PERSAMAAN PERSEPSI

SKENARIO II

BLOK SISTEM REPRODUKSI I

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM MALANG
Semester Ganjil T.A 2013/2014
 Tiga tahun menikah tapi tak kunjung hamil
Seorang pasangan usia subur (wanita 31 tahun, pria 32 tahun) datang ke tempat
praktek dokter dengan keluhan tidak kunjung hamil setelah tiga tahun menikah.
Pasangan tersebut tidak menggunakan alat kontrasepsi sejak menikah.
Apa yang tejadi pada pasangan tersebut?
Pemeriksaan apa saja yang diperlukan untuk menegakkan diagnosa pada gangguan
tersebut?

Langkah Pertama:Identifikasi kata kunci

- pasangan usia subur
- tidak kunjung hamil setelah tiga tahun menikah padahal tidak menggunakan alat
kontrasepsi

Langkah kedua:Daftar masalah

1. Apa saja kemungkinan differential diagnosa pada wanita tersebut (tinjauan pada
sistem reproduksi wanita)
2. Apa saja anamnesa, pemeriksaan fisik dan pemeriksaan penunjang yang diperlukan
untuk menegakkan diagnosa pada pasien tersebut?
3. Apa saja penatalaksanaan farmakoterapi dan nonfarmakoterapi beserta pencegahan
tahap primer, sekunder dan tersier pada pasien tersebut?
4. Apa tinjauan kasus ini dari aspek bioetik, Keislaman, hukum dan hak asasi manusia
dalam kajian kehamilan melalui IVF (in vitro fertilization)?

Langkah ketiga:Brainstorming
Mahasiswa mencari literatur mengenai:
1. Fisiologi kehamilan pada wanita perubahan saat hamil dan tanda-kehamilan baik
aspek klinis maupun psikologi.
2. Fisiologi buah kehamilan, termasuk proses fertilisasi, nidasi, implantasi dan
beberapa gangguannya (infertilitas, gangguan pada fetus)
3. Anamnesis dan pemeriksaan klinik dan penunjang untuk menegakkan diagnosis
kehamilan dan gangguannya (trisemester pertama) beserta penatalaksanaan
komprehensif (termasuk aspek primary, secondary dan tertiary prevention).
4. Tinjauan Patologi Anatomi, Mikrobiologi dan Parasitologi gangguan kehamilan
trisemester pertama
5. Aspek Bioetik, keislaman, hukum dan hak azasi manusia pada masalah gangguan
kehamilan (IVF/ in vitro fertilization), pengguguran janin yang teridentifikasi penyakit)

Learning Objectives
 1. Mekanisme kehamilan (fertilisasi, nidasi, implantasi, plasentasi dan organogenesis)
dan gangguannya (infertilitas, gangguan pada fetus)
2. Anatomi dan Fisiologi pada wanita hamil
3. Penegakkan diagnosis dan differential diagnosis gangguan kehamilan awal (early
pregnancy problems) (kriteria diagnosis berbagai jenis gangguan kehamilan
berdasarkan etiopatogenesis)
4. Penatalaksanaan komprehensif pada gangguan kehamilan termasuk aspek
prevention (primary, secondary dan tertiary)
5. Aspek bioetik dan keislaman pada kasus IVF maupun abortus medicinalis
Mengacu pada tema blok maka Learning objectives berdasarkan topik
bahasan OBG yakni:
1. Basic science (maternal physiology, the placenta and fetal membranes, normal fetal
growth)
2. Normal pregnancy (pre-conception counselling and ANC)
3. Early pregnancy problems (spontaneous misscarriage, recurrent misscarriage,
Gestational trophoblasts tumours, ectopic pregnancy, induced abortion)
4. Inability to conceive (infertility)
Mapping Konsep Development of Human Embryo

Gametogenesis

Fertilization

1. Begins ~ 12 hours post-fertilization

2. Zygote divides into 2 cells (mitosis)
3. 46 chromosomes in zygote = 46 chromosomes in both
Cleavage daughter cells
4. 2 cell into 4 cell stage (24 36 hours)
5. 4 cell into 8 cell stage (36 72 hours)
6. 16 cell stage -- Morula

Morula ~ 16 cell stage

Develops ~ 72 hours (3 days)
from fertilization
Morula enters the uterus ~ after 3
Morula days in oviduct

72 hours post-fertilization
entering uterus
 Morula, once entering the Inner cell mass
uterine cavity, floats freely
Morula begins to accumulate
fluid and forms a cavity trophoblast
Blastocyst between its cells
Once cavity appears, it is now
called a blastocyst
Blastocyst has fluid-filled inner
cavity
Evolves from morula on day 5

Week 2
Implantation continues
Erosion of maternal blood vessels
Implantation Complete emersion into endometrium of uterus

Week 3-4 Development of CV and nervous systems

Embryo will develop all

Week 5-8 structures that an adult has by the
end of week 8

Fetal period

9-12

13-16 17-20

21-38

Embryonic period is weeks 1-8

Fetal period begins on week 9 and goes
until birth at 38 weeks.
Embryonic period is characterized by
development of structures (organs).
Fetal period is characterized by growth of
those structures.
Critical period in Human Development
 Mapping konsep perubahan fisiologi pada Kehamilan

Kehamilan

Rehearse of ovulatory luteal phase

Prostaglandin me, estrogen me

Adaptasi sistemik

Next page

Body water me Hematology Cardiovascular Respiratory system

chronic volume RAASRBC me Upper

cardiac output me
overload RBC mass me 30-50%
Hyperemic mucosa of nasopharynx
Polyposis of nose and sinuses
Chronic cold
Heart rate me
Peripheral leucocytes me Peripheral vascular resistance me
plasma volume me mechanicalConfiguration of thoracic
Before 24 wArterial blood pressure cage>>
platelets me
After 24 w gradually
Hemodilution Pulmonary
TV DYSPNEA
Coagulation factors: Venous compliance ERV Likely due to various
I, VII, X: me Minute ventilation factors
II, V, XII:tetap O2 consumption - reduced PaCO2
PACO2 levels
XI, XIII:me Left ventricular dimensions and
volume, but parameters of LVF re RR unchanged - awareness of
the same as in the non-pregnant increased tidal
state volume of pregnancy
 Renal system Gastrointestinal System Endocrine System Liver Skin

Anatomy Apetite Pancreas Spider angiomata (face,

Kidney enlargement Increase early 1st upper chest, and arm)
Ureteral and renal pelvis dilatation by 8 Increase intake 200 kcal by end 1st Striae gravidarum
weeks Sense of taste may be blunted Increased eccrine sweating
Right>left and sebum excretion
Pica
Renal haemodynamic Mouth
Effective renal plasma flow (ERPF) and
Gums edematous and softMay bleed after brushing
GFR increase
Epulis gravidarum
Metabolites
Decline ureum and creatinin Stomach
Salt and water Decreased tone and motility
Plasma osmolality begins to decline Reduced tone of the gastroesophageal junction sphincter
Sodium loss Lower incidence of PUD due to decreased gastric acid
Renal tubular reabsorption of Na+ secretion
Nutrient Excretion Small bowel
Increase in glucose excretion Reduced motility of small bowel
Increase in amino acid excretion Enhanced iron absorption
Increased urinary loss of folate and Colon
vitamin B12 Constipation
Portal venous pressure is increasedesophageal varices,
haemorrhoids
Nausea &vomitting Relaxation of smooth muscle of
stomach, elevated levels of steroids and hCG
 Perubahan Sistem Genetalia pada masa awal kehamilan

Perubahan pada genitalia eksterna Perubahan pada genitalia interna Perubahan pada uterus

Pembuluh darah alat genitalia interna Bentuk rahim.

Pada vulva
Hormon Estrogen dan Progesteron
mempersiapkanVagina agak mengalami
distensi selama persalinandengan cara
memproduksi mukosa vagina
Meningkatkan vaskularisasi menghasilkan
warna violet kebiruan dari mukosa vagina dan
servik Pada awal minggu ke 8
akan membesar,hal ini karena
Rahim berkembang untuk menyediakan ruangan
oksigenisasi dan nutrisi pada alat
genitalia interna ini meningkat
Pada vagina pembuluh darah dinding
vagina bertambah dan warna selaput
dinding vagina membiru ( tanda
cadwiks ),kekenyalan vagina bertambah
yang berarti keregangan vagina
bertambah, buat persiapan persalinan.
yang sehat untuk janin tumbuh
Endometrium
Berubah nama menjadi desidua pada bagian
fundus dan atas tebal (tempat implantasi yang
normal) banyak aliran darah, banyak zat
glikogen yang berguna untuk makanan bagi
janin
Desidua ada 3 lapis (basalis, vera dan
capcularis)

Perubahan pada Payudara Myometrium Perimetrium Perubahan ovarium

Buah dada biasanya membesar
karna hipertropi alveoli
Meningkatnya progesteron dan
estrogen berakibat:
Rasa penuh dan padat
Sensitifitas yang tinggi
Geli dan rasa berat
Areola hiperpigmentasi .
Hiperplasia karena pengaruh estrogen
Selama pada 20 mg pertama berkembang
dan meregang untuk menampung isinya
karena pengaruh progesteron pada otot
lunak
Pd kehamilan 8 mg adanya kontraksi
braxton his yang berlanjut sampai pada
saat persalinan
Lapisan sebelah luar tidak seluruhnya
menutupi rahim
Posisinya dibelokkan dimuka kandung kemih
membentuk kantong uterovesikal
Dibelakang anus untuk membentuk kantong
douglas
Susunan ini memberikan tempat pada rahim
untuk berkembang bebas tanpa batas
Pada awal kehamilan masih ada corpus luteum
grafiditas dan setelah plasenta terbentuk
lengkap pada kehamilan 16 minggu corpus
luteum berdegenerasi (corpus albicans )
selanjutnya hormon progesteron dan estrogen
diproduksi oleh Plasenta
 Concept Mapping of Issues in Early Pregnancy

Early pregnancy

Location Viability

Intrauterine Ectopic 1. Normal

2. Miscarriage (there are different types!)
3. Molar pregnancy (mola hidatidosa) A viable pregnancy is
intrauterine pregnancy
Evaluation: has cardiac motion-sho
1. Dating of pregnancy Types of nonviable intrauterine pregnancies see by 7-8 weeks
2. USG Anembryonic (blighted ovum) No yolk sac or fetal
pole, Mean gestational sac diameter of 30 mm
Threatened abortion First trimester bleeding, Fetal
95% are in the fallopian tube (70%
pole with a heartbeat, If there is a heartbeat there is less
ampulla, 12% isthmus, 11% fimbria,
than 10% chance of miscarriage
2% interstitial/cornual)
Inevitable abortion Deformation and/or descent of
Ovarian occurs about 3% of the time,
gestational sac with a dilated cervix
abdominal 1% of the time and cervical
Complete abortion Products of conception
<1% of the time
completely expelled
Missed abortionIntrauterine pregnancy with an
embryo, but no cardiac activity by 8 weeks gestation

5 weeks Fetal pole by 6-7 weeks

 Mapping Kasus
Pre Marital counselling

Faktor resiko: Pasangan Usia Subur (PUS) Pre Conception counselling

STD (sexually transmitted
disease):C trachomatis Causes:
Environmental factors 3 tahun belum punya anak Male factors,
Life style Tanpa alat kontrasepsi disorders of ovulation,
tubal factors,
endometriosis and
Definisi Infertilitas unexplained infertility

History Examination

Infertility - Duration of infertility General - Height, weight, BMI

- Length and type of contraceptive use - Fat and hair distribution
- Fertility in previous relationships as well (Ferriman Gallwey
as in present liaison
score to quantify
- Previous investigation and treatment
hirsutism)
- Fertility subsequently, if known, in any
former partners - Note presence or
- Previous fertility investigations and absence of acne
treatment - and galactorrhoea
Medical - Menstrual history: menarche, cyclicity, Abdominal Check for abdominal
pain, bouts of amenorrhoea, masses or tenderness
menorrhagia, intermenstrual bleeding Pelvis - Assess state of hymen
- Number of previous pregnancies - Assess normality of
including abortions, miscarriages and
clitoris and labia
ectopic pregnancies
- Any associated sepsis
- Assess vagina, looking
- Time to initiate previous pregnancies for such
- Drug history and present, e.g. agents - problems as infection
which cause hyperprolactinaemia, past or vaginal
cytotoxic treatment or radiotherapy - septa, endometriotic
Surgical - Previous abdominal or pelvic surgery, in deposits
particular gynaecological procedures - Check for presence of
Occupational - Work patterns including separation cervical polyps
Sexual from partner - Assess accessibility of
- Coital frequency and timing, including
the cervix for
knowledge of the fertile period
- Dyspareunia - insemination
- Postcoital bleeding - Record uterine size,
position, mobility
- and tenderness
- Perform cervical
Pemeriksaan lab dan penunjang smear if appropriate

Penatalaksanaan sesuai penyebab

Referensi

Hamilton, M. 2012. OBG Dewhursts texbook of Obstetrics and Gynaecology. Edited by

Edmonds, K.D. Eight edition. Section 1. Part 1-5. pg 5-230. Willey Blackwell. UK

Hamilton, M. 2012. OBG Dewhursts texbook of Obstetrics and Gynaecology. Edited by

Edmonds, K.D. Eight edition. Inability to conceive. Part 11. Chapter 45 pg 565-577. Willey
Blackwell. UK