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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)
-

Patients 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 didnt go to
any health facility for pre-natal check-up. She admits that she engaged on pre-marital
sex with her partner, but they didnt 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 akoas 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. Doctors ordered were carried out; her diet was NPO, with an IVF
D5LRs 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 D5LRs 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 D5LRs 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 dont 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 / L
31.10 / L
4544.2/ L

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

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

D5LRs

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 didnt 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 .