Task 1 Gestational Disorder

1. Antepartum vaginal bleeding

A 30-year-old G3P4 woman at 32 weeks gestation complains of significant bright-red
vaginal bleeding. She denies uterine contractions, leakage of fluid, or trauma. The patient states
that, 4 weeks previously, she experienced some vaginal spotting after engaging in sexual
intercourse. On examination, her blood pressure is 110/60, hear rate 80 bpm, and temperature
37C. heart and lung examination are normal. The abdomen is soft and uterus non tender. Fetal
heart tones range from 140-150 bpm.
a. What is the next step in therapy?
Monitoring
- Transabdominal or transvaginal ultrasound for placement of the placenta
- Fetal monitoring for fetal well-being assessment
- Hemoglobin and hematocrit for blood loss assessment
- Complete blood count
- ABO blood typing and Rh factor
- Coagulation profile
- Emergency cesarean birth
interventions for placenta previa include:
Bed rest (1) nothing inserted vaginally(2)Intravenous fluids should be administered as prescribed(3)
.
Corticosteroids given for fetal lung maturation if delivery of the fetus is anticipated (cesarean). (4)
Blood replacement as prescribed (5)
b. What is the most likely diagnosis ?
Placenta previa
The main symptom of placenta praevia is painless vaginal bleeding. There may sometimes be
lower abdominal discomfort where there are minor degrees of associated placental abruption.
Signs and symptoms of placenta previa: Painless, bright red vaginal bleeding that increases as
the cervix dilates.A soft, relaxed, nontender uterus with normal tone.A fundal height greater
than usually expected for gestational age.A fetus in a breech, oblique, or transverse position.
A palpable placenta.Vital signs that are usual and within normal limits.
c. What will be the long-term management of this patient ?
2. Postpartum vaginal bleeding (Haemorrage Post Partum / HPP)
A 29-year-old G5P4 woman at 39 weeks gestation with preeclampsia delivers vaginally. Her
prenatal course has been uncomplicated except for asymptomatic bacteriuria caused by Escherichia
colli in the first trimester treated with oral cephalexin. She denies a family history of bleeding
diasthesis. After the placenta is delivered, there is appreciable vaginal bleeding estimated at 1000
mL.
a. What is the most likely diagnosis ?
Atonia uteria
Uterine atony is a hypotonic uterus that is not firm and is described as boggy. The inability of
the uterine myometrium to contract and stay contracted around the open blood vessels of the
uteroplacental implantation site is the most common cause of postpartum hemorrhage.
Uterine atony if untreated will result in postpartum hemorrhage and may result in uterine
inversion
b. What is the next step in therapy?
Bimanual compression by the primary care provider consists of:Insertion of a fist into the vagina
applying pressure with the knuckles against the anterior side of the uterus and then placing the
other hand on the abdomen and massaging the posterior uterus. Manual exploration of the
uterine cavity for retained placental fragments is performed by the primary care provider. Surgical
management such as a hysterectomy.
Terapi uterotonik medis sebagai berikut:
1. Infus oksitosin secara cepat (1-40 unit dalam 1L atau i.m atau intra miometrial)

Kalo bolus i.v bisa hipotensi

2. metilergonovin 0.2mg IM per 2 jam, maks 3 dosis (hindari untuk penderita HTN)
3. 15-metil prostaglandin F2 (Hemabate) 0.25mg IM atau intramiometrial per 15-20 menit, maks 8
dosis (hindari untuk penderita asma)
4. Dinoproston (PGE2) 20mg atau misoprostil (PGE1)
Jika tidak respon, maka:
1. uterine packaging (jarang digunakan)
2. Angiografi dan embolisasi
3.Laparotomi eksploratif dengan pilihan pembedahan termasuk pengikatan pembuluh
uterus,/utero-ovarium/invundibulopelvis, pengikatan arteri hipogastrika, histerektomi.
Task 2 Infection in Reproductive System
A 23-year-old G0P0 woman complains of lower abdominal tenderness and subjective fever.
She states that her last menstrual period started 5 days previously and was heavier than usual. She
also complains of duspareunia of recent onset. She denies vaginal discharge or prior sexually
transmitted diseases. On examination, her blood pressure is 90/70, heart rate 90 bpm, and
temperature 36C. Heart and lung examination are normal. The abdomen has slight lower
abdominal tenderness. No costovertebral angle tenderness is noted. On pelvis examination, the
external genetalia are normal. The cervix is somewhat hyperemic, and uterus as well as adnexa are
exquisitely tender. The pregnancy test is negative.
a. What is the most likely diagnosis ?

b. What are long-term complications that can occur with this condition ?
Task 3 Reproductive Oncology
A 50-year-old G5P5 woman complains for postcoital spotting over the past six months.
Most recently, she complains of a malodorous vaginal discharge. She states that she had syphilis in
the past. Her deliveiries were all vaginal and uncomplicated. She has smoked one pack of
cigarettes per day for 20 years. On examination, her blood pressure is 100/80, heart rate 80 bpm,
and temperature 37.5C. heart and lung examinations are within normal limits. The abdomen
reveals no masses, ascites or tenderness. Back examination is unremarkable, and there is no
costovertebral angle tenderness. Pelvis examination reveals normal external female genetalia.
Speculum examination reveals a 3-cm exophytic lesion on the anterior lip of the cervix. No other
masses are palpated.
a. What is your next step ?

b. What is the most likely diagnosis ?