Case Case PresentationPresentation

Clerk Julius Jay S. EstacioClerk Julius Jay S. Estacio

Consultant Adviser: Dr. Janice Consultant Adviser: Dr. Janice Bernal-LacunaBernal-Lacuna

General DataGeneral Data

J.C.J.C. 21 year old21 year old G1P0G1P0 SingleSingle FilipinoFilipino CatholicCatholic

Chief ComplaintChief Complaint

Vaginal bleedingVaginal bleeding

PAST MEDICAL PAST MEDICAL HISTORYHISTORY

No history of hypertensionNo history of hypertension No history of diabetes mellitusNo history of diabetes mellitus No history of heart disease No history of heart disease No asthmaNo asthma No known allergies to food or No known allergies to food or

medicationmedication No previous operationsNo previous operations

FAMILY MEDICAL FAMILY MEDICAL HISTORYHISTORY

Asthma - maternal side Asthma - maternal side No other known heredofamilial No other known heredofamilial

diseasesdiseases

PERSONAL AND SOCIAL PERSONAL AND SOCIAL HISTORYHISTORY

UnemployedUnemployed Co-habitating for 5 months with Co-habitating for 5 months with

a 21 year-old paintera 21 year-old painter Non-smokerNon-smoker Non-alcoholic beverage drinkerNon-alcoholic beverage drinker First coitus: 18 years old, 1 First coitus: 18 years old, 1

sexual partnersexual partner

MENSTRUAL HISTORYMENSTRUAL HISTORY

Menarche: 14 years oldMenarche: 14 years old Subsequent menstrual period: Subsequent menstrual period:

regularly at 28-day intervalregularly at 28-day interval Lasting for 4 - 7 daysLasting for 4 - 7 days Consuming 1 - 2 pads per day, Consuming 1 - 2 pads per day,

fully soakedfully soaked No dysmenorrheaNo dysmenorrhea

GYNECOLOGIC HISTORYGYNECOLOGIC HISTORY

No history of dyspareuniaNo history of dyspareunia No post coital bleeding No post coital bleeding No leucorrheaNo leucorrhea No history of any form of No history of any form of

contraceptioncontraception

OBSTETRICAL HISTORYOBSTETRICAL HISTORY

LNMP: January 19, 2009 LNMP: January 19, 2009 PMP: December 21, 2008 PMP: December 21, 2008 AOG: 10 weeks and 3 daysAOG: 10 weeks and 3 days G1P0G1P0

G1 – present pregnancyG1 – present pregnancy

HISTORY OF PRESENT HISTORY OF PRESENT PREGNANCYPREGNANCY

No prenatal check upsNo prenatal check ups Pregnancy test positive at 6Pregnancy test positive at 6thth week week

AOGAOG Denied taking any medications Denied taking any medications

HISTORY OF PRESENT HISTORY OF PRESENT PREGNANCYPREGNANCY

1 week prior to admission1 week prior to admission Vaginal spottingVaginal spotting No hypogastric painNo hypogastric pain No other signs and symptomsNo other signs and symptoms

HISTORY OF PRESENT HISTORY OF PRESENT PREGNANCYPREGNANCY

Few hours PTAFew hours PTA Increase in vaginal bleeding, soaking 2 Increase in vaginal bleeding, soaking 2

pads per daypads per day passage of meaty materialspassage of meaty materials severe, crampy hypogastric pain, 8/10 severe, crampy hypogastric pain, 8/10

in intensityin intensity Persistence prompted --- consult Persistence prompted --- consult AdmittedAdmitted

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

General Survey:General Survey: ConsciousConscious CoherentCoherent Ambulatory Ambulatory Not in cardiopulmonary distressNot in cardiopulmonary distress

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

Vital SignsVital Signs BP=100/70 mmHgBP=100/70 mmHg PR=92 bpmPR=92 bpm RR=18 cpmRR=18 cpm Temp=36.5 Temp=36.5 ººCC Ht=5’1” or 154.94 cms.Ht=5’1” or 154.94 cms. Wt=110 lbs. or 50 kgs.Wt=110 lbs. or 50 kgs.

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

SkinSkin Good skin turgorGood skin turgor Warm to touchWarm to touch No pallorNo pallor No jaundiceNo jaundice

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

HEENT:HEENT: pink palpebral conjunctivaepink palpebral conjunctivae anicteric scleraanicteric sclera no cervicolymphadenopathiesno cervicolymphadenopathies

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

Chest and Lung:Chest and Lung: Symmetrical chest expansionSymmetrical chest expansion no retractionsno retractions clear breath soundsclear breath sounds

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

CVS:CVS: Adynamic precordiumAdynamic precordium normal ratenormal rate regular rhythmregular rhythm no murmursno murmurs

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

Abdomen:Abdomen: FlatFlat Normoactive bowel sounds Normoactive bowel sounds TympaniticTympanitic SoftSoft No tendernessNo tenderness

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

Pelvic ExaminationPelvic Examination:: Inspection Inspection

Normal external genitalia with fair Normal external genitalia with fair hair distributionhair distribution

No massesNo masses No lesionsNo lesions No dischargeNo discharge

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

Pelvic ExaminationPelvic Examination::Speculum ExaminationSpeculum Examination

Cervix is pink, smooth, no Cervix is pink, smooth, no erosions, with meaty material erosions, with meaty material within the oswithin the os

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

Pelvic ExaminationPelvic Examination:: Internal ExaminationInternal Examination

Vagina admits 2 fingers with easeVagina admits 2 fingers with ease Cervix openCervix open Uterus enlarged to 8 weeksUterus enlarged to 8 weeks No adnexal masses and tendernessNo adnexal masses and tenderness

PHYSICAL PHYSICAL EXAMINATIONEXAMINATION

ExtremitiesExtremitiesFull and equal peripheral Full and equal peripheral

pulsespulsesno edemano edema

IMPRESSIONIMPRESSION

Incomplete abortion, 10 weeks Incomplete abortion, 10 weeks and 3 days, spontaneous, non-and 3 days, spontaneous, non-

septic, G1P0septic, G1P0

SALIENT FEATURESSALIENT FEATURES

HistoryHistory Positive Positive

pregnancy testpregnancy test Vaginal bleedingVaginal bleeding Hypogastric painHypogastric pain Passage of Passage of

meaty materialmeaty material

Physical Physical ExaminationExamination afebrileafebrile Presence of meaty Presence of meaty

material plugging material plugging cervical oscervical os

Open cervixOpen cervix Uterus enlarged Uterus enlarged

to 8 weeksto 8 weeks

DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSIS

Ectopic pregnancyEctopic pregnancy Complete abortionComplete abortion Threatened abortionThreatened abortion

Ectopic PregnancyEctopic Pregnancy

Rule in:Rule in: Positive Positive

pregnancy testpregnancy test Abdominal painAbdominal pain Abnormal Abnormal

vaginal bleedingvaginal bleeding

Rule OutRule Out:: No adnexal mass No adnexal mass

and tenderness and tenderness appreciatedappreciated

No wriggling No wriggling tenderness of cervixtenderness of cervix

Uterus was Uterus was enlarged to 8 weeksenlarged to 8 weeks

Cervix was open Cervix was open with placental-like with placental-like tissue within the ostissue within the os

Complete AbortionComplete Abortion

Rule in:Rule in: Positive Positive

pregnancypregnancy Vaginal bleedingVaginal bleeding Abdominal pain Abdominal pain

or crampsor cramps

Rule OutRule Out:: Uterus was Uterus was

enlarged to 8 enlarged to 8 weeksweeks

Presence of Presence of meaty material meaty material plugging the osplugging the os

Cervix was openCervix was open

Threatened AbortionThreatened Abortion

Rule in:Rule in: Positive Positive

pregnancy testpregnancy test Vaginal bleedingVaginal bleeding Hypogastric painHypogastric pain

Rule Out:Rule Out: Cervix was openCervix was open Uterus was Uterus was

incompatible incompatible with the age of with the age of gestationgestation

Presence of Presence of meaty material meaty material plugging the osplugging the os

PLAN AND PLAN AND MANAGEMENTMANAGEMENT

Completion curettageCompletion curettage

DISCUSSIONDISCUSSION

ABORTIONABORTION

pregnancy termination prior to pregnancy termination prior to 20 weeks gestation or less than 20 weeks gestation or less than 500g birthweight500g birthweight Spontaneous – abortion without Spontaneous – abortion without

medical or mechanical meansmedical or mechanical means Induced – medical or surgical Induced – medical or surgical

meansmeans

ABORTIONABORTION

PathologyPathology:: Hemorrhage in the decidua basalis Hemorrhage in the decidua basalis

followed by necrosis of tissues followed by necrosis of tissues beside the bleedingbeside the bleeding

Ovum detaches which stimulates Ovum detaches which stimulates uterine contractions resulting in uterine contractions resulting in expulsionexpulsion

ABORTIONABORTION

Early abortionEarly abortion 1st trimester or 1st 12 weeks1st trimester or 1st 12 weeks 50% secondary to chromosomal 50% secondary to chromosomal

abnormalitiesabnormalities death of fetus usually precedes death of fetus usually precedes

expulsionexpulsion

ABORTIONABORTION

Late abortionLate abortion 13 weeks to 20 weeks13 weeks to 20 weeks other etiologies (other etiologies (infection, endocrine infection, endocrine

abnormalities, drug use and nutritional abnormalities, drug use and nutritional status)status)

fetus usually alive before fetus usually alive before expulsionexpulsion

PLAN/MANAGEMENT PLAN/MANAGEMENT

Laboratory work-ups for abortion Laboratory work-ups for abortion includeinclude complete blood count with differentialcomplete blood count with differential blood type and Rh factorblood type and Rh factor qualitative and quantitative human qualitative and quantitative human

chorionic gonadotropin-beta chorionic gonadotropin-beta Ultrasound Ultrasound

TREATMENTTREATMENT

Treatment goalTreatment goal::evacuation of the uterus to evacuation of the uterus to

prevent complications such as prevent complications such as further hemorrhage and/or further hemorrhage and/or infectioninfection

Completion CurettageCompletion Curettage

THANK YOU.THANK YOU.GOD BLESS US ALWAYS.GOD BLESS US ALWAYS.