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Study Guide The Reproductive System and Disorders INTRODUCTION The medical curriculum has become increasingly vertically integrated, with a much greater use of clinical examples and cases to help in the understanding of the relevance of the underlying basic science, and conversely use of basic science concepts to help in the understanding of the phatophysiology and treatment of disease. The reproductive system and disorder block has been written to take account of this trend, and to integrate core aspects of basic science, pathophysiology and treatment into a single, easy to use revision aid. In accordance the lectures that have been full integrated for studens in 6 semester, period of 2016, one of there is The Reproductive System and Disorders Block. Th There are many topics will be discuss as below: Anatomy of female genital system, histology of male and female, physiology of male and female, antenatal care normal labor & delivery, early pregnancy disorders, abnormal pregnancy, abnormal labor, puerperium & disorders, obstetric emergency, common gynecology and disorders, diseases of the breast, male and female genital disorders, male and female family planning, drugs therapy in pregnant and genital disorders. Beside those topics, also describes the learning outcome, learning objective, learning task, self assessment and references. The learning process will be carried out for 4 weeks (20 days). Due to this theme has been prepared for the second time, so many locking mill is available on it. Perhaps it will better in the future Thank you. Planners Udayana University Faculty of Medicine, DME 1 Study Guide The Reproductive System and Disorders CURRICULUM CONTENTS Aims: Comprehend the biologic function of reproductive system in male and female. Comprehend the pathological process of the reproductive disorders in male and female. Diagnose and manage patient with male genital disorders. Diagnose and manage patient with gynecologic and obstetric problem. Educate patient and their family and community about reproductive disorders. Learning outcome: Explain (differentiate) the functional structure of male and female reproductive system. Explain pathological process related to symptom and sign of male disorders. Explain pathological process related to symptom and sign of gynecologic and obstetric disorders. Interpret the common laboratory and imaging result in male genital disorders. Interpret the common laboratory and imaging result in gynecologic and obstetric problems. Diagnose and manage patient with male genital disorders. Diagnose and manage patient with normal pregnant Diagnose and manage patient with infertility and family planning Diagnose and manage patient with gynecologic and obstetric problems Communicate the education principle in male genital problems, gynecologic and obstetric problems. Curriculum contents: Anatomy of female reproductive system Histology of male and female reproductive system Physiology of male and female reproductive system Male and female family planning Normal labor and ANC Abnormal labor Obstetric emergency Common gynecologic and disorders/ morphology Benign and malignant diseases of the breast/ morphology Puerperium and disorders Male genital disorders Male and female infertility Pharmacology Udayana University Faculty of Medicine, DME 2 Study Guide The Reproductive System and Disorders PLANNERS TEAM NO NAME DEPARTEMENT 1. Dr.dr. IBG Fajar Manuaba, SpOG, MARS 2. dr. I.G.A Sri Darmayani, SpOG Obgyn Medical Education (DME) LECTURERS NO NAME DEPARTEMENT PHONE Obgyn 081558101719 DME 081338644411 1. Dr.dr. I.B.G Fajar Manuaba, SpOG, MARS 2. dr. I.G.A Sri Darmayani, SpOG 3. Prof.DR.dr. Nyoman Mangku Karmaya, M.Repro, PA (K), FIASS Anatomy 0811387105 4. dr. I.W Sugiritama, M.Kes Histology 08164732743 5. Dr. dr. Susy Purnawati.M.KK Physiology 6. Dr.dr.I Nyoman Bayu Mahendra, SPOG (K) 08123989891 081339550423 7. dr. A.A.A.N. Susraini, Sp.PA(K) 8. Obgyn Anatomy Pathology 0811398913 Dr.dr I Nyoman Gede Budiana, SpOG (K) Obgyn 08123997401 9. Dr. dr. I Gede Ngurah Harry Wijaya Surya,Sp.OG Obgyn 0811386935 10. Obgyn 082283387245 11. Dr Jaqueline Sudiman,GrandDipRepSc,MrepSc,PhD Dr.dr.Bagus Komang Satriyasa,M.Repro Pharmacology 081805368922 12. dr. Putu Anda Tusta Adiputra, Sp.B (K) Onk Surgery/Oncology 08123826430 13. dr.Gede Wirya Kusuma Duarsa M.Kes,SpU Surgery/Urology 08155753377 14. dr. Wayan Sudarsa, SpB.K.Onk Surgery/Oncology 0811398971 15. dr Yukhi Kurniawan, SpAnd Andrologi 08123473593 16. Dr Made Wardana Anatomy 087860405625 Udayana University Faculty of Medicine, DME 3 Study Guide The Reproductive System and Disorders FACILITATORS Regular Class (Class A) No 1 2 3 4 5 6 7 8 9 10 11 12 Name Dr.dr. I Gede Ngurah Harry Wijaya Surya,Sp.OG dr. Nyoman Paramita Ayu, Sp.PD dr. Anak Agung Ayu Ngurah Susraini, Sp.PA (K) dr. I Made Putra Swi Antara, Sp.JP dr. I G N Sri Wiryawan, M.Repro dr. I Dewa Ayu Inten Dwi Primayanti, M.Biomed dr. I Gede Sastra Winata, M.Biomed, Sp.OG Dr. dr. I Wayan Suranadi, Sp.An-KIC Dr. dr. I Wayan Putu Sutirta Yasa, M.Si dr. I Nyoman Gede Wardana, M.Biomed dr. Yukhi Kurniawan, Sp.And dr. I G A Sri Darmayani, Sp.OG Group A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 Departement Phone Obgyn 0811386935 Interna 08123837372 Anatomy Pathology Cardiology 0811398913 08123804782 Histologi 08123925104 Fisiology 081337761299 Obgyn 081338713951 Anasthesi 08123847675 Clinical Pathology Anatomy 08123953344 087860405625 Andrology 08123473593 DME 081338644411 Departement Phone Fisiology 0811397971 Anasthesi 085238514999 Fisiology 08123989891 Orthopaedi 0817776126 Obgyn 081339550423 Histology 085104550344 Public Health 08123816424 Microbiology 08123921590 Obgyn 081558101719 Biochemistry 081338776244 Obgyn 082283387245 Obgyn 082147087905 Venue (2nd floor) 2nd floor: R.2.09 2nd floor: R.2.10 2nd floor: R.2.11 2nd floor: R.2.12 2nd floor: R.2.13 2nd floor: R.2.14 2nd floor: R.2.15 2nd floor: R.2.16 2nd floor: R.2.23 3nd floor: R.3.21 3nd floor: R.3.22 3nd floor: R.3.23 English Class (Class B) No 1 2 3 4 5 6 7 8 9 10 11 12 Name Prof.Dr.dr N Adiputra, MOH dr. Dewa Ayu Mas Shintya Dewi, Sp.An Dr.dr. Susy Purnawati, MKK dr. Cok Gde Oka Dharmayuda, Sp.OT (K) Dr.dr. I Nyoman Bayu Mahendra, Sp.OG (K) dr. I G A Dewi Ratnayanti , M.Biomed Dr.dr. G.N. Indraguna Pinatih, M.Sc.AkP, Sp.GK dr. Made Agus Hendrayana , M.Ked Dr.dr. I B G Fajar Manuaba, Sp.OG, MARS Dr. dr. Desak Made Wihandani, M.Kes dr. Jaqueline Sudirman, GrandDipRepSc, PhD dr. Ryan Saktika Mulyana, M.Biomed, Sp.OG Udayana University Faculty of Medicine, DME Group B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 Venue (2nd floor) 2nd floor: R.2.09 2nd floor: R.2.10 2nd floor: R.2.11 2nd floor: R.2.12 2nd floor: R.2.13 2nd floor: R.2.14 2nd floor: R.2.15 2nd floor: R.2.16 2nd floor: R.2.23 3nd floor: R.3.21 3nd floor: R.3.22 3nd floor: R.3.23 4 Study Guide The Reproductive System and Disorders TIME TABLE English Class (B) DAY TIME LEARNING ACTIVITY VENUE CONVEYER DATE 1. Thurday 16 June 2016 08.00-08.15 08.15-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 2 Friday 17 June 2016 3. Monday 20 June 2016 4. Tuesday 21 June 2016 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 Introduction to the Block The Reproductive System and Disorders Lecture 1. Anatomy of female genital system Individual Learning SGD Break Student Project Plenary Lecture 2. Histology of male and female genital system Individual Learning SGD Break Student Project Plenary Lecture 3. Physiology of male genital system Individual Learning SGD Break Student Project Plenary Lecture 4. Physiology of female genital system Individual Learning SGD Break Student Project Plenary Udayana University Faculty of Medicine, DME 4.01 dr. Fajar Manuaba dr. Sri Darmayani 4.01 Prof.Mangku Karmaya, Disc room 4.01 4.01 Disc room 4.01 4.01 Disc room 4.01 4.01 Disc room 4.01 Fasilitator Prof. Mangku Karmaya, dr. Sugiritama Fasilitator dr. Sugiritama dr. Susy Purnawati Fasilitator dr. Susy Purnawati dr. Susy Purnawati Fasilitator dr. Susy Purnawati 5 Study Guide The Reproductive System and Disorders DAY TIME LEARNING ACTIVITY VENUE CONVEYER DATE 5. Wednes day 22 June 2016 08.00-09.30 09.30-11.00 12.30-14.00 14.00-15.30 6. 08.00-09.00 Thursday 23 June 2016 09.00-10.30 7. Friday 24 June 2016 8 Monday 27 June 2016 9 Tuesday 28 June 2016 Basic clinical skill (1) Anatomy (SGD 1-6) Anatomy (SGD 7-12) Histology(SGD 1-6) Histology (SGD 7-12) Lecture 5. Antenatal Care, Normal Labor & Delivery Individual Learning Anatomy Histology 4.01 Dr sugiritama dr.Bayu Mahendra 10.30-12.00 12.00-12.30 SGD Break 12.30-14.00 Student Project 14.00-15.00 Plenary 4.01 dr.Bayu Mahendra 08.00-09.00 Lecture 6. Early Pregnancy Disorders Individual Learning SGD Break Student Project Plenary Lecture 7 Abnormal Pregnancy Individual Learning SGD Break Student Project Plenary Lecture 8 Abnormal Labor Individual Learning SGD Break Student Project Plenary Lecture 9 Puerperium & Disorders Individual Learning SGD Break Student Project Plenary 4.01 dr. Harry Wijaya Surya 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 08.00-09.00 10 Thursday 30 June 2016 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 Udayana University Faculty of Medicine, DME Disc room Dr Wardana Disc room 4.01 4.01 Disc room 4.01 4.01 Disc room 4.01 4.01 Disc room 4.01 Fasilitator Fasilitator dr. Harry Wijaya Surya Dr Budiana Fasilitator Dr Budiana Dr Budiana Fasilitator Dr Budiana dr.Bayu Mahendra Fasilitator dr.Bayu Mahendra 6 Study Guide The Reproductive System and Disorders DAY TIME LEARNING ACTIVITY VENUE 08.00-09.00 Lecture 10 Obstetric Emergency Individual Learning SGD Break Student Project Plenary Lecture 11. Common Gynecology and Disorders Individual Learning SGD Break Student Project Plenary Lecture 12. Diseases of the breast Individual Learning SGD Break Student Project Plenary 4.01 CONVEYER DATE 11. Friday 1 July 2016 12. Monday 11 July 2016 13 Tuesday 12 July 2016 14 Wednes day 13 July 2016 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 15 08.00-09.00 Thursday 14 July 09.00-10.30 2016 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 16 Friday 15 July 2016 08.00-09.00 09.00-10.30 10.30-12.00 12.00-12.30 12.30-14.00 14.00-15.00 Lecture 13. Male infertility & Male genital disorders Individual Learning SGD Break Student Project Plenary Lecture 14 Female Infertility Individual Learning SGD Break Student Project Plenary Lecture 15 Drugs Therapy In Pregnant and Genital disorders Individual Learning SGD Break Student Project Plenary Udayana University Faculty of Medicine, DME Disc room 4.01 4.01 Disc room 4.01 4.01 Disc room 4.01 4.01 Disc room 4.01 4.01 Disc room 4.01 4.01 Disc room 4.01 dr. Harry Wijaya Surya Fasilitator dr. Harry Wijaya Surya dr. Fajar Manuaba Fasilitator dr. Fajar Manuaba dr. Wayan Sudarsa dr. AAAN Susraini Facilitators dr. Wayan Sudarsa dr. AAAN Susraini dr Yukhi dr. G Wirya Kusuma Duarsa Facilitators dr. G Wirya Kusuma Duarsa, dr Yukhi, dr. Fajar Manuaba / dr Jaqueline Facilitators dr. Fajar Manuaba / dr Jaqueline DR.dr. Bgs Km Satriyasa,M.Repro Facilitators DR.dr. Bgs Km Satriyasa,M.Repro 7 Study Guide The Reproductive System and Disorders DAY TIME LEARNING ACTIVITY VENUE CONVEYER DATE 17 Monday 18 July 2016 08.00-09.00 09.00-10.00 11.00-12.00 12.00-13.00 18. Tuesday 19 July 2016 08.00-09.00 09.00-10.00 11.00-12.00 12.00-13.00 19. Wednes day 20 July 2016 20. Thursday 21 July 2016 08.00-10.00 10.00-11.00 11.00-12.00 Basic clinical skill (2) Leopold, normal labor Puerperium & insisi abses bartolini Individual Learning Tutorial Basic clinical skill (3) Pap smear, IVA, swab vagina male genital examination, sperm analysis Individual Learning Tutorial Basic clinical skill (4) Individual Learning Breast examination 13.00-14.00 Female genital examination Tutorial 08.00-09.00 Basic clinical skill (5) Male family planning 09.00-10.00 Female family planning 11.00-12.00 12.00-13.00 Individual Learning Tutorial 401 Skill Lab 401 dr. Harry Wijaya Surya dr. Fajar Manuaba Fasilitator dr. Susraini,SpPA(K) dr Yukhi Skill Lab 401 Skill lab 401 Skill lab Fasilitator dr. Putu Anda Tusta Adiputra dr. Sri Darmayani Fasilitator dr. G Wirya Kusuma Duarsa dr. Sri Darmayani Fasilitator Pre-evaluation Break 22-24 July 2016 Monday 25 July 2016 Udayana University Faculty of Medicine, DME Evaluation 8 Study Guide The Reproductive System and Disorders Regular Class (A) DAY TIME LEARNING ACTIVITY VENUE CONVEYER 09.00-09.15 Introduction to the Block The Reproductive System and Disorders Lecture 1. Anatomy of female genital system Individual Learning Student Project Break SGD Plenary 4.01 dr. Fajar Manuaba dr. Sri Darmayani 4.01 Prof.Mangku Karmaya, DATE 1. Thurday 16 June 2016 09.15-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 2 Friday 17 June 2016 3. Monday 20 June 2016 4. Tuesday 21 June 2016 5. Wednes day 22 June 2016 Disc room 4.01 Fasilitator Prof. Mangku Karmaya, dr. Sugiritama 10.00-11.30 Lecture 2. Histology of male and female genital system Individual Learning Student Project Break SGD Plenary Lecture 3. Physiology of male genital system Individual Learning Student Project Break SGD Plenary Lecture 4. Physiology of female genital system Individual Learning 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 Student Project Break SGD Plenary Disc room 4.01 Fasilitator dr. Susy Purnawati 08.00-09.30 Basic clinical skill (1) Histology (SGD 1-6) Histology Dr Wardana 09.30-11.00 Histology (SGD 7-12) 12.30-14.00 14.00-15.30 Anatomy (SGD 1-6) Anatomy (SGD 7-12) Anatomy Dr sugiritama 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 Udayana University Faculty of Medicine, DME 4.01 Disc room 4.01 4.01 Fasilitator dr. Sugiritama dr. Susy Purnawati Disc room 4.01 4.01 Fasilitator dr. Susy Purnawati dr. Susy Purnawati 9 Study Guide The Reproductive System and Disorders DAY TIME LEARNING ACTIVITY VENUE CONVEYER DATE 6. 09.00-10.00 Thursday 23 June 2016 10.00-11.30 7. Friday 24 June 2016 8 Monday 27 June 2016 9 Tuesday 28 June 2016 Lecture 5. Antenatal Care, Normal Labor & Delivery Individual Learning 4.01 dr.Bayu Mahendra 11.30-12.00 12.00-13.30 Student Project Break 13.30-15.00 SGD 15.00-16.00 Plenary 4.01 dr.Bayu Mahendra 09.00-10.00 Lecture 6. Early Pregnancy Disorders Individual Learning Student Project Break SGD Plenary Lecture 7 Abnormal Pregnancy Individual Learning Student Project Break SGD Plenary Lecture 8 Abnormal Labor Individual Learning Student Project Break SGD Plenary Lecture 9 Puerperium & Disorders Individual Learning Student Project Break SGD Plenary Lecture 10 Obstetric Emergency Individual Learning Student Project Break SGD Plenary 4.01 dr. Harry Wijaya Surya Disc room 4.01 4.01 Fasilitator dr. Harry Wijaya Surya Dr Budiana Disc room 4.01 4.01 Fasilitator Dr Budiana Dr Budiana Disc room 4.01 4.01 Fasilitator Dr Budiana dr.Bayu Mahendra 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 10 Thursday 30 June 2016 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 11. 09.00-10.00 Friday 1 July 10.00-11.30 2016 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 Udayana University Faculty of Medicine, DME Disc room Disc room 4.01 4.01 Disc room 4.01 Fasilitator Fasilitator dr.Bayu Mahendra dr. Harry Wijaya Surya Fasilitator dr. Harry Wijaya Surya 10 Study Guide The Reproductive System and Disorders DAY TIME LEARNING ACTIVITY VENUE CONVEYER 09.00-10.00 Lecture 11. Common Gynecology and Disorders Individual Learning Student Project Break SGD Plenary Lecture 12. Diseases of the breast Individual Learning Student Project Break SGD Plenary 4.01 dr. Fajar Manuaba Disc room 4.01 4.01 Fasilitator dr. Fajar Manuaba dr. Wayan Sudarsa dr. AAAN Susraini Disc room 4.01 Facilitators dr. Wayan Sudarsa dr. AAAN Susraini dr Yukhi dr. G Wirya Kusuma Duarsa DATE 12. Monday 11 July 2016 13 Tuesday 12 July 2016 14 Wednes day 13 July 2016 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 15 09.00-10.00 Thursday 14 July 10.00-11.30 2016 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 16 Friday 15 July 2016 09.00-10.00 10.00-11.30 11.30-12.00 12.00-13.30 13.30-15.00 15.00-16.00 17 Monday 18 July 2016 09.00-11.00 11.00-12.00 12.00-13.00 14.00-15.00 Lecture 13. Male infertility & Male genital disorders Individual Learning Student Project Break SGD Plenary Lecture 14 Female Infertility Individual Learning Student Project Break SGD Plenary Lecture 15 Drugs Therapy In Pregnant and Genital disorders Individual Learning Student Project Break SGD Plenary Basic clinical skill (2) Individual Learning Leopold, normal labor Puerperium & insisi abses bartolini Tutorial Udayana University Faculty of Medicine, DME 4.01 Disc room 4.01 4.01 Disc room 4.01 4.01 Disc room 4.01 Facilitators dr. G Wirya Kusuma Duarsa, dr Yukhi, dr. Fajar Manuaba/ dr Jaqueline Facilitators dr. Fajar Manuaba / dr Jaqueline DR.dr. Bgs Km Satriyasa,M.Repro Facilitators DR.dr. Bgs Km Satriyasa,M.Repro 401 dr. Harry Wijaya Surya dr. Fajar Manuaba Skill Lab Fasilitator 11 Study Guide The Reproductive System and Disorders DAY TIME LEARNING ACTIVITY VENUE CONVEYER DATE 18. Tuesday 19 July 2016 09.00-11.00 11.00-12.00 12.00-13.00 14.00-15.00 Basic clinical skill (3) Individual Learning Pap smear, IVA, swab vagina male genital examination, sperm analysis Tutorial Basic clinical skill (4) Individual Learning Breast examination Female genital examination Tutorial 09.00-11.00 11.00-12.00 Basic clinical skill (5) Individual Learning Male family planning 09.00-11.00 11.00-12.00 12.00-13.00 14.00-15.00 19. Wednes day 20 July 2016 20. Thursday 21 July 2016 12.00-13.00 14.00-15.00 Female family planning Tutorial Pre-evaluation Break 401 dr. Susraini,SpPA(K) dr Jaqueline, dr Yukhi Skill Lab 401 Skill lab 401 Skill lab Fasilitator dr. Anda Tusta dr. Sri Darmayani Fasilitator dr. G Wirya Kusuma Duarsa dr. Sri Darmayani Fasilitator 22-24 July 2016 Monday 25 July 2016 Udayana University Faculty of Medicine, DME Evaluation 12 Study Guide The Reproductive System and Disorders MEETING Meeting of the student representatives The meetings between block planers and student group representatives will be held 30 of June 2016, at 10.00 until 11.00 at class room. In this meeting, all of the student group representatives are expected to give suggestions and inputs or complaints the team planners for improvement. For this purpose, every student group should choose one student as their representative to attend the meeting. Meeting of the facilitators The meeting between block planners and facilitators will take place on 30 of June 2016, at 11.00 until 12.00 at class room. In this meeting all the facilitators are expected to give suggestions and inputs as evaluation to improve the study guide and the educational process. Because of the importance of this meeting, all facilitators are expected to attend the meeting. ASSESSMENT METHOD Assessment will be carried out on Monday 25th of July 2016. There will be 100 questions consisting of Multiple Choice Questions (MCQ). The minimal passing score for the assessment is 70. Other than the examinations score, your performance and attitude during group discussions will be consider in the calculation of your average final score. Final score will be sum up of student performance in small group discussion, student project and score in final assessment. Clinical skill will be assessed in form of Objective structured clinical examination (OSCE) at the end of semester as part of Basic Clinical Skill Block’s examination. STUDENT PROJECT Students have to write a paperwork with topic given by the lecturer. The topic will be chosen randomly on the first day. Each small group discussion must work on one paperwork with different tittle. The paperwork will be written based on the direction of respective lecturer. The paperwork is assigned as student project and will be presented in class. The paper and the presentation will be evaluated by respective facilitator and lecturer. Format of the paper : 1. Cover Title (TNR 16) Name Student Registration Number Faculty of Medicine, Udayana University 2013 2. Introduction 3. Journal critism/literature review 4. Conclusion 5. References Green coloured cover Example : Journal Porrini M, Risso PL. 2005. Lymphocyte Lycopene Concentration and DNA Protection from Oxidative Damage is Increased in Woman. Am J Clin Nutr 11(1):79-84. Textbook Abbas AK, Lichtman AH, Pober JS. 2004. Cellular and Molecular Immunology. 4th ed. Pennysylvania: WB Saunders Co. Pp 1636-1642. Note. Minimum 10 pages; line spacing 1.5; Times new roman 12 Udayana University Faculty of Medicine, DME 13 Study Guide The Reproductive System and Disorders ~ STUDENT PROJECT ~ Regular Class (Class A) No Group Topic 1 A1 Kehamilan ganda 2 A2 toksoplasmosis 3 A3 Inkompeten serviks 4 A4 Fibroadenoma mammae (FAM) 5 A5 Diabetes gestasional 6 A6 Ruptur uteri 7 A7 tromboflebitis 8 A8 Inkontinensia urine 9 A9 endometriosis 10 A10 Kista ovarium 11 A11 Gangguan ereksi 12 A12 Karsinoma serviks English Class (Class B) No Group Topic 1 B1 Janin tumbuh lambat 2 B2 Infeksi virus herpes tipe 2 3 B3 polihidramnion 4 B4 ginekomastia 5 B5 Kehamilan post term 6 B6 Intra-uterine fetal death (IUFD) 7 B7 Thrombosis vena dalam 8 B8 Inkontinensia feses 9 B9 hematokolpos 10 B10 Kista dermoid 11 B11 Gangguan ejakulasi 12 B12 Karsinoma payudara Udayana University Faculty of Medicine, DME 14 Study Guide The Reproductive System and Disorders LEARNING PROGRAMS ABSTRACT AND TASK OF LECTURES Lecture 1 Anatomy of Female Genital System (Prof.DR.dr. Nyoman Mangku Karmaya, M.Repro, PA (K), FIASS) FEMALE GENITAL ORGANS ABSTRACT: The female internal genital organs The female internal genital organs include the vagina, uterus, uterine tubes and ovaries. The vagina, a musculomembranous tube, extends from yhe cervix of the uterus to the vestibule, the cleft between the labia minora into which the vagina and urethra open. The superior end of the vagina surrounds the cervix of the uterus. The vagina is usually collapsed so its anterior and posterior walls are in contact, except at its superior end, where the cervix holds them apart. The vagina: serves as a canal for menstrual fluid, form the inferior part of the pelvic (birth) canal, receives the penis and ejaculate during sexual intercourse. The uterus is a thick-walled, pear-shaped, hollow muscular organ. The uterus usually lies in the lesser pelvis, with its body lying on the urinary bladder and its cervix between the urinary bladder and the rectum. The adult uterus is usually anteverted and anteflexed so that its mass lies over the bladder. The uterus is divisible into two main part: the body and the cervix. The wall of the body of the uterus consist of the three layers: perimetrium, myometrium and endometrium. The uterine tubes extend laterally from the uterine horns and open inyo the peritoneal cavity near the ovaries. The uterine tubes lie in the mesosalphinx in the free edges of the broad ligament. Each uterine tube is divisible into four parts: the infundibulum, ampulla, isthmus and the uterine part. Ovaries: the almond-shaped ovaries are typically near the attachment of the broad ligament to the lateral pelvic walls, suspended from both by peritoneal folds, the mesovarium from the posterosuperior aspect of the broad ligament and the suspensory ligament of the ovary from the pelvic wall. The female external genitalia organs The female external genitalia include the mons pubis and labia majora (enclosing the pudendal cleft), labia minora (enclosing the vestibule), clitoris, bulbs of the vestibule and greater and lesser vestibular glands. The synonymous terms pudendum and vulva include all these parts. The vulva serves as sensory and erectile tissue for sexual arousal and intercourse, direct the flow of urine and prevent entry of foreign material into the urogenital tract. Breasts Both males and females have breasts (mammae), normaly the mammary glands are well developed only in women. Mammary glands in women are accessory to reproduction, but in men they are functionless, consisting of only a few small ducts or cords. The mammary glands are modified sweat glands and therefore have no special capsule or sheath. The contour and volume of the breasts are produced by subcutaneous fat, except during pregnancy when the mammary glands enlarge and new glandular tissue forms. Breast size and shape result from genetic, racial, and dietary factors. The roughly circular base of the female breast extends transversely from the lateral border of the sternum to the midaxillary line and vertically from the 2nd – 6th ribs. Udayana University Faculty of Medicine, DME 15 Study Guide The Reproductive System and Disorders LEARNING TASK: CASE 1: A 42-year-old woman is referred for vaginal sonography to rule out a luteal cyst. The sonic probe is placed in the anterior vaginal fornix and aimed anteriorly. 1. What is the normal position of the uterus and its relation to other structure in pelvic cavity? 2. How much of the uterus can normally be felt per rectum? 3. What is the normal support of the uterus? 4. Why do you think the uterus is in that position? 5. Describe the ovaries, uterine tubes, uterus and broad ligaments 6. Describe the peritoneal relationships of the ovary and the uterine tube 7. Describe the walls, fornices and the immediate visceral relations of the vagina 8. To describe the blood supply and lymph drainage of the female genital tract 9. To describe general anatomy, vascularisation and lymphatic system of the breast 10. Explain the anatomical feature of the female pelvis and its difference the male pelvis 11. Describe the pelvic diaphragm and perineum SELF ASSESSEMENT: 1. To describe the component parts of the uterine tube 2. To identify the female external genitalia 3. Describe the vascularisation, inervation and limphatic drinage of internal and external female genital organs. 4. Discuss with your colleagues the growth and development and their anomalies of female genital organs. Lecture 2 Histology of Male & Female Genital System (dr. I Wayan Sugiritama, M.Kes) ABSTRACT The Female Genital System The female reproductive system consists of the internal reproductive organs (the paired ovaries and oviducts, the uterus and the vagina) and the external genitalia (the clitoris, the labia majora, and the labia minora). The ovaries are indistinctly divided into a cortex and medulla. Cortex is composed of connective tissue stroma that houses ovarian follicles in various stages of development (primordial, primary, secondary and graafian follicles). During the follicle growth, fibroblast of the stroma around the follicle differentiate to form the theca folliculi and it subsequently differentiates into theca interna and theca externa. The cells of theca interna responsible for synthesize a steroid hormone. The oviducts are paired muscular-walled tubular structures, their walls are composed of mucosa, muscularis and serosa. The mucosa layer lines by two different cells: (1) non ciliated peg cells which is facilitated capacitation of spermatozoa, and (2) ciliated cells which is responsible for transport of the fertilized ovum to the uterus. The oviducts act as a conduit for spermatozoa to reach the primary oocyte and convey the fertilized egg to uterus. The uterine wall of uterus composed by an endometrium, myometrium, and serosa. The endometrium consists of two layer, the superficial functionalis which is sloughed at menstruation, and deeper basalis whose glands and connective tissue elements. Myometrium is composed of inner longitudinal, middle circular and outer longitudinal layers of smooth muscle. The vagina, a fibromuscular tubular structure, is compose of three layers that are: mucosa, muscularis, and adventitia. Udayana University Faculty of Medicine, DME 16 Study Guide The Reproductive System and Disorders The mammary glands, although not strictly a part of the female reproductive tract their physiology and function are so closely associated with the reproductive system. The mammary gland is a compound tubuloalveolar gland of 15-20 lobes. The reproductive organs are incompletely development and remain in a state of rest until gonadotropic hormones secreted by the pituitary gland signal the initiation of puberty. Thereafter, many changes take places in the entire reproductive system, culminating in menarche. After the first menstrual flow (menarche), the menstrual cycle which involves many hormonal and histological changes is repeated each month. Around the middle of each cycle, a single ovum is released from one of the ovaries (ovulation) and passes in to the oviduct, where it may, or may not, encounter a spermatozoon for its fertilization. The menstrual cycle ceases after menopause, there is a slow involution of reproductive organ. The Male Genital System The male reproductive system is composed of the testes, genital ducts, accessory glands, and penis. The dual function of the testis is to produce spermatozoa and hormones. The genital ducts and accessory glands produce secretions that, conduct spermatozoa toward the exterior. Spermatozoa and the secretions of the genital ducts and accessory glands make up the semen. Each testis is surrounded by tunica albuginea. The testis divide into 250 pyramidal compartments called the testicular lobules. Each lobule is occupied by one to four seminiferous tubules enmeshed in a web of loose connective tissue that is rich in blood and lymphatic vessels, nerves, and Leydig cells. Seminiferous tubules produce spermatozoa, whereas Ledig cells secrete testicular androgens. These seminiferous tubules are enclosed by a thick basal lamina and surrounded by 3-4 layers of smooth muscle cells. The lumen are lined with seminiferous epithelium (germinal epithelium), which consists of two types of cells: spermatogenic cells and Sertoli cells.The cells of the spermatogenic lineage produce spermatozoa. Spermatogenesis is the process by which spermatozoids are formed. It begins with spermatogonium, at sexual maturity spermatogonia begin dividing, producing two type cells: type A spermatogonia and type B spermatogonia. Type B spermatogonia will differentiate into primary spermatocytes. After their formation, these cells divide into secondary spermatocytes. Division of each secondary spermatocyte results in spermatids. Spermiogenesis is the final stage of production of spermatozoids. Spermiogenesis is a complex process that includes formation of the acrosome, condensation and elongation of the nucleus, development of the flagellum, and loss of much of the cytoplasm. The end result is the mature spermatozoon, which is then released into the lumen of the seminiferous tubule. Spermatozoa transported from seminiferous tubules to the ductus epididymidis by the intratesticular genital ducts (tubulus rectus, rete testis, and ductuli efferentes). Excretory genital ducts transport the spermatozoa produced in the testis toward the penile meatus. These ducts are the ductus epididymidis, the ductus (vas) deferens, and the urethra The Sertoli cells are important for the function of the testes. These cells are elongated pyramidal cells that partially envelop cells of the spermatogenic lineage. Adjacent Sertoli cells are bound together by occluding junctions at the basolateral part of the cell, forming a blood-testis barrier. Sertoli cells has another function are: Support, protection, and nutritional regulation of the developing spermatozoa, Phagocytosis, Secretion of an ABP and inhibin, Production of the anti-mullerian hormone and inhibin B. Case: A couple came to a doctor with complaints not having children. The couple has been married for three years. Doctor recommend to do some examination to find out the etiology. Task 1 From the history taking is known that the woman had regular menstruation. Udayana University Faculty of Medicine, DME 17 Study Guide The Reproductive System and Disorders Question: 1. Describe the structure of the ovaries in each stage of the menstrual cycle! 2. If the endometrial biopsy was performed on the every stages of menstrual cycle, try to describe the results! 3. Describe the changes in the cervix at each stage of the menstrual cycle! Task 2 HSG (Hystero Salpingo Graphy) was done to examination the patency of Tuba Fallopian. Examination found there is no abnormalities Question: 1. Describe the structure of the Tuba Fallopian! 2. Explain the structure of the Tuba Fallopian which plays an important role in oocyte transport! Task 3 Semen examination results showed that the number of spermatozoa is low (Oligospermia). Question: 1. Describe the microscopic structure of organs that play a role in the formation of semen! 2. Explain the process of spermatogenesis? 3. Explain the importance of Sertoli and Leydig cells in spermatogenesis? Task 4 On physical examination and additional tests are found abnormalities in his testes, known as varicocele. His doctor suspected it as the cause of the low number of sperm (oligospermia) on the semen. Question: 1. Describe the structure that transports semen from the seminiferous tubules to the meatus penis! 2. Explain the process of sperm maturation that occurs on genital duct! Self Assessment 1. Describe the histological structure of the ovary 2. Describe the stages of ovarian follicular development! 3. Describe the histological structure of the endometrium on menstrual, follicular and luteal phase! 4. Describe the histological structure of oviduct! 5. Describe the histological structure of the vagina! 6. Describe the histological structure of the external genital system! 7. Describe the histological structure of mammary gland on the following: (a) before puberty, (b) after puberty but nonpregnant, and (c) during pregnancy! 8. Describe the histological structure of the testis! 9. Describe the process of spermatogenesis! 10. Describe the structure and function of Blood-Testis Barrier! 11. Describe the intratesticular and external genital duct! 12. Describe the structure of accessory gland! 13. Describe the structure of Penis! Udayana University Faculty of Medicine, DME 18 Study Guide The Reproductive System and Disorders Lecture 3&4 Physiology of Male & Female Genital System (Dr. dr. Susy Purnawati.M.KK) My Wife Haven’t Pregnant Yet Anton's wife (Maria, 34 y.o) is not get pregnant after 1 year her married. Anton (35 years old) visited Reproduction Specialist doctor with his wife to have some consultation. During consultation with doctor, Anton explained that he had his first "wet dreaming" (ejaculation in sleep) at his 14 years old. Start from 25 years old he always use anabolic steroid as addition of his fitness muscle building to get more gentle muscle performance. He is worry if he get infertile. The doctor made some assessment include of Anton's erection and refer him to do sperm analysis test and also did assessment of his wife reproduction condition include of her menstruation history. Maria explained to doctor that she always feel pain during her menstruation and she has not had her menstruation every month. Learning task (female physiology) 1. Explain of the monthly ovarian cycle and control of ovarian function. 2. Explain of the menstruation and factors are related (e.g. behavior) 3. Discuss the influence of estrogens on female without and during pregnancy 4. Discuss of correlation of ovulation and fertility 5. Explain Maria’s body changes and mechanism if she is getting pregnant Self assessment Explain the following items: 1. Hormonal and ovarian changes that occur at menopause 2. Puberty and menarche 3. Environmental factors influence female reproduction. Learning task (male physiology) 1. Explain about the role of spinal integration center, tactile stimuli, psychological stimuli, and NO (nitric oxide) in erection mechanism! 2. Explain about the mechanism of ejaculation and semen characteristics and composition. 3. Explain about the role of Sertoli cells and Leydig cells and their regulation by hormonal control. How the environmental factor influence to spermatozoa and testosterone of testical. 4. Is there Anton's history of using anabolic steroid have correlation with his current problem? Give your explanation! Self assessment: Explain the following items: 1. Control of FSH, LH, testosterone on male reproduction 2. Puberty and menopause 3. Infertility and related factors as a problem in male. 4. The influence of androgens on male secondary sex characteristics. 5. Sperm production and some factors are related. 6. Erection and ejaculation as a male sex act and factors are related. Udayana University Faculty of Medicine, DME 19 Study Guide The Reproductive System and Disorders Lecture 5 Antenatal Care, Normal labor & Delivery (Dr.dr.I Nyoman Bayu Mahendra, SPOG (K)) Abstract Antenatal care, labor and delivery are integrated part to achieve good obstetric outcome. By do focused antenatal care will impact to the labor and also the delivery. In this lecture we will focused on how to manage a good ANC and how to manage the labor. And finally we can manage safe and good delivery. It is important to make a diagnosis based on International Classification of Diseases (ICD)-10. ICD-10 coding making easier to communicate between health provider and insurance coverage. Introduction Obstetrics is concerned with human reproduction and as such is always a subject of considerable contemporary relevance. The specialty promotes health and well-being of the pregnant woman and her fetus through quality perinatal care. Such care entails appropriate recognition and treatment of complications, supervision of labor and delivery, ensuring care of the newborn, and management of the puerperium. The importance of obstetrics is reflected by the use of maternal and neonatal outcomes as an index of the quality of health and life among nations. Intuitively, indices that reflect poor obstetrical and perinatal outcomes would lead to the assumption that medical care for the entire population is lacking. Antenatal Care (ICD-10: Z.36) A comprehensive antepartum program involves a coordinated approach to medical care, continuous risk assessment, and psychological support that optimally begins before conception and extends throughout the postpartum period and interconceptional period. Optimizing the health and well-being of women before pregnancy should logically be an integral prelude to prenatal care. Adequate and appropriate preconceptional care, has the potential to assist women by reducing risks, promoting healthy lifestyles and improving readiness for pregnancy. Pregnancy is usually identified when a woman presents with symptoms and possibly a positive home urine pregnancy test result. Typically, such women receive confirmatory testing of urine or blood for human chorionic gonadotropin (hCG). Further, there may be presumptive or diagnostic findings of pregnancy during examination. Sonography is often used, particularly if miscarriage or ectopic pregnancy is a concern. Labor and Delivery (ICD-10: O.80) Labor is a sequence of uterine contractions that result in effacement and dilatation of the cervix and voluntary bearing down effort leading to expulsion pervagina of the product of conception. Delivery is the mode of expulsion of the fetus and placenta. Labor and delivery is a normal physiologic process that most women experience without complications. Normal labor is a continuous process which has been devided into four stage of labor for purposes of study, with the first stage further subdivided into two phases, latent and active phase. The first stage of labor is the interval between the onset of labor and full cervical dilatation. The second stage is the interval between full cervical dilatation and delivery of the infant. The third stage of labor is the period between the delivery of the infant and the delivery of the placenta. The hour immediately following delivery is critical and it has been designated by some as the fourth stage of labor. Even thought oxytocins are administered, postpartum hemorrhage as the result of uterine atonia is more likely at this time. The uterus frequently evaluated and perineum like wise is inspected frequently to detect excessive bleeding. The mechanism of labor in the vertex position consists of engagement of the presenting part, flexion, descent, internal rotation, extension and expulsion. Udayana University Faculty of Medicine, DME 20 Study Guide The Reproductive System and Disorders The partograph is a tool that can be used to assess the progress of labor and to identify when intervention is necessary. Using the partograph can be highly effective in reducing complications from prolonged labor for the mother and for the newborn. The partograph is used to plot the following parameters for the progress of labor, monitoring fetal conditions, and monitoring maternal conditions. Learning Outcome Manage, establish tentative diagnosis, management patient with normal labor and delivery by WHO partograph Learning Objective - Describe the mechanism of normal labor and delivery - Apply to do anamnesis, physical examination patients in labor - Capable to establish the diagnosis of patients in labor - Capable to plan management of patients in labor - Describe the plan monitoring of patients in labor - Communicate all information about labor and delivery to the patients and family - Describe the WHO partograph - Apply the WHO partograph to monitoring and evaluation of patients in labor PIC Dr. dr. I Nyoman Bayu Mahendra, SpOG(K) SSR - Cunningham, F., et al. 2014. Preconseptional and Prenatal Care. In: Cunningham, F., et al. editors. Williams Obstetric. 24th Ed. New York: McGraw Hill. pp. 155-92. - Cunningham, F., et al. 2014. Labor. In: Cunningham, F., et al. editors. Williams Obstetric. 24th Ed. New York: McGraw Hill. pp. 407-534. - Cunningham, F., et al. 2014. Delivery. In: Cunningham, F., et al. editors. Williams Obstetric. 24th Ed. New York: McGraw Hill. pp. 535-622. - WHO Partograph Guidelines. Summary Good quality of antenatal care will lead the mother into minimal or no labor and delivery complications. We must prepare the mother in the optimal condition since initial period of pregnancy. By focused ANC, the mother also in the good condition at labor period. Finally we can deliver good baby and good generation. Learning Task Case: Woman, 28 years old, para I (2 years, spontaneous labor, 3300 g). At 9.00 am came with complaints of abdominal pain since two hour ago, she also had complaints vaginal discharge like blood slyms. Fetal movement was good. Last menstrual period 17-09-2015 and history of regular menstrual period. She is in good condition, compos mentis, blood pressure 120/80 mmHg, pulse 88 x/mnt, respiration rate 20 x/mnt, temp.ax 36.5 0C. Status generalis was normal Status obstetric: Abdominal: fundal uterine height 35 cm, head presentation 3/5, back on the left side, uterine contraction 3x/10 mnt, duration 40’’, Fetal heart rate 140 bpm. Udayana University Faculty of Medicine, DME 21 Study Guide The Reproductive System and Disorders Vaginal examination: Cervical dilatation 6 Cm, effacement 50%, amniotic membrane intack, Left occiput anterior, placenta and small part of fetus not palpable. Lab: HGB 12 g/dl. Questions: 1. What is the diagnosis of this patient? 2. What the anamnesis, sign and symptoms and examination to support the diagnosis? 3. What is the management of this patient? 4. How to use WHO partograph for this case? 5. What are the communication, education and counseling to patient and her family? SELF ASSESSMENT: 1. How to diagnosis and confirmation of labor? 2. Explain the normal mechanism of labor? 3. Explain the stage and phase of labor? 4. How to assessment of engagement and descent of the fetus? 5. How to identification of presentation and position of the fetus? 6. How to assessment of progress of labor? 7. How to assessment of fetal condition? 8. What is the partograph? 9. How to use the partograph? 10. Explain the active management of the third stage of labor? Lecture 6 Early Pregnancy Disorders Dr. dr. I Gede Ngurah Harry Wijaya Surya, Sp.OG Early pregnancy disorder are include abortus, hiperemesis gravidarum, mola hidatidosa, ectopic pregnany. Abortus happened when the products of conception temerminate before it can survive outside the womb. Abortus spontaneus that happened more then three times call abortus habitualis. Hiperemesis gravidarum define as pregnancy accompenied with severe nausea vomiting that interfere daily activity, patient can not eat and drink. Mola hydatiform define as abnormal pregnancy where almost all villi chorialis changed into hidrofik. Pregnancy occuring can accompanied with fetus and mola bubbles or just mola bubbles. Ectopic pregnancy is pregnancy where the fetus developed and grown out of the womb. Case Female, 20 yo, came to Emergency Room with main complain can’t do daily activities because feel week. For last few days can’t take eat and drink. This is her first pregnancy. In examination: BP: 90/60, P: 100, sunken eye +/+, in abdomen: turgor decreased +/+ Learning task 1. What are the first management treatment for this patient? 2. What are the diagnosis and differential diagnosis for this case? Udayana University Faculty of Medicine, DME 22 Study Guide The Reproductive System and Disorders Lecture 7 Abnormal Pregnancy (Dr.dr I Nyoman Gede Budiana, SpOG (K)) Abstract Obstetrics is concerned with human reproduction and as such is always a subject of considerable contemporary relevance. The specialty promotes health and well-being of the pregnant woman and her fetus through quality perinatal care. Such care entails appropriate recognition and treatment of complications, supervision of labor and delivery, ensuring care of the newborn, and management of the puerperium. Postpartum care promotes health and provides family planning options. According to the Centers for Disease Control and Prevention the total number of pregnancies and their outcomes in 2008 most 65 percent ended with live births. Approximately 5 percent were early-pregnancy deaths due to ectopic gestation or abortive outcomes. The deadly obstetrical triad of hemorrhage, preeclampsia, and infection accounted for a third of all deaths. Obstetrical hemorrhage is one of the leading causes of maternal morbidity and mortality throughout the world. Not only is hemorrhage the leading reason for an obstetrical admission to the intensive care unit, it is responsible for 17% to 25% of all pregnancyrelated deaths. Hypertensive disorders are among the most common medical complications of pregnancy, with a reported incidence between 5% and 10%. The incidence varies among different hospitals, regions, and countries. Preterm birth is the leading cause of infant mortality in developing world. Moreover, the incidence of preterm birth has increased, from 9.4% in 1981 to 10.9% in 2005. The overall increase in prevalence of multifetal births is of concern because the corresponding increase in the rate of preterm birth compromises neonatal survival and increases the risk of lifelong disability. And lastly perinatal mortality rates increase after the expected due date has passed. Perinatal morbidity in post-term pregnancies is attributable, primarily, to fetal macrosomia, birth trauma, placental insufficiency, oligohydramnios, intrapartum fetal distress, meconium aspiration, and postmaturity syndrome. Introduction Too many women still die in pregnancy and childbirth in developing countries. The estimated number of maternal deaths has been stable for many years, with between 515,000 and 536,000 maternal deaths per year, most of which occur in developing countries. The international community has recognized the gravity of the situation by endorsing the improvement of maternal health as the fifth of its eight millennium development goals (MDG). International efforts are increasing to meet the MDG-5 target of reducing maternal mortality by 75% from 1990 to 2015 but there are strong signs that this target might not be met. There are many reasons for this, including a lack of political will, human and financial resources, as well as some biologic and demographic factors, such as the impact of the HIV epidemic on women and health systems, and the continuing population growth. This chapter will review the levels and causes of abnormal pregnancy complication that contributed to maternal and fetal mortality and morbidity in the developing world and what can be done to improve maternal health in developing countries. Hypertensive Disorder The basic classification for hypertensive disease based on American College of Obstetricians and Gynecologists (2013): 1. Gestational hypertension: this diagnosis is made in women whose blood pressures reach 140/90 mm Hg or greater for the first time after midpregnancy, but in whom proteinuria is not identified and the blood pressure returns to normal by 12th weeks postpartum. Udayana University Faculty of Medicine, DME 23 Study Guide The Reproductive System and Disorders 2. Preeclampsia and eclampsia syndrome Preeclampsia is defined as new-onset blood pressure elevations accompanied by proteinuria in pregnancy. The diagnosis includes at least two measurements of systolic pressures greater than or equal to 140 mmHg or diastolic pressures greater than or equal to 90 mmHg. Proteinuria is defined by the presence of 300 mg of protein or more in a 24-hour urine specimen or 30 mg/dL (1+ dipstick) in a random urine specimen. Alternatively, a timed collection corrected for creatinine excretion can be performed if a 24-hour urine collection is not feasible. Eclampsia is the occurrence of seizures that cannot be attributed to other causes in a woman with preeclampsia. 3. Chronic hypertension of any etiology Chronic underlying hypertension is diagnosed in women with documented blood pressures ≥ 140/90 mm Hg before pregnancy or before 20 weeks’ gestation, or both. 4. Preeclampsia superimposed on chronic hypertension The diagnosis of superimposed preeclampsia is often suspected based on the new onset of proteinuria after 20 weeks’ gestation. Table 1: Diagnostic Criteria for Pregnancy-Associated Hypertension Udayana University Faculty of Medicine, DME 24 Study Guide The Reproductive System and Disorders Table 2: Risk Factor of Preeclampsia Theories of etiology Preeclampsia: 1. Abnormal trophoblast invasion or poor implantation 2. Imbalance in angiogenesis 3. Coagulation abnormalities 4. Vascular endothelial damage 5. Cardiovascular maladaptation 6. Immunologic maladaptation 7. Genetic predisposition 8. Exaggerated inflammatory response 9. Increased oxidative stress Complications: Maternal: Worsening Hypertension, superimposed preeclampsia (20%), severe preeclampsia, eclampsia, HELLP syndrome, and cesarean delivery. Pulmonary edema, hypertensive encephalopathy retinopathy, cerebral hemorrhage, and acute renal failure are uncommon, but more common with severe Hypertension. Fetal: Growth restriction (8–15%); oligohydramnios, placental abruption (0.7–1.5%, about a twofold increase), PTB (12–34%), and perinatal death (two- to fourfold increase). All of these complications have higher incidences with severe or high-risk hypertension Management: Preeclampsia is one of the most common, and perhaps most typical, obstetric complications. The only interventions associated with significant prevention of preeclampsia are antiplatelet agents, primarily low-dose aspirin, and calcium supplementation. It is important to understand that preeclampsia’s only cure is delivery. As such, preeclampsia is a temporary disease, which resolves usually 24 to 48 hours after delivery. Magnesium Prophylaxis is the drug of choice for prevention of eclampsia. Compared with placebo or no anticonvulsant, magnesium sulfate is associated with a 59% reduction in the risk of eclampsia (number needed to treat for an additional beneficial outcome: 100), a 36% reduction in abruption, and a nonstatistically significant but clinically important 46% reduction in maternal death. Intravenous administration is preferable with 1 g/hr, and for around 24 hours usually given at least in active labor and for 12 to 24 hours postpartum, but can be given for a shorter or longer period depending on the severity of preeclampsia. Delivery timing and mode: Before 37 weeks, in the absence of severe criteria, or preterm labor, and in the presence of reassuring fetal testing, expectant management is suggested, with delivery for development of any severe criteria. Vaginal delivery is preferred, with induction of labor if necessary. Udayana University Faculty of Medicine, DME 25 Study Guide The Reproductive System and Disorders Preterm labor Preterm or premature births are terms used to define neonates who are born too early. Thus, infants born before term can be small or large for gestational age but still fit the definition of preterm. Low birthweight refers to births 500 to 2500 g; very low birthweight refers to births 500 to 1500 g; and extremely low birthweight refers to births 500 to 1000 g. In the United States in 2005, 28,384 infants died in their first year of life. Preterm birth, which is defined as delivery before 37 completed weeks, was implicated in approximately two thirds of these deaths. A variety of morbidities, largely due to organ system immaturity, are significantly increased in infants born before 37 weeks' gestation compared with those delivered at term. Corticosteroid therapy was effective in lowering the incidence of respiratory distress and neonatal mortality rates if birth was delayed for at least 24 hours after initiation of betamethasone. A National Institutes of Health Consensus Development Panel recommended corticosteroids for fetal lung maturation in threatened preterm birth. Major Short- and Long-Term Problems in Very-Low-Birthweight Infants Organ or System Pulmonary Gastrointestinal or nutritional Immunological Central nervous system Short-Term Problems Respiratory distress syndrome, air leak, bronchopulmonary dysplasia, apnea of prematurity Hyperbilirubinemia, feeding intolerance, necrotizing enterocolitis, growth failure Hospital-acquired infection, immune deficiency, perinatal infection Intraventricular hemorrhage, periventricular leukomalacia, hydrocephalus Ophthalmological Retinopathy of prematurity Cardiovascular Hypotension, patent ductus arteriosus, pulmonary hypertension Water and electrolyte imbalance, acid–base disturbances Iatrogenic anemia, need for frequent transfusions, anemia of prematurity Hypoglycemia, transiently low thyroxine levels, cortisol deficiency Renal Hematological Endocrinological Udayana University Faculty of Medicine, DME Long-Term Problems Bronchopulmonary dysplasia, reactive airway disease, asthma Failure to thrive, shortbowel syndrome, cholestasis Respiratory syncytial virus infection, bronchiolitis Cerebral palsy, hydrocephalus, cerebral atrophy, neurodevelopmental delay, hearing loss Blindness, retinal detachment, myopia, strabismus Pulmonary hypertension, hypertension in adulthood Hypertension in adulthood Impaired glucose regulation, increased insulin resistance 26 Study Guide The Reproductive System and Disorders Risk factor include: History: 1. Obstetric-gynecological history: prior spontaneous preterm birth (sPTB of twins is a minor risk factor for PTB when the next pregnancy is a singleton pregnancy); prior ≥ 2 D&Es; prior cone biopsy; uterine anomalies; DES exposure;myomata; extremes of interpregnancy interval; ART 2. Maternal lifestyle (smoking, drug abuse, STIs, etc.) 3. Maternal pre-pregnancy weight <120 lb (<50 kg) or low BMI; poor nutritional status 4. Maternal age (<19 years old; >35 years old) 5. Race (especially Afro-American) 6. Education (<12 grades) 7. Certain medical conditions (e.g. DM, HTN) 8. Low socioeconomic status 9. Limited prenatal care 10. Family history of spontaneous PTB (poorly studied) 11. Vaginal bleeding (especially during second trimester) 12. Stress (mostly related to above risks) Identifiable by screening: 1. Anemia 2. Periodontal disease 3. TVU CL <25 mm (especially <30 weeks) 4. fFN positive (>50 ng/mL) Usually symptomatic: Uterine contractions Not spontaneous (indicated/iatrogenic): 1. Fetal demise/major anomaly/compromise/polyhydramnios 2. Placenta previa 3. Placental abruption 4. Major maternal disease (HTN complications, DM, etc.) Management: Women with PTL but negative fetal fibronectin (fFN) and transvaginal ultrasound (TVU) cervical length (CL) ≥ 30 mm have a ≤ 2% chance of delivering within 1 week, and a > 95% chance of delivering ≥ 35weeks without therapy, and should therefore not receive any treatment. Corticosteroids (betamethasone 12 mg IM every 24 hours × 2 doses between 24 and 33 6/7 weeks is preferred if available) given to the mother prior to preterm birth (either spontaneous or indicated) are effective in preventing respiratory distress syndrome, intraventricular hemorrhage (IVH), and neonatal mortality. Tocolytics should not be used without concomitant use of corticosteroids for fetal maturity. Antepartum and Postpartum Hemorrhage 1. Ante partum hemorrhage Placental separation from its implantation site before delivery has been variously called placental abruption, abruptio placentae, and in Great Britain, accidental hemorrhage. The Latin term abruption placentae means "rending asunder of the placenta" and denotes a sudden accident, which is a clinical characteristic of most cases. The cumbersome term premature separation of the normally implanted placenta is most descriptive. It differentiates the placenta that separates prematurely but is implanted some distance beyond the cervical internal os from one that is implanted over the cervical internal os—that is, placenta previa. Udayana University Faculty of Medicine, DME 27 Study Guide The Reproductive System and Disorders The bleeding of placental abruption typically insinuates itself between the membranes and uterus, ultimately escaping through the cervix, causing external hemorrhage. Less often, the blood does not escape externally but is retained between the detached placenta and the uterus, leading to concealed hemorrhage. Placental abruption may be total or partial. Concealed hemorrhage carries much greater maternal and fetal hazards. This is not only because of possible consumptive coagulopathy, but also because the extent of the hemorrhage is not readily appreciated, and the diagnosis typically is delayed. Predisposition factors for placental abruption are, hypertension, prematurely ruptured of the membrane, smoking, thrombophilias, traumatic abruption and leiomyomas. Placental abruption is initiated by hemorrhage into the decidua basalis. The decidua then splits, leaving a thin layer adhered to the myometrium. Consequently, the process in its earliest stages consists of the development of a decidual hematoma that leads to separation, compression, and ultimate destruction of the placenta adjacent to it. Total (complete) placenta previa is defined as a placenta that covers the internal os. Marginal (incomplete) placenta previa is defined as a placenta that comes within 0.1–2.0 cm of the internal os but does not cover it. Low lying placenta is defined as a placenta that comes between 2.1–3.5 cm from internal os. Placental location should be assessed any time an ultrasound is performed. If placenta previa is suspected, a transvaginal ultrasound (TVU) should be performed. The risk of previa at delivery depends on several factors, especially gestational age (GA) at detection, how many millimeters the placenta overlaps the internal os or its distance from it, prior cesarean delivery, etc.Most previa diagnosed before the third trimester resolve. Women who have the inferior edge of the placenta ≥ 1cm from the internal os at around 20 weeks do not require further ultrasounds for placental location. All patients with suspected placenta previa (i.e. inferior placental edge <1 cm from the internal os or overlying the os by <2.5 cm at around 20 weeks) should be rescanned at least once between 32 and 35 weeks’ gestation to assess for persistence of true placenta previa. Measuring distance from placental edge to internal os in the third trimester can help estimate the risk of bleeding with trial of labor. For patients with low-lying placenta or marginal previa, velamentous cord insertion, succenturiate lobed or bilobed placenta, vasa previa should be excluded by TVU. Udayana University Faculty of Medicine, DME 28 Study Guide The Reproductive System and Disorders 2. Post partum hemorrhage Traditionally, postpartum hemorrhage has been defined as the loss of 500 mL of blood or more after completion of the third stage of labor. This is problematic because half of all women delivered vaginally shed that amount of blood or more when losses are measured quantitatively Pritchard and associates (1962) used precise methods and found that approximately 5 percent of women delivering vaginally lost more than 1000 mL of blood. They also reported that estimated blood loss is commonly only approximately half the actual loss. Because of this, estimated blood loss in excess of 500 mL should call attention to mothers who are bleeding excessively. Toledo and colleagues (2007) have shown that calibrated drape markings improve estimation accuracy. Still, as shown by the study of Sosa and associates (2009) cited above, even this technique underestimates blood loss when compared with more precise methods described by Pritchard and colleagues It is therefore readily apparent that fatal postpartum hemorrhage can result from uterine atony despite normal coagulation. Conversely, if the myometrium within and adjacent to the denuded implantation site contracts vigorously, fatal hemorrhage from the placental implantation site is unlikely even Except possibly when intrauterine and intravaginal accumulation of blood is not recognized, or in some instances of uterine rupture with intraperitoneal bleeding, the diagnosis of postpartum hemorrhage should be obvious. The differentiation between bleeding from uterine atony and that from genital tract lacerations is tentatively determined by predisposing risk factors and the condition of the uterus. If bleeding persists despite a firm, well-contracted uterus, the cause of the hemorrhage most likely is from lacerations. Bright red blood also suggests arterial blood from lacerations. To confirm that lacerations are a cause of bleeding, careful inspection of the vagina, cervix, and uterus is essential. Late Postpartum Hemorrhage is bleeding after the first 24 hours of birth. Most of cause was placental rest. Postterm Pregnancy Post-term pregnancy is defined as a singleton pregnancy that has lasted until ≥ 42weeks or ≥ 294 days. Complications include, for the baby, increased incidences of meconium aspiration, intrauterine infection, oligo hydramnios, macrosomia, non-reassuring fetal heart testing (NRFHT), low umbilical artery pH, low 5- minute Apgar score, dysmaturity syndrome, and perinatal mortality; for the mother, increased risk of labor dystocia, perineal injury, and cesarean delivery. Pregnancies with risk factors such as maternal (e.g. hypertension, diabetes, etc.) and fetal (growth restriction, etc.) diseases necessitate special management, as described in the pertinent guidelines. Prevention of post-term pregnancy can be effectively achieved with routine early pregnancy (< 20 weeks) ultrasound and with stripping of membranes starting at 38 or 41 weeks. There is insufficient evidence to assess the efficacy of antepartum testing for pregnancies after their due date, but twice-weekly fetal testing starting at 41 weeks with the non-stress test (NST), or NST and amniotic fluid volume (AFV), or biophysical profile (BPP) have been proposed. At ≥ 41 weeks, even if the cervix is still unfavorable, routine induction of labor reduces perinatal mortality, mainly as a result of the decrease in fetal deaths. Routine induction of labor is associated with a decrease in the incidence of cesarean delivery in women who are nulliparous, ≥ 41 weeks, induced with prostaglandins, or delivered in a center with a cesarean delivery rate >10%. In women with a prior cesarean delivery, induction of labor is associated with an increase in uterine rupture. Twin Pregnancy Multiple gestation is a gestation carrying more than one fetus. The overwhelming majority are twins. There are two types of twins: Udayana University Faculty of Medicine, DME 29 Study Guide The Reproductive System and Disorders 1. Monozygotic (MZ) twins are formed when a single fertilized ovum splits into two individuals who are almost always genetically identical, unless after their division there is a spontaneous mutation. 2. Dizygotic (DZ) twins are formed when two separate ova are fertilized by two different sperms resulting in genetically different individuals. Table 2: Type of Zygote Division and Type of Twin Complication: Fetal: spontaneous reduction, spontaneous loss, higher rates of chromosomal and congenital anomalies, fetal growth restriction and discordant growth, single fetal demise in multiple gestations, immaturity, intrapartum complications, perinatal neurologic damage, perinatal mortality Maternal: Heartburn, hemorrhoids, tiredness, anxiety, hyperemesis gravidarum, maternal anemia, preeclampsia, abruption placenta, thrombocytopenia, acute fatty liver, gestational diabetes. Learning task: Vignette 1: A 20-year-old G1 at 36 weeks is being monitored for preeclampsia; she rings the bell for the nurse because she is developing a headache and feels funny. As you and the nurse enter the room, you witness the patient undergoing a tonic-clonic seizure. You secure the patient’s airway, and within a few minutes the seizure is over. The patient’s blood pressure monitor indicates a pressure of 160/110 mm Hg. Question: 1. What is the diagnosis of this patient? 2. What is the best planning management for this patient? Vignette 2 A 20 year-old woman came to hospital with abdominal cram, and vaginal blood spotting. She’s pregnancy of 29 weeks. The blood pressure 120/80 mmHg, pulse rate 80 bpm, RR 20 times/mt, Hb 11 g/dl. Abdominal examination: uterine fundal 29 cm, uterine contraction twice within 10 minutes. Cervical dilatation 2 cm. estimated fetal weight 1000 g. Udayana University Faculty of Medicine, DME 30 Study Guide The Reproductive System and Disorders Question: 1. What is the diagnosis this patient? 2. What do you plan to maturation of the fetal lung? 3. How to manage a patient that diagnose like a case above? Self assessment 2: 1. What is the definition of preterm pregnancy? 2. What are the short term and long term complications of preterm birth? 3. How to minimize that complications? 4. Describe about fetal lung maturity. Vignette 3: A 35 year-old woman complain about severe abdominal pain. She’s 3rd pregnancy 37 weeks, singleton baby and there was history of high blood pressure. Current conditions; BP 150/100 mmHg, pulse rate 96x/mt, RR 20x/mt, Hb 9 d/dl. Abdominal examination; uterine fundal 4 cm below procesus xiphoideus, difficulty palpation of baby part, fetal heart tone 170 bpm. There was dark brawn vaginal bleeding. Question: 1. What the diagnosis these patient? 2. What are predisposition factors in a case above? 3. What are differential diagnosis a case like this? 4. How to manage the patient in case above? Self assessment 3: 1. What the definition of placental abruption? 2. What does it mean: concealed hemorrhage, external hemorrhage, consumptive coagulopathy 3. Describe about pathogenesis of solutio placenta. 4. What are complications of the solution placenta? Vignette 4: A 30 year-old woman, with history of spontaneous vaginal birth one hour ago. She was referred by midwife at cause active vaginal bleeding. Blood pressure was 100/60 mmHg. Pulse rate 100x/minute, RR 22x/minute, uterine fundus as level as umbilical. Weakness uterine contraction. Vaginal examination, much of blood clot in vagina. Question: 1. What is approximate diagnosis of this patient? 2. What are the predisposition factors in case like above? 3. What do you planning in “primary survey”? 4. Definitive management for this patient are? Self assessment 4: 1. What is the definition of post partum hemorrhage? 2. The most frequents cause of post partum hemorrhage is? 3. Would you like explain about late post partum hemorrhage? 4. What kind of uterotonica usually need to make better uterine contraction? Vignette 5: A 34-year-old woman, gravida 3, para 1, abortions 1, at 42 and 1/7 weeks of gestation by a Week-6 ultrasound, presents to your clinic. Her NST is reactive and AFI is 8.5. Her cervix is 0.5 cm dilated, 20% effaced, midposition, and fi rm, and the fetal vertex is at -4 station Udayana University Faculty of Medicine, DME 31 Study Guide The Reproductive System and Disorders Question: 1. What is the diagnosis of this patient? 2. What is the best planning management for this patient? Vignette 6: Ms. Jason, a 31-year-old G2 P1 patient presents to your office seeking prenatal care. She is unsure of her last menstrual period due to a history of Irregular menses. On physical examination, her uterus Is noted to be approximately 12-week size. You perform an abdominal ultrasound to establish an estimated due date. You see the following image. Question: 1. What is the diagnosis of this patient? 2. What is the best planning management for this patient? Lecture 8 Abnormal Labor (Dr.dr I Nyoman Gede Budiana, SpOG (K)) Abstract Labor is the physiologic process by which a fetus is expelled from the uterus to the outside world. A switch from contractures (long-lasting, low-frequency activity) to contractions (frequent, high-intensity, high-frequency activity) occurs before progressive cervical effacement and dilation of the cervix and regular uterine contractions. Most guidelines for normal human labor progress are derived from Friedman’s clinical observations of women in labor. Friedman characterized a sigmoid pattern for labor when graphing cervical dilation against time. He divided labor into three functional divisions: the preparatory division, dilation division, and pelvic division. The preparatory division is better known as the latent phase, during which little cervical dilation occurs but considerable changes are taking place in the connective tissue components of the cervix. The dilation division or active phase is the period when dilation proceeds at its most rapid rate to complete cervical dilation. These two phases together make up the first stage of labor. The pelvic division or second stage of labor refers to the time of full cervical dilation to the delivery of the infant. The third stage of labor refers to the time from the delivery of the infant Udayana University Faculty of Medicine, DME 32 Study Guide The Reproductive System and Disorders to expulsion of the placenta. The fourth stage of labor refes to 2 hours after delivery of placenta. Although cervical dilation does accelerate as labor advances, a precipitous dilation as described by Friedman may not necessarily occur, especially in nulliparas. Additional analyses regarding contemporary labor progress are expected from this project. Regardless of those results, a graduated approach for diagnosis of labor protraction and arrest should be considered, based on the level of cervical dilation. Introduction Abnormal labor, or labor dystocia (literally, “difficult labor or childbirth”) is characterized by the abnormal progression of labor. Labor is the occurrence of uterine contractions of sufficient intensity, frequency, and duration to bring about demonstrable effacement and dilation of the cervix. Dystocia results from what have been categorized classically as abnormalities of the “power” (uterine contractions or maternal expulsive forces), “passenger” (position, size, or presentation of the fetus), or “passage” (pelvis or soft tissues). It is important to recognize because it has been associated with adverse consequences for the fetus and mother. Morbidities that have been attributed to prolonged labor include fetal and maternal infections, uterine rupture, postpartum hemorrhage, obstetric fistulae, and perineal injuries. This chapter will detail the factors which distinguish normal from abnormal labor, discuss underlying etiologies, and finally address management options in the setting of labor dystocia. Etiology Maternal Causes 1. Bony Contraction • Contracted pelvis • Tumors of pelvis • Bony deformities 2. Soft Tissue Obstruction • Uterine-impacted fibroid – Constriction ring – Sacculation of uterus • Cervical-stenosis, tumors – Vaginal-stenosis, septa, tumors – Ovarian-neoplasm 3. Others • Pelvic kidney • Tumors of urinary bladder and rectum • Vesical calculus Fetal Conditions 1. Large size baby (macrosomia) 2. Malpresentations and malpositions 3. Locked twins 4. Fetal anomalies in babies The various consequences of obstructed labor are as follows: 1. Premature rupture of membranes 2. Abnormalities in dilatation 3. Danger of uterine rupture 4. Fistula formation 5. Postpartum lower extremity nerve injury Labor is divided by Pritchard and MacDonald into four stages: 1. First stage: from onset of labor to full dilation of the cervix Udayana University Faculty of Medicine, DME 33 Study Guide The Reproductive System and Disorders 2. Second stage: from full dilation of the cervix to delivery of the infant 3. Third stage: from delivery of the infant to delivery of the placenta 4. Fourth stage: comprising the hour immediately following delivery of the placenta. Abnormal labor are classified based on this stage which are: 1. First stage: Protraction Disorders and Arrest Disorders 2. Second stage: Abnormalities of Rotation and Descent and shoulder distocia 3. Third stage: Retained Placenta and Inversion of the Uterus 4. Fourth stage: Postpartum Hemorrhage Diagnosis General sign and symptoms includes: 1. Maternal physical and mental exhaustion 1. Dehydration and ketoacidosis (sunken eyes, thirsty, dry mouth, dry skin identified by skin pinch going back slowly) 2. Fever (raised temperature) 3. Abdominal pain which may be continuous 4. Shock, rapid, weak pulse (100 per minute or more), diminished urinary output, cold clammy skin, pallor, low blood pressure (systolic less than 90 mm Hg), rapid respiratory rate (30 per minute or more), anxiousness, confusion or unconsciousness. Shock may be due to a ruptured uterus or sepsis Spesific sign includes abdominal and vaginal examination. From abdomen examination: 1. The widest diameter of the fetal head can be felt above the pelvic brim because it is unable to descend; a large caput succedaneum may be fixed in the pelvic brim and this can be misleading, but careful palpation should identify that the widest diameter of the head is still above the brim; if the uterus is tonic, it will be very difficult to palpate because it is continuously hard and very painful for the woman. 2. Frequent, long and strong uterine contractions (although if a woman has been in labor for a long time, contractions may have stopped because of uterine exhaustion); they restart with renewed vigor. 3. The uterus may have gone into tonic contraction (i.e. it is continuously hard) and sits tightly molded around the fetus. 4. Bandl’s ring may be seen. a) Bandl’s ring is the name given to the area between the upper and lower uterine segments when it becomes visible and/or palpable during labor. In the process of normal pregnancy and labor, this area is called a retraction ring. It should not normally be seen or felt on abdominal examination b) Bandl’s ring is a late sign of obstructed labor. It can be seen as a depression across the abdomen at about the level of the umbilicus. Above this is the grossly thickened, retracted upper uterine segment. Below the Bandl’s ring is the distended, dangerously thinned lower uterine segment. The lower abdomen can be further distended by a full bladder and gas in the intestines. 5. Fetal heart may not be heard in severe cases of obstructed labor because the fetus dies from anoxia Udayana University Faculty of Medicine, DME 34 Study Guide The Reproductive System and Disorders Table 1: Abnormal Labor Patterns, Diagnostic Criteria, and Methods Of Treatment From vaginal examination we can found: 1. Foul-smelling meconium draining 2. Amniotic fluid already drained away 3. Catheterization will produce concentrated urine which may contain meconium or blood 4. Edema of the vulva, especially if the woman has been pushing for a long time 5. Vagina hot and dry because of dehydration 6. Edema of the cervix 7. Incomplete dilatation of the cervix (may be fully dilated in case of outlet obstruction) 8. A large caput succedaneum can be felt 9. The cause of the obstruction, e.g. excessively molded head stuck in pelvis, shoulder, brow or posterior face presentation, prolapsed arm Management Six Steps to Providing Effective Management Abnormal Labor: 1. Identify the problem 2. Decide on the aim of management 3. Select the best management 4. Provide management, determining priorities 5. Evaluate the outcome 6. Provide further management, if necessary may include referral Udayana University Faculty of Medicine, DME 35 Study Guide The Reproductive System and Disorders Rehydrate the Patient, the aim: to maintain normal plasma volume and prevent or treat dehydration and ketosis 1. Put up an intravenous (IV) infusion. Use a large needle (No. 18) or cannula 2. If the woman is shocked, give normal saline or Ringer’s lactate. Run in 1 liter as quickly as possible, then repeat 1 liter every 20 minutes until the pulse slows to less than 90 beats per minute, systolic blood pressure is 100 mm Hg or higher. Give Antibiotics, if there are signs of infection, or the membranes have been ruptured for 18 hours or more, or the period of gestation is 37 weeks or less, give antibiotics as follows: 1. Ampicillin 2 g every 6 hours, and 2. Gentamicin 5 mg/body weight IV every 24 hours If the woman is delivered by cesarean section, continue antibiotics and give metronidazole 500 mg IV every 8 hours until the woman is fever-free for 48 hours. Give Supportive Care, the woman’s birth companion should be encouraged to stay with her to provide comfort and support. Staff should explain all procedures to the woman, seek her permission, discuss results with her, listen and be sensitive to her feelings and deliver the baby. Flowchart 1: Management Abnormal Labor Udayana University Faculty of Medicine, DME 36 Study Guide The Reproductive System and Disorders Flowchart 1: Management Abnormal Labor (con’t) Complications Maternal Complications 1. Genital tract trauma and rupture of uterus 2. Postpartum hemorrhage 3. Pulmonary embolism 4. Puerperal infection 5. Septicemia and shock 6. Subinvolution of uterus 7. Delayed healing of wounds 8. Urinary fistulae (0.5–1%) 9. Obstetric palsies 10. Postpartum psychosis 11. Future obstetric complications Fetal Complications 1. Asphyxia 2. Sepsis 3. Fetal trauma 4. Intracranial hemorrhage 5. Death Udayana University Faculty of Medicine, DME 37 Study Guide The Reproductive System and Disorders Learning Task: Vignette 1 A 30-year-old G2P0 at 39 weeks is admitted in active labor with spontaneous rupture of membranes occurring 2 hours prior to admission. The patient noted clear fluid at the time. On examination, her cervix is 4 cm dilated and completely effaced. The fetal head is at 0 station and the fetal heart rate tracing is reactive. Two hours later on repeat examination her cervix is 5 cm dilated and the fetal head is at +1 station. Early decelerations are noted on the fetal heart rate tracing. Question: 1. What is the diagnosis of this patient? 2. What is the best planning management for this patient? 3. What is the risk and complication that may occur? Vignette 2 A 32-year-old G3P2 at 39 weeks gestation presented to the hospital with ruptured membranes and 4 cm dilated. She has a history of two prior vaginal deliveries, with her largest child weighing 3800g at birth. Over the next 2 hours she progresses to 7cm dilated. Two hours later, she remains 7cm dilated. The estimated fetal weight by ultrasound is 3200g. Question: 1. What is the diagnosis of this patient? 2. What is the best planning management for this patient? 3. What is the risk and complication that may occur? Vignette 3 A 23-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are occurring every 4 to 8 minutes and each lasts approximately 1 minute. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 2 to 10 minutes. The nurse states that the contractions are mild to palpation. On examination the cervix is 2 cm dilated, 50% effaced, and the vertex is at −1 station. The patient had the same cervical examination in your office last week. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations Question: 1. What is the diagnosis of this patient? 2. What is the best planning management for this patient? 3. What is your education and information for this patient? Vignette 4 A 25-year-old G3P2 at 39 weeks is admitted in labor at 5 cm dilated. The fetal heart rate tracing is reactive. Two hours later, she is reexamined and her cervix is unchanged at 5 cm dilated. An IUPC is placed and the patient is noted to have 280 Montevideo units (MUV) by the IUPC. After an additional 2 hours of labor, the patient is noted to still be 5 cm dilated. The fetal heart rate tracing remains reactive. Question: 1. What is the diagnosis of this patient? 2. What is the best planning management for this patient? 3. What is the risk and complication that may occur? 4. What is your education and information for this patient? Udayana University Faculty of Medicine, DME 38 Study Guide The Reproductive System and Disorders Self Assesment: 1. What is the definition of abnormal labor? 2. What is the etiology of abnormal labor? 3. How to make diagnose of abnormal labor? 4. What is the management plan for abnormal labor? 5. What is the complication in abnormal labor? Lecture 9 Puerperium & Disorders (Dr.dr.I Nyoman Bayu Mahendra, SPOG (K)) Abstract A woman giving birth in a hospital may leave the hospital as soon as she is medically stable and chooses to leave, which can be as early as a few hours postpartum, though the average for a vaginal birth is 1-2 days. During this time, the mother is monitored for bleeding, bowel and bladder function, and also baby care. In this lecture we learn the physiologic change during puerperium period and the disorders of this period as the complication to the mother. It is important to make a diagnosis based on International Classification of Diseases (ICD)-10. ICD-10 coding making easier to communicate between health provider and insurance coverage. Introduction The puerperium defines the time following delivery during which pregnancy-induced maternal anatomical and physiological changes return to the nonpregnant state. Its duration is understandably inexact, but is considered to be between 4 and 6 weeks. Although much less complex compared with pregnancy, the puerperium has appreciable changes, some of which may be either bothersome or worrisome for the new mother. Importantly, several complications can develop, and some are serious. The puerperium may be a time of intense anxiety for many women. Some mothers have feelings of abandonment following delivery because of a newly aimed focus on the infant. Kanotra and colleagues (2007) analyzed challenges that women faced from 2 to 9 months following delivery. A third of these new mothers felt the need for social support, and 25 percent had concerns with breast feeding. Physiologic Change Involution of the reproductive tract: - Birth canal: vagina and its outlet gradually diminish in size but rarely regain heir nulliparous dimensions. Rugae begin to reappear by the third week but are less prominent than before. The hymen is represented by several small tags of tissue, which scar to form he myrtiform caruncles. Vaginal epithelium begins to proliferate by 4 to 6 weeks, usually coincidental with resumed ovarian estrogen production. Lacerations or stretching of the perineum during delivery may result in vaginal outlet relaxation. Some damage to the pelvic floor may be inevitable, and parturition predisposes to urinary incontinence and pelvic organ prolapse. - Uterus: uterus caliber gradually diminishes to approximately that of of the prepregnant state. Within the puerperal uterus, larger blood vessels become obliterated by hyaline changes, are gradually resorbed, and are replaced by smaller ones. Postpartum, the fundus of the contracted uterus lies slightly below the umbilicus. It consists mostly of myometrium covered by serosa and internally lined by basal decidua. The anterior and posterior walls, which lie in close apposition, are each 4 to 5 cm thick. At this time, the uterus weighs approximately 1000 g. Myometrial involution is a truly remarkable tour de force of e destruction or deconstruction that begins as soon as 2 days after delivery. Best estimates are that by 1 week, the uterus weighs approximately 500 g; by 2 weeks, about 300 g; and at Udayana University Faculty of Medicine, DME 39 Study Guide The Reproductive System and Disorders 4 weeks, involution is complete and the uterus weighs approximately 100 g. After each successive delivery, the uterus is usually slightly larger than before the most recent pregnancy. - Decidua and endometrial regeneration: within 2 or 3 days after delivery, the remaining deciduas becomes differentiated into two layers. The superficial layer becomes necrotic and is sloughed in the lochia. The basal layer adjacent to the myometrium remains intact and is the source of new endometrium. This arises from proliferation of the endometrial glandular remnants and the stroma of the interglandular connective tissue. Endometrial regeneration is rapid, except at the placental site. Within a week or so, the free surface becomes covered by epithelium. Histological endometritis is part of the normal reparative process. Moreover, microscopic inflammatory changes characteristic of acute salpingitis are seen in almost half of women between 5 and 15 days, but these findings do not reflect infection Clinical aspects: - Afterpain: In primiparous women, the uterus tends to remain tonically contracted following delivery. In multiparas, however, it often contracts vigorously at intervals and gives rise to afterpains, which are similar to but milder than labor contractions. - Lochia: early in the puerperium, sloughing of decidual tissue results in a vaginal discharge of variable quantity. The discharge is termed lochia and contains erythrocytes, shredded deciduas, a epithelial cells, and bacteria. For the first few days after delivery, there is blood sufficient to color it red—lochia rubra. After 3 or 4 days, lochia becomes progressively pale in color—lochia serosa. After approximately the 10th day, because of an admixture of leukocytes and reduced fluid content, lochia assumes a white or yellow-white color—lochia alba.The average duration of lochial discharge ranges from 24 to 36 days - Subinvolution: in some cases, uterine involution is hindered because of infection, retained placental fragments, or other causes. Such subinvolution is accompanied by varied intervals of prolonged lochia as well as irregular or excessive uterine bleeding. On bimanual examination, the uterus is larger and softer than would be expected. - Late postpartum hemorrhage: secondary postpartum hemorrhage as bleeding 24 hours to 12 weeks after delivery. Clinically worrisome uterine hemorrhage develops within 1 to 2 weeks in perhaps 1 percent of women. Such bleeding most often is the result of abnormal involution of the placental site. It occasionally is caused by retention of a placental fragment or by a uterine artery pseudoaneurysm. Breast and Lactation After delivery, the breasts begin to secrete colostrum, which is a deep lemon-yellow liquid. It usually can be expressed from the nipples by the second postpartum day. Compared with mature milk, colostrum is rich in immunological components and contains more minerals and amino acids. It also has more protein, much of which is globulin, but less sugar and fat. Secretion persists for 5 days to 2 weeks. The precise humoral and neural mechanisms involved in lactation are complex. Progesterone, estrogen, and placental lactogen, as well as prolactin, cortisol, and insulin, appear to act in concert to stimulate the growth and development of the milk-secreting apparatus. With delivery, there is an abrupt and profound decrease in the levels of progesterone and estrogen. This decrease removes the inhibitory influence of progesterone on a-lactalbumin production and stimulates lactose synthase to increase milk lactose. Progesterone withdrawal also allows prolactin to act unopposed in its stimulation of alactalbumin production. Serotonin is produced in mammary epithelial cells and has a role in maintaining milk production. This may explain the decreased milk production in women taking selective serotonin-reuptake inhibitor. The nipples require little attention other than cleanliness and attention to skin fissures. Fissured nipples render nursing painful, and they may have a deleterious influence on milk production. These cracks also provide a portal of entry for pyogenic bacteria. Because dried milk is likely to accumulate and irritate the nipples, washing the areola with water and mild soap is helpful before and after nursing. Udayana University Faculty of Medicine, DME 40 Study Guide The Reproductive System and Disorders Puerperium Disorders Basic principal of puerperium disorders are genital tract infection after delivery process, body temperature ≥ 38°C started 2nd days postpartum and examinee at least 4 times ~ postpartum febrile and increase of body temperature in the puerperium period ~ puerperium infection (no other source of infection). General management of this condition are anticipate each predisposition factor, rational and effective treatment, do not discharge the patient, if critical period have not finished yet. Signs and symptoms Others sign Probably diagnosis Lower abdomen pain Purulen lochia Uterine subinvolution and tender Vaginal bleeding Shock Leucocytosis (PMN) Metritis (ICD-10: O86.11) (Endometritis/ Endomiometritis) Lower abdomen pain Lower abdomen enlargement Continuing fever Any improvement with antibiotics Oedema of adnexa and douglas pouch Pelvic abscess (ICD-10: O86.19) Lower abdomen pain Absent bowel sound Rebound tenderness Anorexia/vomit Peritonitis (ICD-10: K65) Breast pain and tender Breast oedema and strain Occur between 3rd – 5th after delivery Breast engorgement (ICD10: O92.2) Breast pain and oedema Inflammation, with previous engorgement Redness with clear border Only one breast Occur 3-4th weeks after delivery Mastitis (ICD-10: O91.2) Oedema and redness of breast Oedema with fluctuation Pus Breast abscess (ICD-10: O91.1) Wound incision pain and induration Wound incision thickening Pus Redness Wound selulitis (ICD-10: O86.0) (perineal / abdominal) Wound incision abscess/hematoma (ICD10: O86.0) Thickening of the wound with serous fluid/wredness wound no or minimal erithema Dysuria Waist tenderness Suprapubic pain Shivering Urinary tract infection (ICD-10: O86.2) Severe fever with antibiotics Lower extremities strain Deep vein thrombosis Lung, kidney, joint, eye and subcutaneous tissue Thrombophlebitis: (ICD-10: Udayana University Faculty of Medicine, DME 41 Study Guide The Reproductive System and Disorders Shivering O87.1) complication Pelviothrombo-phlebitis femoralis (ICD-10: O87.4) Pneumonia (ICD-10: J13) (ICD-10Consolidation Sputum Cough Dyspneu Tachypneu Chest pain Shivering Hepatomegali Malaria (ICD-10: B52) Splenomegali Thypoid (ICD-10: A01.09) Icteric Hepatitis (ICD-10: B15-B19) Epigastrial pain Learning Outcome Appropriate management during normal puerperium period Manage, establish tentative diagnosis, management patient with puerperium disorders Learning Objective PIC SSR - Describe normal physiologic of puerperium period - Describe routine management for normal puerperium period - Describe cause of puerperium disorders - Describe puerperium fever and choose of appropriate antibiotics for metritis, phlebitis or sepsis Dr. dr. I Nyoman Bayu Mahendra, SpOG(K) Cunningham, F., et al. 2014. The Puerperium. In: Cunningham, F., et al. editors. Williams Obstetric. 24th Ed. New York: McGraw Hill. pp. 668-94. Summary Puerperium period is a critical period to the mother who have deliver the baby. Many anatomical, functional and clinical aspects of the mother return to the normal state as before the pregnancy. As medical practitioner, we must put special attention to all of the symptoms that the mothers complain. And can manage appropriately to prevent advance morbidity and mortality to the mother. Learning Task Case: Mrs. S, 30 yo, P3003 7 days post SVD, labor was helped by traditional attendant, comes to PHC with complains of fever and smelly lochia. From physical examination found BP: 100/70 mmHg, axillary temperature: 39oC, rectal temperature: 39,7 oC, pulse: 100x/mnts, respiration rate: 20x/mnts. Udayana University Faculty of Medicine, DME 42 Study Guide The Reproductive System and Disorders Questions 1. What is the diagnosis of this patient? 2. What the anamnesis, sign and symptoms and examination to support the diagnosis? 3. What is the management of this patient? 4. What are the communication, education and counseling to patient and her family? SELF ASSESSMENT: 1. Explain the change during normal puerperium period 2. How to diagnosis and confirmation of puerperium disorders? 3. Explain the management of puerperium period? 4. How to prevent puerperium disorders? Lecture 10 Obstetric Emergency Dr. dr. I Gede Ngurah Harry Wijaya Surya, Sp. OG Emergency definition: occur suddenly, threaten mother or child, urgency, dangerous that for needed immediate action. In obstetric cases there are two cause that can make emergency: hemorrhage and non hemorrhage. The cause of hemorrhage are: Abortus: inevitable, incomplete, infectious, hidatidiform mole, ruptured ectopic pregnancy, APB: placenta previa, solutio placenta, rupture vasa previa, Rupture Uteri Imminen (RUI) and uterine rupture, HPP: atony, laceration, rest placenta, coagulopathy. The cause of non hemorrhage are: Severe PE / eclampsia, fetal distress, sepsis, umbilical cord prolaps, uterine inversion, pregnancy & other disease Case Female, 21 yo, came to Emergency Room in the afternoon with main complain abdominal pain that came suddenly, slightly bleeding from vagina (+), history of collapse (+), delayed menstrual periode (+) but last menstrual periode forgotten (± 4-5 weeks ago). Plano Pregnancy Test (+) 1 weeks ago. This is her first pregnancy, never done ante natal visit. Eye: conjuctiva pale +/+, abdominal pain (+), VT: slinger pain (+) Learning task: 1. What are the first management treatment for this patient? 2. What are the diagnosis and differential diagnosis for this case? Lecture 11 Common gynecologic disorders Dr. dr. I.B.G. Fajar Manuaba, Sp.OG, MARS Abstract Gynecologic disorders are disorders that affect the female reproductive system. The most common symptoms of gynecologic disorders include pelvic pain, vaginal itching, vaginal discharge, abnormal vaginal bleeding, and breast pain and lumps. In this lecture we will be focused on common gynecologic infection which could be found in general practitioners. Gynecologic infection has a lot of variant, it is important to make a diagnosis based on International Classification of Diseases (ICD) – 10. ICD-10 coding making easier to communicate between health provider also for insurance coverage. Introduction Gynecologic disorders are disorders that affect the female reproductive system. The most common symptoms of gynecologic disorders include pelvic pain, vaginal itching, vaginal discharge, abnormal vaginal bleeding, and breast pain and lumps. Most of the common symptoms caused by common gynecologic infection. This symptom lead the women to come to health facility. Udayana University Faculty of Medicine, DME 43 Study Guide The Reproductive System and Disorders In general we divide gynecologic infection into: lower genital infection and upper genital infection. In lower genital infection we will discuss about vulvitis, vaginitis, cervicitis, condylomata acuminata, and bacterial vaginosis. In upper genital infection we will discuss about pelvic inflammatory disease. Also in this lecture we will discuss etiology of gynecologic infection. Vulvitis (ICD-10: N76.2 and N76.3) It is an inflammation of the vulva area - that is the fleshy tissue that covers the entrance to the vagina. It is not a condition in itself but rather a symptom of a number of other diseases, infections, allergies or external irritants. Bad diet, tiredness, stress and poor hygiene can increase a woman's risk of vulvitis. Except in rare cases not associated with vulva cancer, vulvitis is not a serious condition but it can be agonizingly uncomfortable. It is often difficult to pinpoint a cause which makes treatment frustratingly difficult. In ICD-10 vulvitis case divide into: acute vulvitis (N.76.2) also subacute and chronic vulvitis (N76.3). The following are signs of vulvitis: • Red, swollen skin. • Excruciating itching (pruritus) around the labia and other parts of the vulva. • Small cracks in the skin. • Possible vaginal discharge. • Clear fluid filled blisters that eventually burst and crust over. • If the condition is chronic the skin becomes thickened and develops white Vaginitis (ICD 10: N76.0 and N76.1) Vaginitis refers to any inflammation or infection of the vagina. It is common in women of all ages. One-third of women have at least one form of vaginitis at some time during their lives.When the walls of the vagina become inflamed, because some irritant has disturbed the balance of the vaginal area, vaginitis can occur. Bacteria, yeast, viruses, chemicals in creams or sprays, and even clothing can cause vaginitis. Sometimes, it occurs from organisms that are passed between sexual partners. Also, a number of different factors can affect the health of your vagina. These include your overall health, your personal hygiene, medicines, hormones (particularly estrogen), and the health of your sexual partner. Changes in any of these factors can trigger vaginitis. In general we divide vaginitis into acute vaginitis (N76.0) also subacute and chronic vaginitis (N76.1). These are more specific types of vaginitis and vulvitis: • Chlamydial vulvovaginitis (A56.02) • Gonococcal vulvovaginitis, unspecified (A54.02) • Herpesviral vulvoginitis (A60.04) • Trichomonal vulvovaginitis (A59.01) • Candidiasis of vulva and vagina (B37.3) Condylomata acuminata (ICD 10: A63.0) Genital warts (or condylomata acuminata, venereal warts, anal warts and anogenital warts) are symptoms of a highly contagious sexually transmitted disease caused by some types of human papillomavirus (HPV). It is spread through direct skin-to-skin contact, usually during oral, genital, or anal sex with an infected partner. Warts are the most easily recognized symptom of genital HPV infection. Despite the fact that some types of HPV cause cervical cancer and anal cancers, these are not the same types of HPV that cause genital warts. About 90% of those who contract HPV will not develop genital warts, but the remaining 10% who are infected can still transmit the virus. Although estimates of incidence vary between studies, HPV is so common that nearly all sexually active people will get it at some point in their lives. HPV types 6 and 11 are most frequently the cause of genital warts. The HVP vaccine includes coverage for these types. While types 6 and 11 are considered low risk for progression to cancers, it is also possible to be infected with different varieties of HPV, such Udayana University Faculty of Medicine, DME 44 Study Guide The Reproductive System and Disorders as a low-risk HPV that causes warts and a high-risk HPV, either at the same or different times. Bacterial vaginosis (ICD 10: B96 or N76) Bacterial vaginosis (BV) is a disease of the vagina caused by excessive growth of bacteria. Common symptoms include increased vaginal discharge that often smells like fish. The discharge is usually white or gray in color. Burning with urination may occur. Itching is uncommon. Occasionally there may be no symptoms. Having BV approximately doubles the risk of infection by a number of other sexually transmitted infections including HIV/AIDS. It also increases the risk of early delivery among pregnant women. BV is caused by an imbalance of the naturally occurring bacteria in the vagina. There is a change in the most common type of bacteria and a hundred to thousand fold increase in total numbers of bacteria present. Typically bacteria other than Lactobacilli become more common. Risk factors include douching, new or multiple sex partners, antibiotics, and using an intrauterine device among others. [10] However, it is not considered a sexually transmitted infection. Diagnosis is suspected based on the symptoms and may be verified by testing the vaginal discharge and finding a higher than normal vaginal pH and large numbers of bacteria. BV is often confused with a vaginal yeast infection or infection with Trichomonas. Bacterial vaginosis is a term that common used in clinical setting. In ICD-10 there is no spesific term for bacterial vaginosis. Usually we code this case become: other specified bacterial agents as the cause of diseases classified to other chapters (B96) or vaginitis (N76). Cervicitis (ICD 10: N72) Cervicitis is inflammation of the uterine cervix. Cervicitis in women has many features in common with urethritis in men and many cases are caused by sexually transmitted infections. Non-infectious causes of cervicitis can include intrauterine devices, contraceptive diaphragms, and allergic reactions to spermicides or latex condoms. The condition is often confused with vaginismus which is a much simpler condition and easily rectified with simple exercises. Cervicitis can be caused by any of a number of infections, of which the most common are chlamydia and gonorrhea, with chlamydia accounting for approximately 40% of cases. As many half of pregnant women are asymptomatic with a gonorrhea infection of the cervix. Trichomonas vaginalis and herpes simplex are less common causes of cervicitis. There is a consistent association of M. genitalium infection and female reproductive tract syndromes. M. genitalium infection is significantly associated with increased risk of cervicitis. In ICD-10 term inflammatory disease of cervix uteri (N72) include cervicitis, endocervicitis, exocervicitis. Erosion and ectropion of cervix uteri sometime mimic like cervicitis, but if in this case there no sign of cervicitis we use code N86. Pelvic inflammatory disease (ICD 10: N70, N71, N73, N74) Pelvic inflammatory disease or pelvic inflammatory disorder (PID) is an infection of the upper part of the female reproductive system namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often there may be no symptoms. Signs and symptoms, when present may include lower abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, or irregular menstruation. Untreated PID can result in long term complications including infertility, ectopic pregnancy, chronic pelvic pain, and cancer. The disease is caused by bacteria that spread from the vagina and cervix. Infections by Neisseria gonorrhoeae or Chlamydia trachomatis are present in 75 to 90 percent of cases. Often multiple different bacteria are involved. Without treatment about 10 percent of those with a chlamydial infection and 40 percent of those with a gonorrhea infection will develop PID. Risk factors are similar to those of sexually transmitted infections generally and include a high number of sexual partners and drug use. Vaginal douching may also increase the risk. The diagnosis is typically based on the presenting signs and symptoms. It Udayana University Faculty of Medicine, DME 45 Study Guide The Reproductive System and Disorders is recommended that the disease be considered in all women of childbearing age who have lower abdominal pain. A definitive diagnosis of PID is made by finding pus involving the fallopian tubes during surgery. Ultrasound may also be useful in diagnosis Pelvic inflammatory disease or pelvic inflammatory disorder is a wide term in clinical setting. In ICD-10 setting the physician must be more specific to code base on spesific upper part of the female reproductive system: • Salpingitis and oophoritis (N70) • Inflammatory disease of uterus, except cervix (N71) • Other female pelvic inflammatory diseases (N73) • Female pelvic inflammatory disorders in diseases classified elsewhere (N74) Summary The most common gynecologic disorders are infection. Gynecologic infection has a lot of variant sometime the term in medical setting has a wide interpretation. In ICD-10 era we have to make more specific term and coding. Specific ICD-10 coding making easier to communicate between medical provider also for insurance coverage. Indonesian universal health insurance (BPJS) will not pay the health provider without ICD-10 coding. Learning task Woman 35 years old, Para 1, IUCD user (Copper T 380 A) since 2 years ago. She has some complaint of unwanted effect: fever, lower abdominal pain, abnormal vaginal discharge, dyspareunia, malaise. There is know complaint about her period. Her temperature of 38oC other vital sign in within normal limit. There is uterine tenderness without adnexal tenderness. Inspekulo found bad odor of vaginal discharge, portio within normal appearance with IUCD tail. Vaginal touched: uterine in normal size with cervical motion tenderness, there is no adnexal mass, also there is no adnexal tenderness. Question: 1. What is the diagnosis of this patient? 2. What are the anamnesis, sign and symptom, examination to suspect the diagnosis? 3. What is the risk factor for this case? 4. What is ICD-10 coding for this patient? 5. What is your differential diagnosis? 6. Do you need laboratory test or other test to support your diagnosis? 7. What is the treatment planning of this patient? 8. What will you do with IUCD? 9. What is your take home massage for this patient? 10. When will her next visit? What will you evaluate her in the next visit? Lecture 12 BENIGN AND MALIGNANT DISEASES OF THE BREAST Dr. dr. I Wayan Sudarsa, Sp.B(K)Onk & dr.Anak Agung Ayu Ngurah Susraini,Sp.PA(K) When a patient present with a breast problem the basic question for general practitioner is, “Is there a chance that cancer is present, and, if not, can I manage these symptoms myself?” ABSRTACT The Breast, or mammary glands, of mammals are important for the survival of the newborn and thus of species. An understanding of the morphology an physiology of the breast and the many endocrine interrelationships of both is essential to study of the pathophysiology of the breast and the management of benign and malignant disorders. One woman in four is referred to a Breast Clinic at some time in her life, and breast problems constitute up to a quarter of all women in the general surgical workload. Although Udayana University Faculty of Medicine, DME 46 Study Guide The Reproductive System and Disorders breast cancer is the most common malignancy in women, 80-90% of clinical evaluations for breast disorders are for benign conditions. Triple assessment is most common used in the evaluation of patient with breast problem. This is combination of clinical examination, imaging, and pathologic examination. The goal is to avoid missing the diagnosis of a malignancy while providing reassurance for benign conditions. Breast cancer are derived from the epithelial cells that are found in the terminal lobular unit (TDLU). Cancer cells that are remain within the basement membrane of the TDLU are classified as in situ or non-invasive. An Invasive cancers is one in which there is dissemination of cancer cells outside the basement membrane of the ducts and lobules into surrounding adjacent normal tissue. Epidemiologically, breast cancer is the most common malignancy in women in developed countries and comprises 18% of all female cancers. Breast cancer is single most common cause of death among women aged 40-50. Lack of knowledge of the pathogenesis breast cancer means that primary prevention is currently distant prospect for most women. Early detection (Screening for breast cancer) represents an alternative approach for reducing mortality from this disease. In general, comprehensive management of patient with breast cancer is needed to achieve long overall survival, long disease free survival, and good quality of life. LEARNING OUTCOME 1: Able to manage the patients with Benign disorders and diseases of THE BREAST Learning task 1: Kasus: A mother came to surgery outpatient department with her 9 years old daughter. She complained that her daughter’s left breast hasn’t develop while the right one has developed normally. She is very worry with her daughter’s condition. 1. Please try to discuss and explain to this mother about the abnormality that might happen to her daughter and explain about the treatment. Learning task 2: Kasus: A 2nd year students of faculty of medicine Udayana University came to a private practice of a general doctor with chief complain a mass as big as marble in her right breast since 6 month ago. This mass is getting bigger, rounded, solid, very mobile, and sometimes causing pain. 1. Please try to discuss what is might happen to this girl 2. Please try to discuss about the plan of treatment to this girl 3. Does this abnormality need to be referred immediately to the hospital? 4. Does this abnormality can be handled by a general practitioner? Learning task 3: Case: A 30 years old woman complaining a yellowish liquid pour out from her right nipple since 1 month ago. She had married, had a 5 years old daughter, had a history of not breastfeed her daughter, and consuming contraception tablet. 1. Discuss about the efforts that can be done to get the right diagnosis about the abnormality that happen to this woman 2 Discuss about the plan of treatment to this abnormality schematically Learning task 4: Case: A 25 years old woman, post partum 2 weeks ago, complaining her left breast is swollen, red, and very painful. She also has had fever since 3 days ago. Her breastmilk can’t be pouring out from her breast. Udayana University Faculty of Medicine, DME 47 Study Guide The Reproductive System and Disorders 1. Discuss about the abnormality that might be happen to this woman. 2 Does this abnormality need to be treated and referred to the hospital immediately? 3 Discuss about the plan of treatment of this case Learning task 5: Kasus: A 25 years old woman, single, complaining pain in both of her breast since this last 3 months. Pain sometimes disturbing her activities. Please discuss about diagnostic method (anamnesis, physical examination, additional examination) dan complete plan of treatment to this case. LEARNING OUTCOME 2: Able to manage the patients with Malignant Diseases of THE BREAST Learning task 1: Case A 25 years old woman, came to the general practitioner because she is afraid and very worry because her older sister, 35 years old, had breast cancer. Her mother was also died when she was 40 years old because of breast cancer. Her mother’s sister was also died because of ovarium cancer when she was 50 years old. 1. Discuss in your group about the efforts that can be done to the women in this family 2. Please discuss about the principles of breast cancer screening. Learning task 2: Case A woman, 50 years old, single, came to surgery outpatient department with complain mass with ulcus in her left breast since 6 month ago. She also complain shortness of breath. 1. Discuss about how to diagnose (anamnesis, risk factor, clinical examination, dan additional examination) to this patient 2. Discuss about how to difine the stage of the disease 3. Discuss about the complete plan of treatment of this case. 4. Discuss the plan for communication and follow up to this patient SELF ASSESSMENT: Learning outcome 1: 1. Describe the symptoms, assessment, and guidelines for referral of woman with breast problem. 2. Explain briefly what is ANDI (Aberrations of Normal Development and Involution) of the Breast. 3. Explain the role of TRIPPLE ASSESSMENT in comprehensive approach of woman with breast problem. 4. Describes the holistic approach in woman complain with breast pain, lump, or nipple discharge. 5. Distinguish between breast infections (Mastitis) during lactation and non-lactation Learning outcome 2: 1. Describe briefly the epidemiology, risk factors, and genetics of breast cancer 2. Explain the principles of breast cancer prevention (primary prevention and screening/early detection of breast cancer). 3. Describe the steps in comprehensive management of breast cancer. 4. Describe briefly the role of surgery, radiotherapy, chemotherapy, and hormonal therapy in management of breast cancer. Udayana University Faculty of Medicine, DME 48 Study Guide The Reproductive System and Disorders ABSTRACT The most common symptoms reported by women which had breast lesions are pain, a palpable mass, “lumpiness” (without a discrete mass), or nipple discharge. Inflammatory diseases of the breast are uncommon, accounting for less than 1% of women with breast symptoms. Breast inflammation usually present with an erythematous swollen, painful breast and fever is often present. Almost all cases of acute mastitis occur during the first month of breastfeeding. During this time the breast is vulnerable to bacterial infection because of the development of cracks and fissures in the nipples, from this portal of entry, Staphylococcus aureus or, less commonly, streptococci invade the breast tissue. At the outset only one duct system or sector of the breast is involved. If not treated the infection may spread to the entire breast. Periductal mastitis: This condition is known by a variety of names, including recurrent subareolar abscess, squamous metaplasia of lactiferous ducts. It could affected women, and sometimes men, present with a painful erythematous subareolar mass that clinically appears to be an infectious process. More than 90% of the afflicted are smokers. This condition is not associated with lactation, a specific reproductive history, or age. Granulomatous inflammation is present in less than 1% of all breast biopsy specimens. The causes include systemic granulomatous diseases (e.g., Wegener granulomatosis or sarcoidosis) that occasionally involve the breast. It is caused by mycobacteria or fungi. Infections of this type are most common in immunocompromised patients or adjacent to foreign objects such as breast prostheses or nipple piercings. Granulomatous lobular mastitis is an uncommon breast-limited disease that only occurs in parous women. The granulomatous inflammation is confined to the lobules, suggesting that it is caused by a hypersensitivity reaction to antigens expressed by lobular epithelium during lactation. CASE A 35 years old woman visit the National Referal Hospital of Sanglah with chief complaint lump and pain on her left breast since 3 months ago, the complaint more severe day after day, no fever felt by patient. After physical examination, found a nodule with irregular border on upper left lateral quadrant, with size for about 2 cm in diameter, pain in preasure, body temperature 36,6oC. TASK: 1. What are the differential diagnose for the case above? 2. What kinds of test suggested by the clinician? 3. What are the differences on clinical finding between Mastitis, Benign Tumor, and Malignant Tumor? SELF ASSESSMENT: 1. Explain the macroscopic finding of Invasive Carcinoma! 2. Explain microscopic feature of Granulomatous Mastitis! 3. What kind of Carcinoma that often misinterpreted with inflammation on breast? Udayana University Faculty of Medicine, DME 49 Study Guide The Reproductive System and Disorders Lecture 13 Male Infertility & Male Genital Disorders (dr Yukhi Kurniawan, SpAnd & dr.Gede Wirya Kusuma Duarsa M.Kes,SpU) Abstarct Infertility is defined by the World Health Organization (WHO) as “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse”. While most studies agree that infertility affects approximately 15–20 % of all couples, data relating to male infertility are more uncertain. An epidemiologic study of male infertility in fact presents a clinical problem because fertility is a couple-related concept and male fecundity (i.e., his biological capacity to reproduce) is a component of the fertility rate. Both male and female partners make an independent contribution to a couple’s fertility, but the outcomes of fertility are only fixed in terms of pregnancy rate or births. Sperm analysis is only the first step; all male patients with abnormal sperm should have a full clinical history taken and should undergo a complete clinical examination. Semen analysis is poorly predictive of the male fertility status, mainly giving information about the status of the male genital tract and, thus, only indirect indications of potential male fertility. In certain cases, the hormonal test is needed. A correct andrologic diagnostic work out may unveil infertility factors in about 70 % of infertile males. Many of such factors are correctable or treatable, with the perspective ideally to allow the couple to spontaneously conceive, but also to have better chances of success when exposed to ART. Scientific evidence suggests that considering the high cost, success rates, and possible side effects of ART, early efforts to improve male fertility appear to be an attainable and worthwhile primary goal. The main results obtained concern evidencesupported indications regarding other causes of male infertility, and their early detection and treatment. LEARNING OUTCOME LEARNING OBJECTIVE PIC 1. Manage,establi sh tentative diagnosis, provide initial management, and/or refer patien with male infertility Male Infertility Capable to explain the definition of infertility, fecundity & fecundability Capable to explain epidemiology of male infertility. Capable to explain causes of male infertility Comprehend a systematic clinical investigation of male infertility Capable to establish the diagnosis of male infertility. Comprehend a systematic approach to the treatment t of the patient with male infertility Capable to refer the male infertility to the second/tertier healt service for getting spesialistic treatment/Assisted reproductive Technology (ART) Udayana University Faculty of Medicine, DME dr. Yukhi Kurniawan Sp, And 2. 3. 4. STUDENT REFERENCE Eberhard Nieschlag, 2010. Andrology Male Reproductive Health and Dysfunction 3rd Edition. Giorgio Cavallini, 2015. Clinical Management of Male Infertility W.-B. Schill, 2006. Andrology for the Clinician Infertility and Assisted Reproduction. Cambridge University Press, 2008 50 Study Guide The Reproductive System and Disorders Learning Task Mr. RH, 28 years old with primary infertility 5 years, come to clinical practitioner, sperm analysa is azoospermia. Arm span greater than height (eunuchoid body proportions), female distribution pattern of adipose tissue, no beard growth with and no sexual desire. 1. Physical exam: Weight; 90 kg, Height: 175 cm, Penis lenght 6cm, Testicular volume: 3ml/ 3ml with consistency: soft/soft. 2. Semen analysis : Azoospermia, Semen Volume: 0.5 ml, pH: 8. 3. Hormon assay FSH: 0, 13 mIU/mL. Prolactin: 12.73 ng/mL, Testosteron: 1 nmol/L Question 1. Explain the problem of secondary sex characteristics? 2. Explain the problem of sexual activity? 3. What are the diagnosis and differential diagnosis of this patient? 4. What are the anamnesis, sign and symptom, examination to suspect the diagnosis? 5. What are the planning treatment of this patient? Self Assesment 1. Describe the classification of disorder of sex development (DSD)? 2. What are the disease of hypogonadotropic hypogonadism? 3. What are the disease of hypergonadotropic hypogonadism? 4. Describe the classification of male sexual dysfunction? 5. Explain the kind of assisted reproductive technology (ART)? I. LEARNING TASK Man 34 years old, came with complaint of secondary infertile. His first child was born 6 years ago. He also complaint of intermittent left scrotal pain. No complaint on erectile capability. He has a good general condition, composmentis, normal blood pressure 120/80, pulse 88x/minutes. Normal scrotal finding, right testicle normal, left testicle a little bit smaller than right one. Both of epydidimis are normal. Small, cystic, worm like mass was felt during valsava maneuver. Questions: What is the diagnosis of this patient? What are the anamnesis, signs, symptoms and examination to support the diagnosis? What is your planning to complete the diagnosis? What is your planning treatment of this patient? II. SELF ASSESMENT 1. What is the cause of Male infertility? 2. What is Testicular Dysgenesis Syndrome? 3. What is correlation between male infertility and hypospadias, varicocel, undecensus testis? 4. What is the caused of testicle undecensus? What is the complication of cryptorchidism? How is the management of this condition? 5. How are the division, diagnostic and treatment management of obstructive azoospermia? 6. What are the symptoms of Varicocele that make patients visit the doctor? 7. When does the varicocele need an operation in tenagers? Udayana University Faculty of Medicine, DME 51 Study Guide The Reproductive System and Disorders Lecture 14 Female Infertility (Dr Jaqueline Sudiman,GrandDipRepSc,MrepSc,PhD & Dr.dr. IBG Fajar Manuaba, SpOG, MARS) Infertility is defined as the inability to achieve a spontaneous pregnancy after one year of unprotected intercourse for female age below 35 years old and six months of unprotected intercourse for female age above 35 years old. There are two types of female infertility which are primary infertility where the female never have pregnancy before and secondary infertility where the infertility occurs after previous pregnancy regardless of outcome. Infertility affects 15% of reproductive couples and it affects both male and female. Therefore the management of infertility must include male and female as a couple. To achieve a spontaneous pregnancy, female should produce a healthy egg which is known as oocyte from either left or right ovary and male produces normal sperm from testis. The fimbriae of fallopian tubes catch the oocyte and it travels to the ampulla of the tube where oocyte will be fertilized with spermatozoa. The fertilized oocyte which is known as zygote travels towards the tube by the activity of tubal cilia and tubal muscle into the womb (uterus) for 5 days. On day 5 of embryo development the embryo develops to the big cell which is known as blastocyst. Blastocyst consists of inner cell mass which become a baby and trophactoderm which become a placenta. If there is a disturbance in the process above then spontaneous pregnancy will not occur. In women’s side there are several problems which could disturb the fecundity: 1. Ovulation disorder (affect approximately 40% of infertile women). Ovulation occurs approximately in the midway through the menstrual cycle. The process of ovulation is controlled by the hypothalamus through the release of gonadotropin releasing hormone (GnRH) which triggers the releasing of follicle stimulating hormone (FSH) and Luteinizing hormone (LH) from the anterior lobe of pituitary gland (hypophyses). FSH stimulates the development of follicles during follicular phase through the estrogen activity. During this period follicles undergo a series of transformation (primary follicle to pre-antral follicle to antral follicle) as well as oocytes inside the follicles. Usually only one mature oocyte at metaphase II stage will develop in antral follicle. Due to a spike of FSH and LH released from the gland, ovulation will occur marked by releasing a mature oocyte from an antral follicle. Therefore the hypothalamus-hypophyses-gonal axis should work properly to proceed ovulation. 2. Non-patent fallopian tube/ fallopian tube obstruction (40%). The main cause of nonpatent fallopian tube is infection such as chlamydia and gonorrhea. Severe endometriosis could also cause obstruction of fallopian tubes. 3. Uterus abnormalities (10%). Another factors could affect the implantation of embryos are uterus abnormalities such as abnormality of uterus anatomy, tumors such as myoma, polyp, and asherman syndrome. 4. Other factors such as age, lifestyle, physiological problems and unexplained infertility (10%). In general, reproductive potential decreases as women get older. Woman has been expected to get pregnant in the age below 35 years old. Other factors such as obesity, lack of exercise, alcohol, nicotine and stress also reduce fecundity of women. Few cases of infertility are still unexplained. The investigation of infertility focuses on the couple and not on one or the other partner. Any investigations of infertility begin with a careful clinical anamnesis, physical examination and laboratory finding. Anamnesis covers relevant medical history finding include parity, cycle length and characteristic, coital frequency, duration of infertility, past surgery, exposure of sexually-transmitted infection, occupation, intake of tobacco, alcohol, and other drugs, dyspareunia and stress related factors. General physical evaluation such as weight and body mass index, any thyroid enlargement, breast secretion, signs of androgen excess, galactorrhea, and hirsutism are important factors to be examined. Local findings such as pelvic or abdominal tenderness, vaginal or cervical abnormality and discharge should be carefully examined. The modalities of diagnostic tool for evaluating the Udayana University Faculty of Medicine, DME 52 Study Guide The Reproductive System and Disorders cause of infertility include Ultrasonografi (transvaginal sonografi) to evaluate the ovarial reserve, follicle development and ovulation, and uterine patology; laboratory medical machine to evaluate the hormonal status; hystrerosalphingografi (HSG) to evaluate tubal patency and pathology of uterine cavity; hysteroscopy and laparoscopy to evaluate abnormalities of ovarium, uterine cavity, tubal patency and any abnormalities of pelvic cavity. Based on the result of these investigations, couples are to be selected for treatment at different levels of infertility care unit. Depending on the personnel competence and availability of facilities for investigations and treatments, there should be three levels of infertility care units. Primary infertility care unit which is responsible for completion of basic investigations, treatment of minor anatomical defect, medical management of minimal and mild endometriosis, induction ovulation in non-ovulation women and referring couples to secondary or tertiary infertility care units. Secondary infertility care unit is responsible for further investigations such as immunological test for infertility, hysteroscopy, laparoscopy and transvaginal sonography (TVS), and extending treatments of infertility such as repairing tubal obstruction. Tertiary infertility care unit is responsible for advanced diagnostic procedures, therapeutic and research such as examine endocrine assay for hormonal profile, use Color Doppler for growing follicles, perform all varieties of assisted reproductive technologies including conservative intrauterine insemination (IUI), intracytoplasmic sperm injection (ICSI), sperm or oocyte banking and embryo cryopreservation. FEMALE INFERTILITY LEARNING OUTCOME Capable to diagnose female infertility and the causes that lay beneath as well as to manage female infertility treatment in the primary level unit LEARNING OBJECTIVE Female Infertility To explain the definition of infertility, primary and secondary infertility To explain the hypothalamus, hypophysis and gonadal axis, menstrual cycle and ovulation To explain the causes of female infertility To diagnose female infertility To manage treatments of female infertility in primary health services and or to refer patients to the advance facilities Udayana University Faculty of Medicine, DME PIC dr. Jaqueline Sudiman, PhD and & Dr.dr. IBG Fajar Manuaba, SpOG, MARS STUDENT REFERENCES Strauss III, JF, and RL Barbieri 2009 Yen and Jaffe's Reproductive Endocrinology, The ovarian life cycle, edn Sixth edition. Saunders/ Elsevier. Speroff, L, RH Glass, NG Kase Clinical Gnecologic Endocrinology and Infertility, edn Sixth edition. Lippincott Williams & Wilkins Rao, KA, PR Brinsden, AH Sathananthan The infertility Manual, edn second edition. Asnhan 53 Study Guide The Reproductive System and Disorders LEARNING TASK OF FEMALE INFERTILITY Woman age 31 years old and her husband age 34 years old have been married for about 5 years but she failed to get pregnant. Her husband is a bus driver and frequently have a urinary tract problems. She comes to public health center to consult with doctor about her fertility. From anamnesis you found that they routinely have sexual intercourse twice a week without any protections, she has irregular menstrual period since one year ago but there is no sign of dysmenorrhea during menstrual period. She gets a little bit stress lately with her job as a teacher. From physical examination you found that her BMI index is 29 and there are signs of hirsutism and acne. Moreover, there is vaginal discharge in her vagina (flour +) but uterine corpus is in normal size and she has pain on the left and right adnexa but there is no mass palpable. Questions : 1. List medical & reproductive problems of this woman and man 2. List the risk factors which affect reproductive capacity for this couple 3. What are the diagnoses of this woman? 4. What are the next examinations should be done to support your diagnoses to this woman? 5. What are your medical advices and treatments for this woman? Self Assessment : 1. What is the definition of infertility? 2. Explain the risk factors and causes of female infertility 3. Explain the examination methods of female infertility 4. Explain the treatments of female infertility Lecture 15 Drugs Therapy in Pregnant and Genital Disorders Dr. dr. Bgs Komang Satriyasa, M.Repro 1. DRUGS THERAPY IN GENITAL DISORDRES Vaginal infections with Candida albicans (yeast) cause itching, discharge and painful intercourse. In some women, chronic Candida infections do not respond to conventional agents used to control the infection. Although diabetes mellitus, birth control use and some recent antibiotic therapies can predispose the vagina to Candida overgrowth, other factors are thought to play a role in chronic infections. An allergic response to Candida produced by a defect in the immune system is one of many possible explanations of chronic Candida infections. Immunotherapy is a technique used to boost the patient's own immune system by administering increasingly higher doses of the offending organism to build up immunity to the organism. To see if immunotherapy resolves Candida infections in women who are hypersensitive to the fungus, 18 women were studied. An initial skin test was performed to determine whether women were sensitive to the Candida organism. A skin test was considered positive if a red mark was produced after a skin prick with the Candida antigen. Of the 18 skin tests, 15 had immediate positive skin tests and three had a late reaction. Immunotherapy injections offered symptomatic improvement in 16 of the patients, reducing the number of Candida infection from 17.2 to 4.3 infections per year. This was a 79 percent overall improvement. It is concluded that a subgroup of women allergic to Candida albicans in the vagina can benefit from standard immunotherapy. Erectile dysfunction (impotence) is difficulty achieving or maintaining an erection. Occasionally, every man has difficulty achieving an erection. Erectile dysfunction occurs when the problem is frequent or continuous. Erectile dysfunction becomes more common with aging. Although about half of men aged 65 or over and three fourths of men aged 80 or Udayana University Faculty of Medicine, DME 54 Study Guide The Reproductive System and Disorders over have erectile dysfunction, it is not a normal part of aging. Depending on the cause, the only treatment needed may be reducing alcohol consumption, having a doctor substitute a different drug, or taking testosterone therapy. Psychologic therapy that deals with the mental and emotional factors contributing to erectile dysfunction sometimes corrects the dysfunction. Most drugs used to treat erectile dysfunction work regardless of the cause. However, these drugs are particularly effective if erectile dysfunction results from inadequate blood flow to the penis. Most of them increase blood flow to the penis. Examples are sildenafil, tadalafil, and vardenafil. These drugs are taken by mouth. Men who take a nitrate, such as nitroglycerin, to treat a heart disorder should not take sildenafil, tadalafil, or vardenafil. If nitrates are taken within several hours of taking one of these drugs, blood pressure may become dangerously low, and occasionally, death results. Alprostadil also increases blood flow to the penis. This drug is inserted into the urethra as a pellet (suppository). Learning task Case 1 Women with vulvovaginitis may present with itch, discharge, dyspareunia, burning, soreness, dysuria and swelling. Symptoms may vary with the menstrual cycle. Symptoms are often not a reliable clue to diagnosis, and patients with a variety of different conditions may experience similar symptoms. 1. Which conditions cause vulvovaginal symptoms? 2. If skin swabs show a clinically relevant infection, what is the treatment of choice for this case? 3. If vulvovaginitis caused by any type of allergic or irritation, what is the treatment of choice? 4. What medication treatment should I use for my Bacterial Vaginosis? Case 2 A hypothetical 58-y-old male presents to his physician with the complaint of erectile dysfunction (ED) for about 1 y. He reports that sexual desire is present but that he has a lack of ability to achieve and maintain erection. He notes that he has avoided physical affection with his wife in order to avoid the embarrassment of 'not being able to perform.' He often falls asleep early so that he may avoid initiation of sexual contact. The man is overweight and has a 5-y history of hypertension, which is being treated with a thiazide diuretic and calcium channel blocker. He has a history of smoking one pack of cigarettes every few days for at least 30 y. He does not exercise and occasionally notes cramps in his legs when he walks more than four blocks. 1. What the physician to do? 2. What is the treatment of choice for this case? 3. Describe the Pharmacokinetics and Pharmacodynamics tadalafil for ED Self assessment 1. Which one of the following drugs was recommended for female epileptic patients? A. Sodium valproat B. Phenytoin C. Oxytocin D. TRH E. Vasopresin. 2. Which one of the following drugs cause chondrodysplasia punctata and Facial anomalies A. Lithium B. Phenytoin C. Warfarin Udayana University Faculty of Medicine, DME 55 Study Guide The Reproductive System and Disorders D. Sex hormone E. Carbamazepine 3. Which one of the following drugs taken during the first trimester of pregnancy can lead to Ebstein complex: A. Lithium B. Phenytoin C. Warfarin D. Sex hormone E. Carbamazepine 4. Which one of the following drugs taken during the first trimester of pregnancy caused craniofacial, cardiac, and CNS abnormalities: A. Lithium B. Phenytoin C. Warfarin D. Retionic acids E. Carbamazepine 5. All the following drugs cross the placenta and a drugs to harm the fetus when taken during pregnancy. EXCEP: A. Lithium B. Phenytoin C. Heparin D. Retionic acids E. Carbamazepine 2. DRUGS THERPY IN PREGNANT Pregnant women commonly use medications. Although most drugs have an excellent safety profile, some have unproven safety or are known to adversely affect the fetus. The safety profile of some medications may change according to the gestational age of the fetus. Because an estimated 10 percent or more of birth defects result from maternal drug exposure. For a drug to harm the fetus it must cross the placenta and be present in fetal tissue. The drugs in this list are those for which evidence is either conclusive or highly suggestive. Not included are drugs that are used infrequently during pregnancy or for which a teratogenic effect may occur but for which evidence is lacking. The list does not include the likely risk of fetal abnormality after exposure in the first trimester.The risk of anatomic defects in the fetus recedes after the first trimester. For the remainder of pregnancy, the fetus undergoes growth and development. The impact of drugs after the first trimester moves from structural to physiologic effects. In addition, the long-term use of some agents can have adverse effects on the mother that, if not unique to pregnancy, are at least exaggerated by the State. Learning Task: 1. List and describe drugs in common clinical use have teratogenic effect in humans 2. Describe the teratogenic effect of warfarin in humans 3. Describe the teratogenic effect of phenytoin in humans 4. Explain anticonvulsant drugs cause fetal abnormality. 5. Explain corticosteroids used prevent complications of prematurity Udayana University Faculty of Medicine, DME 56 Study Guide The Reproductive System and Disorders References: 1. Thorp JM. Laughon SK. Clinical Aspect of Normal and Abnormal Labor. In: Creasy and Resnik: Maternal Fetal Medicine Principles and Practice. Creasy RK. Resnik R. editors.7th ed. Elsevier. 2014;43:673-85. 2. Cuningham FG.Leveno KJ. Bloom SL. Abnormal Labor. In: William Obstetrics. 24th ed. McGraw-Hill. 2014;23:455-72 3. Wing DA. Farinelli CK. Abnormal Labor and Induction of Labor. In: Obstetric: Normal and Problems in Pregnancy. Gabbe SG. Niebyl JR. editors. 6th ed. Elsevier. 2012;14:287-311 4. Berghella V. Obstetric Evidence Based Guideline. Informa uk.2007. 5. Berghella V. Maternal-Fetal Evidence Based Guideline.2nd ed. Informa uk.2012. 6. Kumar P. Management of Obstructed Labor at Referral Center. In: Principles and Practice of Obstetric and Gynecology. Malhotra N. Shah PK. editors. 4th ed. Jaypee Brother medical Publiser. 2014;34:308-17. Udayana University Faculty of Medicine, DME 57 Study Guide The Reproductive System and Disorders ~ CURRICULUM MAP ~ Smstr Program or curriculum blocks 10 Senior Clerkship 9 Senior Clerkship 8 Senior clerkship 7 Medical Emergency (3 weeks) Special Topic: -Travel medicine (2 weeks) Elective Study III (6 weeks) Clinic Orientation (Clerkship) (6 weeks) 6 BCS (1 weeks) The Respiratory System and Disorders (4 weeks) The Cardiovascular System and Disorders (4 weeks) The Urinary System and Disorders (3 weeks) The Reproductive System and Disorders (3 weeks) BCS (1 weeks) Alimentary & hepatobiliary systems & disorders (4 Weeks) BCS (1 weeks) The Endocrine System, Metabolism and Disorders (4 weeks) BCS (1 weeks) Clinical Nutrition and Disorders (2 weeks) BCS (1 weeks) BCS (1 weeks) Musculoskeletal system & connective tissue disorders (4 weeks) Neuroscience and neurological disorders (4 weeks) Behavior Change and disorders (4 weeks) BCS (1 weeks) Hematologic system & disorders & clinical oncology (4 weeks) BCS (1 weeks) Immune system & disorders (2 weeks) BCS(1 weeks) Infection & infectious diseases (5 weeks) BCS (1 weeks) The skin & hearing system & disorders (3 weeks) BCS (1 weeks) Medical Professionalism (2 weeks) BCS(1 weeks) Evidence-based Medical Practice (3 weeks) BCS (1 weeks) Health Systembased Practice (3 weeks) BCS(1 weeks) Community-based practice (4 weeks) - BCS (1 weeks) Stadium Generale and Humaniora (3 weeks) Medical communication (3 weeks) BCS (1 weeks) The cell as biochemical machinery (3 weeks) Growth & development (4 weeks) BCS (1 weeks) BCS(1 weeks) BCS: (1 weeks) BCS (1 weeks) Elective Study II (1 weeks) 5 4 3 2 BCS (1 weeks) Special Topic : - Palliative medicine -Compleme ntary & Alternative Medicine - Forensic (3 weeks) Elective Study II (1 weeks) Special Topic - Ergonomi - Geriatri (2 weeks) Elective Study I (2 weeks) The Visual system & disorders (2 weeks) 1 Pendidikan Pancasila & Kewarganegaraan (3 weeks) Udayana University Faculty of Medicine, DME 58
