Ppt Kelompok 5.pptx

Tutorial Scenario A Group 5 Nanik Wardani Muslikah Aulia Loren Aprilia M. Alandanu Bakara Resy Shafira Pratiwi Della Peratiwi Siti Syarifah Jasmin Vivienka Nyimas Salsabiila Khoirunisa M. Reza Alfath Dhea Nadhila Usman Primawijaya Tessa Maretha

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Scenario Case Mrs. Vanessa, a 30 years old woman, claimed that she is in the early state of pregnancy, came to the ED of RSMP on 12th of march 2019 with a chief complain of blood dripping from her genital since 2 days ago.Mrs. Vanessa claimed that the blood were in a form of dark red blotches. Mrs. Vanessa also complaining an abdominal cramps. Mrs. Vanessa havent done any pregnancy examination. History of trauma and masages on the abdomen area were declined, but she claimed that she had a history of frequent vaginal discharge.

Mrs Vanessa having her first menstruation at the age of twelve,her menstrual period were regular (28 day), pain during menstruation were declined. Her first day of last menstrual period was on 25 th december 2018. Rightnow she was on her fourth pregnancy, her first child now 5 years old, and born with a help of midwife through normal labor. She had abortion on her early second and third pregnancy. Physical Examination General appearance: look midly sick

Vital sign: BP: 120/80 mmHg, P: 88 x/m, RR: 22x/m, Temp: 36º8C. Specific Examination Head: anemic conjungtivity (-), icteric sclera (-)

Thorax: within normal limit Extremities: warm hand and leg, edema (-)

Gynecologic Examination Outher Examination:

During inspection, on the surface of the abdoment theres no abnormalities Fundus utery height 2 finger above the symphisis pubis There is no tenderness Inspeculo : Portio: Livide OUE opened there is no tissue on the OUE Fluxus (+) innactive Bleeding Fluor (+)

Polip,erotion, laseration (-)

Bimanual Examination:

Portio spongy OUE opened 1 cm, theres no palpable tissue on the OUE Corpus utery 11-12 weeks Left and right adnexa supple Protruding cavum douglas (-) Laboratory Examination Blood examinaion : Hb : 10,0 g/dl, trombocite : 200.000 /mm 3, leukocyte : 11.000/mm 3

Term Clarification No.

Terms

Clarification

1.

Abdominal cramps

Tight constrictive usually intermittent abdominal discomfort usually the result of spasm of an internal organ

2.

Pain

sensory and emotional experience of unhappiness due to actual and potential tissue damage and stimulate periphery nerve system to send the impulse to the central nerves system and interpreted as pain

3.

Pregnancy

The condition contains embrio or fetus whograw in the body

4.

Vaginal discharge

Fluid that comes out of the vagina.

5.

Menstruation

The process in woman of discharging blood and other material from the lining of the uterus at interval of about on luner month from puberty untill menaupose, exampt during pregnancy

No.

Terms

Clarification

6.

Portio

The lower part of utecori that project into the vaginal

7.

Abortion

The ending of pregnancy doe to remoung an embrio or fetus before it can survive from in uterus

8.

Cavum douglas

Expansion of peritoneal cavity between the rectum and the posterior wall of the uterus in the female human body

9.

Adnexa supple

the structure most closely related structurally and functionally to the vagina

Problem Identification 1. Mrs. Vanessa, a 30 years old woman, claimed that she is

in the early state of pregnancy, came to the ED of RSMP on 12th of march 2019 with a chief complain of blood dripping from her genital since 2 days ago.Mrs. Vanessa claimed that the blood were in a form of dark red blotches. Mrs. Vanessa also complaining an abdominal cramps.

2. Mrs. Vanessa havent done any pregnancy examination.

History of trauma and masages on the abdomen area were declined, but she claimed that she had a history of frequent vaginal discharge.

3.

Mrs Vanessa having her first menstruation at the age of twelve,her menstrual period were regular (28 day), pain during menstruation were declined.

4.

Her first day of last menstrual period was on 25 th december 2018.

5.

Rightnow she was on her fourth pregnancy, her first child now 5 years old, and born with a help of midwife through normal labor. She had abortion on her early second and third pregnancy.

6.

Physical Examination

General appearance: look midly sick Vital sign: BP: 120/80 mmHg, P: 88 x/m, RR: 22x/m, Temp: 36º8C.

Specific Examination Head: anemic conjungtivity (-), icteric sclera (-) Thorax: within normal limit

Extremities: warm hand and leg, edema (-)

7. Gynecologic Examination

Outher Examination: During inspection, on the surface of the abdoment theres no abnormalities

Fundus utery height 2 finger above the symphisis pubis There is no tenderness Inspeculo :

Portio: Livide OUE opened there is no tissue on the OUE Fluxus (+) innactive Bleeding

Fluor (+) Polip,erotion, laseration (-)

Bimanual Examination: Portio spongy

OUE opened 1 cm, theres no palpable tissue on the OUE Corpus utery 11-12 weeks

Left and right adnexa supple Protruding cavum douglas (-) 8. Laboratory Examination Blood examinaion : Hb : 10,0 g/dl, trombocite : 200.000 /mm 3, leukocyte : 11.000/mm 3

Problem Analysis 1. A. How is the anatomy, histology, and physiology of organs involve in this case? Answer:

1. Ovaries

Like the testes in men, the ovaries develop high on the posterior abdominal wall and then descend before birth, bringing with them their vessels, lymphatics, and nerves. The ovaries are the sites of egg production (oogenesis). 2. Uterine tubes

Each uterine tube has an expanded trumpet-shaped end (the infundibulum), which curves around the superolateral pole of the related ovary. The fimbriated infundibulum facilitates the collection of ovulated eggs from the ovary. Fertilization normally occurs in the ampulla.

3. Uterus The uterus is a thick-walled muscular organ in the midline between the bladder and rectum. Implantation of the blastocyst normally occurs in the body of the uterus. During pregnancy, the uterus dramatically expands superiorly into the abdominal cavity. 4. Cervix

The cervix forms the inferior part of the uterus and is shaped like a short, broad cylinder with a narrow central channel. 5. Vagina The vagina is the copulatory organ in women. It is a distensible fibromuscular tube that extends from the perineum through the pelvic floor and into the pelvic cavity.

1.B. What is the meaning with a chief complain of blood dripping from her genital since 2 days ago?

Answer: First trimester pregnancy bleeding is also called young pregnancy bleeding is vaginal bleeding in pregnancies of less than 22 weeks.

1.C. What is relation age, and conditional mrs vanessa with the chief complaint? Answer:

Mrs. Vanessa age doesn’t has a relation with chief complain. But, the condition that she is in pregnancy is possible to bleeding happened.

1.D. What is the possible causes of blood dripping from her genital since 2 days ago.Mrs. Vanessa claimed that the blood were in a form of dark red blotches. Mrs. Vanessa also complaining an with abdominal cramps? Answer: The possible causes of blood dripping from her genital and abdominal cramps are (Wiknjosastro, H. 2000) : Trimester I : Abortus, Ectopic pregnancy, Hidatidosa Mola Trimester II : Partus Prematurus Imminen Trimester III: Placenta Praevia, Placental Abruption

1. E. What is the kind of abortion? Answer: 1. Spontan Abortus : happen without medical

treatment to clear uterus. - Imminens abortus - Incipiens abortus

- Incomplete and Complete abortus - Infeksiosa abortus and Septic abortus

- Missed abortus - Habitualis abortus

2. Provokatus Abortus - Therapeutic abortus

- Criminal abortus - Unsafe abortus

1.F. What is pathofisiology of blood dripping from her genital since 2 days ago.Mrs. Vanessa claimed that the blood were in a form of dark red blotches. Mrs vanessa also complaining an abdominal cramps? Answer: Risk Factor (frequent vaginal discharge, abortion, distance of pregnancy) -> disruption of the pregnancy process -> disruption of implantation process -> the results of conception are easily separated from the endometrium -> decidual basal bleeding -> necrosis in surrounding tissue that is bleeding -> the conceptus is released from the implantation site -> the conceptus results are considered foreign objects -> uterus contraction -> dilatation of serviks > expulsion of conception results -> bleeding

Risk Factor (frequent vaginal discharge, abortion, distance of pregnancy) -> disruption of the pregnancy process -> disruption of implantation process -> he results of conception are easily separated from the endometrium -> decidual basal bleeding -> necrosis in surrounding tissue that is bleeding -> the conceptus is released from the implantation site -> the conceptus results are considered foreign objects -> uterus contraction -> abdominal cramps

1.G. What is the interpretation of the blood were in a form of dark red blotches?

Answer: because there’s a bleeding in the decidua basalis. Then necrosis happened. Because of the necrosis, the blood is not oxygenated well, then the color of the blood is become dark.

1. H. The possible causes of dark of red blotches? Answer: Bleeding in young pregnancies (<22 weeks) : Abortion, Mola Hidatidosa, Ectopic pregnancy Bleeding in later pregnancy (> 22 weeks) : Placenta Previa, Plasenta Solutions, Ruptura Uteri Postpartum haemorrhage (> 500 ml, 24 h postpartum) : Atonia Uteri, Placental Retention

1.I. What is the meaning mrs vanessa also complaining an abdominal cramps? Answer: The meaning Mrs Vanessa having an abdominal cramps is clinic manifestation of abortus. The abdominal cramps come from uterus contraction which an effort to removing the bleeding results.

1.J. What is the relation between of abdominal cramps with the chief complaint?

Answer : The relation of abdominal cramps with the chief complaint is a manifestation clinic of imminent abortion. Abdominal cramping symptoms due to uterine contractions caused by the conceptus which is released from the implantation.

2.A. What the meaning mrs vanessa havent done any pregnancy examination? Answer : The meaning Mrs.Vanessa haven’t done any pregnancy examination is Mrs. Vanessa did not know fetal development, fetal age and estimated birth.

2.B. What the interpretation of history of trauma and massage on the abdomen area were declined, but she claimed that she had a history of frequent vaginal discharge?

Answer: The interpretation of trauma and stomatch massaged denied is the abortion etiology in this case wasn’t caused by trauma or stomach massages.

2.C. What is the relation between of history of frequent vaginal discharge with chief complaint? Answer: Physiological changes in pregnant women can be flour albus characterized by vaginal secretions become thick, white, and more it due to hiperprogesteronemia. One of risk factor of abortion is infection. The infection of lower genitalia spread ascending to the uterus.

2.D. What the impact if she hasn’t done examination? Answer: The impact if she hasn’t done examination is Mrs. Vanessa did not know fetal development, fetal age and estimated birth.

2.E. What kind of examination that pregnant woman need? (anc)

Answer: The first ANC should be as early as possible in pregnancy, preferably in the first trimester. The last visit should be at around 37 weeks or near the expected date of birth to ensure that appropriate advice and care have been provided to prevent and manage problems such as multiple births (e.g. twins), postmaturity, and abnormal positions of the baby (breech, where the baby’s head is not the presenting part at birth

2.F. What the classification of the vaginal discharge? Answer :

Physiological Vaginal Discharge (normal) This is a white or clear, non-offensive discharge that varies with the menstrual cycle. Pathological Vaginal Discharge (abnormal) Pathological vaginal discharge is called vaginal discharge with many traits, the color is white like stale milk, yellow or greenish, accompanied by flavor itchy and painful, sometimes foul-smelling or fishy.

2.G. What the impact the pregnant women get trauma and massage while pregnant? Answer :

In young pregnancy trauma can lead to miscarriages (abortion, miscarriage). The main sign is vaginal bleeding, uterine contractions accompanied by the release of pregnancy products.

3.A. What is the meaning having her first menstruation at the age of twelve her menstrual period were regular (28 days), pain during menstruation were declined? Answer: It means that she has Menarch in 12 years old which is normal.

3.B. What is the factor that impact of menstruation ?

Answer: Pregnancy, Endocrin disease, Polycystic Ovary Syndrome (PCOS), Disruption at GnRH, Decreased of Body weight, Excessive activity, Change in diet and sleep patterns, Increased stress level, Uncrontoled diabetic, Turner Syndrome, Unstable physical and hormonal.

3.C. How is the normal menstrual cycle ? Answer: 1) Menstrual phase

The most obvious phase, marked by the release of blood and the rest of the endometrium through the vagina. This phase coincides with the follicular phase of the ovary. When the corpus luteum degenerates because fertilization does not occur, progesterone and estrogen levels drop sharply, stimulating the release of prostaglandin which causes endometrial vascular vasoconstriction.

2) Proliferation phase Takes together with the end of the ovarian follicular phase. When menstrual blood stops, the endometrium begins to repair itself and proliferates under the influence of estrogen from newly developing follicles. Estrogen promotes endometrial epithelial, glandular and vascular cell proliferation. The peak level of estrogen triggers a surge in LH which is the cause of ovulation. 3) Secretory phase

It takes place simultaneously with the luteal phase of the ovary. After ovulation, a new corpus luteum is formed which secretes large amounts of progesterone and estrogen. Progesterone converts the endometrium into vascular-rich and glycogen which is prepared for implantation.

4.A. How to make a GPA status of pregnancy?

Answer: GPA Status of Mrs.Vanessa G4P1A2

G: Gravid, The gravidity is the number of times a woman has been pregnant. P: Parity, The parity is the number of live births and stillbirths that a woman has had. A: Abortion. The abortions is the number of pregnancies that have been terminated

4.B. How to count Estimate delivery , gestational age in this case? Answer:

Calculate HPHT by using the Neagle formula : (Day + 7) (month - 3) (year + 1) for last mensturation from April until december or

(Day + 7) (month + 9) (year) for last mensturation January until March (25+7)(12-3)(2018+1) = 01th October 2019 (Estimate delivery)

Gestational age in this case is 11 weeks 2 days.

2.C. What is the meaning of her first day of last menstrual period was on 25 th december 2018? Answer:

Her HPHT. It means her gestational age is 11-12 weeks now and to know her estimate delivery.

2.D. How is the physiology of pregnancy? Answer: During pregnancy woman will experiencing some changes like in her breast, metabolic changes, water metabolism, weight gain, protein metabolism, carbohydrate metabolism, hematology changes etc.

5. A. What is the meaning of rightnow she was on her fourth pregnancy, her first child now 5 years old, and born with a help of midwife through normal labor?

Answer: It is means that the distance of pregnancy is too short that can be the risk factor of abortus in Mrs Vanessa pregnancy now.

5.B. What is the indication of normal delivery? Answer : Power Passageway Passanger

5.C. What is the meaning she had abortion on her early second and third pregnancy? Answer:

The meaning she had abortion on her early second and third pregnancy is it is a risk factor of abortus and it can be meaning that mrs. Vanessa had a hematology factor.

5.D. What is the possible cause of abortus? Answer: Genetic factors Uterine congenital abnormalities Autoimmune Luteal phase defect Infection Environment

6. A. How the interpretation of physical examination and specific examination? Answer:

General Appereance: Looks midly sick (abnormal). The other examinations are normal.

6.B. How is the abnormal mechanism of physical and specific examination? Answer:

Risk Factor (frequent vaginal discharge, abortion, distance of pregnancy) -> disruption of the pregnancy process -> disruption of implantation process -> he results of conception are easily separated from the endometrium -> decidual basal bleeding -> necrosis in surrounding tissue that is bleeding -> the conceptus is released from the implantation site -> the conceptus results are considered foreign objects -> uterus contraction -> abdominal cramps -> midly sick

7.A.How the examination?

interpretation

of

gynecology

Answer: Fluxus (+) innactive Bleeding Fluor (+)

(Hemorrhage)

(Leuchoria/Fluor Albus)

OUE opened 1 cm, theres no palpable tissue on the OUE (Abortus Imminent)

7.B. How the examination?

mecanism

abnormal

gynecology

Answer: Risk Factor (frequent vaginal discharge, abortion, distance of pregnancy) -> disruption of the pregnancy process -> disruption of implantation process -> he results of conception are easily separated from the endometrium -> decidual basal bleeding -> necrosis in surrounding tissue that is bleeding -> the conceptus is released from the implantation site -> the conceptus results are considered foreign objects -> uterus contraction -> dilatation of serviks > expulsion of conception results -> bleeding from her genital -> fluxus (+) inactive bleeding

Risk Factor (frequent vaginal discharge, abortion, distance of pregnancy) -> disruption of the pregnancy process -> disruption of implantation process -> he results of conception are easily separated from the endometrium -> decidual basal bleeding -> necrosis in surrounding tissue that is bleeding -> the conceptus is released from the implantation site -> the conceptus results are considered foreign objects -> uterus contraction -> dilatation of serviks -> OUE opened 1 cm

8.A. How the interpretation of laboratory examination? Answer:

Hb : 10,0 g/dl

Abnormal

Trombocite : 200.000 /mm 3,

Normal

Leukocyte : 11.000/mm 3

Normal

8.B. How the examination?

mecanism

abnormal

of

laboratory

Answer Risk Factor (frequent vaginal discharge, abortion, distance of pregnancy) -> disruption of the pregnancy process -> disruption of implantation process -> he results of conception are easily separated from the endometrium -> decidual basal bleeding -> necrosis in surrounding tissue that is bleeding -> the conceptus is released from the implantation site -> the conceptus results are considered foreign objects -> uterus contraction -> dilatation of serviks -> expulsion of conception results -> bleeding from her genital -> HB decreased.

9. How to diagnose in this case? Answer : 1. Anamnesis 2. Physical and specific examination 3. Gynecology examination 4. Laboratory examination

10. What are the Differential diagnose in this case? Answer:

Imminent Abortion Incipient Abortion

Complete Abortion

11. What are the Additional examination in this case? Answer:

USG

12. What is Working diagnose in this case? Answer: Gestational Hemorrhage e.c imminens abortion

13. What is the Treatment in this case? Answer

Rest bed Coitus is prohibited for 2 weeks after bleeding stops Give tranquilizers, usually phenobarbital 3x30 mg. Give hematinic preparations, for example ferosus sulfur 600-1000 mg. High protein diet and added vitamin C.

Check the pulse and body temperature twice a day Clean the vulva at least twice a day with antiseptic fluids to prevent infection.

14. What is the Complication in this case? Answer: Incipient abortus Imcomplete abortus Complete abortus

15. What is the Prognose in this case? Answer: Depends on the level of HCG in the urine (with or without dilution) If the urine show positive in both, Prognosis : Bonam If the urine show negative on the dilution, prognosis : Dubia ad malam.

16. What is the level of competence for general practitioner? Answer :

3B. Emergency case

17. What is the islamic value? Answer: And verily we have created man from a quintessence (from) from the graund. “ (Surah Al-Mu’minun:12) Then we made the essence of semen (which was stored) in a firm place (womb). “(Surat AlMu’minun:13)

Then we made the semen a lump of blood, then we made a lump of blood, a lump of flesh, and we made a lump of flesh, then we wrapped the bones with meat. Then we made him another (shaped) being. Then be godful the best creator. “(Surah AlMu’minun:14)

Conclusion Mrs. Vanessa a 30 years old woman complain blood dripping from her genital because of gestational hemorrhage e.c imminens abortion

Frame Concept