Incomplete

Abortion
Case
Analysis

Case Handled: February 10 and 11, 2020

By: Felix, Irish Eunice A
Sec: BSN – 2A
Introduction

Abortion is the loss or termination of pregnancy less than the age of viability which is
20-24 weeks of gestation or if the fetus weighs less than 500 grams.

Early abortion happens before 12 weeks of gestation

Late abortion happens 12-20 weeks of gestation

Abortus is a fetus that weighs less than 500 grams or expelled from uterus before age
of viability.

Factors are Fetal factors, Maternal factors and Paternal factors.

Demographic Data

This is the case of Patient IC, a 39 year old G1P0 (0010), female, Filipino, Roman
Catholic, married, currently live in Taguig City, admitted for Vaginal bleeding in Pasay
City General Hospital on January 27, 2020.

Chief Complaint

Vaginal Bleeding

History of Present Illness

3 days prior to admission, the patient experienced abdominal pain in the hypogastric
area, with a scale of 6/10. She took mefenamic 500mg.

2 days prior to admission, the patient experienced heavy vaginal bleeding consuming 3
napkins, fully soaked. Along with the the abdominal pain in the hypogastic region that is
radiating to the lower back.

1 day prior to admission, the patient experiences intermittent fever and headache. She
took Paracetamol 500 mg to relieve the symptoms.

Few hours prior to admission, heavy vaginal bleeding, hypogastric pain, fever with
nausea and vomiting along with headache that prompted her for hospitalization as she
complaint her symptoms at the PCGH.

Past Medical History

The patient has no previous hospitalization or any surgeries noted. No medical history
of Cancer, Tuberculosis, Asthma, Diabetes Mellitus, or Hypertension.
Family History

The patient’s mother has hypertension, her father is deceased.

Personal and Social History

The patient lives in Taguig City with her husband. She uses her household chores as an
exercise. Patient IC is a non smoker and an occasional drinker consuming 1 bottle of
emperador lights. Diet consists mainly of fish, meat, eggs, vegetables and rice.

Menstrual History

Patient IC menarche started when she was 13 years old, her menstrual period duration
is 4-5 days, regular cycle of 28 days, consumes 3-4 pads per day, heavily soaked at her
2nd and 3rd day period.

Medications

Her medications are Cefalexin 500mg, Mefenamic Acid 500 mg, Ferrous Sulfate.

Course in the OBWard (February 10, 2020)

Patient IC was admitted at Pasay City General Hospital with a chief complaint
“Dinudugo ako” as verbalized by the patient last January 27, 2020. Her admitting v/s
was Temp-36.6 C, PR-67 bpm, RR 20 cpm, BP – 110/70 mmHg. She was told to stay
for more than 10 days by the doctor for observation because she might need another
surgery because there is still a positive heavy vaginal bleeding. She will undergo a
transvaginal ultrasound at 2 pm. The patient doesn’t have any contraptions. V/S
monitored and recorded every 4 hours.

Patient’s Vital Sign February 10, 2020

8 AM 12 PM

BP: 90/60 mmHg BP: 100/70 mmHg

CR: 59 bpm CR: 64 bpm

RR: 19 cpm RR: 18 cpm

Temp: 36.1 C Temp: 36.1 C

Course in the OBWard (February 11, 2020)

On the following day, Patient IC was fully awake and coherent, patient instructs diet as
tolerated. V/S was taken and recorded every 4 hours. Health teaching was done
regarding perineal care. She still doesn’t have an order of MGH yet because she’s
awaiting for her surgery for today.

Patient’s Vital Sign February 11, 2020

7:05 AM 11 PM

BP: 100/70 mmHg BP: 100/80 mmHg

CR: 64 bpm CR: 66 bpm

RR: 19 cpm RR: 18 cpm

Temp: 35.8 C Temp: 36.3 C

Case Discussion

Patient IC is a 39 year old noted to have a heavy vaginal bleeding, and hypogastric pain
radiating to the back, had fever, headache, nausea and vomiting with a BP of 100/80
mmHg. Vaginal bleeding during pregnancy is the most predictive factor for pregnancy
loss or abortion. Classifications of abortions include spontaneous abortion, recurrent
miscarriage, incuded abortion, and contraception following miscarriage or abortion.

There are 4 types of spontaneous abortion:

1. Threatened abortion- the clinic diagnosis of threatened abortion is presumed

when a bloody vaginal discharge or bleeding appears through a closed cervical
os during the first half of pregnancy. With miscarriage, bleeding usually begins
first and cramping abdominal pain usually follows a few hours to several days
later. The pain may present as anterior and clearly rhythmic cramps. There is
also a persistent low back ache associated with a feeling of pelvic pressure or as
a dull, midline, suprapubic discomfort, because ectopic pregnancy, ovarian
torsion may mimic threatened abortion. Women with early vaginal bleeding and
pain should be evaluated. Hematocrit is performed when there is persistent or
heavy vaginal bleeding. If there is significant anemia or hypovolemia, pregnancy
evacuation is usually indicated.
 There are no effective therapies for threatened abortion. Bed rest, although often
prescribed but does not alter it’s course. Acetaminophen, based on analgesia
may be given for discomfort.

Rule in: the patient experience heavy vaginal bleeding, abdominal pain on her
first trimester of pregnancy.
Rule out: the clinical diagnosis of threatened abortion is presumed when a bloody
vaginal discharge or bleeding appears through a closed cervical os during the
first half of pregnancy.

2. Missed abortion- is described as dead products of conception that were

retained for days, weeks, or even months in the uterus with a closed cervical os.
Early pregnancy appear to be normal, with amenorrhea, nausea and vomiting,
breast changes and uterine growth. After embryonic death, there may or may not
be vaginal bleeding or any other symptoms of threatened abortion. There is
gradual decrease in size of the uterus and mammary changes usually regress
and women often lose a few pounds.

Rule in: Heavy vaginal bleeding

Rule out: described as dead products of conception in the uterus with a closed
cervical os.

3. Septic abortion- is a condition where in the product of conception and uterus is

infected. Endomyometritis is the most common manifestation of postbortal
infection. Treatment of infection includes prompt administration of intravenous
broad spectrum antiobiotics followed by a uterine evacuation. With severe sepsis
syndrome, acute respiratory syndrome or dessiminated intravascular
coagulopathy may develop, and supportive care is essential.

Rule in: heavy vaginal bleeding, intermittent fever, nausea and vomiting.
Rule out: the patient has no severe infections noted prior to pregnancy.

4. Incomplete abortion- during incomplete abortion, the internal cervical os opens

and allows passages of blood. The fetus or placenta may remain entirely in utero
or may partially extrude through the dilated os. In many cases retained placental
tissue simply lies loosely in the cervical canal, allowsing easy extraction from an
exposed external os with ring forceps.

Hemorrhage from incomplete abortion of a more advanced pregnancy is

occasionally severe but rarely fatal. Therefore, in women with more advanced
pregnancy or with heavy bleeding,evacuation is promptly performed. If there is
fever, appropriate antiabiotics is given before curettage.

Rule in: heavy vaginal bleeding with open cervical os, fever, nausea and
vomiting.
Risk Factors:

Maternal Factors

Clinically, apparent miscarriage increases with parity as well as maternal and paternal
age. The frequency doubles from 12% from women younger than 20 years to 26% in
those older than 40 years old.

Drug and Environmental factors

A variety of different agents have been reported to be associated with an increase

incidence of abortion.

Alcohol. Both spontaneous abortion and fetal anomalies may result from frequent
alcohol use during the first 8 weeks of pregnancy.

Surgical techniques in abortion

Dilation and Curettage

Is a procedure to remove tissue from inside the uterus. Doctors perform D and C to
diagnose and treat certain uterine conditions – such as heavy bleeding – or to clear the
uterine lining after a miscarriage or abortion.

In a dilation and curettage — sometimes spelled "dilatation" and curettage — your

doctor uses small instruments or a medication to open (dilate) your cervix — the lower,
narrow part of your uterus. Your doctor then uses a surgical instrument called a curette
to remove uterine tissue. Curettes used in a D&C can be sharp or use suction.

To diagnose a condition

Your doctor might recommend a type of D&C called endometrial sampling to diagnose a
condition if:

 You have abnormal uterine bleeding

 You experience bleeding after menopause
 Your doctor discovers abnormal endometrial cells during a routine test for
cervical cancer
To perform the test, your doctor collects a tissue sample from the lining of your uterus
(endometrium) and sends the sample to a lab for testing. The test can check for:

 Endometrial hyperplasia — a precancerous condition in which the uterine lining

becomes too thick
 Uterine polyps
 Uterine cancer

Risks

Dilation and curettage is usually very safe, and complications are rare. However, there
are risks. These include:

 Perforation of the uterus. Perforation of the uterus occurs when a surgical

instrument pokes a hole in the uterus. This happens more often in women who
were recently pregnant and in women who have gone through menopause.

Most perforations heal on their own. However, if a blood vessel or other organ is
damaged, a second procedure may be necessary to repair it.

 Damage to the cervix. If the cervix is torn during the D&C, your doctor can apply
pressure or medicine to stop the bleeding, or can close the wound with stitches
(sutures).

 Scar tissue on the uterine wall. Rarely, a D&C results in development of scar

tissue in the uterus, a condition known as Asherman's syndrome. Asherman's
syndrome happens most often when the D&C is done after a miscarriage or
delivery. This can lead to abnormal, absent or painful menstrual cycles, future
miscarriages and infertility.
 Infection. Infection after a D&C is possible, but rare.

Contact your doctor if you experience any of the following after a D&C:

 Bleeding that's heavy enough that you need to change pads every hour
 Fever
 Cramps lasting more than 48 hours
 Pain that gets worse instead of better
 Foul-smelling discharge from the vagina
After the procedure

You may spend a few hours in a recovery room after the D&C so that your doctor can
monitor you for heavy bleeding or other complications. This also gives you time to
recover from the effects of anesthesia.

If you had general anesthesia, you may become nauseated or vomit, or you might have
a sore throat if a tube was placed in your windpipe to help you breathe. With general
anesthesia or light sedation, you may also feel drowsy for several hours.

Normal side effects of a D&C may last a few days and include Mild cramping and
Spotting or light bleeding

For discomfort from cramping, your doctor may suggest taking ibuprofen (Advil, Motrin
IB, others) or another medication.

You should be able to resume your normal activities within a day or two.

Wait to put anything in your vagina until your cervix returns to normal to prevent bacteria
from entering your uterus, possibly causing an infection. Ask your doctor when you can
use tampons and resume sexual activity.

Your uterus must build a new lining after a D&C, so your next period may not come on
time. If you had a D&C because of a miscarriage, and you want to become pregnant,
talk with your doctor about when it's safe to start trying again.

Conclusion

Patient IC is a 39 year old G1P1 (0010), rushed and admitted to Pasay City General
Hospital last January 27, 2020 because of Vaginal bleeding. She has an incomplete
abortion and for undergoes a Dilation and Curettage procedure under the service of
Doctor Wong.

Patient IC was unstabled after the day of her procedure, she still has a positive heavy
vaginal bleeding and awaits for another surgery so the doctor cannot order an MGH.