PREFACE

Thanks to Allah SWT for helping and give us chance to finish this Scenario A
tutorial report on the 17th blok timely. Shalawat and salam always be with our prophet
Muhammad SAW and his family, friends, and followers until the end of time.

We recognize that this tutorial report is far from perfect. Therefore we expect
constructive criticism and suggestions, in order to refine the next tasks.

In completing this tutorial task, we got a lot of help, guidance and advice. On
this occasion we would like to express our respect and gratitude to:

1. dr. Muhammad Abdul Basith as tutor of group 5

2. All of the members who involved in the making of this report

May Allah SWT give a reward for all the charity given to all those who have
supported us and hopefully this tutorial report, useful for us and the development of
science. May we always be in the protection of Allah SWT. Amen.

Palembang, March 20, 2018

Author
 CHAPTER I
INTRODUCTION

1.1 Issue Background

Scenario A Block 17

“My Tummy”

Mrs. Y, a 35 years old, admitted to ER RSMP on March 20th, 2018 with vaginal
bleeding since 8 hours ago. She claimed to have 4 times replace the sanitary napkins
for a day. Blood is blackish red and out blood clots. She also complained of abdominal
cramping. She has never had a pregnancy check-up. She claimed to have out white
discharge history. She denied any history of trauma and stomach massaged.

Mrs. Y had menarche at the age of 12 years with regular menstrual cycle (28
days). Pain during menstruation is denied. She is pregnant with 2nd child, the first child
is 5 years old with a history of normal delivery assisted midwife. She has never used
any contraception. Last menstrual period at Januari 8th, 2018.

Physical Examination :

General inspection : severe illness.

Vital Sign : Pulse : 110x/minutes, BP: 80/50 mmHg, RR : 24x/minutes, T : 36,0 oC

Specific Examination :

Head : Pale hands and feet, feel cold, edema (-)

Gynecologic Examination :

External Examination :

- Inspection : normal
- Palpation : the fundus is found at pubic symphysis, no tenderness.
Inspeculo :

- Portio : Livide
- OUE : dilated, looks clots tissue
- Fluxus (+), active blood
- Fluor (+)
- Polyp, erosion, laceration (-)

Vaginal Toucher :

- Portio : palpable soft

- OUE : dilated, palpable clots tissue
- Corpus uteri of 11-12 weeks
- Right-left adnexa : palpable soft
- Cavum Douglas doesn’t bulge

Laboratory Examination :

Routine blood : Hb : 7,0 g/dl, Platelets : 200.000/mm3, leukocytes : 25.000/mm3

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the Faculty
of Medicine, Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the method of analysis and learning
group discussion.
3. Achieving the objectives of the tutorial learning method.
 CHAPTER II

DISCUSSION

2.1 Tutorial Data

Tutor : dr. Muhammad Abdul Basith
Moderator : Livia Hanisamurti
Secretary : Yuni Ayu Lestari
Notulis : Ressy Irma Juwita
Day and date : Tuesday, March 20, 2018
(13.00-15.00 WIB)
Thursday, March 22, 2018
(13.00-15.00 WIB)
Rule of tutorial : 1. Gadget should be nonactive or in silent mode.
2. Everyone in the group should express their opinion.
3. ask for permission if want to go outside.
4. Eating and drinking are not allowed in the room.

2.2 Case Scenario

“My Tummy”

Mrs. Y, a 35 years old, admitted to ER RSMP on March 20th, 2018 with vaginal
bleeding since 8 hours ago. She claimed to have 4 times replace the sanitary napkins
for a day. Blood is blackish red and out blood clots. She also complained of abdominal
cramping. She has never had a pregnancy check-up. She claimed to have out white
discharge history. She denied any history of trauma and stomach massaged.

Mrs. Y had menarche at the age of 12 years with regular menstrual cycle (28
days). Pain during menstruation is denied. She is pregnant with 2nd child, the first child
is 5 years old with a history of normal delivery assisted midwife. She has never used
any contraception. Last menstrual period at Januari 8th, 2018.

Physical Examination :

General inspection : severe illness.

Vital Sign : Pulse : 110x/minutes, BP: 80/50 mmHg, RR : 24x/minutes, T : 36,0 oC

Specific Examination :

Head : Pale hands and feet, feel cold, edema (-)

Gynecologic Examination :

External Examination :

- Inspection : normal
- Palpation : the fundus is found at pubic symphysis, no tenderness.

Inspeculo :

- Portio : Livide
- OUE : dilated, looks clots tissue
- Fluxus (+), active blood
- Fluor (+)
- Polyp, erosion, laceration (-)

Vaginal Toucher :

- Portio : palpable soft

- OUE : dilated, palpable clots tissue
- Corpus uteri of 11-12 weeks
- Right-left adnexa : palpable soft
- Cavum Douglas doesn’t bulge
Laboratory Examination :

Routine blood : Hb : 7,0 g/dl, Platelets : 200.000/mm3, leukocytes : 25.000/mm3

2.3 Clarification of Terms

No Terms Clarification of Term

1. Vaginal Bleeding Blood discharge passed through vagina.
2. Menarche Beginning of the menstrual function.
3. Abdominal Cramping Muscular spasmodic contraction that cause
abdominal pain.
4. Menstruation Monthly shedding of female uteral lining at last
about three-five days, and contain blood and
tissue that exist her body and through cervix and
vagina
5. Contraception Prevention of contraception in pregnancy
6. White discharge Excretion of substants avacuated.
7. Fluxus Fluid that out from vagina in large quantities
8. Menstrual period The time of menstruation
9. Cavum Douglas The recto uterine pouch is also called Recto
uterine exavation
10. Portio A part of the cervix uterine that project into the
vagina

2.4 Problems of Identification

1. Mrs. Y, a 35 years old, admitted to ER RSMP on March 20th, 2018 with vaginal
bleeding since 8 hours ago. She claimed to have 4 times replace the sanitary
napkins for a day. Blood is blackish red and out blood clots. She also
complained of abdominal cramping.
 2. She has never had a pregnancy check-up. She claimed to have out white
discharge history. She denied any history of trauma and stomach massaged.
3. Mrs. Y had menarche at the age of 12 years with regular menstrual cycle (28
days). Pain during menstruation is denied.
4. She is pregnant with 2nd child, the first child is 5 years old with a history of
normal delivery assisted midwife. She has never used any contraception. Last
menstrual period at Januari 8th, 2018.
5. Examinations

2.5 Problem of Analysis

1. Mrs. Y, a 35 years old, admitted to ER RSMP on March 20th, 2018 with vaginal
bleeding since 8 hours ago. She claimed to have 4 times replace the sanitary
napkins for a day. Blood is blackish red and out blood clots. She also
complained of abdominal cramping.
a. How is anatomy in this case ?
Answer :
The reproductive tract in women is contained mainly in the pelvic cavity
and perineum, although during pregnancy, the uterus expands into the abdomen
cavity. Major components of the system consist of :
 An ovary on each side, and n
 A uterus, vagina, and clitoris in the midline
(Sherwood, 2014)

In addition, a pair of accessory glands (the greater vestibular glands) are

associated with the tract.
 Picture. Reproductive system in women (Drake, 2012)

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. Unlike the testes, the ovaries do not migrate through
the inguinal canal into the perineum, but stop short and assume a position on
the lateral wall of the pelvic cavity (Sherwood, 2014).
The ovaries are the sites of egg production (oogenesis). Mature eggs are
ovulated into the peritoneal cavity and normally directed into the adjacent
openings of the uterine tubes by cilia on the ends of the uterine tubes. The
ovaries lie adjacent to the lateral pelvic wall just inferior to the pelvic inlet.
Each of the two almond-shaped ovaries is about 3 cm long and is suspended by
a mesentery (the mesovarium) that is a posterior extension of the broad ligament
(Sherwood, 2014).

2. Uterine tubes
The uterine tubes extend from each side of the superior end of the body
of the uterus to the lateral pelvic wall and are enclosed within the upper margins
of the mesosalpinx portions of the broad ligaments. Because the ovaries are
 suspended from the posterior aspect of the broad ligaments, the uterine tubes
pass superiorly over, and terminate laterally to, the ovaries. Each uterine tube
has an expanded trumpet-shaped end (the infundibulum), which curves around
the superolateral pole of the related ovary. The margin of the infundibulum is
rimmed with small finger-like projections termed fimbriae. The lumen of the
uterine tube opens into the peritoneal cavity at the narrowed end of the
infundibulum. Medial to the infundibulum, the tube expands to form the
ampulla and then narrows to form the isthmus, before joining with the body of
the uterus. The fimbriated infundibulum facilitates the collection of ovulated
eggs from the ovary. Fertilization normally occurs in the ampulla (Sherwood,
2014).

3. Uterus

Picture. Uterus and vagina A. Angles of anteflexion and anteversion B. The cervix
protrudes into the vagina (Drake, 2012)

The uterus is a thick-walled muscular organ in the midline between the

bladder and rectum. It consists of a body and a cervix, and inferiorly it joins the
 vagina. Superiorly, uterine tubes project laterally from the uterus and open into
the peritoneal cavity immediately adjacent to the ovaries (Sherwood, 2014).
The body of the uterus is flattened anteroposteriorly and, above the level
of origin of the uterine tubes, has a rounded superior end (fundus of uterus).
The cavity of the body of the uterus is a narrow slit when viewed laterally, and
is shaped like an inverted triangle when viewed anteriorly. Each of the superior
corners of the cavity is continuous with the lumen of a uterine tube and the
inferior corner is continuous with the central canal of the cervix. Implantation
of the blastocyst normally occurs in the body of the uterus. During pregnancy,
the uterus dramatically expands superiorly into the abdominal cavity
(Sherwood, 2014).

4. Cervix

The cervix forms the inferior part of the uterus and is shaped like a short,
broad cylinder with a narrow central channel. The body of the uterus normally
arches forward (anteflexed on the cervix) over the superior surface of the
emptied bladder. In addition, the cervix is angled forward (anteverted) on the
vagina so that the inferior end of the cervix projects into the upper anterior
aspect of the vagina. Because the end of the cervix is dome shaped, it bulges
into the vagina, and a gutter, or fornix, is formed around the margin of the cervix
where it joins the vaginal wall. The tubular central canal of the cervix opens,
below, as the external os, into the vaginal cavity and, above, as the internal os,
into the uterine cavity (Sherwood, 2014).

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. The internal end of the canal is enlarged to form a region
called the vaginal vault. The anterior wall of the vagina is related to the base of
 the bladder and to the urethra; in fact, the urethra is embedded in, or fused to,
the anterior vaginal wall. Posteriorly, the vagina is related principally to the
rectum. Inferiorly, the vagina opens into the vestibule of the perineum
immediately posterior to the external opening of the urethra. From its external
opening (the introitus), the vagina courses posterosuperiorly through the
perineal membrane and into the pelvic cavity, where it is attached by its anterior
wall to the circular margin of the cervix. The vaginal fornix is the recess formed
between the margin of the cervix and the vaginal wall. Based on position, the
fornix is subdivided into a posterior fornix, an anterior fornix, and two lateral
fornices (Sherwood, 2014).

Picture. Vagina A. Left half of pelvis cut away B. Vaginal fornices and cervix as
viewed through a speculum (Drake, 2012)

The vaginal canal is normally collapsed so that the anterior wall is in

contact with the posterior wall. By using a speculum to open the vaginal canal,
a physician can see the domed inferior end of the cervix, the vaginal fornices,
and the external os of the cervical canal in a patient. During intercourse, semen
is deposited in the vaginal vault. Spermatozoa make their way into the external
os of the cervical canal, pass through the cervical canal into the uterine cavity,
and then continue through the uterine cavity into the uterine tubes (Sherwood,
2014).

b. How is the physiology of pregnancy and menstrual cycle ?

Answer :
Menstruation is the cyclic, orderly sloughing of the uterine lining, in
response to the interactions of hormones produced by the hypothalamus,
pituitary, and ovaries. The menstrual cycle may be divided into two phases:
(1) follicular or proliferative phase, and (2) the luteal or secretory phase.
The length of a menstrual cycle is the number of days between the first day
of menstrual bleeding of one cycle to the onset of menses of the next cycle.
The median duration of a menstrual cycle is 28 days with most cycle lengths
between 25 to 30 days (Sherwood, 2014).
Patients who experience menstrual cycles that occur at intervals less
than 21 days are termed polymenorrheic, while patients who experience
prolonged menstrual cycles greater than 35 days, are termed
oligomenorrheic. The typical volume of blood lost during menstruation is
approximately 30 mL. Any amount greater than 80 mL is considered
abnormal (Sherwood, 2014).
The menstrual cycle is typically most irregular around the extremes of
reproductive life (menarche and menopause) due to anovulation and
inadequate follicular development. The luteal phase of the cycle is relatively
constant in all women, with a duration of 14 days. The variability of cycle
length is usually derived from varying lengths of the follicular phase of the
cycle, which can range from 10 to 16 days (Sherwood, 2014).
 (Sherwood L, 2014)

1. The Follicular Phase

The follicular phase begins from the first day of menses until ovulation.
Lower temperatures on a basal body temperature chart, and more
importantly, the development of ovarian follicles, characterize this phase.
Folliculogenesis begins during the last few days of the preceding menstrual
cycle until the release of the mature follicle at ovulation (Sherwood, 2014).
Declining steroid production by the corpus luteum and the dramatic fall
of inhibin A allows for follicle stimulating hormone (FSH) to rise during
the last few days of the menstrual cycle. Another influential factor on the
FSH level in the late luteal phase is related to an increase in GnRH pulsatile
secretion secondary to a decline in both estradiol and progesterone levels .
This elevation in FSH allows for the recruitment of a cohort of ovarian
 follicles in each ovary, one of which is destined to ovulate during the next
menstrual cycle. Once menses ensues, FSH levels begin to decline due to
the negative feedback of estrogen and the negative effects of inhibin B
produced by the developing follicle. FSH activates the aromatase enzyme
in granulosa cells, which converts androgens to estrogen. A decline in FSH
levels leads to the production of a more androgenic microenvironment
within adjacent follicles to the growing dominant follicle. Also, the
granulosa cells of the growing follicle secrete a variety of peptides that may
play an autocrine/paracrine role in the inhibition of development of the
adjacent follicles (Sherwood, 2014).

2. Ovulation

Ovulation occurs approximately 10-12 hours after the LH peak. The LH

surge is initiated by a dramatic rise of estradiol produced by the
preovulatory follicle. To produce the critical concentration of estradiol
needed to initiate the positive feedback, the dominant follicle is almost
always >15mm in diameter on ultrasound. The beginning of the LH surge
occurs roughly 34 to 36 hours prior to ovulation and is a relatively precise
predictor for timing ovulation. The LH surge stimulates luteinization of the
granulosa cells and stimulates the synthesis of progesterone responsible for
the midcycle FSH surge. Also, the LH surge stimulates resumption of
meiosis and the completion of reduction division in the oocyte with the
release of the first polar body. It has been demonstrated in cultured
granulosa cells that spontaneous luteinization can occur in the absence of
LH. It is hypothesized that the inhibitory effects of factors such as oocyte
maturation inhibitor or luteinization inhibitor are overcome at ovulation
(Sherwood, 2014).
3. Luteal Phase

This phase is usually 14 days long in most women. After ovulation, the
remaining granulosa cells that are not released with the oocyte continue to
enlarge, become vacuolated in appearance, and begin to accumulate a
yellow pigment called lutein. The luteinized granulosa cells combine with
the newly formed theca-lutein cells and surrounding stroma in the ovary to
become what is known as the corpus luteum. The corpus luteum is a
transient endocrine organ that predominantly secretes progesterone, and its
primary function is to prepare the estrogen primed endometrium for
implantation of the fertilized ovum. The basal lamina dissolves and
capillaries invade into the granulosa layer of cells in response to secretion
of angiogenic factors by the granulosa and thecal cells. Eight or nine days
after ovulation, approximately around the time of expected implantation,
peak vascularization is achieved. This time also corresponds to peak serum
levels of progesterone and estradiol. The central cavity of the corpus luteum
may also accumulate with blood and become a hemorrhagic corpus luteum.
The life span of the corpus luteum depends upon continued LH support.
Corpus luteum function declines by the end of the luteal phase unless
human chorionic gonadotropin is produced by a pregnancy. If pregnancy
does not occur, the corpus luteum undergoes luteolysis under the influence
of estradiol and prostaglandins, and forms a scar tissue called the corpus
albicans (Sherwood, 2014).

Estrogen levels rise and fall twice during the menstrual cycle. Estrogen
levels rise during the mid-follicular phase and then drop precipitously after
ovulation. This is followed by a secondary rise in estrogen levels during the
mid-luteal phase with a decrease at the end of the menstrual cycle. The
secondary rise in estradiol parallels the rise of serum progesterone and 17α-
 hydroxyprogesterone levels. Ovarian vein studies confirm that the corpus
luteum is the site of steroid production during the luteal phase (Sherwood,
2014).

c. How is the histology in this case ?

Answer :
1. Ovary

Ovaries function to produce female gametes (egg cells). It also produces

sex hormones such as progesterone and estrogen. The ovaries are located in
the pelvic cavity and attached to the dorsal portion of the body wall by the
connective tissue membrane called mesovarium. Ovarium in mammals
especially in humans has a relatively small size and is covered by a layer of
cells derived from the peritoneum called the germinal epithelium.Inside is
the tunica albugenia (connective tissue causing the ovaries are white). The
basic tissue of the ovary is called the stroma (Eroschenko, V P, 2010).

Picture : Eroschenko, V P, 2010

The structure of ovarian histology, consisting of two regions :

Cortical region: contains many egg follicles, each consisting of an

oocyte that is covered by follicle cells. The follicle cells are the oocytes along
with the granulose cells that surround them. There are 3 kinds of follicles,
namely:

 Primordial follicles: composed of primary oocytes that are slightly to the

core, which are coated with flat-shaped follicle cells.
 Primary follicle: consists of primary oocytes coated follicle cells
(granulose cells) in the form of cubes and the formation of zona pellucida.
Is a layer of glycoproteins that exist between the oocyte and granulose
cells.
 Secondary follicles: composed of primary oocytes coated granulose cells
in the form of multilayered cubes or called granulose staratum.
 Tertiary follicles: composed of primary oocytes, the stratum volume of
granulosa increases. There are several gaps in the antrum between
granulose cells. And the connective tissue of stroma outside the stratum
granulose forms theca intern (contains many blood vessels) and theca
extern (many contain collagen fibers).
(Eroschenko, V P, 2010).

Graff follicles: also called mature follicles. In this follicle, the oocyte is
ready to be ovulated from the ovaries. The secondary oocyte is coated by
several layers of granulose cells located in a jorokan into the stratum called
cumulus oophorus. The granulose cells that surround the oocyte are called
corona radiate. Antrum contains liquor follicul containing estrogen hormone
(Eroschenko, V P, 2010).
2. Oviduct (Fallopian tube)
Based on histology structure consists of layers of mucosa, muscle layer,
and peritoneal layer.
- Mucosal layer: composed of high ciliated columnar epithelium and gland
cells
- Layers of muscle: composed of top
 The thick intrinsic muscle layer of the mucosa
 Blood-resembling muscle
 Peritoneal sub layer is fibers such as lattices and ribbons.
- Peritoneal layer: allows the uterine tube to move against its surroundings.
(Eroschenko, V P, 2010).

3. Uterus
Thick-walled funnel, serves to channel sperm to the place of fertilization,
as a place of implantation and development of embryo.
The walls are 3 layers:
a) Endometrium (Mucosa): the inside of the epithelial coated
cylindrical coating is ciliated and there are also mucous uterine
glands from the surface.
b) Miometrium (muscle wall): There are 3 layers of muscle whose
limits are less clear. The three layers of muscle are
 Sub vascular layer: muscle fibers composed lengthwise
 Vascular layer: thick middle muscle layer, fibers arranged
circular and oblique with many blood vessels.
 Supravascular layer: the outer muscle layer is thinner.
c) Peritoneum: is typical serosa typical of mesotel cells coated with
thin connective tissue.
(Eroschenko, V P, 2010)
d. What are the possibilities of vaginal bleeding during pregnancy?
Answer :
First Trimester of Pregnancy :
o Abortion/miscarriage
o Ectopic pregnancy
o Mola pregnancy

Second Trimester of Pregnancy :

o Spontaneous Preterm labor

Third Trimester of Pregnancy :

o Placenta previa
o Placenta abruption
o Uteri rupture

(Wiknjosastro, H. 2000)

e. How is the mechanism of vaginal bleeding since 8 hours ago ?

Answer :
Vaginal bleeding since 8 hours ago due to incomplete abortion. The risk
factors which induce to abortion are genital infection (history of white
discharge and maternal age). The mechanism abortion in this case are :
1. Infection
Maternal infection can induce abortion causes :
o From the bacterial microorganism can produce some toxin,
endotoxin or cytokine which impact to fetal or feto-placenta
o Bacterial/microorganism can infect the fetus which will make fetal
death (fetal infection)
o Bacterial/microorganism can infect the placenta which will make
fetal death (Placenta infection)
o Bacterial/microorganism from maternal genital can spread to
endometrium which will make disturbing the implantation process.
o Amnionitis
(sarwono, 2016)

For most of the pathogens where an association has been

demonstrated, the exact mechanism that leads from infection to
miscarriage is unknown. Bacteria, protozoa and viruses utilize different
mechanisms to infect their host and each one seems to induce a unique
cascade of events in the feto–maternal interface, most of which remains
to be determined. Our knowledge is derived mostly from animal studies
and data on human pregnancies are scarce (Sevi Giakoumelou, 2016).
Bacterial infections initiate different responses from the immune
system compared with viruses but gram-negative and gram-positive
bacteria are both capable of activating the innate immune system. Most
of our knowledge regarding bacterial infections and pregnancy comes
from studies in mouse models. Nitric oxide and prostaglandins
produced in the presence of bacterial lipopolysaccharides (LPS) were
shown to be associated with embryonic resorption, as inhibition of this
pathway reversed the effect in mice. Poor uterine receptivity and
implantation failure due to exposure to bacterial LPS was also reported
in another study in mice (Sevi Giakoumelou, 2016).
Bacteria, viruses and protozoa utilize various mechanisms to
infect fetal and maternal tissues a few of which have been elucidated
yet several remain unknown. These pathways are possibly implicated in
miscarriage caused by infection. Further research is however required,
as understanding the exact mechanisms behind infection-induced
 miscarriages could lead to effective treatment and thus prevention (Sevi
Giakoumelou, 2016).

2. Maternal Age
As women mature, the incidence of spontaneous miscarriages
increases. Typically, the distribution of miscarriage rates by age occurs
as follows: younger than 35 years old, 15% miscarriage rate; 35-39
years old, 20-25% miscarriage rate; 40-42 years old, about 35%
miscarriage rate; and older than 42 years old, about 50% miscarriage
rate. A fifth study analysed the risk of spontaneous abortion in mothers
with a child presenting a possible genetic defect (Anne Marie, 2000).

f. What is the meaning of Mrs. Y have 4 times replace the sanitary napkins
for a day in this case ?
Answer :
The meaning of Mrs. Y have 4 time replace the sanitary napkins for a
day is vaginal bleeding due to abortion. But in this case, type of abortion is
incomplete abortion. Cause it have massive bleeding. Incomplete abortion
is a pregnancy that is associated with vaginal bleeding, dilatation of the
cervical canal, and passage of products of conception. Usually, the cramps
are intense, and the vaginal bleeding is heavy. Patients may describe
passage of tissue, or the examiner may observe evidence of tissue passage
within the vagina. Ultrasound may show that some of the products of
conception are still present in the uterus (Elizabeth Puscheck, 2017).

g. What is the meaning of blood is blackish red and out blood clots ?
Answer :
 The meaning of blood is blackish red and out blood clots are that sign
of abortion. Blood clots in this case is a conception which realese from the
uteri. So, in this case is incomplete abortion (Elizabeth Puscheck, 2017).
An abortion is the spontaneous or induced loss of an early pregnancy.
The period of pregnancy prior to fetal viability outside of the uterus is
considered early pregnancy. Most consider early pregnancy to end at 20
weeks' gestation or when the fetus weighs 500 grams. The term miscarriage
is used often in the lay language and refers to spontaneous abortion
(Elizabeth Puscheck, 2017).
Incomplete abortion is a pregnancy that is associated with vaginal
bleeding, dilatation of the cervical canal, and passage of products of
conception. Usually, the cramps are intense, and the vaginal bleeding is
heavy. Patients may describe passage of tissue, or the examiner may
observe evidence of tissue passage within the vagina. Ultrasound may show
that some of the products of conception are still present in the uterus
(Elizabeth Puscheck, 2017).

h. What is the mechanism of abdominal cramping ?

Answer :
Risk factor: 35 years old & infection with white discharge. -> a disturbance
in pregnancy -> bleeding into the decidua basalis disetai necrosis of tissue
around -> endometrial bleeding -> the conception results apart from the
uterus -> uterine contraction expulsion -> abdominal cramping
(Sarwono, 2016)

i. What is the correlation of maternal age with chief complain ?

Answer :
As women mature, the incidence of spontaneous miscarriages
increases. Typically, the distribution of miscarriage rates by age occurs as
 follows: younger than 35 years old, 15% miscarriage rate; 35-39 years old,
20-25% miscarriage rate; 40-42 years old, about 35% miscarriage rate; and
older than 42 years old, about 50% miscarriage rate. A fifth study analysed
the risk of spontaneous abortion in mothers with a child presenting a
possible genetic defect (Anne Marie, 2000).

j. What the risk factor of abortus ?

Answer :
1. Embryonic abnormalities
 Embryonic abnormalities account for 80-90% of first-trimester
miscarriages. Note the following:
 Chromosomal abnormalities are the most common cause of
spontaneous miscarriage. More than 90% of cytogenic and
morphologic errors are eliminated through spontaneous
miscarriage.
 Chromosomal abnormalities have been found in more than 75% of
fetuses that miscarry in the first trimester.
 The rate of chromosomal abnormalities increases with age, with a
steep increase in women older than 35 years.
 Trisomy chromosomes commonly are encountered, with trisomy 16
accounting for approximately a third of chromosomal abnormalities
in early pregnancy.
2. Maternal factor
Maternal factors account for the majority of second-trimester
miscarriages, with advanced age and a previous early pregnancy loss as
[1]
the most common risk factors. Chronic maternal health factors
include the following:
  Maternal insulin-dependent diabetes mellitus (IDDM): As many as
30% of pregnancies in women with IDDM result in spontaneous
miscarriage, predominantly in patients with poor glucose control in
the first trimester.
 Severe hypertension
 Renal disease
 Systemic lupus erythematosus (SLE)
 Hypothyroidism and hyperthyroidism
3. Other factors that may contribute to miscarriage.
Exogenous factors include the following:
 Alcohol
 Tobacco
 Cocaine and other illicit drugs
4. Anatomic factors include the following:
who have recurrent spontaneous miscarriages.
 Congenital anatomic lesions include müllerian duct anomalies (eg,
septate uterus, diethylstilbestrol [DES]-related anomalies).
Müllerian duct lesions usually are found in second-trimester
pregnancy loss.
 Anomalies of the uterine artery with compromised endometrial
blood flow are congenital.
 Acquired lesions include intrauterine adhesions (ie, synechiae),
leiomyoma, and endometriosis.
 Other diseases or abnormalities of the reproductive system that may
result in miscarriage include congenital or acquired uterine defects,
fibroids, cervical incompetence, abnormal placental development,
or grand multiparity.
5. Endocrine factors include the following:
Endocrine factors potentially contribute to recurrent miscarriage in 10-
20% of cases.
 Luteal phase insufficiency (ie, abnormal corpus luteum function
with insufficient progesterone production) is implicated as the most
common endocrine abnormality contributing to spontaneous
miscarriage.
 Hypothyroidism, hypoprolactinemia, poor diabetic control,
and polycystic ovarian syndrome are contributive factors in
pregnancy loss.
6. Infectious factors include the following:
 Presumed infectious etiology may be found in 5% of cases.
 Bacterial, viral, parasitic, fungal, and zoonotic infections are
associated with recurrent spontaneous miscarriage.
7. Immunologic factors include the following:
Immunologic factors may contribute in up to 60% of recurrent
spontaneous miscarriages.
 Both the developing embryo and the trophoblast may be considered
immunologically foreign to the maternal immune system.
 Antiphospholipid antibody syndrome generally is responsible for
more second-trimester pregnancy losses than first-trimester losses.
(Elizabeth Puscheck, 2017).

Risk Factor in first trimester miscarriage are high maternal age;

previous miscarriage, termination and infertility; assisted conception; low
pre-pregnancy body mass index; regular or high alcohol consumption;
feeling stressed (including trend with number of stressful or traumatic
events); high paternal age and changing partner. Previous live birth, nausea,
vitamin supplementation and eating fresh fruits and vegetables daily were
 associated with reduced risk, as were feeling well enough to fly or to have
sex. After adjustment for nausea, we did not confirm an association with
caffeine consumption, smoking or moderate or occasional alcohol
consumption; nor did we find an association with educational level, socio-
economic circumstances or working during pregnancy (Maconochie N, et
al, 2007)

k. What kind of abortus ?

Answer :
An abortion is the spontaneous or induced loss of an early pregnancy.
The period of pregnancy prior to fetal viability outside of the uterus is
considered early pregnancy. Most consider early pregnancy to end at 20
weeks gestation or when the fetus weighs 500 grams. The term miscarriage
is used often in the lay language and refers to spontaneous abortion
(Elizabeth Puscheck, 2017).
A spontaneous abortion is a process that can be divided into 4 stages—
threatened, inevitable, incomplete, and complete. The 4 stages of abortion
form a continuum. Most studies do not differentiate separately between the
epidemiology and pathophysiology of each entity (Elizabeth Puscheck,
2017).
1. Threatened abortion
Threatened abortion consists of any vaginal bleeding during early
pregnancy without cervical dilatation or change in cervical consistency.
Usually, no significant pain exists, although mild cramps may occur. More
severe cramps may lead to an inevitable abortion (Elizabeth Puscheck,
2017).
Threatened abortion is very common in the first trimester; about 25-
30% of all pregnancies have some bleeding during the pregnancy. Less than
one half proceed to a complete abortion. On examination, blood or brownish
discharge may be present in the vagina. The cervix is not tender, and the
cervical os is closed. No fetal tissue or membranes have passed. The
ultrasound shows a continuing intrauterine pregnancy. If an ultrasound was
not performed previously, it is required at this time to rule out an ectopic
pregnancy, which could present similarly. If the uterine cavity is empty on
ultrasound, obtaining a human chorionic gonadotropin (hCG) level is
necessary to determine if the discriminatory zone has been passed
(Elizabeth Puscheck, 2017).
The discriminatory zone is the level of hCG beyond which a normal,
singleton, intrauterine pregnancy is consistently visible by ultrasound. The
discriminatory zone may vary depending on a number of factors, including
the hCG assay type and reference calibration standard used, ultrasound
equipment resolution, the skill and experience of the sonographer, and
patient factors (eg, obesity, leiomyomas, uterine axis, multiple gestations).
Also, the discriminatory zone will vary depending on whether the
ultrasound is performed abdominally or vaginally. Therefore, having a
universal discriminatory zone is difficult, and it optimally should be
calculated at each site (Elizabeth Puscheck, 2017).
Some studies recommend that a gestational sac should be visualized by
5.5 weeks' gestation; a gestational sac should be visualized with an hCG
level of 1500-2400 mIU/mL for transvaginal ultrasound or with an hCG
level over 3000 mIU/mL for a transabdominal ultrasound. If the hCG level
is higher than the discriminatory zone and no gestational sac is visualized
in the uterus, then consider that an ectopic pregnancy may be present.
Multiple gestations are an exception and can have higher hCG levels earlier
in gestation because more hCG is being made by the trophoblasts from the
multiple implantations. Thus, the gestational sac(s) may not be visible on
ultrasound despite the hCG levels being higher than the discriminatory
zone. Even with multiple gestations, the gestational sacs should be visible
at a similar gestational age as singleton gestations or about 6 weeks'
gestation if the dating is good (Elizabeth Puscheck, 2017).
A clinician should be concerned about ectopic pregnancy but cannot
make the diagnosis of ectopic pregnancy just because the hCG level is
higher than the discriminatory zone and the uterus appears empty on
ultrasound. Many of these pregnancies are abnormal intrauterine
pregnancies as opposed to ectopic. One needs to take into consideration the
clinical history, and estimated gestational age by LMP or date of
conception, if known. A positive pregnancy test result and an ultrasound
that does not reveal the location is known as a pregnancy of unknown
[3]
location (PUL). Occasionally, a normal intrauterine pregnancy does
result. Depending on the clinical scenario, a clinician may choose to observe
this patient with serial hCG levels and ultrasonography instead of
intervening, or a clinician may need to intervene depending on the situation
(Elizabeth Puscheck, 2017).
2. Inevitable abortion
Inevitable abortion is an early pregnancy with vaginal bleeding and
dilatation of the cervix. Typically, the vaginal bleeding is worse than with
a threatened abortion, and more cramping is present. No tissue has passed
yet. On ultrasound, the products of conception are located in the lower
uterine segment or the cervical canal (Elizabeth Puscheck, 2017).
3. Incomplete abortion
Incomplete abortion is a pregnancy that is associated with vaginal
bleeding, dilatation of the cervical canal, and passage of products of
conception. Usually, the cramps are intense, and the vaginal bleeding is
heavy. Patients may describe passage of tissue, or the examiner may
observe evidence of tissue passage within the vagina. Ultrasound may show
that some of the products of conception are still present in the uterus.
(Elizabeth Puscheck, 2017).
 4. Complete abortion
Complete abortion is a completed miscarriage. Typically, a history of
vaginal bleeding, abdominal pain, and passage of tissue exists. After the
tissue passes, the patient notes that the pain subsides and the vaginal
bleeding significantly diminishes. The examination reveals some blood in
the vaginal vault; a closed cervical os; and no tenderness of the cervix,
uterus, adnexa, or abdomen. The ultrasound demonstrates an empty uterus
(Elizabeth Puscheck, 2017).
5. Missed abortion
A fifth term that does not follow the continuum but is important to be
aware of is missed abortion. A missed abortion is a nonviable intrauterine
pregnancy that has been retained within the uterus without spontaneous
abortion. Typically, no symptoms exist besides amenorrhea, and the patient
finds out that the pregnancy stopped developing earlier when a fetal
heartbeat is not observed or heard at the appropriate time. An ultrasound
usually confirms the diagnosis. No vaginal bleeding, abdominal pain,
passage of tissue, or cervical changes are present (Elizabeth Puscheck,
2017).

2. She has never had a pregnancy check-up. She claimed to have out white
discharge history. She denied any history of trauma and stomach massaged.
a. How many times ideally do a pregnancy check-up (ANC) ?
Answer :
Based on WHO clinical guideline for ANC, 4 time ideally do a pregnancy
check-up. First visit is 8-12 weeks, second visit is 24-26 weeks, third visit
is 32 weeks, and fourth visit is 36-38 weeks (WHO, 2016)
 (WHO 2016)

b. What checks are done on ANC ?

Answer :

(WHO, 2016)
c. What is the meaning of she claimed to have out white discharge history ?
Answer :
Vaginitis (inflammation of the vagina) is the most common
gynecologic condition encountered in the office. It is a diagnosis based on
the presence of symptoms of abnormal discharge, vulvovaginal discomfort,
or both. Cervicitis may also cause a discharge and sometimes occurs with
vaginitis (Hetal B Gor, 2017).
Discharge flows from the vagina daily as the body’s way of
maintaining a normal healthy environment. Normal discharge is usually
clear or milky with no malodor. A change in the amount, color, or smell;
irritation; or itching or burning could be due to an imbalance of healthy
bacteria in the vagina, leading to vaginitis (Hetal B Gor, 2017).
The most common causes of vaginitis in symptomatic women are
bacterial vaginosis (40-45%), vaginal candidiasis (20-25%), and
trichomoniasis (15-20%); yet 7-72% of women with vaginitis may remain
undiagnosed (Hetal B Gor, 2017).
The workup for patients with vaginitis depends on the risk factors for
infection and the age of the patient. Accurate diagnosis may be elusive, and
care must be taken to distinguish vaginitis from other infectious and
noninfectious causes of symptoms. All women presenting with abnormal
vaginal discharge should have a careful pelvic examination. Condition-
specific tests (ie, colposcopy and cervical biopsies) are indicated for
suspected cervical cancer (Hetal B Gor, 2017).
Studies that may be performed in cases of suspected vaginitis include
saline wet mount, the so-called whiff test, pH testing, culture, nucleic acid
amplification testing, and a number of other second-line tests (see
Presentation, DDx, and Workup) (Hetal B Gor, 2017).
d. What is the relationship between white discharge and chief complaint ?
Answer :
White discharge (genital infection) is risk factor for abortion incomplete.
(Elizabeth Puscheck, 2017).

e. What are the type of vaginal discharge ?

Answer :
Leucorrhoea (flur albus) is divided into two types: physiological
whiteness (normal) and pathological vaginal (abnormal). Physiological
(normal) vaginal discharge occurs before and after menstruation, sexual
stimulation, severe stress, pregnancy or fatigue. On the physiological
discharge the fluid that comes out is clear or yellowish and odorless (Hetal
B Gor, 2017).
The characteristics of physiological discharge is the discharge of the
liquid that is not too thick, clear, white or yellowish color if contaminated
by the air is not accompanied by pain and does not arise excessive itching.
Whitish pathologissering called abnormal vaginal discharge or abnormal
whiteness that is categorized as a disease (Hetal B Gor, 2017).
The characteristics of pathological vaginal discharge are very thick and
yellowish color, strong odor, excessive amount and cause itching, pain as
well as pain and heat during urination (Hetal B Gor, 2017).

f. What is the meaning of Mrs. Y denied any history of trauma and stomach
massaged ?
Answer :

The meaning is that Mrs. Y has an abortion not caused by trauma and
stomach massaged.
 The cause of abortion include:

1. Incompentio orificium uteri internum

2. Systemic disease from the mother, such as diabetes mellitus
3. Incompatibility of rhesus factor or ABO system
4. Uterine abnormalities, such as uterine myoma
5. Physical or mental trauma
(Manuaba, IBG, 2010)

3. Mrs. Y had menarche at the age of 12 years with regular menstrual cycle (28
days). Pain during menstruation is denied.
a. What is the meaning of Mrs. Y had menarche at 12 years old with regular
menstruation cycle ?
Answer :

Menarche is a start of reproductive capacity. The landmarks of the

pubertal events in girls are the onset of puberty, peak height velocity (PHV)
and menarche. The onset of puberty is marked by the development of breast
tissue, while PHV is the highest velocity that is observed during the pubertal
growth spurt. Menarche is a rather late event in puberty and usually occurs
6 months after PHV is achieved. The age that menarche occurs varies and
is dependent on the interaction between genetic and environmental factors
(Parent AS, at al, 2003).
The Third National Health and Nutrition Examination Survey,
demonstrated that the mean age at onset of pubic hair, breast development
and menarche was 9.5, 9.5, and 12.1 years for black girls; 10.3, 9.8, and
12.2 for Mexican American girls; and 10.5, 10.3 and 12.7 for white girls
(Parent AS, at al, 2003).
 Age at menarche in Asian is similar to Mediterranean girls; mean
menarcheal age in Hong Kong [39] and Japan [40] is 12.38 and 12.2 years,
respectively, and in Greece [41] or Spain [42] 12.27 and 12.34, respectively.
The Bogalusa Heart Study included data from 7 cross-sectional
examinations of school-aged children, which were used for both cross-
sectional and longitudinal analyses. black girls experienced menarche, on
average, 3 months earlier than did white girls (12.3 vs 12.6 years). The
racial difference in pubertal maturation may reflect genetic factors. Black
girls present higher insulin response to a glucose challenge, and
subsequently increased levels of free IGF1, which is associated with
skeletal and sexual maturation compared to white girls (Parent AS, at al,
2003).

(Parent AS, at al, 2003)

b. When the first menstruation does happen normally ?

c. What is the meaning of pain during menstruation is denied ?
4. She is pregnant with 2nd child, the first child is 5 years old with a history of
normal delivery assisted midwife. She has never used any contraception. Last
menstrual period at Januari 8th, 2018.
a. What is the meaning of first child is 5 years old even though Mrs. Y never
using any contraception?
Answer :
Possibility, Mrs. Y or her husband are secondary infertile.

b. What is the meaning of having last menstrual period on January 8th 2018?
Answer :
That’s a last menstrual period before pregnancy to calculate the age of
pregnancy.

c. How to calculate the age of pregnancy?

Answer :
- Last Menstrual Period : 08 January 2018 (there is 31 days on January)
8 january – 31 january 2018 : 23 days (3 weeks 2 days)
- Februari : 28 days (4 weeks)
- Come to doctor on 20 march 2018
20 march (2 weeks 6 days)
So, 3 weeks 2 days + 4 weeks + 2 weeks 6 days = 10 weeks 1 days

d. How to estimate baby delivery?

Answer :
1. Naegele's rule
Naegele's rule is a standard way of calculating the due date for a
pregnancy. The rule estimates the expected date of delivery (EDD) by
adding one year, subtracting three months, and adding seven days to the
first day of a woman's last menstrual period (LMP). The result is
 approximately 280 days (40 weeks) from the start of the last menstrual
period. Another method is by adding 9 months and 7 days to the first day of
the last menstrual period.
- How to Calculation
The rule estimates the expected date of delivery (EDD) (also called
EDC, for estimated date of confinement) from the first day of the woman's
last menstrual period (LMP) by adding one year, subtracting three months,
and adding seven days to that date. The result is approximately 280 days
(40 weeks) from the start of the last menstrual period.
Example:
LMP = 8 May 2009
+1 year = 8 May 2010
−3 months = 8 February 2010
+7 days = 15 February 2010
280 days past the start of the last menstrual period is found by
checking the day of the week of the LMP and adjusting the calculated date
to land on the same day of the week. Using the example above, 8 May 2009
is a Friday. The calculated date (15 February) is a Monday; adjusting to the
closest Friday produces 12 February, which is exactly 280 days past 8 May.
The calculation method does not always result in 280 days because not all
calendar months are the same length; it does not account for leap years.
2. Parikh’s Formula
Parikh's formula is a calculation method that considers cycle duration.
Naegele's rule assumes an average cycle length of 28 days, which is not true
for everyone. EDD is calculated using Parikh's formula by adding nine
months to the start of the last menstrual period, subtracting 21 days, then
adding duration of previous cycles.
In modern practice, calculators, reference cards, or sliding wheel
calculators are used to add 280 days to the LMP.
 (Rakesh M. Parikh, 2007)

e. What the gravid status of Mrs. Y ?

Answer :
G2P1A0. G for gravida means the total number of pregnancies. P
for partus means the number of births. A for abortus means the number of
miscarriages or induced abortions.

5. Examinations
Physical Examination :
General inspection : severe illness.

Vital Sign : Pulse : 110x/minutes, BP: 80/50 mmHg, RR : 24x/minutes, T : 36,0

o
C

Specific Examination :

Head : Pale hands and feet, feel cold, edema (-)

Gynecologic Examination :

External Examination :

- Inspection : normal
- Palpation : the fundus is found at pubic symphysis, no tenderness.

Inspeculo :

- Portio : Livide
- OUE : dilated, looks clots tissue
- Fluxus (+), active blood
- Fluor (+)
- Polyp, erosion, laceration (-)
 Vaginal Toucher :

- Portio : palpable soft

- OUE : dilated, palpable clots tissue
- Corpus uteri of 11-12 weeks
- Right-left adnexa : palpable soft
- Cavum Douglas doesn’t bulge

Laboratory Examination :

Routine blood : Hb : 7,0 g/dl, Platelets : 200.000/mm3, leukocytes : 25.000/mm3

a. What is the interpretation of examination ?

Answer :

b.What is the abnormal mechanism of examination ?

6. What are the differential diagnosis in this case ?

Answer :
First Semester of Pregnancy :
o Incomplete abortion
o Ectopic pregnancy
o Mola pregnancy

Diagnose Bleeding Abdominal Uterus Cervix Specific

cramping symptom
Abortus Mild Mild - According Close There is
iminens Moderate to age of no
pregnancy epulsion of
conception
tissue
 Abortus Severe Severe According Open There is
insipiens to age of no
pregnancy epulsion of
conception
tissue
Abortus Moderate severe According Open A part of
incomplitus – severe to age of epulsion of
pregnancy conception
tissue
Abortus Without- Without- Less than Close Full
komplit mild mild age of epulsion of
pregnancy conception
tissue
Missed - - Less than Close Fetus was
abortion age of die, there
pregnancy is no
epulsion
KET +/- + More than Close
normal (a
little)

7. What additional examination are needed to diagnose this case?

Answer :
1. USG
2. Plano test (Test Pack): (+)
(Wiknjosastro, H. 2000)

8. What are working diagnosis in this case?

Answer :
Incomplete abortion with hypovolemic syock and anemia

9. How does the comprehensive management?

 Answer :

Maximizing oxygen delivery

The patient's airway should be assessed immediately upon arrival and stabilized if
necessary. The depth and rate of respirations, as well as breath sounds, should be
assessed. If pathology (eg, pneumothorax, hemothorax, flail chest) that interferes with
breathing is found, it should be addressed immediately. High-flow supplemental
oxygen should be administered to all patients, and ventilatory support should be given,
if needed. Excessive positive-pressure ventilation can be detrimental for a patient
suffering hypovolemic shock and should be avoided.

Resuscitation

Whether crystalloids or colloids are best for resuscitation continues to be a matter for
discussion and research. Many fluids have been studied for use in resuscitation; these
[5]
include isotonic sodium chloride solution, lactated Ringer solution, hypertonic
saline, albumin, purified protein fraction, fresh frozen plasma, hetastarch, pentastarch,
and dextran 70.

Proponents of colloid resuscitation argue that the increased oncotic pressure produced
with these substances decreases pulmonary edema. However, the pulmonary
vasculature allows considerable flow of material, including proteins, between the
intravascular space and interstitium. Maintenance of the pulmonary hydrostatic
pressure at less than 15 mm Hg appears to be a more important factor in preventing
pulmonary edema.

Gulati A. Vascular endothelium and hypovolemic shock. Curr Vasc Pharmacol.

2016. 14(2):187-95. [Medline].
 Pacagnella RC, Souza JP, Durocher J, et al. A systematic review of the relationship
between blood loss and clinical signs. PLoS One. 2013. 8(3):e57594. [Medline]. [Full
Text].

Tranexamid acid
Tranexamic acid is useful in a wide range of haemorrhagic conditions. The drug
reduces postoperative blood losses and transfusion requirements in a number of
types of surgery, with potential cost and tolerability advantages over aprotinin,
and appears to reduce rates of mortality and urgent surgery in patients with
upper gastrointestinal haemorrhage. Tranexamic acid reduces menstrual blood
loss and is a possible alternative to surgery in menorrhagia, and has been used
successfully to control bleeding in pregnancy.
Tranexamic Acid 500mg/5ml Solution for Injection

Adults

Unless otherwise prescribed, the following doses are recommended:

1. Standard treatment of local fibrinolysis:

0.5 g (1 ampoule of 5 ml) to 1 g (1 ampoule of 10 ml or 2 ampoules of 5 ml) tranexamic

acid by slow intravenous injection (= 1 ml/minute) two to three times daily

2. Standard treatment of general fibrinolysis:

1 g (1 ampoule of 10 ml or 2 ampoules of 5 ml) tranexamic acid by slow intravenous

injection (= 1 ml/minute) every 6 to 8 hours, equivalent to 15 mg/kg BW.
 Antibiotic
Ampisilin 4x1 g + Gentamisin 2x80 mg, and then antibiotic appropriate with
result of culture
(sarwono, 2016)
Refer to specialis

10. What will happen if these circumstances are not manage comprehensively?
Answer :

Complications of spontaneous miscarriages and therapeutic abortions include the

following:

 Complications of anesthesia
 Postabortion triad (ie, pain, bleeding, low-grade fever)
 Hematometra
 Retained products of conception
 Uterine perforation
 Bowel and bladder injury
 Failed abortion
 Septic abortion
 Cervical shock
 Cervical laceration
 Disseminated intravascular coagulation (DIC)

The term "septic abortion" refers to a spontaneous miscarriage or therapeutic/artificial

abortion complicated by a pelvic infection.

Postabortion complications develop as a result of 3 major mechanisms as follows:

incomplete evacuation of the uterus and uterine atony, which leads to hemorrhagic
complications; infection; and injury due to instruments used during the procedure.
In septic abortion, infection usually begins as endometritis and involves the
endometrium and any retained products of conception. If not treated, the infection may
spread further into the myometrium and parametrium. Parametritis may progress into
peritonitis. The patient may develop bacteremia and sepsis at any stage of septic
abortion. Pelvic inflammatory disease (PID) is the most common complication of
septic abortion.

Upadhyay UD, Desai S, Zlidar V, Weitz TA, Grossman D, Anderson P, et al. Incidence
of emergency department visits and complications after abortion. Obstet Gynecol. 2015
Jan. 125 (1):175-83. [Medline].

Kalilani-Phiri L, Gebreselassie H, Levandowski BA, Kuchingale E, Kachale F,

Kangaude G. The severity of abortion complications in Malawi. Int J Gynaecol Obstet.
2014 Nov 6. [Medline].

11. What is the prognosis in this case ?

12. how does the competence of general practitioner for this case?
Answer :
3B. Emergency case
General practitioner are able to make clinical diagnoses and provide
preliminary therapy in emergency cases, to determine the most appropriate
referral for the next patient's treatment and also able to follow up after returning
from referrals (KKI, 2012).

13. how does the Islamic point of view of this case?

Answer :
 "And indeed we have created man from a quint (derived) from the
ground (12). Then we make the juice of the semen (which is stored) in a firm
place (womb) (13). Then we put the semen into a clot of blood, and then we
made a plume of blood into a lump of flesh, and we made a bone of the flesh,
and then we wrapped the bones with flesh. Then we made him another (shaped)
creature. So God is the Most Good Creator (14). Then, after that, you will all
really die (15). (Al-Mu'minun: 12-15)
2.6 Hypothesis
Mrs. Y, a 35 years old, with vaginal bleeding and abdominal cramping due to
abortus incompletus with hypovolemic shock and anemia

2.7 Conceptual Framework

Risk Factors
Maternal age and genital infection

Abnormality of
fertilization and
implantation process

Release part of fetus from

uteri

Contraction of uteri

Abortus Incompletus

Vaginal Bleeding

Anemia Hypovolemic Syock