REPRODUCTIVE

SYSTEM

LABORATORY ANATOMY
MEDICAL FACULTY
MUHAMMADIYAH UNIVERSITY OF PURWOKERTO
2017

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Editors tim :
1. Bayu Aji Wicaksono (1313010033)
2. Nila Munaya (1313010022)
3. Faradilla Nur Muliana (1313010047)
4. Almira Meida (1313010039)
5. Afra Brygest Tamia (1313010020)
6. Riska Siela S (1313010041)
7. Cita Dianita Zealand (1313010026)
8. Rosela Alfi Sahara (1313010040)
9. Zaky Rabbani M (1313010016)
10. Mukhammad Arifin (1313010025)
11.

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Anatomy of Human Embriology, Pelvis and Reproductive Systems

A. Embriology
1. Human Embryogenesis
2. Fetal development
B. Anatomy of Pelvis
C. Genitalia Feminina
1. Genitalia Interna
2. Genitalia Eksterna
D. Genitalia Masculina
1. Genitalia interna
2. Genitalia externa

A. EMBRIOLOGY
1. Human Embryogenesis
a. Fertilization/ conception : when the males and females gametes fuse
b. Embryological development : comprises the events during the first
two months after fertilization
c. Fetal development : begins at the start of the ninth week and continues
until birth.
d. Prenatal development : embryological and fetal development are
sometimes referred to collectively
e. Postnatal development : begins at birth and continues to maturity, the
state of full development or completed growth.

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 Picture 1. Embryogenesis

2. Fetal Development
The time spent in prenatal development is known as gestation. For
convenience, we usually think of the gestation period as consisting of three
integrated trimesters, each three months in duration:
1. The first trimester
Is the period of embryological and early fetal development. During this
time, the rudiments of all the major organ systems appear.
2. The second trimester
Is dominated by the development of organs and organ systems, a
process that nears completion by the end of the sixth month. During this time,

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 body shape and proportions change. By the end of this trimester, the fetus looks
distinctively human.
3. The third trimester
Is characterized by rapid fetal growth and deposition of adipose tissue.
Early in the third trimester, most of the fetuss major organ systems become
fully functional. An infant born one month or even two months prematurely has
a reasonable chance of survival.

Picture 2. Fetal Development

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B. Anatomy of Pelvis
Pelvis consists of:
a. Hard Part : Bone
b. Soft Part : Ligamentum and muscles

1. Ossa Pelvis
Consists of 4 bone :
a. Os Coxae (two)
b. Os Sacrum (one)
c. Os Coccygeus (one)
Ossa Coxae divided into three parts :
a. Os Ilium
b. Os Ischium ; acetabulum
c. Os Pubis ; symphisis ossis pubis

2. Apertura Pelvis
Divided into three parts :
a. Apertura Pelvis Superior (pelvic inlet), the boundaries :
a) Promontorium os sacrum
b) Linea terminalis
c) Margo superior symphisis ossis pubis
b. Apertura Pelvis Media (Narrow field of pelvic), the boundaries :
a) Os sacrum 4-5
b) Spina ischiadicae
c) Margo inferior symphisis ossis pubis
c. Apertura Pelvis Inferior (pelvic otutlet), the boundaries :
Consists of two triangles with the same basis :
a) Front triangle
- Arcus Pubicus
- Connecting line between tuber ischiadicum dextra et sinistra

b) Rear triangle
- End of os sacrum
- Ligamentum sacro tuberosum dextra
- Ligamentum sacro tuberosum sinistra
- Connecting line between tuber ischiadicum dextra et sinistra

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3. Pelvic cavity
Consists of two cavity :
a. Pelvic major (false greater pelvis)
b. Pelvic minor (true messer pelvis)

Picture 3. Males pelvis (A), females pelvis (B) anterior view.

Tabel 1. Comparison between males and females pelvis

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There are 4 diameters on apertura pelvic superior : the anteroposterior diameter,
transverse diameter, and two diameter oblikua.

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 Picture 4. Field of Apertura pelvic Superior
Long distance from the upper edge of the symphysis to the promontory of
approximately 11 cm, so-called conjugate vera. The farthest distance transverse to
the apertura pelvic superior of approximately 12.5 to 13 cm, called the transverse
diameter. When the line is drawn from articulatio sacroiliaca to the point of
communion between tranversa and conjugate diameter vera and forwarded to the
linea terminalis, discovered diameter called oblikua diameter along approximately
13 cm.

Pictures 5. Apertura Pelvic Superior with conjugate vera, transverse diameter and
the diameter

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oblikua
How to measure the conjugate vera is with second digiti and third digiti inserted
into the vagina to touch the promontorium. Distance of the inferior part of the
symphysis to the promontorium known as conjugate diagonalis. Statistically vera
is known that the same conjugate with conjugate diagonalis subtract 1.5 cm. If
promontorium can be felt, then the conjugate diagonalis can be measured, along
the distance between the tip of our fingers were touching up the perimeter under
the symphysis. If promontorium not palpable, meaning the size of the conjugate
diagonalis is longer than the distance between our fingertips were touching up the
perimeter below the symphysis. If the distance between the tip of our fingers to
the lower limit of the symphysis is 13 cm, the mean conjugate vera more than 11.5
centimeters (13cm - 1.5 cm). In addition to these two conjugate, also known as
conjugate obstetrika, ie the distance from the middle part of the symphysis to the
promontorium. Actually obstetrika conjugate is most important.

Picture 6. How to measure conjugata diagonalis

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REPRODUCTIVE SYSTEM

C. Feminine genital organs

Picture 7. Feminine genital organs

Tabel 2. Division genitalia feminina

1. PART INTERNA
a. Ovarium
1) The location and number of organs
Located in front of the lateral wall of the pelvis in the curve fossa
ovarica
The amount of 2 pieces, oval shape, size 4x2 cm

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 2) Function
Endocrine function produce the hormones estrogen and
progesterone
The funstion of the exocrine to produce ova.
3) Ligament of ovarium
Ligamentum ovarii proprium
Ligamentum suspensorium ovarii
Mesovarium/mesosalphinx
b. Tuba uterine
1) Divided into several segments
Infundibulum (equipped with fimbriae)
Ampulla tubauterina
Isthmus tubauterina
Pars uterine
2) Function
Receive an ovum from the ovary and is the site of fertilization
(ampulla tubauterine)
Providing food for the ovum has been fertilized
c. Uterus
1) The uterus normally has two angles, namely:
Anteversi (the angle between the cervix uteri and vagina)
Anteflexi (the angle between the cervix uteri and corpus uteri)
2) Layer of the terus
Endometrium
Myometrium
Perimetrium
3) Part of the uterus
4) Ligament of the uterus
Ligamentum latum uteri
Ligamentum teres uteri / ligamentum rotundum
Ligamentum sacrouterina
Ligamentum cardinal

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 Picture 8. Feminine internal genital organs

d. Vagina
1) Structures
Hymen

The forms of hymen:

1. Annularis (round)

2. Cribiformis (leather)

3. Falciformis (crescent)

4. Imperforate (no holes)

Walls of the vagina (vaginal rugae formed)
Fornix vaginae

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 Picture 9. Kinds of hymens form

Clinical applications
a. Tubectomy,ooveroctomy

b. Ca cerviks

c. Ca ovarium (silent lady killer)

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2. PART OF GENITALIA FEMININA EXTERNA
Vulva
Mons pubis
Labium majus pudenda
Labium minus pudenda
Clitoris
Vestibulum
There are 4 ostium, namely:
1. Meatus urethra externus

2. Introitus vagina

3. Muara glandula vestibularis major

4. Muara glandula paraurethralis

Picture 10. Internal organs of feminine genitalia with embryo

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Picture 11. External organs of feminine genitalia

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 Picture 12. External organs of feminine genitalia

Ectopic Pregnancy
Ectopic pregnancy is the result of a flaw in human reproductive
physiology that allows the conceptus to implant and mature outside the
endometrial cavity (see the image below), which ultimately ends in the death of
the fetus. Without timely diagnosis and treatment, ectopic pregnancy can become
a life-threatening situation.

Signs and symptoms

The classic clinical triad of ectopic pregnancy is as follows:
- Abdominal pain
- Amenorrhea
- Vaginal bleeding
Unfortunately, only about 50% of patients present with all 3 symptoms.
Patients may present with other symptoms common to early pregnancy (eg,
nausea, breast fullness). The following symptoms have also been reported:

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- Painful fetal movements (in the case of advanced abdominal pregnancy)
- Dizziness or weakness
- Fever
- Flulike symptoms
- Vomiting
- Syncope
- Cardiac arrest
The presence of the following signs suggests a surgical emergency:
- Abdominal rigidity
- Involuntary guarding
- Severe tenderness
- Evidence of hypovolemic shock (eg, orthostatic blood pressure changes,
tachycardia)
Findings on pelvic examination may include the following:
- The uterus may be slightly enlarged and soft
- Uterine or cervical motion tenderness may suggest peritoneal inflammation
- An adnexal mass may be palpated but is usually difficult to differentiate
- Uterine contents may be present in the vagina, due to shedding of endometrial
lining stimulated by an ectopic pregnancy

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Masculina Reproduction Organ

Picture 13. Masculina reproduction organs

Tabel 3. Masculina reproduction organs

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A. PARS INTERNA
1. Ductuli
a. Testis
Location : inside the scrotum
Left/sinistra testis lower than right/dextra testis
Testis divided into lobule-lobule (lobuli testis)
Inside the testis, there is tubuli seminiferus which is winding tubuli
Tubuli seminiferus orifice in rete testis
Ductuli efferent connecting rete testis with the top of epididymis
Travel of sperm:
Tubulus seminiferus tubulus rectus rete testis ductus efferent
epididymis ductus deferens (Vas deferens + ductus vesicula seminalis)
ductus ejaculatorius urethrae ostium urethrae externa (OUE)

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 Picture 14. Organs of masculines genitalia

CLINICAL ANATOMY
Testis and epidydymis
1. Varicocele
A varicocele is a condition in which the veins of the pampiniform
plexus are elongated and dilated. This is thought to be because the right
testicular vein joins the low-pressure inferior vena cava, whereas the left
vein joins the left renal vein, in which the venous pressure is higher.
2. Malignant tumor of the testis
A malignant tumor of the testis spreads upward via the lymph
vessels to the lumbar (paraaortic) lymph nodes at the level of the first
lumbar vertebra. It is only later, when the tumor spreads locally to involve
the tissues and skin of the scrotum, that the superficial inguinal lymph
nodes are involved.
3. Torsion of the testis
Torsion of the testes is a rotation of the testis around the spermatic
cord within the scrotum. It is often associated with an excessively large
tunica vaginalis. Torsion commonly occurs in active young men and
children and is accompanied by severe pain. If not treated quickly, the
testicular artery may be occluded, followed by necrosis of the testis.
4. Congenital anomalies of the testis

b. Epididymis
Structure:
Caput epididymis
Corpus epididymis
Cauda epididymis

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c. Ductus deferens/vas deferens
Lining mature sperm from epididymis to ductus ejaculatoriusand urethrae.
Ampulla ductus deferens is the part that much bigger

d. Ductus ejaculatorius
Flow cement to urethrae

e. Urethrae masculina
Divided into 5 parts:
Urethtrae pars intramural
Urethrae pars prostatica
Urethrae pars membranancea
Urethrae pars bulbourethralis
Urethrae pars spongiosa

2. Funiculus spermaticus

a. Consist of nervus, artery, vein, lymphatic vessel

b. It is from annulus inguinalis profundus canalis inguinalis annulus
inguinalis superficialis

3. Accessory Gland

a. Vesicula seminalis
b. Glandula prostat
c. Glandula bulbourethralis

Clinical application :
1. Vasectomy
2. BPH (Benigna Prostat Hyperplasia)
3. Hernia Inguinalis

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Vas deferens

1. Vasectomi

Bilateral vasectomy is a simple operation performed to produce

infertility. Under local anesthesia, a small incision is made in the upper
part of the scrotal wall, and the vas deferens is divided between ligatures.
Spermatozoa may be present in the first few postoperative ejaculations,
but that is simply an emptying process.

The Prostate gland

1. Beningn enlargment of the prostate

The cause is possibly an imbalance in the hormonal control of the

gland. The median lobe of the gland enlarges upward and encroaches
within the sphincter vesicae, located at the neck of the bladder. The
leakage of urine into the prostatic urethra causes an intense reflex desire to
micturate.
The enlargement of the median and lateral lobes of the gland
produces elongation and lateral compression and distortion of the urethra
so that the patient experiences difficulty in passing urine and the stream is
weak. Backpressure effects on the ureters and both kidneys are a common
complication. The enlargement of the uvula vesicae (owing to the enlarged
median lobe) results in the formation of a pouch of stagnant urine behind
the urethral orifice within the bladder.

2. Prostate cancer and the prostatic venous plexus

Many connections between the prostatic venous plexus and the
vertebral veins exist. During coughing and sneezing or abdominal
straining, it is possible for prostatic venous blood to flow in a reverse
direction and enter the vertebral veins. This explains the frequent
occurrence of skeletal metastases in the lower vertebral column and pelvic

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 bones of patients with carcinoma of the prostate. Cancer cells enter the
skull via this route by floating up the valveless prostatic and vertebral
veins.

B. PARS EXTERNA

1. Scrotum : testis pack that consist of several layers, that are:

a. Cutis
b. M. Dartos
c. Fascia spermatica interna
d. Fascia cremasterica
e. M. Cremaster
f. Fascia spermatica interna
g. Tunica vaginalis testis lamina parietalis (periorchium)
h. Cavum scrotalis
i. Tunica vaginalis testis lamina visceralis (epiorchium)
j. Tunica albuginea

Picture 15. Scrotal layers

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2. Penis

Consist of 2 parts:

a. Pars fixata/afixa

1) Crus penis
2) Bulbus penis
b. Pars libera

1) Corpora cavernosa (a. centralis inside there)

2) Corpus spongiosum (urethrae inside there)

Consist of 3 parts:
a. Radix penis
b. Corpus penis
c. Glans penis

The Bulbourethral glands

1. Infection

The bulbourethral glands are the common sites for chronic

venereal infection (e.g., gonorrhoea). The organisms reach the gland by
ascending from the bulbous part of the urethra along the duct of the gland.
Scrotum

1. Hydrocele

This is an accumulation of fluid within the tunica vaginalis. Most

hydroceles are idiopathic, but some may be caused by spread of infection
from the testis or epididymis.

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Penis

1. Circumcision

Circumcision is the operation of removing the greater part of the

prepuce, or foreskin. In many newborn males, the prepuce cannot be
retracted over the glans. This can result in infection of the secretions
beneath the prepuce, leading to inflammation, swelling, and fibrosis of the
prepuce. Repeated inflammation leads to

3. Vascularisation of Penis

a. Nervus dorsalis penis

b. Arteri dorsalis penis
c. Vena dorsalis superficialis penis
d. Vena dorsalis penis
e. Arteri profunda penis

Picture 16. Vasculrisation of Penis

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 Clinical application:
1. Circumcision
2. Cremaster reflex
3. Constriction of the orifice of the prepuce (phimosis) with
obstruction to urination.
4. Urethra infection
5. Trauma
6. Congenital anomalies

Homologue Genital Organs

Tabel 4. Homologue genital organs

Disease realted woman reproduction system :

1. Abruptio placenta

A. Definition

Abruptio placentae is defined as the premature separation of

the placenta from the uterus. Patients with abruptio
placentae, also called placental abruption, typically present
with bleeding, uterine contractions, and fetal distress (Deering,
2016).

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 Picture 1. Placental abruption seen after delivery (Deering, 2016).

B. Patophysiology
Trauma, hypertension, or coagulopathy, contributes to
the avulsion of the anchoring placental villi from the expanding
lower uterine segment, which in turn, leads to bleeding into
the decidua basalis. This can push the placenta away from
the uterus and cause further bleeding. Bleeding through the
vagina, called overt or external bleeding, occurs 80% of the
time, though sometimes the blood will pool behind the placenta,
known as concealed or internal placental abruption.
Women may present with vaginal bleeding, abdominal or back
pain, abnormal or premature contractions, fetal distressor
death.
C.Classification
Abruptions are classified according to severity in the following
manner:

1. Grade 0: Asymptomatic and only diagnosed

through post partum examination of the placenta.
2. Grade 1: The mother may have vaginal bleeding with
mild uterine tenderness or tetany, but there is no
distress of mother or fetus.

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 3. Grade 2: The mother is symptomatic but not in shock.
Some evidence of fetal distress can be found with fetal
heart rate monitoring.

4. Grade 3: Severe bleeding (which may be occult) leads

to maternal shock and fetal death. There may be
maternaldisseminated intravascular coagulation.
Blood may force its way through the uterine wall into the
serosa, a condition known as Couvelaire uterus.

D. Etiology
The primary cause of placental abruption is usually unknown,
but multiple risk factors have been identified. Risk factors in
abruptio placentae include the following (Deering, 2016):
1. Maternal hypertension - Most common cause of
abruption, occurring in approximately 44% of all cases
2. Maternal trauma (eg, motor vehicle collision [MVC],
assaults, falls) - Causes 1.5-9.4% of all cases
3. Cigarette smoking
4. Alcohol consumption
5. Cocaine use
6. Short umbilical cord
7. Sudden decompression of the uterus (eg, premature
rupture of membranes, delivery of first twin)
8. Retroplacental fibromyoma
9. Retroplacental bleeding from needle puncture (ie,
postamniocentesis)
10. Idiopathic (probable abnormalities of uterine blood
vessels and decidua)
11. Previous placental abruption
12. Chorioamnionitis
13. Prolonged rupture of membranes (24 h or longer)
14. Maternal age 35 years or older
15. Maternal age younger than 20 years
16. Male fetal sex
17. Low socioeconomic status

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 18. Elevated second trimester maternal serum alpha-
fetoprotein (associated with up to a 10-fold increased risk
of abruption)
19. Subchorionic hematoma
E. Prognosis
If the bleeding continues, fetal and maternal distress may
develop. Fetal and maternal death may occur if appropriate
interventions are not undertaken.
The severity of fetal distress correlates with the degree of
placental separation. In near-complete or complete abruption,
fetal death is inevitable unless an immediate cesarian delivery
is performed.
If an abruption occurs, the risk of perinatal mortality is
reported as 119 per 1,000 people in the United States, but this
can depend on the extent of the abruption and the gestational
age of the fetus. This rate is higher in patients with a significant
smoking history.
Currently, placental abruption is responsible for approximately
6% of maternal deaths (Deering, 2016).

2. Retained Placenta (Retensio Placenta)

A. Definition
Retained placenta is failure of placental delivery within 60
minutes after delivery of the fetus, complicates 2% of births
(Midwifer Educator, 2015).
B. Risk Factors (Midwifer Educator, 2015):
a. Previous retained placenta
b. Previous injury or surgery to the uterus
c. Preterm delivery
d. Induced labor
e. Multiparity
C. Causes (Midwifer Educator, 2015):

a. Constriction ring-reforming cervix

b. Full bladder

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 c. Uterine abnormality

d. Morbid adherence of the placenta (Placenta

Accreta, Placenta Increta , Placenta Percreta)

3. Placenta previa

A. Definition

Placenta praevia is an obstetric complication in which

the placenta has attached to the uterine wall close to or
covering the cervix. It can some times occur in the latter
part of the first trimester, but usually during the second
or third. It is a leading cause of antepartum
haemorrhage (vaginal bleeding). It affects
approximately 0.5% of all labours.

B. Patophysiology
No specific cause of placenta praevia has yet been found but
it is hypothesized to be related to abnormal vascularisation of
the endometrium caused by scarring or atrophy from previous
trauma, surgery, or infection.

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 In the last trimester of pregnancy the isthmus of
the uterus unfolds and forms the lower segment. In a normal
pregnancy the placenta does not overlie it, so there is no bleeding.
If the placenta does overlie the lower segment, it may shear off and
a small section may bleed.

C. Clinical Manifestation
Women with placenta praevia often present with painless,
bright red vaginal bleeding. This bleeding often starts mildly and may
increase as the area of placental separation increases. Praevia
should be suspected if there is bleeding after 24 weeks of
gestation. Abdominal examination usually finds the uterus non-
tender and relaxed.
D. Physical Examination
Leopold's Maneuversmay find the fetus in an oblique or
breech position or lying transverse as a result of the abnormal
position of the placenta. Praevia can be confirmed with
an ultrasound. In parts of the world where an ultrasound not
available, it is not uncommon to confirm the diagnosis with an
examination in the surgical theatre.
The proper timing of an examination in theatre is important. If
the woman is not bleeding severely she can be managed non-
operatively until the 36th week. By this time the baby's chance of
survival is as good as at full term.
E. Classification
Placenta praevia is classified according to the placement of
the placenta:

1. Type I or low lying: The placenta encroaches

the lower segment of the uterus but does not infringe on
the cervicalos.
2. Type II or marginal: The placenta touches, but
does not cover, the top of the cervix.

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 3. Type III or partial: The placenta partially
covers the top of the cervix.
4. Type IV or complete: The placenta completely
covers the top of the cervix. This type of praevia often will
not bleed until labour starts.

4. Bartholin cyst

A. Defintion

Bartholin cyst is a fluid-filled enlargement caused by

blockage in one of the ducts so that mucus produced
can not secreted. Cysts may develop in the gland itself
or at the ducts, including small ductal and glandular
acini. Cysts may unilobuler or multilobuler.

B. Anatomy
Bartholin's glands or major vestibular gland is one organ of
the external genitalia, , the normally size of is like a pea and
size rarely exceeds one cm. The glands is not palpable except
in circumstances of illness or infection. The outlet of these
glands leads to the gap that exists between labium minus
pudendi and the edge of the hymen. These glands are
homologous with bulbourethralis gland in men. These glands

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 are depressed at the time of coitus and remove secretions to
moisten or lubricate the vaginal surface
C. Patophysiology
Bartholin's glands produce a liquid wetting the vagina started
puberty, which functions to lubricate the vagina begin puberty,
which functions to lubricate the vagina during intercourse also
in normal conditions. Inflammation of the Bartholin gland
caused by bacteria Gonococcus.

D. Signs and symptoms

Bartholin's Cyst does not always lead to complaints but
sometimes perceived as something heavy and cause difficulties
during coitus. When large-sized Bartholin's Cyst can cause an
uncomfortable feeling when walking or sitting. Signs uninfected
Bartholin's Cyst form of protrusion that is not painful on one side
of the vulva accompanied by redness or swelling .As if the cyst
becomes infected, it can develop become Bartholin abscess with
clinical symptom form :
a. Pain when walking, sitting, physical activity or sexual
intercourse.
b. Commonly there are not feve, unless it is infected with
organism that is transmitted through sexual
intercourse.
c. Swelling of the vulva immersion 2-4 days.
d. Usually there are no secret in the vagina.
e. Spontaneous rupture can occur.

E. Physical examination
Bartholin's cyst or abscess is diagnosed through
pemeriksaanfisik, particularly with gynecological pelvic
examination. On examination with the lithotomy position, the
cysts are in unilateral side, pain, and swelling fluctuations are
erythematous at position 4 o'clock or 8 o'clock in the posterior
labium minus. If the cyst infected, examination of tissue culture

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 needed to identify the type of bacteria that cause abscesses and
to determine whether there is infection due to infectious sexual
diseases for example Gonorrhea and Chlamydia. For culture
swab taken from abse or from other areas such as the cervix.
The results of these tests recently viewed after 48 hours later,
but it does not delay treatment. From these results it can be
seen that the right antibiotic is necessary. Biopsi can be done in
cases of suspected malignant.

5. Bartholinitis

A. Definition

Bartholinitis is inflammation of one or both of the two

Bartholin's glands, which are located in each side behind
the labia (lips). The inflammation is sometimes due to
germs picked up during sex, but in many cases the
inflammation is not sexually transmitted.

B. Etiology

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 Germs that quite commonly infect these glands include the
following:

Staphylococci, which are 'bugs' found in skin spots and in

people's noses.

Streptoccci, which are the common organisms found in

sore throats and on the skin.

Coliforms, which are bowel germs.

Also, bartholinitis may be caused by the gonococcus,

which is the germ of the sexually transmitted infection
gonorrhoea.

C. Symptoms

Pain and soreness in the region of one of the labia minora

(inner lips)

swelling in the same area

possibly a slight discharge from the same region (Omole,

2013)

6. Salpingitias

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 Picture. Acute Salpingitis of left fallopian tube (CDC)

A. Definition
Salpingitis is included into pelvic inflammatory disease (PID).
Salpingitis is infection of salphinx.
B. Etiology and Transmission
Pelvic inflammatory disease (PID) is usually the result of
infection ascending from the endocervix causing endometritis,
salpingitis, parametritis, oophoritis, tuboovarian abcess and/or
pelvic peritonitis.
Neisseria gonorrhoeae and Chlamydia trachomatis have been
identified as causative agents: Mycoplasma genitalium and
anaerobes can also be implicated. Micro-organisms from the
vaginal flora including streptococci, staphylococci, E. Coli and
H. Influenzae are also associated with upper genital tract
inflammation.The relative importance of different pathogens
varies in different countries and regions within Europe.
C. Risk Factor
a. Factors related to sexual behaviour
b. Young age
c. Multiple partners
d. Recent new partner (within previous 3 months)
e. Past history of sexually transmitted infections (stis) in
the patient or their partner
D. Treatment
a. Termination of pregnancy
b. Insertion of intrauterine device within the past 6 weeks

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 c. Hysterosalpingography
d. In vitro fertilisation

7. Endometriosis

A. Definition
Endometriosis is a very common condition where cells of the
lining of the womb (the endometrium) are found elsewhere,
usually in the pelvis and around the womb, ovaries and fallopian
tubes.
B. Etiology
Failure of immune mechanisms to destroy the ectopic tissue
and abnormal differentiation of endometriotic tissue have been
suggested as underlying mechanisms in a stromal-cell defect
associated with increased estrogen and prostaglandin
production, along with resistance to progesterone
Retrograde menstruation, whereby menstrual tissue refluxes
through the fallopian tubes and implants on pelvic structures.
In the coelomic-metaplasia theory, endometriotic lesions
develop when coelomic mesothelial cells of the peritoneum
undergo metaplasia. Another theory postulates the circulation
and implantation of ectopic menstrual tissue via the venous or
the lymphatic system, or both.
C. Epidemiology
An estimated two million women in the UK have this
condition. Endometriosis is a long-term condition which affects
women of all ages during their reproductive years (from the
onset of menstrual periods to the menopause). It affects women
from all social and ethnic groups.
D. Symptoms
The main symptoms of endometriosis are pelvic pain,
pain during or after sex, painful, sometimes heavy periods and,

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 for some women, problems with getting pregnant. Endometriosis
can affect many aspects of a womans life including her general
physical health, emotional wellbeing and daily routine.
Endometriosis is common and many women may have no
symptoms.
Women who do experience symptoms may have one or more
conditions:
Painful menstruation (dysmenorrhoea) which do not
respond to over-the-counter pain relief. Some women
have heavy periods.
Pain during or after sexual intercourse (dyspareunia)
Lower abdominal pain
Painful micturition (dysuria)
Painful defecation (dyschezia)
Pelvic pain which can be long-term (chronic)
Difficulty in getting pregnant or infertility
Pain related to the bowels and bladder (with or without
abnormal bleeding)
Long-term fatigue.
Some women do not have any symptoms at all
Infertility
E. Location of Endometriosis
Endometriosis commonly occurs in the pelvis. It can be
found:
On the ovaries where it can form cysts (often referred to as
chocolate cysts)
In or on the fallopian tubes
Almost anywhere on, behind or around the womb
In the peritoneum (the tissue that lines the abdominal wall
and covers most of the organs in the abdomen).
Less commonly, endometriosis may occur on the bowel
and bladder, or deep within the muscle wall of the uterus
(adenomyosis).
It can also rarely be found in other parts of the body.

39
F. Classification of Endometriosis

40
41
 Picture. Stage of Endometriosis

Endometriosis is classified into one of four stages (I-

minimal, II-mild, III-moderate, and IV-severe) depending on
location, extent, and depth of endometriosis implants; presence
and severity of adhesions; and presence and size of ovarian
endometriomas.
Most women have minimal or mild endometriosis, which is
characterized by superficial implants and mild adhesions.
Moderate and severe endometriosis is characterized by chocolate
cysts and more severe adhesions. The stage of endometriosis
does not correlate with the presence of or severity of symptoms;
with stage IV endometriosis, infertility is very likely (Debnath et
al., 2011).

8. Pelvic Organ Prolaps

42
 A. Definition
Pelvic organ prolapse (POP) occurs when one or more organs
in pelvic include: cervix, uterus, vagina, urethra, bladder or
rectum shifts downward and bulges into or even out of vaginal
canal.
B. Symptoms
Symptoms vaginal or pelvic fullness or pressure or feel as if a
tampon is falling out and experience incontinence, inability to
completely empty the bladder, pain in the pelvic area unrelated
to menstruation, lower back pain and difficulty getting stools
out. Some women also complain of not being able to fully void
stools and of fecal soiling of underwear.
Some women experience sexual dysfunction, such as
problems reaching orgasm and reduced sexual desire or libido.
Although prolapse does not directly interfere with sexuality, it
may affect self-image. Data shows that women with urge
incontinence have the most problems with sexuality and that
urge incontinence interferes with sexuality more than any other
form of incontinence. Some women avoid sex because they are
embarrassed about the changes in their pelvic anatomy, and
some worry that having sex will "hurt" something or cause more
damage. Nothing could be further from the truth. Intercourse
exercises the pelvic floor muscles and replaces the prolapsed
organs to their appropriate position. It does not cause any
damage and, for most women, when their partner is on top, the
prolapse is not visible.
C. Kind of POP
Cystocele (bladder into vagina)

43
 Enterocele (small intestine into vagina)

Rectocele (rectum into vagina)

Urethrocele (urethra into vagina)

44
 Uterine prolapse (uterus into vagina)

Vaginal vault prolapse (roof of vagina)

D. Physical Examination

45
 Diagnosis POP begins with a complete medical history and
physical examination. The examination vulva and vagina for any
lesions, masses or ulcers and will perform an internal
examination to identify any prolapsed organs. The doctor have to
conduct a rectal examination to test for the resting tone and
contraction of the anal muscle and to look for any abnormalities
in that region. The doctor also examination standing (to see if
gravity brings the organs down) (George et al., 2016).

9. Ectopis Pregnancy

A. Definition

Ectopic pregnancy is the result of a flaw in human

reproductive physiology that allows the conceptus to
implant and mature outside the endometrial cavity (see
the image below), which ultimately ends in the death of
the fetus. Without timely diagnosis and treatment,
ectopic pregnancy can become a life-threatening
situation.

B. Sign and Symptomps

The classic clinical triad of ectopic pregnancy is as

follows:

Abdominal pain
Amenorrhea
Vaginal bleeding

Unfortunately, only about 50% of patients present with

all 3 symptomsPatients may present with other symptoms

46
common to early pregnancy (eg, nausea, breast fullness). The
following symptoms have also been reported:
Painful fetal movements (in the case of advanced
abdominal pregnancy)
Dizziness or weakness
Fever
Flulike symptoms
Vomiting
Syncope
Cardiac arrest
The presence of the following signs suggests a
surgical emergency:
Abdominal rigidity
Involuntary guarding
Severe tenderness
Evidence of hypovolemic shock (eg, orthostatic
blood pressure changes, tachycardia)
Findings on pelvic examination may include the
following:
The uterus may be slightly enlarged and soft
Uterine or cervical motion tenderness may suggest
peritoneal inflammation
An adnexal mass may be palpated but is usually
difficult to differentiate from the ipsilateral ovary
Uterine contents may be present in the vagina, due
to shedding of endometrial lining stimulated by an
ectopic pregnancy

47
 Sites and frequencies of ectopic pregnancy. By
Donna M. Peretin, RN. (A) Ampullary, 80%; (B)
Isthmic, 12%; (C) Fimbrial, 5%; (D)
Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F)
Ovarian, 0.2%; and (G) Cervical, 0.2%.

10. Mola hidatidosa (cystic drift)

Cystic drift is a kind of disease chorion, characterized

by the transformation of the villi in botryoidal education,
consisting of a transparent bubbles (Fig a, b, C).

while examining
the introduction
(General view); b, C - type of fibers in norm and molar. The size of

48
 each bubble varies on the value of millet grain to large berries of
grapes, and sometimes comes to a considerable size. The bubbles
are connected by tree trunks with a grayish color. They contain a
clear liquid, which can be defined albumin and mucin. Gallbladder,
drift occurs in 0,05-0,06% of pregnancies.
There are two forms of a molar: one of them is characterized by
degeneration of only the part of the villi, the other - all villi. Full
gallbladder introduction develops in the first months of pregnancy,
when the chorion in the entire periphery of the eggs is equipped with
a lint; partial gallbladder drift occurs only after the division will
happen hairy sheath on chorion frondosum a. chorion laeve, i.e.,
after 3 months of pregnancy. In view of this, the clinical picture is
different: with full bubble entry fruit is always dies when partial - can
sometimes be born alive and viable.

11. Abortion

A. Definition

Introduction Pregnancy is a significant event in a

womans life, and emotional attachment to the
pregnancy and developing baby may begin early in the
first trimester. For most women, experiencing a first
trimester loss is a difficult and vulnerable time. When it
occurs, the grief can be as profound as for any perinatal
or other major loss. Spontaneous abortion (a pregnancy
that ends spontaneously before the fetus has reached a
viable gestational age) is among the most common
complications of pregnancy. Approximately 1215% of

49
 recognized pregnancies and 1722% of all pregnancies
end in spontaneous abortion .The best-documented risk
factors for spontaneous abortion are advanced
maternal age, a previous spontaneous abortion, and
maternal smoking. Most spontaneous abortions are
attributed to structural or chromosomal abnormalities in
the embryo.

B. Stages and Types of Spontaneous Abortions

There are various stages and types of spontaneous

abortions (threatened, inevitable, incomplete and
complete abortions, missed abortion, and
fetal/embryonic demise). These types are clearly
defined.

a. Spontaneous abortion/miscarriage: A
pregnancy that ends spontaneously before the
fetus has reached a viable gestational age. The
World Health Organization defines it as expulsion
or extraction of an embryo or fetus weighing 500
g (typically corresponds to a gestational age of 22
weeks).

b. Threatened abortion: Bleeding through a closed

cervical os during the first half of pregnancy. The
bleeding is often painless, although it may be
accompanied by mild suprapubic pain. On

50
 examination, the uterine size is appropriate for
gestational age, and the cervix is long and closed.
Fetal cardiac activity can be detectable if the
gestation is sufficiently advanced.

c. Inevitable abortion: When abortion is pending,

there may be increased bleeding, intensely painful
uterine cramps, and a dilated cervix. The
gestational tissue can often be felt or visualized
through the internal cervical os.

d. Incomplete abortion: When the fetus is passed,

but significant amounts of placental tissue may be
retained, also called an abortion with retained
products of conception (RPOC) (commonly occurs
after 12 weeks gestation). On examination, the
cervical os is open, gestational tissue may be
observed in the vagina/ cervix, and the uterus is
smaller than expected for gestational age but not
well contracted. The amount of bleeding varies but
can be severe enough to cause hypovolemic shock.
Painful cramps are often present.

e. Complete abortion: When an abortion occurs

(usually before 12 weeks of gestation) and the
entire contents of the uterus are expelled. More
than one-third of all cases are complete abortions.
If a complete abortion has occurred, the uterus is
small and well contracted with a closed cervix;
slight vaginal bleeding and mild cramping can be
present.

51
 f. Missed abortion: Refers to in utero death of the
embryo or fetus prior to the 20th week of
gestation, with prolonged retention of the
pregnancy (48 weeks). Vaginal bleeding may
occur, and the cervix is usually closed.

g. Septic abortion: An abortion accompanied by

fever, chills, malaise, abdominal pain, vaginal
bleeding, and frequently purulent discharge.
Physical examination may reveal tachycardia,
tachypnea, lower abdominal tenderness, and a
tender uterus with dilated cervix. Infection is
usually due to Staphylococcus aureus, Gram-
negative bacilli, or some Gram-positive cocci.
Mixed infections (anaerobic organisms and fungi)
can also be encountered. The infection may
spread, leading to salpingitis, generalized
peritonitis, and septicemia.

12. Uterine abnormalities

Uterine abnormalities are structural problems with

the uterus that are either congenital (from birth) or
acquired from infection, surgery or other problems. These
abnormalities can lead to infertility and difficulties in
carrying a pregnancy. Other factors that affect the uterus,
such as Ashermans syndrome (scar tissue acquired via
surgery or infection) and uterine fibroids, can hamper
fertility, but these generally are not considered uterine
abnormalities.

52
 Its not known how many women have uterine
abnormalities, as many women are not aware they have
the condition until they present with a problem, such as
infertility, and the abnormality is found as part of the
evaluation to determine a cause for infertility. Its
estimated that one in 13 women who are infertile have
uterine abnormalities.

The uterus is normally about three inches long, two

inches wide and one inch from front to back. The lower part
is called the cervix and connects the uterus to the vagina.
The upper part is called the fundus and that is where the
embryo implants in pregnancy. A uterus that does not
conform to this structure is often due to an abnormality
from birth (congenital), also called Mllerian abnormalities,
which are the most common (Amesse 2016).

Birth abnormalities are caused when the uterus and

vagina do not fully combine in the middle when the female
fetus is developing in the womb. Types of congenital
uterine abnormalities include:

Agenesis uterus does not form properly, possibly not

at all

Uterus didelphys uterus has two small, separate

cavities, each with its own cervix

Unicornuate uterus half the size of a normal

uterus and has a horn shape (unicorn), which can happen
when only half the uterus forms, with only one fallopian
tube (surgery is not an option to make the uterus larger)

53
 Bicornuate uterus heart shaped rather than pear
shaped uterus, in which the uterus has two cavities
(spaces) instead of one large cavity; most women with
this condition dont need surgery to repair it

Septate uterus the inside of the uterus is

separated by a fibrous wall of muscle or tissue, dividing
the uterus into two sections; this is the most common
congenital uterine abnormality, and can cause women to
have repeat miscarriages

Arcuate uterus slight indentation at the top of the

uterus.

(Letterie, 2013)

54
 13. Imperforate hymen
An imperforate hymen is a congenital disorder where
a hymen without an opening completely obstructs the vagina. It is
caused by a failure of the hymen to perforate during fetal
development. It is most often diagnosed in adolescent girls when
menstrual blood accumulates in the vagina and sometimes also in
the uterus. It is treated by surgical incision of the hymen (Adams,
2016).

Imperforate hymen, classic appearance of bulging, blue-domed, translucent

membrane.

14. Labial
ahesion
Labial adhesions (also referred to as labial agglutination) are
a common disorder in prepubertal females. They are a fusion of
labia minora in the midline, are usually asymptomatic, and typically
can be treated conservatively. Labial adhesions must be
differentiated from other pediatric vaginal or urethral disorders (eg,
an imperforate hymen or a septate vagina). They most commonly

55
 occur between 3 months and 3 years of life. See the image below
(Braverman PK, 2013)

15. Mllerian
agenesis
Mllerian
agenesis also is referred to as mllerian aplasia, Mayer
RokitanskyKsterHauser syndrome, or vaginal agenesis. Mayer-
Rokitansky-Kster-Hauser (MRKH) syndrome (also referred to as
Mayer-Rokitansky syndrome or Rokitansky-Kster-Hauser syndrome)
consists of vaginal aplasia with other mllerian (ie,
paramesonephric) duct abnormalities. Type I MRKH syndrome is
characterized by an isolated absence of the proximal two thirds of
the vagina, whereas type II is marked by other malformations,
including vertebral, cardiac, urologic (upper tract), and otologic
anomalies. [2] Surgical correction of the vaginal anomaly permits
normal sexual function and, possibly, reproduction with assisted
techniques (Edmons, 2013)

56
16. Vaginal Septum
A DEFINITION
Vaginal Septa are developmental defects of the female
genital tract. Embryologically, the vagina develops in two parts. The
upper 2/3rd portion develop from the fused Mullerian ducts and the
lower portion from the fused sinovaginal bulbs. These sinovaginal
bulbs arise as two swellings from the endoderm of the urogenital
sinus. Vaginal plate forms at the junction of the sinovaginal bulbs
and the Mullerian ducts. This vaginal plate canalizes to form the
vagina.
The transverse vaginal septum occurs because of defective
fusion of the Mullerian duct to the urogenital sinus i.e. persistence
of the vaginal plate. The longitudinal vaginal septum of the upper

57
 two third of the vagina occurs due to defective fusion of the
Mullerian ducts and are usually associated with septate uterus and
uterus didelphys. They usually appear as double barreled cervix and
vagina (Vijaylakshmi dan Rai, 2016).

a
(
b)
Figure 1. (a). Transverse vaginal septum (b).
Longitudinal vaginal septum
(http://www.atlasofpelvicsurgery.com)

B CAUSE AND SYMPTOMS

Development of the female reproductive tract is a
complicated process during which cellular development must occur
in a specific order. When it doesnt, a condition known as vaginal
septum can occur. It is a congenital partition within the vagina, and
may be either transverse (across) or longitudinal (top to bottom).

Transverse vaginal septum

A transverse vaginal septum is a wall of tissue created when
the uteral-genital sinus and mullerian ducts inside the vagina do not
develop correctly. The external genitalia appears normal, but the
vagina is shortened and blocked.

58
 A complete transverse vaginal septum where the tissue spans an
entire area of the vagina will block menstrual flow and results in
cryptomenorrhea, meaning menstruation occurs but is blocked by an
obstruction in the vaginal outflow tract. Women with this condition
may suffer pain during intercourse (dyspareunia) (El-Agwany dan
Mostafa, 2015).

Longitudinal vaginal septum

A longitudinal vaginal septum develops when there is an
incomplete fusion of the lower parts of the two mullerian ducts,
which means that the two ducts did not come together to create one
space. As a result, there is a wall of tissue running down the length
of the vaginal canal, partitioning the space into two vaginal
passageways.
A woman may realize she has a vertical septum, or two
vaginas, when she inserts a tampon during her period and blood still
leaks. It is possible that one vaginal area will be too narrow for
tampon insertion.Some women with a vertical vaginal spetum will
have no symptoms. During sexual activity, the septum may tear and
create one vagina, or one side may be favored because it is larger
(Neto et al., 2014)
It is not always necessary to remove a longitudinal vaginal
septum unless the condition causes pain during intercourse. A
women born with a vertical or complete vaginal septum may also
have duplications in the upper reproductive tract, meaning that she
may have a double cervix or double uterus.

17. Vaginal Atresia

Vaginal Atresia is an entity to which little textbook space and
less lecture time is devoted. Yet its occurrence may cause
confusion unless the physician is at least aware of the possibility of

59
its existence in any age group. The extent of this anatomical defect
varies from mild narrowing to complete absence of the vagina. The
causation of this uncommon condition is somewhat obscure. About
the congenital variety there is not complete agreement, and indeed
various lesions may arise from different maldevelopments.
Embryonic arrests at or about the 50 mm. length, branching
or reduplication of the original vaginal plate, longitudinal and lateral
extensions of the mesonephric (Wolffian) duct as it progresses into
the duct of Gaertner-are three good springboards for conjecture. As
yet this knowledge is of more theoretical than practical value to the
surgeon. Atresia of the acquired variety may result from traumatic
factors, neoplasms or inflammatory lesions. Hormonal influiences
also exist (Ryan et al., 1954).
Vaginal atresia is a congenital defect resulting in uterovaginal
outflow tract obstruction. It occurs when the caudal portion of the
vagina, contributed by the urogenital sinus, fails to form. This caudal
portion of the vagina is replaced with fibrous tissue. Vagina atresia
and agenesis are congenital anomalies of the female genitourinary
tract and may occur as an isolated developmental defect (extremely
rare) or as part of a complex of anomalies (more common).
Examples of some of these associations are as follows:

1 Mayer-Rokitansky-Kster-Hauser (MRKH)
syndrome, also referred to as Mayer-Rokitansky
syndrome, or Rokitansky-Kster-Hauser syndrome, or,
simply, Rokitansky syndrome (Londra et al., 2015).
2 Bardet-Biedl syndrome
3 Kaufman-McKusick syndrome
4 Fraser syndrome
5 Winters syndrome

60
 In 1998, the American Society for Reproductive
Medicine classified the uterine anatomic types as mllerian
anomalies or vaginal anomalies. According to this
classification system, vaginal atresia is an anomaly
classified as type I, which refers to agenesis and hypoplasia
of the uterus. As a consequence, vaginal atresia is
occasionally termed mllerian agenesis (Burgis, 2001).

The most common clinical presentation of type I

mllerian anomalies is vaginal or mllerian agenesis, which
occurs in conjunction with an absent uterus (ie, MRKH
syndrome). Renal anomalies, which may include unilateral
agenesis of the kidney, ectopic kidneys, horseshoe kidney,
and crossed-fused ectopia, occur in 30% of patients with
MRKH syndrome. Associated skeletal anomalies may
include anomalies found in Klippel-Feil syndrome (ie,
aberrations of cervicothoracic somite development), which
manifest as fused vertebrae or other variants. Anomalies of
the ribs and limbs are also encountered.

Variants of vaginal atresia, formerly called partial

vaginal agenesis, are more correctly classified as variants
of a transverse vaginal septum. These variants and other
developmental variants, such as obstructed duplications of
the uterovaginal tract, occur on the basis of other
pathophysiologic events and should be treated as separate
entities.

Each examination of a newborn should include an

inspection of the genitalia, as absence of the vagina or
atresia could be detected during this simple evaluation.

61
Delayed detection is common and can result in major risk
to the female patient because of associated urinary tract
anomalies. Early detection is possible if healthcare
providers include a genital examination as part of their
well-child examination.

Surgical management of vaginal atresia has been

described in the European literature since the turn of the
century. In the United States, Baldwin was the first to
describe construction of a neovagina using an intestinal
graft. As the technique became popular, the potential for
clinically significant morbidity and mortality became
evident. (Masson, 1940). In 1940, Masson reported two
deaths, which provided the impetus to consider the skin-
graft technique McIndoe and Counsellor first reported
(McIndoe, 1950).

62
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