KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

UNIVERSITAS SRIWIJAYA

FAKULTAS KEDOKTERAN
UNIT PENDIDIKAN KEDOKTERAN (UPK)
Zona F. Gedung I Kampus Unsri Indralaya OI Sumatera Selatan, Indonesia Telp. 0711 580061 atau / or Jl. dr. Muh. Ali Komplek RSUP Palembang 30126, Indonesia, Telp. 0711 352342, Fax. 0711 373438,

BLOCK 17: REPRODUCTIVE SYSTEM

SCENARIO A Learning outcome: The graduated doctors capable of doing these following things: 1. Have the ability for anamnesis, general and gynecology physical examination and to plan supporting examination as indicated, such as routine blood, urine and ultrasound examination. 2. Have the ability to conclude (diagnose) based on the data from physical and supporting examination. 3. Have the ability to make a good gynecology medical record. 4. Have the ability to plan a management (treatment) based on competence. 5. Have the ability to plan follow up and evaluation. 6. Have the ability to make evidence based medicine-prognosis and give good explanation (Informed Consent) about the case.

Learning objectives: In this tutorial, students should learn about: 1. Anatomy of reproductive system 2. Gynecology physical examination, which include: a. External examination (inspection, palpation , percussion Auscultations) b. Internal examination (speculum & bimanual) 3. Etiology, symptoms, clinical signs, physical examination and management of bleeding in early pregnancy and Gynecologic disease 4. Term in pregnancy 5. Differential diagnosis of bleeding in early pregnancy 6. Interpretation of laboratory findings (blood and urine) 7. Ideal pregnancy planning

SKENARIO A

Mrs. Y, 37 years old, from middle income family is come to doctor (public health centre) with chief complain vaginal bleeding. The mother also complains abdominal cramping. She also missed her period for about 8 weeks. The mother also feels nauseous, sometimes have vomiting and breast tenderness. Since 1 year ago she complain about vaginal discharge with smelly odor and sometime accompanied by vulvar itchy. She already have 2 children before and the youngest child is 6 years old. Her husband is a truck driver. You act as the doctor in public health centre and be pleased to analyse this case.

In the examination findings: Height = 155 cm; Weight 50 kg; Blood pressure = 120/80 mmHg; Pulse = 80 x/m; RR = 20 x/m. Palpebral conjunctival looked normal, hyperpigmented breasts. External examination: abdomen flat and souffl, symmetric, uterine fundal not palpable, there is no mass, no pain tenderness and no free fluid sign. Internal examination: Speculum examination: portio livide, external os open with blood come out from external os, there are no cervical erotion, laceration or polyp. Bimanual examination: cervix is soft, the external os open, no cervical motion tenderness, uterine size about 8 weeks gestation, both adnexa and parametrium within normal limit. Hb 11 g/dL; WBC 16.000/mm3; ESR 15 mm/hour Peripheral Blood Image: WNL Urine: Pregnacy test (HCG) positive

OBJECTIVES Term Classification G3P2A0 Vaginal bleeding Abdominal cramping Missing period Nausea and vomiting Livide Cervical motion tenderness

Problem Identification A pregnant woman (37 years old) from middle income family G3P2A0 Vaginal bleeding Abdominal cramping

Missing period about 8 weeks Nausea and vomiting Breast tenderness Smelly vaginal discharge Husband occupation truck driver The youngest child is 6 years old Portio livide with blood come from open external os Uterine size about 8 weeks gestation Pregnacy test (HCG) positive

Problem Analysis A pregnant woman (37 years old) from middle income family o What is the definition of middle income? o What is its connection with pregnancy and abortion? o What is the connection between middle income and abortion? o What is the connection between age and abortion? G3P2A0 o What is the meaning of G3P2A0? o Possible complication from abortion? 8 weeks pregnancy with inevitable abortion o What are the causes and the pathophysiology of abortion? o How is the physical examination of 8 weeks pregnancy ? o Epidemiology of abortion in Indonesia? o What are the differential diagnosis? o What are the possible complications that can occur? o How are the right and comprehensive management? Bedrest, sedation, evacuation product of conception,histophatology examination, laboratory screening, documentation. Complain of vaginal bleeding and abdominal cramp o How is its relation with vaginal bleeding and abdominal cramp in this case (pathophysiology)? o How about the management and education? Missing period, nausea and vomiting, breast tenderness o How to make diagnose whether a woman pregnant or not? o What is the differential diagnosis? Smelly vaginal discharge and husband a truck driver o Is there any connection between vaginal discharge and husband occupation? o Is there any connection between smelly discharge and abortion? The youngest child age is 6 years old

o How is ideal pregnancy range? o How if the pregnancy range is too long (clinical risk, caring pattern, outcome, etc)? o How to manage ideal pregnancy planning (contraception; conselling, methods and effectivity)? How is the prognosis? Management?

Hypothesis: Mrs. Y has an inevitable abortion due to infection and advance maternal age.

Learning Issues: 1. Anatomy of reprodustion system 2. Gynecology physical examination, which include: a. External examination (inspection, palpation, percussion) b. Internal examination ( speculum, bimanual) 3. Etiology, symptoms, clinical signs, physical examination and management of abortion 4. Determine the risk factors of abortion 5. Exclude the other differential diagnosis 6. Terms in pregnancy 7. Interpretation of laboratory findings (blood, urine) and ultrasound 8. Ideal pregnancy planning

Concepts Framework: Risk factors, etiology, predisposition abortion outcome, management, complication, prevention.

Theory Review.

ABORTION

I. II.

DEFINITION A spontaneous lost of pregnancy before 20 weeks INCIDENCE 15-25% of all pregnancy

III. CLASSIFICATION 1. Threatened abortion: fetus is still viable and cervical os is closed. 2. Inevitable abortion: fetus may still be alive but the cervical os is open 3. Incomplete abortion: some products of conception have been expelled already 4. Complete abortion: fetus and placental tissue have all been expelled 5. Missed abortion: the pregnancy has succumbed but has not been expelled IV. ETIOLOGY The majority of abortion are due to chromosomal defects. If they are in the first trimester is not necessarily helpful investigating women who misscarry- unless they had three consecutive spontaneous misscarriages. The causes can be: 1. Abnormal conceptus (chromosomal and structural) 2. Immunologigal 3. Uterine abnormality 4. Cervical incompetence 5. Endocrine 6. Maternal disease (including systemic lupus erythematosus) 7. Infection 8. Toxins and cytotoxic drugs 9. Trauma

V.

CLINICAL FEATURES Patients will present with amenorrhea followed by vaginal bleeding. Pain may be present. The symptoms of pregnancy may have disappeared. On examination there may be lower abdominal tenderness. The bleeding may vary from spotting to heavy bleeding. The uterine size may be smaller (if products have been expelled), the same size, or larger than dates (if bleeding has occurred into the uterine cavity). The cervix may be closed or open depending on the stages of abortion. DIFFERENTIAL DIAGNOSIS 1. Ectopic pregnancy 2. Hydatidiform mole 3. Dysfunctional uterine bleeding

VI.

VII. INVESTIGATIONS If the cervical os open, the pregnancy will not continue and no further investigations are needed. If the os is closed, an ultrasound scan will determine whether a viable fetus is present in the uterine cavity. VIII. MANAGEMENT There is no proven treatment for threatened abortion. Inevitable, incomplete, complete and missed abortions all require evacuation of the uterus. REFERRENCE
1. 2. Rymer J, Fish A (eds). Early pregnancy problems. In: Gynaecology Infocus. 1st ed, Elsevier Limited, Edinburgh, 2005; 38-40 Stead LG, Stead SM, Kaufman MS (eds). Spontaneous abortion, ectopic pregnancy, and fetal death. In: First Aid For The Obstetrics & Gynecology Clerckship. A Student to Student Guide. Internantional ed. McGraw-Hill, Boston, 2002; 127-135