11. OB Score: G3P2 (1112)
G1 2007 Live baby boy Premature
10days incubated
7 lbs. Family Care
Hospital
G2 2009 Live baby girl Normal spontaneous
delivery
6 lbs. Gavino Alvarez
Lying In
G3 2013 Present pregnancy
LMP: April 15, 2013
PMP: March 2013
AOG: 12 3/7 weeks AOG by LMP
EDC: January 20, 2014
12. 5 Weeks amenorrhea
(+) Pregnancy Test
1st prenatal check up at a
health center
Urinalysis done - revealed
normal result
Given Ferrous Sulfate and
Multivitamins
Lost to follow up
13. 3 DAYS PTA
consuming 3 fully-soaked
regular napkin pads
with episodes of blood clots
NO MEDICATIONS TAKEN.
NO CONSULTATION DONE.
14. • Vaginal bleeding
• Consuming 1 fully-soaked
regular napkin pad
• sought consult at the ER
• advised for admission
1 DAY PTA
(JULY 10, 2013)
ADMITTED
16. General Survey: conscious, coherent, ambulatory, agitated and
not in cardiorespiratory distress.
Vital Signs: BP: 120/80 mmHg RR: 19 cpm
HR: 80 bpm Temp.: 36.70C
Skin: warm to touch, good skin turgor, no pallor, no jaundice
HEENT/Neck:
Eyes: anicteric sclerae, pink palpebral conjuctivae
Ears: no mass, no tenderness, no discharge
Nose: (-) nasal flaring, (-) nasoaural discharge
Mouth: moist lips & oral mucosa, (-) tonsilopharyngeal congestion
Neck: (-) cervical lymphadenopathy
Chest/Lungs: symmetrical expansion, (-) retractions, clear breath sounds
Heart: adynamic precordium, regular rate and rhythm, no murmur
Abdomen: flabby, normoactive bowel sounds, non-tender
Extremities: grossly normal, full and equal pulses, CRT <2 sec.
Pelvic Examination
I: parous introitus
SE: cervix violaceous, smooth, (+) placental tissues
plugging per os
IE: cervix open, uterus at 12 weeks size, (-) bilateral
adnexal mass and tenderness, (-) cervical motion
tenderness
17.
18. • Incomplete Abortion
= cervical os open
• Non septic non induced
= no intake of abortifacient
• Anemia secondary to Acute blood loss
= vaginal bleeding
Hgb threshold1 g/dL = 0.6206 mmol/L
Hb threshold (g/dl)
11.0
Hb threshold (mmol/l)
6.8
19. Chief Complaint of
VAGINAL BLEEDING
SALIENT FEATURES
Pelvic Exam: cervical
os open, (+) placental
tissues plugging per
os
Uterus at 12 weeks size
3 days history of
vaginal bleeding,
consuming 3 fully-
soaked regular napkin
pads
No medications taken
26 y/o
G3P2(1112)
LMP: April 15, 2013
AOG: 12 3/7 weeks
(+) pregnancy test at
5 weeks amenorrhea
Irregular pre-natal
check-up (lost to
follow-up)
No abortifacients
taken
Incomplete
Abortion
21. DIFFERENTIAL DIAGNOSIS
ECTOPIC PREGNANCY
Rule In:
5 weeks amenorrhea
Vaginal bleeding
Positive Pregnancy Test
Usually occurs <28 weeks AOG
Presence of gestational sac in TV-UTZ
Rule Out:
No abdominal pain noted (usually
hypogastric, colicky in character)
No palpable adnexal mass
(-) Wiggling tenderness or cervical
motion tenderness
HYDATIDIFORM MOLE
Rule In:
(+) Pregnancy Test
Vaginal bleeding
Absence of fetal heart tones upon
doppler ultrasound
Rule Out:
Uterus inconsistent with gestational
age
No hyperemesis
No increased BP and proteinuria (Pre-
eclampsia)
Sandstorm appearance in UTZ
22. Ectopic Pregnancy
• implantation of a fertilized egg in a location
outside of the uterine cavity, including the ff:
– fallopian tubes (approximately 97.7%),
– cervix, ovary,
– cornual region of the uterus,
– abdominal cavity.
– Of tubal pregnancies, the ampulla is the most
common site of implantation (80%), followed by
the isthmus (12%), fimbria (5%), cornua
(2%), and interstitia (2-3%).
23. Hydatidiform Mole
• a rare mass or growth that forms inside the
womb (uterus) at the beginning of a
pregnancy
• a type gestational trophoblastic disease
(GTD) A cancerous form of GTD is called
choriocarcinoma.
24. DIFFERENTIAL DIAGNOSIS
THREATENED ABORTION
Rule In:
(+) Pregnancy Test
Vaginal bleeding
(-) Uterine contraction
Rule Out:
Usually presents with
closed cervix
(-) Uterine size
compatible with
gestational age
(-) Intact bag of water
FHT was no longer
appreciated
INEVITABLE ABORTION
Rule In:
Vaginal bleeding
Open cervical os
Uterine size is
incompatible with
gestational age
Rule Out:
(-) Uterine
Contraction
Bag of water is
usually ruptured but
BOW in this case was
not appreciated
No FHT
COMPLETE ABORTION
Rule In:
No uterine contraction
noted
Vaginal bleeding
Uterine size
incompatible with
gestational age
BOW not appreciated
Rule Out:
Absent signs of
pregnancy
Closed cervical os
25. INCOMPLETE ABORTION
RULE IN
5 weeks amenorrhea
Positive Pregnancy Test
No uterine contraction
3 day history of vaginal bleeding
Open cervical os
Uterine size incompatible with
gestational age
Bag of water not appreciated
Retained tissues characterized as
“meaty material”
BACKGROUND
Internal cervical os opens and
allows passage of blood
Fetus and placenta may remain
entirely in utero or may partially
extrude through the dilated os
Vaginal bleeding
Absence of fetal heart tones
upon doppler ultrasound
Bleeding ensues when the
placenta, in whole or in
part, detaches from the uterus
26. ABO and RH Typing:
“O” Rh (D) Positive
HBSAg Screening :
Non Reactive
28. S O A P
Stable vital signs
(+) palmar pallor
(+) pale palpebral
conjunctiva
conscious, coherent, not in cardio
respiratory distressanicteric sclera
pale palpebral conjuctiva
no tonsillopharyngeal congestion
no cervicolymphadenopathy
no nasoaural discharge
clear breath sounds, symmetrical chest
expansion
no retractions
adynamic precordium
normal rate
regular rhythm
no murmurs
Flat, soft, nontender
grossly normal extremities
no cyanosis
no edema
full and equal pulses
G3P2 (1112)
Incomplete
Abortion 12
3/7weeks AOGby
uterine size, Non
septic non
inducedCompletio
n curettage under
GA-IV, Anemia
secondary to
Acute blood loss
on going
correction awaits
histopath
Diet on NPO
IVF: D5LR 1L x 8hours
BT line: PNSS 1LxKVO
CBCwith platelet and
Urinalysis
HBSAg and Bloodtyping
done
Medications:
Ceftriaxone 1amp IV ()ANST
Diphenhydramine 1 amp IV
prior to BT
BT of 2units PRBC properly
typed and crossmatched
UPON ADMISSION
30. Intraoperative Findings:
Obtained 1 tablespoon of
placental tissues admixed with
blood
Non friable
Non foul smelling
Estimated blood loss
approximately 80cc
31. S O A P
Stable vital signs
Not yet voiding freely
Post BT of 2 ‘u’ PRBC
done
conscious, coherent, not in cardio
respiratory distressanicteric sclera
pale palpebral conjuctiva
no tonsillopharyngeal congestion
no cervicolymphadenopathy
no nasoaural discharge
clear breath sounds, symmetrical chest
expansion
no retractions
adynamic precordium
normal rate
regular rhythm
no murmurs
Flat, soft, nontender
grossly normal extremities
no cyanosis
no edema
full and equal pulses
G3P2 (1112)
Incomplete
Abortion 12
3/7weeks AOGby
uterine size, Non
septic non
inducedCompletio
n curettage under
GA-IV, Anemia
secondary to
Acute blood loss
on going
correction awaits
histopath
Post curettage medications:
Cefuroxime 500mg / tab 1 tab
BID
Mefenamic Acid 500mg tab
q12 x 7days
Patient placed on moderate
high back rest
Oral fluid intake was increased
2 HOURS POST-CURETTAGE
32. S O A P
Stable vital signs
voiding freely
Scanty vaginal
bleeding
No hypogastric
pain
conscious, coherent, not in cardio
respiratory distressanicteric sclera
pale palpebral conjuctiva
no tonsillopharyngeal congestion
no cervicolymphadenopathy
no nasoaural discharge
clear breath sounds, symmetrical chest
expansion
no retractions
adynamic precordium
normal rate
regular rhythm
no murmurs
Flat, soft, nontender
grossly normal extremities
no cyanosis
no edema
full and equal pulses
G3P2 (1112)
Incomplete
Abortion 12
3/7weeks AOGby
uterine size, Non
septic non
inducedCompletio
n curettage under
GA-IV, Anemia
secondary to
Acute blood loss
on going
correction awaits
histopath
Diet was Regular diet
IVF: D5LR 1L x 8hours
H&H repeated 10 hrs
post BT
Vital signs monitored
every 4 hours
Oral medications:
Cefuroxime 500mg tab 1
tab BID
Mefenamic acid 500mg
cap 1 cap TID
HOME MEDICATIONS:
1ST HOSPITAL DAY
33. FIRST HOSPITAL DAY
• Results were normal and advised to go
home
• HOME MEDICATIONS:
Cefuroxime500mg / tab 1 tab BID
Mefenamic Acid 500mg tab q12 x
7days
34.
35.
36. a·bort (-bôrt)
To terminate (a pregnancy)
To cause by expulsion (an embryo or fetus)
To miscarry (an embryo or fetus)
Abortus- a fetus or embryo removed or
expelled from the uterus during the first half of
gestation—20 weeks or less—and weighing less
than 500 g.
37. Spontaneous Abortion
• Abortion occurring without medical or
mechanical means to empty the uterus
Induced Abortion
• the medical or surgical termination of
pregnancy before the time of fetal
viability
38. • Increases with parity
• Associated with paternal and
maternal age
• Incidence of abortion increases if a
woman conceives within 3 months
following a term birth
39. • More than 80 percent of abortions occur in
the first 12 weeks of pregnancy
• Half result from chromosomal anomalies
• After the first trimester
both the abortion rate and the incidence
of chromosomal anomalies decrease.
40. Abnormal Zygotic Development
Aneuploid Abortion
• Abnormal number of chromosomes
50-60% of embryos and early fetuses
that are spontaneously aborted contain
chromosomal abnormalities, accounting for most
of early pregnancy
Euploid Abortion
• Abnormal development w/a normal
chromosomal complement
• incidence increase dramatically after age of 35
42. Infections
Uncommon causes of abortion in human:
Listeria monocytogenes
Clamydia trachomatis
Mycoplasma hominis
Ureaplasma urealyticum
Toxoplasma gondii
43. Chronic debilitating diseases
• In early pregnancy, fetuses seldom abort
secondary to chronic wasting disease such
as tuberculosis or carcinomatosis
• Celiac sprue
44. Endocrine abnormalities
Hypothyroidism
• Iodine deficiency associated with excessive
miscarriages
• Thyroid autoantibodies → incidence of abortion↑
Diabetes mellitus
• The rates of spontaneous abortion & major
congenital malformations
• Poor glucose control → incidence of abortion↑
Progesterone deficiency
• Luteal phase defect
• Insufficient progesterone secretion by the corpus
luteum or placenta
• Poor glucose control → incidence of abortion↑
45. Nutrition
Dietary deficiency of any one nutrients → not important
cause
Drug use and environmental factor
Tobacco
↑ Risk for euploid abortion
More than 14 cigarettes a day → the risk twofold greater ↑
Alcohol
Spontaneous abortion & fetal anomalies → result from
frequent alcohol use during the first 8 weeks of pregnancy
Drinking twice a week → abortion rates doubled ↑
Drinking daily → abortion rates tripled ↑
Caffeine
At least 5 cups of coffee per day → slightly increased risk of
abortion
46. Drug use and environmental factor
Radiation
In sufficient doses → abortifacient
Contraceptives
When intrauterine devices fail to prevent pregnancy →
abortion↑
Environmental toxins
Anesthetic gases : exact fetal risk of chronic maternal
exposure is unknown
Arsenic, lead, formaldehyde, benzene, ethylene oxide →
abortifacient
Video display terminal & accompanying electromagnetic
fields *short waves & ultrasound do not increase the risk of abortion
48. • Hemorrhage into the decidua
basalis, followed by necrosis of tissues
adjacent to the bleeding
49. Early Abortion
• Ovum detaches , stimulating uterine
contractions that results in expulsion
• When Gestational sac is opened, fluid is
commonly found surrounding a small
macerated fetus, or alternatively no fetus is
visible—the so-called blighted ovum.
50. Late Abortion
• The retained fetus may undergo
maceration, in which the skull bones
collapse, the abdomen distends with blood-
stained fluid, and the internal organs
degenerate
• fetus compressus, fetus papyraceous
52. Symptoms
Usually bleeding begins first
Cramping abdominal pain follows a few hours to several
days later
Presence of bleeding & pain
→ Poor prognosis for pregnancy continuation
Treatment
Bed rest & acetaminophen-based analgesia
Progesterone (IM) or synthetic progestational agent (PO or
IM)
D-negative women with threatened abortion
Probably should receive anti-D immunoglobulin
53. Treatment after death of conceptus
Uterus should be emptied
→ examination of all passed tissue whether
the abortion is complete
54. Gross rupture of membrane, evidenced by leaking
amnionic fluid, in the presence of cervical
dilatation, but no tissue passed during 1st half of
pregnancy
Placenta (in whole or in part) is retained in the uterus
→ Uterine contractions begin promptly or infection
develops
The gush of fluid is accompanied by bleeding, pain, or
fever, abortion should be considered inevitable
55. Complete abortion
Following complete detachment & expulsion of
the conceptus
The internal cervical os closes
Incomplete abortion
Expulsion of some but not all of the products of
conception during 1st half of pregnancy
The internal cervical os remains open & allows
passage of blood
→ Remove retained tissue without delay
56. Definition: Three or more consecutive
spontaneous abortions
Clinical investigation of recurrent miscarriage
Parental cytogenetic analysis
Lupus anticoagulant & anticardiolipin antibodies assays
Postconceptional evaluation
Serial monitoring of ß–hCG from missed mens period
ß–hCG>1500mIU/ml → USG
Maternal serum α-fetoprotein assessment (GA16-18wks)
Amniocentesis → fetal karyotype
57. • nonviable intrauterine pregnancy that has been
retained within the uterus without
spontaneous abortion
• Typically, no symptoms exist besides
amenorrhea
• Patient finds out that the pregnancy stopped
developing earlier when a fetal heartbeat is not
observed or heard at the appropriate time
58. • Early pregnancy appears to be normal
• After fetal death, there may or may not be
vaginal bleeding or other symptoms of
threatened abortion
• Uterus becomes gradually smaller
59. • No increase in fundic height
• Absence of FHT
• Regression of changes in pregnancy
• Loss of weight
60. • Many women have no symptoms except
persistent amenorrhea
• Uterus remain stationary in size, but
mammary changes usually regress → uterus
become smaller
• Most terminates spontaneously
• Serious coagulation defect occasionally
develop after prolonged retention of fetus
61. • TRANSVAGINAL ULTRASOUND
• Absence of any growth of the gestational
sac or fetal pole over a 5-day period of
observation.
• Gestational sac larger than 12 mm mean
diameter (around 5 weeks 5 days) without
visual evidence of a yolk sac.
62. • TRANSVAGINAL ULTRASOUND
Absence of a visible fetal heartbeat when
the crown-rump length (CRL) is greater
than 5 mm.
Yolk sac larger than 6 mm diameter
Yolk sac that is abnormally shaped or
echogenic (sono dense rather than the
normal sono lucent).
No fetal cardiac activity
63.
64. • DILATATION ANG CURETTAGE
Dilatation and curettage
Hygroscopic dilators
: swell slowly & dilate cervix → cervical trauma can be
minimized
Laminaria tents
: stem of brown seaweed ( Laminaria digitata or japonica)
→ drawing water from proteoglycan complexes of cervix
→ dissociation allow the cervix to soften & dilate
Insertion technique : tip rests just at the level of internal os
Usually after 4-6hours, laminaria dilate the cervix sufficiently to allow
easier mechanical dilation & curettage
May cause cramping pain
→ easily managed with 60 mg codeine every 3-4 hours
65. • DILATATION ANG CURETTAGE
Technique for dilatation & curettage
Remove laminaria → Uterus is sounded
carefully to
Identify the status of the internal os
Confirm uterus size & position
Further dilation of cervix with Hegar dilator
66.
67. • Pathology results from specimen sent from an
early pregnancy should reveal chorionic villi.
68. Complications : uterine perforation
2 important determinants
Skill of the physician
Position of the uterus (retroverted)
• Small defects by uterine sound or narrow dilator
→ often heal without complication
• Suction & sharp curettage
→ Considerable intra-abdominal damage risk↑
→ Laparotomy to examine abdominal content (safest
action)
• Other complications – cervical incompetence or uterine
synechiae
69. • MIFEPRISTONE- anti- progestin
• METHOTREXATE- anti- metabolite
• MISOPROSTOL- PG E1
• These agents increases uterine contractility
• MOA: reversing the progesterone-induced
inhibition of contractions
• stimulating the myometrium directly
70. Oxytocin
Successful induction of 2nd trimester abortion is
possible with high doses of oxytocin
administered in small volumes of IV fluids
Satisfactory alternatives to PG E2 for
midtrimester abortion
Laminaria tents inserted the night before
Chance of successful induction is greatly enhanced
71. Prostaglandins
Used extensively to terminate
pregnancies, especially in the 2nd T
PG E1, E2, F2α
Technique: Can act effectively on the cervix &
uterus (86~95% effectiveness)
Vaginal prostaglandin E2 suppository & prostaglandin
E1 (misoprostol)
As a gel through a catheter into the cervical canal &
lowermost uterus
Injection into the amnionic sac by amniocentesis
Parenteral injection
Oral ingestion
72. Types
Uterine
contraction
Bleeding
Cervical
dilatation
Uterine size
vs.
gestation
BOW
Other
findings
Threatened +/- +/- Closed Compatible Intact (+)FHT
Imminent ++ + Open Compatible Intact (+)FHT
Inevitable +++ ++ Open Incompatible Ruptured (+)FHT
Incomplete +/- ++ Open Incompatible Ruptured
or
Not
appreciated
MEATY
TISSUE
Complete - +/- Closed Incompatible Not
appreciated
Abs signs
of
preg.
Missed - Spotting Closed Incompatible Not
appreciated
(-) FHT
Habitual +/- + + Compatible +/- (+) FHT
Hinweis der Redaktion
Ate Abie, please edit the type of vaginal bleeding noted by the patient (if there are any clots, meaty material noted).
