Anatomi Sistem Reproduksi

Wanita & Payudara

LO 1
 PERSARAFAN PAYUDARA
Cabang cutaneous lateralis &
anterior dari Nervus
intercostalis 4-6
Melewati fascia pectoralis
menutupi pectoralis
mahor  jar subkutan &
kulit payudara
Cabang nervus IC  serat
sensorik dari kulit mammae &
simpatis ke p.d payudara +
smooth muscle pd kulit &
nipple

FIGURE 1.23. Vasculature of breast. A. The mammary gland is supplied from its medial aspect mainly by perforating

branches of the internal thoracic artery and by several branches of the axillary artery (principally the lateral thoracic artery)

superiorly and laterally. B. The breast is supplied deeply by branches arising from the intercostal arteries. C. Venous drainage
B. The red arrows indicate lymph flow from the right breast.
Most lymph, especially superior lateral quadrant & center of the breast, drains to the axillary
lymph nodes  subclavian lymphatic trunk  right side  enters the venous system via the
right lymphatic duct.
C. Most lymph from the left breast returns to the venous system via the thoracic duct.
Female Internal Genital Organ
Contents of the broad ligament:

A, posterior aspect of the right broad ligament of the uterus. The posterior layer of the ligament has been removed to show the contents;
 Pelvis
• It is made up of 4 bones
• The functions of the pelvis
are:
– It contains the pelvic
viscera (urinary bladder
and rectum in both sexes
and uterus in female) and
protects them.
– Supports the weight of
the body
– During walking pelvis
swings from side to side
by rotatory movements at
the lumbosacral
articulation.
– It provides attachments
for muscles.
– In the female, it provides
bony support for the
birth canal.
 Obstetric Pelvis (True Pelvis)
• The pelvis is divided into:
– false or greater pelvis above
– true or lesser pelvis below
• The plane of division is pelvic inlet formed by the sacral promontory + linea
terminalis
– linea terminalis: continuous line from arcuate line of the ilium, the iliopectineal
line (pecten), and the pubic crest.

https://www.studyblue.com/notes/note/n/femur-pelvic-girdle/deck/16390608
The true pelvis presents the pelvic inlet, pelvic outlet, and
pelvic cavity.
Boundaries of Pelvic Inlet:
1. Promontory + anterior margin of alae sacrum
(anterior)
2. Arcuate + pectineal lines (Lateral)
3. Upper margin pubic symphysis + pubic crest (in fron)
Boundaries of Pelvic Outlet
4. Anterior: lower margin pubic symphysis
5. Anterolateral: conjoint ischiopubic ramus
6. Lateral: Ischial tuberosity
7. Posterolateral: Sacrotuberous ligaments
8. Posterios: tip of coccyx
Boundaries of pelvic cavity
9. Anterior: Pelvic surface of bodies of pubic bone,
rami, symphisis
10. Posterior: pelvic surface of sacrum & coccyx
11. Lateral: Pelvic surface of ilium ischium below arcuate
line
Obstretical Pelvic Measurment

PELVIC
DIAMETERS
Adaptation of the fetal head in the pelvis during parturition:
• During the process of parturition, the baby’s head adapts
itself to the dimensions of the pelvic cavity in order to
pass through it smoothly.
• Therefore, during fixation of the head of fetus, the occiput
of the head faces toward right/left,
– i.e., anteroposterior diameter of the head lies transversely at
the inlet (13 cm in diameter).
• Then the head rotates about 90° so that the occiput of the
head usually faces anteriorly,
– i.e., anteroposterior diameter of the head lies anteroposteriorly
at the pelvic outlet (13 cm in diameter).
Assessment of adequacy of the pelvis during
obstetrical examination:
– Transverse diameter of the pelvic outlet:
• Measuring distance between the ischial tuberosities
along a plane passing across the anus.
– Anteroposterior diameter of the pelvic outlet:
• measured from the pubis to the sacroiliac joint.
– Diagonal conjugate (most important) is assessed
by per vaginal examination.
• Size of the subpubic arch.
• In normal gynecoid pelvis, examiner’s
knuckles (with fist clenched) should be
comfortably accommodated between
the ischial tuberosities below the pubic
symphysis (Fig. 13.14).
 Fisiologi Reproduksi
(siklus menstruasi, mekanisme hormon ibu & bayi, perkembangan janin
selama kehamilan)

LO 2
 Menstrual Cycle
• Feature: periodic vaginal bleeding that occurs
with shedding of the uterine mucosa
(menstruation).
• The length of the cycle is variable, average
figure is 28 days from the start of 1 menstrual
period to the start of the next.
 Ovarian Cycle
• From the time of birth, there are many primordial follicles under
the ovarian capsule. Each contains an immature ovum
• At the start of each cycle: several of these follicles enlarge and a
cavity forms around the ovum (antrum formation) filled with
follicular fluid.
• In humans, 1 of the follicles in 1 ovary starts to grow rapidly on
about the sixth day and becomes the dominant follicle.
– The others regress, forming atretic follicles.
• It is not known how 1 follicle is singled out for development
during this follicular phase of the menstrual cycle
– seems to be related to the ability of the follicle to secrete the estrogen
inside it that is needed for final maturation.
• The structure of a mature ovarian follicle (graafian
follicle)
• The cells of the theca interna of the follicle are the
primary source of circulating estrogens.
• The follicular fluid has a high estrogen content, and much
of this estrogen comes from the granulosa cells.
• ~14th day of the cycle distended follicle ruptures, 
ovum is extruded into the abdominal cavity. This is the
process of ovulation.
• The ovum is picked up by the fimbriated ends of the
uterine tubes (oviducts)  transported to the uterus.
• Unless fertilization occurs, the ovum degenerates or is
passed on through the uterus and out the vagina.
• The follicle that ruptures at the time of ovulation promptly fills with blood,
forming what is sometimes called a corpus hemorrhagicum.
– Minor bleeding from the follicle into the abdominal cavity may cause peritoneal
irritation and fleeting lower abdominal pain ("mittelschmerz").
• The granulosa and theca cells of the follicle lining promptly begin to
proliferate  the clotted blood is rapidly replaced with yellowish, lipid-rich
luteal cells  corpus luteum.
• Luteal phase of the menstrual cycle, during which the luteal cells secrete
estrogens and progesterone.
– Growth of the corpus luteum depends on its developing an adequate blood supply,
and there is evidence that vascular endothelial growth factor (VEGF) is essential for
this process.
• If pregnancy occurs, the corpus luteum persists, and there are usually no
more menstrual periods until after delivery.
• If there is no pregnancy, the corpus luteum begins to degenerate about 4
days before the next menses (day 24 of the cycle) and is eventually replaced
by fibrous tissue, forming a corpus albicans.
 Uterine Cycle
• The events that occur in the uterus during the menstrual cycle terminate in the
menstrual flow.
• By the end of each menstrual period, all but the deep layer of the endometrium
has sloughed.
• Under the influence of estrogens from the developing follicles, the endometrium
regenerates from the deep layer and increases rapidly in thickness during the
period from the fifth to 16th days of the menstrual cycle.
• As the thickness increases, the uterine glands are drawn out so that they lengthen,
but they do not become convoluted or secrete to any degree.
• These endometrial changes are called proliferative, and this part of the menstrual
cycle is sometimes called the proliferative phase. It is also called the preovulatory
or follicular phase of the cycle.
• After ovulation, the endometrium becomes more highly vascularized and slightly
edematous under the influence of estrogen and progesterone from the corpus
luteum.
• The glands become coiled and tortuous, and they begin to secrete a clear fluid.
• Consequently, this phase of the cycle is called the secretory or luteal phase.
• Late in the luteal phase, the endometrium, produces prolactin, but the function of
this endometrial prolactin is unknown.
• Vasospasm occurs and probably is produced by locally released
prostaglandins.
• There are large quantities of prostaglandins in the secretory endometrium
and in menstrual blood, and infusions of prostaglandin F2a (PGF2a) produce
endometrial necrosis and bleeding.
• The proliferative phase of the menstrual cycle represents the restoration
of epithelium from the preceding menstruation
• the secretory phase represents the preparation of the uterus for
implantation of the fertilized ovum.
• The length of the secretory phase is remarkably constant, at about 14
days, and the variations seen in the length of the menstrual cycle are
mostly due to variations in the length of the proliferative phase.
• When fertilization fails to occur during the secretory phase, the
endometrium is shed, and a new cycle starts.
• The endometrium is supplied by 2 types of arteries.
– Superficial 2/3 of the endometrium that is shed during
menstruation, the stratum functionale, is supplied by long,
coiled spiral arteries
– the deep layer, the stratum basale, which is not shed, is supplied
by short, straight basilar arteries.
• When the corpus luteum regresses, hormonal support for
the endometrium is withdrawn.
– The endometrium becomes thinner, which adds to the coiling of
the spiral arteries.
– Foci of necrosis appear in the endometrium, and these coalesce.
• There is, in addition, necrosis of the walls of the spiral
arteries  spotty hemorrhages that become confluent 
produce the menstrual flow.
 Normal Menstruation
• Menstrual blood is predominantly arterial, only 25% of the blood being of
venous origin.
• It contains tissue debris, prostaglandins, and relatively large amounts of
fibrinolysin from the endometrial tissue.
• The fibrinolysin lyses clots, so menstrual blood does not normally contain
clots unless the flow is excessive.
• The usual duration of the menstrual cycle: 3–5 days
– but flows as short as 1 day and as long as 8 days can occur in normal women.
• The average amount of blood lost is 30 mL
– range from slight spotting to 80 mL.
– Loss of more than 80 mL is abnormal.
• Amount of flow can be affected by various factors, including:
– thickness of the endometrium
– medications and diseases that affect the clotting mechanism.
• After menstruation, the endometrium regenerates from the stratum
basale.
 Reproductive Hormones in Pregnancy
2 phases of hormonal secretion during pregnancy:
1. Corpus luteum phase – secretes hormones to maintain
endometrium & dev.placenta
– Progesterone & estrogen ~10 days following ovulation  regresses
 dramatic fall in progesterone  degeneration  menstruation
– Blastocyst must prevent next menses by maintaining corpus luteum
& steroid secretion
– After implantation (~6th day)  syncytiotrophoblast secretes hCG
(~to LH)  acts on corpus luteum to prevent regression 
progesterone continues to rise  functional endometrium
maintained
– Corpus luteum: Progesterone + estrogen for 1st 6 wks of dev
2. Placental phase – placenta takes over hormonal secretion
(to allow maternal adaptation to pregnancy, birth,
lactation)
– Placenta secretes:
• hCG
• Progesteron & estrogen
• hPL (humal placental lactogen)
• Relaxin
• Other: GnRH, placental CRH, placental TRH, ACTH, inhibin, GH
– By 6th wk  placenta as main source of progesterone &
estrogen  help mother adapt
– hPL regulate nutrient level & metabolism & causes glandular
tissue of breast to develop
– Relaxin secreted towards end of pregnancy to prepare for birth
 Reproductive hormones

hCG Progesterone Estrogen

●
Rise throughout pregnancy
●
Rise throughout pregnancy ●
Placenta lacks key enzymes to
●
Maintenance & dev of synthesize estrogen from cholestrol 
●
Secreted by SCT, structure functional endometrium performed by fetal adrenal gland
similar to LH
●
Inhibit smooth muscle uterus ●
Growth of SMC of uterus
to prevent premature expulsion (myometrium)
●
Maintain corpus luteum ●
Increase BF to uterus
●
Metabolic changes (includes fat
●
Regulate estrogen secretion storage)
●
Soften cervix & pelvic ligaments
●
Stimulate breast growth & dev
of placenta ●
Adaptation to pregnancy ●
Inhibit LH & FSH
●
Stimulation testosterone ●
Relax smooth muscle ●
Stimulate prolactin secretion from
secretion in male fetus throughout body  pituitary
●
Stimulate receptors of oxytocin in
constipation & esophageal
myometrium in late pregnancy
reflux ●
Water retention
 Relaxi Inhibi Prolac
hPL n n tin
●
Secreted by SCT, rise ●
Secretion from pituitary gland
throughout pregnancy, ●
Secreted by placenta
●
By ovary in ●
stimulated by estrogen
Stimulates growth & dev of
similar to GH & prolactin
●
Maternal lipolysis & FA
in late pregnancy pregnant/non- breasts & regulate fat
●
Relaxes myometriym, metabolism
metabolism pregnant ●
High lvl placental estrogen
●
Insulin resistance cervix, pelvic ligs ●
Supress FSH prevent milk secretion
(sparing glucose for ●
Alolow uterus to ●
After birth, fall in estrogen
fetus) enlarge & pelvis secretion allows prolactin to act on
AA transfer across breast
●
stretch during birth
●
Stimulate ●
High prolactin lvl:
placenta
●
Growth & dev of breast
●
Stimulate progesterone ●
Secretion of milk *oxytocin
causes ejection
●
Cell growth & prot collagenase enzyme during pregnancy ●
Inhibits FSH, LH (contraceptive
synthesis effect)
 Maternal adaptation to pregnancy

The Reproductive System at a Glance, 2010

 Histologi sistem Reproduksi
(Uterus, placenta, mammae)
LO 3
 Mammary Glands
• Mammary glands: highly modified apocrine
sweat glands persists on each side of the
chest.
• Each mammary gland consists of 15-25 lobes
of the compound tubuloalveolar type
– function is to secrete nutritive milk for
newborns.
• Each lobe, separated from the others by
dense connective tissue with much adipose
tissue, is a separate gland with its own
excretory lactiferous duct
– each 2-4.5 cm long
– emerge independently in the nipple w/ 15
to 25 pore-like openings, each about 0.5
mm in diameter.
– histologic structure of the mammary
glands varies according to sex, age, and
physiologic status.
Nonpregnant women:
• Inactive with small ducts + few
lobules (L)
• Secretory alveoli not well-
developed.
• Large lumen in each lobule: part of
the duct; smaller structures are the
small, undeveloped alveoli.
• Breasts are composed largely of
connective tissue (CT) + considerable
fat.
During pregnancy:
• glands become active
• Duct system growing rapidly
• the secretory units of each
lobule becoming much larger
extensively branched.
• Adipocytes (A) are included,
only a small fraction of those
present.
During lactation,
• the lobules are greatly enlarged
• the lumens of both the
numerous glandular alveoli (A)
and the excretory ducts (D) are
filled with milk.
• The intralobular connective
tissue is more sparse and dif cult
to see, except for small septa
(arrows).
 After weaning, all glandular
alveoli of the breast regress
section of a single alveolus:
• The secretory cells have
Glandular alveoli develop completely only during • Secretory cells of the undergone autophagy and are
pregnancy; begin milk production near the end of lactating gland: more now squamous.
pregnancy. columnar and contain
• Alveoli (A) spherical structures: cuboidal • Many apoptotic cells have
epithelial cells surrounded by the contractile
variously sized lipid sloughed into the lumen.
processes of myoepithelial cells (M). droplets, which are also • Milk with lipid droplets is also
• Late in pregnancy lymphocytes (L) leave venules visible in the milk (LD). still present there.
(V), accumulate in the intralobular connective • Connective tissue (CT) • The dead cells and other
tissue  differentiate as plasma cells (P) contains small blood tissue debris are removed by
secreting IgA. vessels (V).
• Intralobular ducts (D) are lined by epithelium
invading macrophages.
containing secretory cells, nonsecretory cells,
and plasma cells; larger lumens may show milk
(arrow).
 Breast dev during puberty
• Before puberty: mammary gl composed only of
lactiferous sinuses near the nipple
– very small, branching ducts emerging from these sinuses.
– In girls puberty, estrogens cause the breasts to grow:
adipocyte accumulation + elongation of the duct system.
• non-pregnant adult women each mammary gland
lobe consists of many lobules/terminal duct lobular
units (TDLU).
– Each lobule has several small, branching ducts, but the
attached secretory units are small and rudimentary
• Lactiferous sinuses: stratified cuboidal epithelium
• Lactiferous ducts & terminal ducts: simple cuboidal epithelium
covered by closely packed myoepithelial cells.
• Sparse fibers of smooth muscle also encircle the larger ducts.
• Duct system is embedded in loose, vascular connective tissue, and a
denser, less cellular connective tissue separates the lobes.
• Pre-menstrual phase of the reproductive cycle: connective tissue of
the breast edematous, breasts slightly larger.
• Areola/skin covering the nipple: thin skin with sebaceous glands +
abundant sensory nerves
– continuous with the mucosa of the lactiferous sinuses
• Areola contains more melanin and darkens further during
pregnancy.
• Connective tissue of the nipple: rich in smooth muscle fibers, run
parallel to the lactiferous sinuses  nipple erection when they
contract.
 Breast during Pregnancy & Lactation
• Growth during pregnancy as a result of the synergistic action
of mainly estrogen, progesterone, prolactin, and the placental
lactogen  cell proliferation in secretory alveoli at the ends
of the intralobular ducts (Figures 22–25 and 22–26).
• Spherical alveoli: cuboidal epithelium + stellate myoepithelial
cells b/w secretory cells and the basal lamina.
• Stroma becomes less prominent (Figures 22–26 and 22–27).
• Loose connective tissue within lobules is in infiltrated by
lymphocytes and plasma cells  latter becoming more
numerous late in pregnancy.
• Late in pregnancy: glandular alveoli and ducts
are dilated by accumulation of colostrum
(fluid rich in proteins + leukocytes); produced
under the influence of prolactin.
– Immunoglobulin A (IgA) antibodies are
synthesized abundantly by plasma cells and
transferred into colostrum, from which passive
acquired immunity is conferred on the breastfed
newborn.
• Following parturition, the alveoli of mammary glands start
lactation, stimulated by prolactin
• Epithelial cells of the alveoli enlarge and activate various
processes involved in lactation:
– Protein are synthesized packaged to secretory vesicle 
merocrine secretion into the lumen (Figure 22–28).
– Lipid droplets form initially from short-chain fatty acids
synthesized in the epithelial cells + longer fatty acids and
cholesterol from the diet or fat stores  undergo apocrine
secretion, droplets become enveloped with a portion of
the apical cell membrane (see Figure 22–28)
– Lactose, major carbohydrate and energy source in milk, is
synthesized in the Golgi apparatus and secreted with
lactalbumin.
 Postlactational Regression in the Mammary
Glands
• Breast-feeding is stopped (weaning):
– most alveoli that developed during pregnancy and lactation
degenerate.
– Epithelial cells undergo apoptosis, autophagy, or sloughing
(Figure 22–29) + dead cells and debris removed by macrophages.
– duct system of the gland returns to its general appearance in the
inactive state (Figure 22–25).
• After menopause:
– alveoli and ducts of the mammary glands are reduced further in
size
– loss of fibroblasts, collagen, and elastic fibers in the stroma.
 Uterine Tube
• Wall of the oviduct:
– folded mucosa
– thick, well-defined muscularis with interwoven circular (or spiral)
+ longitudinal layers of smooth muscle (Figure 22–15a)
– Thin serosa covered by visceral peritoneum with mesothelium.
• Numerous branching, longitudinal folds most prominent in
the ampulla
– cross section resembles a labyrinth (Figure 22–14b).
• Mucosal folds become smaller in the regions closer to the
uterus
• Absent in the intramural portion of the tube.
• Mucosa is lined by simple columnar epithelium
on a lamina propria of loose connective tissue
(Figure 22–15b).
• Epithelium contains two interspersed,
functionally important cell types:
1. Ciliated cells in which ciliary movements
sweep fluid toward the uterus,
2. Secretory peg cells, nonciliated, darker
staining, apical bulge into the lumen, secrete
glycoproteins of a nutritive mucus film covers
the epithelium.
• Trigger (estrogens)  cilia elongate  both cells
hypertrophy (follicular growth phase of the ovarian cycle)
 atrophy; loss of cilia (late luteal phase)
• Ovulation  mucosal hypertrophy & increased local blood
flow have enlarged & moved the uterine tubes.
– Fringed infundibulum lies close to the ovary; fimbriae partially
surround that organ: transport of the ovulated secondary oocyte
 tube.
• Promoted by sweeping muscular contractions of the
fimbriae and ciliary activity  oocyte  infundibulum 
ampulla
• Secretion covering the mucosa: nutritive + protective
functions for oocyte and the sperm, including capacitation
factors that activate sperm; cells able to fertilize an oocyte.
cross section of uterine
tube with a high
magnification of the
mucosa

uterine wall with the

myometrium and the
two layers of the
endometrium
Cross section of the uterine tube at The oviduct mucosa, with Epithelium two cell types: Peg cells shown
the ampulla shows the interwoven folds projecting into the ciliated cells (CC) are at their most
circular (C) and longitudinal (L) layers lumen (L), has simple interspersed with the developed and
of smooth muscle in the muscularis columnar epithelium (E) on secretory peg cells (PC), most active state
and in the complex of folded the lamina propria (LP) which produce the nutritive in the period
mucosa, the lamina propria (LP) fluid covering the shortly after
underlying a simple columnar epithelium. ovulation when
epithelium (arrows). an embryo might
be present
 Uterus
• Uterine wall has three major layers
1. An outer connective tissue layer, the perimetrium, continuous
with the ligaments, which is adventitial in some areas, but largely
a serosa covered by mesothelium
2. A thick tunic of highly vascularized smooth muscle, the
myometrium
3. A mucosa, the endometrium, lined by simple columnar
epithelium.
Three layers are continuous with their counterparts in the uterine
tubes.
Thickness & structure is influenced cyclically by the shifting levels of
ovarian hormones even more than the mucosa of the uterine tubes
 Myometrium
• Thickest tunic of the uterus
• Bundles of smooth muscle fibers separated by connective tissue containing
venous plexuses and lymphatics
– Smooth muscle forms interwoven layers
• During pregnancy:
– Myometrium extensive growth: hyperplasia & hypertrophy
– increased collagen production by the muscle cells,
• strengthens the uterine wall.
– Well-developed uterine myometrium contracts very forcefully during parturition to
expel the infant from the uterus.
• After pregnancy:
– uterine smooth muscle cells shrink; many undergo apoptosis
– Removal of unneeded collagen
– uterus returns almost to its prepregnancy size.
 Endometrium

• Lamina propria/stroma of the endometrium:

– Nonbundled type III collagen fibers
– abundant fibroblasts and ground substance.
– Simple columnar epithelial lining + ciliated and secretory cells
– latter line the numerous tubular uterine glandspenetrate the full
thickness of the endometrium
• Endometrium, 2 concentric zones:
– basal layer adjacent to the myometrium:
• highly cellular lamina propria
• contains the deep basal ends of the uterine glands
• remains relatively unchanged
– superficial functional layer:
• spongier lamina propria
• richer in ground substance, and includes most of the length of the glands, as well
as the surface epithelium
• Undergoes profound changes during the menstrual cycles
BV supplying the endometrium have
special significance in the periodic
sloughing of the functional layer during
menses
• Arcuate arteries in the middle layers of
the myometrium send two sets of
smaller arteries into the endometrium
– straight arteries: supply only the
basal layer
– long, progesterone-sensitive spiral
arteries: extend farther & bring
blood throughout the functional
layer.
• Spiral arteries branch with
numerous arterioles supplying
a rich, superficial capillary bed:
many dilated, thin-walled
vascular lacunae drained by
venules.

The basal layer (B) of the
endometrium, bordering the
myometrium (M), contains the basal
ends of the uterine glands (G) and
many small arteries (A) embedded in
a distinctive connective tissue stroma
with many fibroblasts, ground
substance and primarily fine type III
collagen, but no adipocytes.
Superficial to the basal layer of the
endometrium is its functional
layer, the part that changes
histologically and functionally
depending on estrogen levels.
This micrograph shows only the
functional layer and includes parts
of the long uterine glands (G) as
well as one spiral artery (A).
The surface epithelium (SE)
lining the endometrium is
simple columnar, with many
cells having cilia. The
underlying stroma (S) has an
extensive microvasculature,
much ground substance, and
broblastic cells with large,
active nuclei.
 Menstrual Cycle
PROLIFERATIVE PHASE
• Cells in the basal ends of glands proliferate, migrate  form the new
epithelial covering over the surface exposed during menstruation.
• Endometrial lining: simple columnar surface epithelium
• Uterine glands: straight tubules with narrow, nearly empty lumens
• Mitotic figures can be found among both the epithelial cells and
fibroblasts.
• Spiral arteries lengthen as the functional layer is reestablished and
grows and extensive microvasculature forms near the surface of the
functional layer.
• At the end of the proliferative phase, the endometrium is 2 to 3 mm
thick.
SECRETORY PHASE
• Progesterone stimulates epithelial cells of the
uterine glands that formed during the
proliferative phase  secrete and accumulate
glycogen  dilating the glandular lumens 
causing the glands to become coiled
• Superficial microvasculature: thin-walled,
blood-filled lacunae
• Endometrium reaches its maximum thickness
(5 mm) during the secretory phase as a result
of the accumulation of secretions and edema
in the stroma.
MENSTRUAL PHASE
drop in progesterone produces:
1. Spasms of muscle contraction in the small spiral arteries of
the functional layer, interrupting normal blood flow
2. Increased synthesis by arterial cells of prostaglandins 
produce strong vasoconstriction and local hypoxia  Cells
hypoxic  release cytokines  increase vascular
permeability & immigration of leukocytes  leukocytes
release collagenase and several other matrix
metalloproteinases (MMPs)  degrade basement
membranes and other ECM components
• At the end of the menstrual phase, the endometrium is
usually reduced to a thin layer and is ready to begin a new
cycle as its cells begin dividing to reconstitute the mucosa.
 Proliferative phase (a, d)
functional layer is still relatively
thin,
the stroma is more cellular
the glands (G) are relatively
straight, narrow, and empty.

Secretory phase (b, e)

functional layer is less heavily cellular and
perhaps four times thicker than the basal
layer.
Tubular glands have wider lumens
containing secretory product and coil
tightly up through the stroma, giving a
zigzag or folded appearance histologically.
Superficially in the functional layer,
lacunae (La) are widespread and filled
with blood.
Short premenstrual phase
(c, f)
begins with constriction of
the spiral arteries, which
produces hypoxia that
causes swelling and
dissolution of the glands
(G).
The stroma of the
peripheral functionalis is
more compact and that
near the basal layer
typically appears more
sponge-like during this
time of blood stasis,
apoptosis, and breakdown
of the stromal matrix
Embryonic Implantation, Decidua, Placenta

• Zygote produced by fertilization  mitotic

cleavages as it is moved toward the uterus
(blastomeres)  compact aggregate called
the morula
– No growth occurs during the period of cell
cleavage, with blastomeres becoming smaller at
each division
– morula is about the same size as the oocyte at
fertilization.
IMPLANTATION
• Embryo enters the uterus as a
blastocyst about 5 days after
ovulation or fertilization, when the
uterus is in the secretory phase and
best prepared for implantation.
• To begin implantation, receptors on
cells of the outer embryonic
trophoblast bind glycoprotein ligands
on the endometrial epithelium.
• The trophoblast forms an invasive,
outer syncytial layer called the
syncytiotrophoblast.
• Proteases are activated and/or
released locally to digest stroma
components, which allows the
developing embryo to embed itself
within the stroma.
• The newly implanted embryo absorbs
nutrients and oxygen from the
endometrial tissue and blood in the
lacunae.
• Endometrial stroma undergoes histologic changes in
the period following implantation.
– Fibroblasts enlarged, polygonal, active in protein synthesis
= decidual cells.
– Whole endometrium is now called the decidua
– Includes 3 areas (Figure 22–21):
• decidua basalis between the implanted embryo and the
myometrium;
• decidua capsularis, the region between the embryo and the
uterine lumen which thins as the embryo gets larger;
• decidua parietalis, on the side of the uterus away from the
embryo
PLACENTA:
site of exchange for nutrients, wastes, O2, and CO2 between the mother and
the fetus and contains tissues from both individuals.
• embryonic part: chorion, derived from the trophoblast
• maternal part: from the decidua basalis.
• Exchange occurs between embryonic blood in chorionic villi
outside the embryo and maternal blood in lacunae of the decidua
basalis.
• Chorionic villi of the developing placenta go through three stages:
– Primary villi: 2 days after implantation
• simple cords of proliferating cytotrophoblast cells
• covered by syncytiotrophoblast extend into lacunae containing maternal blood.
– Secondary villi ~15th day of embryonic development as the primary villi
are invaded by extraembryonic mesenchyme.
– Tertiary villi few more days as mesenchyme in the secondary villi
differentiates  form capillary loops continuous with the embryonic
circulatory system.
• By the end of the 1st month of the pregnancy,
the placenta contains thousands of tertiary
chorionic villi, each branching many times and
each branch having one or more capillary loops
• Suspended in pools of maternal blood in the
decidua, the chorionic villi provide an enormous
surface area for metabolite exchange
– diffusion occurring across the trophoblast layer and
the capillary endothelium.
• Placenta = endocrine organ, producing HCG, a
lactogen, relaxin, and various growth factors, in
addition to estrogen and progesterone.
(a) A full-term placenta has many villus
stems, containing arteries (A) and (V) of
the extraem- bryonic vasculature, and
hundreds of smaller villus branches
(arrows) that contain connective tissue
and microvasculature. Maternal blood
(MB) lls the space around the villi.
Higher magnification of villus branches surrounded by maternal
blood (MB) each containing capillaries (C) or
sinusoids (S) with fetal blood.
By the end of pregnancy cytotrophoblast cells have greatly
decreased in number in many areas, leaving only a thin
syncytiotrophoblast and basement membrane covering the villus
in these regions (arrows).
The extraembryonic blood vessels become closely associated with
these areas of thin trophoblast for maximal diffusion of material
between the two pools of blood.
 Cervix
Cervix differs histologically from the rest of the uterus.
• Endocervical mucosa:
– simple columnar epithelium
– thick lamina propria
– large, branched, mucus-secreting cervical glands.
• Lacks spiral arteries
• does not change its 2-3 mm thickness during the ovarian cycle, is not shed
during menstruation.
• Cervical region (near external os) projects to upper vagina; covered by the
exocervical mucosa: nonkeratinized stratified squamous epithelium
– continuous with that of the vagina.
• Junction between this squamous epithelium & mucus-secreting columnar
epithelium of the endocervix = transformation zone
– Periodic exposure of the squamous-columnar junction to the vaginal environment 
stimulate reprogramming of epithelial stem cells  leads to intraepithelial neoplasia at
that site.
• Deeper wall of the cervix:
– mainly of dense connective tissue
– much less smooth muscle than the rest of the uterus
(Figure 22–23).
• Cervix becomes relatively rigid during pregnancy;
helps retain the fetus in the uterus.
• Before parturition:
– a process of cervical effacement occurs:
• connective tissue undergoes extensive remodeling and
significant collagen removal (mediated in part by macrophages)
 cervix softens, the cervical canal dilates  birth occurs more
easily.
 C
• Squamous cells, stained on a slide
by the Papanicolaou procedure
using hematoxylin, orange G, and
epithelial junction (arrow) is eosin, stain differently according
seen more clearly. to their content of keratins.
• Cells with atypical nuclei or other
abnormalities can be detected by
this method that is used routinely
to check for cervical carcinoma.

A
• Mucosa of the cervical canal (CC) is continuous with
the endometrium: simple columnar epithelium (SC).
D
• Endocervical mucosa includes many large branched
• The endocervical mucosa is exposed to a relatively high
cervical mucous glands (arrows).
population of microorganisms and normally has a large
• External os: cervical canal opens into the vagina (V),
number of neutrophils and other leukocytes.
an abrupt junction (J) between the columnar
• Such cells occur in the lamina propria and epithelium
epithelium & the stratified squamous epithelium
(arrows), but they are also numerous and readily apparent in
(SS) covering the exocervix and vagina seen
the layer of mucus (M) that was fixed in place here.
• Deeper, the cervical wall is primarily fibromuscular
tissue (F)
 Vagina
• Wall of the vagina (L., vagina, sheath, scabbard):
– lacks glands
– consists of a mucosa, a muscular layer, and an adventitia.
• Epithelium of the vaginal mucosa: stratified squamous,
– thickness of 150-200 μm in adults
• Estrogens  epithelial cells synthesize and accumulate
glycogen.
• Lamina propria of the mucosa is rich in elastic fibers + numerous
narrow papillae projecting into the overlying epithelium
• Mucosa normally contains lymphocytes and neutrophils in
relatively large quantities.
• Muscular layer of the vagina is composed
mainly of two indistinct layers of smooth
muscle:
– disposed as circular bundles next to the mucosa
– as thicker longitudinal bundles near the adventitial
layer (Figure 22–24).
– dense connective tissue of the adventitia is rich in
elastic bers, making the vaginal wall strong and
elastic while binding it the surrounding tissues.
– The outer layer also contains an extensive venous
plexus, lymphatics, and nerves.
The vagina has mucosal, muscular, and adventitial layers. Higher magni cation
(a) The lamina propria (L) is highly cellular and extends of the epithelium and
narrow papillae into the thick, nonkeratinized stratified lamina propria (LP)
squamous epithelium (E). shows invasion of
(b) The muscular layer (M) has bundles of smooth muscle leukocytes (arrows)
arranged in a circular manner near the mucosa and between epithelial
longitudinally near the adventitia. cells from the
connective tissue.
Tatalaksana Kehamilan Normal
(Dx, Kontrol, Presentasi janin)
LO 5
 Terms
• Pregnancy/gestation: developing fetus in the body
• Human conceptus from fertilization  8 wks of pregnancy: EMBRYO
• 8th wk  delivery: FETUS
• Obstetric purposes: duration of pregnancy based on gestational age =
estimated age of fetus
– Calculated from 1st day of last (normal) mens period (LMP) ~28 day cycle
– Expressed in weeks
• Developmental age (fetal age): calculated from implantation
• Gravid: pregnant, gravidity: # of total pregnancy (n/abnr)
• Parity: State of having given birth to infants >= 500 g (alive/dead)
– Fetus considered viable when reaching 23-24 wks weighing 500-600 g or more
– Rarely fetus w/ 20-23 wks =< 50 g survive
• Live brith: complete expulsion/extraction of products of conception from
mother (after separation) breathes/shows evidence of life: breathing,
pulsation of umbilical cord, movement)
• Live born: birth  1 yr of life
 Diagnosa Kehamilan Normal

Manifestations of pregnancy classified into three groups:

presumptive, probable, and positive.
1. PRESUMPTIVE MANIFESTATION
Symptoms:
• Ammenorhea: cessation of menses due to increase of
estro/progesterone by corpus luteum
– Delayed menses: emotional tension, chronic disease, opioid, dopaminergic meds,
endocrine disorders, genitourinary tumors
• Nausea & Vomiting: 50% pregnancy, most marked in 2-12 wks
gestation; severe in morning; precipitated by odors & pungent
smell
– Extreme: sign of multiple gestation/molar pregnancy (hyperemis gravidarum:
dehydration + ketonuria)  hospitalizaiton + relieve w/ antiemetic
• Breast:
– Mastodynia/tenderness: due to increased hormonal response of ducts
& alveolar system. Circulatory increases  engorgement & venous
prominence
• Similar tenderness experienced just before menses
– Enlargement of circumlacteal sebaceous gl of areola (Montgomery’s
tubercles)
• At 6-8 wks gestation: hormone stimulation
– Secondary breasts: prominent size & coloration along nipple line,
hypertrophy of axillary breast tissue  lump in axilla
– Colostrum secretion: begin after 16 wks gestation
• Quickening: 1st perception of fetal movement at 18-20 wks in primips, 14-
16 wks multips
– Mistaken w/ intestinal peristalsis
• Urinary tract: bladder irritability, freq nocturia,  increase bladder
circulation & pressure from enlarged uterus
– Mistaken UTI
Signs:
• Increased basal body temperature
• Skin:
– Cholasma: darkening skin over forehead, bridge of nose,
cheekbones (>16 wks gestation, precipitated by sunlight
exposures)
– Linea nigra: darkening of nipples and lower midline abdomen
from umbilicus  pubis (darkened linea alba)
• Increased MSH
– Stretchmarks/striae in breast, abd, thigh: separation of
collagen tissue  irregular scars due to greater tension
• Multips: + silvery due to cicratics of prev striae
– Spider telangiectasia/angioma, palmar erythema
• Could be in pts w/ liver failure
 Diagnosa Kehamilan Normal

2. PROBABLE MANIFESTATION
Symptoms: same as presumptive
Signs:
1. Pelvic organs:
• Chadwick’s sign: congestion of pelvic vascularization  bluish/purplish
vagina/cervix
• Leukorrhea: increased vaginal discharge (+ epith/ cell & cervical mucus) 
hormone stimulation
• Bones & ligaments of pelvis: slight & definite relaxation of joints (mostly in
symphysis pubic)
2. Abdominal enlargement: progressive 7-28 weeks
3. Uterine contractions:
• Globular  rotates to right
• Painless uterine contraction (Braxton Hicks): tightening or pressure begins
about 2-8 wks; increased in regularity, disappear w/ walking/exercise
True labor: contraction more intense
 Diagnosa Kehamilan Normal
3. POSITIVE MANIFESTATION
• Not produced until 1st trimester
• Fetal Heart tones (FHTS)
– Hand held dopplers in 10 wks
gestation
• N fetal HR: 120-160 bpm
– Detected by fetoscope by 18-20
wks gestation
• Palpation of fetus
– After 22 wks  fetal outline can
be palpated through abdominal
wall
– Fetal movement palpated after 18
wks
• US of fetus
– Cardiac activity at 5-6 wks
– Limb buds at 7-8 wks
– Finger & limb movement at 9-10
wks
– Embryonic period (10 wks LMP) 
human appearance
• Pregnancy test
– Early: changes in lvl of hCG (beta)
– hCG produced by
syncytiothrophoblast 8 dys after
fertilization  detected in
maternal serum after implantation
(~8-11 days after conception)
– Urinary pregnancy test: Most
common to confirm
• Identifies B-hCG (1-5 minutes
for result)
• Qualitative +/- based on color
change
• hCG lvl = 5-50 mIU/mL
• First voided morning urine
sample used
 ANC (Kontrol Kehamilan)
• Untuk menghindari risiko komplikasi pd kehamilan & persalinan,
dianjurkan tiap bumil u/ kunjungan antenatal komprehensif
berkualitas minimal 4 kali, minimal 1 kali kunjungan diantar
suami/pasangan atau anggota keluarga sbg berikut:

• Anjurkan ibu u/ px diri ke dokter setidaknya 1x u/ deteksi kelainan medis scr umum
• Memantau kehamilan gunakan buku KIA, diisi tiap kali melakukan kunjungan antenatal,
berikan pd ibu u/ disimpan & bawa kembali pd kunjungan berikutnya
• + info perencanaan persalinan & pencegahan komplikasi (P4k) pd ibu
• Anjurkan mengikuti kelas Ibu
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
 • Kunjungan 1: lengkapi riwayat
medis spt tertera d tabel:
• Kunjungan berikutnya,
perhatikan catatan kunjungan
sebelumnya + tanya keluhan
ibu slm kehamilan berlangsung

Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
 Pemeriksaan Fisik Umum
Pemeriksaan fisik umum pada kunjungan Pemeriksaan fisik umum pada
pertama: kunjungan berikutnya:
• Tanda vital: (tekanan darah, suhu badan, • Tanda vital: (tekanan
frekuensi nadi, frekuensi napas) darah, suhu badan,
• Berat badan frekuensi nadi, pernafasan
• Tinggi badan napas)
• Lingkar lengan atas (LILA) • Berat badan
• Muka : apakah ada edema atau terlihat • Edema
pucat • Pemeriksaan terkait
• Status generalis atau pemeriksaan fisik masalah yang telah
umum lengkap, meliputi: teridentifikasi pada
– kepala, mata, higiene mulut dan gigi, karies, kunjungan sebelumnya
– tiroid, jantung, paru,
– payudara (apakah terdapat benjolan, bekas
operasi di daerah areola, bagaimana kondisi
puting),
– abdomen (terutama bekas operasi terkait uterus),
– tulang belakang, ekstremitas (edema,varises,
refleks patella), serta
– kebersihan kulit
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
 Pemeriksaan Fisik Obstetri
Pemeriksaan fisik obstetri pada kunjungan pertama:
• Tinggi fundus uteri (menggunakan pita ukur bila usia kehamilan > 20
minggu)
• Vulva/perineum: varises, kondiloma, edema, hemoroid, atau kelainan
lainnya.
• Pemeriksaan dalam untuk menilai: serviks*, uterus*, adneksa*, kelenjar
bartholin, kelenjar skene , dan uretra (*bila usia kehamilan < 2 minggu)
• Pemeriksaan inspekulo untuk menilai: serviks, tanda-tanda infeksi, dan
cairan dari ostium uteri

Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
Pemeriksaan fisik obstetri pada setiap kunjungan berikutnya:
• Pantau tumbuh kembang janin dengan mengukur tinggi
fundus uteri. Sesuaikan dengan grafik tinggi fundus (jika
tersedia), atau lihat gambar berikut:
• Palpasi abdomen menggunakan manuver Leopold I-IV:
– Leopold I : menentukan tinggi fundus uteri dan bagian janin yang
terletak di fundus uteri (dilakukan sejak awal trimester I)
– Leopold II : menentukan bagian janin pada sisi kiri dan kanan
ibu(dilakukan mulai akhir trimester II)
– Leopold III : menentukan bagian janin yang terletak di bagian bawah
uterus (dilakukan mulai akhir trimester II)
– Leopold IV : menentukan berapa jauh masuknya janin ke pintu atas
panggul (dilakukan bila usia kehamilan > 36 minggu)
• Auskultasi denyut jantung janin menggunakan fetoskop atau
doppler (jika usia kehamilan > 16 minggu)

Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
 Pemeriksaan Penunjang
• pemeriksaan laboratorium (rutin maupun sesuai indikasi) +
pemeriksaan ultrasonografi.
Lakukan pemeriksaan laboratorium rutin (untuk semua ibu hamil) pada
kunjungan pertama:
• Kadar Hb
• Golongan darah ABO & rhesus
• Tes HIV:
– ditawarkan pada ibu hamil di daerah epidemi meluas dan terkonsentrasi,
– di daerah epidemi rendah tes HIV ditawarkan pada ibu hamil dengan IMS dan
TB
• Rapid test atau apusan darah tebal dan tipis untuk malaria:
– ibu yang tinggal di atau memiliki riwayat bepergian kedaerah endemik malaria
dalam 2 minggu terakhir

Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
Lakukan pemeriksaan
laboratorium sesuai indikasi:
• Urinalisis
– terutama protein urin pada
trimester kedua dan ketiga
– jika terdapat hipertensi
• Kadar hemoglobin pada
trimester ketiga terutama jika
dicurigai anemia
• Pemeriksaan sputum bakteri
tahan asam (BTA)
– ibu dengan riwayat defisiensi
imun, batuk > 2 minggu atau
– LILA < 23,5 cm
• Tes sifilis
• Gula darah puasa
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
Lakukan pemeriksaan ultrasonografi
(USG).
Pemeriksaan USG direkomendasikan:
• Pada awal kehamilan (idealnya
sebelum usia kehamilan 15 minggu)
– menentukan usia gestasi,
– viabilitas janin,
– letak dan jumlah janin
– deteksi abnormalitas janin yang berat
• Pada usia kehamilan sekitar 20
minggu untuk deteksi anomali janin
• Pada trimester ketiga untuk
perencanaan persalinan
Lakukan rujukan untuk pemeriksaan
USG jika alat atau tenaga kesehatan
tidak tersedia
 Suplemen & pencegahan penyakit
Zat besi & Folat
• Beri ibu 60 mg zat besi elemental
segera setelah mual/muntah
berkurang + 400 μg asam folat
1x/hari sesegera mungkin selama
kehamilan.
– Catatan: 60 mg besi elemental = 320
mg sulfas ferosus.
• Efek samping umum dari zat besi:
gangguan saluran cerna (mual,
muntah, diare, konstipasi).
• Tablet zat besi sebaiknya tidak
diminum + teh/kopi =
mengganggu penyerapan.
• Idealnya asam folat sudah mulai
diberikan sejak 2 bulan sebelum
hamil (saat perencanaan
kehamilan).
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
Kalsium
• Di area dengan asupan
kalsium rendah,
suplementasi kalsium 1,5-2
g/hari dianjurkan
– pencegahan preeklampsia
bagi semua ibu hamil,
terutama yang memiliki risiko
tinggi (riwayat preeklampsia
di kehamilan sebelumnya,
diabetes, hipertensi kronik,
penyakit ginjal, penyakit
autoimun, atau kehamilan
ganda)
Aspirin
• Pemberian 75 mg
aspirin tiap hari
dianjurkan untuk
pencegahan
preeklampsia bagi
ibu dengan risiko
tinggi, dimulai dari
usia kehamilan 20
minggu
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
Vaksin TT
• Beri ibu vaksin tetanus toksoid
(TT) sesuai status imunisasinya.
• Pemberian imunisasi pada
wanita usia subur atau ibu hamil
harus didahului dengan skrining
untuk mengetahui jumlah dosis
(dan status) imunisasi tetanus
toksoid (TT) yang telah
diperoleh selama hidupnya.
• Pemberian imunisasi TT tidak
mempunyai interval (selang
waktu) maksimal, hanya
terdapat interval minimal antar
dosis TT.
• Jika ibu belum pernah imunisasi atau status
imunisasinya tidak diketahui, berikan dosis vaksin
(0,5 ml IM di lengan atas) sesuai tabel berikut.

Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
 • Dosis booster mungkin diperlukan pada ibu yang sudah pernah
diimunisasi. Pemberian dosis booster 0,5 ml IM disesuaikan dengan
jumlah vaksinasi yang pernah diterima sebelumnya seperti pada tabel
berikut:

Vaksin TT aman & tidak mempunyai KI dalam pemberiannya.

Meskipun demikian imunisasi TT jangan diberikan pada ibu dengan riwayat reaksi berat terhadap imunisasi
TT pada masa lalunya (contoh: kejang, koma, demam >400C, nyeri/bengkak ekstensif di lokasi bekas
suntikan).
Ibu dengan panas tinggi dan sakit berat dapat diimunisasi segera setelah sembuh.

Selalu sedia KIPI Kit (ADS 1ml, epinefrin 1:1000 dan infus set (NaCl 0.9% jarum infus, jarum suntik 23 G)
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
 KIE
Pastikan bahwa ibu memahami hal-hal
berikut:
• Persiapan persalinan, termasuk:
– Siapa yang akan menolong persalinan
– Dimana akan melahirkan
– Siapa yang akan membantu dan
menemani dalam persalinan
– Kemungkinan kesiapan donor darah
bila timbul permasalahan
– Metode transportasi bila diperlukan
rujukan
– Dukungan biaya
• Pentingnya peran suami atau
pasangan dan keluarga selama
kehamilan dan persalinan.
• Tanda-tanda bahaya yang perlu
diwaspadai:
– Sakit kepala lebih dari biasa
– Perdarahan per vaginam
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
– Gangguan penglihatan
– Pembengkakan pada wajah/tangan
– Nyeri abdomen (epigastrium)
– Mual dan muntah berlebihan
– Demam
– Janin tidak bergerak sebanyak
biasanya
• Pemberian makanan bayi, air susu
ibu (ASI) eksklusif, dan inisiasi
menyusu dini (IMD)
– Catatan: Konseling pemberian
makanan bayi sebaiknya dimulai
sejak usia kehamilan 12 minggu
dan dimantapkan sebelum
kehamilan 34 minggu.
• Penyakit yang dapat mempengaruhi kesehatan ibu dan janin misalnya
hipertensi, TBC, HIV, serta infeksi menular seksual lainnya.
• Perlunya menghentikan kebiasaan yang berisiko bagi kesehatan, seperti
merokok dan minum alkohol.
• Program KB terutama penggunaan kontrasepsi pascasalin
• Informasi terkait kekerasan terhadap perempuan
• Kesehatan ibu termasuk kebersihan, aktivitas, dan nutrisi
• Menjaga kebersihan tubuh dengan mandi teratur dua kali sehari,
mengganti pakaian dalam yang bersih dan kering, dan membasuh vagina
• Minum cukup cairan
• Peningkatan konsumsi makanan hingga 300 kalori/hari dari menu
seimbang. Contoh: nasi tim dari 4 sendok makan beras, ½ pasang hati
ayam, 1 potong tahu, wortel parut, bayam, 1 sendok teh minyak goreng,
dan 400 ml air.
• Latihan fisik normal tidak berlebihan, istirahat jika lelah.
• Hubungan suami-istri boleh dilanjutkan selama kehamilan (dianjurkan
memakai kondom)

Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
Catatan:
Tabel di atas adalah pedoman untuk ibu yang menjalani asuhan antenatal sesuai jadwal.
Jika ada jadwal kunjungan yang terlewatkan, lengkapi tatalaksana yang terlewatkan pada
kunjungan berikutnya.
Lakukan rujukan sesuai indikasi jika menemukan kelainan pada pemeriksaan terutama jika
kelainan tersebut tidak membaik pada kunjungan berikutnya.
( = rutin, (*) = sesuai indikasi, (*) = rutin untuk daerah endemis
Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
 Identifikasi
Komplikasi &
Rujukan

Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
Untuk kehamilan dengan masalah kesehatan/komplikasi yang
membutuhkan rujukan, lakukan langkah-langkah berikut:
• Rujuk ke dokter untuk konsultasi
• Bantu ibu menentukan pilihan yang tepat untuk konsultasi (dokter
puskesmas, dokter spesialis obstetri dan ginekologi, dsb)
• Lampirkan kartu kesehatan ibu hamil berikut surat rujukan
• Minta ibu untuk kembali setelah konsultasi dan membawa surat dengan
hasil dari rujukan
• Teruskan pemantauan kondisi ibu dan bayi selama kehamilan
• Lakukan perencanaan dini jika ibu perlu bersalin di fasilitas kesehatan
rujukan:
• Menyepakati rencana kelahiran di antara pengambil keputusan dalam
keluarga (terutama suami dan ibu atau ibu mertua)
• Mempersiapkan/mengatur transportasi ke tempat persalinan, terutama
pada malam hari atau selama musim hujan
• Merencanakan pendanaan untuk biaya transportasi dan perawatan
• Mempersiapkan asuhan bayi setelah persalinan jika dibutuhkan

Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
untuk kehamilan dengan kondisi kegawatdaruratan yang
membutuhkan RUJUKAN SEGERA:
• Rujuk segera ke fasilitas kesehatan terdekat di mana
tersedia pelayanan kegawatdaruratan obstetri yang sesuai.
• Sambil menunggu transportasi, berikan pertolongan awal
kegawatdaruratan, jika perlu berikan pengobatan.
• Mulai berikan cairan infus intravena
• Temani ibu hamil dan anggota keluarganya
• Bawa obat dan kebutuhan-kebutuhan lain
• Bawa catatan medis atau kartu kesehatan ibu hamil, surat
rujukan, dan pendanaan yang cukup

Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan
 Factors Affecting Labor
• These are easily remembered as the 5 P's:
– passenger (fetus and placenta),
– passageway (birth canal),
– powers (contractions),
– Position of mother
– psychologic response.

N.Petrenko, MD, PhD. Normal & Complicated Labour.

http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/adn/ptn/2/Nursing%20Care%20of
 Passenger (fetus)
• The way the passenger moves through the birth canal is
determined by several interacting factors:
– the size of the fetal head,
– fetal presentation,
– fetal lie,
– fetal attitude,
– fetal position.
Because the placenta must also pass through the birth canal, it
can be considered a passenger along with the fetus.
However, the placenta rarely impedes the process of labor in
normal vaginal birth, except in cases of placenta previa.

N.Petrenko, MD, PhD. Normal & Complicated Labour.

http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/adn/ptn/2/Nursing%20Care%20of
 Position of Fetus
• Important to determine position of fetus before onset of labor 
potential problems can be identified + preparations made
• Position assessed through palpation + US scan
• 3 aspect of fetal position:
1. Fetal lie: orientation of baby’s long axis: orientation of the back
– Longitudinal: normal (back lying along uterus)
– Oblique (back at an angle across uterus)
– Transverse (back lies across uterus)
2. Fetal presentation: part of fetus nearest the cervix: most likely to come
out first, 3 main presentation:
– Cepahlic: head first (N) – 4 variations
– Breech: bottom or feet first
– Shoulder: transverse lie associated
3. Fetal position: direction that the denominator (foremost part of head) is
facing compared w/ pelvis
– L/R/straight (faces symphysis or sacrum directly)
– Anterior(facing pubic bone)/Transverse (across pelvis)/posterior (facing sacrum)
These 2 section combined: e.g: Left occipitoanterior (LOA)
N.Petrenko, MD, PhD. Normal & Complicated
Labour.
http://intranet.tdmu.edu.ua/data/kafedra/inter
nal/ginecology2/classes_stud/en/nurse/adn/pt
n/2/Nursing%20Care%20of%20Childbearing
%20Family/02.%20Unit%20test%20II.htm
N.Petrenko, MD, PhD. Normal & Complicated
Labour.
http://intranet.tdmu.edu.ua/data/kafedra/int
ernal/ginecology2/classes_stud/en/nurse/ad
n/ptn/2/Nursing%20Care%20of
%20Childbearing%20Family/02.%20Unit
 Fetal Attitude
• Attitude: relationship of the fetal body parts to each other.
• The fetus assumes a characteristic posture (attitude) in utero partly because
of the mode of fetal growth and partly because of the way the fetus conforms
to the shape of the uterine cavity.
• Normally, the back of the fetus is rounded so that the chin is flexed on the
chest, the thighs are flexed on the abdomen, and the legs are flexed at the
knees.
• The arms are crossed over the thorax, and the umbilical cord lies between
the arms and the legs.
• This attitude is termed general flexion (see Fig. 2).
• Deviations from the normal attitude may cause difficulties in childbirth.
– For example, in a cephalic presentation, the fetal head may be extended or flexed in a
manner that presents a head diameter that exceeds the limits of the maternal pelvis,
leading to prolonged labor, forceps- or vacuum-assisted birth, or cesarean birth.

N.Petrenko, MD, PhD. Normal & Complicated Labour.

http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/adn/ptn/2/Nursing%20Care%20of%20Childbearing
 Station
• Relationship of the presenting part of the fetus to an imaginary line drawn
between the maternal ischial spines and is a measure of the degree of
descent of the presenting part of the fetus through the birth canal.
• The placement of the presenting part is measured in centimeters above or
below the ischial spines
– For example, when the lowermost portion of the presenting part is 1 cm above the
spines, it is noted as being minus (—) 1.
– At the level of the spines, the station is referred to as 0 (zero).
– When the presenting part is 1 cm below the spines, the station is said to be plus (+) 1.
• Birth is about to happen when the presenting part is at +4 to +5 cm.
• The station of the presenting part should be determined when labor
begins so that the rate of descent of the fetus during labor can be
accurately determined.

N.Petrenko, MD, PhD. Normal & Complicated Labour.

http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/adn/ptn/2/Nursing%20Care%20of%20Childbearing
N.Petrenko, MD, PhD. Normal & Complicated Labour.
http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/adn/ptn/2/Nursing%20Care%20of%20Childbearing
 Engagement
• Indicate that the largest transverse diameter of the
presenting part (usually the biparietal diameter) has
passed through the maternal pelvic brim or inlet into
the true pelvis and usually corresponds to station 0.
• Engagement often occurs in the weeks just before
labor begins in primigravidas and may occur before
labor or during labor in multigravidas.
• Engagement can be determined by abdominal or
vaginal examination.

N.Petrenko, MD, PhD. Normal & Complicated Labour.

http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/adn/ptn/2/Nursing%20Care%20of%20Childbearing
 Passageway
• The passageway, or birth canal, is composed o:
– the mother's rigid bony pelvis
– soft tissues of the cervix, pelvic floor, vagina, and introitus (the
external opening to the vagina).
• Although the soft tissues, particularly the muscular layers
of the pelvic floor, contribute to vaginal birth of the fetus,
the maternal pelvis plays a far greater role in the labor
process because the fetus must successfully accommodate
itself to this relatively rigid passageway.
• Therefore the size and shape of the pelvis must be
determined before childbirth begins.

N.Petrenko, MD, PhD. Normal & Complicated Labour. http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/adn/ptn/2/Nursing

%20Care%20of%20Childbearing%20Family/02.%20Unit%20test%20II.htm
 Menentukan Usia kehamilan

HPHT
• Tanggal perkiraan lahir: Rumus Naegele
– Hari +7, Bulan -3, Tahun +1
• Mis: HPHT 4 Januari 2017  4+7=11; 01 -3bln = 10; 2017+1tahun = 2018  11
Oktober 2018
Tinggi fundus uteri
• Cara Bartholinen
– Mgg 12: 3 jari di atas simfisis
– 16: pertengahan simfisis – pusat
– 20: 1 jari d bawah pusat
– 24: 1 jari di atas pusat
– 26: 3 jari
– 32: pertengahan pusat – proc. Xiphoideus
– 36: 3 jari di bawah proc xiphoideus
– 40: 4 jari di bawah proc xyphoideus

Dasar-dasar Phantoom. Seksi diktat senat mahasiswa FK Undip

 Kelainan Payudara
(Mastitis, Inverted Nipple, Cracked Nipple, Inflamasi/abses,
fibrokista, FAM, Tumor filoides, Paget’s, Ginekomastia, Ca Mammae)

LO 6
 Inverted Nipple
• Inverted nipple: non-projectile nipple
• The nipple is located on a plane lower than the areola.
• The nipple is invaginated and instead of pointing outward, is retracted into
the breast parenchymal and stromal tissue.
• The terms retraction and inversion often are used interchangeably, but such
usage is inexact.
– Retraction: only a slit shape area is pulled inward, whereas
– Inversion: entire nipple is pulled inward occasionally, far enough to lie below the
surface of the breast
• Inverted nipple may be seen in different forms and structures related to:
– the severity of fibrosis, lack of soft tissue bulk, and lactiferous ductus.
• In some cases, the nipple may be temporarily protruded if stimulated, but in
others, the inversion remains regardless of stimulus.

Ercan Karacaoglu. Correction of Inverted Nipple: Comparison of Techniques with

Novel Approaches: Yeditepe University/School of Medicine Department of Plastic
Surgery; Turkey. http://cdn.intechopen.com/pdfs-wm/33480.pdf
 Classification, grading, pathologic basis of deformity
Nipple inversion can be either acquired or congenital.
• Acquired inverted nipple: Nipple inversion secondary to the previous breast
surgery, infiltrating ductal carcinoma, and mastitis are examples of the acquired
types.
• Congenital inverted nipple: Congenital inverted nipple is the most frequent type.
The prevalance is reported as 2-10% (Lee et al., 2003; Alaxander & Campbell
1997).
Congenital inverted nipple is clinically classified into 3 groups:

Grade I Grade II Grade III

nipple nipple nipple
●
Easily pulled out manually & ●
Popped out by palpation but not as easily as in severe form in which inversion and retraction are
●

grade I. significant.
maintains its projection quite well Manually popping out the nipple is extremely difficult.
●
●
The nipple tends to retract.
without traction. ●
The nipple has moderate fibrosis and the A traction suture is needed to keep these nipples
●

protruded.
●
The nipple is popped out by gentle lactiferous ductus is mildly retracted but does not
The fibrosis beneath the nipple is significant and the
●

need to be cut to release the fibrosis.

palpation around the areola.
●
The soft tissue is intact in this form
and the lactiferous ducts are normal.
(Sanghoo Yoon, 1999, Kim et al., 2003)
●
These nipples have been shown to have rich
collagenous stromata with numerous bundles of
smooth muscle.
soft tissue is markedly insufficient.
Histo examination: terminal lactiferous ductus and
●
lobular units are atrophic and replaced with severe
fibrosis
 Cracked nipple
• Nipple may become painful due
to:
– Loss of surface epithelium
– Fissure situated at the tip or base
of nipple
These 2 coexist = cracked nipple
• Caused by:
– Unclean hygiene  crust over
nipple
– Retracted nipple
– Trauma from baby’s mouth due
to incorrect attachment to
breast (assymptomatic but
painful when infant suck)
– When infected  mastitis
*spread to deeper tissue
Hiralal Konar. DC Dutta's Textbook of Obstetrics
• Prophylaxis:
– Local cleanliness during
pregnancy & in puerperium
(before & after breastfeeding to
prevent crust)
• Treatment:
– Correct attachment 
immediate relief & rapid healing
– Severe  use breast pump
– Inflamed nipple due to trush =
miconazole lotion applied
– If fails to heal, use breast pump
– Nipple shield can be used
– Persistent nipple ulcer  biopsy

• Inflammation of parenchyma of
breast
• Infectious: bacteria, fungi,
parasites
• Non-infectious: plasma cell
mastitis, granulomatous mastitis,
lymphocytic mastitis
– Nonpyogenic & non-infx
mastitis: more subtle
presentation (pain or lump; or
incidental finding on screening
mammography)
• Uncommon, most cases of mastitis
& breast abscess occur during
lactation, diabetic patients, heavy
smokers
Breast Imaging Expert Radiology Series. Lawrence W. Bassett, Mary C Mahoney, Sophia Apple, Carl D'Orsi
Mastitis
Pathophysiology: bacteria gain access to the
breast tissue through:
the ducts;
when there is inspissation of secretions;
through fissures in the nipples, which
usually develop during the early weeks of
nursing;
or from various forms of dermatitis
involving the nipple
• Immediate source of organisms is
almost always infant’s nose & throat
• Infecting organisms can be cultured
from the milk
J M Dixon ABC of breast diseases
 • Breast infection is now much less common than it used to
be.
• It is seen occasionally in neonates; most commonly affects
women aged between 18 and 50 divided into: lactational
& non lactational infection.
– Infection can affect the skin overlying the breast:
• primary event
• secondary either to a lesion in the skin: sebaceous cyst, or to an
underlying skin condition, such as hidradenitis suppurativa.
• If an abscess develops, a small incision placed as
peripherally as possible to avoid damaging the breast bud
leads to rapid resolution.

J M Dixon ABC of breast diseases

 Lactating Infection
• Better maternal & infant hygiene + early treatment antibiotics = reduced
the incidence of abscess formation during lactation.
• Infection is more frequent following a first child
– Commonly seen within the first six weeks of breastfeeding,
• Lactating infection presents with:
– Pain, swelling and tenderness.
– There is usually a history of a cracked nipple or skin abrasion
– S aureus is the most common organism responsible, but S epidermidis and
streptococci are occasionally isolated.
– Drainage of milk from the affected area is reduced.
• Promotion of milk drainage + early antibiotic therapy are the
cornerstones of treatment.
• Tetracycline, ciprofloxacin and chloramphenicol should not be used to
treat lactating breast infection as they may enter breast milk and can harm
the baby.
• The pain of lactation mastitis is helped by the application of gel packs

J M Dixon ABC of breast diseases

• If infection does not settle after one course of antibiotics, no
pus is detected on ultrasonography, clinical and imaging
assessments indicate that the lesion is infective or
inflammatory = antibiotic should be changed to cover other
possible pathogens, including MRSA.
• If inflammation or an associated mass lesion persists, further
investigation is required to exclude an underlying
inflammatory carcinoma
Breast Abscess (Suppurative stage)
• Erythema increases + breast are very tender + chills & fever
Non-lactating infection:
Periareolar infection
• Most commonly seen in young
women (mean age 32).
• Histologically: + active inflammation
around non-dilated subareolar breast
ducts – a condition that is called
periductal mastitis.
– Has been confused with and called duct
ectasia:
– duct ectasia is a separate condition
affecting older women
– characterised by subareolar duct dilatation
– less pronounced and less active periductal
inflammation.
• Current evidence suggests that
smoking is the most important factor
in the aetiology of periductal mastitis
but not in duct ectasia
J M Dixon ABC of breast diseases
– Substances in cigarette smoke may either
directly or indirectly damage the wall of
the subareolar breast ducts.
– Aerobic or anaerobic organisms then infect
the damaged tissues.
• All non-lactating women’s ducts are
plugged with keratin, so duct
obstruction cannot be important
• Squamous metaplasia is likely to be a
consequence of infection, not the
cause of it.
• Initial presentation of periductal
mastitis: periareolar inflammation
(with or without an associated mass)
or with an established abscess.
• Associated features: breast pain,
nipple retraction at the site of the
diseased duct and nipple discharge.
 Treatment of Periareolar inflammatory
• Course antibiotics that includes anaerobic cover + investigated
by ultrasonography;
– any abscess should be managed by aspiration or incision and drainage
• If the skin overlying the abscess is necrotic then the dead skin
should be excised
– If the mass is solid on ultrasonography or inflammation does not
resolve after appropriate treatment, care should be taken to exclude
an underlying neoplasm
• Abscesses associated with periductal mastitis recur commonly
because treatment by aspiration or incision does not remove
the underlying diseased duct and most patients continue to
smoke.
• Recurrent episodes of periareolar sepsis should be treated by
excision of diseased ducts under antibiotic cover by an
experienced breast surgeon.
J M Dixon ABC of breast diseases
non-puerperal peripheral infection:
• less commonly seen.
• Seen in older women with underlying chronic
medical conditions:
– diabetes, rheumatoid arthritis;
– women taking steroids or underwent a recent
breast intervention
 Complication of periareolar inflammation
Mammary duct fistula
• A mammary duct fistula is a communication between the skin,
usually in the periareolar region, and a major subareolar breast
duct (Figure 4.13).
• A fistula can develop after incision and drainage of a non-lactating
abscess, it can follow spontaneous discharge of a periareolar
inflammatory mass, or it can result from biopsy of a periductal
inflammatory mass.
Treatment:
• Opening the fistula (fistulotomy) or excising of the fistula
(fistulectomy) and diseased duct or ducts under antibiotic cover.
– The best results are from fistula excision rather than fistulotomy
(Figure 4.15).
– Recurrence is common after surgery.
– The lowest rates of recurrence and best cosmetic results are
achieved by specialist breast surgeons.
J M Dixon ABC of breast diseases
J M Dixon ABC of breast diseases
J M Dixon ABC of breast diseases
 Skin-associated infection

• Primary infection of the skin of the breast, which can present as cellulitis
or an abscess, most commonly affects the skin of the lower half of the
breast
• These infections are often recurrent in women who are overweight, have
large breasts or have poor personal hygiene.
• Cellulitis is more common after surgery or radiotherapy and in people with
skin conditions such as eczema.
• S aureus is the usual causative organism.
• Cellulitis is seen in the neonatal and pubertal periods
Treatment of acute bacterial infection is with antibiotics and drainage or
aspiration of abscesses.
• Women with recurrent infections and areas of intertrigo should be advised
about weight reduction and keeping the area as clean and dry as possible
(this includes careful washing of the area up to twice a day, using a hair
dryer to dry the skin, avoiding skin creams and talcum powder, and
wearing either a cotton bra or a cotton T shirt or vest worn inside the bra)

J M Dixon ABC of breast diseases

 • Sebaceous cysts are common in the skin of the breast and
may become infected
• Some recurrent infections in the inframammary fold are due
to hidradenitis suppurativa
• This is another smoking-related condition and most women
with hidradenitis are heavy smokers.
• In this condition, infection should be controlled with
appropriate antibiotics and drainage of any pus (the same
organisms are found in hidradenitis as in non-lactating
infection).
• Patients should be encouraged to stop smoking.
• Excision of the affected skin is effective at stopping further
infection in about half of patients; the remainder go on to
have further episodes of infection despite surgery.

J M Dixon ABC of breast diseases

 Other infections & Inflammatory conditions
Tuberculosis of the breast is now rare
• It can be primary or, more commonly, secondary.
• Clues to its diagnosis include the presence of a breast or axillary sinus in up to half of
patients.
• The commonest presentation of tuberculosis nowadays is with an abscess resulting
from infection of a tuberculous cavity by an acute pyogenic organism such as S
aureus.
• An open biopsy is often required to establish the diagnosis.
Treatment is by a combination of surgery and antituberculous chemotherapy
• Syphilis, actinomycosis and mycotic, helminthic and viral infections occasionally
affect the breast but are rare.
• Infection with Candida albicans has been implicated in causing deep breast pain after
breastfeeding.
– The evidence for this association is extremely weak and does not justify the use of fluconazole
in these women.

J M Dixon ABC of breast diseases

 Radiographic features of Mastitis
• On mammography:
– ill-defined regions of increased density and
skin thickening.
• US
– ill-defined area of hyperechogenicity =
infiltrated and inflamed fat lobules
– hypoechoic areas in the glandular
parenchyma, and associated mild skin
thickening are seen.
– Inflammatory axillary lymph nodes may also
be encountered.
– Occasionally abscess formation may be visible.
 Nipple discharge
• Physiologic discharge
– Nonspontaneous, bilateral, induced from multiple ducts
– Colors: white, yellow, green, brown, bluish-gray-black
– Copious milky (non-assc w/ pregnancy): indicative galactorrhea (secondary to
medications: oral contraceptives, phenothiazines, antihypertensives or pituitary tumor
(prolactinoma))
• Bloody discharge: intraductal papilloma, periductal mastitis, duct ectasia
• Pathologic discharge usually spontaneous & unilateral, arises from single duct.
– Suspicious lesion on mammography  cytology or core biopsy of lesion
• Spontaneous or inducible discharge from a single duct warrants surgery if it has
any of the following char:
– Bloody
– Persistent (2x/wk)
– + mass
– Woman >40

Atluri P. The Surgical Review: An Integrated Basic and Clinical Science Study Guide. 506 p.
 Tumor of Breast
FIBROADENOMA
• Most common benign neoplasm of the female
breast.
• Increase in estrogen activity is thought to
contribute to its development
• Similar lesions may appear with fibrocystic
changes (fibroadenomatoid changes).
• Fibroadenomas usually appear in young women;
the peak incidence is in the third decade of life
• Clinically: solitary, discrete, movable masses.
– may enlarge late in the menstrual cycle and during
pregnancy.
– After menopause they may regress and calcify.
• Cytogenetic studies reveal that the stromal
cells are monoclonal = represent the
neoplastic element of these tumors.
• Perhaps the neoplastic stromal cells secrete
growth factors that induce proliferation of
epithelial cells.
– Fibroadenomas almost never become malignant.
Morphology
• The fibroadenoma occurs as a
discrete, usually solitary, freely
movable nodule, 1 to 10 cm in
diameter.
– Rarely, multiple tumors are
encountered and, equally
rarely, they may exceed 10
cm in diameter (giant
fibroadenoma).
– Whatever their size, they are
usually easily "shelled out.”
Grossly
• all are firm, with a uniform tan-
white color on cut section,
punctuated by softer yellow-pink
specks representing the
glandular areas
Histologically
• loose fibroblastic stroma
containing ductlike, epithelium-
lined spaces
• These ductlike or glandular
spaces are lined with single or
multiple layers of regular + well-
defined cells w/ intact basement
membrane.
• Ductal spaces are open, round to
oval, and fairly regular
(pericanalicular fibroadenoma)
• Others are compressed by
extensive proliferation of the
stroma; cross-section: slits or
irregular, star-shaped structures
(intracanalicular fibroadenoma)
Phyllodes Tumor
• less common than fibroadenomas
• thought to arise from the periductal stroma and not from preexisting
fibroadenomas.
• They may be small (3-4 cm in diameter), but most grow to large, possibly
massive size, distending the breast.
• Some become lobulated and cystic; because on gross section they exhibit
leaflike clefts and slits, they have been designated phyllodes (Greek for
"leaflike") tumors.
• The most ominous change:
– appearance of increased stromal cellularity with anaplasia and high
mitotic activity
– rapid increase in size, usually with invasion of adjacent breast tissue by
malignant stroma.
– Most of these tumors remain localized and are cured by excision;
– malignant lesions may recur, but they also tend to remain localized.
– Only the most malignant, about 15% of cases, metastasize to distant
sites.
 Paget disease

• Paget’s disease is an eczematoid change of the

nipple associated with an underlying
malignancy
• Paget’s disease may be localised or occupy a
large area
• Clinically, Paget’s disease always affects the
nipple from the start, whereas eczema affects
the areolar region initially
– only rarely involves nipple skin

J M Dixon ABC of breast diseases

 Gynecomastia

• The growth of breast tissue in males to any extent in all ages

• Benign and usually reversible.
• It is commonly seen during puberty and old age.
• Occurs in 30–60% of boys aged 10–16 years and usually requires no
treatment, as 80% of cases resolve spontaneously within two years.
• Embarrassment or persistent enlargement is an indication for surgical
referral.
• Senescent gynaecomastia commonly affects men aged between 50 and
80, and in most it does not seem to be associated with any significant
endocrine abnormality.

J M Dixon ABC of breast diseases

 • Breast enlargement without pain or tenderness and without an easily
identifiable cause = indication for blood, hormone and biochemical
measurement.
• Mammography and ultrasound: differentiate between breast enlargement
due to fat or gynaecomastia and are valuable if malignancy is suspected.
• drug-related gynaecomastia = withdrawal of the drug or change to an
alternative treatment
• Gynaecomastia is seen in body builders who take anabolic steroids;
– some have learnt that by taking tamoxifen they can combat this.
– Both tamoxifen anddanazol improve symptoms in patients with
gynaecomastia, but recurrence after stopping drugs can be a problem.
– Tamoxifen at a dose of 10 mg is effective and produces fewer side
effects than 20 mg of tamoxifen or danazol, so it is the drug of first
choice.
• Surgery for gynaecomastia is not easy, should follow recognised protocols
and should be performed by experienced breast or plastic surgeons.

J M Dixon ABC of breast diseases

Ca Mammae