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Zona F. Gedung I Kampus Unsri Indralaya OI Sumatera Selatan, Indonesia Telp. 0711 !00"1 atau # or $l. dr. %u&. 'li Komple( )SU* *alem+ang ,01-", Indonesia, Telp. 0711 , -,.-, Fa/. 0711 ,7,.,!,


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 ma e 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 ma e evidence based medicine!prognosis and give good

explanation ("nformed #onsent) about the case.

Learning ob$ectives: "n this tutorial, students should learn about:

1. %natomy of reproductive system 2. &ynecology physical examination, which include: a.

'xternal examination (inspection, palpation , percussion "nternal examination (speculum ( bimanual)

b. 3. 'tiology, symptoms, clinical signs, physical examination and management of

bleeding in early pregnancy and &ynecologic disease

4. Term in pregnancy 5. )ifferential diagnosis of bleeding in early pregnancy 6. "nterpretation of laboratory findings (blood and urine) 7. "deal pregnancy planning

SKENARIO A *rs. +, ,- years old, from middle income family is come to doctor (public health centre) with chief complain vaginal bleeding. The mother also complains abdominal cramping. .he also missed her period for about / wee s. The mother also feels nauseous, sometimes have vomiting and breast tenderness. .ince 0 year ago she complain about vaginal discharge with smelly odor and sometime accompanied by vulvar itchy. .he already have 1 children before and the youngest child is 2 years old. Her husband is a truc driver. +ou act as the doctor in public health centre and be pleased to analyse this case. "n the examination findings: Height 3 044 cm5 6eight 47 g5 8lood pressure 3 0179/7 mmHg5 :ulse 3 /7 x9m5 ;; 3 17 x9m. :alpebral con$unctival loo ed normal, hyperpigmented breasts. 'xternal examination: abdomen flat and souffl<, symmetric, uterine fundal not palpable, there is no mass, no pain tenderness and no free fluid sign. "nternal examination: .peculum examination: portio livide, external os open with blood come out from external os, there are no cervical erotion, laceration or polyp. 8imanual examination: cervix is soft, the external os open, no cervical motion tenderness, uterine si=e about / wee s gestation, both adnexa and parametrium within normal limit. Hb 00 g9dL5 68# 02.7779mm,5 '.; 04 mm9hour :eripheral 8lood "mage: 6>L ?rine: :regnacy test (@H#&) positive

OBJECTIVES Term #lassification

&,:1%7 Aaginal bleeding %bdominal cramping *issing period >ausea and vomiting Livide #ervical motion tenderness

:roblem "dentification

% pregnant woman (,- years old) from middle income family &,:1%7 Aaginal bleeding %bdominal cramping

*issing period about / wee s >ausea and vomiting 8reast tenderness .melly vaginal discharge Husband occupation truc driver The youngest child is 2 years old :ortio livide with blood come from open external os ?terine si=e about / wee s gestation :regnacy test (@H#&) positive

:roblem %nalysis

% pregnant woman (,- years old) from middle income family

o o o o

6hat is the definition of middle incomeB 6hat is its connection with pregnancy and abortionB 6hat is the connection between middle income and abortionB 6hat is the connection between age and abortionB

o o

6hat is the meaning of &,:1%7B :ossible complication from abortionB

/ wee s pregnancy with inevitable abortion

o o o o o o

6hat are the causes and the pathophysiology of abortionB How is the physical examination of / wee s pregnancy B 'pidemiology of abortion in "ndonesiaB 6hat are the differential diagnosisB 6hat are the possible complications that can occurB How are the right and comprehensive managementB
8edrest, sedation, evacuation product of conception,histophatology

examination, laboratory screening, documentation.

#omplain of vaginal bleeding and abdominal cramp


How is its relation with vaginal bleeding and abdominal cramp in this case (pathophysiology)B How about the management and educationB

*issing period, nausea and vomiting, breast tenderness

o o

How to ma e diagnose whether a woman pregnant or notB 6hat is the differential diagnosisB

.melly vaginal discharge and husband a truc driver

o o

"s there any connection between vaginal discharge and husband occupationB "s there any connection between smelly discharge and abortionB

The youngest child age is 2 years old

o o

How is ideal pregnancy rangeB How if the pregnancy range is too long (clinical ris , caring pattern, outcome, etc)B How to manage ideal pregnancy planning (contraception5 conselling, methods and effectivity)B

How is the prognosisB *anagementB

Hypothesis: *rs. + has an inevitable abortion due to infection and advance maternal age. Learning "ssues:
1. %natomy of reprodustion system 2. &ynecology physical examination, which include:

a. 'xternal examination (inspection, palpation, percussion) b. "nternal examination ( speculum, bimanual)

3. 'tiology, symptoms, clinical signs, physical examination and management of abortion 4. )etermine the ris factors of abortion 5. 'xclude the other differential diagnosis 6. Terms in pregnancy 7. "nterpretation of laboratory findings (blood, urine) and ultrasound 8. "deal pregnancy planning

#oncepts Cramewor :


factors, etiology, predisposition D abortion D outcome, management,

complication, prevention. Theory ;eview.


I. II.

DEFINITION % spontaneous lost of pregnancy before 17 wee s INCIDENCE 04!14E of all pregnancy CLASSIFICATION 1. Threatened abortion: fetus is still viable and cervical os is closed. 2. "nevitable abortion: fetus may still be alive but the cervical os is open 3. "ncomplete abortion: some products of conception have been expelled already 4. #omplete abortion: fetus and placental tissue have all been expelled 5. *issed abortion: the pregnancy has succumbed but has not been expelled ETIOLOGY The ma$ority of abortion are due to chromosomal defects. "f 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. %bnormal conceptus (chromosomal and structural) 2. "mmunologigal 3. ?terine abnormality 4. #ervical incompetence 5. 'ndocrine 6. *aternal disease (including systemic lupus erythematosus) 7. "nfection 8. Toxins and cytotoxic drugs 9. Trauma




CLINICAL FEATURES :atients will present with amenorrhea followed by vaginal bleeding. :ain may be present. The symptoms of pregnancy may have disappeared. Fn examination there may be lower abdominal tenderness. The bleeding may vary from spotting to heavy bleeding. The uterine si=e may be smaller (if products have been expelled), the same si=e, 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.
1. 2. 3.


DIFFERENTIAL DIAGNOSIS 'ctopic pregnancy Hydatidiform mole )ysfunctional uterine bleeding


INVESTIGATIONS "f the cervical os open, the pregnancy will not continue and no further investigations are needed. "f the os is closed, an ultrasound scan will determine whether a viable fetus is present in the uterine cavity.


There is no proven treatment for threatened abortion. "nevitable, incomplete, complete and missed abortions all reGuire evacuation of the uterus. REFERRENCE
1. 2.
;ymer H, Cish % (eds). 'arly pregnancy problems. "n: &ynaecology "nfocus. 0 st ed, 'lsevier Limited, 'dinburgh, 17745 ,/!I7 .tead L&, .tead .*, Jaufman *. (eds). .pontaneous abortion, ectopic pregnancy, and fetal death. "n: Cirst %id Cor The Fbstetrics ( &ynecology #lerc ship. % .tudent to .tudent &uide. "nternantional ed. *c&raw!Hill, 8oston, 17715 01-!0,4