Pretes 1. dr. Syah Rini Wisdayanti Sp.OG,M.Kes

Pretes 1

dr. Syah Rini Wisdayanti Sp.OG,M.Kes

https://meducine.id/account/membership/kelas-rehab- medik-oktober-2021

DEFINISI

Kehamilan Ektopik Terganggu :

‘’

Kehamilan Ektopik Terganggu

Kehamilan Ektopik :

Implantasi produk kehamilan selain di endometrium pada cavum uteri. (RCOG, 2016)

Proses ruptur di lokasi implantasi produk kehamilan yang akan menyebabkan gangguan hemodinamik perdarahan

masif dan nyeri abdomen akut (BPPSDMK Kemenkes, 2014)

Implantasi Kehamilan Ektopik

FAKTOR RESIKO

KEHAMILAN EKTOPIK

KEHAMILAN TUBA

ABORTUS TUBA

• Terjadi perdarahan bila

plasenta dan dinding tuba terganggu

• Produk konsepsi dapat keluar dari ujung fimbria ke rongga peritoneum

• Atau tetap diujung fimbria

yang akan berakumulasi di

cul-de-sac rectouterus dan

RUPTUR TUBA

• Produk konsepsi yang

menginvasi dan membesar

 Ruptur tuba

• Bila terjadi beberapa

minggu pertama biasanya kehamilan terjadi di bagian ismus tuba

• Ruptur biasanya spontan

• Kehamilan ektopik yang jarang terjadi

• Antara minggu ke 8-16 akan terjadi ruptur pada tuba

• Kriteria :

• Cavum uteri tampak kosong

• Jarak ditemukan GS > 1cm

KEHAMILAN INTERTITIAL

• Kriteria Spiegelberg :

• Tuba ipsilateral intak dan terpisah dari ovarium

• Implantasi produk kehamilan terjadi di ovarium

• kehamilan ektopik dihubungkan oleh ligamentum uteroovarian ke uterus

• Hasil histopatologi menunjukkan

KEHAMILAN INTRA OVARIUM

DIAGNOSIS TRIAS KET

Amenore Uterine

bleeding Nyeri perut

bagian

Pembesaran tuba

Tarikan pada

peritoneum dinding tuba Rangsangan pada nervi

erigentes

PEMERIKSAAN FISIK

Vital Sign :

Gangguan hemodinamik dapat

terjadi akibat perdarahan yang

menyebabkan hipovolemia

Inspekulo

Akan ditemukan penonjolan pada cul-

de-sac (cavum douglas)

Vaginal Toucher

Akan teraba penonjolan pada cul-

de-sac, serta nyeri saat portio digerakan

Penunjang ^:

- Beta HCG - Darah rutin - USG

PENATALAKSANAAN

• Tatalaksana Bedah

Laparoskopi adalah terapi bedah yang dianjurkan untuk kehamilan ektopik, kecuali secara

hemodinamik tidak stabil

• Terapi Konservatif (tuba diselamatkan) : Salpingostomi, salpingotomi, dan ekspresi KE melalui fimbria

• Radikal : Salpingektomi

TINDAKAN PEMBEDAHAN

• Salpingostomi : insisi pada tuba untuk mengangkat kehamilan kecil yang panjangnya < 2 cm dan terletak di sepertiga distal tuba

uterina, dan kemudian insisi tidak dijahit

• Salpingotomi : prosedur hampir sama dengan salpingostomi tetapi insisi dijahit

• Salpingektomi : Reseksi tuba atau reseksi kornu

1. A 27-year-old G3P2 was recently seen in the emergency room with vaginal bleeding and

passed products of conception while

undergoing evaluation. Her β-hCG at the time of presentation was 2500 mIU/mL. At her 7- day follow-up her β-hCG is again measured.

What value is most consistent with a completed spontaneous abortion?

a. 500 mIU/mL b. 1250 mIU/mL c. 1750 mIU/mL d. 2000 mIU/mL

2. What progesterone value threshold is most helpful to exclude ectopic pregnancy?

a. >10 ng/mL b. >15 ng/mL c. >20 ng/mL d. >25 ng/mL

3. A 39-year-old G5P3 presents at 6 weeks’

gestation with lower abdominal pain. A transvaginal ultrasound is performed for further evaluation. What findings would be expected on transvaginal ultrasound if her

dates are correct and her pregnancy is viable?

a. Gestational sac only

b. Gestational sac and yolk sac

c. Gestational sac, yolk sac, and fetal pole with cardiac motion

d. Gestational sac, yolk sac, and fetal pole without cardiac motion

4. A 31-year-old G3P1 at 6 to 7 weeks’

gestation by last menstrual period presents with severe abdominal pain, weakness, and dizziness. On sonographic evaluation, she is

noted to have a complex left adnexal mass with free fluid in Morrison pouch. What is the

minimum amount of accumulated

hemoperitoneum which would be expected at the time of surgery?

a. 100–200 mL b. 200–300 mL c. 300–400 mL d. 400–500 mL

5. What is the purpose of performing a dilation and curettage prior to administering

methotrexate?

a. To confirm a secretory endometrium b. To assess for endometrial

decidualization

c. To confirm the absence of trophoblastic tissue

d. To avoid the heavy vaginal bleeding provoked by methotrexate

6. What is the cellular mechanism of action of methotrexate?

a. DNA intercalation

b. Inhibition of microtubule formation c. Impedance of DNA and RNA synthesis d. Alkylation of proteins, DNA, and RNA

7. What is the ectopic resolution rate following methotrexate administration?

a. 66%

b. 78%

c. 90%

d. 97%

8. A 35-year-old G4P2 presents at 7 to 8 weeks’ gestation complaining of mild lower abdominal pain and spotting and is found to have a 3-cm left ectopic pregnancy. She has a history of severe persistent asthma and was treated for an asthma exacerbation 2 days ago. She also has a history of a prior ectopic pregnancy treated with salpingectomy, chronic hypertension for which she takes labetalol, and type 2 diabetes managed with insulin.

What aspect of her history would preclude treatment with methotrexate?

a. Type 2 diabetes

b. Chronic hypertension

c. Severe persistent asthma with recent exacerbion

d. History of a prior ectopic pregnancy treated with salpingectomy

9. What is the single best predictor of successful treatment with single-dose methotrexate?

a. β-hCG

b. Progesterone level

c. Ectopic pregnancy size

d. Absence of fetal cardiac activity

10. A 23-year-old G1 is diagnosed with a right ectopic pregnancy and given a single dose of methotrexate. Her β-hCG is 3153 mIU/mL on day 1 following methotrexate administration, 3256 mIU/mL on day 4, and 2548 mIU/mL on day 7. What is the most appropriate course of action based on these values?

a. Diagnostic laparoscopy

b. Recheck β-hCG level in 1 week

c. Administer second dose of methotrexate

d. No further intervention or follow-up is required

Terminologi MOLA

• Penyakit trofoblas gestasional yang secara histologik ditandai dengan proliferasi sel trofoblas, villi choriales yang avaskuler dan mengalami degenerasi hidropik.

• Proliferasi trofoblas: sitotrofoblas, sinsisiotrofoblas atau

intermediate trofoblas?

Mola hidatidosa komplit & parsial

Histopatologi mola hidatidosa

Etiologi

• Sitogenetika mola hidatidosa

• Fertilisasi androgenesis ataupun fertilisasi normal

• Mola hidatidosa komplet dan parsial mempunyai gambaran

histologi, morfologi, gambaran klinik ataupun penyebab yang

berbeda

Hipotesis kromosom hasil konsepsi

Sperma Ovum Hasil konsepsi

- 23 Menstruasi

23 Y atau X 23 Kehamilan normal

Mola komplet 23 Y - Blighted ovum, 46 YY

Mola komplet 23 X (2) - 46 XX (90%)

Mola komplet 23 X + 23 Y - 46 XY (10%)

Mola parsial 23 X (2) 23 X 69 XXX (27%)

Mola parsial 46 XY 23 X 69 XXY (70%)

Kelainan ekspresi gen/protein

• Ekspresi gen yang meningkat pada protoonkogen atau ekspresi yang menurun pada tumor suppresor gene (TSG) pada sel

trofoblas.

• 90% mola hidatidosa berDNA paternal saja tanpa DNA maternal.

• Perbedaan ekspresi kolagen tipe IV

Faktor nutrisi

• Defisiensi vitamin A

• Vitamin A berperanan dalam mengatur proliferasi, diferensiasi dan aktivitas apoptosis sel.

• Gangguan mekanisme kendali terhadap proliferasi dan diferensiasi sel.

• Dugaan peranan vitamin A dalam mengontrol

proliferasi melalui p53 menyebabkan G1 arrest &

pRb menyebabkan S phase arrest.

• Risiko MH meningkat 6,29 kali pada wanita dengan

defisiensi vitamin A.

Gejala klinik

• Keluhan subyektif seperti kehamilan normal trimester pertama:

• Terlambat haid

• Mual

• Muntah yang berlebihan

• Ukuran uterus lebih besar dari umur kehamilannya.

• Perdarahan pervaginam

• Keluar gelembung mola

USG Mola Hidatidosa inkomplit

USG Mola hidatidosa komplit

Snow storm appearance

Pemeriksaan hCG

• Cara yang paling bermanfaat dalam penegakan diagnosis maupun monitoring penyakit trofoblas.

• hCG serum kuantitatif

• Normal puncak hCG pada trimester I kehamilan (hari

ke 60-70)= 100.000 mIU/ml

Kurva regresi hCG

Penyulit-penyulit Mola Hidatidosa

• Penyulit dini: perdarahan, preeklamsia, hipertiroidisme dan tirotoksikosis.

• Penyulit lanjut: tumor trofoblas gestasional pasca mola.

• Perdarahan sering mengancam akibat terlambatnya penegakkan diagnosis MH.

• Preeklamsia sudah terjadi pada trimester I kehamilan.

• Ukuran uterus > 24 minggu cenderung terjadi

Pengelolaan Mola Hidatidosa

• Evakuasi jaringan mola

• Penyulit harus diatasi sebelum evakuasi MH

• Bila terdapat perdarahan yang mengancam, maka perlu segera dilakukan evakuasi jaringan mola.

• Raber Interna

• Evakuasi jaringan mola: kuretase tajam, kuretase

vakum atau histerekstomi.

Pengelolaan Mola Hidatidosa

• Dahulu, kuretase dilakukan 2 kali dengan interval 2 minggu.

• Awal kuretase vakum (hisap) dengan drip oksitosin 10 IU dan jaringan dikirim ke PA, dilanjutkan

kuretase ke-2 dengan kuretase tajam.

• Sekarang, oleh karena ukuran uterus tidak besar, kuretase tajam dilakukan setelah pengosongan uterus dengan kuretase hisap (vakum).

• Histerektomi sebagai cara evakuasi jaringan mola

pada kasus risiko tinggi dengan paritas cukup.

Kriteria Mola Hidatidosa risiko tinggi (RSHS)

• Ukuran uterus > 20 minggu

• Umur penderita > 35 minggu

• Hasil PA kuretase menunjukkan gambaran proliferasi trofoblas berlebihan.

• hCG praevakuasi ≥ 100.000 mIU/ml

Follow-up paska evakuasi

• Mulai minggu ke-2 sampai dengan minggu ke-12 paska evakuasi jaringan mola, follow-up setiap 2 minggu.

• Pemeriksaan yang dilakukan: hCG & pemeriksaan klinis ( besar & involusi uterus, ada tidaknya

perdarahan dan tanda-tanda metastasis).

• Bila setiap kali follow-up kadar hCG menurun dan

kurvanya mengikuti pola kurva regresi hCG (sesuai

pola kurva regresi hCG normal) dan secara klinis tak

ada tanda & gejala klinis pertumbuhan baru jaringan

trofoblas dilakukan follow-up s/d minggu ke-

12 paska evakuasi.

• Mulai bulan ke-4 sampai bulan ke-6, follow-up dilakukan setiap bulan.

• Bulan ke-6 dilakukan Ro thorax PA.

• Bila perkembangan baik, maka mulai bulan ke-8 sampai bulan ke-12 dianjurkan follow-up setiap 2 bulan.

• Bulan ke-12 dilakukan Ro thorax PA.

• Pasien dianjurkan untuk tidak hamil selama follow- up paska evakuasi mola.

• Kontrasepsi paska evakuasi mola: hormonal

maupun non hormonal.

Kriteria penghentian follow-up MH

• Penderita dianggap sembuh bila sampai dengan follow-up 12 bulan tidak ada tanda-tanda

pertumbuhan baru jaringan trofoblas atau bila

penderita ternyata sudah hamil kurang dari 12 bulan paska evakuasi mola.

• Sembuh, masih mungkin terjadi tumor trofoblas

gestasional, karena sifat sel trofoblas dormant.

Pemberian kemoterapi profilaksis

• Diberikan pada mola risiko tinggi dengan kemoterapi tunggal:

• Methotrexate 20 mg/hari IM dan asam folat 5

mg/hari IM yang diberikan 12 jam (selama 5 hari berturut-turut).

• Actinomycin D o,5 mg/hari IV (selama 5 hari

berturut-turut).

PSTT

11. Which of the following features is most characteristic of an invasive mole?

a. Penetrates deeply into myometrium b. Displays minimal trophoblastic growth c. A hallmark is the association with

distant metastases

d. Most frequently follows a term or preterm euploid pregnancy

.

12. Which of the following features is most

characteristic of gestational choriocarcinoma?

a. Pathological hallmark is diffuse, hyperplastic villi

b. Most frequently follows a partial or complete molar pregnancy

c. Are commonly accompanied by ovarian theca-lutein cysts

d. All of the above

13. Which of the following features is most characteristic of placental site trophoblastic tumor?

a. A high proportion of free β-hCG is considered diagnostic

b. Is best treated by hysterectomy due to chemotherapy resistance

c. Arises from intermediate trophoblasts at the placental site

d. All of the above

14. Clinical features of epithelioid trophoblastic tumor are most similar to which other

histological class of gestational trophoblastic neoplasia?

a. Invasive mole

b. Gestational choriocarcinoma c. Complete hydatiform mole

d. Placental-site trophoblastic tumor

15. Metastatic spread of choriocarcinoma is most common via which of the following

routes?

a. Lymphatic

b. Hematogenous

c. Cerebrospinal fluid

d. Peritoneal spread via fallopian tubes

16. Distant metastases from choriocarcinoma are most commonly found in which organ?

a. Lung b. Liver c. Brain d. Spleen .

17. A 42-year-old G3P3003 has been diagnosed with choriocarcinoma 6 months after her term vaginal delivery of a healthy female neonate.

Her β-hCG was 1 million

mIU/mL, and she had a single 2-cm metastasis identified in her liver. What is her stage per the International Federation of Gynecology and Obstetrics

staging system?

a. Stage I

18. The patient in Question 17 is being seen for the first time since her diagnosis for a discussion of available treatments. She has had no intervention to date. What do you recommend?

a. She has low-risk disease; radical hysterectomy is curative

b. She has low-risk disease; single-agent chemotherapy is recommended as sole therapy c. She has high-risk disease; combination chemotherapy is recommended as sole therapy d. She has high-risk disease; combination chemotherapy is recommended as first-line

19. Response to therapy by the patient in Question 17 will primarily be monitored with what method?

a. Serial β-hCG levels

b. Serial endometrial biopsies

c. Serial positron-emission tomographic scans

d. All of the above

20. The patient in Question 17 inquires as to the success rate of your recommended

treatment plan for her disease. What percentage of women are cured?

a. Approximately 60% of women like her will be cured.

b. Approximately 70% of women like her will be cured.

c. Approximately 80% of women like her will be cured.

d. Approximately 90% of women like her will be cured

.

21. Which of the following is NOT associated with an increased risk of lymph node metastasis?

a. Clitoral lesion

b. Depth of invasion c. Increasing tumor diameter

d. Lymphovascular space invasion

22. Which of the following correctly defines how depth of invasion is measured of vulvar cancer?

a. From the epidermal surface to the greatest depth of tumor invasion

b. From the deepest dermal papilla to the greatest depth of tumor invasion

c. From the greatest depth of tumor

invasion to the dermal-subcutaneous junction d. From the epithelial-stromal junction of the adjacent, most superficial dermal papilla to the greatest depth of tumor invasion

23. What is the approximate risk of recurrence if the

margin of resection of a vulvar cancer is < 8 mm?

a. 1 to 10 percent b. 11 to 20 percent c. 21 to 50 percent d. 71 to 90 percent

24. What is the most common complication of an inguino femoral lymph node dissection?

a. Lymphocele b. Lymphedema c. Groin infection

d. Wound dehiscence

25. The rate of which of the following complications is reduced by leaving the cribriform fascia intact?

a. Infection

b. Lymphedema

c. Wound breakdown d. All of the above