CHAPTER II CASE DIAGNOSIS AND LITERATURE REVIEW

PROBLEM LIST

Acute Pain related to biological injury secondary to Urinary tract Infection

24

DEFINITION OF MEDICAL DIAGNOSIS

Threatened Abortion is a condition that occurs during the first 20 weeks of
pregnancy, in which vaginal bleeding suggests an increased risk of miscarriage. Any
vaginal bleeding other than spotting during early pregnancy is considered a
threatened miscarriage. (A miscarriage may also be referred to as a spontaneous
abortion.) Vaginal bleeding is common in early pregnancy. About one of every four
pregnant women has some bleeding during the first few months. About half of these
women stop bleeding and have a normal pregnancy.
Threatened Abortion is an early-pregnancy bleeding can originate from the uterus,
cervix, or vagina, or it can come from outside the genitals. In many cases, the cause
of the bleeding is due to a minor condition that requires no treatment. However, if
you experience any vaginal bleeding during your pregnancy, particularly if it is
associated with abdominal pain, you should consult your doctor. Possible causes of
bleeding.
Threatened miscarriage, threatened spontaneous abortion Obstetrics Vaginal
bleeding at any time within the first 20 wks of pregnancy, accompanied by colicky
pain, backache and a bright red to brownish discharge; TAs occur in up to 20% of
early pregnancies of which 12 progress to inevitable abortion; no therapy is
consistently effective; bed rest, analgesics and sedatives are advised.
The bleeding and pain associated with threatened miscarriage are usually mild. In
the best case, the cervical os (mouth of the womb) is closed. (A health care
professional can determine if the cervical os is open by performing a pelvic exam.)
Typically, no tissue has been passed from the womb. The womb and Fallopian tubes
may be tender.

25

 When a miscarriage is inevitable, the cervical os is open (dilated). Bleeding is often

heavier, and abdominal pain and cramping often occur. If a miscarriage is
incomplete, the cervical os is open, and the pregnancy is being expelled. Ultrasound
reveals some material that remains in the womb. Bleeding is heavy and abdominal
pain is almost always present.

REVIEW OF ANATOMY AND PHYSIOLOGY

URINARY SYSTEM

26

Ever wonder how the universe could allow the existence of someone as annoying as
your bratty little brother or sister? The answer lies in reproduction. If people like your
parents (ew!) didn't reproduce, families would die out and the human race would
cease to exist.

Reproduction
All living things reproduce. Reproduction the process by which organisms make more
organisms like themselves is one of the things that set living things apart from

27

nonliving matter. But even though the reproductive system is essential to keeping a
species alive, unlike other body systems, it's not essential to keeping an individual alive.
In the human reproductive process, two kinds of sex cells, or gametes (pronounced:
gah-meetz), are involved. The male gamete, or sperm, and the female gamete, the egg
or ovum, meet in the female's reproductive system to create a new individual. Both the
male and female reproductive systems are essential for reproduction. The female needs
a male to fertilize her egg, even though it is she who carries offspring through
pregnancy and childbirth.
Humans, like other organisms, pass certain characteristics of themselves to the next
generation through their genes, the special carriers of human traits. The genes that
parents pass along to their children are what make children similar to others in their
family, but they are also what make each child unique. These genes come from the
father's sperm and the mother's egg, which are produced by the male and female
reproductive systems.

What Is the Female Reproductive System?

Most species have two sexes: male and female. Each sex has its own unique
reproductive system. They are different in shape and structure, but both are specifically
designed to produce, nourish, and transport either the egg or sperm.
Unlike the male, the human female has a reproductive system located entirely in the
pelvis (that's the lowest part of the abdomen). The external part of the female
28

reproductive organs is called the vulva, which means covering. Located between the
legs, the vulva covers the opening to the vagina and other reproductive organs located
inside the body.
The fleshy area located just above the top of the vaginal opening is called the mons
pubis (pronounced: manz pyoo-bis). Two pairs of skin flaps called the labia (which
means lips and is pronounced: lay-bee-uh) surround the vaginal opening. The clitoris
(pronounced: klih-tuh-rus), a small sensory organ, is located toward the front of the
vulva where the folds of the labia join. Between the labia are openings to the urethra
(the canal that carries urine from the bladder to the outside of the body, which is
pronounced: yoo-ree-thruh) and vagina. Once girls become sexually mature, the outer
labia and the mons pubis are covered by pubic hair.
A female's internal reproductive organs are the vagina, uterus, fallopian tubes, and
ovaries.
The vagina is a muscular, hollow tube that extends from the vaginal opening to the
uterus. The vagina is about 3 to 5 inches (8 to 12 centimeters) long in a grown woman.
Because it has muscular walls it can expand and contract. This ability to become wider
or narrower allows the vagina to accommodate something as slim as a tampon and as
wide as a baby. The vagina's muscular walls are lined with mucous membranes, which
keep it protected and moist. The vagina has several functions: for sexual intercourse, as
the pathway that a baby takes out of a woman's body during childbirth, and as the route
for the menstrual blood (the period) to leave the body from the uterus.

29

A thin sheet of tissue with one or more holes in it called the hymen partially covers the
opening of the vagina. Hymens are often different from person to person. Most women
find their hymens have stretched or torn after their first sexual experience, and the
hymen may bleed a little (this usually causes little, if any, pain). Some women who have
had sex don't have much of a change in their hymens, though.
The vagina connects with the uterus, or womb, at the cervix. The cervix has strong,
thick walls. The opening of the cervix is very small (no wider than a straw), which is why
a tampon can never get lost inside a girl's body. During childbirth, the cervix can expand
to allow a baby to pass.
The uterus is shaped like an upside-down pear, with a thick lining and muscular walls
in fact, the uterus contains some of the strongest muscles in the female body. These
muscles are able to expand and contract to accommodate a growing fetus and then
help push the baby out during labor. When a woman isn't pregnant, the uterus is only
about 3 inches (7.5 centimeters) long and 2 inches (5 centimeters) wide.
At the upper corners of the uterus, the fallopian (pronounced: fuh-lo-pee-un) tubes
connect the uterus to the ovaries (pronounced: o-vuh-reez). The ovaries are two ovalshaped organs that lie to the upper right and left of the uterus. They produce, store, and
release eggs into the fallopian tubes in the process called ovulation (pronounced: avyoo-lay-shun). Each ovary measures about 1 to 2 inches (4 to 5 centimeters) in a
grown woman.

30

There are two fallopian tubes, each attached to a side of the uterus. The fallopian tubes
are about 4 inches (10 centimeters) long and about as wide as a piece of spaghetti.
Within each tube is a tiny passageway no wider than a sewing needle. At the other end
of each fallopian tube is a fringed area that looks like a funnel. This fringed area wraps
around the ovary but doesn't completely attach to it. When an egg pops out of an ovary,
it enters the fallopian tube. Once the egg is in the fallopian tube, tiny hairs in the tube's
lining help push it down the narrow passageway toward the uterus.
The ovaries are also part of the endocrine system because they produce female sex
hormones

such

as

estrogen

(pronounced:

es-truh-jun)

and

(pronounced: pro-jes-tuh-rone).

What Does the Female Reproductive System Do?

The female reproductive system enables a woman to:

produce eggs (ova)

have sexual intercourse

protect and nourish the fertilized egg until it is fully developed

31

progesterone

give birth

Sexual reproduction couldn't happen without the sexual organs called the gonads.
Although most people think of the gonads as the male testicles, both sexes actually
have gonads: In females the gonads are the ovaries. The female gonads produce
female gametes (eggs); the male gonads produce male gametes (sperm). After an egg
is fertilized by the sperm, the fertilized egg is called the zygote (pronounced: zi-gote).
When a baby girl is born, her ovaries contain hundreds of thousands of eggs, which
remain inactive until puberty begins. At puberty, the pituitary gland, located in the central
part of the brain, starts making hormones that stimulate the ovaries to produce female
sex hormones, including estrogen. The secretion of these hormones causes a girl to
develop into a sexually mature woman.

Menstruation
Toward the end of puberty, girls begin to release eggs as part of a monthly period called
the menstrual cycle. Approximately once a month, during ovulation, an ovary sends a
tiny egg into one of the fallopian tubes. Unless the egg is fertilized by a sperm while in
the fallopian tube, the egg dries up and leaves the body about 2 weeks later through the
uterus. This process is called menstruation (pronounced: men-strew-ay-shun). Blood
and tissues from the inner lining of the uterus combine to form the menstrual flow, which

32

in most girls lasts from 3 to 5 days. A girl's first period is called menarche (pronounced:
meh-nar-kee).
It's common for women and girls to experience some discomfort in the days leading to
their periods. Premenstrual syndrome (PMS) includes both physical and emotional
symptoms that many girls and women get right before their periods, such as acne,
bloating, fatigue, backaches, sore breasts, headaches, constipation, diarrhea, food
cravings, depression, irritability, or difficulty concentrating or handling stress. PMS is
usually at its worst during the 7 days before a girl's period starts and disappears once it
begins.
Many girls also experience abdominal cramps during the first few days of their periods.
They are caused by prostaglandins, chemicals in the body that makes the smooth
muscle in the uterus contract. These involuntary contractions can be either dull or sharp
and intense.
It can take up to 2 years from menarche for a girl's body to develop a regular menstrual
cycle. During that time, her body is adjusting to the hormones puberty brings. On
average, the monthly cycle for an adult woman is 28 days, but the range is from 23 to
35 days.
Fertilization and Pregnancy
If a female and male have sex within several days of the female's ovulation (egg
release), fertilization can occur. When the male ejaculates (which is when semen leaves
a man's penis), between 0.05 and 0.2 fluid ounces (1.5 to 6.0 milliliters) of semen is

33

deposited into the vagina. Between 75 and 900 million sperm are in this small amount of
semen, and they "swim" up from the vagina through the cervix and uterus to meet the
egg in the fallopian tube. It takes only one sperm to fertilize the egg.
About a week after the sperm fertilizes the egg, the fertilized egg (zygote) has become a
multi-celled blastocyst (pronounced: blas-tuh-sist). A blastocyst is about the size of a
pinhead, and it's a hollow ball of cells with fluid inside. The blastocyst burrows itself into
the lining of the uterus, called the endometrium (pronounced: en-doh-mee-tree-um).
The hormone estrogen causes the endometrium to become thick and rich with blood.
Progesterone, another hormone released by the ovaries, keeps the endometrium thick
with blood so that the blastocyst can attach to the uterus and absorb nutrients from it.
This process is called implantation.
As cells from the blastocyst take in nourishment, another stage of development, the
embryonic stage, begins. The inner cells form a flattened circular shape called the
embryonic disk, which will develop into a baby. The outer cells become thin membranes
that form around the baby. The cells multiply thousands of times and move to new
positions to eventually become the

embryo (pronounced: em-bree-o). After

approximately 8 weeks, the embryo is about the size of an adult's thumb, but almost all
of its parts the brain and nerves, the heart and blood, the stomach and intestines,
and the muscles and skin have formed.
During the fetal stage, which lasts from 9 weeks after fertilization to birth, development
continues as cells multiply, move, and change. The fetus (pronounced: fee-tus) floats in
amniotic (pronounced: am-nee-ah-tik) fluid inside the amniotic sac. The fetus
34

receives oxygen and nourishment from the mother's blood via the placenta
(pronounced: pluh-sen-tuh), a disk-like structure that sticks to the inner lining of the
uterus and connects to the fetus via the umbilical (pronounced: um-bih-lih-kul) cord.
The amniotic fluid and membrane cushion the fetus against bumps and jolts to the
mother's body.
Pregnancy lasts an average of 280 days about 9 months. When the baby is ready for
birth, its head presses on the cervix, which begins to relax and widen to get ready for
the baby to pass into and through the vagina. The mucus that has formed a plug in the
cervix loosens, and with amniotic fluid, comes out through the vagina when the mother's
water breaks.
When the contractions of labor begin, the walls of the uterus contract as they are
stimulated by the pituitary hormone oxytocin (pronounced: ahk-see-toh-sin). The
contractions cause the cervix to widen and begin to open. After several hours of this
widening, the cervix is dilated (opened) enough for the baby to come through. The baby
is pushed out of the uterus, through the cervix, and along the birth canal. The baby's
head usually comes first; the umbilical cord comes out with the baby and is cut after the
baby is delivered.
The last stage of the birth process involves the delivery of the placenta, which is now
called the afterbirth. After it has separated from the inner lining of the uterus,
contractions of the uterus push it out, along with its membranes and fluids.

35

Stages of Pregnancy: Introduction

Introduction
This series aims to introduce you to the changes taking place inside a pregnant
woman's uterus, some of the changes that pregnant women may experience during
pregnancy, and routine doctor appointments. In this series, the developmental age is
referred to as the pregnancy age or weeks.
What is gestational age?
This series is headed by gestational age. Gestational age refers to the number of
weeks since the pregnant woman's last menstrual period (LMP). This differs from the
developmental age of the foetus which, depending on the exact time of fertilisation, is
approximately 2 weeks less than the gestational age.

36

What is my due date?

The expected length of gestation in humans is 40 weeks 2 weeks. The due date
(expected birth date of your baby) is therefore the date 40 weeks after your last
menstrual period (LMP). If the date of your last menstrual period is uncertain, an early
dating ultrasound (an ultrasound performed early in the pregnancy) is performed to
calculate the age of the foetus, and from this information, the expected date of delivery.
During the early stages of embryo development (i.e. 6 Weeks Pregnant), there are
several key external features that can be used to accurately determine the age of the
embryo developing in your womb.
Why is it important I see my doctor regularly during my pregnancy?
Antenatal care refers to the series of doctors' appointments and/or interventions that a
woman receives from healthcare services during her pregnancy. While the majority of
care takes place during the pregnancy, antenatal care also includes those
appointments and/or interventions related to the pregnancy that occur before and after
the pregnancy i.e. doctors' appointments related to pregnancy planning and
optimising medical conditions/medication before falling pregnant (preconception
counselling), and care after the delivery of the baby (postpartum period).
A definition from the 1930s that still stands today is that antenatal care is "the whole art
of preventive obstetrics". Hence antenatal care acts to prevent or identify and treat
conditions that may cause harm to the foetus/newborn or the mother. In doing so, it also
aims to help women have positive pregnancy and birth experiences.

37

It is important to attend regular antenatal care so that the best health outcomes for both
you and your baby can be achieved. Having an understanding of the changes taking
place within your body will help you to understand some of the symptoms that you may
experience during your pregnancy and when you should seek help from your doctor.

Stages of Development of the Fetus

A baby goes through several stages of development, beginning as a fertilized egg. The
egg develops into a blastocyst, an embryo, then a fetus.
Fertilization
During each normal menstrual cycle, one egg (ovum) is usually released from one of
the ovaries, about 14 days before the next menstrual period. Release of the egg is
called ovulation. The egg is swept into the funnel-shaped end of one of the fallopian
tubes.
At ovulation, the mucus in the cervix becomes more fluid and more elastic, allowing
sperm to enter the uterus rapidly. Within 5 minutes, sperm may move from the vagina,
through the cervix into the uterus, and to the funnel-shaped end of a fallopian tubethe
usual site of fertilization. The cells lining the fallopian tube facilitate fertilization.
38

If a sperm penetrates the egg, fertilization results. Tiny hairlike cilia lining the fallopian
tube propel the fertilized egg (zygote) through the tube toward the uterus. The cells of
the zygote divide repeatedly as the zygote moves down the fallopian tube. The zygote
enters the uterus in 3 to 5 days. In the uterus, the cells continue to divide, becoming a
hollow ball of cells called a blastocyst. If fertilization does not occur, the egg
degenerates and passes through the uterus with the next menstrual period.
If more than one egg is released and fertilized, the pregnancy involves more than one
fetus, usually two (twins). Such twins are fraternal. Identical twins result when one
fertilized egg separates into two embryos after it has begun to divide.
Development of the Blastocyst
Between 5 and 8 days after fertilization, the blastocyst attaches to the lining of the
uterus, usually near the top. This process, called implantation, is completed by day 9 or
10.
The wall of the blastocyst is one cell thick except in one area, where it is three to four
cells thick. The inner cells in the thickened area develop into the embryo, and the outer
cells burrow into the wall of the uterus and develop into the placenta. The placenta
produces several hormones that help maintain the pregnancy. For example, the
placenta produces human chorionic gonadotropin, which prevents the ovaries from
releasing eggs and stimulates the ovaries to produce estrogen and progesterone

39

continuously. The placenta also carries oxygen and nutrients from mother to fetus and
waste materials from fetus to mother.
Some of the cells from the placenta develop into an outer layer of membranes (chorion)
surrounding the embryo. An inner layer of membranes (amnion) develops by about day
10 to 12, forming the amniotic sac. The amniotic sac fills with a clear liquid (amniotic
fluid) and expands to envelop the developing embryo, which floats within it.

Development of the Embryo

The next stage in development is the embryo, which develops under the lining of the
uterus on one side. This stage is characterized by the formation of most internal organs
and external body structures. Organ formation begins about 3 weeks after fertilization,
when the embryo elongates, first suggesting a human shape. Shortly thereafter, the
area that will become the brain and spinal cord (neural tube) begins to develop. The
heart and major blood vessels begin to develop by about day 16 or 17. The heart begins
to pump fluid through blood vessels by day 20, and the first red blood cells appear the
next day. Blood vessels continue to develop in the embryo and placenta.
Almost all organs are completely formed by about 8 weeks after fertilization (which
equals 10 weeks of pregnancy). The exceptions are the brain and spinal cord, which
continue to mature throughout pregnancy. Most malformations (birth defects) occur
during the period when organs are forming. During this period, the embryo is most
vulnerable to the effects of drugs, radiation, and viruses. Therefore, a pregnant woman
40

should not be given any live-virus vaccinations or take any drugs during this period
unless they are considered essential to protect her health (see Drug Use During
Pregnancy).

Development of the Fetus and Placenta

At the end of the 8th week after fertilization (10 weeks of pregnancy), the embryo is
considered a fetus. During this stage, the structures that have already formed grow and
develop. The following are markers during pregnancy:

By 12 weeks of pregnancy: The fetus fills the entire uterus.

By about 14 weeks: The sex can be identified.

By about 16 to 20 weeks: Typically, the pregnant woman can feel the fetus
moving. Women who have been pregnant before typically feel movements about
2 weeks earlier than women who are pregnant for the first time.

By about 24 weeks: The fetus has a chance of survival outside the uterus.

The lungs continue to mature until near the time of delivery. The brain accumulates new
cells throughout pregnancy and the first year of life after birth.
41

As the placenta develops, it extends tiny hairlike projections (villi) into the wall of the
uterus. The projections branch and rebranch in a complicated treelike arrangement.
This arrangement greatly increases the area of contact between the wall of the uterus
and the placenta, so that more nutrients and waste materials can be exchanged. The
placenta is fully formed by 18 to 20 weeks but continues to grow throughout pregnancy.
At delivery, it weighs about 1 pound.
THE FORMATION OF URINE
FIGURATION, REABSORPTION, AND SECRETION
Every one of us depends on the process of urination for the removal of certain waste
products in the body. The production of urine is vital to the health of the body. Most of us
have probably never thought of urine as valuable, but we could not survive if we did not
produce it and eliminate it. Urine is composed of water, certain electrolytes, and various
waste products that are filtered out of the blood system. Remember, as the blood flows
through the body, wastes resulting from the metabolism of foodstuffs in the body cells
are deposited into the bloodstream, and this waste must be disposed of in some way. A
major part of this "cleaning" of the blood takes place in the kidneys and, in particular, in
the nephrons, where the blood is filtered to produce the urine. Both kidneys in the body
carry out this essential blood cleansing function. Normally, about 20% of the total blood
pumped by the heart each minute will enter the kidneys to undergo filtration. This is
called the filtration fraction. The rest of the blood (about 80%) does not go through the
filtering portion of the kidney, but flows through the rest of the body to service the
various nutritional, respiratory, and other needs that are always present.

42

For the production of urine, the kidneys do not simply pick waste products out of the
bloodstream and send them along for final disposal. The kidneys' 2 million or more
nephrons (about a million in each kidney) form urine by three precisely regulated
processes: filtration, reabsorption, and secretion.

Filtration
Urine formation begins with the process of filtration, which goes on continually in the
renal corpuscles (Figure 3). As blood courses through the glomeruli, much of its fluid,
containing both useful chemicals and dissolved waste materials, soaks out of the blood
through the membranes (by osmosis and diffusion) where it is filtered and then flows
into the Bowman's capsule. This process is called glomerular filtration. The water,
waste products, salt, glucose, and other chemicals that have been filtered out of the
blood are known collectively as glomerular filtrate. The glomerular filtrate consists
primarily of water, excess salts (primarily Na + and K+), glucose, and a waste product of
the body called urea. Urea is formed in the body to eliminate the very toxic ammonia
products that are formed in the liver from amino acids. Since humans cannot excrete
ammonia, it is converted to the less dangerous urea and then filtered out of the blood.
Urea is the most abundant of the waste products that must be excreted by the kidneys.
The total rate of glomerular filtration (glomerular filtration rate or GFR) for the whole
body (i.e., for all of the nephrons in both kidneys) is normally about 125 ml per minute.

43

That is, about 125 ml of water and dissolved substances are filtered out of the blood per
minute. The following calculations may help you visualize how enormous this volume is.
The GFR per hour is:
125 ml/min X 60min/hr= 7500 ml/hr.
The GFR per day is:
7500 ml/hr X 24 hr/day = 180,000 ml/day or 180 liters/day.
Now, see if you can calculate how many gallons of water we are talking about. Here
are some conversion factors for you to consider: 1 quart = 960 ml, 1 liter = 1000 ml, 4
quarts. = 1 gallon. Remember to cancel units and you will have no problem.
Now, what we have just calculated is the amount of water that is removed from the
blood each day - about 180 liters per day. (Actually it also includes other chemicals, but
the vast majority of this glomerular filtrate is water.) Imagine the size of a 2-liter bottle of
soda pop. About 90 of those bottles equals 180 liters! Obviously no one ever excretes
anywhere near 180 liters of urine per day! Why? Because almost all of the estimated 43
gallons of water (which is about the same as 180 liters - did you get the right answer?)
that leaves the blood by glomerular filtration, the first process in urine formation, returns
to the blood by the second process - reabsorption.
Reabsorption
Reabsorption, by definition, is the movement of substances out of the renal tubules
back into the blood capillaries located around the tubules (called the peritubular
copillaries). Substances reabsorbed are water, glucose and other nutrients, and
44

sodium (Na+) and other ions. Reabsorption begins in the proximal convoluted tubules
and continues in the loop of Henle, distal convoluted tubules, and collecting tubules
(Figure 3). Let's discuss for a moment the three main substances that are reabsorbed
back into the bloodstream.
Large amounts of water - more than 178 liters per day - are reabsorbed back into the
bloodstream from the proximal tubules because the physical forces acting on the water
in these tubules actually push most of the water back into the blood capillaries. In other
words, about 99% of the 180 liters of water that leave the blood each day by glomerular
filtration returns to the blood from the proximal tubule through the process of passive
reabsorption.
The nutrient glucose (blood sugar) is entirely reabsorbed back into the blood from the
proximal tubules. In fact, it is actively transported out of the tubules and into the
peritubular capillary blood. None of this valuable nutrient is wasted by being lost in the
urine. However, even when the kidneys are operating at peak efficiency, the nephrons
can reabsorb only so much sugar and water. Their limitations are dramatically illustrated
in cases of diabetes mellitus, a disease which causes the amount of sugar in the blood
to rise far above normal. As already mentioned, in ordinary cases all the glucose that
seeps out through the glomeruli into the tubules is reabsorbed into the blood. But if too
much is present, the tubules reach the limit of their ability to pass the sugar back into
the bloodstream, and the tubules retain some of it. It is then carried along in the urine,
often providing a doctor with her first clue that a patient has diabetes mellitus. The value
of urine as a diagnostic aid has been known to the world of medicine since as far back

45

as the time of Hippocrates. Since then, examination of the urine has become a regular
procedure for physicians as well as scientists.
Sodium ions (Na+) and other ions are only partially reabsorbed from the renal tubules
back into the blood. For the most part, however, sodium ions are actively transported
back into blood from the tubular fluid. The amount of sodium reabsorbed varies from
time to time; it depends largely on how much salt we take in from the foods that we eat.
(As stated earlier, sodium is a major component of table salt, known chemically as
sodium chloride.) As a person increases the amount of salt taken into the body, that
person's kidneys decrease the amount of sodium reabsorption back into the blood. That
is, more sodium is retained in the tubules. Therefore, the amount of salt excreted in the
urine increases. The process works the other way as well. The less the salt intake, the
greater the amount of sodium reabsorbed back into the blood, and the amount of salt
excreted in the urine decreases.
Secretion
Now, let's describe the third important process in the formation of urine. Secretion is the
process by which substances move into the distal and collecting tubules from blood in
the capillaries around these tubules (Figure 3). In this respect, secretion is reabsorption
in reverse. Whereas reabsorption moves substances out of the tubules and into the
blood, secretion moves substances out of the blood and into the tubules where they mix
with the water and other wastes and are converted into urine. These substances are
secreted through either an active transport mechanism or as a result of diffusion
across the membrane. Substances secreted are hydrogen ions (H+), potassium ions

46

(K+), ammonia (NH3), and certain drugs. Kidney tubule secretion plays a crucial role in
maintaining the body's acid-base balance, another example of an important body
function that the kidney participates in.

ETIOLOGY
Early-pregnancy bleeding can originate from the uterus, cervix, or vagina, or it
can come from outside the genitals. In many cases, the cause of the bleeding is due to
a minor condition that requires no treatment. However, if you experience any vaginal
bleeding during your pregnancy, particularly if it is associated with abdominal pain, you
should consult your doctor. Possible causes of bleeding include:
Table 7. Precipitating Factors

Ideal

Actual

Justification

Infection (UTI)

Present

In

pregnant

women,

hormones cause changes in

the

urinary

predispose
infections.

tract,

which

women
In

addition,

to
a

growing uterus presses on

the bladder, preventing the
complete emptying of urine.
47

This stagnant urine is a likely

source

for

infection.

Untreated, these infections

may

lead

to

kidney

infections. Urinary tract and

kidney infections in pregnant
women should be treated to
prevent complications.

Table 8. Predisposing Factors

Ideal

Actual

Justification

AOG (7 weeks)

Present

Approximately
pregnant

20%

women

of

experience

some vaginal bleeding, with

or without

abdominal

cramping,

during the first trimester. This is

known as a threatened abortion.
However,

most

of

these

pregnancies go on to term with or

without treatment. Spontaneous
abortion occurs in less than
30%

of

the

experience

women

who

vaginal bleeding

during pregnancy. In the cases

that

result

in

spontaneous

abortion, the usual cause is

48

fetal

death.

typically

the

Such

death

result

is

of

chromosomal or developmental
abnormality. Other
causes

include

potential
infection,

maternal anatomic defects,

e n d o c r i n e f a c t o r s , immunologic
factors, and maternal systemic disease

SYMPTOMATOLOGY
Threatened abortion is a condition that occurs during the first 20 weeks of
pregnancy, in which vaginal bleeding suggests an increased risk of Miscarriage.
Any vaginal bleeding other than spotting during early pregnancy is considered a
threatened miscarriage. (A miscarriage may also be referred to as a spontaneous
abortion.) Vaginal bleeding is common in early pregnancy. About one of every four
pregnant women has some bleeding during the first few months. About half of these
women stop bleeding and have a normal pregnancy.
The bleeding and pain associated with threatened miscarriage are usually mild.
In the best case, the cervical os (mouth of the womb) is closed. (A health care
professional can determine if the cervical os is open by performing a pelvic exam.)

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Typically, no tissue has been passed from the womb. The womb and Fallopian tubes
may be tender.
When a miscarriage is inevitable, the cervical os is open (dilated). Bleeding is
often heavier, and abdominal pain and cramping often occur.
If a miscarriage is incomplete, the cervical os is open, and the pregnancy is being
expelled. Ultrasound reveals some material that remains in the womb. Bleeding is
heavy and abdominal pain is almost always present.
With a complete miscarriage, bleeding and abdominal pain have occurred but
have usually stopped. Products of conception have been passed. The early fetus has
been passed and was not alive. Ultrasound reveals an empty womb.

Table 9. Symptoms of Threatened Abortion

Ideal

Actual

Vaginal Bleeding

Present

Justification
Early-pregnancy bleeding
can

originate

from

the

uterus, cervix, or vagina, or

it can come from outside
the

genitals.

In

many

cases, the cause of the

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bleeding is due to a minor

condition that requires no
treatment. However, if you
experience
bleeding

any

vaginal

during

your

pregnancy, particularly if it
is

associated

with

abdominal pain, you should

consult your doctor.
Epigastric Pain

Present

Pain and cramping are in

the lower abdomen. They
may be on one side, both
sides, or in the middle. The
pain can go into the lower
back,

buttocks,

and

genitals.
Lower Back Pain

Present

The

bleeding

and

pain

associated with threatened

abortion are usually mild.

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Threatened Miscarriage Symptoms

Symptoms of a spontaneous miscarriage include vaginal bleeding and abdominal pain.

Bleeding may be only slight spotting, or it can be heavy. The health care
professional
will ask how heavy the bleeding is, and how many pads are being soaked
through per hour. The health care professional will also ask about blood clots or
tissue passed.

Pain and cramping are in the lower abdomen. They may be on one side, both
sides, or in the middle. The pain can go into the lower back, buttocks, and
genitals.

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Causes of Threatened Abortion

Early-pregnancy bleeding can originate from the uterus, cervix, or vagina, or it can
come from outside the genitals. In many cases, the cause of the bleeding is due to a
minor condition that requires no treatment. However, if you experience any vaginal
bleeding during your pregnancy, particularly if it is associated with abdominal pain, you
should consult your doctor. Possible causes of bleeding include:

Implantation of the embryo

Infection

Irritation (eg, after intercourse)

Miscarriage

Ectopic Pregnancy -the baby starts to develop outside the uterus, such as in a
fallopian tube

Molar pregnancy-usually benign formations of placental cells (trophoblasts) in the

uterus that can spread to nearby tissues and become malignant

Table 10: Subgroups of Spontaneous Abortion

Subgroup
Threatened abortion

Definition
Presents as vaginal bleeding in the presence of
a viable pregnancy with a closed cervix
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Inevitable abortion

Occurs when the cervix has dilated and the

membranes have ruptured, but the products of

Missed abortion

conception remain in utero

Characterized by intrauterine fetal death and

Complete abortion

retention of the products of conception

Refers to the spontaneous passage of all the
products of conception; does not require
medical treatment
A history of 3 or more spontaneous pregnancy

Recurrent abortion

PATHOPHYSIOLOGY

Precipitating Factors

Predisposing Factors

Age: 19 years old

Health Status: UTI

Age of Gestation: 7 weeks

During egg implantation, egg slightly separates or tears from the uterus

Blood collects between the chorionic membrane (a membrane that develops around a
fertilized egg) and the wall of the uterus

Blood leaks in the cervix

Mild uterine cramping

Date: March 19, 2013

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Minimal vaginal spotting/bleeding

Date: March 19. 2013

Subchorionic hemorrhage

Severe SC bleeding can lead to rupture of the suchorionic membrane

Risk for miscourage and still birth (threatened abortion)

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