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dr. Nashria
dr. Reagan Resadita
Keganasan
2
Serviks
Siklus
Menstruasi
Abnormal
Menstruasi
Infertilitas
Analisis Sperma
Perdarahan
Uterus Abnormal
Korpus Uteri
Endometriosis
Polycystic
ovarian
syndrome
Infeksi
Kongenital
Toxoplasmosis
Rubella
CMV
Amenorrhea
Ovarium
Menopause
Tes Fertilitas
Wanita
Varicella
Neoplasma
Benigna VS Maligna
Solid VS Cystic
Gejala Utama
Tumor Benigna
Perdarahan abnormal
Massa pelvis
Gejala vulvovaginal
Tumor Maligna
Menyebabkan penyakit klinis
yang lebih signifikan seperti
invasif, pertumbuhan cepat
mudah berdarah, ulserasi dan
infeksi
Sindrom Para neoplastic
(endocrinopathies)
cachexia
Lokasi Tersering
Patogenesis
5
Zona Transformasi
6
Displasia
adalah
hilangnya
diferensiasi normal dari epitel serviks
Tempat paling sering terjadinya
displasia dan SCC 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).
Penurunan estrogen menstimulus
epitel kolumnar untuk masuk
kembali ke kanalis endoserviks
Tanda Klinis
Nodul, ulkus, erosi serviks
Advanced: crater-shaped
ulcer with high or friable
warty mass
Perdarahan
Mobilitas serviks tergantung
derajat ca
Gejala
Pencegahan
Primer: Gaya hidup sehat
dan vaksinasi HPV
(kuadrivalen- genotipe 6,
Kecuali...
Women at increased risk
of CIN :
1. in utero DES
(diethylstilbestrol)
exposure,
2. immunocompromise,
3. a history of CIN II/III or
4. Cancer
should continue to be
screened at least
annually.
Keluhan
Lesi anatomis
Rekomendasi
skrining
IVA
Syarat:
PAP SMEAR
Lakukan
Paps
smear
pada fase proliferasi (1
minggu setealah mens
berakhir)
Biopsi
Mendeteksi perubahan
pada morphology
sel(dysplasia) yang
merupakan precursors
dari carcinoma.
Tidak
melakukan
hubungan sexual 24-48
jam sebelum paps smear
Tidak
menggunakan
lubrikan vagina.
2015 UpToDate
14
Diagnosis
Tests may include:
another Pap test if mild changes found
HPV test, which may be done on a sample of
cervical cells taken during a Pap test
colposcopy and biopsy
endocervical curettage during colposcopy
Treatment
15
Terapi
Penjelasan
Krioterapi
16
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 Pengambilan
jaringan
Excision Procedure (LEEP)
yang mengandung sel
prakanker
dengan
menggunakan alat LEEP
Konikasi
Pengangkatan
jaringan
yang
megandung
sel
prakanker dengan operasi
Histerektomi
Pengangkatan
seluruh
rahim termasuk leher rahim
Type of Leiomyoma
1. Submucous : beneath
endometrium, if
pedunculated
geburt myoma
2. Intramural/interstitial:
within uterine wall
3. Subserous/subperitone
al: at the serosal
surface or bulge
outward from
myometriuml ; if
pedunculated : satelite
myoma
19
20
Tumor Ovarium
Mortalitas tinggi dari semua tumor gyn (silent
lady killer)
Gejala
Low abdominal discomfort (fullness,
bowel symptom)
Loss of weight, malaise, anorexia
Pain due to torsion, hemorage or
rupture
Pressure symptom
Benign Tumor
Small can be felt by bimanual
Medium may have long pedicle and
rise out of pelvis
Malignant Tumor
Early detection would improve
prognosis, bimanual, USG or tumor
marker
Ovarian teratoma
Bizarre
tumor,
biasanya
benigna, rata2 mengenai wanita
di usia 30 tahun
Kista dermoid berkembang dari
sel germinal totipotensial (oosit
primer) yang tetap berada di
ovarium, sehingga berkembang
menjadi semua bentuk sel matur
seperti rambut, gigi, tulang,
jaringan saraf.
23
24
Menstrual cycle
25
Image source:https://embryology.med.unsw.edu.au/
FSH
26
LH
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.
27
Estrogen
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.
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..
28
30
Ovulasi
>> kadar
progesterone 2ng/ml
LH surge (dg
Tanda dan tes :
Radioimunoassay)
Rasa sakit di perut bawah (mid cycle
pain/mittleschmerz)
USG folikel >1,7 cm
Perubahan temperatur basal efek
termogenik progesteron
Perubahan lendir serviks
Uji membenang (spinnbarkeit): Fase
folikular : lendir kental, opak,
menjelang ovulasi encer, jernih,
mulur
Fern test : gambaran daun pakis
Fertility Test
31
32
33
34
Polyp
Coagulopathy
Adenomyosis
Ovulatory disorder
Malignancy and
hyperplasia
leiomyoma
Endometrial
iatrogenic
Polip
35
Endocervical polip
Endometrial polip
Adenomyosis
Part of endometrial that penetrate to myometrium
Leiomyoma
Submucosal
SUbserosal
intramural
Coagulopathy
36
Ovulatory disurbance
Endocrinopatie (PCOS, Hypotiroid, obesity, anorexia)
Extreme exercise, stress
Endometrial
Endometrial inflammation
Endometrial infecton
Defisiensi endothelin-1, defisiensi Prostaglandin F2-alpha
Iatrogenic
Drugs : rifampicin, griseofulvin, trisiklik,
phenothiazine, anticoagulant, antiplatelet,
Infrequent bleeding
1. Therapy should be directed at the underlying cause
when possible.
2. If the CBC and other initial laboratory tests & history
and physical examination are normal reassurance
3. Ferrous gluconate, 325 mg bid-tid
ACOG 2008
39
ACOG 2008
40
Dysmenorrhea
Dysmenorrhea refers to the symptom of painful menstruation. It can be
divided into 2 broad categories: primary (occurring in the absence of
pelvic pathology) and secondary (resulting from identifiable organic
diseases).
Primary
Usual duration of 48-72 hours (often starting several hours before or just after
the menstrual flow)
Cramping or laborlike pain
Background of constant lower abdominal pain, radiating to the back or thigh
Often unremarkable pelvic examination findings (including rectal)
Current evidence suggests that the pathogenesis of primary dysmenorrhea is
due to prostaglandin F2 (PGF2), a potent myometrial stimulant and
vasoconstrictor, in the secretory endometrium.
Secondary
41
Drug Therapy
Dysmenorrhoea can be effectively treated by drugs that inhibit
prostaglandin synthesis and hence uterine contractility.
These drugs include aspirin, mefenamic acid, naproxen or
ibuprofen.
Endometriosis
42
Penyakit estrogen dependen yang sering menyebabkan morbiditas, nyeri pelvis yang berat,
operasi berulang dan infertilitas.
Secara klinis ditemukan jaringan endometrial-like diluar uterus, yang menyebabkan reaksi
inflamasi
Pathophysiology
43 In situ from wolffian or mullerian duct remnants (metaplastic theory)
Coelemic metaplasia
Sampsons theory
Iron-induced oxidative stress
Stem cells
Sign Symptom
Classic signs:
severe dysmenorrhea, dyspareunia,
chronic pelvic pain,
infertility
Dysmenorrhea
Heavy or irregular bleeding
Cylical/noncylical pelvic pain
Lower abdominal or back pain
Dyschezia, often with cycles of
diarrhea/constipation
Bloating, nausea, and vomiting
Inguinal pain
Dysuria
Dyspareunia with or without penetration
Nodules may be felt upon pelvic exam
Imaging may indicate pelvic mass/endometriomas
44
Imaging studies
Transvaginal or endorectal USG may reveal US
feature varying from cyst with internal echoes to
solid masses, usually devoid of vascularity
CT may reveal endometrioma appearing as cystic
masses; however, apperance are non specific and
imaging modalities should not be relied upon on for
diagnosis
MRI : may detect even smallest lesion and
distinguish hemorragic signal of endometrial
implant
MRI demonstrated to accurately detect
rectovaginal disease and obliteration in more than
90% of cases when USG gel was inserted in the
vaginal and rectum
45
Endometriosis therapy
Medical Therapies
Gonadotropin-releasing
hormone agonists (GnRH),
oral contraceptives,
Danazol,
aromatase inhibitors,
Progestins
Surgical Intervention
Laparoscopy
Hysterectomy/Oophorect
omy/Salpingooophorectomy
Nonsurgical Therapies
Medical Therapies
Alternative Therapies
Endometriosis therapy
46
Moderate-Severe Pain
NSAID
GnRH agonis
Oral contraceptive
Danazole
progestin
Aromatase inhibitor
47
Endometriosis therapy
Oral contraceptive
Generally well tolerated,
fewer metabolic and
hormonal side effect than
similar therapies
Relieve dismenorrhea throuh
ovarian supresion and
continous progestin
administration
Often simple, effective
choice to manage
endometriosis through
avoidance or delay menses
for upwards of 2 years
Reasonable cost
Ready availability
Progestins
Inhibit growth of lesion by infucing
ecidualization followed by
athropy uterine type tissue
48
Endometriosis therapy
Aromatase Inhibitor
GnRH agonist
Danazol
Amenorrhea
49
Amenorrhea is
menstruation.
the
absence
of
Primary
50
Terminology
51
Definition
Menstrual period
exceeding 8 days inbleeding
duration on regular basis
Definisi heavy
menstrual
dkk
Prolonged menstrual
bleeding
Shortened menstrual
bleeding
Infrequent 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
52
Terminology
Definition
Precocious menstruation
Amenorrhea primer
53
54
Diagnosis of
primary
amenorrhea
55
Diagnosis of
secondary
amenorrhea
56
58
Menopause
Perimenopause
It is 3-5 years period before menopause with increase frequent
irregular anovulatory bleeding followed by episodes of
ammenorrhea and intermittent menopausal symptoms.
Menopause:
- The point in time at which menstrual cycles permanently cease. It is
a retrospective diagnosis after 12 months of ammenorrhea women
classified as being menopause.
- Mean age 51 years.
II. Pathophysiology
pada usia sekitar 50 tahun fungsi ovarium menjadi sangat menurun.
59
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 kadar FSH lebih dari 30
mIU/ml
60
61
62
63
3. Psychological changes
decreased level of
central
neurotransmitters
- Depression
- Irritability
- Anxiety
- Insomia
- lose of concentration
64
4. Atrophic Changes
Vagina
*vaginitis due to thinning of epithelium, PH and lubrication.
*dysparnuedue to decrease vascularity and dryness
65
Diagnosis
Diagnosis menopause dibuat setelah terdapat
amenorea sekurang-kurangnya 12 bulan terakhir, kadar
FSH > 30 mIU/ml dan kadar E2 < 30pg/ml (Rogerio, 2000;
Baziad, 2003).
Terapi
Estrogen a minimum of 2mg of oestradiol is needed to
mantain bone mass and relief symptoms of menopause.
Women with uterus add progestin at last 10 days to
prevent endometrial Hyperplastic
Sequential Regimens - used in patient close to
menopause.
Oestrogen in the first of 28 day per pack
& Oestrogen & Progetin in 2nd 1/12 of 28 day pack..
66
Benefits of HRT:
Etiologi:
Endometrial Ca:
The most common Gynecological malignancy.
-Endometrial neoplasia can progress from simple hyperplasia to investive Ca
caused by unopposed oestrogen.
The mechanism of many End. Ca. is 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 Stimulation of Endometrium
PMM
Many patients with psychiatric disorders
also complain of worsening of their
symptoms around the premenstrual phase,
called premenstrual magnification.
ACOG 2008
69
INFERTILITAS
70
Infertility
71
Infertilitas
failure of a couple to conceive after 12 months of regular intercourse
without use of contraception in women less than 35 years of age; and
after six months of regular intercourse without use of contraception in
women 35 years and older
40% faktor istri
40% faktor suami
20% pada keduanya
wanita: 35-60% faktor tuba & peritonium
10-25% kasus: Unexplained infertility
Faktor Suami
a. 35% : faktor sperma
-b. Gangguan transportasi: Varikokel, prostatitis, Epididimitis, Orkhitis, kelainan
kongenital (Hipospadia, agenesis vas deferens, klinefelters syndrome,
Myotonic distrophy), kelainan hipotalamus-hipofisa
-c. Autoimunitas, Impotensi dan yang tak diketahui sebabnya.
72
Faktor Istri:
73
Infeksi
Gangguan ovulasi
Gangguan anatomi
Gangguan Ovulasi
Penuaan (usia)
POF
Polikistik Ovarii (PCOS)
74
75
Analisa Sperma
ANALISA SPERMA
76
C : bergerak ditempat
D : tidak bergerak
Teratozoospermia
Morfologi sperma normal < <30%
Astenozoospermia
OligoAstenoTeratozoospermia sindroma
OAT
77
Kelainan endokrin
Definisi klinis
Terdapatnya
hiperandrogenemia yang
berhubungan dengan
anovulasi kronik pada wanita
tanpa adanya kelainan dasar
spesifik pada adrenal atau
kelenjar hipofisa
Gejala :
Siklus menstruasi yang iregular: oligomenore dan amenore
Hiperandrogen: hirsutisme, jerawat dan alopesia
79
Source: http://www.pathophys.org/pcos/
Therapy
Lifestyle modification: may help
80 all symptoms of PCOS
attenuate
and reduce the long-term risk of
infertility, CVD and T2DM.
Anti-androgens (e.g.
spironolactone,finasteride,
flutamide): treatment of acne and
hirsutism.
Clomiphene
81
Ovarian drilling involves the creation of ~10 perforations in the ovary using
either cautery or laser. The ablation of some of the ovarian theca is thought
to help induce ovulation by decreasing androgen production.
IVF involves the retrieval of oocytes from the ovaries and in vitro
combination with sperm to produce embryos. Viable embryos are then
transferred into the uterus. Women with PCOS have similar success and live
birth rates compared to women without PCOS.
82
Fertility Test
LH-FSH Ratio : the relative value of 2 gonadotropin hormone produce by
the pituitary gland in women
Luteinizing hormone (LH) and Follicle stimulating hormone (FSH) stimulate
ovulation by working in different ways.
83
Kista Gartner
Kista yang terdapat didinding
lateral vagina
Berkembang dari sisa duktus
mesonephric atau duktus
gartner
Biasanya asimtomatis
85
86
Patologi
Abses Bartholini merupakan
polymikrobal infeksi
Neisseria gonorrhoeaea
yang paling umum
Jika tidak inflamasi
asimtomatik
Simtom: nyeri vulva,
dispareunia, kesulitan
berjalan/olah raga
87
Patofisiologi
Infeksi bakteri cepat menjadi abses keluar
lewat duktus tersumbat: abses membesar
Radang bisa berulang (68-75%)
Jika menahun terbentuk kista
88
Penatalaksanaan
Asimtomatik tidak perlu terapi
MARSUPIALIZATION
INCISI & DRAINASE
WORD CATHETER
Pembuatan 5 mm incisi pada
kista atau abses
Masukkan kateter Word dan
dikembangkan dengan 2-3 ml
saline selama 3-4 minggu
Jika tidak ada bukti infeksi
tidak perlu antibiotik
89
Marsupialisasi
Membuka rongga tertutup mjd kantong
terbuka.
Untuk cegah kista berulang
Dengan lokal anestesi
Pembuatan insisi vertikal elips 1,5-3 cm
(sesuai garis Langer)
Cukup dalam sampai kulit vestibular
dinding kista
Pengeluaran isi kista dg sendok kuret
kecil sampai bersih
Dinding kista dijahit ke kulit vertibular
dengan jahitan interupted
91
Kekambuhan
Pemasangan balon kateter Word (Kambuh 3-17%)
Marsupialisasi (Kambuh 10-24%)
Eksisi risiko perdarahan
92
Kista Nabothian
Kista nabothian merupakan benjolan kecil di leher
rahim yang berisi cairan.
Benjolan ini terjadi karena adanya penyumbatan
dari kelenjar.
Tidak didapatkan tanda dan gejala apapun, kista
nabothian biasanya di temukan pada saat
pemerikasaan spekulum.
Kista nabothian tidak berbahaya, sehingga tidak
diperlukan pengobatan apapun.
93
INFEKSI KONGENITAL
94
Teratogen: TORCH
95
96
97
TOXOPLASMOSIS
98
99
100
101
102
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
103
Congenital Toxoplasmosis
Uptodate.com, medscape
104
105
Rubella
106
107
108
109
110
111
CMV
112
114
115
116
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.
Source;
http://www.peri
natology.com/e
xposures/Infecti
on/CMV/Cytom
egalovirus.htm#
DXMOTHER
117
Varicella Infection
118
Hepatic calcification
Zooster Lesion
119
Management
Fetal Infection
Amniocentesis (culture or PCR of virus)
Fetal MRI : CNS
120
Alhamdulillah