GYNECOLOGY

dr. Nashria
dr. Reagan Resadita

2
Neoplasm

Abnormal
Menstrual
Cycle

Infertility

Gonorrhea

Menstruation
Cervix

Infection

Congenital
infection

Sperm Analysis

Abnormal uterine
bleeding

Toxoplasmosis
Trichomoniasis
Candidiasis
Rubella

Uterine Corpus

Endometriosis

Polycystic ovarian
syndrome

Bacterial Vaginosis
PID
CMV
Syphilis

Amenorrhea
Ovarium
menopause

Woman Fertility
Test

Condiloma
acuminata
Bartholin abscess

Varicella

NEOPLASM

Neoplasma
Abnormal, excessive growth of tissue
4

Common
symptoms:

Malignant
Vs

Solid

Benign

Vs

Abnormal
bleeding

(myoma,ovarian
cyst)

Cystic

Pelvic mass
Vulvovaginal
symptoms

Clinical Aspects : Benign vs Malignant Tumor

Benign Tumor

Malignant tumor

May cause significant clinical

disease

Clinical significant much greater :

invasive, rapid growing more
often cause bleeding, ulceration,
infection

Exert pressure : uterine myoma

low back pain, obstipation, urine
retention
Superimposed complication :
abnormal bleeding, ulceration,
secondary infection
Undergo malignant
transformation

Para neoplastic syndrome

(endocrinopathies)
cachexia

Common Location of tumors

Tumor of the Uterine Cervix

7

Cervix:
Classification
lower
1/3 of Benign tumor
Leiomyoma (myoma)
uterus;
at and Malignant tumor
A. Carcinoma of the
below
cervix
level of
1. Squamous cell
internal
carcinoma 91 %
cervical
2. Adenocarcinoma
os
3. Adenosquamous
carcinoma
4. Adenoacanthoma
B. Sarcoma ( very
rare)

Risk Factors
HPV infection:
type 16, 18, 45 and 56
Sexual factor:

early marriage,
young age of first
coitus
multiple sexual
partners

Cigarette smoking
Socio economic
status, Parity, Race

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.

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12

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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

14

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

15

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

16

Aceto White Sign Pre Cancerous Lession

Pedoman teknis Ca Payudara dan Ca

Serviks, kemenkes

Screening for cervical cancer Visual Inspection Test

17

Aceto White Sign Pre Cancerous Lession

Pedoman teknis Ca Payudara dan Ca

Serviks, kemenkes

Screening for Cervical Cancer

18

19

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 :
20
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.

DISCONTINUE
ACOG guideline 2008

21

Summary Recommendation
Keluhan

Lesi anatomis

Rekomendasi
skrining
IVA

PAP SMEAR

Biopsi

Methods to Improve Accuracy of Pap Smears

22

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 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

24

AAFP Guideline

25

26

Terapi

Penjelasan

Krioterapi

Perusakan sel sel prakanker

dengan
cara
dibekukan
(dengan membentuk bola es
pada permukaan serviks)

elektrokauter

Perusakan sel sel prakanker

dengan cara dibakar dengan
alat kauter, dilakukan leh
SpOG dengan anestesi

Loop ElectroSutgican 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

27

Tumor of the Uterine Corpus

28

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

29

Influencing factors of
Myoma Uterine

SYMPTOMS
30

Menorrhagia heavy &

prolonged menstruation
(common)
Pelvic pain : occurs in
pregnancy if undergoing
degeneration or torsion
Pelvic pressureurinary
frequency, constipation
Spontaneous abortion
Infertility

SIGN
A palpable abdominal tumor :
arising from pelvis, well defined
margins , firm consistency, smooth
surface, mobile from side to side.
Pelvic examinationUterus
enlarged and irregular, hard
Diagnosis : Bimanual exam, USG,
hysteroscopy, Laparacospy

TREATMENT

Whorl like pattern / Pusaran air

Observation: for small myoma,

premenopause
Operation : myomectomy or
hysterectomy

Perubahan Sekunder Myoma

31

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.

32

Tumor of the Uterine Corpus

Malignant Tumors

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Tumor of the Ovary

34

Tumor of the Ovary

Ovarian cancer has highest mortality of
all gynecological tumor
Called as silent lady killer
Symptom (many ovarian tumor cause
no symptom only discover during routine
examinatiion.

Benign Tumor
Small can be felt by bimanual, moile
Medium may have long pedicle and
rise out of pelvis
Benign mucinous cyst may be vary in
sixe

Low abdominal discomfort (fullness,

bowel symptom)

Benign teratoma cyst the commonest

undergo torsion

Loss of weight, malaise, anorexia

Benign solid tumor are less common

Pain due to torsion, hemorage or

rupture

Meig syndrome : solid tumor, ascites,

pleural effusion

Pressure symptom
Endocrinopaties
Abnominal gross swelling

Malignant Tumor
Early detection would improve
prognosis, bimanual, USG or tumor
marker

35

Also called a dermoid cyst of the ovary,

this is a bizarre tumor, usually benign, in the
ovary that typically contains a diversity of
tissues including hair, teeth, bone, thyroid,
etc.
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.

Ovarian
teratoma

36

Menstrual cycle abnormalities

Menstrual cycle
37

Image source:https://embryology.med.unsw.edu.au/

38

Normal Menstrual Bleeding

39

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
40

In sexually-mature females, FSH

(assisted by LH) acts on the follicle
to stimulate it to release estrogens.
FSH produced by recombinant
DNA technology (Gonal-f) is
available to promote ovulation in
women planning to undergo in
vitro fertilization (IVF) and other
forms of assisted reproductive
technology.

LH
In sexually-mature females, a surge of LH
triggers the completion of meiosis I of the
egg and its release (ovulation) in the
middle of the menstrual cycle;
stimulates the now-empty follicle to
develop into the corpus luteum, which
secretes progesterone during the latter half
of the menstrual cycle.

41

Ovulasi

Terjadi 14 hari sebelum mens

berikutnya

>> kadar
progesterone 2ng/ml
LH surge (dg
Tanda dan tes :
Radioimunoassay)
Rasa sakit di perut bawah (mid cycle
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

42

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

43

44

Abnormal Uterine Bleeding

45

Polyp

Coagulopathy

Adenomyosis

Ovulatory disorder

Malignancy and
hyperplasia

leiomyoma

Endometrial

iatrogenic

Not Yet Classified

Polip
46

Endocervical polip
Endometrial polip

Adenomyosis
Part of endometrial that penetrate to myometrium

Leiomyoma
Submucosal
SUbserosal
intramural

Malignancy and hyperplasia

- Endometrial cancer

Coagulopathy
47

Von Willebrand disease

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

48

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

49

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

50

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

51

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.

Secondary
52

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

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.

53

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
54

In situ from wolffian or mullerian duct remnants (metaplastic theory)

Coelemic metaplasia
Sampsons theory
Iron-induced oxidative stress
Stem cells

Sign Symptom
Classic signs:
severe dysmenorrhea, dyspareunia,
chronic pelvic pain,
infertility

Dysmenorrhea
Heavy or irregular bleeding
Cylical/noncylical pelvic pain
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

55

Physical exam and imaging

Physical examination has poor

sensitivity, specificity, and Predictive
value in diagnosis endometriosis.
Combination of History, Physical
exam and laboratory and diagnostic
studies is indicated to determine
cause of pelvic pain and rule out non
endometriosis concerns
Pain mapping may help isolate
location spesific disease such as
nodulas masses in posterior
rectovaginal septum
Absence of evidence during exam is
not evidence of disease absence

Imaging studies
Transvaginal or endorectal USG may reveal US feature
varying from simple cyst to complex cyst with internal
echoes to solid masses, usually devoid of vascularity
CT may reveal endometrioma appearing as cystic
masses; however, apperance are non specific and
imaging modalities should not be relied upon on for
diagnosis
MRI : may detect even smallest lesion and distinguish
hemorragic signal of endometrial implant

MRI demonstrated to accurately detect rectovaginal

disease and obliteration in more than 90% of cases
when USG gel was inserted in the vaginal and rectum

56

Endometriosis therapy
Medical Therapies

Gonadotropin-releasing
hormone agonists (GnRH),
oral contraceptives,
Danazol,
aromatase inhibitors,
Progestins

Surgical Intervention
Laparoscopy
Hysterectomy/Oophorecto
my/Salpingooophorectomy
Nonsurgical Therapies
Medical Therapies
Alternative Therapies

Indications for surgical management:

diagnosis of unresolved pelvic pain
severe, incapacitating pain with
significant functional impairment
and reduced quality of life
advanced disease with anatomic
impairment
(distortion of pelvic organs,
endometriomas, bowel or bladder
dysfunction)
failure of expectant/medical
management
endometriosis-related emergencies,
ie, rupture or torsion of
endometrioma, bowel obstruction,
or obstructive uropathy

Endometriosis therapy

57

Mild Moderate Pain

Moderate-Severe Pain

NSAID

GnRH agonis

Oral contraceptive

Danazole

progestin

Aromatase inhibitor

58

Endometriosis therapy
Oral contraceptive

Non Steroidal Anti Inflamatory

Generally well tolerated, fewer

metabolic and hormonal side
effect than similar therapies

Proven efficacy fot treatment of

primary dismenorhea

Relieve dismenorrhea throuh

ovarian supresion and continous
progestin administration
Often simple, effective choice to
manage endometriosis through
avoidance or delay menses for
upwards of 2 years

Acceptable side effects

Reasonable cost

Ready availability

59

Endometriosis therapy
Progestins

Aromatase Inhibitor

Inhibit growth of lesion by infucing

ecidualization followed by athropy
uterine type tissue

Endometriotic implan express

aromatase and consequently
generate esterogen, maintaining
own viability

Compared to GnRH therapy, both

modalities show comparable
effectiveness
Medroxyprogesterone acetat
proven for pain suppresion both
oral and injectable
Adverse effect : weight gain, fluid
retention, depresion, breakhrough
bleeding

Inhibit local esterogen production in

endometrioticimplant

Significantly reduce pain,

compared with GnRH agonit alone.

60

Endometriosis therapy
GnRH agonist

Danazol

Produced hypogonadic state

through down regulation of pituitary
gland

Among oldest f medical therapy

for endometriosis

Efective as other therapies in relieving

pain and reduce progression
No fertility improvement
High cost, bone density loss,
intolerable hypoesterogeninc side
effect
Preoperative therapy reported to
reduce pelvic vascularity and size of
lesion, reduce intraoperative blood
loss

Inhibit midcycle FSH and LH surge

and prevent steroidogenesis in
corpus luteum

Higher incidence of adverse

effect more recent therapy
Androgenic manifestation (oily
skin, ane, weight gain, deepening
voice, hirsutism) maybe
intolerable

Amenorrhea

61

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

62

Lect. By dr. Hasto Wardoyo, Sp. OG

63

64

Menstrual period
exceeding 8 days inbleeding
duration on regular basis
Definisi heavy
menstrual
dkk

Prolonged menstrual
bleeding
Shortened menstrual
bleeding

Uncommon, define as bleeding of no longer than 2 days

Irregular menstrual bleeding

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

Absent menstrual bleeding

(amenorhea)

No bleeding in a 90 days period

Infrequent menstrual
bleeding

One or two episode in a 90 day period

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

menstrual bleeding

Less common than HMB, its important to make a distinction from HMB
given they may have different etiologies and respond to different
therapies

Light Menstrual Bleeding

Based on patient complaint, rarely related to pathology

65
term
Acute Abnormal Uterine
Bleeding

Episode of bleeding in a woman of reproductive age, who is not

pregnant, of sufficient quantity to require immediate intervention to
prevent further blood loss

Chronic Abnormal uterine

bleeding

Bleeding from the uterine corpus hat is abnormal in duration,

volume, and/or frequency and has been present for the majority of
the last 6 month

Irregular Non Menstrual

Bleeding

Irregular episode of bleeding, often light and short, occurring

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

66

Diagnosis of
primary
amenorrhea

67

Diagnosis of
secondary
amenorrhea

68

69

Functional
hypothalamic
amenorrhea:

the hypothalamicpituitary-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.

70

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

71

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.

72

73

III. Symptoms of Menopause:

1. Hot flushes - cutaneous
vasodilation
- occurs in 75% of
women
- more severe after
surgical menopause
- continue for 1 year
- 25% continue more
than 5 years
2. Urinary Symptoms
- urgency
- frequency
- nocturia

3. Psychological changes
decreased level of
central
neurotransmitters
- Depression
- Irritability
- Anxiety
- Insomia
- lose of concentration

74

4. Atrophic Changes

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

75

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.

76

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.

77

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%

78

INFERTILITAS

79

Infertility

80

Infertilitas
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.

81

Faktor Istri:
82

Infeksi

Gangguan ovulasi
Gangguan anatomi

Gangguan Ovulasi
Penuaan (usia)
POF
Polikistik Ovarii (PCOS)
Kelainan pada hipotalamushipofisis
Hiperprolaktin
Kelainan kongenital

83

84

Analisa Sperma

ANALISA SPERMA

85

Fertilitas seorang pria ditentukan

oleh jumlah dan kualitas
spermanya
Normozoospermia
Jumlah sperma 20 juta/ml
Oligozoospermia

Jumlah sperma < 20 juta/ml

A: bergerak cepat dan lurus

B: Bergerak lambat dan tidak lurus

C : bergerak ditempat
D : tidak bergerak
Teratozoospermia
Morfologi sperma normal < <30%

Astenozoospermia

oligoAstenoTeratozoospermia sindroma
OAT

Motilitas sperma a<25% atau

a+b <50%

Azoopermia 0 sperma + plasma semen

Aspermia 0 sperma + 0 plasma semen

86

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%

87

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

88

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

Therapy
Lifestyle modification: may help
89 all symptoms of PCOS
attenuate
and reduce the long-term risk of
infertility, CVD and T2DM.

Estrogen and progestin oral

contraceptive (OCP)
therapy: treatment of acne,
hirsutism and irregular menstrual
cycles.

Can be used to normalize androgen levels and attenuate the signs of

hyperandrogenism as well as to regulate menstrual cycles. This also helps to
reduce the risk of heavy and irregular menstrual bleeding associated with the loss
of normal estrogen and progestrone levels.

Anti-androgens (e.g.
spironolactone,finasteride,
flutamide): treatment of acne and
hirsutism.

Spironolactone and flutamide competitively inhibits DHT and testosterone by

binding to their receptors in peripheral cells (e.g. hair follicles).
Finasteride is a 5a-reductase inhibitor that inhibits conversion of testosterone to the
more potent DHT in peripheral cells.
Anti-androgens can be used synergistically with OCPs, which act centrally to
suppress androgen release.

First line of PCOS management.

Increased exercise, improved diet, and weight loss can help to reduce the
metabolic abnormalities associated with PCOS.
Weight loss 5-10% correct oligoanovulation & improve conception.

Metformin reduces glucose intolerance and hyperinsulinemia by increasing insulin

Metformin: treatment of glucose
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

90

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
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

hCG can be used to induce ovulation in
cases where treatment with clomiphene
citrate and metformin has been unsuccessful.

Exogenous gonadoptropins can be administered to mimic physiological

mechanisms of follicle development. FSH is given to promote growth of a
dominant follicle to a particular size, and then human chorionic
gonadotropin is used to induce ovulation.

Ovarian drilling: a laparoscopic surgical

procedure that may be used to treat
clomiphene citrate-resistant anovulation.

Ovarian drilling involves the creation of ~10 perforations in the ovary using
either cautery or laser. The ablation of some of the ovarian theca is thought
to help induce ovulation by decreasing androgen production.

IVF: used for the treatment of infertility in

women who have not responded to other
therapies to induce ovulation.

IVF involves the retrieval of oocytes from the ovaries and in vitro
combination with sperm to produce embryos. Viable embryos are then
transferred into the uterus. Women with PCOS have similar success and live
birth rates compared to women without PCOS.

91

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

92

93

GYNECOLOGIC INFECTIONS

Cervicitis
94

*Tidak mudah
membedakan servisitis
dari vaginitis
4 faktor risiko u/ prediksi
servisitis:
1.
2.
3.
4.

umur < 21 th
Lajang
CS > 1 org dlm 3 bln terakhir
CS dg pasangan baru dlm
3 bln terakhir

Servisitis menular seksual =

Servisitis mukopurulenta
Biasanya asimtomatis
Datang karena mitra
menderita IMS
Penyebab:
GO; Non-GO (C.trachomatis)

Lect. By dr. Retno Satiti, Sp.KK

CERVICITIS GO
95

Definisi: peradangan serviks o/k N.

Gonorrhoeae (diplokokus Gram negatif,
terlihat di luar dan di dalam leukosit)
Klinis: asimtomatis; keputihan warna kuning
Px:
- vulva tenang
- inspeculo: dd vagina eritem/tenang
-

ektoserviks: eritem/normal

endoserviks: eritem, edem,

ektopi, bleeding,
discar mukopurulen

Diagnosis:
Gram: pmn > 30; DGNI (+)
Kultur: Media Thayer Marthin
PCR

Lect. By dr. Retno Satiti, Sp.KK

Komplikasi Gonorhea Pada Pria

96

Infeksi
Pertama:
Uretritis

Komplikasi Lokal:

-Tysonitis
-Parauretritis
-Littritis
-Cowperitis

Komplikasi Gonorhea pada

Wanita

Infeksi
pertama:
-Uretritis
-Servisitis

Komplikasi asenden :
-Prostatitis
-Vesikulitis
-Funikulitis
-Epididimitis
-Trigonitis
Ilmu Penyakit Kulit dan Kelamin FKUI

Komplikasi Lokal:
-Parauretritis
-Bartholinitis
Komplikasi
asenden :

-Salphingitis
-PID

CERVISITIS NON GO
97

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

Lect. By dr. Retno Satiti, Sp.KK

98

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

99

TRIKOMONIASIS/Vaginitis Trikomonal
100

Definisi:

Diagnosa :

1. Discar vagina kuning kehijauan,atau

peny. Infeksi protozoa yg
disebabkan oleh T. vaginalis berbuih dan bau busuk, strawberry cervix
(+)
2. Peradangan pd dinding vagina
inkubasi: 3-28 hr
3. Lab: NaCl 0,9% : T. vaginalis motil

Lect. By dr. Retno Satiti, Sp.KK

101

102

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
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
Lab KOH 10% : pseudohifa

Lect. By dr. Retno Satiti, Sp.KK

103

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

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

104

Pengobatan sindrom duh tubuh vagina karena vaginitis

Pengobatan untuk trikomoniasis
DITAMBAH
Pengobatan untuk vaginosis bakterial .
BILA ADA INDIKASI,
Pengobatan untuk kandidiasis vaginalis

Lect. By dr. Retno Satiti, Sp.KK

105

Pengobatan sindrom duh tubuh vagina karena infeksi

serviks
Pengobatan untuk gonore tanpa komplikasi
DITAMBAH
Pengobatan untuk klamidiosis

Lect. By dr. Retno Satiti, Sp.KK

Pelvic Inflammatory Disease

106
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
Mixed infection strep, e.coli, klebsiella,
anaerobes

Risk factors
Number of sexual partners
Age
15-25 years old w/ highest frequency
Symptomatic male partner
Previous PID
African American women

Clinical symptoms
Abdominal pain
Vaginal bleeding
Vaginal discharge
Dispareunia
Disuria/ureteritis
Physical exam:
Abdominal pain
Fever
Bimanual exam with CMT
or adnexal tenderness
Cervical discharge
Diagnosis
Pregnancy test
Cervical sample for GC/
Chlamydia
Pelvic ultrasound

107

Indikasi Rawat Inap Pada pasien Penyakit Radang

Panggul

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)

108

Pedoman penanggulangan IMS, 2011

109

Indikasi Rawat Inap Pada pasien Penyakit Radang

Panggul
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

110

Sindroma Ulkus Genital

* Sifilis
* Chancroid = ulkus mole
* Herpes genitalis
* Limfogranuloma venereum
* Granuloma inguinale

Ulkus Durum vs Ulkus Mole

111

Ulkus Durum

Ulkus Mole

Terkait dengan Sifilis

Cenderung tunggal
Dasar bersih
Tempat tersering : sulcus
coronarius (pria), wanita
(labia mayora)

Chancroid / H. Ducreyi
Cenderung multiple
Dasar kotor, tampak
kemerahan hingga
nekrotik

Sifilis

112
Peny. Infeksi sistemik & kronis

Etiologi: T. pallidum (Spirochaeta,

spiral, Gram neg., Bergerak

berputar, atau maju spt
pembuka tutup botol)

Transmisi:
* Kontak seksual
* Trans-Plasenta
Patogenesis: kontak langsung dari
lesi infeksius
treponema selaput lendir
kelenjar limfe pemb.darah
seluruh tubuh

Perjalanan sifilis tanpa Tx:

1. Sifilis primer
2. Sifilis sekunder
3. Laten dini
4. Laten lanjut tertier benign,
kardiovaskuler, neurosifilis

113

Sifilis Primer
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

114

Sifilis sekunder
(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

115

Sifilis Laten

Sifilis Tersier

Sifilis Laten Dini :

stadium sifilis tanpa
gejala klinis
tes serologis reaktif <
1 th

Muncul beberapa lesi kulit, distribusi

asimetris
Sulit menemukan TP dlm lesi kurang
infeksius
Terjadi kerusakan jaringan/organ
Lesi spesifik: Gumma
- endarteritis obliterans peradangan
nekrosis
- neurosifilis, kardiosifilis

Sifilis laten lanjut sifilis

tersier
Muncul 2-20 tahun
sesudah infeksi
primer
Terjadi pada 30%
kasus sifilis

116

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

117

Sifilis kongenital dini: < 2 th

lesi kulit: terjadi segera,
vesikobulosa, erosi,
papuloskuamosa,
mukosa: hidung, pharing:
perdarahan
tulang: osteokondritis tl
panjang
anemia hemolitik
hepatosplenomegali
SSP

Sifilis
kongenital
lanjut: > 2 th

118

Sklerosis
sabre

Neurosifilis

Gangguan
saraf pusat VIII
tuli

Keratitis
interstisialis,

Bilateral gigi
hutschinson

Gigi Mulberry

Diagnosis: klinis + lab

119

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

120

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
121
Termasuk dalam STD
Pria = Wanita
Penularan : kontak kulit
langsung
Etiologi : Human Papilloma
Virus (HPV) tipe 6,11,16,18,
30, 31, dsb
Virus DNA
Keluarga Papova

Predileksi :
Pria : perineum, sekitar anus,
sulkus koronarius, glans penis,
muara uretra eksterna, korpus
penis
Wanita : vulva, introitus vagina,
porsio uteri (<<), disertai fluor
albus, pada wanita hamil
pertumbuhan lebih cepat

Vegetasi bertangkai, merahhitam, papilomatosa

Giant condyloma (Buschke)
biopsi!

Terapi
122

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
123

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

124

Kondiloma akuminata vs kondiloma lata

Kondiloma akuminata
Etiologi : HPV virus
Kondiloma lata
Etiologi : triponema
palidum (sifilis
sekunder)

125

Kista dan Abses Bartholini

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

126

Patologi
Abses Bartholini merupakan
polymikrobal infeksi
Neisseria gonorrhoeaea
yang paling umum
Jika tidak inflamasi
asimtomatik
Simtom: nyeri vulva,
dispareunia, kesulitan
berjalan/olah raga

Isolates from Bartholin's Gland

Abscesses
Aerobic organisms
Neisseria gonorrhoeae
Staphylococcus aureus
Streptococcus faecalis
Escherichia coli
Pseudomonas aeruginos
Chlamydia trachomatis
Anaerobic organisms
Bacteroides fragilis
Clostridium perfringens
Peptostreptococcus
species
Fusobacterium species

127

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

128

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

130

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

131

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

Jika menahun terbentuk kista

132

INFEKSI KONGENITAL

133

Teratogen: TORCH

134

135

136

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

137

138

139

140

Amniocentesis should not

be offered at less than 18
weeks gestation
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

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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

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Rubella

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Risk of congenital defects:

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

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CMV

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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)

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Treatment
Once the diagnosis of congenital CMV infection
is confirmed, one option is pregnancy
termination.
A second proposed option: treatment of the
mother with antiviral agents (ganciclovir,
foscarnet, and cidofovir.)
These drugs are of moderate effectiveness in treating
CMV infection in the adult

Source;
http://www.peri
natology.com/e
xposures/Infecti
on/CMV/Cytom
egalovirus.htm#
DXMOTHER

No proven value in preventing or treating congenital

CMV infection.

The most promising therapy for congenital CMV

infection appears to be hyperimmune globulin.

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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

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Zooster Lesion

Hepatic calcification

Radioulnar hipoplasia and

missing hand

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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

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Gynecology is done.... For now!

Alhamdulillah