CASE REPORT

Abnormal Uterine Bleeding

Presented by
Siti Nur Fauziah (2013730102)

Supervised by
dr. Hj. Hesty Duhita Permata, Sp.OG

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

GENERAL HOSPITAL OF R. SYAMSUDIN, SH SUKABUMI
MEDICAL FACULTY OF MUHAMMADIYAH JAKARTA
2017
 Abnormal uterine bleeding (AUB) is a term used to define all kind of menstrual
abnormalities, including both its amount and duration. The clinical manifestation
includes mild or severe vaginal bleeding, and prolonged or irregular menstrual cycle.
A United States population-based survey of women ages 18 to 50 years reported an
annual prevalence rate of 53 per 1000 women.2 Based on the result of the research at
Prof. Dr. R. D. Kandou Hospital Manado, abnormal uterine bleeding is the most frequent
gynecological symptomps in women of reproductive age outpatients with a prevalence
of 11 of 13 women and is increasing with aging reaching 25% among women of
reproductive age
FIGO classified AUB into 9 category:
PALM-COIEN
PALM is structural abnormality of organ reproductive
COIEN is non-structural abnormality of organ reproductive

Introduction Case Case Analysis Conclusion

 PATIENTS IDENTITY
Name : Mrs. I
Age : 39 years old
Address : Kp. Sumur Agung RT 01/02 Mekartanjung
Status : Married
Education : Elementary School
Occupation : Housewife
Race : Sundanese
Religion : Moslem
Date of admission : September, 10th 2017

Introduction Case Case Analysis Conclusion

 HUSBANDS IDENTITY
Husbands name : Mr. M
Age : 45 years old
Education : Elementary School
Occupation : Laborers
Race : Sundanese
Religion : Moslem

Introduction Case Case Analysis Conclusion

 CHIEF COMPLAIN
Patient P5A0 complained about irregular vaginal bleeding since a month before
admission.

Introduction Case Case Analysis Conclusion

 HISTORY OF PRESENT ILLNESS
Since 1 month ago

2 weeks after the initial 1 week prior to her visit to the

The bleeding lasted for 3
complain, the patient hospital, the patient
days and she thought that
suffered from a more experienced another vaginal
it was a normal menstrual
severe vaginal bleeding bleeding which had not
bleeding
which lasted for 5 days stopped until now

The patient was then referred 3 hours before admission, the

to RSUD R. Syamsudin SH due patient lost consciousness for
to her worsening condition. 3 minutes and was brought
to a nearby Puskesmas

Introduction Case Case Analysis Conclusion

 HISTORY OF PAST ILLNESS
History of surgery : Denied
History of curettage : Denied
History of malignancy : Denied
History of hypertension : Denied
History of Diabetes Mellitus : Denied
History of Haemathology Disease : Denied
History of decreased of body weight : Denied

Introduction Case Case Analysis Conclusion

 Menarche : 12 years old
Last Menstrual Period : Agustus, 2017
Menstrual Cycle : Regular
Duration : 7 days
Amount of Menstrual Blood : 2-3 normal pads/day ( 40-60 cc)
Dysmenorrhea : (-)

Introduction Case Case Analysis Conclusion

FAMILY DISEASE HISTORY
Patient denied that her family members have the same complaints.
History of Hypertension : Denied
Hystory of Diabetes Mellitus : Denied

Marital history
Married once, has been going on for 26 years.

Contraception history
Never had a contraception method.

Introduction Case Case Analysis Conclusion

 GESTATIONAL HISTORY
No Year Gestational Age Labour History Sex Birth Weight Info

1 1993 Preterm Spontaneous Male - Died

Vaginal Delivery

2 1996 Aterm Spontaneous Male - Live

Vaginal Delivery

3 2001 Aterm Spontaneous Female - Died

Vaginal Delivery

4 2004 Aterm Spontaneous Male - Live

Vaginal Delivery

5 2011 Aterm Spontaneous Male - Live

Vaginal Deivery

Introduction Case Case Analysis Conclusion

 PHYSICAL EXAMINATION
General Condition : Moderately ill
Alert : Composmentis
Skin Colour : Pale
Blood Pressure : 100/60 mmHg
Heart Rate : 89 bpm
Respiratory Rate : 21 x/minutes
Temperature : 36.7C
Body Weight : 40 kg
Height : 150 cm
BMI : 17.7 Underweight

Introduction Case Case Analysis Conclusion

 GENERAL EXAMINATION
Eye : Conjunctiva anemic (+/+), Icterric sclera (-/-)
Mouth : Wet oral mucosa membrane
Heart : Regular 1st and 2nd heart sound, murmur (-), gallop (-)
Lung

Inspection : Symmetric chest expansion in breathing

Percussion : Resonant on both lungs
Auscultation : Vesicular breath sounds (+), ronchii (-), wheezing (-)
Abdomen
Inspection : Flat
Auscultation : Bowel sound (+)
Palpation : Not palpable mass, tenderness (-)
Percution : Deaf side/deaf move (-)
Extremities : Warm, edema -/-/-/-, CRT < 2 seconds

Introduction Case Case Analysis Conclusion

 External Genital Examination
Inspection : Vulva or vagina are within normal limit
Palpation : Within normal limit
Regional Anal : Within normal limit
Inspeculum Examination :
Fluxus (+), Fluor (-)
Portio : Normal
Blood coming out from the OUE
Internal Genital Examination/Vaginal Toucher
Vulva : Within normal limit
Vaginal Structure : Within normal limit
Portio : Within normal limit
Corpus Uteri : Within normal limit
Adnexa si/dex : Not palpable mass, tenderness (-)
Douglas Pouch : Not palpable mass

Introduction Case Case Analysis Conclusion

 LABORATORY EXAMINATION
Haemathology (24/08/2017)
Complete Blood Count (CBC)
Hb : 6.4 g/dL
Leukocyte : 9.700 /L
Hematocryte : 19 %
Eritrocyte : 2.2 million/L
Eritrocyte Index
MCV : 83 fL
MCH : 29 pg
MCHC : 35 g/dL
Trombocyte : 127.000 /L

Introduction Case Case Analysis Conclusion

 WORKING DIAGNOSIS
Mrs. I, P5A0, 39 years old, with abnormal
uterine bleeding and anemia

Introduction Case Case Analysis Conclusion

 MANAGEMENT AND THERAPY
Stabilization of general condition with :
Blood transfuse
Drug administration Tranexamic Acid 3x500 mg IV
Drug administration Mefenamic Acid 3x500 mg PO
Planning of dilatation and curettage

Introduction Case Case Analysis Conclusion

 FOLLOW UP
Date Assesment
11/09/2017 S : Headache and weakness
O:
- General Condition : moderately ill
- Alert : Compos Mentis
- BP : 90/60 mmHg
- HR : 85 x/minute
- RR : 21 x/minute
- Temperature : 36.9 C
- Eye : Sclera icteric (-/-), Conjunctiva anemis (+/+)
- Abdomen : Not palpable mass, tenderness (-)
- Vaginal bleeding (+)
- Lab : Hb 6.4 gr/dL
A : Mrs. I, P5A0, 39 years old, with abnormal uterine bleeding and anemia

P:
- Blood transfuse
- Drug administration Tranexamic Acid 3x500 mg IV
- Drug administration Mefenamic Acid 3x500 mg PO
- Planning of dilatation and curettage

Introduction Case Case Analysis Conclusion

 12/09/2017 S : No complaint
O:
- General Condition : moderately ill
- Alert : Compos Mentis
- BP : 100/60 mmHg
- HR : 80 x/minute
- RR : 21 x/minute
- Temperature : 36.2 C
- Eye : Sclera icteric (-/-), Conjunctiva anemis (-/-)
- Abdomen : Not palpable mass, tenderness (-)
- Vaginal bleeding (+)
- Lab : Hb 8.3 gr/dL
A : Mrs. I, P5A0, 39 years old, with abnormal uterine bleeding and anemia

P:
- Blood transfuse
- Drug administration Tranexamic Acid 3x500 mg IV
- Drug administration Mefenamic Acid 3x500 mg PO
- Planning of dilatation curettage

Introduction Case Case Analysis Conclusion

13/09/2017 S : No complaint
O:
- General Condition : moderately ill
- Alert : Compos Mentis
- BP : 100/60 mmHg
- HR : 84 x/minute
- RR : 20 x/minute
- Temperature : 36.8 C
- Eye : Sclera icteric (-/-), Conjunctiva anemis (-/-)
- Abdomen : Not palpable mass, tenderness (-)
- Vaginal bleeding (-)
- Lab : Hb 11.5 gr/dL
A : Mrs I, P5A0, 39 years old, abnormal uterine bleeding
P:
- Blood transfuse
- Drug administration Tranexamic Acid 3x500 mg IV
- Drug administration Mefenamic Acid 3x500 mg PO

Introduction Case Case Analysis Conclusion

 PROGNOSIS
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia
Quo ad sanationam : dubia

Introduction Case Case Analysis Conclusion

 How to diagnose this patient?
How is the management of abnormal uterine bleeding for this case?

Introduction Case Case Analysis Conclusion

 Theory
History Abnormal Uterine Bleeding (AUB) have
several patterns of clinical presentation
that is menorrhagia, polymenorrhea,
metrorrhagia, oligomenorrhea,
hypomenorrhea.
Menorrhagia is cyclic bleeding at normal
intervals, the bleeding is either excessive
in amount (>80ml or change more than 6
pads) or duration (>7days) or both.
Polymenorrhea is defined as cyclic
bleeding where the cycle is reduced to an
arbitrary limit of less than 21 days and
remains constant at that frequency.
Metrorrhagia is defined as irregular,
acyclic bleeding from the uterus.
Oligomenorrhea is menstrual bleeding
occurring more than 35 days apart and
which remains constant at that frequency.
Hypomenorrhea is when menstrual
bleeding is unduly scanty and lasts for less
than 2 days.
Introduction Case Case Analysis
Case
Patient, 39 years old came because of
irregular vaginal bleeding since a
month before admission. The bleeding
lasted for 3 days and she thought that it
was a normal menstrual bleeding. She
replaced her pads 3 times a day. 2
weeks after the initial complain, the
patient suffered from a more severe
vaginal bleeding which lasted for 5
days. 1 week prior to her visit to the
hospital, the patient experienced
another vaginal bleeding which had not
stopped until now. She replaced her
sarongs 3 times. The bleeding
worsened with time.
This patient has AUB patterns of
menorrhagia and metrorrhagia
Conclusion
Risk Factors Risk factors of AUB, can
affect woman with all age
Physical Examination - General physical examinations
begin with full body system
evaluation to identify pathology
outside the ovarium and
endometrium.
- Gynecologic examination begins
with external examination,
inspeculo, internal vaginal and
bimanual palpation to examine
any other cause of bleeding.
Introduction Case Case Analysis
This patient was 39 years
old. She was at risk for
AUB.
- Patient have anemic
conjunctiva +/+. Another
examination within normal
limits.
- In this patient, when doing
inspeculo, bleeding is came
out from OUE. It was indicated
that bleeding is from uterus.
Another gynecology
examination are normal.
Conclusion
 Laboratory Investigations Complete hemogram, thyroid In this patient Hb 6.4 g/dL
profile, pregnancy test, Pregnancy test was done
coagulation profile. twice with negative result.

Imaging Studies Ultrasound to assess the Not performed

myometrium, endometrium, and
ovulation.

Introduction Case Case Analysis Conclusion

Introduction Case Case Analysis Conclusion
 MANAGEMENT OF ABNORMAL UTERINE
BLEEDING
Drug of choice Abnormal Uterine Bleeding :
Non-Hormonal
Tranexamat Acid (Antifibrinolityc)
Mefenamat Acid (NSAID)
Hormonal
Progestin
Estrogen
Combined Contraceptive Pill
Agonic GnRH
Danazol
Dilatation and curettage if vaginal bleeding continues for 12-24 hours.

Introduction Case Case Analysis Conclusion

 MANAGEMENT ON THIS PATIENT
Stabilization of general condition with:
Blood transfuse
Tranexamat Acid 3x1 IV
Mefenamat Acid 3x1
Planning of dilatation and curettage

Introduction Case Case Analysis Conclusion

1. The diagnosis were made by the history, physical
exam and additional exam.The final diagnosis:
abnormal uterine bleeding and anemia
2. Management on this patient is appropriate with
management abnormal uterine bleeding.

Introduction Case Case Analysis Conclusion