Pemicu 1

Blok REPRODUKSI
JESSICA GRACIA
405140041
L.I
• 1. MM fisiologis pada kehamilan :
• Perubahan hormonal selama kehamilan (Siklus mens)
• Perubahan payudara
• Proses kehamilan (uterus, perubahan janin)
• 2. MM histologi sistem reproduksi wanita dan mammae
• 3. MM anatomi sistem reproduksi wanita dan mammae
• 4. MM pemeriksaan pada ibu hamil dan screening sebelum kehamilan:
• Pemeriksaan obstetri
• Pemeriksaan penunjang
• 5. MM pemeriksaan kehamilan (ANC), diagnosa kehamilan
• 6. MM tatalaksana farmako dan non farmako ibu hamil
• 7. MM kelainan payudara:
• Benjolan
• Nipple  discharge, cracked nipple, mastitis, inverted nipple
LI 1 MM fisiologis pada kehamilan
• REPRODUCTIVE TRACT:
• Uterus
• Nonpregnant woman  the uterus weighs 70 g and is almost solid, except for a cavity of 10 mL or less
• Pregnancy  the uterus is transformed into a relatively thin-walled muscular organ of sufficient capacity to
accommodate the fetus, placenta, and amnionic fluid.
• The total volume of the contents at term averages approximately 5 L but may be 20 L or more.
• By the end of pregnancy, the uterus has achieved a capacity that is 500 to 1000 times greater than in the non- pregnant
state.  by term, the organ weighs nearly 1100 g.
• Uterine enlargement :
• involves stretching and marked hypertrophy of muscle cells, whereas the production of new myocytes is limited.
• Accompanying the increase in myocyte size is an accumulation of fibrous tissue,
• the external muscle layer, together with a considerable increase in elastic tissue content  adds strength to the uterine wall.
• Although the walls of the corpus become considerably thicker during the first few months of pregnancy, they
then begin to thin gradually.
• By term, the myometrium is only 1 to 2 cm thick. In these later months, the uterus is changed into a
muscular sac with thin, soft, readily indentable walls through which the fetus usually can be palpated.
• Uteroplacental Blood Flow
• The delivery of most substances essential for fetal and placental growth, metabolism, and waste removal is
dependent on adequate perfusion of the placental intervillous space
• Placental perfusion is dependent on total uterine blood flow. Estimates range from 450 to 650 mL/min near
term. These estimates are remarkably similar to those obtained with invasive methods—500 to 750 mL/min
(blood flow in the entire circulation of a nonpregnant woman is approximately 5000 mL/min)
• Uterine veins also significantly adapt during pregnancy. Specifically, their remodeling includes reduced elastin
content and adrenergic nerve density  increased venous caliber and distensibility (changes are necessary to
accommodate the massively increased uteroplacental blood flow)
• Uteroplacental Blood Flow Regulation
• Maternal-placental blood flow progressively increases during gestation principally by means of vasodilation.
• Uterine artery diameter doubled by 20 weeks, slight diameter increases in the uterine artery produces a
tremendous blood flow capacity increase
• the vessels that supply the uterine corpus widen and elongate while preserving contractile function. In
contrast, the spiral arteries, which directly supply the placenta, widen but completely lose contractility.
• This presumably results from endovascular trophoblast invasion that destroys the intramural muscular
elements
• The vasodilation during pregnancy is at least in part the consequence of estrogen stimulation.
• 17β-estradiol has been shown to promote uterine artery vasodilation and reduce uterine vascular
resistance
• estradiol and progesterone, as well as relaxin, contribute to the downstream fall in vascular resistance in
women with advancing gestational age.
 • Uterine hypertrophy early in pregnancy probably is stimulated by the action of estrogen and perhaps progesterone.
• Approximately 12 weeks, the uterine size increase is related to pressure exerted by the expanding products of
conception.
• Uterine enlargement is most marked in the fundus.
• The position of the placenta also influences the extent of uterine hypertrophy. The portion of the uterus surrounding
the placental site enlarges more rapidly than does the rest.
• Myocyte Arrangement
• The uterine musculature during pregnancy is arranged in three strata:
• The first is an outer hoodlike layer, which arches over the fundus and extends into the various ligaments.
• The middle layer is composed of a dense network of muscle fibers perforated in all directions by blood vessels.
• Last is an internal layer, with sphincter-like fibers around the fallopian tube orifices and internal cervical os.
• Uterine Size, Shape, and Position
• Pregnancy advances, the corpus and fundus become more globular and almost spherical by 12 weeks’ gestation.
• By the end of 12 weeks, the uterus has become too large to remain entirely within the pelvis. As the uterus enlarges, it
contacts the anterior abdominal wall, displaces the intestines laterally and superiorly, and ultimately reaches almost to the
liver.
• Uterine Contractility
• Beginning in early pregnancy, the uterus undergoes irregular contractions that are normally painless.
• During the second trimester, these contractions may be detected by bimanual examination. Such contractions appear
unpredictably and sporadically and are usually nonrhythmic. Their intensity varies between approximately 5 and 25 mm
Hg
• Until the last several weeks of pregnancy, these Braxton Hicks contractions are infrequent, but their number increases
during the last week or two. At this time, the uterus may contract as often as every 10 to 20 minutes and with some
degree of rhythmicity.
• Late in pregnancy, these contractions may cause some discomfort and account for so-called false labor (Chap. 21, p. 409).
• CERVIX
• As early as 1 month after conception, the cervix begins to undergo pronounced
softening and cyanosis. These changes result from increased vascularity and edema
of the entire cervix, together with hypertrophy and hyperplasia of the cervical glands
• Ovaries
• Ovulation ceases during pregnancy, and maturation of new follicles is suspended.
The single corpus luteum found in preg- nant women functions maximally during the
first 6 to 7 weeks of pregnancy—4 to 5 weeks postovulation
• Vagina and Perineum
• During pregnancy, increased vascularity and hyperemia develop in the skin and
muscles of the perineum and vulva, with softening of the underlying abundant
connective tissue.
• Also, Bartholin gland duct cysts of 1-cm size are common
• Increased vascularity prominently affects the vagina and results in the violet color
characteristic of Chadwick sign.
BREAST
• In the early weeks of pregnancy:
• women often experience breast tenderness and paresthesias.
• After the second month:
• the breasts increase in size, and delicate veins become visible just beneath the skin.
• The nipples become considerably larger, more deeply pigmented, and more erectile.
• After the first few months, a thick, yellowish fluid—colostrum—can often
be expressed from the nipples by gentle massage.
• During the same months, the areolae become broader and more deeply pigmented.
• Scattered through the areolae are a number of small elevations, the glands of
Montgomery, which are hypertrophic sebaceous glands. If the increase in breast size
is extensive, striations similar to those observed in the abdomen may develop.
• For most normal pregnancies, breast size and volume of milk production do
not correlate.
SKIN
• Abdominal Wall
• Beginning after midpregnancy, reddish, slightly depressed streaks commonly develop in the
abdominal skin and sometimes in the skin over the breasts and thighs  striae gravidarum or
stretch marks.
• Hyperpigmentation
• up to 90 percent of women.
• It is usually more accentuated in those with a darker complexion
• The midline of the anterior abdominal wall skin— linea alba—takes on dark brown-black
pigmentation to form the linea nigra.
• Occasionally, irregular brownish patches of varying size appear on the face and neck, giving rise to
chloasma or melasma gravidarum—the so-called mask of pregnancy.
• Pigmentation of the areolae and genital skin may also be accentuated. These pigmentary changes
usually disappear, or at least regress considerably, after delivery.
• Oral contraceptives may cause similar pigmentation
• However, levels of melanocyte-stimulating hormone, a polypeptide similar to corticotropin, are
elevated remarkably throughout pregnancy. Estrogen and progesterone also are reported to have
melanocyte-stimulating effects.
• Vascular Changes
• Angiomas, called vascular spiders, develop in approximately two thirds of
white women and approximately 10 percent of black women.
• Particularly common on the face, neck, upper chest, and arms, these are
minute, red skin elevations, with radicles branching out from a central lesion.
• The condition is often designated as nevus, angioma, or telangiectasis.
• Palmar erythema is encountered during pregnancy in approximately two
thirds of white women and one third of black women, disappear in most
women shortly after pregnancy. They are most likely the consequence of
hyperestrogenemia.
• increased cutaneous blood flow in pregnancy serves to dissipate excess heat
generated by increased metabolism.
METABOLIC CHANGES:
• Weight Gain
• attributable to the uterus and its contents, the breasts, and increases in blood volume and extravascular
extracellular fluid.
• increase accumulation of cellular water, fat, and protein—so- called maternal reserves. average weight gain
during pregnancy is approximately 12.5 kg or 27.5 lb
• Water Metabolism
• Increased water retention is a normal physiological alteration of pregnancy  mediated, at least in part, by a
fall in plasma osmolality of approximately 10 mOsm/kg induced by a resetting of osmotic thresholds for thirst
and vasopressin secretion
• At term, the water content of the fetus, placenta, and amnionic fluid approximates 3.5 L. Another 3.0 L
accumulates from increases in maternal blood volume and in the size of the uterus and breasts.
• Clearly demonstrable pitting edema of the ankles and legs is seen in most pregnant women, especially at the
end of the day  caused by increased venous pressure below the level of the uterus as a consequence of
partial vena cava occlusion.
• A decrease in interstitial colloid osmotic pressure induced by normal pregnancy also favors edema late
• Protein Metabolism
• The products of conception, the uterus, and maternal blood are relatively rich in protein rather than fat or
carbohydrate
• Amino acid concentrations are higher in the fetal than in the maternal compartment largely regulated by the
placenta.
• The placenta not only concentrates amino acids into the fetal circulation, but also is involved in protein
synthesis, oxidation, and transamination of some nonessential amino acids
• Carbohydrate Metabolism
• Normal pregnancy is characterized by mild
fasting hypoglycemia, postprandial
hyperglycemia, and hyperinsulinemia
• after an oral glucose meal, gravid women
demonstrate prolonged hyperglycemia
and hyperinsulinemia as well as a greater
suppression of glucagon
• Instead, this response is consistent with a
pregnancy-induced state of peripheral
insulin resistance, the purpose of which is
likely to ensure a sustained postprandial
supply of glucose to the fetus.
• Indeed, insulin sensitivity in late normal
pregnancy is 45 to 70 percent lower than
that of nonpregnant women
• Fat Metabolism
• The concentrations of lipids, lipoproteins, and apolipoproteins in plasma increase
appreciably during pregnancy
• Increased insulin resistance and estrogen stimulation during pregnancy are responsible for the
maternal hyperlipidemia.
• increased lipid synthesis and food intake contribute to maternal fat accumulation during the first
two trimesters.
• In the third trimester, however, fat storage declines or ceases.  enhanced lipolytic activity, and
decreased lipoprotein lipase activity reduces circulating triglyceride uptake into adipose tissue.
• This transition to a catabolic state favors maternal use of lipids as an energy source and spares glucose and
amino acids for the fetus.
• LDL-C (267 ± 30 mg/dL);
• HDL-C (136 ± 33 mg/dL);
• triglyceride (245 ± 73 mg/dL)
• Leptin >  regulation of body fat and energy expenditure
• Ghreline >  fetal growth and cell proliferation; regulates growth hormone secretion
• Electrolyte & mineral metabolism
• 1000 mEq of sodium + 300 mEq of potassium  retained
• Enhanced tubular activity  GFR >, but excretion unchanged
• Total serum calcium levels <, because albumin <, ionized calcium 
unchanged
•  fetal skeleton  doubling of maternal intestinal calcium absorption + dietary
• Serum magnesium levels <
• Serum phosphate levels are within the nonpregnant range
• increased requirement for iron
• iodine requirements increase during normal pregnancy
HEMATOLOGIC CHANGES
• Blood volume
• > 40-45% after 32-34 weeks
Purposes
-. metabolic demands of the
enlarged uterus +
hypertrophied vascular
-. provide an abundance of
nutrients and elements 
growing placenta and fetus
-. protect the mother and in
turn the fetus
-. safeguard the mother
against the adverse effects
of blood loss associated with
parturition
• Because of great plasma augmentation
• hemoglobin concentration and hematocrit decrease slightly during pregnancy  whole blood viscosity
decreases
• Hemoglobin concentration at term averages 12.5 g/dL, and in approximately 5 percent of women, it is below
11.0 g/dL
• hemoglobin concentra tion below 11.0 g/dL, especially late in pregnancy,  abnormal and usually due to iron
deficiency rather than pregnancy hypervolemia.
• Iron Metabolism
• normal adult women : 2.0 to 2.5 g, or approximately half that found normally in men.
• iron stores of normal young women are only approximately 300 mg
• Iron requirement
• 1000 mg of iron required for normal pregnancy,
• about 300 mg are actively transferred to the fetus and placenta, and another 200 mg are lost through various
normal excretion routes, primarily the gastrointestinal tract.
• The average increase in the total circulating erythrocyte volume—about 450 mL—requires another 500 mg.
Recall that each 1 mL of erythrocytes contains 1.1 mg of iron
• iron requirement becomes large after midpregnancy and averages 6 to 7 mg/day
• without supplemental iron, the optimal increase in maternal erythrocyte volume will not develop
•
• Immunological function
• early pregnancy is pro- inflammatory: the blastocyst must break through the uterine cavity
epithelial lining to invade endometrial tissue during implantation and placentation
• midpregnancy is antiinflam- matory: During this period of rapid fetal growth and
development, the predominant immunological feature is induction of an antiinflammatory
state
• parturition is characterized by an influx of immune cells into the myometrium to promote
recrudescence of an inflammatory process.
• suppression of a variety of humoral and cell-mediated immunological functions to
accommodate the "foreign" semiallogeneic fetal graft
• suppression of Th1 & Tc1 cells  Il-2, IFN-gamma, TNF-B <
• Leukocytes
• chemotaxis and adherence functions <  T II
• leukocyte count  5000 to 12,000/microL
• Inflammatory markers
• Many tests performed to diagnose inflammation cannot be used reliably during pregnancy
• leukocyte alkaline phosphatase  >
• C-reactive protein  >
• erythrocyte sedimentation rate (ESR)  >
• Coagulation and Fibrinolysis
• During normal pregnancy, both coagulation and fibrinolysis are augmented but remain balanced to
maintain hemostasis
• Platelets
• average platelet count was decreased slightly during pregnancy to 213,000/μL compared with
250,000/μL in nonpregnant control women.
• Thrombocytopenia defined as below the 2.5th percentile corresponded to a platelet count of
116,000/μL.  are partially due to hemodilutional effects.
• Spleen
enlarges by up to 50 percent compared with that in the first trimester
 Cardiovascular system
• Hemodynamic changes
-. systemic vascular resistance < +
heart rate >  cardiac output > (5
weeks)

-. Ventricular performance
influenced by both the decrease in
systemic vascular resistance and
changes in pulsatile arterial flow

-. The resting pulse rate increases

approximately 10 beats/min during
pregnancy. Between weeks 10 and
20, plasma volume expansion begins,
and preload is increased.
• Heart -. Elevating of diapraghm 
displaced to the left and
upward; rotated somewhat on
its long axis

-. benign pericardial effusion

-. Altered cardiac sound (systolic

murmur  90%
• Cardiac output
-. Late pregnancy  large
pregnant uterus compress
venous return from the lower
body / compress aorta 
cardiac filling <  cardiac
output < (supine position)

-. Standing position  normal

• Renin, angiotensin II, plasma volume
• RAA axis >
• Progesteron >  refractoriness to angiotensin II >

• Cardiac natriuretic peptide

• ANP & BNP  normal range; > when severe preeclampsia

• Prostaglandin
• > prostaglandin  control of vascular tone, blood pressure, and sodium balance; natriuretic

• Endotelin
• Endothelin-1 is a potent vasoconstrictor produced in endo- thelial and vascular smooth muscle
cells and regulates local vasomotor tone
• Vascular sensitivity to endothelin-1 is not altered during normal pregnancy

• Nitric oxide
• important implications for modifying vascular resistance during pregnancy
Respiratory tract
• Pulmonary function
• Acid-base equilibrium
• Tidal volume >  PCO2 <  dyspnea
• Progesterone  lowers the threshold and increases the sensitivity of the
chemoreflex response to CO2
• Compensation  plasma bicarbonate levels decrease from 26 to
approximately 22 mmol/L
• PCO2 <  carbon dioxide (waste) transfer from the fetus to the mother while
also facilitating oxygen release to the fetus
URINARY SYSTEM
• Kidney
• Kidney size increases approx- imately 1.5 cm
• Both the glomerular filtration rate (GFR) and renal plasma flow increase early in pregnancy.
• result from : hypervolemia-induced hemodilution lowers the protein concentration and oncotic pressure of plasma entering
the glomerular microcirculation.
• Second, renal plasma flow increases by approximately 80 percent before the end of the first trimester.
• Primarily as a consequence of this elevated GFR, approximately 60 percent of women report urinary frequency during
pregnancy
• Urinalysis
• Glucosuria during pregnancy may not be abnormal. increase in GFR, together with impaired tubular reabsorptive capacity for
filtered glucose,  glucosuria
• Hematuria is often the result of contamination during collection. If not, it most often suggests urinary tract disease
• Proteinuria is typically defined in nonpregnant patients as a protein excretion rate of more than 150 mg/day. Because of
hyperfiltration and possible reduction of tubular reabsorption,
• significant proteinuria during pregnancy is usually defined as a protein excretion rate of at least 300 mg/day
• Ureters
• uterus rises completely out of the pelvis  rests upon the ureters  displacing and compressing them at the pelvic brim 
ureteral dilatation (effects of progesteron)
• Bladder
• increased uterine size  hyperplasia of the bladder's muscle + elevates the bladder trigone and causes thickening of its
posterior
GASTROINTESTINAL TRACT
• stomach and intestines are displaced by the enlarging uterus
• Gastric emptying time  unchanged
• Pyrosis (heartburn)
• altered position of the stomach  esophageal sphincter tone <
• The gums may become hyperemic and softened  focal, highly vascular swelling of the gums
(epulis of pregnancy)
• Mild trauma  bleeding
• Hemorrhoids
• Liver
• no distinct morphological changes
• Leucine aminopeptidase (proteolytic liver enzyme)  > in liver disease; > in pregnant woman
• Gallblader
• contractility of the gallbladder < because Progesterone potentially impairs gallbladder contraction
by inhibiting cholecystokinin-mediated smooth muscle stimulation, which is the primary regulator
of gallbladder contraction.
•  stasis  cholesterol gallstones (multiparous woman)
ENDOCRINE SYSTEM
• Pituitary gland
• enlarges by approximately 135 percent  compress the optic chiasma 
reduce visual fields
• Growth hormone
• > slowly from approximately 3.5 ng/mL at 10 weeks to plateau after 28 weeks at
approximately 14 ng/mL
• 17 weeks  placenta produces GH (peak: 14 to 15 weeks )  influence on fetal growth
& preeclampsia
• Prolactin
• > markedly  10x
• decrease after delivery even in women who are breast feeding
• Parathyroid glands
• PTH & calcium
• < during the first trimester and then increase progressively throughout the remainder of
pregnancy
• Estrogens  block the action of parathyroid hormone on bone resorption  another
mechanism to increase parathyroid hormone during pregnancy  physiological
hyperparathyroidism ( supply fetus)
• Calcitonin & calcium
• > calcitonin levels
• Vit D & calcium
• > increased during normal pregnancy
• Adrenal glands
• Cortisol -. serum concentration >
-. metabolic clearance
rate of cortisol <

-. Progesterone > 
cortisol > to maintain
homeostasis (normal
increase plasma volume
during late pregnancy)
• Aldosterone
• > (15 weeks); T III  1 mg/day
•  affords protection against the natriuretic effect of progesterone and atrial natriuretic
peptide
• Deoxycorticosterone
• > progressively during pregnancy (1500 pg/mL by term / 15x)
• Dehydroepiandrosterone Sulfate
• < during normal pregnancy
• e/  increased metabolic clearance through extensive maternal hepatic 16-
hydroxylation and placental conversion to estrogen
• Androstenedione and Testosterone
• > during pregnancy
• Converted to estradiol in placenta
Musculoskeletal system
• Progressive lordosis
• sacroiliac, sacrococcygeal, and pubic joints mobility >
•  alteration of maternal posture and in turn may cause discomfort in the
lower back
• The bones and ligaments of the pelvis undergo remarkable
adaptation during pregnancy
Eyes
• < intraocular pressure
• < corneal sensitivity; > corneal thickness (edema)
• Brownish-red opacities on the posterior surface of the cornea
(Krukenberg spindles)
CNS & sleep
• problems with attention, concentration, and memory
• blood flow in the middle and posterior cerebral arteries <<  from
147 and 56 mL/min

• difficulty going to sleep, frequent awakenings, fewer hours of night

sleep, and reduced sleep efficiency (12weeks – 2 mo post partum) 
decreased significantly in pregnant women rather than post partum
The Ovarian–Endometrial Cycle
• The Ovarian Cycle
• Follicular or Preovulatory Ovarian Phase
• Ovulation
• Luteal or Postovulatory Ovarian Phase
• The Endometrial Cycle
• Proliferative or Preovulatory Endometrial Phase
• Secretory or Postovulatory Endometrial Phase
• Menstruation
Perkembangan Janin
The Decidua
Implantation and Early Trophoblast Formation
• Fertilization
Implantation and Early Trophoblast Formation
• Blastocyst Implantation
• apposition
• adhesion
• invasion
• Early Trophoblast
Invasion
Implantation and Early Trophoblast Formation
LI 2. MM histologi sistem reproduksi wanita dan
mammae
Ovaries
• almond-shaped bodies (3 cm long, 1.5 cm wide, and 1 cm thick)
• Ovarian follicles
• Primordial ovarian follicles
• single layer of the flattened
follicular cells
• found in the superficial areas of
the cortex
• Primary follicles
• simple cuboidal
epithelium
• zona pellucida
develops
• Secondary/antral follicles
• increasing oocyte size and
numbers of granulosa cells
• secrete follicular fluid (or liquor
folliculi)
• hyaluronate,
• growth factors,
• plasminogen,
• fibrinogen,
• the anticoagulant heparan sulfate
proteoglycans
• steroids (progesterone,
androstenedione, and estrogens)
• Wall of the antral follicles
• Mature/graafian follicle
• diameter of 20-30 mm
• large enough to protrude from the
surface of the ovary
• antrum increases greatly in size by
accumulating follicular fluid
• oocyte adheres to the wall of the
follicle through the cumulus
oophorus of granulosa cells
• Follicular atresia
Ovulation
• Large mature primary oocyte  escapes from the ovary  caught by
the dilated end of the uterine tube
• large mature follicle bulging against the tunica albuginea develops a
whitish or translucent ischemic area  stigma
• Stigma  granulosa cells and theca interna begin to secret
progesterone as well as estrogen.
• Estrogen  surge of LH secreted by the anterior pituitary gland 
hyaluronate and prostaglandin synthesis and overall fluid production
• Progesterone, LH and FSH  activate proteolytic enzyme (plasmin
and collagenases)  weaken the granulosa layer & tunica albuginea
• ballooning and then rupture of the ovarian surface at the stigma
• contraction of theca externa smooth muscle triggered by
prostaglandins from the follicular fluid  expel the oocyte and
corona radiata, along with follicular fluid and cells from the cumulus
• oocyte completes the 1st meiotic division (prophase)
• Secondary oocyte (2nd meotic division  metaphase)
• First polar body
Corpus Luteum
• the granulosa cells and theca interna of the ovulated follicle
reorganize  corpus luteum in the ovarian cortex
• former granulosa  invaded by capillaries
• LH  change histologically and functionally cells of both the
granulosa and theca interna  production of the steroid
progesterone in addition to estrogens
• Granulosa lutein cells (GL), producing progesterone
• The theca lutein cells (TL) <half the size , stain more darkly> , produce
estrogens
• Following the LH surge  secrete progesterone for 10–12 days
• Without stimulation  cease steroid production and undergo
apoptosis while the tissue regresses
• Decreased secretion of progesterone  menstruation
• Estrogen  inhibits FSH  no new menstrual cycle
• Corpus luteum
• Corpus albicans
• Uterine tubes
• folded mucosa
• thick muscularis with somewhat
interwoven circular (or spiral) and
longitudinal layers of smooth
muscle
• thin serosa covered by visceral
peritoneum with mesothelium
• Uterus
• Perimetrium  an outer
connective tissue layer; adventitial
in some areas, but largely a serosa
covered by mesothelium
• Myometrium  thick tunic of
highly vascular smooth muscle
• Endometrium  mucosa; lined by
simple columnar epithelium
Embryo implantation
• Embryoblast rearrange as two new cavities,
• Amnion
• Yolk sac.
• Where the cells lining these cavities make contact, the bilaminar
embryonic disc develops
• epiblast layer continuous with the amnion and
• hypoblast layer continuous with the yolk sac
• Trophoblast differentiates during implantation into
• Cytotrophoblast
• syncytial trophoblast (an invasive, multinucleated mass),
• Trophoblast cells  anti-inflammatory cytokines  prevent an
adverse reaction of the uterus to the implanted embryo
• Endometrial stroma  decidual cells
• decidua basalis
• decidua capsularis
• decidua parietalis
• Placenta  site of nutrient, waste, O2, and CO2 exchanges between
the mother and the fetus
• The embryonic part is the chorion  derived from the former trophoblast
• maternal part is from the decidua basalis
•  chorionic villi
• Uterine cervix
• Endocervix  mucus-secreting
simple columnar epithelium on a
thick lamina propria
• Exocervix  stratified squamous
epithelium
• Vagina
• mucosa, muscular, adventitia layer
• stratified squamous
• small amount of keratohyaline, but
do undergo keratinization to form
keratin plates as in the epidermis
• Mammary glands
• resembling highly modified
apocrine sweat glands persists on
each side of the chest
• 15–25 lobes of the compound
tubuloalveolar type
• Adult ; non pregnant • Pregnancy
• Lactation
LI 3 MM anatomi

Breast
Breast
• The breasts  most prominent superficial structures in the anterior thoracic wall,
especially in women.
• Mammae  consist of glandular & supporting fibrous tissue embedded within a
fatty matrix, + blood vessels, lymphatics, & nerves.
• men & women  have  well developed only in women
• The mammary glands  in the subcutaneous tissue overlying the pectoralis
major & minor muscles.
• greatest prominence of the breast  the nipple, surrounded by a circular
pigmented area of skin  the areola
• The mammary glands  are accessory to reproduction in women.
• rudimentary & functionless  in men, consisting of only a few small ducts or epithelial cords.
• the fat present in male breasts  not different from that of subcutaneous tissue elsewhere,
and the glandular system does not normally develop .

Source : Clinical Oriented Anatomy – Moore 6th Edition

Female Breast
• The amount of fat surrounding the glandular tissue  determines the size
of non-lactating breasts.
• The roughly circular body of the female breast  rests on a bed of the
breast
• rests transversely from the lateral border of the sternum to the midaxillary line
• vertically from the 2nd through 6th ribs.
• 2/3 of the bed  formed by the pectoral fascia overlying the pectoralis
major;
• 1/3  by the fascia covering the serratus anterior.
• Between the breast & the pectoral fascia  loose subcutaneous tissue
plane / potential space  the retromammary space (bursa).
• containing  small amount of fat  allows some degree of movement on the
pectoral fascia.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Female Breast
• A small part of the mammary gland  may extend along the
inferolateral edge of the pectoralis major toward the axillary fossa
(armpit)  forming an axillary process or tail (of Spence).
• The mammary glands  firmly attached to the dermis of the
overlying skin, especially by substantial skin ligaments (L. retinacula
cutis), the suspensory ligaments (of Cooper).
• These fibrous connective tissue  well developed in the superior part of the
gland  support the lobes & lobules of the mammary gland.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Breast

Source : Clinical Oriented Anatomy – Moore 6th Edition

Female Breast
• During puberty (ages 8–15 years)  normally enlarge
• glandular development & ⬆ fat deposition.
• The areolae and nipples also enlarge.
• Breast size & shape  determined in part by genetic, ethnic, and dietary factors.
• The lactiferous ducts  give rise to buds that develop into 15–20 lobules of the
mammary gland  constitute the parenchyma (functional substance) of the
mammary gland.
• Thus each lobule  drained by a lactiferous duct  each open independently.
• Each duct has a dilated portion deep to the areola  the lactiferous sinus 
small droplet of milk accumulates or remains in the nursing mother.
• As the neonate begins to suckle  compression of the areola & lactiferous sinus
 expresses the accumulated droplets  encourages the neonate to continue
nursing as the hormonally mediated let-down reflex ensues.
• The mother’s milk is secreted into the baby’s mouth.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Female Breast
• The areolae  contain sebaceous glands
• enlarge during pregnancy
• secrete an oily substance  provides a protective lubricant for the areola and nipple.
• The nipples  cylindrical prominences in the centers of the areolae.
• no fat, hair, or sweat glands.
• The tips of the nipples  fissured w/ the lactiferous ducts opening.
• composed mostly of circularly smooth muscle fibers  compress the lactiferous ducts during
lactation & erect the nipples in response to stimulation, as when a baby begins to suckle.
• The mammary glands  modified sweat glands  have no capsule or sheath.
• The rounded contour & volume of the breasts  produced by subcutaneous fat
• except during pregnancy  mammary glands enlarge & new glandular tissue forms.
• The milk-secreting alveoli (L. small hollow spaces) are arranged in grape-like clusters.
• breasts enlarge slightly during the menstrual period  from ⬆ gonadotropic hormones
on the glandular tissue.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Female Breast
• The arterial supply derives from the:
• Medial mammary branches of perforating branches and anterior intercostal branches of the
internal thoracic artery  originating from the subclavian artery.
• Lateral thoracic and thoraco-acromial arteries  branches of the axillary artery.
• Posterior intercostal arteries  branches of the thoracic aorta in the 2nd, 3rd, and 4th ICS.
• The venous drainage
• mainly to the axillary vein
• internal thoracic vein
• lymphatic drainage
• Lymph passes from the nipple, areola, and lobules of the gland  to the subareolar lymphatic
plexus
• Nerves
• derive from anterior & lateral cutaneous branches of the 4th–6th ICS nerves.
• The branches of the ICS nerves  pass through the pectoral fascia  to reach subcutaneous
tissue & skin of the breast.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Breast

Source : Clinical Oriented Anatomy – Moore 6th Edition

Breast

Source : Clinical Oriented Anatomy – Moore 6th Edition

Breast

Source : Clinical Oriented Anatomy – Moore 6th Edition

Female External Genitalia
 mons pubis
• rounded, fatty eminence anterior to the pubic symphysis, pubic
tubercles, and superior pubic rami.

Female External • The eminence is formed by a mass of fatty subcutaneous tissue.

• The amount of fat  ⬆ at puberty and ⬇ after menopause.
• The surface  continuous with the anterior abdominal wall.
• After puberty  covered with coarse pubic hairs.

Genitalia labia majora

• prominent folds of skin  indirectly protect the clitoris and
urethral and vaginal orifices
• The labium majus passes inferoposteriorly from the mons pubis
toward the anus
• The labia majora lie on the sides of a central depression (a
narrow slit when the thighs are adducted)  Pudendal cleft
• include the • The external aspects  covered with pigmented skin containing
• mons pubis many sebaceous glands, and are covered with crisp pubic hairs.
• labia majora (enclosing the pudendal cleft), • The internal aspects  are smooth, pink, and hairless
• labia minora (enclosing the vestibule of vagina),
• clitoris,
labia minora
• rounded folds of fat-free, hairless skin.
• enclosed in the pudendal cleft
• both the external urethral and vaginal orifices open.
• have a core of spongy connective tissue (erectile tissue at their
base and many small blood vessels).
• Anteriorly, the labia minora form two laminae.
clitoris • The medial laminae  unite as the frenulum of the clitoris.
• erectile organ • The lateral laminae  anterior to the glans clitoris, forming
• consists of a root and a small, cylindrical body, which are the prepuce (foreskin) of the clitoris.
composed of two crura, two corpora cavernosa, and the glans
clitoris
• The body of the clitoris is covered by the prepuce
• Together, the body and glans clitoris are approximately 2 cm in
length and <1 cm in diameter.
Female Internal Genitalia
Ovaries
Ovaries
• The ovaries  almond-shaped & -sized female gonads  which the oocytes
(female gametes or germ cells) develop.
• endocrine glands  produce reproductive hormones.
• Each ovary  suspended by a short peritoneal fold or mesentery, the
mesovarium
• In prepubertal females  the connective tissue capsule (tunica albuginea)
comprising the surface of the ovary is covered by a smooth layer of ovarian
mesothelium or surface (germinal) epithelium, a single layer of cuboidal cells
that gives the surface a dull, grayish appearance, contrasting with the shiny
surface of the adjacent peritoneal mesovarium with which it is continuous
• After puberty  the ovarian surface epithelium  progressively scarred &
distorted (due to repeated rupture of ovarian follicles & discharge of oocytes
during ovulation).
• The scarring is less in women who have been taking oral contraceptives that inhibit ovulation.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Ovaries
• The ovarian vessels, lymphatics, & nerves  cross the pelvic brim  passing to &
from the superolateral aspect of the ovary within the suspensory ligament of
the ovary  which becomes continuous with the mesovarium of the broad
ligament.
• Medially  within the mesovarium, a short ligament of ovary tethers the ovary
to the uterus.
• The ligament of ovary  is a remnant of the superior part of the ovarian gubernaculum of
the fetus
• The ligament of the ovary  connects the proximal (uterine) end of the ovary to the lateral
angle of the uterus  just inferior to the entrance of the uterine
• The ovary  suspended in the peritoneal cavity  its surface is not covered by
peritoneum  the oocyte expelled at ovulation passes into the peritoneal cavity.
• normally trapped by the fimbriae of the infundibulum of the uterine tube  into the
ampulla

Source : Clinical Oriented Anatomy – Moore 6th Edition

Uterine Tubes
Uterine Tubes
• The uterine tubes (oviducts / fallopian tubes)  conduct the oocyte to the uterine cavity.
• provide the usual site of fertilization.
• The tubes  extend laterally from the uterine horns  open into the peritoneal cavity near the
ovaries
• The uterine tubes (10 cm)  lie in a narrow mesentery  the mesosalpinx
• The uterine tubes are divisible into four parts, from lateral to medial:
• Infundibulum:
• the funnel-shaped distal end of the tube  opens into the peritoneal cavity through the abdominal ostium.
• Fimbriae spread over the medial surface of the ovary.
• Ampulla:
• widest & longest part of the tube
• Isthmus:
• the thick-walled part of the tube, which enters the uterine horn.
• Uterine part:
• the short intramural segment of the tube that passes through the wall of the uterus and opens via the uterine ostium into the
uterine cavity at the uterine horn

Source : Clinical Oriented Anatomy – Moore 6th Edition

Uterine Tubes [Arteries]
• The ovarian arteries  from the abdominal aorta
• abdominal aorta  descend along the posterior abdominal wall  At the
pelvic brim  they cross over the external iliac vessels  enter the
suspensory ligaments  approaching the lateral aspects of the ovaries and
uterine tubes.
• The ascending branches of the uterine arteries (from internal iliac arteries) 
course along the lateral aspects of the uterus  approach the medial aspects
of the ovaries and tubes.
• Both the ovarian and ascending uterine arteries  terminate by bifurcating
into ovarian and tubal branches

Source : Clinical Oriented Anatomy – Moore 6th Edition

Uterine Tubes [Veins]
• Veins draining the ovary  form a vine-like pampiniform plexus of
veins in the broad ligament
• The veins of the plexus  usually merge to form a singular ovarian
vein  leaves the lesser pelvis with the ovarian artery.
• The right ovarian vein  ascends to enter the IVC
• The left ovarian vein  drains into the left renal vein
• The tubal veins  drain into the ovarian veins and uterine
(uterovaginal) venous plexus

Source : Clinical Oriented Anatomy – Moore 6th Edition

Uterus
Uterus
• The uterus (womb)  thick-walled, pear-shaped, hollow muscular organ.
• The embryo & fetus develop in the uterus.
• The non-gravid (non-pregnant) uterus  lies in the lesser pelvis, with its
body lying on the urinary bladder and its cervix between the urinary
bladder and rectum
• The adult uterus  usually
• anteverted (tipped anterosuperiorly relative to the axis of the vagina)
• anteflexed (flexed or bent anteriorly relative to the cervix, creating the angle of
flexion) so that its mass lies over the bladder.
• The position of the uterus changes with the degree of fullness of the
bladder & rectum, & stage of pregnancy.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Uterus
• The uterus  divisible into 2 main parts : the body & cervix.
• The body of the uterus
• forming  superior 2/3 of the organ, includes the fundus of the uterus
• The body lies between the layers of the broad ligament  freely movable
• has 2 surfaces: vesical (related to the bladder) and intestinal.
• demarcated from the cervix by the isthmus of the uterus
• The cervix of the uterus
• cylindrical, relatively narrow inferior third of the uterus, approximately 2.5 cm long in an adult
non-pregnant woman.
• 2 parts:
• a supravaginal part  between the isthmus and the vagina
• separated from the bladder anteriorly by loose connective tissue and from the rectum
posteriorly by the recto-uterine pouch (Fig. 3.43A).
• a vaginal part  protrudes into the superiormost anterior vaginal wall
• The rounded vaginal part surrounds the external os of the uterus and the vaginal fornix

Source : Clinical Oriented Anatomy – Moore 6th Edition

Uterus
• uterine cavity  approximately 6 cm in length from the external os to the wall of the fundus
• The uterine horns  are the superolateral regions of the uterine cavity, where the uterine tubes
enter.
• The uterine cavity  continues inferiorly as the cervical canal  extends from internal os 
through the supravaginal and vaginal parts of the cervix  communicating with the lumen of the
vagina through the external os.
• The wall of the body of the uterus consists of three coats, or layers:
• Perimetrium (outer serous coat)  consists of peritoneum supported by a thin layer of connective tissue.
• Myometrium (the middle coat of smooth muscle) 
• becomes greatly distended (more extensive but much thinner) during pregnancy.
• The main branches of the blood vessels & nerves of the uterus are located in this coat.
• Endometrium (the inner mucous coat) 
• firmly adhered to the underlying myometrium.
• The endometrium  actively involved in the menstrual cycle, differing in structure with each stage of the cycle.
• If conception occurs, the blastocyst becomes implanted in this layer;
• if conception does not occur, the inner surface of this coat is shed during menstruation.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Uterus
• Ligaments of Uterus.
• Externally  ligament of the ovary attaches to the uterus postero-inferior to the uterotubal junction
• The round ligament of the uterus (L. ligamentum teres uteri)  attaches antero-inferiorly to this junction.
• The broad ligament of the uterus  a double layer of peritoneum (mesentery)  extends from
the sides of the uterus to the lateral walls and floor of the pelvis.
• keeping the uterus in position.
• The uterus  dense structure located in the center of the pelvic cavity.
• The principal supports of the uterus holding it in position  passive & active or dynamic.
• Dynamic support  provided by the pelvic diaphragm.
• Its tone during sitting and standing and active contraction during periods of increased intra-abdominal pressure (sneezing,
coughing, etc.)  is transmitted through the surrounding pelvic organs & the endopelvic fascia.
• Passive support  provided by its position  normally anteverted and anteflexed uterus rests on top of the
bladder.
• intra-abdominal pressure is ⬆ the uterus is pressed against the bladder.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Uterus
• The cervix  the least mobile part  because of the passive support
provided by attached condensations of endopelvic fascia (ligaments)
• Cardinal (transverse cervical) ligaments  extend from the supravaginal
cervix & lateral parts of the fornix to the lateral walls of the pelvis
• Uterosacral ligaments  pass superiorly & slightly posteriorly from the sides
of the cervix to the middle of the sacrum; they are palpable during a rectal
examination.

Source : Clinical Oriented Anatomy – Moore 6th Edition

Uterus
• relations of the uterus
• Anteriorly (antero-inferiorly in its normal anteverted position):
• the vesico-uterine pouch & superior surface of the bladder;
• the supravaginal part of the cervix  related to the bladder and is separated from it by only fibrous
connective tissue.
• Posteriorly:
• the recto-uterine pouch containing loops of small intestine & the anterior surface of rectum;
• only the visceral pelvic fascia uniting the rectum and uterus here resists increased intra-abdominal
pressure.
• Laterally:
• the peritoneal broad ligament & the fascial cardinal ligaments on each side of the cervix and vagina;
• Arterial Supply and Venous Drainage of Uterus.
• The blood supply  mainly from the uterine arteries + ovarian arteries
• The uterine veins  enter the broad ligaments  form a uterine venous plexus on each side
of the cervix. Veins from the uterine plexus drain into the internal iliac veins.

Source : Clinical Oriented Anatomy – Moore 6th Edition

LI 4. MM pemeriksaan pada ibu hamil dan
screening sebelum kehamilan
LI5 MM pemeriksaan kehamilan (ANC), diagnosa
kehamilan
Prenatal care
Kessner index criteria
Pemeriksaan ante natal
• Lengkap  K1, K2, K3, K4
• Min 1x hingga usia kehamilan 28 minggu
• 1x kunjungan selama kehamilan 28-36 minggu
• 2x kunjungan pd waktu usia kehamilan > 36 minggu

• Identifikasi & riwayat kesehatan

• Data umum pribadi
• Keluhan saat ini
• Riwayat haid (HPHT; usia kehamilan dan taksiran persalinan)
• Riwayat kehamilan & persalinan
• Riyawat kehamilan saat ini
• Riwayat penyakit dalam keluarga
• Riwayat penyakit ibu
• Riwayat penyakit yg memerlukan tindakan pembedahan
• Riwayat mengikuti KB, imunisasi, menyusui
PELAYANAN/ASUHAN STANDAR MINIMAL TERMASUK
“7T”
• (Timbang) berat badan
• Ukur (Tekanan) darah
• Ukur (Tinggi) fundus
• Pemberian Imunisasi (Tetanus Toksoid) TT lengkap
• Pemberian Tablet zat besi, minimum 90 tablet selama
kehamilan
• Tes terhadap Penyakit Menular Seksual
• Temu wicara dalam rangka persiapan rujukan
MEMANTAU TUMBUH KEMBANG JANIN (NILAI NORMAL)
Usia kehamilan Tinggi fundus Tinggi fundus
Dalam cm Menggunakan
penunjuk badan
12 minggu - Teraba di atas simfisis pubis

16 minggu - Di tengah, antara simfisis pubis

dan umbilikus
20 minggu 20 cm (±2 cm) Pada umbilikus

22-27 minggu Usia kehamilan dalam minggu= -

cm (±2 cm)

28 minggu 28 cm (±2 cm) Ditengah, antara umbilikus dan

prosesus sifoideus
29-35 minggu Usia kehamilan dalam minggu= -
cm (±2 cm)
36 minggu 36 cm (±2 cm) Pada prosesus sifoideus
IMUNISASI TT
Antige Interval Lama % per-
n (selang waktu Perlindunga lindungan
minimal) n
TT1 Pada kunjungan - -
antenatal pertama
TT2 4 minggu setelah TT1 3 tahun* 80

TT3 6 bulan setelah TT2 5 tahun 95

TT4 1 tahun setelah TT3 10 tahun 99

TT5 1 tahun setelah TT4 25 thn/ 99

seumur hidup
Keterangan : * artinya apabila dlm waktu 3 tahun WUS tersebut
melahirkan, maka bayi yang dilahirkan akan terlindung dari TN (Tetanus
Neonatorum)
PEMBERIAN VITAMIN ZAT BESI

• Satu tablet sehari, sesegera mungkin setelah rasa mual hilang. Fe SO4
mg (zat besi 60 mg) dan Asam Folat 500 g, minimal masing-masing
90 tablet.
Pem. Fisik:
• Pemeriksaan Leopold I : untuk menentukan tinggi fundus uteri,
sehingga usia kehamilan dapat diketahui.
• Dengan pemeriksaan Leopold II: ditentukan batas samping uterus dan
posisi punggung pada bayi letak memanjang. Pada letak lintang
ditentukan kepala.
• Pemeriksaan Leopold III menentukan bagian janin yang berada di
bawah. bagian kepala yang telah masuk pintu atas panggul (PAP).
• Leopold IV selain menentukan bagian janin yang berada di bawah,
juga seberapa dalam masuk ke rongga panggul
Diagnosis of pregnancy
(sign&symptom)
• Amenorrhea
• reliable pregnancy indicator until 10 days or more after expected menses.
• Lower-Reproductive-Tract Changes
• the vaginal mucosa usually appears dark- bluish red and congested—Chadwick sign,
• As pregnancy progresses, the external cervical os and cervical canal may become sufficiently
patulous to admit a fingertip, but the internal os should remain closed.
• The substantial increase in progesterone secretion associated consistency and microscopic
appearance of cervical mucus.  fernlike pattern of mucus, which is typically seen in the
midportion of the menstrual cycle,  makes pregnancy unlikely
• Uterine Changes
• During the first few weeks: uterine size grows principally in the anteroposterior diameter.
• During bimanual examination: it feels doughy or elastic.
• softer fundus and compressible interposed softened isthmus (Hegar sign)
• Auscultation  uterine souffle (later month of pregnancy)
• soft, blowing sound that is synchronous with the maternal pulse; passage of blood through the dilated uterine
vessels; lower portion of uterus
•  funic souffle is a sharp, whistling sound that is synchronous with the fetal pulse. caused by the rush of blood
through the umbilical arteries and may not be heard consistently.
• Breast and Skin Changes
• Increased pigmentation and visual changes in abdominal striae are common
to  They may be absent during pregnancy and may also be seen in women
taking estrogen-containing contraceptives.
• Fetal Movement
• In general, after a first successful pregnancy, a woman may first perceive fetal
movements between 16 and 18 weeks’ gestation.
• A primigravida At about 20 weeks,
• Pregnancy test
• Detection of hCG in maternal blood and urine is the
basis. This hormone is a glycoprotein with high
carbohydrate content
• HCG prevents involution of the corpus luteum, which is
the principal site of progesterone formation during the
first 6 weeks of pregnancy.
• Syncytiotrophoblast produce hCG in amounts that
increase exponentially during the first trimester
following implantation
• Elevated hCG levels may also reflect molar pregnancy
and its associated cancers
positive assays without pregnancy:
(1) exogenous hCG injection used for
weight loss,
(2) renal failure with impaired hCG
clearance,
(3) physiological pituitary hCG, and
(4) hCG-producing tumors that most
commonly originate from
gastrointestinal sites, ovary, bladder,
or lung
 • detection limit of 12.5 mIU/mL would be
required to diagnose 95% of pregnancies
• Sonographic Recognition of Pregnancy
• A gestational sac—a small anechoic fluid
collection within the endometrial cavity—is the
first sonographic evidence of pregnancy.
• (transvaginal sonography by 4 to 5 weeks’
gestation)
• pseudogestational sac or pseudosac
• intradecidual sign—or two concentric echogenic
rings surrounding the gestational sac (the double
decidual sign)
• Visualization of the yolk sac—a brightly
echogenic ring with an anechoic center
LI 6. MM tatalaksana farmako dan non farmako ibu
hamil:
Callories
• additional 80,000 kcal  most are accumulated in the last 20 weeks
•  caloric increase of 100 to 300 kcal per day is recommended
• Protein
• added the demands for growth and remodeling of the fetus, placenta, uterus,
and breasts, as well as increased maternal blood volume
• second half of pregnancy  1000 g of protein are deposited; amounting to 5
to 6 g/day
• ornithine, glycine, taurine, and proline <
• glutamic acid and alanine >

• Sources  meat, milk, eggs, cheese, poultry, and fish

• Vitamins
Vitamin
• Folic Acid
•  400 microg daily (prevent neural tube defect); 100 microg per day (childbearing age)
• Prevent neural-tube defects
• the month before conception and during the first trimester
• Vitamin A
• routine supplementation during pregnancy is not recommended  birth
defect
• produced by the vitamin A derivative isotretinoin  potent teratogen
• precursor of vitamin A found in fruits and vegetables, has not been shown to
produce vitamin A toxicity
• Vitamin B12
• strict vegetarians may give birth to infants whose B12 stores are low
• may increase the risk of neural-tube defects
• Excessive ingestion of vitamin C also can lead to a functional deficiency of
vitamin B12
• Vitamin B6
• combined with the antihistamine doxylamine  helpful in many cases of
nausea and vomiting of pregnancy
• Minerals
LI6. MM tatalaksana farmako dan non farmako ibu
hamil
Drug Therapy in Pregnancy (pharmacokinetics)
• Lipid Solubility
• Lipophilic drugs (thiopental) & non ionized drugs & non polar  diffuse
readily across the placenta & enter the fetal circulation
• *Salicylate  completely ionized at physiologic pH  crosses the placenta
rapidly  because small amount of salicylate that is not ionized is highly lipid-
soluble
• polar compounds  if high enough concentration gradients achieved  cross
placenta
• Molecular Size
• molecular weights of 250–500 can cross the placenta easily
• 500–1000 cross the placenta with more difficulty
• greater than 1000 cross very poorly
• Use of heparin  high MW (not warfarin  teratogenic)
• Placental Transporters
• P-glycoprotein transporter encoded by the MDR1 (cancer drugs (eg,
vinblastine, doxorubicin)
• Protein Binding
• if a compound is very lipid-soluble (eg, some anesthetic gases not be
affected greatly by protein binding
• some drugs exhibit greater protein binding in maternal plasma than in fetal
plasma because of a lower binding affinity of fetal proteins  sulfonamides,
barbiturates, phenytoin, and local anesthetic agents
• Placental and Fetal Drug Metabolism
• Two mechanisms help protect the fetus from drugs in the maternal
circulation
• The placenta act as a semipermeable barrier & as a site of metabolism
• Umbilical venous blood flow  enter the fetal liver to be metabolized before
enter fetal circulation
Drug Therapy in Pregnancy
(pharmacodynamics)
• Maternal Drug Actions
• requiring the use of drugs that are not needed by the same woman when she
is not pregnant.
• cardiac glycosides and diuretics  for heart failure precipitated by the
increased cardiac workload of pregnancy
• insulin  control of blood glucose in pregnancy-induced diabetes
• Therapeutic Drug Actions in the Fetus
• corticosteroids  stimulate fetal lung maturation when preterm birth is
expected
• Phenobarbital  induce fetal hepatic enzymes responsible for the
glucuronidation of bilirubin (lower incidence of jaundice)
• Zidovudine  decreases by two thirds transmission of HIV from the mother
to the fetus
• combinations of three antiretroviral agents can eliminate fetal infection
almost entirely
• Predictable Toxic Drug Actions in the Fetus
• Chronic use of opioids  dependence in the fetus and newborn
• angiotensin-converting enzyme inhibitors  significant and irreversible renal
damage in the fetus and (contraindicated in pregnant women)
Teratogenic Drug Actions
• Thalidomide  affect the development of the limbs after only brief
exposure (phocomelia)
• Risk occurs during the fourth through the seventh weeks of gestation
• Vit A (retinol)  (isotretinoin, etretinate) are powerful teratogens 
alter the normal processes of differentiation
• Folic acid deficiency  neural tube defects (spna bifida)
• Chronic consumption of high doses of ethanol during pregnancy 
first and second trimesters  fetal alcohol syndrome  affect CNS,
growth, and facial development
Kategori penggunaan obat2an selama kehamilan
(United Stae Food & Drug Administration)
• Kategori A
•  tdk menunjukan peningkatan risiko abnormalitas terhadap
janin
• Kategori B
•  pada hewan tdk menunjukan bukti bahwa obat berbahaya pd
janin, tapi belum ada penelitian yg memadai dgn menggunakan
pembanding pada ibu hamil
• Kategori C
•  pada hewan telah menunjukan efek yg tdk dikehendaki pd
janin, belum ada penelitian memadai dgn menggunakan
pembanding pd ibu hamil
• Kategori D
•  penelitian menunjukan risiko bagi janin pd pembanding ibu
hamil; pertimbangan manfaat pemberian obat dibanding risiko
yg dpt ditimbulkan
• Kategori X
•  bukti positif terjadinya abnormalitas pada janin
Daftar obat yg terbukti teratogenik
LI 7. MM kelainan payudara:
Benjolan
Nipple  discharge, cracked nipple, mastitis,
inverted nipple
• MASTITIS
• defined as inflammation of the breast. Although it can occur spontaneously or
during lactation, mastitis defined clinically as localized, painful inflammation
of the breast occurring in conjunction with flu-like symptoms (e.g., fever,
malaise).
• Prevention of Mastitis
• Because mastitis is thought to result partly from inadequate milk removal
from the breast, optimizing breastfeeding technique is likely to be beneficial.
• bedside hand disinfection by breastfeeding mothers in the postpartum unit
has been shown to reduce the incidence of mastitis.
• RISK FACTOR: