Clinical Note 4--Maternity Hospital.

Esam Al Amad
208111721
Maternity Hospital
Date:April 23th, 2014

Personal Data:

Name: Hanan
Age: 32
Date of admission: 20th
th
April, 2014.
Civil Status: Married for 6 years.
Occupation: Housewife
Ethnicity: Non Kuwaiti- Arab.
LMP: 12/3/14
Getatsional age: 6 Weeks
EDD: 17/12/14

Presenting Complaint:
Fever, lower abdominal pain, and vaginal bleeding of 1-day duration.

History of presenting complaint:
The patient suffered a miscarriage at 6 weeks gestation after which she developed a
high-grade fever of 39 C, chills, and lower abdominal pain in the suprapubic region
associated with vaginal bleeding of foul smelling discharge with blood. The pain was
in the suprapubic region; it was associated with fever, chills and vaginal bleeding. It
was a dull aching and cramping pain, and did not radiate to anywhere else in her
body. The pain was not alleviated by analgesics. The pain was of gradual onset over
the course of 1 day. It was continuous and the patient graded the pain as 5/10.

Obstetric history:
P2+0+1+2

The patient is a known case of a previous miscarriage in her first trimester in
2013 for which she was diagnosed as a case of complete miscarriage
(abortion).

Her two children are alive and well and were born by cesarean section.

1
st
child: 2009- C-Section due to breech presentation. Pregnancy was
otherwise uneventful. Baby born at 37 weeks with birth weight of 2.9 kg

2
nd
Child: 2012- C-section due to patient choice in private hospital. Pregnancy
was otherwise uneventful. Baby born at 38 Weeks with birth weight of 3.2 Kg

The pregnancy was not planned, and she was not on any contraceptive
medication or devices.

The patient had a pregnancy test 4 days after she missed her period.

The patient has had an uneventful pregnancy up until now.

Gynecological history:

The patient reached menarche at the age of 12 years
Her menstrual cycle is regular in pattern with normal duration of around 28
days.
The period would last 5 days with normal amount and contents.
The patient has never had a cervical smear.

She has never had investigations for any infertility, PID, or any sexually
transmitted. She does not have any history of bleeding or any disruption in her
menstrual cycle.
Last menstrual Period was on 12/3/14

Past medical and surgical history
The patient does not have any chronic conditions such as hypertension or Diabetes
Mellitus and is otherwise normal. She has never been admitted for any illness, and
this is the first time she experienced these symptoms.

Family History:
Her father is alive and has diabetes and hypertension. Her mother is also alive and
well. Her siblings are also healthy and well. There are no documented or known
diseases that run in the family.

Social History:
Husband: Smokes tobacco outdoors only, does not consume alcohol.
Patient: Does not smoke tobacco or consume alcohol.
Residence: She lives in Hawally with her husband in an apartment on the 3
rd
floor.
She is unemployed
No pets in the house.

Drug and allergies history:
The patient is not on any known drugs or medication. She has no known allergies to
any food or medication.

General Health status:
Appetite: Normal
Bowel Habit: Normal
Weight: Steady-She is at an optimum weight.
Well-being: Good.
Sleep: Uninterrupted
Micturition: Normal
Energy: Good



Systems Review
Cardiovascular No palpitations, No dyspnea, No chest pain or peripheral edema
Respiratory No SOB on exertion, no cough, no wheeze
Urogenital No polyuria no dysuria
Joints/muscles No joint pain, stiffness or back pain
Special Senses Hearing and vision are both intact
Neurological No headaches, dizziness or vertigo. Balance and coordination normal

Examination performed by senior Doctor on the day of admission:

BP: 100/50
Pulse 120
Temp: 38.2 C
Abdomen: soft and lax, Mild suprapubic tenderness.
P/V: Closed OS, Soft cervix, Positive for bleeding.


Physical Examination-By Student:
Alert, cooperative, and responsive. Sitting in bed in comfortably not in pain. She is
attached to an IV line.


Vital Signs:

Heart Rate 78 BPM
Blood pressure 100/60mmHg
Respiratory 14/min
Temperature 37 C

General Inspection:

General Patients looks well, not in pain. No deformities, or any visible scarring.
No central obesity
Hands No evidence of clubbing or nail abnormality
Eyes No jaundice, No conjunctival pallor or exophthalmos,
Mouth No central cyanosis or oral ulceration, and good dental hygiene
Muscles/joints No visible deformities

Abdominal Examination
Inspection There was no distention of the abdomen. No redness or visible
pulsations. There was a previous lower segment cesarean section scar.
Previous striae from pregnancy that were white colored. No linea nigra
seen. Flat umbilicus.

Palpation The abdomen is soft, lax and mildly tender/discomfort. No
organomegaly.
Auscultation Normal bowel sounds
Fundal height: Not Felt.


Cardiovascular
Radial pulse Good volume and regular rhythm, symmetrical
Apex Not palpated
Auscultation S1 and S2 normal with no added sounds
JVP normal
Pulses All felt and normal
Inspection of legs: No scars or ulcers no lower limb edema

Respiratory System
Trachea Central
Inspection normal, no scars, normal chest movements.
Percussion RT = Left
Auscultation Vesicular breath sounds were heard and Vocal resonance was equal in
all areas.


Musculoskeletal examination: Normal range of movement






Plan:
IV Lines access
Triple Antibiotics
U/S Transvaginal
Methergine
Anti D

Progress notes:
Seen next day:
Patient is doing well , she is stable, not febrile. Her vitals are stable.
Her abdominal pain has decreased and she is on regular analgesic medication.
She spiked a fever last night at 3 am, and it has now subsided.
BP 110/70
Pulse-77
Temp: 37



Investigation:
Transvaginal Ultrasound:
Anteverted uterus
No IUGS
Ovaries sonogrpohically free
Clear Adnexa

CBC:
MPV: High-12.5
Neutrophils: High-78
Monocytes: High-13.6

Coagulation Prpfile: Normal
Clinical Chemistry:
Pottassium Low: 3.3
Uric Acid: Low- 130
ALT: Low 25
Iron: Low-3.4



Summary in the box:

Septic abortion refers to a complicated form of spontaneous abortion
accompanied by an intrauterine infection. Septic abortion is uncommon in women
with spontaneous abortion and is more frequently associated with induced abortion. It
is important to recognize the signs and symptoms of septic abortion, because the
condition can be severe and life threatening.

Common clinical features of septic abortion include fever, chills, malaise,
abdominal pain, vaginal bleeding, and discharge, which is often sanguinopurulent.
Physical examination may reveal tachycardia, tachypnea, lower abdominal
tenderness, and a boggy, tender uterus with dilated cervix.
Infection is usually due to Staphylococcus aureus, Gram-negative bacilli, or
some Gram positive cocci. Mixed infections, anaerobic organisms, and fungi, can also
be encountered. The infection may spread, leading to salpingitis, generalized
peritonitis, and septicemia.

Management of septic abortion includes:
Stabilizing the patient
Obtaining blood and endometrial cultures
Promptly administering parenteral broad spectrum antibiotics
Intravenous antibiotics are administered until the patient has improved and
been afebrile for 48 hours, then are typically followed by oral antibiotics to
complete a 10- to 14-day course.
Surgically evacuating the uterine contents

Evacuation of the uterus should begin promptly after initiating antibiotics and
stabilizing the patient in cases of suspected septic abortion or retained products of
conception as delay in evacuation may be fatal

Suction curettage is less traumatic than sharp curettage. Indications for surgery
and possible hysterectomy include failure to respond to uterine evacuation and
antibiotics, pelvic abscess, and clostridial necrotizing myonecrosis (gas gangrene).

A discolored, woody appearance of the uterus and adnexa, suspected clostridial
sepsis, crepitation of the pelvic tissue, and radiographic evidence of air within the
uterine wall are indications for total hysterectomy and adnexectomy. Surgery, if
indicated, may be performed by laparoscopy

References: Up To Date: Miscarriage-Post abortion sepsis-Management and care
guidelines.