Artha Falentin Putri Susilo

Purpose: Primary ovarian insufficiency (POI) is ovarian follicular depletion or dysfunction before age 40, affecting an estimated 3.5% of women worldwide. It is an under-recognized cause of secondary amenorrhea and infertility, and diagnostic delay is common because early symptoms overlap with more benign menstrual disorders. Interpretation of biochemical tests is further complicated in women receiving exogenous hormonal therapy. Case Illustration: A 36-year-old nulligravid woman presented with 8 years of infertility and 23 years of irregular, sparse menstruation since menarche, with scheduled withdrawal bleeding during cyclical estrogen-progestin therapy. Serum follicle-stimulating hormone (FSH) was 21.85 and 21.8 IU/L on two occasions, below the 25 IU/L threshold of the 2024 international guideline. Anti-Müllerian hormone (AMH) was undetectable (< 0.01 ng/mL) on both occasions. Thyroid-stimulating hormone and 17-hydroxyprogesterone were normal. Hysterosalpingography showed a normal uterine cavity and patent tubes. Diagnostic laparoscopy revealed grade I–II omental-pelvic adhesions and bilaterally small ovaries (approximately 20 × 10 × 10 mm); adhesiolysis was performed and chromopertubation confirmed tubal patency. During ovulation induction, one letrozole-stimulated cycle produced a single left ovarian follicle of 20.3 mm, whereas subsequent cycles with clomiphene citrate, human menopausal gonadotropin, and letrozole showed minimal or absent follicular development, and both ovaries were later described as streak-like on ultrasonography. She continued cyclical hormone therapy. Discussion: The findings indicate severely diminished ovarian reserve with a clinical phenotype suggestive of POI, although the FSH values do not meet the current biochemical criterion and may have been influenced by exogenous hormones. The mild grade of the adhesions and the patent tubes make the adhesions unlikely to be the principal cause of infertility. Conclusion: Women under 40 with persistent oligomenorrhea or amenorrhea and infertility warrant timely evaluation for POI, and incidental pelvic findings are best interpreted in the context of the endocrine and functional data. Very low AMH may support concern for severe ovarian reserve depletion when FSH is borderline; however, guideline-concordant biochemical confirmation, preferably off hormonal therapy, and etiologic evaluation are required before a definitive diagnosis is assigned.

Introduction: Recurrent pregnancy loss is a complex condition that affects a small number of women, with antiphospholipid syndrome being a well-recognized cause. Antiphospholipid syndrome is an autoimmune disorder associated with vascular thrombosis and pregnancy complications.Case report: We present a 23-year-old woman with four consecutive pregnancy losses and cerebral venous sinus thrombosis. Despite an initial inability to fully confirm APS using the Sydney criteria due to resource limitations that hindered repeated laboratory testing, consultation with the rheumatology department led to a diagnosis based on the European Alliance of Associations for Rheumatology and American College of Rheumatology (ACR/EULAR) 2023 criteria. This case highlights the diagnostic challenges of antiphospholipid syndrome, especially in low-resource settings where repeat laboratory testing is often not feasible, underscoring the importance of alternative classification systems for confirming antiphospholipid syndrome when standard criteria cannot be met. Further research is necessary to validate the ACR/EULAR 2023 classification criteria and evaluate their impact on pregnancy outcomes in patients.Conclusion: To optimize limited resources, improved diagnosis and pregnancy planning for patients with antiphospholipid syndrome and cerebral venous sinus thrombosis are achieved by applying current classification criteria along with multidisciplinary management, including anticoagulation and obstetric care.Tantangan Diagnosis Sindrom Antifosfolipid pada Keguguran Berulang: Sebuah Laporan KasusAbstrakPendahuluan: Keguguran berulang adalah kondisi multifaktorial yang memengaruhi sebagian kecil wanita, dengan sindrom antifosfolipid sebagai salah satu penyebab yang dikenal. Sindrom antifosfolipid adalah gangguan autoimun yang berhubungan dengan trombosis vaskular dan komplikasi kehamilan.Laporan kasus: Kami melaporkan seorang wanita berusia 23 tahun yang mengalami empat kali keguguran berturut-turut dan didiagnosis dengan trombosis sinus vena serebri. Meskipun pada awalnya konfirmasi penuh sindrom antifosfolipid, menurut kriteria Sydney tidak memungkinkan karena keterbatasan sumber daya yang menghambat pengulangan pemeriksaan laboratorium, konsultasi dengan bagian reumatologi menghasilkan diagnosis berdasarkan kriteria 2023 dari European Alliance of Associations for Rheumatology dan American College of Rheumatology (ACR/EULAR). Kasus ini menyoroti tantangan diagnostik sindrom antifosfolipid, terutama di lingkungan dengan sumber daya terbatas dengan pemeriksaan laboratorium berulang tidak selalu dapat dilakukan, serta pentingnya penggunaan sistem klasifikasi alternatif untuk menegakkan diagnosis ketika kriteria standar tidak dapat dipenuhi. Diperlukan penelitian lebih lanjut untuk memvalidasi kriteria klasifikasi ACR/EULAR 2023 dan menilai dampaknya terhadap hasil kehamilan pada pasien.Kesimpulan: Untuk mengoptimalkan sumber daya yang terbatas, penggunaan kriteria klasifikasi saat ini bersama perawatan antikoagulasi dan obstetri secara multidisipliner memungkinkan diagnosis dan perencanaan kehamilan yang lebih baik bagi pasien dengan sindrom antifosfolipid dan trombosis sinus vena serebral.

Introduction: Primary amenorrhea, defined as the absence of menstruation by age 15, has a broad differential diagnosis, including anatomical, endocrine, hypothalamic-pituitary, and genetic causes. Turner syndrome and Kallmann syndrome are two distinct etiologies with different pathophysiological mechanisms. Turner syndrome is characterized by hypergonadotropic hypogonadism due to gonadal dysgenesis, whereas Kallmann syndrome results from gonadotropin-releasing hormone (GnRH) deficiency and is often associated with anosmia.Case Presentation: A 17-year-old female was referred with primary amenorrhea and absent secondary sexual development. Physical examination revealed Tanner Stage I breast and pubic hair development, with no reported olfactory disturbances. Hormonal assays indicated hypogonadotropic hypogonadism, with low FSH, LH, and estradiol levels. Pelvic ultrasonography revealed a hypoplastic uterus and non-visualized ovaries. Cranial MRI showed pituitary hypoplasia and bilateral agenesis of the olfactory bulbs, suggestive of Kallmann syndrome. However, karyotype analysis revealed a mosaic 45,X/46,XX pattern, consistent with Turner syndrome. This combination of clinical, hormonal, imaging, and cytogenetic findings posed a unique diagnostic dilemma.Discussion: The overlapping features of Turner and Kallmann syndromes make this case highly unusual. Turner syndrome typically presents with hypergonadotropic hypogonadism, whereas Kallmann syndrome is characterized by hypogonadotropic hypogonadism, often with anosmia. Comprehensive evaluation, including cytogenetic analysis and MRI, was essential for accurate diagnosis. Management focused on pubertal induction with hormone replacement therapy and appropriate genetic and systemic evaluation.Conclusion: This case underscores the diagnostic complexity of primary amenorrhea with overlapping features of Turner and Kallmann syndromes. Accurate diagnosis requires integrated hormonal, imaging, and cytogenetic evaluation, with management focused on hormonal correction and long-term supportive care.

Background: Surgical site infection (SSI) is a significant postoperative complication in gynecological surgery, increasing morbidity, mortality, and healthcare costs. This study aimed to compare postoperative surgical site infection (SSI) outcomes between patients receiving cefazolin or ceftriaxone as preoperative antibiotics and to identify clinical predictors of postoperative SSI. Methods: This retrospective cohort study involved 366 gynecological surgery patients at Dr. Hasan Sadikin General Hospital, Bandung. Medical record data were analyzed using bivariate analysis and multivariable logistic regression. Variables analyzed included age, body mass index (BMI), hemoglobin, leukocyte count, neutrophil-to-lymphocyte ratio (NLR), and type of antibiotic used (cefazolin or ceftriaxone). The primary outcome was postoperative surgical site infection documented during postoperative follow-up. Results: No significant difference was found between cefazolin and ceftriaxone in the incidence of surgical site infection (p = 0.097). However, several clinical parameters were significantly associated with SSI. A BMI > 24.89 kg/m² was associated with an odds ratio (OR) of 4.27 (95% CI: 2.74– 6.65). Leukocyte count > 12,580/μL had an OR of 2.31 (95% CI: 1.44– 3.69). An NLR > 14.68 showed an OR of 2.53 (95% CI: 1.65– 3.89). Lower hemoglobin levels (< 11.9 g/dL) were associated with an OR of 2.70 (95% CI: 1.67– 4.35), while hematocrit ≤ 32.5% showed an OR of 2.47 (95% CI: 1.58– 3.87). The area under the curve (AUC) value for NLR was 0.641, indicating modest discriminative ability in predicting SSI. Discussion: Cefazolin and ceftriaxone were associated with comparable postoperative SSI outcomes in this retrospective cohort. Considering antimicrobial stewardship principles and Indonesian national guidelines, cefazolin may be preferred as the first-line preoperative antibiotic. Higher BMI, leukocytosis, elevated NLR, and anemia were associated with an increased risk of SSI and may help identify patients at greater postoperative risk. Conclusion: Cefazolin and ceftriaxone showed comparable postoperative SSI outcomes in this retrospective cohort. BMI, hemoglobin level, hematocrit, and NLR were independent predictors of postoperative SSI.

Background: Histopathological diagnosis can be challenging because epithelioid trophoblastic tumor (ETT) may closely mimic choriocarcinoma, particularly due to overlapping cytologic and architectural features of intermediate trophoblasts. Therefore, immunohistochemical studies are essential for accurate classification of GTN subtypes. Case Illustration: A 27-year-old woman, para 4 abortion 1, with a history of two curettage procedures for partial hydatidiform mole, presented with persistent post-curettage vaginal bleeding for five months and was admitted to the emergency department with severe anemia. Serial β-hCG monitoring demonstrated a significant rise, raising suspicion for GTN. Ultrasonography revealed a vesicular pattern, while additional investigations showed no evidence of metastasis. Based on a FIGO score < 7, the patient was classified as low-risk GTN. The patient declined chemotherapy and opted for total hysterectomy with bilateral salpingectomy. Intraoperative gross examination revealed an irregular, friable, and necrotic uterine mass consistent with GTN. Initial histopathological evaluation suggested epithelioid trophoblastic tumor; however, further immunohistochemical analysis demonstrated negative p63 expression, high Ki-67 index, and positive β-hCG staining, findings more consistent with choriocarcinoma. Discussion: This case highlights the importance of post-molar β-hCG surveillance as a cornerstone for early GTN diagnosis. The biological differences between ETT and choriocarcinoma have significant therapeutic implications, given the poorer chemotherapy response observed in ETT. Overlapping histopathological features emphasizes that diagnosis cannot rely solely on morphology but requires integration of clinical data, disease latency, β-hCG levels, and an appropriate immunohistochemical panel, particularly p63. Conclusion: Delayed post-molar β-hCG monitoring may lead to GTN progression and increased morbidity. Immunohistochemical examination plays a crucial role in differentiating ETT from choriocarcinoma to ensure accurate diagnosis and appropriate management.

Background: Kallmann syndrome (KS) is a rare genetic disorder characterized by hypogonadotropic hypogonadism and anosmia. It is often underdiagnosed in females due to subtle clinical presentation. This can lead to delays in accurate diagnosis and proper long-term management, particularly in women presenting with amenorrhea and uterine hypoplasia. Case Illustration: A 25-year-old nulligravid woman presented with lifelong absence of spontaneous menstruation, anosmia, and partial pubertal development. She was initially misdiagnosed with secondary amenorrhea after a positive progesterone withdrawal test, but later recognized as having primary amenorrhea. Examination revealed Tanner stage M3P3, uterine and ovarian hypoplasia on transvaginal ultrasonography, low estradiol with suppressed gonadotropins, normal 46,XX karyotype, and bilateral absence of the olfactory bulbs on brain MRI, confirming Kallmann syndrome. Dual-energy X-ray absorptiometry demonstrated reduced bone mass consistent with chronic hypoestrogenism. She was started on combined estrogen–progestin therapy with calcium and vitamin D supplementation for estrogen priming and bone protection, with fertility-oriented management and baseline psychological screening integrated into care. Discussion: This case illustrates the diagnostic challenges of Kallmann syndrome in women with partial pubertal development. Insufficient estrogen exposure may allow secondary sexual characteristic development while failing to achieve uterine maturation and spontaneous menstruation. Chronic hypoestrogenism contributes not only to reproductive tract hypoplasia but also poses long-term risks to bone, cardiovascular, metabolic, and mental health, underscoring the importance of comprehensive evaluation and management. Conclusion: Kallmann Syndrome should be suspected in any female patient with hypogonadotropic hypogonadism and anosmia. Withdrawal bleeding should not be mistaken for true menarche, as this may obscure the diagnosis. Early diagnosis is essential to optimize hormonal replacement, preserve fertility potential, and improve long-term systemic health outcomes.

BACKGROUND Vaginal bleeding in prepubertal girls is an uncommon finding and should always prompt thorough evaluation. Puberty is a complex physiological process resulting from maturation of the hypothalamic-pituitary-gonadal axis. Precocious puberty is defined as the early onset of secondary sexual characteristics before the age of 8 years in girls. The incidence ranges from 1 in 5000 to 1 in 10 000 girls worldwide. In contrast, isolated premature menarche is a rare and benign condition characterized by vaginal bleeding without other signs of pubertal activation and remains a diagnosis of exclusion. CASE REPORT We report a 17-month-old female infant who presented with recurrent vaginal bleeding every month over the 3 months prior to admission. Physical examination showed normal external genitalia, with no signs of inflammation, trauma, foreign body, or sexual abuse. There were no secondary sexual characteristics, and growth parameters were appropriate for age. Laboratory examination revealed prepubertal basal gonadotropin levels, normal hormonal levels, normal thyroid function tests, and bone age consistent with chronological age. Platelet function testing showed hyperaggregation, considered a transient and incidental finding. Pelvic ultrasonography demonstrated the size of the uterus was consistent with the age of puberty. After exclusion of local, endocrine, and systemic causes, a diagnosis of isolated premature menarche was established. CONCLUSIONS Menstrual-like vaginal bleeding in prepubertal girls requires systematic and comprehensive examination to differentiate isolated premature menarche from other diseases. Recognition of this benign entity is important to avoid unnecessary interventions and ascertain appropriate follow-up.

Introduction and importance: Interstitial pregnancy is a rare and potentially fatal type of ectopic pregnancy, comprising 2–4% of all ectopic cases. Deep myometrial implantation often leads to delayed diagnosis and a high risk of rupture. Early recognition and fertility-preserving management are essential, though the optimal conservative approach remains debated. Case presentation: A 24-year-old primiparous woman at 8 weeks of gestation presented with vaginal bleeding and abdominal pain. Transvaginal ultrasonography showed a viable left interstitial pregnancy with fetal cardiac activity and elevated β-hCG level of 59 588.4 mIU/ml. She underwent laparoscopic cornuostomy followed by intralesional methotrexate (1 mg/kg) injection under ultrasound guidance. The surgery was uneventful with minimal blood loss. β-hCG levels declined to negative within 1 month. At 5-month follow-up, ultrasonography and hysterosalpingography demonstrated a normal uterus and bilateral tubal patency. Clinical discussion: Interstitial pregnancy carries a sevenfold higher mortality risk than other ectopic types. In stable patients desiring fertility, conservative options are preferred. Laparoscopic cornuostomy minimizes uterine trauma compared to wedge resection, while intralesional methotrexate provides local trophoblastic control with limited systemic toxicity. The combination achieves effective resolution and preserves fertility. Conclusion: Laparoscopic cornuostomy combined with intralesional methotrexate is a safe and effective conservative treatment for interstitial pregnancy, providing excellent outcomes and fertility preservation through early diagnosis and individualized management.

Purpose: Endometriosis, a chronic estrogen-dependent condition characterized by the implantation of tissue beyond the uterine cavity, impacts 10% of women of reproductive age. Endometriosis manifests through menstrual discomfort, chronic pelvic pain, dyspareunia, and cyclical digestive issues. It is additionally linked to infertility. Early diagnosis and effective treatment are crucial but remain limited in many settings. This study aims to identify specific clinical characteristics that could aid in the early diagnosis and treatment of endometriosis. Patients and Methods: The study conducted at Province General Hospital Margono, Indonesia, involved endometriosis patients who had registered from 2020 to 2024. Some inclusion and exclusion criteria are applied in this study. Statistical analysis was performed to determine the rate, odd ratio and prevalence ratio. Results: Our analysis indicates that women experiencing dysmenorrhea, particularly with an onset occurring more than three years after menarche, are significantly associated with endometriosis. Dysmenorrhea had nearly 17.5 times higher odds [OR 17.5, 95% CI 4.75– 64.4, p-value 0.00] of being correlated with endometriosis, and the onset of dysmenorrhea more than 3 years after menarche had 1.67 times higher [OR 2.790; CI 95%; 1.011– 7.698, p-value 0.045] of being associated with endometriosis. Conclusion: Multiple studies have shown that diagnosing endometriosis early is challenging due to its various symptoms. Our findings highlight the significance of dysmenorrhea characteristics, particularly its onset timing, as potential indicators of endometriosis. This findings suggest that incorporating dysmenorrhea onset into clinical assessments may enhance non-surgical diagnostic approaches, facilitating earlier detection and management of endometriosis.