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Gynecology
dr. Winda Yanuarni Meye
dr. Afrilia Intan Pratiwi
dr. Lintang Unggul Rini

The word "gynaecology" comes from the Greek γυνή gyne "woman"
and -logia, meaning "study."
Tumor of the Female Reproductive Organs
Clinical Aspects : Benign vs Malignant
 Tumor of the Uterine Cervix
Classification Risk Factors
• Benign tumor
• HVP infection, particularly
Leiomyoma (myoma)
type 16, 18, 45 and 56
• Malignant tumor • Sexual factor: early
A. Carcinoma of the cervix marriage, young age of
1. Squameus cell carcinoma 91 %
first coitus, multiple sexual
2. Adenocarcinoma
3. Adenosquameus carcinoma
partners, promiscuity
4. Adenoacanthoma • Female factor
B. Sarcoma ( very rare)
• Cigarette smoking
• Ca. of the Cervix is the most • Socio economic status,
common female malignancy in
developing countries
Parity, Race

1/23/2015 Lect. By dr. Heru Pradjatmo, Sp. OG 3

 Early detection
• Cytology examination
(Pap smear)
• Visual Inspection with
Acetic acid application
(VIA)
• Colpocopy examination
1/23/2015 Lect. By dr. Heru Pradjatmo, Sp. OG
Clinical Aspects
Symptoms
• Bleeding: vaginal, rectal, urethral
• Exert pressure: obstipasi, anuria
hydronephrosis --> renal failure
--> uremia
• Infection --> odor watery vaginal discharges
Physical signs
• discover follow cytology examination
• nodule, ulcer, exuberant erosion of the
cervix
• at advanced as crater-shaped ulcer with
high or friable warty mass
• freely bleeding on examination
• mobility of the cervix depend on the stage
4
HPV and Uterine Cervix - Pathogenesis
Precancerous Lession
Squamous Cell
Carcinoma
Clinical staging of Cervical Cancer
Screening for Cervical Cancer – Pap Smear
• to detect changes in cellular morphology (dysplasia) that are precursors to
carcinoma.
• The use of serial Pap smear screening decreases the false-negative rate; with
repeated smears
• False-negative Pap smears may result from inadequate sampling because of the
location of the lesion (i.e., endocervix), artifacts or poor preparation of slides, or
from reading (interpretive) errors.

Unreliable Pap smear due to inflammation:

If severe inflammation is present, its cause(s) must be investigated. The physician's
goals are to identify the cause of inflammation and to treat and resolve the
condition, if possible. Untreated inflammation can have consequences for the
woman as well as her sexual partner(s).
Physician should repeat the test after the condition resolve to diminish the false
positive result.

Emedicine
Methods to Improve Accuracy of Pap Smears
• Perform a Pap smear when the patient is in the proliferative phase (in the
week following cessation of menses).
• The patient should avoid intercourse or intravaginal products/douches for
24-48 hours before the examination.
• Use no lubricant prior to performing the Pap smear.
• Have cytobrush, spatula, slide, and other supplies on hand before starting
the pelvic exam.
• Rotate the Ayers spatula through a 360-degree arc over the
squamocolumnar junction if visible. Gently brush the spatula over the entire
slide, taking care to avoid a thick smear or shearing of cells by excessive
pressure.
• Collect the endocervical specimen using a cytobrush (about one full turn
with the brush mostly inside the cervix), or use a saline-moistened cotton
swab for pregnant women. Apply this to the same slide using a rolling
motion as noted in step 5.
• Rapidly apply fixative to the slide. If using a spray, hold it about 10 inches
from the slide to avoid dispersing the cells.
• Provide the cytologist with complete clinical information about the patient
including age, menopausal status, hormone use, history of radiation,
dysplasia, malignancy, etc.
Screening for Cervical Cancer – Pap Smear
• started three years after the onset of
sexual activity, but no later than age 21.
• High grade cervical intraepithelial lesions
(HSIL) are almost entirely related to
human papillomavirus (HPV)
• HSIL is a precursor to cervical cancer
• Infection through genital skin to skin
contact
• lesions usually do not occur until three to
ACOG guideline 2008 five years after exposure to HPV.
• annual screening for women younger than
30 years of age regardless of
testing method (conventional or liquid-based
cytology).
• Women aged 30 and over :
• performed annually if conventional
cervical cytology smears (Pap) are
ACOG guideline 2008
used OR
• every two years with liquid based
cytology tests • Exceptions: Women at
• Women aged 30 and over who have had : increased risk of CIN :
• three negative smears, • in utero DES
• no history of CIN II/III, and (diethylstilbestrol)
• are not immunocompromised exposure,
interval between tests to two - three years. • immunocompromise,
• Women aged 30 and over : consider a • a history of CIN II/III or
combined cervical cytology and HPV test. • Cancer
• Women who test negative by both tests should continue to be screened
should be screened every three years. at least annually.
• The United States Preventive Services Task Force
stated screening may stop at age 65 if :
• recent normal smears
• not at high risk for cervical cancer.
• The American Cancer Society guideline stated that
women age 70 or older may elect to stop cervical
cancer screening if :
• had three consecutive satisfactory,
normal/negative test results and no abnormal
test results within the prior 10 years.
• Not recommended in women who have had total
hysterectomies for benign indications (presence of
CIN II or III excludes benign categorization).
• Screening of women with CIN II/III who undergo
hysterectomy may be discontinued after three
consecutive negative results have been obtained.
• However, screening should be performed if the
DISCONTINUE
woman acquires risk factors for intraepithelial
neoplasia, such as new sexual partners or ACOG guideline 2008
immunosuppression.
AAFP Guideline
 Screening for cervical cancer Visual Inspection Test
Aceto White Sign -> Pre Cancerous Lession

screening.iarc.fr/doc/RH_via_evidence.pd
 Tumor of the Uterine Corpus

Benign tumor
• Leiomyoma (myoma): most common tumor in the body (smooth muscle cells)
• Aetiological factors: related to estrogen, three times more in black often found
in nulliparous
• Clinical aspects: exert pressure, pain, abdominal discomfort, abnormal bleeding,
infertility, infection

Type of Leiomyoma
Submucous : beneath endometrium, if
pedunculated -> geburt myoma
Intramural/interstitial: within uterine
wall
Subserous/subperitoneal: at the serosal
surface or bulge outward from
myometriuml ; if pedunculated : satelite
myoma
 SYMPTOMS
Menorrhagia and prolonged
menstrual period (common)
• Pelvic pain : occurs in
pregnancy if undergoing
degeneration or torsion of
a pedunculated myoma
• Pelvic pressure：urinary
frequency, bowel difficulty
(constipation)
• Spontaneous abortion
• Infertility
Whorl like pattern
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SIGN
A palpable abdominal tumor :
Abdominal lump – arising from
pelvis , well defined margins , firm
in consistency and having smooth
surface, tumor is mobile from side
to side .
• Pelvic examination：Uterus —
enlarged and irregular, hard
• Diagnosis : Bimanual exam, USG,
hysteroscopy, Laparacospy
• Treatment:
Observation: for small myoma,
premenopause
Operation : myomectomy or
hysterectomy
 Mioma - Histology
Secara histologis mioma terdiri dari berkas otot polos dan jaringan
ikat yang tersusun seperti konde/ pusaran air (whorl like pattern)
dengan pseudokapsul yang terdiri dari jaringa ikat longgar yang
terdesak karena pertumbuhan sarang mioma ini.
 Perubahan Sekunder Myoma
Jenis Degenerasi Jinak
a. Atrofi : dengan sendirinya mengecil
b. Degenerasi Hialin : pada usia lanjut,myoma
terlalu matang, struktur menjadi homogen,
seperti gelatin
c. Degenerasi Kistik (Likuifikasi)
Merupakan kelanjutan dari degenerasi hialin
sehingga seluruh tumor menjadi mencair seolah-
olah menyerupai,uterus yang gravid atau kista
ovarium.
d. Kalsifikasi (Degenerasi membatu)
Myoma jenis subserosa yang tersering
mengalami kalsifikasi ini karena sirkulasi darah
yang terganggu dan terutama pada wanita
berusia lanjut. Hal ini terjadi karena presipitasi
CaCO3 (calcium carbonate) dan fosfat
e. Degenerasi merah (Red or Carneous)
Terutama terjadi pada kehamilan dan nifas
dikarenakan trombosis vena dan kongesti
dengan perdarahan interstitial (nekrosis
sub akut) sehingga pada irisan melintang
tampak seperti daging mentah dan merah
yang diakibatkan penumpukan pigmen
hemosiderin dan hemofusin.
f.. Degenerasi Lemak (myxomatous or
fatty)
Merupakan degenerasi asimtomatik yang
jarang terjadi dan adalah kelanjutan dari
degenerasi hialin dan kistik.

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 Perubahan Sekunder Myoma
Jenis Degenerasi Ganas

Myoma uteri yang menjadi leiomyosarkoma ditemukan hanya

0,32 – 0,6% dari seluruh myoma serta merupakan 50-75% dari
semua jenis sarkoma uteri
Kecurigaan malignansi apabila myoma uteri cepat membesar
dan terjadi pembesaran myoma pada menopause.

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Tumor of the Uterine Corpus
Malignant Tumors
 Sindroma Ovarium Polikistik

Kelainan endokrin
 wanita usia reproduktif

Definisi klinis
Terdapatnya hiperandrogenemia yang
berhubungan dengan anovulasi kronik
pada wanita
tanpa adanya kelainan dasar spesifik
pada adrenal atau kelenjar hipofisa

•Gejala :
Siklus menstruasi yang iregular: oligomenore dan amenore
Hiperandrogen: hirsutisme, jerawat dan alopesia
Obesitas
> 65% wanita SOPK  IMT > 27
Distribusi lemak = kelainan metabolik
( hipertensi, dislipidemia, resistensi insulin / intoleransi glukosa )
Mulai belasan tahun
 BB   resistensi insulin, penyembuhan siklus menstruasi
pengurangan 10-15 % BB  75% konsepsi spontan

Akantosis nigrikan
Stimulasi insulin  lapisan basal epidermis

Ovarium polikistik
Terdapat pada 16-25% wanita normal & wanita amenora etiologi lain
Kista folikular kecil multipel (< 10mm), mengelilingi stroma.
80% wanita hiperandrogenemia mempunyai ovarium polikistik
(tidak pada wanita yang menggunakan OC, agen sensisitasi insulin, atau
bentuk lain supresi ovarium)
Px penunjang infertilitas

Fisik diagnostik-ginekologik
Foto HSG
Suhu badan basal (ovulasi)
Penunjang USG-TV
Analisa sperma
Penunjang hormonal (bila diperlulkan)
Laparoskopi-histeroskopi

Terapi Induksi Ovulasi

Senggama Terencana • Clomiphene Citrate (CC) 50-150 mg

IUI diberikan pada hari ke 5, 6, 7, 8, 9
Induksi Ovulasi dari siklus menstruasi
Laparoskopi operatif • hMG 2-3 Ampl/hari diberikan pada
Drilling hari ke 5,6,7,8,9,10,11,12,13,14,15
IVF dari siklus menstruasi
• FSH murni (Metrodin) 75 IU cara
pemberian sama dengan hMG
 Cervicitis
*Tidak mudah membedakan servisitis
dari vaginitis •Servisitis menular seksual = Servisitis
•4 faktor risiko u/ prediksi servisitis:
1. umur < 21 th mukopurulenta
2. Lajang
3. CS > 1 org dlm 3 bln terakhir  Biasanya asimtomatis
4. CS dg pasangan baru dlm 3 bln
terakhir Datang karena mitra menderita

UMS

Penyebab: GO; Non-GO

(C.trachomatis)

Lect. By dr. Retno Satiti, Sp.KK

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 CERVICITIS GO
peradangan serviks o/k N. gonorrhoeae
Penyebab: N. gonorrhoeae: diplokokus Gram Diagnosis:
negatif, terlihat di luar dan di dalam leukosit.
•Gram: pmn > 30; DGNI (+)
Klinis: asimtomatis; keputihan warna kuning
Px: • Kultur: Media Thayer Marthin
- vulva tenang
- inspeculo: dd vagina eritem/tenang •PCR
- ektoserviks: eritem/normal
- endoserviks: eritem, edem,
ektopi, bleeding,
discar mukopurulen

Lect. By dr. Retno Satiti, Sp.KK

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 Komplikasi Gonorhea Pada Pria

Infeksi Pertama : Komplikasi Lokal :

Uretritis
-Tysonitis
-Parauretritis
-Littritis
-Cowperitis
Komplikasi asenden :
-Prostatitis
-Vesikulitis
-Funikulitis
-Epididimitis
-Trigonitis
Ilmu Penyakit Kulit dan Kelamin FKUI
 Komplikasi Gonorhea pada Wanita
Pada wanita :
Infeksi pertama : Komplikasi Lokal :
-Uretritis
-Servisitis -Parauretritis
-Bartholinitis
Komplikasi asenden :
-Salphingitis
-PID
Komplikasi diseminata : artritis, miokarditis, endokarditis, perikarditis, meningitis,
dermatitis

Ilmu Penyakit Kulit dan Kelamin FKUI

 CERVISITIS NON GO
Peradangan serviks bukan o/k GO
Penyebab: C. trachomatis (terbanyak)
Klinis: asimtomatis; keputihan kuning
Px: vulva tenang
inspeculo: dd vagina eritem/normal
ektoserviks: eritem/normal
endoserviks: eritem, edem, ektopi, swab bleeding, discar
mukopurulen

C. Trachomatis

immunofluoresence
dg antibodi
monoklonal

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Lect. By dr. Retno Satiti, Sp.KK
 Vaginitis

• Penyebab umumnya: Trikomonas, Kandida, bakteri anaerob

 keputihan tidak selalu ditularkan secara seksual
• Gejala: abnormalitas volume, warna, bau dari discar vagina
• Gejala yg menyertai: gatal, edem, disuri, sakit perut/ punggung
bawah

Lect. By dr. Retno Satiti, Sp.KK

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 TRIKOMONIASIS/Vaginitis Trikomonal

Definisi: peny. Infeksi protozoa

yg disebabkan oleh T. vaginalis
inkubasi: 3-28 hr
Diagnosa :
1. Discar vagina kuning kehijauan,atau
berbuih dan bau busuk, strawberry cervix (+)
2. Peradangan pd dinding vagina
3. Lab: NaCl 0,9% : T. vaginalis motil

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Lect. By dr. Retno Satiti, Sp.KK
 KANDIDOSIS VULVOVAGINAL/
Vulvovaginitis kandidal
Definisi: infeksi vagina dan/atau vulva oleh kandida
khususnya C. albicans
Etiologi: Genus candida t/u C. albicans (80%)
kandida: kuman oportunis: di seluruh badan
Predisposisi: hormonal, DM, antibiotik, imunosupresi, iritasi

Diagnosa :
• keluhan gatal/panas/iritasi, keputihan tak bau/masam
* Dinding vagina &/vulva eritem/erosif
* Discar putih kadang disertai semacam sariawan
(thrush) berupa pseudomembran yg melekat pd
daerah erosif
• Discar putih kental spt susu/keju, bisa banyak, masam
• Dinding vagina dijumpai gumpalan keju
* pH <= 4,5
• Lab KOH 10% : pseudohifa ©Bimbel UKDI MANTAP
Lect. By dr. Retno
Satiti, Sp.KK
 Vaginosis bakterial (VB)
Definisi: * gangguan pada vagina tanpa peradangan
* sindroma klinik akibat perubahan lingkungan lokal
* pergantian flora normal Lactobasilus sp. oleh bakteri
anaerob: terutama G.vaginalis dll
Etiologi: bukan organisme tunggal
perubahan situasi dlm vagina --> anaerob

Inkubasi: bbrp hr-4 mgg

Diagnosa 3 dari 4 gejala:
1. Discar vagina, homogen, putih
keabuan, melekat pd dinding vagina
2. PH vagina > 4,5
3. Discar bau spt ikan --> tes amin
4. Clue cells --> Gram -

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Lect. By dr. Retno Satiti, Sp.KK
Pengobatan sindrom duh tubuh vagina karena vaginitis
Pengobatan untuk trikomoniasis
DITAMBAH
Pengobatan untuk vaginosis bakterial .
BILA ADA INDIKASI,
Pengobatan untuk kandidiasis vaginalis

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Lect. By dr. Retno Satiti, Sp.KK
Pengobatan sindrom duh tubuh vagina karena infeksi serviks
Pengobatan untuk gonore tanpa komplikasi
DITAMBAH
Pengobatan untuk klamidiosis

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Lect. By dr. Retno Satiti, Sp.KK
 Perlvic Inflammatory Disease
• Acute infection of the upper genital tract • Clinical symptoms
structures in women, involving any or all of – Abdominal pain
the uterus, oviducts, and ovaries – Vaginal bleeding
• Microbiology – Vaginal discharge
– N. gonorrhea – 1/3 of cases – Urethritis
– Chlamydia – 1/3 of cases • PE
– Mixed infection – strep, e.coli, klebsiella, – Abdominal pain
anaerobes – Fever
– Bimanual exam with CMT or
• Risk factors adnexal tenderness
– Number of sexual partners – Cervical discharge
– Age
• 15-25 years old w/ highest frequency
• Diagnosis
– Symptomatic male partner
– Pregnancy test
– Previous PID
– Cervical sample for GC/
– African American women
Chlamydia
– Pelvic ultrasound
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 Treatment on Pelvic Inflammatory Disease

Outpatient
• Ceftriaxone 250 mg IM x 1 +
doxycycline 100 mg po BID x
14 days
• Add metronidazole if
concern for pelvic abscess,
suspected
infection with Trichomonas,
or recent instrumentation
Inpatient
• Cefoxitin 2 G IV q 6 +
doxycycline 100 mg po/IV
Q12
• Amp/Sulbactam 3 G IV q 6
+ doxycycline po/IV
• Oral administration of
doxyxycline preferred due
to pain

Complication of Pelvic Inflammatory Disease

Perihepatitis: Fitz-Hugh Curtis Syndrome (RUQ pain with pleuritic
component),Tubo-ovarian abscess,Chronic pelvic pain –seen in 1/3 of
patients,Infertility,Ectopic pregnancy
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Lect. By dr. Retno Satiti, Sp.KK
 Ulkus Durum vs Ulkus Mole
Ulkus Durum Ulkus Mole
• Terkait dengan Sifilis • Chancroid/ H. Ducreyi
• Cenderung Soliter (tunggal) • Cenderung multiple
• Dasar bersih • Dasar kotor, tampak
• Tempat tersering : sulcus kemerahan hingga nekrotik
coronarius (pria), wanita
(labia mayora)
 Sifilis
• Peny. Infeksi sistemik & kronis
• Etiologi: T. pallidum
(Spirochaeta, spiral, Gram neg.,
Bergerak berputar, atau maju spt
pembuka tutup botol)

Transmisi: Perjalanan sifilis tanpa Tx:

* Kontak seksual
1. Sifilis primer
* Trans-Plasenta
2. Sifilis sekunder
Patogenesis: kontak langsung dari lesi 3. Laten dini
infeksius 4. Laten lanjut - tertier benigna,
treponema  selaput lendir  kelenjar limfe kardiovaskuler,
 pemb.darah  seluruh tubuh neurosifilis
 Sifilis Primer
- ulkus di genital eksterna, 3 mgg
setelak CS
• - tunggal/multipel, uk 1-2 cm
- Papula  erosi permukaan
tertutup krusta  ulserasi tepi
meninggi & keras  ulkus
durum
• -pembesaran lln. Inguinal
bilateral
• - sembuh spontan 4-6 mgg
 Sifilis sekunder (3-4 mgg
setelah ulkus durum)
- demam, malaise

- lesi kulit, selaput lendir, organ tubuh

- lesi kulit simetris, makula, papula

- folikulitis, papuloskuamosa,pustula

• moth-eaten alopecia - oksipital

• - papula basah daerah lembab: kondilomata lata

- lesi pd mukosa mulut, kerongkongan, serviks: plakat

• - pembesaran kel. Limfe multipel

• - splenomegali
 Sifilis Laten
• Sifilis Laten Dini :
stadium sifilis tanpa gejala
klinis
- tes serologis reaktif
< 1 th
•Sifilis laten lanjut  sifilis
tersier
•Muncul 2-20 tahun sesudah
infeksi primer
•Terjadi pada 30% kasus sifilis
Sifilis Tersier
• Muncul beberapa lesi kulit,
distribusi asimetris
• Sulit menemukan TP dlm lesi 
kurang infeksius
• Terjadi kerusakan jaringan/organ
• Lesi spesifik: Gumma
• - endarteritis obliterans -
peradangan-nekrosis
• - neurosifilis, kardiosifilis
 Sifilis Kongenital
•Didapat dari Ibu dg Sifilis awal
•Terjadi saat kehamilan > 4 bl (10
bl) 
•< 4 bl sisitem imun blm
berkembang penuh
•Tidak pernah terjadi ulkus
•Manifestasi klinis awal lebih
berat dibanding sifilis dapatan
•Sistem kardiovaskular sering
terlibat
•Dapat mengenai mata, telinga,
hidung
•Sering juga merusak sistem
skeletal
Sifilis kongenital dini: < 2 th

• - lesi kulit: terjadi segera,

vesikobulosa, erosi,

• papuloskuamosa,

• - mukosa: hidung, pharing:

perdarahan

• - tulang: osteokondritis tl
panjang

• - anemia hemolitik

• - hepatosplenomegali

• - SSP
• Sifilis kongenital lanjut: > 2 th

- keratitis interstisialis, pubertas,

bilateral
- gigi hutschinson

- gigi Mulberry

- Gangguan saraf pusat VIII – tuli

- neurosifilis
- Sklerosis – sabre
- Rhagade
• - kardiovaskular
Diagnosis: klinis + lab
1. Lab: medan gelap (dark field)  sifilis primer
2, antibodi serum : VDRL (1/16), TPHA  S sekunder & tersier

Terapi
sifilis primer & sekunder
Benzatin penisilin G 2,4 juta IU, IM, ds tunggal
anak: 50.000 IU/kg , IM, ds tunggal

sifilis laten:
laten dini: Benzatin penisilin G 2,4 juta IU. IM, ds tunggal
laten lanjut: Benzatin penisilin G 2,4 juta IU, IM/mgg, 3 mgg
anak: 50.000 IU/kg,IM,ds tunggal
50.000 IU/kg,IM/mgg, 3 mgg

Sifilis terstier: Benzatin penisilin G 2,4 juta IU/mgg, 3 mgg

Tindak lanjut: ulang serologi, 6, 12, 24 bl
Tx. Berhasil jika titer turun 4 x
 Kondiloma Akuminata
• Termasuk dalam STD • Predileksi :
• Pria = Wanita – Pria : perineum, sekitar anus,
sulkus koronarius, glans penis,
• Penularan : kontak kulit muara uretra eksterna, korpus
langsung penis
– Wanita : vulva, introitus
• Etiologi : Human vagina, porsio uteri (<<),
Papilloma Virus (HPV) tipe disertai fluor albus, pada
6,11,16,18, 30, 31, dsb wanita hamil pertumbuhan
lebih cepat
– Virus DNA
• Vegetasi bertangkai, merah-
– Keluarga Papova
hitam, papilomatosa
• Giant condyloma (Buschke)
 biopsi!
 Terapi
• Podofilin
– Tingtur podofilin 25%, 0,3 cc, dapat diulang setelah 3 hari
– Gejala toksisitas : mual, muntah, nyeri abdomen, gangguan pernafasan,
supresi sumsum tulang, trimbositopenia, leukopenia
– Teratogenik : kematian fetus
– Dapat untuk mengobati condiloma acuminata yang lokasinya berada pada
vagina

• Asam trikloroasetat 50% :

– Dioleskan seminggu sekali
– Efek samping : ulkus
– Dapat diberikan pada ibu hamil

• 5-Fluorourasil 1-5% cr :
– Pada lesi meatus uretra
– Setiap hari sampai lesi hilang, Os tidak miksi sampai 2 jam post pengolesan
• Elektrokauterisasi
– Hanya untuk kondiloma acuminata yang berada di labia / kulit
– Beresiko terjadinya jaringan parut
• Bedah beku (N2, N2O cair)
• Bedah skalpel
• Laser karbondioksida
– Lebih cepat sembuh, sedikit jaringan parut dibandingkan
elektrokauterisasi
• Interferon
– Injeksi IM atau intralesi atau topikal (cr)
– Dosis : 4-6mU IM 3 kali seminggu, 6 mg atau 1-5mU IM, 6 mg
 Kondiloma akuminata vs
kondiloma lata
Kondiloma akuminata
• Etiologi : HPV virus

Kondiloma lata
• Etiologi : triponema
palidum (sifilis sekunder)
 Terapi Scabies

• Belerang endapan (sulf. Precip.)4-20% cr • Krotamiton 10% cr, lotio

– tidak efektif untuk st. telur  penggunaan > – Efek : antiskabies dan antipruritus
3hr
– Berbau, mengotori pakaian, iritatif – Tidak boleh kena mukosa
– Bisa untuk anak < 2 th dan ibu hamil • Permetrin 5% cr:
• Emulsi Benzil Benzoat 20-25% – Efektif untuk semua std, tidak iritatif,
– Efektif untuk semua std mudah dipakai
– Diberikan setiap malam 3 hr
– Tdk untuk anak < 2 bl dan ibu hamil 
– Iritatif, gatal
nefrotoksik
• Gameksan 1% cr, lotio
– Efektif untuk semua std, tidak iritatif, mudah – Pemberian : 1 kali didiamkan 10 jam,
dipakai diulang 1 mg jk msh ada gejala
– Tdk untuk anak < 6 th dan ibu hamil 
nefrotoksik
– Pemberian : 1 kali, diulang 1 mg jk msh ada
gejala
Menstrual cycle

Lect.
©Bimbel UKDI MANTAP By dr. Hasto Wardoyo, Sp. OG
 Normal Menstrual Bleeding

• Occurs approximately once a

month (every 26 to 35 days).
• Lasts a limited period of time (3
to 7 days).
• May be heavy for part of the
period, but usually does not
involve passage of clots.
• Often is preceded by menstrual
cramps, bloating and breast
tenderness, although not all
women experience these
premenstrual symptoms.
• Average : 35-50 cc

Lect.
©Bimbel UKDI MANTAP By dr. Hasto Wardoyo, Sp. OG
 Ovulasi
• Terjadi 14 hari sebelum mens • >> kadar progesterone
berikutnya 2ng/ml
• Tanda dan tes : • LH surge (dg
– Rasa sakit di perut bawah (mid Radioimunoassay)
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
 Disfungsional Uterine Bleeding
• Diagnosis has to be confirmed by a process of exclusion of
pathological causes.

• DUB anovulasi (~90% kasus)

Disfungsi Perubahan
aksis Progesteron vaskular
Proliferasi
hipothalamus Anovulasi tidak endometrium Perdarahan
endometrium
-thalamus- dihasilkan & penurunan
ovarium prostaglandin

• DUB ovulasi
Akibat dilatasi vaskular endometrium
Lect. By dr. Hasto Wardoyo, Sp. OG
 Treatment of uterine
bleeding

Treatment of infrequent bleeding

1. Therapy should be directed at the underlying cause when possible.
2. If the CBC and other initial laboratory tests are normal and the history and
physical examination are normal reassurance
3. Ferrous gluconate, 325 mg bid-tid,

ACOG 2008
Treatment of frequent or heavy bleeding

1. NSAID
• improves platelet aggregation
• increases uterine vasoconstriction.
• NSAIDs are the first choice in the treatment of menorrhagia because they are well
tolerated and do not have the hormonal effects of oral contraceptives.
a. Mefenamic acid (Ponstel) 500 mg tid during the menstrual period.
b. Naproxen (Anaprox, Naprosyn) 500 mg loading dose, then 250 mg tid during the
menstrual period.
c. Ibuprofen (Motrin, Nuprin) 400 mg tid during the menstrual period.

2. Ferrous gluconate 325 mg tid.

3. Patients with hypovolemia or a hemoglobin level below 7 g/dL should be

hospitalized for hormonal therapy and iron replacement.
• Hormonal therapy: estrogen (Premarin) 25 mg IV q6h until bleeding stops.
Thereafter, oral contraceptive pills should be administered q6h x 7 days, then taper
slowly to one pill qd.
• If bleeding continues, IV vasopressin (DDAVP) should be administered.
ACOG 2008
• Hysteroscopy may be necessary, and dilation and curettage is a last
resort. Transfusion may be indicated in severe hemorrhage.
• Ferrous gluconate 325 mg tid.

4. Primary childbearing years – ages 16 to early 40s

A. Contraceptive complications and pregnancy are the most common causes of
abnormal bleeding in this age group. Anovulation accounts for 20% of
cases.
B. Adenomyosis, endometriosis, and fibroids increase in frequency as a woman ages,
as do endometrial hyperplasia and endometrial polyps. Pelvic inflammatory
disease and endocrine dysfunction may also occur.

ACOG 2008
 Endometriosis
An estrogen-dependent disease frequently resulting in substantial morbidity, severe
pelvic pain, multiple surgeries, and impaired fertility

Clinically defined as presence of endometrial-like tissue found outside uterus, resulting

in sustained inflammatory reaction

Ovaries among most common of locations;

gastrointestinal tract, urinary tract, soft tissues,
and diaphragm follow
 Sign Symptom
Dysmenorrhea
Heavy or irregular bleeding Classic signs:
Cylical/noncylical pelvic pain • severe dysmenorrhea,
Lower abdominal or back pain • deep dyspareunia,
• chronic pelvic pain,
Dyschezia, often with cycles of diarrhea/constipation
Bloating, nausea, and vomiting • Mittleschmertz,
Inguinal pain • perimenstrual symptoms
Dysuria
Dyspareunia with or without penetration
Nodules may be felt upon pelvic exam
Imaging may indicate pelvic mass/endometriomas

Pathophysiology
In situ from wolffian or mullerian
duct remnants (“metaplastic
theory”)
Coelemic metaplasia
Sampson’s theory
Iron-induced oxidative stress
Stem cells
 Treatment
• Surgical Intervention
• Laparoscopy
• Hysterectomy/Oophorecto
my/Salpingo-oophorectomy
• Nonsurgical Therapies
• Medical Therapies
• Alternative Therapies
Medical Therapies
• Gonadotropin-releasing
hormone agonists (GnRH),
• oral contraceptives,
• Danazol®,
• aromatase inhibitors,
• Progestins
Alternative
Therapies
Indications for surgical management
of endometriosis include:
• 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
Amenorrhea
Lect. By dr. Hasto Wardoyo, Sp. OG
©Bimbel UKDI MANTAP
Menopause
Diagnosis and Investigations:
• The Triad of:
-Hot flushes
-Amenorrhea
-increase FSH > 15 i.u./L
• Before starting treatment: You should perform
-breast self examination
-mammogram
-pelvic exam (Pap Smear)
-weight, Blood pressure
• No indication to perform
-bone density
-Endometrial Biopsy
but any bleeding should be investigated before starting any
treatment.
Treatment:
• Estrogen – a minimum of 2mg of oestradiol is needed to
mentain 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 ½ of 28 day per pack
& Oestrogen & Progetin in 2nd 1/12 of 28 day pack.
• Combined continuous therapy who has Progesterone
everyday – is useful for women who are few years past the
menopause and who do not to have vaginal bleeding.
• There is evidence that increase risk of endometrial cancer
with sequential regimens for > 5 years while on combined
continuous regimens decrease risk of Cancer.
 PMS (Pre Menstrual Syndrome)
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”.

Lect. By dr. Hasto Wardoyo, Sp. OG ACOG 2008

ACOG 2008
 PMS PMM
Diagnostic criteria Tenth Revision of Diagnostic and
the International Statistical Manual
Classification of of Mental
th
Disease (ICD-10) Disorders, 4 ed.
(DSM-IV)

Providers using Obstetrician/gynec Psychiatrists, other

these criteria ologists, primary mental health care
care physicians providers
Number of One 5 of 11 symptoms
symptoms
required
Functional Not required Interference with
impairment social or role
functioning
required

Prospective Not required Prospective

charting of daily charting of
symptoms symptoms
required for two
cycles

Lect. By dr. Hasto Wardoyo, Sp. OG

 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 F2α (PGF2α), a potent myometrial stimulant and vasoconstrictor,
in the secretory endometrium.The response to prostaglandin inhibitors in patients
with dysmenorrhea supports the assertion that dysmenorrhea is prostaglandin-
mediated. Substantial evidence attributes dysmenorrhea to prolonged uterine
contractions and decreased blood flow to the myometrium.
©Bimbel UKDI MANTAP
 Secondary
Dysmenorrhea beginning in the 20s or 30s, after previous relatively
painless cycles
Heavy menstrual flow or irregular bleeding
Dysmenorrhea occurring during the first or second cycles after menarche
Pelvic abnormality with physical examination
Poor response to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral
contraceptives (OCs)
Infertility
Dyspareunia
Vaginal discharge

Drug Therapy
Dysmenorrhoea can be effectively treated by drugs that inhibit
prostaglandin synthesis and hence uterine contractility.
These drugs include aspirin, mefenamic acid, naproxen or ibuprofen.

©Bimbel UKDI MANTAP

 Infertilitas
Selama 1 tahun, 2-3 x hub sex/minggu, tanpa kontrasepsi, tidak hamil

40% faktor istri

40% faktor suami
20% pada keduanya
wanita: 35-60% faktor tuba & peritonium
10-25% kasus: Unexplained infertility

Faktor Suami
a. 35% : faktor sperma
-b. Gangguan transfortasi: Varikokel, prostatitis, Epididimitis, Orkhitis, kelainan
kongenital (Hipospadia, agenesis vas deferens, klinefelters syndrome,
Myotonic distrophy), kelainan hipotalamus-hipofisa
-c. Autoimunitas, Impotensi dan yang tak diketahui sebabnya.
 Kista dan Abses Bartholini

• Umum pada wanita umur

reproduksi
• Lokasi pada labia mayora
• Abses 3 kali lebih umum dari
pada kista
• Obstruksi pada distal duktus
dapat karena retensi sekret
dan pembentukan kista
 Patologi
• Abses Bartholini Isolates from Bartholin's Gland
Abscesses
merupakan Aerobic organisms
polymikrobal infeksi Neisseria gonorrhoeae
• Neisseria gonorrhoeaea Staphylococcus aureus
Streptococcus faecalis
yang paling umum Escherichia coli
• Jika tidak inflamasi  Pseudomonas aeruginos
Chlamydia trachomatis
asimtomatik Anaerobic organisms Bacteroides
• Simtom: nyeri vulva, fragilis
Clostridium perfringens
dispareunia, kesulitan Peptostreptococcus species
berjalan/olah raga Fusobacterium species
 Penatalaksanaan
• Asimtomatik  tidak perlu terapi
• Incisi dan drainase  tx cepat & mudah 
kemungkinan rekuren
• WORD CATHETER
• MARSUPIALIZATION
• INCISI & DRAINASE
• Kista bartholini adalah kista yang terbentuk
akibat sumbatan pada ductus/ kelenjar bartolini.
Kista jenis ini dapat dilihat dari bagian luar /vulva,
umumnya muncul pada usia reproduksi. Kista ini
dapat berkembang menjadi abses apabila
terinfeksi.
• Kista gardner adalah kista yang muncul pada
liang vagina terutama pada bagian anterolateral,
berasal dari sisa ductus mesonephric/ ductus
wolfii.
Analisa Sperma
ANALISA SPERMA
Toxoplasmosis
 Hormonal Contraception and Lipid Metabolism

• Hormonal contraceptives  produce >> cortisol

• Cortisol  increase the mobilization of free fatty acids from
adipose.
• Excessive cortisol is linked to weight gain in some women.
• Older generations of hormonal contraceptives increase
insulin
secretion and the insulin resistance of cells
• Serum glucose levels are likely to increase in users of these
hormonal contraceptives, generally by 10 milligrams
(mg)/deciliter (dL).
• Newer progestogens do not seem to change fasting or
nonfasting insulin or glucose levels over the long term.
www.nutrition411.com/component/k2/item/d
ownload/1281
• Older generation forms of hormonal
contraceptives (>> estrogen ) increase total
cholesterol and LDL cholesterol, while HDL
cholesterol is decreased.
• Newer forms  increasing HDL and keeping LDL
steady.
• Coagulation proteins, including fibrinogen, are
produced by the liver at a greater rate in women
who are taking hormonal contraceptives. This
increases the risk of thrombosis of all types.

www.nutrition411.com/component/k2/item/d
ownload/1281
Hiperemesis Gravidarum
 Diagnosis Kehamilan

• Tanda Kehamilam tidak pasti (probable sign)

• Tanda kehamilan pasti

Obstetri Fisiologi, 2008.

©Bimbel UKDI MANTAP

 Probable sign

• Amenorrhea • Quickening
– Persepsi gerakan janin I
– Penyebab lain : ketidakseimbangan – 18-20 mg (primigravida), 16 mg
ovarium hipofisis, stres, obat-obatan, (multigravida)
penyakit kronis – Ditemukan jg pada Pseudocyesis
• Mual dan muntah • Keluhan kencing
– Morning sickness  >> estrogen dan – Urinasi >>, kencing malam >>
– Desakan uterus yg membesar
beta HCG, << motilitas gaster pagi hari dan tarikan ke kranial
– >> dg bau menusuk, emosi tidak stabil • Konstipasi
– Beri makanan ringan mudah dicerna – Efek relaksasi profesteron pd
tonus otot usus
• Mastodinia – Perubahan pola makan
– Rasa kencang dan nyeri pada payudara • Perubahan BB
– Pembesaran payudara, vaskularisasi>>, – Kehamilan 2-3 bl  << BB
proliferasi asinus dan duktus – Selanjutnya >>

– Pengaruh estrogen dan progesteron

©Bimbel UKDI MANTAP

Obstetri Fisiologi, 2008.
• >> temperatur basal > 3 mg
• Warna kulit :
– Kloasma, setelah 16 mg
– Warna areola menggelap
– Striae gravidarum
– Linea nigra
– Teleangiektasis
– Stimulasi MSH krn estrogen yang tinggi 
kortikosteroid >>
• Perubahan Payudara :
– Tuberkel montgomery menonjol (UK 6-8 mg)
– Stimulasi prolaktin dan Human Placental Lactogen
– Sekresi kolostrum (UK > 16 mg)
• Perubahan pelvis
– Chadwick sign (+)
– Serviks livid
– Cairan vagina putih, encer, sel eksfoliasi vagina >>
– Estrogen >>
– Hegar sign (+) (UK 6-8 mg)
– Pembesaran uterus (stlh UK 10 mg)

©Bimbel UKDI MANTAP

Obstetri Fisiologi, 2008.
• Pembesaran perut (stlh UK 16 mg)
• Kontraksi uterus
• Balotemen
– UK 16-20 mg
– Dd : asites dg kista ovarium, mioma uteri.

©Bimbel UKDI MANTAP Obstetri Fisiologi, 2008.

 Tanda Kehamilan Pasti
• DJJ • Laboratorium
– Laenec (17-18 mg)
– Doppler (12 mg) – Tes inhibisi
• Palpasi  22 mg koagulasi/PP test
• Rontgenografi • Inhibisi koagulasi
anti HcG
– Tulang tampak mg 12-14
– Jk terdapat keragu-raguan dan • Mendeteksi HcG
mendesak di urin
• USG • Kepekaan pada
– Mg 6 : gestational sac 500-1000 mU/ml
– 6-7 : polus embrional • Positif mg ke 6
– 8-9 : gerak janin
– 9-10 : plasenta, dst
– 2 gestational sac di mg 6  gmeli
• Fetal ECG : 12 mg, dg fetalkardiografi Obstetri Fisiologi, 2008.

©Bimbel UKDI MANTAP

 Gambaran Mola Parsial Mola komplit
Kariotipe Umumnya 69, 46, XX atau 46,
XXX atau 69, XXY XY
Patologi :
- Janin Sering dijumpai Tidak ada
- Amnion, RBC Sering dijumpai Tidak ada
janin Bervariasi, fokal Difus
- Edema vilus Bervariasi, fokal, Bervariasi, ringn-
- Proliferasi ringan-sedang berat
Honey comb appearance trofoblas
Gambaran Klinis :
- Diagnosis Missed abortion Gestasi mola
- Ukuran uterus Kecil untuk masa 50% besar untuk
kehamilan masa kehamilan
- USG Honey comb Snow storm/
appearance granular
appearance
- Penyulit medis Jarang Sering
- Penyakit
pascamola < 5-10% 20%
- Kista teka
Snow storm appearance lutein >> <<
Mola Hidatidosa
Thyroid and Pregnancy
THYROID DISORDER AND PREGNANCY
 Drugs for pregnancy
Chloramphenicol Ciprofloxacin

Ceftriaxon

Gentamycin
FAMILY PLANNING
Metode Kelebihan Kekurangan Indikasi kontraindikasi

Vaginal Mengganggu ASI (-) << sensasi Butuh KB Alergi lateks

pouch/kondo Pengaruh sistemik (-) Not practical pendukung,
m Murah, mudah didapat PMS, menunda
Mencegah PMS, ejakulasi dini hamil jangka
pendek

diafragma Mengganggu ASI (-) Sulit memasang Tdk bs memakai ISK

Dipasang 6 jam pre coitus  tdk Didiamkan di KB lain Alergi lateks
mengganggu sex vagina - 6 jam post Menyusui
Pengaruh sistemik (-) coitus PMS
Mencegah PMS >> infeksi uretra

spermicida Langsung efektif (busa dan krim) Efektivitas rendah Tidak bs ISK
Mengganggu ASI (-) Ketergantungan memakai KB
Metode pendukung pengguna hormonal
Pengaruh sistemik (-) Harus menunggu Tidak mau AKDR
Mudah dipakai, mudah didapat, 15 menit sebelum Menyusui
kapanpun hubungan (tablet,
>> lubrikasi supositoria)
Efektifitas 1x pakai
Coitus Mengganggu ASI (-) << sensasi Tdk bs Ejakulasi dini
interuptus KB pendukung Gagal >> menggunakan Ketaatan rendah
Efek samping (-), gratis, KB lain High risk mother
kapanpun
Metode Kelebihan Kekurangan Indikasi Kontraindikasi

Pil Kombinasi Sangat Efektif, Harus diminum tiap Heavy bleeding, Pregnancy
(estrogen dan reversibel hari Severe cramping, Cardiovascular and
progesterone) Tidak perlu px pelvis Efek samping : mual, irregular menstrual cerebro-vascular
Mengganggu coitus (- bercak perdarahan, period diseases
) nyeri kepala History of benign Breast lump or
Mudah Mengganggu ASI ovarian cyst cancer
Mencegah PID Mahal History of ectopic Malignant diseases
Interaksi dg pregnancy of genital tract
beberapa obat History of breast Abnormal vaginal
Tidak melindungi diseases bleeding
PMS Family history of Liver diseases and
ovarian cancer benign or malignant
liver tumors
- Monofasik :
21 tablet hormon aktif dlm dosis sama,
dan 7 tablet iron/plcbo
- Bifasik :
21 tablet hormon aktif dlm 2 dosis
berbeda dan 7 tablet iron/plcbo
- Trifasik :
21 tablet hormon aktif dg 3 dosis
berbeda dan 7 tablet iron/plcbo
Waktu menggunakan Pil Special attention

- Setiap saat, selagi haid - Pil pertama diminum hari 1

- Hari pertama siklus haid mens
setelah berhenti kb - Pil non hormonal diminum 7 hr
suntik, bs langsung sebelum haid berikutnya
menggunakan kb pil. - Paket 28 pil habis  ganti
- Paket 21 pil habis  tunggu 7
hari  ganti
- Setelah melahirkan :
1. Setelah 6 bulan ASI
eksklusif - Lupa minum 1 hari 
2. Setelah 3 bulan dan hari berikut minum 2
tidak ASI - Lupa 2 hari  minum 2
3. Pasca aborsi (segera- 7 saat ingat, besoknya
hari post aborsi minum 2  kembali ke
jadwal + kb pendukung
- kec. placebo
 Pil Progestin (Mini Pill)
Kelebihan Kekurangan Indikasi Kontraindikasi
- Tdk mengganggu - Gangguan mens- - Wanita menyusui Hamil
ASI amenorrhea - Perokok segala Pedarahan per
- Dosis rendah - Spotting usia vaginam
- Tdk memberi efek - Mens tdk teratus - TD tinggi (< Menggunakan obat
samping estrogen - Mahal 180/110) atau TB, fenitoin,
- KB darurat - Tdk mencegah PMS, masalah barbiturat
HIV pembekuan darah Riw. Kanker payudara
- Nyeri kepala, mual Mioma uteri
- Perubahan mood Riw. stroke
- Gemuk
- Jerawat, hirsutisme
Waktu menggunakan Pil Special attention

- Mulai hari 1-5 mens

Menyusui 6 mg- 6 bulan, - Muntah 2 jam setelah minum
dan tidak haid  minum pil lagi, pakai kondom
- Bl > 6 mg menyusui, saat coitus dlm 48 jam
haid, minipil dimulai hr 1 - Lupa minum 3 jam  lgsg
mens minum saat ingat  pakai
- kondom saat coitus dlm 48 jam

- KB sebelumnya
hormonal  bs lgsg
diganti minipil - Lupa minum 1 hari 
hari berikut minum 2
- KB sebelumnya KB
suntik  minipil diberi di - Lupa 2 hari  minum 2
jadwal selanjutnya saat ingat, besoknya
minum 2  kembali ke
- KB lain  dpt lgsg ganti jadwal + kb pendukung
 PIL KOMBINASI DAN PROGESTIN
Keadaan Saran
DM Tanpa komplikasi Pil dapat diberikan
Migrain Tanpa defisit neurologi fokal Pil dapat diberikan
Menggunakan fenitoin, Dosis etinilestridiol 50 mcg
barbiturat, rifampisin
Sickle cell anemia Pil tdk boleh digunakan

Efek samping penanganan

Amenorrhea PP test  tdk hamil  lanjutkan KB dg dosis estrogen 50 mcg

atau turunkan dosis progesteron.
Hamil  stop pil

Mual, pusing, Tes kehamilan, px ginekologi  tdk hamil  minum pil saat
muntah makan malam/sebelum tidur

Perdarahan per Pp tes, px ginekologi

vaginam/ spotting Biasa pada 3 bulan pertama, akan berhenti sendiri
> 3 bulan  naikkan dosis estrogen (50 mcg)  perdarahan
stop  kembali dosis awal.
 Metode Keuntungan Kerugian Indikasi Kontraindikasi

Injeksi - Efektif - Fertilitas dapat - Menunda hamil - Hamil

Kombinasi - Dapat digunakan tertunda jangka panajang - Ikterik
dan Injeksi - Gangguan hepar
usia > 35 - Invasif - Punya anak cukup
Progestin - Gangguan
- Tidak mengganggu - Dpt - Tidak mau minum pil tromboemboli
ASI menyebabkan tiap hari - DUB
- Tidak mengganggu infeksi - Takut sterilisasi - Tumor payudara
coitus - Mens lebih - Menyusui - DM dg komplikasi, HT
> 180/110 atau st II dg
banyak
komplikasi
- Tidak mencegah - Migrain berat
PMS
- Efek samping
estrogen
(kombinasi)
Jenis suntikan :
- 25 mg Depo Medroksiprogesterone Asetat
(Depo provera) + 5 mg Estradiol Sipionat (1 - Menekan Ovulasi
bulan sekali - Mengentalkan lendir serviks
- 50 mg Noretindron Enantat + 5 mg Estradiol - Atrofi endometrium 
Valerat (sebulan sekali) mengganggu implantasi
- Depoprovera (150 mg DMPA) tiap 3 bln - Menghambat gerakan tuba
- Depo Noretisteron Enantat 200 mg, tiap 2
bln (4 injeksi )  tiap 3 bln
 Keadaan Penanganan
Waktu injeksi Td tinggi < 180/110 dpt diberikan dg
pengawasan

-hari 1 mens** DM Dapat diberikan jk tanpa

- Setelah hari 7 mens dg KB kompikasi
pendukung 7 hari** Migrain Dpt diberikan jk tdk ada
- Post partus 6 bulan, tdk haid, defisit neurologis dan nyeri
ASI  asal tdk hamil kepala
Obat TB dan Ditambah pil etinilestradiol
epilepsi 50 mcg / ganti KB
- Post partus > 6 bl, ASI, haid  ** Sickle cell Tidak boleh diberikan
- Post partus 3 minggus, tidak ASI  tdk anemia
boleh suntik
Amenorrhea Singkirkan kehamilan, KB
- Post aborsi  ** dapat dilanjutkan
- Ganti dari KB non hormonal  **
Mual, pusing, Jk tidak hamil, akan hilang
Ganti dari KB hormonal  sesuai jadwal muntah dalam 2-3 bulan
- Boleh maju 2 mg dari jadwal
Spotting Bl tidak hamil, akan hilang
- Boleh mundur 2 mg dari jadwal asal tdk dalam 2-3 bl.
hamil  pakai KB pendukung 7 hr
 IMPLANT
Keuntungan
Highly effective, first year
preg. rate 0.2-0.5/100
women
Rapidly effective, less than
24 hours
Longterm protection, up to
five years
Immediate return of fertility
after removal
Inexpensive and convenient
Kerugian
Does not protect against
STDs, HIV, HBV
Requires minor surgical
procedur for insertion and
removal
Client can not discontinue
on her own
Implant may be visible
under the skin
Menstrual problems may
happen
Other side effects are similar
to injectables
Indikasi
Wants to have longterm
birth spacing
Has got enough children
Does not want to take dailly
pills
Has contraindication to
estrogen
Does not accept sterilization
Is breastfeeding
Kontraindikasi
Pregnancy
Jaundice, active liver
disesaes or tumors
Active thromboembolic
disorder
Undiagnosed vaginal
bleeding
Breast lump or cancer
Diabetes mellitus and
hypertension
Severe migrain headache
Depression

- Norplant : 6 batang, 36 mg levonogestrel, 5 tahun

- Implanon : 1 batang, 68 mg 3-keto-desogestrel, 3 tahun
- Jadena dan Indoplant : 2 batang, 75 mg levonogestrel, 3
tahun
 AKDR (ALAT KONTRASEPSI DALAM RAHIM)
Keuntungan
Immediate, highly effective
and longterm (up to 8
years for the Tcu 380A)
Immediate return to
fertility upon removal
No hormonal side efeects
(local only)
Cost effective
Suitable for lactating
women
Practical, not user
dependent
Efek Samping :
- Siklu haid terganggu dlm 3 bulan
pertama
- Haid >>
- Spotting antar siklus
Kerugian
Requires pelvic examination
May increase risk of PID
and subsequent infertility
Requires minor surgical
prosedure either on
insertion or removal
May increase menstrual
bleeding and cramping
No protection against STDs,
HIV or HBV
May spontaneously expel
Requires checking the string
Indikasi
Prefers a longterm and
effective method but no
sterilization
Has one or more children
Is breastfeeding
Does want to take
hormonal contraception
because of side effects or
contraindications
Is at low risk of contracting
STDs
Has sucessfully used an IUD
in the past
Kontraindikasi
Pregnancy
Current, recent or recurrent
PID
Acute purulent discharge
from the cervical canal
(gonorrheal or chlamydial
cervicitis)
Undiagnosed vaginal
bleeding
High risk for GTIs or STDs
Available mainly in three types
•Innert IUDs, plastic (Lippes Loop) or Mevhanism of action :
Preventing fertilization, by blocking the
stainless steel (the chiness ring)
migration of the sperms to the ovum,
•Coper bearing IUDs which include the TCu
decreasing the number of sperm and
200, TCu 380A, MLCu 250, MLCu 375, Nova T
inactivating them
and the Medusa Pessar
Less likely a local inflamation may prevent
•Steroid medicated IUDs such as implantation of the fertilized egg
ProgestasertR, and LevoNovaR

Relative Contraindication
Leukemia, diabetes and immunocompromised
women
Severe anemia
Rheumatic or Valvular heart disease
Severe painful menstrual period (dismenorrhea)
History of an ectopic pregnancy
Uterine fibromyomas, uterine abormality and
cervical stenosis
 Metode Laktasi Amenore
• MLA merupakan metode kontrasepsi
alamiah yang mengandalkan
pemberian ASI pada bayinya
• Akan tetap mempunyai efek
kontrasepstif apabila
• Menyusukan secara penuh
(eksklusif)
• Belum haid
• Usia bayi kurang dari 6
bulan
• Efektif hingga 6 bulan
• Bila ingin tetap belum ingin hamil,
kombinasikan dengan metode
kontrasepsi lain setelah bayi berusia 6
bulan
Wanita yang:
 Menyusukan bayinya secara eksklusif
(memberikan ASI secara penuh tanpa
suplementasi lainnya)
 Belum mendapat haid sejak
melahirkan bayinya
 Menyusukan secara eksklusif sejak
bayi lahir hingga bayi berusia 6 bulan
1
TIDAK DILANJUTKAN JIKA
 Setelah beberapa bulan amenorea,
klien mulai mendapat haid
 Tidak menyusukan secara eksklusif
 Bayi telah berusia diatas 6 bulan
 Ibu bekerja dan terpisah dari
bayinya lebih dari 6 jam dalam
sehari 120
 Tubektomi:
Mekanisme Kerja

Mencegah pertemuan
sperma dengan sel telur
(fertilisasi) dengan jalan
menutup atau oklusi
saluran telur (tuba
fallopii)

121
MOP

122
Kontrasepsi Metode Operatif
 Vasektomi: Mekanisme Kerja

Oklusi vasa deferensia

membuat sperma tidak dapat
mencapai vesikula seminalis
sehingga tidak ada di dalam
cairan ejakulat saat terjadi
emisi ke dalam vagina

124
 Emergency post coital contraception
• Digunakan setelah unprotected coitus, gagal KB
• Morning after pill
– Progestin only
– Mekanisme : mukosa cerviks lebih kental, menunda
ovulasi
– Levonogestrel 1,5 mg single dose atau 0,75 mg tiap 12
jam (satu hari) , dalam 5 hari dari unprotected coitus
• Copre bearing IUD (>> efektif)
– Hanya dipasang pada yang sudah menikah
www.nhs.uk
 Abortus
• Perdarahan + hasil konsepsi, UK < 22 mg atau berat < 500
gr
 Early abortion < 12 weeks
 Late abortion 12-20 weeks

• Abortus imminens • Spontaneous abortion: abortion

• Abortus Insipiens
• Abortus Inkomplit
• Abortus Komplit
• Missed Abortion
• Septic abortion
• Habitual abortion
happens by nature, no
intervention
• Induced abortion (artificial
abortion): abortion made for
certain purposes
– Medical or therapeutic abortion
– Criminal abortion: other than
therapeutic abortion (illegal
abortion)
 ETIOLOGY
EARLY ABORTION
• Abnormal product of
conception
• Infections (CMV)
• Autoimmun disorders (SLE)
• Endocrine abnormalities
(luteal phase defect)
• Uterine abnormalities
(septus, arcuatus, bicornual,
didelphys etc)
• Many is still unknown
LATE ABORTION
• Infection (malaria, syphylis,
typhoid)
• Circumvallate placenta
• Metabolic disorders (DM,
Thyroid)
• Physiologic impairment (renal,
cardiac, hepatic diseases,
hypertension)
• Severe dietary insufficiency:
anemia, avitaminosis
• Isoimmunisation
• Poisoning (lead, drugs abuse)
• Trauma to the womb
• Cervical incompetence
 Ab imminens
• Penanganan :
– Bedrest total
– Hindari aktivitas fisik berlebihan dan hub seksual
– Antibiotik  mencegah infeksi
– tokolitik
• Progesterone VS placebo
– Wahabi HA, Abed Althagafi NF, Elawad M. Progestogen for treating threatened
miscarriage. Cochrane Database of Systematic Reviews 2007, Issue 3.

– Jika perdarahan :
• Berhenti  lakukan ANC seperti biasa
• Berlanjut  Pptes, USG
• Rawat inap :
– Untuk menunjang bedrest
– Observasi jika berlanjut menjadi Ab insipiens, inkomplit, atau komplit.
 Abortus insipiens
• UK < 16 mg :
– Evakuasi konsepsi dg aspirasi vakum manual
– Jk tdk bisa : ergometrin 0,2 mg IM (dpt diulang tiap 15
menit jk perlu)
– Atau misoprostol 400 mcg per oral (dapat diulang tiap
4 jam jk perlu)
– Lanjutkan dg kuretase
• UK > 16 mg :
– Tunggu ekspulsi spontan  evakuasi sisa konsepsi
– Jk perlu, berikan oksitosin 20U dalam 500cc RL 40 tpm
untuk mempercepat ekspulsi
 Abortus inkomplit
• UK < 16 mg 
– Evakuasi jaringan secara digital
– Perdarahan berhenti  ergometrin 0,2 mg IM atau misoprostol 400
mcg PO
• UK < 16 mg, perdarahan banyak, terus menerus 
– Aspirasi vakum manual untuk evakuasi jaringan
– Jk tidak ada : kuretase dg sendok kuret tajam
– Jk perlu  ergometrin 0,2 mgIM (dpt diulang stlh 15 menit) atau
misoprostol 400 mcg PO (dpt diulang setelah 4 jam)
• UK > 16 mg :
– Oksitosin 20 U dlm 500 cc RL, drip 40 tpm sampai tjd ekspulsi
– Jk perlu : misoprostol 200 mcg pervag tiap 4 jam smp ekspulsi (maks
800 mcg)
– Jk perlu : kuretase untuk membersihkan sisa jaringan di uterus.
 Abortus Komplit
• Tidak perlu evakuasi jaringan
• Observasi KU, VS, dan perdarahan
• Cek Hb post abortus  anemia ringan  SF
600 mg/hari 2 mingggu
• Jk anemia berat (<7 gr/dl)  transfusi darah
sampai Hb mencapai 10 mg/dl
 Abortus rekuren/habituasi
• Abortus spontan berturut-turut selama tiga
kali atau lebih
• Penyebab : >> anomali kromosom
 Abortus septik

• >> komplikasi pada abortus kriminalis

• Tanda dan gejala :
– demam,
– Sekret vagina berbau
– AL > 11 rb atau < 4 rb
– Dapat terjadi syok septik
• metritis, parametritis, hingga peritonitis
• Penyebab : bakteri anaerob (>>), H. influenzae,
Campylobacter jejuni, streptokokus grup A
• Terapi : evakuasi segera produk konsepsi, spektrum
luas parenteral, tangani syok jk terjadi
 Missed abortion
• perdarahan dari jalan lahir ≥ 8 mg
• Perdarahan sedikit, hitam.
• Nyeri perut <<
• OUE menutup
• PPTest (-)
• Ukuran uterus < UK
• USG : blood clot dalam uterus
• Tx : dilatasi dan kuretase
 Kontrasepsi Post Abortus
Metode Waktu aplikasi Keterangan
Kondom Segera Membantu mencegah PMS
Pil hormonal Segera Butuh ketaatan tinggi
Suntikan Segera
Implan Segera Jk sudah punya anak 1 atau
lebih dan ingin KB jangka
panjang
AKDR Segera atau setelah pasien Tunda insersi jk Hb < 7
pulih gr/dl atau curiga infeksi
Tubektomi Segera Tunda jk curiga infeksi dan
Hb < 7 gr/dl
Safe pregnancy after medical abortion
• Don’t have sex until 2-4 weeks after abortion.
• Patient can get pregnant as soon as two weeks
after an abortion.
• Menstrual cycle will go back to it’s regular
cycle and ovulation at 2 weeks post abortion.

http://www.afterabortion.com/physical.html
 Kehamilan Ektopik
Definisi

Kehamilan yang implantasi blastosisnya

terjadi di luar mukosa endometrium

23/01/2015 19:45 Ectopic Pregnancy 138

Tempat-tempat kehamilan ektopik
Abdomen (< 2%)
Ampulla (>85%)
Isthmus (8%)

Cornual (< 2%)

Ovary (< 2%)

Cervix (< 2%)

1)Fimbria 2)Ampulla 3)Isthemus 4)Interstitial 5)Ovarium

6)Cervic 7)Cornual 8) Secondary abdominal 9) ligamentum
latum 10)Primary abdominal
23/01/2015 19:45 Ectopic Pregnancy 139
 Gambaran Klinis
• Kehamilan ektopik ada yang asimptomatik
hingga ruptur
• Ada dalam 2 variasi: akut dan kronik
• Gejala-gejala:
– Amenorrhea
– Nyeri abdomen
– Syncope
– Perdarahan pervaginam
– Massa pelvis

23/01/2015 19:45 Ectopic Pregnancy 140

 DIAGNOSIS DINI
• Dapat didiagnosis sebelum umur kehamilan 6
minggu, paling awal 4,5 minggu, dan sebelum
adanya gejala-gejala
• Pengukuran hCG kehamilan normal
meningkat 2 kali lipat tiap 2 hari pada minggu
4-8. KE tidak ada peningkatan
• Kadar progesteron serum (8-10 minggu)
• USG  transvaginal: 4-5 mg; hCG 2000 IU/L
• Laparoskopi  gold standard
23/01/2015 19:45 Ectopic Pregnancy 141
 PENATALAKSANAAN

• Tergantung stage penyakit dan kondisi pasien

• Pilihan terapi:
– Ekspektatif
– Medikamentosa
– Pembedahan
• Pilihan terapi berdasarkan penilaian luaran jangka
pendek (menurunnya hCG, trofoblast persisten,
keutuhan tuba) dan luaran jangka panjang (patensi
tuba dan fertilitas berikutnya)
23/01/2015 19:45 Ectopic Pregnancy 142
 PENATALAKSANAAN

• Ekspektatif:
– Bila titer ßhCG < 2000 IU/L, mengalami
penurunan progresif
– USG: ukuran massa < 2 cm, tidak ditemukan
bagian janin
– Hemoperitoneum < 50 ml
– Tidak ada gejala-gejala klinis yang semakin
memburuk
• Efikasi jelek, rawat inap lama, evaluasi lama

23/01/2015 19:45 Ectopic Pregnancy 143

 PENATALAKSANAAN
• Medikamentosa
– Sistemik atau lokal
– Agen: MTX, glukosa hiperosmolar, prostaglandin.
Yang paling banyak digunakan MTX
– Singgle dose 50 mg/m3
• Syarat:
– Titer ßhCG < 2000 IU/L
– Ukuran massa KE < 3,5 cm

23/01/2015 19:45 Ectopic Pregnancy 144

 Pembedahan
Perdebatan:

LAPAROTOMY?
VS.
LAPAROSCOPY?
SALPINGECTOMY?
VS
SALPINGOSTOMY / SALPINGOTOMY?
Tergantung stabilitas hemodinamik, ukuran
dan lokasi KE, keahlian
23/01/2015 19:45 Ectopic Pregnancy 145
IUFD
 TB on pregnancy and lactation
Efek pada kehamilan :
- Gangguan
pertumbuhan janin Rifampicin
- BBLR INH
- Persalinan Preterm
- >> kematian perinatal
Ethambutol

KONTRA INDIKASI :
STREPTOMYCIN
- OTOTOKSIK pd janin
- Nefrotoksik Efek teratogenik tidak terbukti
- Neurotoksik pd n 8
Semua jenis OAT aman untuk ibu menyusui