CASE REPORT

Imminent Abortion With Anemia Gravidarum

Supervised by :
dr.Mutawakil J Pranansa, SpOG

Written by :
Muhamad Dony Ardiansyah

12100116197

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

MEDICINE FACULTY OF BANDUNG ISLAMIC UNVERSITY

RSUD R SYAMSUDIN, SH SUKABUMI

2018
 CHAPTER I
INTRODUCTION
One of the most complications in pregnancy it was a bleeding, that could happen to any

the gestational age. Young in pregnancy, often connected with abortus, miscarriage, and loss of

early pregnancy. Abortus is defined as the threat or spending the products of conception before a

fetus can live outside the utery. Constitutes gestational age is less than 20 weeks or fetus weight

less than 500 grams. Abortus imminens is pervaginam bleeding in pregnancy before 20 weeks

without accompanied the release of the products of conception and dilatation of the uterus. The

prevalence of abortion also increases with age, whereas in 20-year-old women it is 12%, and in

women over 45 years is 50%. Eighty percent of abortions occur in the first 12 weeks of

pregnancy.

Anemia is one of the most commonly encountered medical disorders during pregnancy.

In developing countries it is a cause of serious concern as, besides many other adverse effects on

the mother and the fetus it contributes significantly high maternal mortality. According to United

Nation declaration 1997, anemia is a major public health problem that needs total elimination. It

is estimated that globally two billion people suffer from anemia or iron deficiency.

According to world Health Organization estimates, up to 56% of all women living In

developing countries are anemic. In India, National Family Health Survey -2 in 1998 to 99

shows that 54% of women in rural and 46% women in urban areas are anemics. The relative

prevalence of mild, moderate, and severe anemia are 13%, 57% and 12% respectively in India.

According to WHO, hemoglobin level below 11gm/dl in pregnant women constitutes anemia and

hemoglobin below 7gm/dl is severe anemia. The Center for Disease Control and Prevention

(1990) defines anemia as less than 11gm/dl in the first and third trimester and less than

10.5gm/dl in second trimester.

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 CHAPTER II
CASE REPORT

A. Patient’s Identity
a) Patient

Name : Mrs. F

Date of Birth/ Age : 30 years old

Nationality : Indonesian

Address : Gg Cikole Dalam No.19, Kec. Cikole, Sukabumi

Graduate from : High School

Marital Status : Married

Occupation : Housewife

Religion : Islam

Date of admission : January, 06th 2018

b) Husband

Name : Mr. H

Date of Birth/ Age : 40 years old

Nationality : Indonesian

Address : Gg Cikole Dalam No.19, Kec. Cikole, Sukabumi

Graduate from : High School

Marital Status : Married

Occupation : Employe

Religion : Islam

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 B. History Taking
 Chief Complaint
Vaginal bleeding since 1 days ago

 History of Present Illness

Patient came to the RSUD R. Syamsudin, SH’s obstetrician & gynecologist polyclinic,
with complaint vaginal bleeding since 1 days before admission. The initial bleeding in the form
of spots that are red. Then there are black blood clots, no tissue found. Complaints accompanied
by pain in the lower abdomen. History of intercourse (+) 2 days before admission. History of
fainting is refused. Menarche is 14 years old, with regular cycles every 28 days, 4-5 days
duration each time of menstruation. First day of last menstrual period is November 11th 2017.

 History of Past Illnesses

History of surgery : denied
History of curettage : denied
History of chronic hypertension : denied
History of kidney disease : denied
History of diabetes mellitus : denied
History of auto immune disease : denied
History of asthma : denied
History of allergy : denied
History of cancer : denied
History of TBC : there is a history of tbc already treated

 Familial History
History of hypertension : denied
History of kidney disease : denied
History of diabetes mellitus : denied
History of auto immune disease : denied
History of cancer : denied

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  Menstruation History
Menarche : 14 years old
Menstrual cycle : regularly every 28 days, 5-7 days duration and
without history of pain during menstruation
Amount of menstrual blood : 2-3 normal pads / day ( ± 60 cc )
LMP :-

 Contraception History
History of using injection contraception

 Marital History
Married once, she has been married for 9 years

 Obstetric History
No Age Gestational Labour History Sex Birth Info
Age Weight
1 8 yo Aterm Sectio caesarean w/ indication Male - Live
failed induction of labor
2 3 yo Aterm Sectio caesarean w/ indication Female - Live
previous cesarean section
3 This
Pregnancy

C. Physical Examination
General condition : Moderately ill
Level of conciousness : Compos mentis
Vital signs :
Blood preassure : 110/70 mmHg
Heart rate : 88x/ minutes
Respiration rate : 20x/ minutes
Temperature : 36,5oC
Weight : 47 kg
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 Height : 155 cm
BMI : 34,375 kg/m2
BMI : 28,12 kg/m2

 General Examination
Eyes : anemic conjunctiva +/+, icteric sclera -/-
Mouth : wet oral mucosa membrane
Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
Lung
Inspection : symmetric chest expansion in breathing
Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, rhonchi -/-, wheezing -/-
Abdomen
Inspection : convex, mass (-)
Palpation :mass (-), tenderness (-), soft
Auscultation : bowel sound (+) normal
Extremities : warm, edema -/-/-/-, CRT < 2 seconds

 Obstetric Examination
External Examination :
• Fundal Height : not palpable
• Waist circumference : not examined
• HIS : (-)
• FHR : (-)
Internal Examination :
• Vulva/ vagina : not found any abnomalities
• Portio : thick, soft
• Cervical dilation :-
• Fetal membrane : not examined

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USG examination
November 23th 2015, 18.30, result :
Single fetus live.
The fetal heart rate does not exist yet
Gestational age : -
Estimated birth weight -

Working Diagnosis
Mrs. F, 30 yo, G3P2A0, 30 years old, gravida 8-9 weeks with imminent abortion and anemia
gravidarum

Management
 Conservative Treatment

Prognosis
Quo ad vitam : ad bonam
Quo ad functionam : ad bonam
Quo ad sanationam : ad bonam

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 CHAPTER III
PROBLEMS
Problems:
A. How to diagnose Cervical Intraepithelial Neoplasia?
 History taking
To assess cervical intraepithelial neoplasia from history taking, first thing to be done is
to seek for the risk factors on the patient infection of HPV, HIV and Chlamydia, early sexual
intercourse ( <17 years), history of sexually transmitted diseases, early age of first pregnancy,
too many and too frequent births, low socioeconomic status, multiple sexual partner,
imunosuppresed (HIV positive) individuals, Husband whose previous wife dead of cervical
malignancy, Oral pill users, smoking habit and history of malignancy in family.
The most common clinical presentation of patients with cervical intraepithelial
neoplasia are usually asymptomatic except that the patients had any other problem beside CIN,
In this case, patient is woman, 36 years old, with chief complaint of vaginal discharge,
since three months before hospital admission. She admitted that the discharge intermittent, the
consistency is thick, it is itchy, it is smelly sometimes. The patient also complained about pain
during having sex. She admitted usage of Pill hormonal contraception since 2012 and its been 4
years since she was used pill contraception. Her sister was diagnosed with breast cancer. Patient
denied had a history of sexual transmitted diseases, husband who previous wife died of cervical
malignancy, smoking habit and had multiple sexual partner. The patient married and had first
coitus in 18 years old and first delivery of her baby in 20 years old.
Conclusion:
From the chief complain, the patient was having vaginal discharge since three months
before hospital admission. Because of it, she was required supporting examination, in this case to
diagnose what is the real problem and patient undergo pap smear cytology examination. She
admitted usage of Pill hormonal contraception since 2012 and its been 4 years since she was used
pill contraception which is the usage of pill contraception one of risk factor for CIN. Her sister
was diagnosed with breast cancer which is one of the risk factor cervical intraepithelial neoplasia
.

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  Physical examination
Usually nothing can be found on the physical examination. Gynecologic examination
can be found in inspeculo examination and colposcopy thin smooth white lesion well defined at
portio White epithelium~leukoplakia, Aceto white epithelium~epithelium turning white
following application of 5 percent acetic acid due to cell protein coagulation
,Punctuation~dilated capillaries which appear on the surface as dots, Mosaic~capillaries
encircling polygonal shaped blocks of epithelial cells, Atypical blood vessels~with irregular
diameter and branching are suggestive of invasive carcinoma and Irregular surface contour with
ulceration and friability.

Conclusion:
In gynecologic examination, there was a thin smooth white lesion well defined at portio in
inspeculo examination, other gynecologic examination shows normal results.

 Pap smear cytologic examination

Exfoliative cytology has become the gold standard for screening. The smear should
contain cells from SCJ, TZ and the endocervic ayre’s spatula and an endocervical brush is used
for this purpose. The result can be classified if there is Cervical intraepithelial into three
categories.

Conclusion :
Microscopic : Increase Inflammatory Cell PMN and MN ,Superficial intermediate and parabasal
cell, Nucleus with Mild dyskariosis.
Suggest : Mild-Moderate dysplasia (CIN I and II) and Chronic Non Specified Cervicitis

B. What is Management for Cervical Intraepithelial Neoplasia

Management of CIN falls into two general categories: observation and treatment. The
objective of all treatment is surgical obliteration of the entire cervical transformation zone,
including abnormal tissue. This may be done by use of ablation, that is, tissue destruction with
cryosurgery or laser ablation, or by excision of tissue.

8
 Evidence-based consensus guidelines for the management of women with biopsy-
confirmed CIN have been developed and recently updated through the organizational efforts of
the American Society for Colposcopy and Cervical Pathology (Wright, 2003, 2007a). In general,
histologic CIN 1 can be observed indefinitely, especially in adolescents, or treated if it persists
for at least 2 years observation is repeated every 4-6 month with repeat smear and colposcopy.
This is also the case for CIN 2 lesions in adolescents. However, CIN 2 in adult women and CIN
3 are treated by excision or ablation except in special circumstances. The "see and treat"
approach in which loop excision is performed at initial colposcopy is an acceptable option for
high-risk, adult patients who present with high-grade cytology and corresponding colposcopic
abnormalities. A prospective study using this approach found that 84 percent of patients had CIN
2 or 3 within the excisional biopsy specimen (Numnum, 2005). In the case of unsatisfactory
colposcopy and histologic CIN, a diagnostic excisional procedure is recommended to exclude the
presence of occult high-grade CIN or invasive cancer.

Ablative Treatment Modalities

Before using ablative treatment modalities, there must be no indication of invasive cancer by
cytologic or histologic evaluation or by colposcopic impression and no suspicion of glandular
disease (Spitzer, 1998). Before ablative procedures, colposcopic examination should be deemed
satisfactory, and cytologic and histologic results should be concordant. Ablative treatment
modalities include cryosurgery, electrofulguration, and carbon dioxide (CO2) laser

Cryosurgery

Cryosurgery delivers a refrigerant gas, usually nitrous oxide, through flexible tubing to a metal
probe which freezes tissue on contact (see Section 41-13, Treatment of Ectocervical Preinvasive
Lesions). Cryonecrosis is achieved by crystallizing intracellular water. This treatment is
appropriate for lesions associated with satisfactory colposcopic examination and with biopsy-
proven squamous dysplasia limited to two quadrants of the cervix.

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Carbon Dioxide Laser

Treatment with light amplification by stimulated emission of radiation, or laser, is delivered

using colposcopic guidance with a micromanipulator. This modality vaporizes tissue to a depth
of 5 to 7 mm (see Section 41-13, Treatment of Ectocervical Preinvasive Lesions). Laser ablation
is appropriate for biopsy-proven squamous intraepithelial lesions associated with a satisfactory
colposcopic examination. The laser is well suited for large, irregularly shaped lesions of all
grades.

Excisional Treatment Modalities

Lesions suspicious for invasive cancer and AIS of the cervix must undergo a diagnostic
excisional procedure. In addition, excision is indicated for patients with unsatisfactory
colposcopy with histologic CIN or unexplained high-grade or recurrent AGC cytology

Loop Electrosurgical Excision Procedure

This technique uses a thin wire on an insulated handle through which an electrical current is
passed. This creates an instrument that simultaneously cuts and coagulates tissue under direct
colposcopic visualization. Because LEEP can be performed using local anesthesia, it has become
the primary outpatient treatment modality for high-grade cervical lesions including those that
extend into the endocervical canal LEEP provides a tissue specimen with margins that can be
histologically evaluated to assure complete lesion removal.

Cold-Knife Conization

This surgical procedure removes the entire cervical transformation zone including the cervical
lesion by scalpel (see Section 41-14, Cervical Conization). It is performed in an operating room
and requires general or regional anesthesia (Table 29-12). Cold-knife conization is preferred for
cases of unsatisfactory colposcopy, particularly with high-grade CIN extending deep into the
endocervical canal, with endocervical glandular disease, and with some posttreatment CIN
recurrences.

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Carbon Dioxide Laser Conization

This method has the disadvantages of expense and some thermal compromise of margins, but the
advantages of less blood loss and precise cone size and shape tailoring. Requiring special
training, this procedure can be performed under local or general anesthesia.

Hysterectomy

Hysterectomy is unacceptable as primary therapy for CIN 1, 2 or 3 (Wright, 2007b). However, it

may be considered when treating recurrent high-grade cervical disease if childbearing has been
completed or when a repeat cervical excision is strongly indicated but technically not feasible.
Although hysterectomy provides the lowest recurrence rate for CIN, invasive cancer must always
be excluded beforehand.

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Conclusion :
In this patient, cryosurgery was performed due CIN I and II with mild and moderate dyskariotic
cell CIN II in adult women and CIN III are treated by excision or ablation except in special
cirmcumstances. There is also needed to follow up after local ablative method that need to follow
up for 2 years with every 4-6 months undergo pap smear and colposcopy examination.

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 CHAPTER IV
CASE ANALYSIS
Theory Case
Anamnesis Cervical Intraepithelial Cervical Intraepithelial
Neoplasia Neoplasia
Risk Factor/Etiology Risk Factor/Etiology
 patient infection of HPV,  She admitted usage of
HIV and Chlamydia Pill hormonal
 Early sexual intercourse ( contraception since
<17 years) 2012
 history of sexually  Her sister was
transmitted diseases diagnosed with breast
 early age of first pregnancy cancer
 too many and too frequent
births
 low socioeconomic status
 multiple sexual partner
 imunosuppresed (HIV
positive) individuals
 Husband whose previous
wife dead of cervical
malignancy
 Oral pill users
 smoking habit and history
of malignancy in family
Physical Usually nothing can be found In gynecologic
examination on the physical examination. examination, there was a
thin smooth white lesion
Gynecologic examination well defined at portio in
can be found in inspeculo inspeculo examination,
examination and colposcopy other gynecologic
thin smooth white lesion well examination shows normal
defined at portio White
results
epithelium~leukoplakia,
Aceto white
epithelium~epithelium
turning white following
application of 5 percent
acetic acid due to cell protein

13
 coagulation
,Punctuation~dilated
capillaries which appear on
the surface as dots,
Mosaic~capillaries encircling
polygonal shaped blocks of
epithelial cells, Atypical
blood vessels~with irregular
diameter and branching are
suggestive of invasive
carcinoma and Irregular
surface contour with
ulceration and friability

Supporting Pap smear cytology has Microscopic : Increase

examination become the gold standard for
screening. The smear should
contain cells from SCJ, TZ
and the endocervic ayre’s
spatula and an endocervical
brush is used for this purpose.
The result can be classified if
there is Cervical
intraepithelial into three
categories.
Inflammatory Cell PMN and
MN ,Superficial intermediate
and parabasal cell, Nucleus
with Mild dyskariosis.
Suggest : Mild-Moderate
dysplasia (CIN I and II) and
Chronic Non Specified
Cervicitis
-

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 CHAPTER V
CONCLUSION

The patient name is Mrs. D, 36 years old, admitted on 23rd march 2017 and she was
diagnosed with CIN I, II and Chronic Non specified Cervicitis. She was diagnosed with Cervical
intraepithelial neoplasia from the history taking where she got a risk factor for the disease which
is She admitted usage of Pill hormonal contraception since 2012 Her sister was diagnosed with
breast cancer. General physical examinations are on normal range. Gynecologic examination had
results there was a thin smooth white lesion well defined at portio in inspeculo examination. Pap
smear cytology shows result Increase Inflammatory Cell PMN and MN Superficial intermediate
and parabasal cell, Nucleus with Mild dyskariosis. Conclusion Mild-Moderate dysplasia (CIN I
and II) and Chronic Non Specified Cervicitis. Management for this patient was cryosurgery and
follow up for 2 years every 4-6 months after cryosurgery with pap smear and colposcopy
examination.

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 REFERENCES

1. Cunningham F Williams J. Williams Gynecology. New York: McGraw-Hill Medical;

2010.
2. Dutta D Konar H. DC Dutta's textbook of Gynecology.2013

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