Case study-Incomplete Abortion

Republic of the Philippines City of Olongapo Gordon College SY 2013-2014

A Case Study of G1P0 PU 8 6/7 AOG Incomplete Abortion

In Partial Fulfillment of the Course requirement in Clinical Practicum 205

Presented to: The Faculty Members of School of Midwifery

Submitted by: Taruc, Jane-Vi October 2, 2013

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

Types: Complete abortion- complete expulsion of all the products of conception. Criminal abortion - termination of pregnancy by illegal interference, usually undertaken when legal induced abortion is unavailable. The most frequent complications are severe hemorrhage and sepsis, and for those who delay seeking medical attention the mortality rate is high. Habitual abortion - in three or more consecutive pregnancies before the 20th week of gestation. Incomplete abortion- abortion in which parts of the products of conception are retained in the uterus. Induced abortion -abortion brought on intentionally by medication or instrumentation. Inevitable abortion- a condition in which vaginal bleeding has been profuse, membranes usually show gross rupturing, the cervix has become dilated, and abortion is almost certain. Missed abortion- retention of dead products of conception in utero for more than 8 weeks. Septic abortion - abortion associated with serious infection of the products of conception and endometrial lining of the uterus, leading to generalized infection; it is usually caused by pathogenic organisms of the bowel or vagina. Spontaneous abortion - termination of pregnancy before the fetus is sufficiently developed to survive; called miscarriage .Chromosomal abnormalities cause at least half of spontaneous abortions.

Therapeutic abortion - abortion induced legally by a qualified physician to safeguard the health of the mother. Threatened abortion- a condition in which vaginal bleeding is less than in inevitable abortion, the cervix is not dilated, and abortion may or may not occur; this is the presumed diagnosis when any bloody vaginal discharge or vaginal bleeding occurs in the first half of pregnancy.

Factors: 1. Fetal Factors – abnormal zygotic development 2. Maternal Factors – infections, nutrition, drug use and environmental factors, uterine defects and incompetent cervix. 3. Paternal Factors – abnormalities of sperm Management for incomplete abortion: Dilatation and curettage Dilatation and curettage (D&C) refers to the widening or opening of the cervix and surgical removal of part of the lining of the uterus and or contents of the uterus by scraping and scooping (curettage). It is a therapeutic gynecological procedure as well as a method of first trimester abortion.

Instruments for Dilatation and Curretage:

Speculums, Retractors, Dilators and Tenaculums - Speculums and vaginal retractors move the walls of the vagina and cervix out of the way so that the doctor performing the D&C has a better view during the procedure. Goodel and Hegar Dilators to dilate the cervix. Forceps (Vulsellas) - The doctor uses these instruments for grasping problematic or suspicious matter from the uterus. This is especially useful if the doctor needs to remove specific tissues for lab tests. Hystetometer (UTERINE SOUND) - The hystetometer, also known as a uterometer or uterine sound, is a probe. The doctor uses this instrument to get an idea of how the uterus is placed directionally. Sharp Currette – the most important instrument in D&C.it is used for scraping and gently removes the uterine lining. Dull Currette – for finsidhing touches after the sharp curette. Straight Catheter – to empty bladder

Pathophysiology

Fertilization  implantation  Fetal, Maternal or Paternal Factors

Sign and symptoms: -

Vaginal bleeding Uterine cramps

Threatened

may go to term

inevitable incomplete abortion (passage of some parts of conception)

complete abortion (passage of all parts of conception) -

Patient’s Profie

Patient J is a 20 years old female currently residing at Subic, Zambales. Her menarche was when she was 12 years old with a regular flow of 3 to 4 days consuming 2 pads per day with negative dysmenorrhea. Her coitarche happen when she was 16 years old with a total number of 2 partners with no history of STD. Patient J is known as non smoker and non alcohol drinker. Her height in cm is 160 and weight of 57 kg. Patient tells me that 3 days before admission, she goes to an unlicensed birth attendant and after several hours she experienced vaginal bleeding consuming 3 fully soaked regular napkin pads with episodes of blood clots. She suspects that she is pregnant because of 1 month amenorrhea and a positive pregnancy test but didn’t go to any health facility for pre-natal check-up. She admits that she engaged on pre-marital sex with her partner, but they didn’t want the child because they are not married and still studying and their parents will be in an uproar if they knew this unwanted pregnancy so they decided to get the baby aborted.

Course in the Ward Day 1 June 12, 2013 at 4:10 pm Patient J was admitted at James L. Gordon Memorial Hospital at 4:15 pm with a chief complaint of “dinudugo po ako”as verbalized by the patient , her LMP was April 5, 2013, with 8 6/7 age of gestation, her EDD was January 11, 2014 . Patient J was brought to ER via stretcher and admitted under the service of Dr.Corpuz and consent has been secured for admission and management. Her admitting v/s was Temp-36.6 C, PR-87 bpm, RR 20-bpm, BP – 110/70 mmHg. Her family history reveals that there is negative hypertension. Her physical exam was conscious, coherent, afebrile and not in cardio-pulmonary distress. She has symmetrical chest expansion, no retractions and clear breath sounds. Doctor’s ordered were carried out; her diet was NPO, with an IVF D5LR’s x 30 gtts/min and PNSS 500cc KVO, insert indwelling folley catheter and connect to urine bag. Also she was ordered for diagnostics of CBC with BT stat, U/A, HBSag, GS/CS of blood per vagina and RPR. ANST was done with negative results for hypersensitivity. , IE reveals of cervix open, patient has positive vaginal bleeding and passage of some parts of conception in os. Preparation has been done for completion curettage. V/S and I&O monitored and recorded every 1 hour.

Around 7:08 pm, patient transferred to DR table for D&C. Local anesthesia and sedative was given to patient. Evacuation of placental fragments was aseptically done by Dr. Corpuz, at 7:45 pm oxytocin was given IM to stimulate contractions. Patient was transferred to Gyne ward safely by stretcher around 11:20 pm with an ongoing D5LR’s IVF and PNSS and placed comfortably on bed, with no active bleeding and uterus was firm and contracted. Postpartum orders were as follows which were carried out monitored V/S q 15 minutes x 1 hr, q 30 minutes x 1 hr, q 4 hrs until stable, WOF profuse vaginal bleeding. Refer as necessesary.

Vital Signs Monitoring with the following results: Date 6/12/13

Shift pm

Time 5 6 7 8 9 10 11 12

BP 120/90mmh g 120/90mmh g 110/80mmh g 120/90mmh g 120/80mmh g 110/80mmh g 110/70mmh g 90/60mmhg

PR 82bpm

RR 19bpm

T 36.6 C

80bpm

18bpm

36.7 C

79bpm

18bpm

36.5 C

85bpm

19bpm

36.6 C

87bpm

19bpm

36.5 C

86bpm

20bpm

36.6 C

84bpm

22bpm

36.7 C

89bpm

20bpm

36.5 C

Hematology Time: 6:30 pm Blood Type Hgb Hct WBC Neutrophils Lymphocytes Platelet

O Rh (+) 123 0.37 15-13 x109/L 0.70 0.35 226 x 10 x109/L

Normal Values M: 140-180 F: 120-150 M: 0.40-0.50 F: 0.30-0.40 5.0-10.0 x 10 x109/L 0.30-0.70 0.20-0.40 150-350 x 10 x109/L

Interpretation: The result in hematology was in the range of normal.

Blood type : O Rh (+) Medical Microbiology and culture and sensitivity test:  Blood per vagina : epithelial cells – occasional : no growth of microorganisms after 3 days incubation Day 2 June 13 , 2013 Time: 9:00 am

On the following day, Patient J was fully awake and coherent, not in afebrile condition with an ongoing IVF D5LR’s 1L 300cc level and PNSS terminated, patient instructs diet as tolerated. V/S was taken and recorded and medication was given by staff nurse. Health teaching was done while perineal hygiene was advised. Her uterus has kept well-contracted but have a minimal vaginal bleeding while needs are attended and care was rendered, so the evaluation is stable. After Dr. Corpuz sees the patient , she ordered an MGH disposition. Vital Signs Monitoring with the following results: Date 6/13/13

Shift Am

Time 8 12

PM

4 8 12

BP 120/90mmh g 110/90mmh g 110/80mmh g 110/90mmh g 120/90mmh g

PR 83bpm

RR 20bpm

T 36.6 C

85bpm

18bpm

36.7 C

79bpm

20bpm

36.5 C

84bpm

18bpm

36.7 C

83bpm

19bpm

36.8 C

Serology-Immunology Time: 6:30 am HBSag Syphilis

Result Non-reactive Non-reactive

Interpretation: The patient was non-reactive in both HBSag and Syphilis and it is normal, meaning the patient don’t have the disease. Urinalysis Time: 3 pm Macroscopic Color Transparency Specific gravity Reaction Protein Glucose

Results Yellow Slightly cloudy 1.010 Acidic (-) (-)

Microscopic RBC WBC Bacteria

Results 126.3 / µL 31.10 / µL 4544.2/ µL

Normal Values 0-11 / µL 0-17 / µL 0-1 / µL

Interpretation: The result in Urinalysis (microscopic) was above normal due to the cause of infection prior to D&C and due to the trauma and stress experience by the woman during the procedure. Drug Study: Intrapartum: Medications

Dosage

Route

Indications

Oxytocin

10 unit

IM

To improve and stimulate the uterine contractions

D5LR’s

1 liter Parenteral regulated of 30 drops per minute

A type of hypertonic solution that is source of water electrolytes

Application to the patient To facilitate and stimulate of the uterine contraction of the woman and control postpartum bleeding To replace and replenish the electrolytes mainly glucose of the woman.

PNSS

500 cc regulated KVO

Parenteral

Diazepam

10mg

IM

Medications

Dosage

Route

Fortifier FA

125mg/tab

Oral

Mefenamic acid 500mg/tab with meals

Oral

Co-amoxiclav

Oral

625 mg/cap BID x 7 days

and calories A type of isotonic solution , and prevent for hypocvolemic shock

A sedation that provides light anesthesia and muscle relaxant Indications

A solution for fluid and electrolyte replenishment. And used to woman for prevention of shock Used to sedate the woman during the procedure

Application to the patient To prevent and Because the treat iron patient had a deficiency lot of blood loss anemia so she needs to regain by taking this and she is prone to anemia Relief of pain Because during post op postpartum and postpartum women had a traumatic experience and pain during procedure Used to prevent Mother who an infection have been for completion curettage can be at risk of getting infection, example: the

patient has a poor perineal hygiene Postpartum:

Conclusion Patient J, a 20 years old G31P20PU 8 6/7 weeks of AOG, is rushed and admitted to the James L. Gordon Memorial Hospital because of vaginal bleeding. She has no pre-natal check-up and no TT vaccine. She goes to an unlicensed birth attendant because of unwanted pregnancy eventhough she know the risk and dangers having an illegal abortion. She has an incomplete abortion and for completion curettage under the service of Dr.Corpuz. Patient J was stabled after the day of procedure, uterus was firm and globular,well-contracted, and no post partum problem, also she didn’t acquired any infection so the doctor ordered an MGH disposition.

Recommendation Here are the list of the health teachings that I share to my patient for the health of her baby and herself:

1. Being an adolescent, I suggest that she attend family planning seminar or go the nearest health center to provide information about family planning, so she can have plan for her reproductive health and prevent the recurring of unsafe abortion. Family planning reduces maternal mortality. 2. Counseling the patient is very vital because of having or experiencing an depression and suggest to talk to her family what she feels and also I told her about the danger having an unsafe abortion. 3. I also advised her perineal hygiene washing and wiping from front to back to prevent infection. She may use boiled guava leaves for decoction. 4. She should watch out for any complications and seek immediately medical attention like heavy bleeding. 5. I also told her that she should be able to resume her regular activities within a day or two. Mild cramping and spotting may occur for a few hours or days. 6. She should not put anything inside the vagina (tampons, douches) during this time to prevent infection. 7. I also told her next menstrual period usually occurs within four to six weeks after the procedure .