency case)
Acyclovir 800 mg P.O 5 times a day, for 7 days

Maternal zooster outbreak in pregnancy is not associated with risk of fetal


malformation
192 Gynecology is done.... For now!

Alhamdulillah