Chapter I

Introduction
A miscarriage is any pregnancy that ends spontaneously before the fetus can survive. A miscarriage is
medically referred to as a spontaneous abortion (SAB). The World Health Organization defines this unsurvivable
state as an embryo or fetus weighing 500 grams or less, which typically corresponds to a fetal age (gestational age)
of 20 to 22 weeks or less. Miscarriage occurs in about 15% to 20% of all recognized pregnancies, and usually occurs
before the 13th week of pregnancy. With the development of highly sensitive assays for hCG levels that can detect
an early pregnancy even prior to the expected next period (menstruation), researchers have been able to show that
around 60% to 70% of all pregnancies (recognized and unrecognized) are lost. Because the loss occurs so early,
many miscarriages occur without the woman ever having known she was pregnant. Of those miscarriages that occur
before the eighth week, 30% have no fetus associated with the sac or placenta. This condition is called blighted
ovum, and many women are surprised to learn that there was never an embryo inside the sac.
As described above, some miscarriages occur before women recognize that they are pregnant. About 15%
of fertilized eggs are lost before the egg even has a chance to implant (embed itself) in the wall of the uterus. A
woman would not generally identify this type of miscarriage. Another 15% of conceptions are lost before eight
weeks' gestation. Once fetal heart function is detected in a given pregnancy, the chance of miscarriage is less than
5%. There can be many confusing terms and moments that accompany a miscarriage. There are different types of
miscarriage, different treatments for each, and different statistics for what your chances are of having one.
Why do miscarriages occur?
The reason for miscarriage is varied, and most often the cause cannot be identified. During the first trimester,
the most common cause of miscarriage is chromosomal abnormality - meaning that something is not correct with the
baby's chromosomes. Most chromosomal abnormalities are the cause of a faulty egg or sperm cell, or are due to a
problem at the time that the zygote went through the division process. Other causes for miscarriage include (but are
not limited to):
Hormonal problems, infections or maternal health problems
Lifestyle (i.e. smoking, drug use, malnutrition, excessive caffeine and exposure to radiation or toxic
substances)
Implantation of the egg into the uterine lining does not occur properly
Maternal age
Maternal trauma
Factors that are not proven to cause miscarriage are sex, working outside the home (unless in a harmful
environment) or moderate exercise.


The chances of having a Miscarriage:
For women in childbearing years, the chances of having a miscarriage can range from 10-25%, and in most
healthy women the average is about a 15-20% chance.
An increase in maternal age affects the chances of miscarriage
Women under the age of 35 yrs old have about a 15% chance of miscarriage
Women who are 35-45 yrs old have a 20-35% chance of miscarriage
Women over the age of 45 can have up to a 50% chance of miscarriage
A woman who has had a previous miscarriage has a 25% chance of having another (only a slightly elevated
risk than for someone who has not had a previous miscarriage)
Warning signs of Miscarriage:
If the patient experienced any or all of these symptoms, it is important to contact your doctor or a medical facility to
evaluate if you could be having a miscarriage:
Mild to severe back pain (often worse than normal menstrual cramps)
Weight loss
White-pink mucus
True contractions (very painful happening every 5-20 minutes)
Brown or bright red bleeding with or without cramps (20-30% of all pregnancies can experience some
bleeding in early pregnancy, with about 50% of those resulting in normal pregnancies)
Tissue with clot like material passing from the vagina
Sudden decrease in signs of pregnancy
The different types of Miscarriage:
Miscarriage is often a process and not a single event. There are many different stages or types of
miscarriage. There is also a lot of information to learn about healthy fetal development so that you might get a better
idea of what is going on with your pregnancy. Understanding early fetal development and first trimester
development can help you to know what things your health care provider is looking for when there is a possible
miscarriage occurring. Most of the time all types of miscarriage is just called miscarriage, but you may hear your
health care provider refer to other terms or names of miscarriage such as:
Threatened Miscarriage: Some degree of early pregnancy uterine bleeding is accompanied by cramping
or lower backache. The cervix remains closed. This bleeding is often the result of implantation.
Inevitable or Incomplete Miscarriage: Abdominal or back pain accompanied by bleeding with an open
cervix. Miscarriage is inevitable when there is a dilation or effacement of the cervix and/or there is rupture
of the membranes. Bleeding and cramps may persist if the miscarriage is not complete.
Complete Miscarriage: A completed miscarriage is when the embryo or products of conception have
emptied out of the uterus. Bleeding should subside quickly, as should any pain or cramping. A completed
miscarriage can be confirmed by an ultrasound or by having a surgical curettage performed.
Missed Miscarriage: Women can experience a miscarriage without knowing it. A missed miscarriage is
when embryonic death has occurred but there is not any expulsion of the embryo. It is not known why this
occurs. Signs of this would be a loss of pregnancy symptoms and the absence of fetal heart tones found on
an ultrasound.
Recurrent Miscarriage (RM): Defined as 3 or more consecutive first trimester miscarriages. This can
affect 1% of couples trying to conceive.
Risk Factors of Pregnancy that Result to Miscarriage
Blighted Ovum: Also called an anembryonic pregnancy. A fertilized egg implants into the uterine wall,
but fetal development never begins. Often there is a gestational sac with or without a yolk sac, but there is
an absence of fetal growth.
Ectopic Pregnancy: A fertilized egg implants itself in places other than the uterus, most commonly the
fallopian tube. Treatment is needed immediately to stop the development of the implanted egg. If not
treated rapidly, this could end in serious maternal complications.
Molar Pregnancy: The result of a genetic error during the fertilization process that leads to growth of
abnormal tissue within the uterus. Molar pregnancies rarely involve a developing embryo, but often entail
the most common symptoms of pregnancy including a missed period, positive pregnancy test and severe
nausea.
Treatment of Miscarriage
The main goal of treatment during or after a miscarriage is to prevent haemorrhaging and/or infection. The
earlier you are in the pregnancy, the more likely that your body will expel all the fetal tissue by itself and will not
require further medical procedures.
D&C: If the body does not expel all the tissue, the most common procedure performed to stop bleeding and
prevent infection is a dilation and curettage, known as a D&C.
Medication: Drugs may be prescribed to help control bleeding after the D&C is performed. Bleeding
should be monitored closely once you are at home; if you notice an increase in bleeding or the onset of
chills or fever, it is best to call your physician immediately.
Prevention of Miscarriage
Since the cause of most miscarriages is due to chromosomal abnormalities, there is not much that can be done to
prevent them. One vital step is to get as healthy as you can before conceiving to provide a healthy atmosphere for
conception to occur.
Exercise regularly
Eat healthy
Manage stress
Keep weight within healthy limits
Take folic acid daily
Do not smoke
Once you find out that you are pregnant, again the goal is to be as healthy as possible, to provide a healthy
environment for your baby to grow in:
Keep your abdomen safe
Do not smoke or be around smoke
Do not drink alcohol
Check with your doctor before taking any over-the-counter medications
Limit or eliminate caffeine
Avoid environmental hazards such as radiation, infectious disease and x-rays
Avoid contact sports or activities that have risk of injury
Emotional Treatment
Unfortunately, miscarriage can affect anyone. Women are often left with unanswered questions regarding
their physical recovery, their emotional recovery and trying to conceive again. It is very important that women try to
keep the lines of communication open with family, friends and health care providers during this time.






CHAPTER II
PERSONAL PROFILE

Name : Patient RD
Address : Brgy. Culis Hermosa, Bataan
Gender : Female
Age : 20 years old
Date of Birth : March 21, 1980
Place of Birth : Pasay City, Manila
Religion : Roman Catholic
Nationality : Filipino
Weight : 47 kg
Height : 53 ft
Obstetrical Scoring: G
1
P
0

Name of Hospital: Jose C. Payumo Jr. Memorial Hospital
Name of Doctor: Dra. Dimaunahan





Initial Vital Signs:

Temperature: 35.8C Pulse Rate: 62bpm Respiratory rate: 26bpm BP: 90/60 mmHg

Chief Complaint:

Abdominal pain and vaginal bleeding

Past Medical History:

Patient RD, was admitted to the Orani District Hospital due to dengue. It happened when she was 16 years
old.

Present Medical History:

Ilang araw na akong dinudugo at masakit ang puson ko., as verbalized by the patient. Prior to the
consultation of the patient she experienced abdominal pains and cramps and vaginal bleeding. She is also pregnant.
She became discomfortable due to the pain the patient experienced. Due to a few days of suffering pain, she decided
to consult a doctor.

Family Health History:

Mother Side Father Side
Doesnt have any family disease
(No family history of hypertension, heart diseases,
diabetes, respiratory diseases, vascular diseases or any
diseases that can be inherited.)

Doesnt have any family disease
(No family history of hypertension, heart diseases,
diabetes, respiratory diseases and any vascular diseases
or any diseases that can be inherited.)



Daily Activity Pattern

Prior to Hospitalization During Hospitalization
Nutritional Hygiene The patient eats bread and coffee
every morning and red and white
meat for lunch and dinner. She eats
vegetables and fish sometimes.
Also she ingested paracetamol due
to a headache she suffered.
The patient still eats bread and soup
every morning and red or white
meat for lunch and dinner. She
increased intake of vegetables and
fruits and increased fluid intake.
Personal Hygiene The patient takes a bath twice a day
which is in the morning and before
going to bed.

The patient did not take a bath only
a sponge bath before and after the
D&C.
Rest and sleep Pattern The patient usually sleeps twice a
day, in the afternoon and at night.
The patient sleeps more than her
usual sleeping pattern. She sleeps in
the morning after breakfast, in the
afternoon and at night.
Exercise Pattern The patient does not perform
exercises in the morning. But
performs strenuous activities such
as lifting a pail of water even
though shes pregnant.
The patient does not perform
exercises in the morning either. She
was just on her bed almost all the
time.
Elimination Pattern The patient defecates once a day in
the morning. And urinates at least
four times a day.
The patient defecates once a day in
the morning and urinates five times
a day. Her urine is reddish due to
bleeding and to a volume of 200
mL a day.

Socio-Economic

The patient is living with her family far from civilization. Patient described their place as a clean and with
order surroundings. Shes the oldest among the 4 siblings. Her father was a factory worker while her mother is an
elementary teacher. They have a small sari-sari store and her husband is a construction worker.

Lifestyle
Patient RD said that she with her family takes care of herself. She always stays at home with her nephews while
her husband is at work. She does a lot of household chores whenever she stays at home. She fetches a pail of water
whenever she takes a bath even when she is pregnant. They eat three times a day. They eat meat, fish, and
vegetables, no known vices and cleaning around serves as their exercise.
















Physical Assessment

Part of examine Technique used Result Interpretation
SKIN Inspection


Palpation
Brown complexion
Moist
Pallor

Cold to touch

Normal

Normal
Due to bleeding
Due to low
temperature

NAIL Inspection



Palpation (blanch test)
Slightly pallor

160 (contour)

Return normally after
3 seconds

Due to bleeding
Normal

Normal

SKULL Inspection

Palpation
Normocephalic

No lesions,
tenderness, and
masses upon
palpation
Normal

Normal

SCALP Inspection



Palpation
Lighter in color than
complexion
Presence of dandruff
No lesions,
tenderness, masses
nor irregularity
Thick and smooth
Normal

Due to poor
hygiene
Normal


Normal
FACE Inspection



Distance between the
eyes are equal
Symmetrical

Normal

Normal
EYES Inspection Symmetrical to each
other
Non protruding
Equal palperable
fissure
Normal

Normal
Normal
CONJUNCTIVAE Inspection Pale in color
Moist
Normal
Normal

SCLERAE Inspection Anicteric Normal

PUPIL Inspection PERRLA Normal

EARS Inspection


Palpation
Symmetrical
Bean-shape
Has firm cartilage
No pain or tenderness
Normal
Normal
Normal
Normal

MOUTH

Lips


Gums

Teeth


Inspection
Inspection

Inspection


Symmetrical
Pallor

No receding gums

30 teeth



Yellowish in color


Normal
Due to blood loss
Normal

Due to
inappropriate oral
hygiene (2 teeth
loss)
Normal
NECK Inspection



Palpation
Straight and
symmetrical.
Similar to skin
complexion
No visible masses
Normal

Normal

Normal
CHEST Inspection


Palpation



Lighter than
complexion
Symmetrical
Sternum on midline
Flat sternum
Intercostals spaces
Symmetrical
No tenderness
Normal

Normal
Normal

Normal
Normal
Normal
Normal

ABDOMEN Inspection










Auscultation



Percussion


Palpation
Lighter than
complexion
Slightly round
Moist and free from
lesions
Umbilicus is on
center, clean and free
from implantation and
drainage

Audible bowel sounds
absence of arterial
bruits
Dullness over the
spleen and liver

No tenderness and
enlargement
Normal

Normal
Normal

Normal





Normal

Normal

Normal


Normal

EXTRIMITIES
Upper






Lower


Inspection






Inspection





Palpation


Both arms can be
flexed (ROM)
No scars noted
Trimmed finger nails
No edematous arms
noted

Both legs can be
flexed (ROM)
No scars noted
No swelling of feet
No nodules palpated



Normal

Normal
Normal
Normal
Normal

Normal
GENITALS (female)
Inspection

Pubic hair was shaved
No lesions noted
Swelling of the
vaginal opening


Vaginal opening is
reddish in color


Labia is pinkish in
color but slightly
swelling is noted
Bleeding discharge

Normal

Normal
Due to insertion
of vaginal
speculum
Due to insertion
of vaginal
speculum
Due to the
procedure done
Due to the
procedure done










CHAPTER III
ANATOMY & PHYSIOLOGY


The Female Reproductive System

External Structure










Mons Veneris is a pad of adipose tissue located over the symphysis pubis. It is covered by a triangle of
course, curly hairs. The purpose of this is to protect the junction of the pubic bone from trauma.
Labia Minora is just posterior of the mons veneris spread two hairless fold of connective tissue. Before the
menarche, these folds are fairly small; by child-bearing age they are firm and full; after menopause they
atrophy and again become much smaller.
Labia Majora are two folds of adipose tissue covered by two loose connective tissue and epithelium.
Covered by pubic hair and serve as the protection for external genitalia and distal urethra and vagina.
Vestibule is the flattened smooth surface in the labia. The openings to the bladder (urethra) and the uterus
(vagina) both arise from the vestibule.
Clitoris is a small, rounded organ of erectile tissue at the forward junction of the labia minora. It is covered
by a fold skin, the prepuce. The clitoris is sensitive to touch and temperature and is the center of sexual
arousal and orgasm in the female.








Internal Structure















Ovaries are approximately 4 cm long by 2 cm in diameter and approximately 1.5 cm thick or the size and
shape of almonds. They are grayish-white and appear pitted or with minute indentions on the surface. An
unruptured, glistening, clear fluid-filled grafian follicle (an ovum about to discharged often can be observed
on the surface of an ovary. The function of the two ovaries is to produce mature and discharge ova. In the
process, the ovaries produce estrogen and progesterone and initiate and regulate menstrual cycle.

Fallopian Tubes are next to ovaries approximately 10 cm in length. Their function is to convey the ovum
from the ovaries to the uterus and to provide a place for fertilization of the ovum by sperm.

Uterus is a hollow, muscular, pear-shaped organ located in the lower pelvis, posterior to the bladder and
anterior to the rectum. The function of the uterus is to receive the ovum from the fallopian tube; provide a
place for implantation and nourishment during fetal growth; furnish protection to a growing fetus, expel it
from a womans body.

Vagina is a hollow, musculomembranous canal located posterior to the bladder and anterior to the rectum.
It extends from the cervix of the uterus to the external vulva. Its function is to act as the organ of
intercourse and to convey sperm to the cervix so that sperm can meet with the ovum in the fallopian tube.
Cervix is the lower third portion of the uterus which forms the neck of the uterus and opens into the vagina
which is also called the endocervical canal. The narrow opening of the cervix is called the os. The cervical
os allows menstrual blood to flow out from the vagina during menstruation. During pregnancy the cervical
os closes to help keep the fetus in the uterus until birth. Another important function of the cervix occurs
during labor when the cervix dilates, or widens, to allow the passage of the fetus from the uterus to the
vagina.








CHAPTER V
Laboratory Tests

Name: Patient RD
Vital Signs: T: 35.8C PR: 62bpm RR: 26bpm BP: 90/60 mmHg

Hematology










Complete Blood Count Result Normal Values Interpretation
Hemoglobin (Mass
Concentration)
107.0 M 130-180g/L; F160g/L Low due to vaginal
bleeding
RBC (Number Concentration) M 4.5.5 x 10 12/L; F 4.5 x 10
12/L

WBC (Number Concentration) 4.10 x 10 9/L
Hematocrit 37.0 - 48.0 / 42.0 52.0
Platelets 140 - 415
Lymphocytes 17 44
Monocytes 3 - 10
Neutrophils 45 - 76
Eosinophils 0 - 4
Basophils 0 - 2
DISCHARGE PLANNING

Medication

Teach patient about the proper way of taking her medicines and the actions of each medicines in the
manner that patient can easily and clearly understand the implication and emphasizing the importance of following
the prescribe medication. Instruct the patient to take Ferrous sulfate once a day every 8 in the morning, Cephalexin 3
times a day, methylergometrine maleate3 times a day.

Economy

Inform the patient about the generic name of her medicines yet giving them idea that they can save money buying
generic drugs. The generic name of drug prescribed by doctor is Ferrous sulfate, Cephalexin, methylergometrine.

Treatments

Recommend the patient to follow all prescribe medications in an accurate amount. Encourage also the
patient to increase fluid intake.

Health Teachings
Educate the patient on how she can prevent miscarriage to happen again. To prevent bacteria from entering the
cervix following D&C, she should refrain from sexual intercourse, tampon use, and douches for at least a week.
Showering, bathing, or swimming is permitted as soon as she feel well enough. She should notify her doctor if fever,
abdominal pain, heavy bleeding, or a vaginal discharge with a bad odor occurs. And inform her to make sure she
follows up with her doctor as recommended after the surgery.
Out-patient Referral

Inform that she have a follow-up check-up after a week to her doctor specifically on August 13, 2010.

Diet

Educate patient that her diet is as tolerated but emphasizing the need to increase foods which are rich in
iron like green leafy vegetables and ampalaya and even chicken liver.







Urinalysis
Urine Test Normal Values Interpretation
Color: Reddish Colorless Yellowish Due to vaginal bleeding
Transparency: Slightly Turbid Transparent/Clear Normal
Sugar: Negative Negative Normal
pH: 6 5-7 Normal
Sp. Gravity: 1.0 1.003 - 1.03 Normal
WBC: 4.0 4.1-10.9x10
3
/L Normal
RBC: Plenty 3.8-5.5x10
6
/L (Female) Normal
Epithelial Cells: Rare None- rare Normal
Mucus Threads:
Bacteria: Few None Due to infection


DISCHARGE PLANNING

Medication

Teach patient about the proper way of taking her medicines and the actions of each medicines in the
manner that patient can easily and clearly understand the implication and emphasizing the importance of following
the prescribe medication. Instruct the patient to take Ferrous sulfate once a day every 8 in the morning, Cephalexin 3
times a day, methylergometrine maleate3 times a day.

Exercise

The patient should do some exercise in the morning. She can do some stretching when she wake up in the
morning and some basic exercise like jog in place, walking or even aerobics if she doesnt work.
Treatments

Recommend the patient to follow all prescribe medications in an accurate amount. Encourage also the
patient to increase fluid intake.




Health Teachings
Educate the patient on how she can prevent miscarriage to happen again. To prevent bacteria from entering the
cervix following D&C, she should refrain from sexual intercourse, tampon use, and douches for at least a week.
Showering, bathing, or swimming is permitted as soon as she feel well enough. She should notify her doctor if fever,
abdominal pain, heavy bleeding, or a vaginal discharge with a bad odor occurs. And inform her to make sure she
follows up with her doctor as recommended after the surgery.
Out-patient Referral

Inform that she have a follow-up check-up after a week to her doctor specifically on August 13, 2010.

Diet

Educate patient that her diet is as tolerated but emphasizing the need to increase foods which are rich in
iron like green leafy vegetables and ampalaya and even chicken liver.