GYNECOLOGY
dr. Nashria dr. Reagan Resadita
Neoplasma
Siklus Menstruasi Abnormal
Vulva
Menstruasi
Infertilitas
Analisis Sperma Vagina
Serviks
Perdarahan Uterus Abnormal Endometriosis
Infeksi Kongenital Toxoplasmosis
Rubella Tes Fertilitas Wanita CMV
Korpus Uteri
Ovarium
Amenorrhea
Menopause
Policystic Ovarian Policystic Syndrome
Varicella
Neoplasma
Siklus Menstruasi Abnormal
Vulva
Menstruasi
Infertilitas
Analisis Sperma Vagina
Serviks
Perdarahan Uterus Abnormal Endometriosis
Infeksi Kongenital Toxoplasmosis
Rubella Tes Fertilitas Wanita CMV
Korpus Uteri
Ovarium
Amenorrhea
Menopause
Policystic Ovarian Policystic Syndrome
Varicella
Neoplasma Pertumbuhan Pertumbuhan jaringan yang berlebihan dan abnormal Perdarahan abnormal, massa pelvis, gejala vulvovaginal Gejala Utama : Perdarahan Benigna VS Maligna
Lokasi Tersering
Benigna
vs
Maligna
Tidak invasif i nvasif,, terlokalisasi
Sifat
Invasif, destruktif,
lambat
Pertumbuhan
cepat
Gejala penekanan massa (nyeri punggung, obstipasi, retensi urin)
Gejala
Sindrom Para neoplastik (endokrinopati), cachexia
Perdarahan, ulserasi, infeksi sekunder
Komplikasi
Metastasis
SOLID
KISTIK
Massa padat
Kantong tertutup berisi cairan, gas, atau substansi semisolid Kista ovarium, kista dermoid, kista bartholini
Neoplasma Vulva Kista Bartholini Lokasi Asal
1/3 posterior labium mayus, posisi jam 4 dan 8 sumbatan pada ductus/ kelenjar bartholini (rekurensi 68-75%)
S&S
massa, nyeri, dyspareunia, demam
Tx
-
Word Catheter (kambuh 3-17%) Marsupialisasi (kambuh 10-24%) Insisi drainase
Jika infeksi -> abses (tersering N.gonorrhoeae)
Fibroma Vulva Lokasi
Area vulva, labium mayus
Asal
Proliferasi fibroblast labium mayus
S&S
massa, penekanan urethra, nyeri, dyspareunia
Tx
Eksisi
Treatment Kista Bartholini word CATHETER •
•
Pembuatan 5 mm incisi pada kista atau abses Masukkan kateter Word dan dikembangkan dengan 2-3 ml saline selama 3-4 minggu
MARSUPIALISASI •
•
•
•
Membuka rongga tertutup menjadi kantong terbuka. Pembuatan insisi vertikal elips 1,5-3 cm (sesuai garis Langer) Pengeluaran isi kista dg sendok kuret kecil sampai bersih Dinding kista dijahit ke kulit vertibular dengan jahitan interupted
Neoplasma vagina Kista Gartner • Lokasi: dinding anterolateral vagina • Asal: sisa kanalis Wolfii (duktus gartner) • S&S: massa • Tx: Insisi dan eksisi
Endometriosis Vagina • Lokasi: Fornix posterior • Asal: Endometrium • S&S: nodul subepitel dengan perdarahan ireguler • Tx: sesuai tx endometriosis
Fibroma Vagina • Lokasi: tidak khas • Asal: proliferasi fibroblast jaringan ikat dan otot vagina • S&S: massa, dyspareunia • Tx: eksisi
Neoplasma serviks uteri Kista Nabothian (Retensi)
Polip serviks
Mioma Serviks
• Lokasi: Area endoserviks • Asal: Retensi muara kelenjar endoserviks retensi cairan musin • S&S: asimptomatik • Tx: tidak ada terapi
• Lokasi: Endo-ektoserviks • Asal: Lapisan Stroma endo-ektoserviks • S&S: Massa bertangkai, rapuh, merah/pucat, bleeding, dyspareunia • Tx: Ekstirpasi kuretase , kauterisasi
• Lokasi: 1/3 inferior uterus • Asal: proliferasi fibroblast jaringan otot uterus • S&S: massa, dyspareunia • Tx: ekstirpasi, eksisi, histerektomi
Tumor Maligna Serviks Uteri Klasifikasi A. Karsinoma serviks Squamous cell carcinoma 91 % Adenocarcinoma Adenosquamous carcinoma Adenoacanthoma B. Sarcoma (sangat jarang)
Faktor Resiko
Infeksi HPV tipe16, 18, 45 dan 56 Status sosial ekonomi
Menikah/ memulai aktivitas seksual pada usia muda (kurang 18 tahun)
Berganti ganti pasangan seksual.
Berhubungan seks dengan laki laki yang berganti ganti pasangan
Riwayat infeksi di daerah kelamin atau radang panggul
Perempuan yang melahirkan banyak anak
Perempuan perkokok(2,5x lebih tinggi)
Perokok pasif (1,4x lebih tinggi)
Zona Transformasi
Displasia adalah hilangnya diferensiasi normal dari epitel serviks
Tempat paling sering terjadinya displasia adalah junctio epitelium skuamosum dan kolumnar (zona transformasi)
Daerah ini paling rentan terhadap infeksi virus, perubahan pH vagina dan fluktuasi level estrogen
Peningkatan estrogen menstimulus epitel kolumnar bergerak keluar menuju vagina (kehamilan, konsumsi pil kontrasepsi, bayi baru lahir).
Patogenesis Carcinoma Serviks
Spektrum klinis ca. serviks
GEJALA & TANDA KLINIS Gejala •
•
•
Pre invasive stage: asimtomatik Early invasive stage: perdarahan vagina abnormal, nyeri (dispareunia) dan perdarahan post coitus, vaginal discharge Advanced stage: nyeri panggul (pelvic pain), weight loss, anorexia, anemia
Tanda Klinis Nodul, ulkus, erosi serviks (tahap lanjut: crater-shaped ulcer dengan massa rapuh), massa eksofitik Perdarahan Mobilitas serviks tergantung derajat keganasan (lunak keras) •
• •
MANAJEMEN PREVENTIF Primer: Gaya hidup sehat Vaksinasi HPV (kuadrivalen- genotipe 6, 11, 16 &18 ; bivalen- genotipe 16 &18) usia > 10 th Sekunder: • •
•
Skrining untuk lesi pra kanker & diagnosis awal diikuti dengan terapi
Tersier:
Screening Kanker Serviks IVA
PAP ’S SMEAR
Inspeksi Visual dengan Asam Asetat (IVA) •
•
•
•
•
•
Perempuan berusia 30-50 tahun Pasien klinik IMS dengan discharge dan nyeri abdomen bawah (semua usia) Perempuan yang tidak hamil Perempuan yang mendatangi puskesmas, klinik IMS< dan klinik KB yang meminta screening Jika hasil tes IVA negatif, ulangi 3-5 tahun sekali. Jika hasil tes IVA positif rekomendasi krioterapi ulangi 1 bulan post krioterapi ulangi 6 bulan post krioterapi
PAP SMEAR PAP ’S SMEAR Mendeteksi perubahan pada morfologi sel (dysplasia) yang merupakan prekursors dari keganasan •
Syarat: Lakukan Paps smear pada fase proliferasi (1 minggu setealah mens berakhir) •
Tidak melakukan hubungan sexual 24-48 jam sebelum paps smear •
Tidak menggunakan lubrikan vagina. •
Exception: Women at increased risk of CIN :
1. in utero DES (diethylstilbestrol) exposure annually 2. Immunocompromise 2x in first year then annually 3. History of cervical cancer
ACOG guideline 2012
HASIL PAP SMEAR
ACOG guideline 2012
Recommendation for screening
Keluhan
Lesi anatomis
Rekomendasi skrining
-
-
IVA
+
-
PAP SMEAR
+
+
Biopsi
Cervical Cancer, Am Fam Physician. 2000 Mar 1;61(5):
Kolposkopi adalah pemeriksaan visual bertenaga tinggi (pembesaran) untuk melihat leher rahim, bagian luar dan kanal bagian dalam leher rahim. Biasanya disertai biopsi jaringan. Digunakan terutama untuk DIAGNOSIS
Squamous Cell Carcinoma Cervical dysplasia:
Perubahan abnormal pada sel di permukaan cervix, dilihat menggunakan miscroscope
©2015
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
NEOPLASMA UTERI Tumor Benigna Leiomyoma (myoma) Etiological factors: estrogen, negroid, nullipara •
•
S&S: Menorrhagia – heavy & prolonged menstruation (common) Pelvic pressure：urinary frequency, constipation Spontaneous abortion, Infertility •
•
•
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 myometrium; if pedunculated satelite myoma
A palpable abdominal tumor : arising from pelvis, well defined margins , firm consistency, smooth surface, mobile from side to side. • Pelvic examination Uterus — enlarged and irregular, hard • Diagnosis : Bimanual exam, USG, hysteroscopy, Laparacospy Management Observation: for small myoma, premenopause Operation : myomectomy or •
•
1
2 3
Uterine fibroid therapy
Uterine fibroid therapy 4
Tipe maligna neoplasma uteri Sarkoma Uteri • Myoma uteri yang menjadi leiomyosarkoma hanya 0,32 – 0,6% dari seluruh myoma • Leiomyosarkoma merupakan 50-75% dari semua jenis sarkoma uteri • Kecurigaan malignansi: • Perdarahan pascamenopause • Myoma uteri cepat membesar • Pembesaran myoma pada menopause • Muncul jaringan nekrotik
Kanker endometrium • Insidensi keganasan ini 4,8% (ke-4 terbanyak) pada organ ginekologik • Faktor risiko: obesitas, rangsangan estrogen, menopause terlambat, nulipara, siklus anovulasi, hiperplasi endometrium, HRT • Kecurigaan malignansi: • Perdarahan uterus abnormal • Perdarahan pascamenopause • Diagnosis: kuretase diagnostic, biopsy endometrium
NEOPLASMA OVARIUM Functional - Follicle cy cyst - Corpus Lu Luteum cy cyst - The Theca lutein ein cyst Inflammatory - Tubo-ovarian abcess Benign tumor/cyst - End Endometr metriioti otic cy cyst - Brenner tumor - Benign te teratoma - Fibroma
Robins Basic Pathology 9 th edition
Malignant( or malignant potential) - Mal aliignan antt ter tera atom oma a - Endometrioid carcinoma - Dygerminoma - Sec eco onda dary ry ovaria ian n tumor - Cystadenoma, cystadenocarcinoma - Gr Gran anul ulos osa a ce cell ll tu tumo morr - Arrhenoblastoma - Theca cell tumor
Overview of Ovarian Tumor No 1.
Type
Epithelium
Frequency 65-70%
-Benign -Malignant -Borderline (low malignant potential)
Age Group Adult (20+ years)
Subtype
Serous
Note Most common 60% benign Can be bilateral bilateral (25%) Malignant type highly associated with BRCA gene mutation
Mucinous Endometrioid Clear-cell Brenner Cystadenofibroma 2.
3.
Germ Cell
15-20%
Sex-Cord Stroma
5-10%
0-25+ years
Teratoma Dysgerminoma Endodermal sinus tumor Choriocarcinoma
All ages
Fibroma Granulosa-theca Granulosa-theca cell Sertolli Leydig
Most common in young women Majority are benign.
May produce estrogen or androgen
KANKER OVARIUM
Etiology •
inactivation of tumor suppressor genes (PTEN, p16, p53)
•
activation of oncogenes (HER-2, c-myc, K-ras, Akt)
•
mutations in BRCA1, BRCA2
•
•
•
Age mostly found in older age; >50% cases found >63 y.o patients Family history of ovarian cancer, breast cancer, or colorectal cancer Obesity
•
Reproductive history
•
Fertility drugs
•
•
Estrogen therapy
therapy
and
hormone
Personal history of breast cancer
Known as silent lady killer high mortality
S&S •
Low abdominal discomfort (fullness, bowel symptom) Pressure symptom
•
Loss of weight, malaise, anorexia
•
Pain due to torsion, hemorage or rupture
Risk Factor: •
Increasing menstrual cycle
•
Induction clomiphene citrate
Diagnosis: •
USG
Tumor marker Ca-125
Clinical Work-up Laboratory Testing No tumor marker (eg, CA125, beta-human chorionic gonadotropin, alpha-fetoprotein, lactate dehydrogenase) is completely specific; therefore, use diagnostic immunohistochemistry testing in conjunction with morphologic and clinical findings. Also, obtain a urinalysis to exclude other possible causes of abdominal/pelvic pain, such as urinary tract infections or kidney stones.
CA 125 – . CA 125 is abnormally elevated in about 80 percent of women with advanced ovarian cancer. non-cancerous conditions can cause CA 125 to be elevated e.g endometriosis, uterine fibroids, pelvic infections, heart failure, and liver and kidney disease.
Teratoma ovarian (Dermoid cyst of ovary) •
Bizzare Tumour
•
Insidensi: 15-20% tumor ovarium
•
•
•
•
Sering terjadi pada wanita usia decade 2 semakin muda, semakin maligna Asal: totipotential germ cell (ektodem, mesoderm, endoderm) membentuk rambut, kelenjar keringat, tulang, gigi, sel saraf Gejala: infertilitas, torsio (10-15% kejadian) operasi emergensi Terapi: Laparotomi, kistektomi
Robins Basic Pathology 9th edition
SIKLUS MENSTRUASI
Menstrual cycle
Image
GnRH
GnRH merupakan hormon yang diproduksi oleh hipotalamus di otak. GnRH akan merangsang pelepasan FSH (Folicle Stimulating Hormon) di hipofisis. Bila kadar estrogen tinggi, maka estrogen akan memberikan umpan balik ke hipotalamus sehingga kadar GnRH akan menjadi rendah, begitupun sebaliknya.. •
•
•
LH
Estrogen
LH mempertahankan korpus luteum untuk tetap menghasilkan ovarium. Dibawah pengaruh LH, korpus luteum mengeluarkan estrogen dan progesteron, dengan jumlah progesteron jauh lebih besar. Kadar progesteron meningkat dan mendominasi dalam fase luteal, sedangkan estrogen mendominasi fase folikel. Walaupun estrogen kadar tinggi merangsang sekresi LH, progesteron dengan kuat akan menghambat sekresi LH dan FSH. •
•
•
•
Estrogen dihasilkan oleh ovarium. Estrogen berguna untuk pembentukan ciri-ciri perkembangan seksual pada wanita yaitu pembentukan payudara, lekuk tubuh, rambut kemaluan. Estrogen juga berguna pada siklus menstruasi dengan membentuk ketebalan endometrium, menjaga kualitas dan kuantitas cairan cerviks dan vagina sehingga sesuai untuk penetrasi sperma. • •
•
Progesteron Hormon ini diproduksi oleh korpus luteum. Progesteron mempertahankan ketebalan endometrium sehingga dapat menerima implantasi zygot. Kadar progesteron terus dipertahankan selama trimester awal kehamilan sampai plasenta dapat membentuk hormon HCG. • •
•
FSH
Hormon yang diproduksi oleh hipofisis akibat rangsangan dari GnRH. FSH akan menyebabkan pematangan dari folikel. Dari folikel yang matang akan dikeluarkan ovum. Kemudian folikel ini akan menjadi korpus luteum dan •
• •
Normal Menstrual Bleeding •
•
•
•
•
Occurs approximately once a month (every 21 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
Ovulasi •
•
Terjadi 14 hari sebelum mens berikutnya
Tanda dan tes : –
–
–
Rasa sakit di perut bawah (mid cycle pain/mittleschmerz) 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
•
•
•
>> kadar progesterone 2ng/ml LH surge (dg Radioimunoassay) USG folikel >1,7 cm
Abnormal Uterine Bleeding Term (Previous)
Definition
Pattern
Amenorrhea
No uterine bleeding for moments
Menorrhagia
Excessive amount (>8omL/cycle) or prolonged duration > 7 days, also called “hypermenorrhea ”
Occurs at irregular interval
Metrorrhagia
Uterine bleeding occurring at irregular but frequent interval, amount varies
Irregular
Menometrorrhagia
Irregular, heavy, and prolonged menstrual bleeding
Irregular
Oligomenorrhea
Decreased, scanty flow, the term Interval >36-40 days “hypomenorrhea ” is used for regular timing with scanty amount
Polymenorrhea
Regular, frequent menstruation
Interval < 21 days
Intermenstrual
Bleeding or spotting between
Between periods (usually light flow)
NEW RECOMMENDED TERMINOLOGY, DEFINITIONS, AND CLASSIFICATIONS OF SYMPTOMS OF ABNORMAL UTERINE BLEEDI NG Terminology
Definition
Prolonged menstrual bleeding
Menstrual period exceeding 8 days in duration on regular basis
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 (>80mL)
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 (<5mL)
Terminology
Definition
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 that 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
Polip
Coagulopathy
• Endocervical polip • Endometrial polip
- Von Willebrand disease - Gangguan agregasi platelet
Ovulatory disturbance
Adenomyosis
- Endocrinopatie (PCOS, Hypotiroid, obesity, anorexia)
• Part of endometrial that penetrate to myometrium
-Extreme exercise, stress
Leiomyoma
Endometrial
• Submucosal • Subserosal • intramural
-Endometrial
Malignancy and hyperplasia - Endometrial cancer
inflammation infection -Defisiensi endothelin-1, Prostaglandin F2-alpha
Iatrogenic
defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of
Drugs : rifampicin, griseofulvin, trisiklik, phenothiazine,
Medical Management for Acute AUB Hormonal management is considered the first line of medical therapy for patients with acute AUB without known or suspected bleeding disorders.
ACOG 2013, COMMITTEE OPINION, Management of
Drug
Dosage
Schedule
Contraindication
Conjugated equine estrogen
25 mg IV
Every 4-6 hours for 24 hour
Breast canver. PAD, Venous thrombosis, liver dysfunction
Combined oral contraceptive
Combined oral contraceptive contain 35 microgram ethinyl estradiol
3x/day for 7 days
Cigeratte smoking (aged > 35 years), hypertension, DVT, CVD, migraine, breast cancer, liver dysfunction
Medroxyprogester one acetate
20 mg PO
3x/day for 7 days
DT, breast cancer, liver dysfunction
Tranexamic acid
1,3 gram PO or 10 mg/kg IV (max. 600 mg/dose)
3x/day for 5 days
Trombosis, impaired color vision, thromboembolic disease
PELVIC INFLAMMATORY DISEASE (PID) Infeksi polimikrobial yang melibatkan traktus genital atas Terutama menyerang wanita usia muda yang aktif secara seksual Chlamydia trachomatis dan Neisseria gonorrhoeae adalah patogen tersering
Kriteria minimum (satu atau lebih harus ada untuk PID) - Cervical motion tenderness/nyeri goyang serviks - Uterine tenderness - Adnexal tenderness
-
Kriteria tambahan Temperatur oral > 38.3 C Discharge serviks atau vagina yang mukopurulen dan abnormal Terdapat sel darah putih pada pemeriksaan mikroskopis cairan vagina Peningkatan laju sedimentasi eritrosit Peningkatan CRP Bukti lab adanya gonorrhea atau klamidia
Pemeriksaan Penunjang - Biopsi endometrial - Transvaginal sonografi atau MRI - Laparoskopi
Suggested Criteria for Hospitalization of Patien Patients ts with Pelvic Inflammatory Inflammatory Disease •
Inability to follow or tolerate an outpatient oral medication regimen
•
No clinical response to oral antimicrobial therapy
•
Pregnancy
•
Severe illness, nausea and vomiting, or high fever
•
Surgical emergencies (e.g., appendicitis) cannot be excluded
•
Tubo-ovarian abscess DRUG
ORAL
PARENTERAL
Option 1 Ceftriaxone (Rocephin) plus Doxycycline
DOSAGE
250 mg IM in a single dose 100 mg orally twice per day for 14 days
with or without Metronidazole (Flagyl)
500 mg orally twice per day for 14 days
DRUG
DOSAGE
Regimen A Cefotetan (Cefotan) or Cefoxitin plus Doxycycline
2 g IV every 12 hours 2 g IV every six hours 100 mg orally or IV every 12 hours
Dysmenorrhea menstruation. Divided into 2 broad categories: primary (occurring in Dysmenorrhea: painful cramp during menstruation. secondary (resulting from identifiable organic diseases). the absence of pelvic pathology) and secondary (resulting Primary • • • • •
Onset 6-12 months after menarche 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, pain , radiating to the back or thigh Often unremarkable unremarkable pelvic examination examination findings (including rectal)
Current evidence suggests that the pathogenesis of primary dysmenorrhea is due to prostaglandin F2α (PGF2α), a potent myometrial stimulant and vasoconstrictor, in the secretory endometrium. Treatment: NSAID celecoxib, Ibuprofen, Naproxen, mefenamic acid Hormonal COC, Levonorgestrel-releasing Levonorgestrel- releasing intrauterine system system Medroxyprogesterone injection
Secondary • • • •
Dysmenorrhea Dysmenorrhea beginning in the 20s or 30s, after previous relatively painless cycles Heavy menstrual flow or irregular bleeding Most ethiologies: Endometriosis, adenomyosis, adenomyosis, PID, infection Poor response to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptives (OCs)
Endometriosis Kondisi ditemukannya jaringan endometrium diluar korpus uteri merespon estrogen perdarahhan inflamasi Patofisiologi: mullerian duct remnants theory, menstruasi retrograde, coelomic metaplasia, Sampson’s Sampso n’s theory, theory, Iron -induced oxidative stress
Lokasi tersering: peritoneum, ovarium, tuba falopi
Lokasi lain: vesical urinaria, ureter, ureter, usus halus, fornix posterior posterior,, rectum, diafragma
SIGN and SYMPTOM SYMPTOM • •
TRIAS klasik: dismenorhea berat, dyspareunia/ nyeri panggul kronis, infertil
• • • •
Penunjang: Tr Transvaginal/endorect ansvaginal/endorectal al USG, MRI (deteksi implantasi endometrial)
•
Dismenorea Menorhagia Nyeri goyang panggul Nyeri perut bawah Dyschezia Dysuria Dyspareunia
Endometriosis therapy Medical Therapies
Surgical Intervention Laparoscopy Hysterectomy/Oophorectomy/Salpingooophorectomy •
Mild-Moderate Pain
Moderate – Severe Pain
1. Combined Oral Contraceptive 2. NSAID 3. Progestin
1. GnRH Agonist 2. Danazol 3. Aromatase Inhibitor
•
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
ESHRE guideline: management of women with endometriosis
Amenorrhea Amenorrhea is the absence of menstruation. •
Primary –
•
Absence of menses by age 13 without or age 15 with secondary sexual development
Secondary –
Absence of menses for 3 month in regular or 6 month in iregular cycle menstruation
Amenorrhea: An Approach to Diagnosis and Management Am Fam Physician.
Amenorrhea: An Approach to Diagnosis and Management Am Fam Physician. 2013;87(11):781-788
Amenorrhea: An Approach to Diagnosis and Management Am Fam Physician.
Functional hypothalamic amenorrhea: the hypothalamic-pituitary-ovarian axis is suppressed due to an energy deficit stemming from stress, weight loss (independent of original weight), excessive exercise, or disordered eating. It is characterized by a low estrogen state without other organic or structural disease Menses typically return after correction of the underlying nutritional deficit. •
•
•
Menopause
Perimenopause Periode 3-5 tahun sebelum menopause yang ditandai dengan peningkatan frekuensi irregular anovulatory bleeding yang selanjutnya diikuti periode amenorrhea dan gejala-gejala menopause lainnya Menopause Periode dimana siklus menstruasi secara permanen berhenti. Diagnosis secara retrospektif sejak 12 bulan paska amenorrhea. (Rerata usia 51 tahun). •
•
PATOFISIOLOGIS MENOPAUSE •
• • •
•
•
pada usia sekitar 50 tahun fungsi ovarium menjadi sangat menurun. Folikel mencapai jumlah yang kritis, maka akan terjadi gangguan sistem pengaturan hormon insufisiensi korpus luteum, siklus haid anovulatorik dan pada akhirnya terjadi oligomenore Masa perimenopause aktivitas folikel dalam ovarium mulai berkurang. Ketika ovarium tidak menghasilkan ovum dan berhenti memproduksi estradiol, kelenjar hipofise berusaha merangsang ovarium untuk menghasilkan estrogen, sehingga terjadi peningkatan produksi FSH. Pada pascamenopause kadar LH dan FSH akan meningkat, FSH biasanya akan lebih tinggi dari LH sehingga rasio FSH/ LH menjadi lebih besar dari satu. Hal ini disebabkan oleh hilangnya mekanisme umpan balik negatif dari steroid ovarium dan inhibin terhadap pelepasan gonadotropin. Diagnosis menopause dapat ditegakkan bila kadarFSH lebih dari 30 mIU/ml
S
S
I
Y
G M N P T A O N M D P
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
5. Atrophic Changes •
*vaginitis due to thinning of epithelium, ↓ PH and lubrication. *dysparnue→due to decrease vascularity and dryness •
• • •
3. Psychological changes decreased level of central neurotransmitters Depression Irritability Anxiety Insomia lose of concentration • •
•
•
•
•
• • •
4. Skin Collagen – ↓ collagen & thickness → ↓ elasticity of the skin.
Vagina
size of breDecrease 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 ast and benign cysts.
6. Reversal of premenstrual syndrome
Diagnose •
Retrospective diagnose, FSH > 30 mIU/ml and E2 < 30pg/ml (Rogerio, 2000; Baziad, 2003).
THERAPY •
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.
•
o
Oestrogen – in the first ½ of 28 day per pack
o
Oestrogen & Progetin in 2 nd 1/12 of 28 day pack
Benefit for HRT: o
Vagina-↑ vaginal thickness of epithelium →↓ dyspareunia & vaginitis.
o
Urinary tract – enhancing normal bladder function.
o
Osteoporosis – decrease fractures by more than 50%
o
CVS – decrease by 30% by observation studies but recent studies shows no benefits.
o
Colon Cancer decrease up to 50%
Post Menopausal Bleeding: •
•
Vaginal bleeding occurs after 12 months of Amenorrhea in middle age women who are not receiving replacement therapy. Endometrial Ca: •
•
•
Endometrial neoplasia can progress from simple hyperplasia to investive Ca caused by unopposed oestrogen. Mechanism: prolonged oestrogen stimulation of the endometrium unopposed by progesterone. The source may be: a)
Exogenous Estrogen (E2) (ERT)
b)
Peripheral Aromatization of Androstendione to estrone –obesety or PCO
c)
Estrogen (E2) producing tumor (like granuloza cell ovarian tumour)
d)
Tamoxifen aStimulation of Endometrium
Risk Factor o
No pregnancy
o
Prolonged Reproductive Life – late menopause
o
Unopposed estrogen
o
Triad of diabetes, hypertension & obesity
PMS the cyclic recurrence in the luteal phase of the menstrual cycle of a combination of distressing physical, psychological, and/or behavioral changes of sufficient severity to result in deterioration of interpersonal relationships and/or interference with normal activities..
PMM Many patients with psychiatric disorders also complain of worsening of their symptoms around the premenstrual phase, called “premenstrual magnification”.
PMS
PMM
Diagnostic criteria
Tenth Revision of the International Classification of Disease (ICD-10)
Providers using these criteria
Obstetrician/gynec Psychiatrists, other ologists, primary mental health care care physicians providers
Number of symptoms required
One
5 of 11 symptoms
Functional impairment
Not required
Interference with social or role functioning required
Prospective charting of symptoms
Not required
Prospective daily charting of symptoms required for two cycles
ACOG
Diagnostic and Statistical Manual of Mental Disorders, 4 th ed. (DSM-IV)
Infertilitas Kegagalan dalam konsepsi, mempertahankan kehamilan , atau melahirkan bayi hidup bagi pasangan suami-istri yang telah melakukan hubungan seksual secara regular tanpa kontrasepsi setelah: 1. Usia wanita < 35 tahun melewati durasi 12 bulan 2. Usia wanita > 35 tahun melewati durasi 6 bulan Prevalensi: a. 40% faktor istri a. Infeksi: Servisitis Inflamasi uterus salfingitis perituba adesi stenosis tuba oklusi tuba b. Gangguan ovulasi: Penuaan (usia), Polikistik Ovarii (PCOS), Kelainan pada hipotalamus-hipofisis, Hiperprolaktin c. Gangguan anatomi: Kelainan kongenital
b. 40% faktor suami a. Kelainan sperma b. Gangguan transportasi: Varikokel, Prostatitis, Epididimitis, Orkhitis, c. Kelainan kongenital (Hipospadia, agenesis vas deferens, klinefelters syndrome), d. Kelainan hipotalamus-hipofisis e. Autoimunitas, Impotensi c.
20% pada keduanya
Primary infertility When a woman is unable to ever bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth she would be classified as having primary infertility. Thus women whose pregnancy spontaneously miscarries, or whose pregnancy results in a still born child, without ever having had a live birth would present with primarily infertility. Secondary infertility When a woman is unable to bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth , she would be classified as having secondary infertility. Thus those who repeatedly spontaneously miscarry or whose pregnancy results in a stillbirth, or following a previous pregnancy or a previous ability to do so, are then not unable to carry a pregnancy to a live birth would present with secondarily infertile. WHO - National, regional, and global trends in infertility: a systematic analysis of 277
WHO 2010 sperm analysis
Terminologi analisa sperma Normozoospermia
Jumlah sperma ≥ 15 juta/ml
Oligozoospermia
Jumlah sperma < 15 juta/ml
Astenozoospermia
Motilitas sperma A < 32 % atau a+b <40% A
: bergerak cepat dan lurus
B
: Bergerak lambat dan tidak lurus
C : bergerak ditempat D : tidak bergerak
Teratozoospermia
Morfologi sperma normal < 4%
OligoAstenoTeratozoospermia
(sindroma OAT)
Azoopermia
0 sperma + plasma semen
Aspermia
0 sperma + 0 plasma semen
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
Contoh: Dari 100 sperma yang dihitung, 80 sperma kepala bening, 20 sperma kepala ungu Uji Viabilitas 80% Laki-laki dinyatakan fertill jika uji viabilitas >60%
Fertility Test for women •
•
•
•
•
•
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
POLYCYSTIC OVARIAN SYNDROME (PCOS) 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
Syarat PCOS menurut Rotterdam Consensus (2003) yaitu 2 dari berikut: 1. Hiperandrogenisme klinis dan/atau hiperandrogenemia: hirsutisme, jerawat, alopesia 2. Oligoanovulasi: oligomenorhea dan/atau amenorhea 3. USG: polikistik ovari
Pathophysiology of pcos Lifestyle modification as First line of PCOS management
OVULATION INDUCTION. Approach to ovulation induction in women with polycystic ovarian syndrome. IVF: In vitro fertilization
TORCH Toxoplasmosis Other (sifilis, varicella-zoster, parvovirus B19) Rubella Cytomegalovirus (CMV) Herpes Infection
INFEKSI KONGENITAL
IgM is too large to cross placenta and does not confer maternal immunity
IgG crosses placenta and confers passive immunity on the fetus
Table 1: Clinical Features Associated with TORCH Infections
Infection
Clinical Features Intracranial calcifications in a diffuse pattern Hydrocephalus Chorioretinitis Mononuclear CSF pleocytosis or elevated CSF protein
•
Toxoplasmosis
•
• •
Cataracts, glaucoma, pigmented retinopathy Congenital heart disease (patent ductusarteriosus and peripheral pulmonary artery stenosis) Radiolucent bone disease Sensorineural hearing loss •
•
Rubella
• •
Periventricular intracranial calcifications Microcephaly Thrombocytopenia
•
Cytomegalovirus (CMV)
• •
Mucocutaneous vesicles or scarring CSFpleocytosis Thrombocytopenia Elevated liver transaminases Conjunctivitis or keratoconjunctivitis
• •
Herpes Simplex Virus (HSV)
•
• •
Skeletal abnormalities such as osteochondritis and periostitis Pseudoparalysis Persistent rhinitis
•
•
Syphilis
•
CLINICAL FEATURES ASSOCIATED WITH TORCH INFECTIONS
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 li
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
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
Ultrasonographic findings - Fetal hydrocephalus - Fetal intracranial calcification
Classic triad (affected in ~80%) of congenital toxoplasmosis: - Hydrocephalus - Chorioretinitis - Intracranial calcification
Rubella (German Measles)
Congenital rubella syndrome
Algorithm for serologic evaluation of pregnant women exposed to rubella
www.cdc.gov
Diagnosis of congenital rubella
Congenital rubella syndrome
•
Risk of congenital defects: Before 11 weeks of gestation 90% 13 -14 weeks 11% 15-16 weeks 24% After 16 weeks 0% •
•
•
CITOMEGALOVIRUS (CMV)
CMV Identification of Primary CMV in Pregnancy
Mother Serologic testing: CMV – IgG positive with low IgG avidity CMV-IgM positive
•
•
Fetus Amniocentesis: Viral/antigen detection CMV-PCR Viral load = severe infection Ultrasound
•
•
Newborn CMV-IgM positive Virus/PCR positive in body fluid •
•
CMV: Ultrasonographic findings Diagnostic clue: Calcification - Intracranial - Hepatic -- Hepatosplenomegaly -- Amnniotic fluid volume disorder
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)
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 No proven value in preventing or treating congenital CMV infection.
The most promising therapy for congenital CMV infection appears to be hyperimmune globulin.
Source; http://www.perinatology.com/exposures/I
VARICELLA
Hepatic calcification
Radioulnar hipoplasia and missing hand
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
Management •
•
Fetal Infection Amniocentesis (culture or PCR of virus) or 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 •
Zooster Lesion
Maternal zooster outbreak in pregnancy is not associated with risk of fetal malformation
