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,

Skenario G Blok 23 Tahun 2014

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 and
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
Mrs. Anita, a 39-year-old woman in her first pregnancy delivered twin sons 2 h
ago. There were no significant antenatal complications. She had been prescribed
ferrous sulphate and folic acid during the pregnancy as anemia prophylaxis, and her
last haemoglobin was 10.9 g/dL at 38 weeks.
The fetuses were within normal range for growth and liquor volume on serial scan
estimations. A vaginal delivery was planned and she went into spontaneous labor at
38 weeks and 4 days. The labor had been unremarkable and the midwife recorded
both placenta as appearing complete.
As this was a twin pregnancy, an intravenous cannula had been inserted when
labor was established. The lochia has been heavy since delivery but the woman is
now bleeding very heavily and passing large clots of blood.
On arrival in the room you find that the sheets are soaked with blood and there
is also approximately 500 mL of blood clot in a kidney dish on the bed.
You act as the doctor in public health centre and be pleased to analyse this case.

The woman is conscious but drowsy and pale.

Height = 155 cm; Weight 50 kg
In the examination findings:
The temperature is 35.9C, blood pressure 120/70 mmHg and heart rate 112/min. The
peripheral extremities are cold. The uterus is palpable to the umbilicus and felt soft.
The abdomen is otherwise soft and non-tender. On vaginal inspection there is a
second-degree tear which has been sutured but you are unable to assess further due to
the presence of profuse bleeding.
The midwife sent blood tests 30 min ago because she was concerned about the blood
loss at the time.
Haemoglobin
7.2 g/dL
Mean cell volume
99.0 fL
White cell count
3.200/mm3
Platelets
131.000/mm3
International normalized ratio (INR)
1.3
Activated partial thromboplastin time (APTT)
39 s
Sodium
138 mmol/L
Potassium
3.5 mmol/L
Urea
5.2 mmol/L
Creatinine
64 mol/L
OBJECTIVES
Term Clarification
First pregnancy
Twin delivery
Ferrous sulphate
Folic acid
Anemia prophylaxis
Vaginal bleeding
Heavy lochia
Drowsy and pale
Intravenous cannula
A second-degree tear
Problem Identification
Mrs. Anita, a 39-year-old woman in her first pregnancy
Twin delivery
Ferrous sulphate and folic acid during the pregnancy as anemia prophylaxis
The lochia has been heavy since delivery
Approximately 500 mL of blood clot in a kidney dish on the bed.
Drowsy and pale
The peripheries feel cool.
The uterus is palpable to the umbilicus and feels soft.
A second-degree tear which has been sutured
Haemoglobin 7.2 g/dL
Mean cell volume 99.0 fL
White cell count 3.200/mm3
Platelets 131.000/mm3
International normalized ratio (INR) 1.3

 Activated partial thromboplastin time (APTT) 39 s

Problem Analysis
Mrs. Anita, a 39-year-old woman in her first pregnancy
o What is the risk of pregnancy in the age 39 year old?
o What is the connection of age in first pregnancy and postpartum
bleeding?
Twin delivery
o What is twin delivery?
o What are the cause of twin delivery?
o How is the management of twin delivery?
o What is the connection of twin delivery and postpartum bleeding?
Ferrous sulphate and folic acid during the pregnancy as anaemia prophylaxis
o What is ferrous sulphate?
o What is folic acid?
o What is the mechanism of ferrous sulphate as anaemia prophylaxis?
o What is the mechanism of folic acid as anaemia prophylaxis?
The lochia has been heavy since delivery
o What is lochia?
o How is the lochia after delivery?
Approximately 500 mL of blood clot in a kidney dish on the bed.
o How much blood is considered as normal bleeding?
o What are the risk of heavy bleeding?
o How is the management of postpartum bleeding?
Drowsy and pale
o What is the meaning of drowsy and pale?
o What is the connection of drowsy and pale with heavy bleeding?
The peripheries feel cool.
o What is the meaning of the condition of cool peripheries?
The uterus is palpable to the umbilicus and feels soft.
o How is the uterus after delivery?
o What is the meaning of soft contraction?
o What is the connection of soft uterus and vaginal bleeding ?
A second-degree tear which has been sutured
o How is the degree of perineal tear ?
o How is the management of perineal tear according to the degree?
Haemoglobin 7.2 g/dL
o How is normal hemoglobin count?
o What is the meaning of haemoglobin 7.2 g/dL?
o What is the management of hemoglobin 7.2 g/dL?
Mean cell volume 99.0 fL
o How is normal mean cell volume?
o What is the meaning of mean cell volume 99.0 fL ?
o What is the management of mean cell volume 99.0 fL?
Platelets 131.000/mm3
o How is normal platelets?
o What is the meaning of platelets 131.000/mm3?
o What is the management of platelets 131.000/mm3?
International normalized ratio (INR) 1.3
o How is normal international normalized ratio (INR)?

o What is the meaning of international normalized ratio (INR) 1.3?

o What is the management of international normalized ratio (INR) 1.3?
Activated partial thromboplastin time (APTT) 39 s
o How is normal Activated partial thromboplastin time (APTT) ?
o What is the meaning of Activated partial thromboplastin time (APTT) 39 s
o What is the management of Activated partial thromboplastin time (APTT)
39 s?
Hypothesis:
Mrs. Anita has a postpartum bleeding due to twin delivery and advance maternal
age.
Learning Issues:
1. Anatomy of reproduction system
2. Obstetric 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
postpartum bleeding
4. Determine the risk factors of postpartum bleeding
5. Exclude the other differential diagnosis
6. Terms in pregnancy
7. Interpretation of laboratory findings (blood, urine)

Concepts Framework:
Risk factors, etiology, predisposition postpartum bleeding outcome,
management, complication, prevention.
Theory Review.
POSTPARTUM HAEMORRHAGE
I.
DEFINITION
The diagnosis is primary postpartum haemorrhage (PPH), defined as the loss of more
than 500 mL of blood in the first 24 h following delivery. This classification applies
even if the blood is lost at Caesarean section or while awaiting placental delivery.
II.

INCIDENCE
15-25% of all pregnancy

III. CAUSES AND RISK FACTORS

1. Uterine atony (multiple pregnancy, grand multiparity, polyhydramnios,
prolonged labour)
2. Antepartum haemorrhage
3. Uterine sepsis (chorioamnionitis)
4. Retained placenta
5. Lower genital tract trauma (perineal or cervical tears)
6. Coagulopathy (heparin treatment, inherited bleeding disorders)
7. Previous PPH

This womans major risk factor is multiple pregnancy and with the high uterus, the
cause is likely to be uterine atony (inability of the uterus to contract adequately).
Blood loss is often underestimated, the high uterus may contain a large volume of
concealed blood, and the blood pressure in young fit women remains relatively
normal until decompensation occurs. Therefore this woman is in fact extremely sick
and at risk of cardiac arrest if immediate management is not employed.
IV.

MANAGEMENT
rub up a contraction by placing the dominant hand over the uterus and
rubbing and
squeezing firmly until the uterus becomes firm
ensure two large-bore cannulae are inserted with cross-matched blood
requested
recheck full blood count and coagulation
commence intravenous fluids for volume expansion
give 500 g ergometrine intramuscularly or intravenously to enhance uterine
contraction
start a syntocinon infusion to maintain uterine contraction
consider other uterotonics such as misoprostol or carboprost
transfer to theatre for examination under anaesthetic to assess for vaginal
trauma, cervical laceration or retained placental tissue
the doctor or midwife should continue bimanual compression until the
clinical situation is under control
if the bleeding does not settle with the above measures then further options
are uterine artery embolization or laparotomy with B-Lynch haemostatic
suture, uterine artery ligation or hysterectomy.

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,

Skenario G Blok 23 Tahun 2014

Mrs. Anita, a 39-year-old woman in her first pregnancy delivered twin sons 2 h
ago. There were no significant antenatal complications. She had been prescribed
ferrous sulphate and folic acid during the pregnancy as anemia prophylaxis, and her
last haemoglobin was 10.9 g/dL at 38 weeks.
The fetuses were within normal range for growth and liquor volume on serial scan
estimations. A vaginal delivery was planned and she went into spontaneous labor at
38 weeks and 4 days. The labor had been unremarkable and the midwife recorded
both placenta as appearing complete.
As this was a twin pregnancy, an intravenous cannula had been inserted when
labor was established. The lochia has been heavy since delivery but the woman is
now bleeding very heavily and passing large clots of blood.
On arrival in the room you find that the sheets are soaked with blood and there
is also approximately 500 mL of blood clot in a kidney dish on the bed.
You act as the doctor in public health centre and be pleased to analyse this case.
The woman is conscious but drowsy and pale.
Height = 155 cm; Weight 50 kg
In the examination findings:
The temperature is 35.9C, blood pressure 120/70 mmHg and heart rate 112/min. The
peripheral extremities are cold. The uterus is palpable to the umbilicus and felt soft.
The abdomen is otherwise soft and non-tender. On vaginal inspection there is a
second-degree tear which has been sutured but you are unable to assess further due to
the presence of profuse bleeding.
The midwife sent blood tests 30 min ago because she was concerned about the blood
loss at the time.
Haemoglobin
7.2 g/dL
Mean cell volume
99.0 fL
White cell count
3.200/mm3
Platelets
131.000/mm3
International normalized ratio (INR)
1.3
Activated partial thromboplastin time (APTT)
39 s
Sodium
138 mmol/L
Potassium
3.5 mmol/L
Urea
5.2 mmol/L
Creatinine
64 mol/L