Ahuja, Jaikishin U.

February 21, 2020

CASE REPORT IN OBSTETRICS AND GYNECOLOGY

 Identifying Data
Name: PF Date of admission: February 13, 2020
Age: 38
Sex: Female
 Chief Complaint
Vaginal bleeding
 History of Present Illness
Patient's LMP was on December 16,2019. In the interim, no pregnancy test was done but
patient was experiencing vomiting and dizziness. 2 weeks PTC, patient experienced heavy
menstrual bleeding of 2 days consuming 2 packs of fully soaked pads with meaty material and
dark colored lumps. patient was given unrecalled medication and was advised for D&C after
taking medications. few hrs PTC, transvaginal ultrasound was done which showed endometrial
mass to consider retained products of conception. patient was advised for D&C hence admission.

 Past Medical History

(-) asthma
(-) allergies
(-) HTN
(-) DM
(-) pneumonia
(-) tuberculosis
(-) surgeries

 Family History
(+) hypertension- maternal;
(-) dm
(-) heart diseases
(-) renal diseases
(-) asthma
(-) cancer
(-) stroke
 Personal and Social History
(-) smoker
(-) alcoholic beverage drinker
 OB-Gyne History

G4P3 (3003) LMP: December 16, 2019 AOG: 8-9 weeks

M- 12
I- regular
D- 3-4 days
A- 4 pads
S- (+) dysmenorrhea
 Review of Systems
General survey : (-)weight loss, (-) weakness,(-) loss of appetite, (-) fever
Skin : (-) pruritus, (-) jaundice, (-) rashes, (-) clubbing of fingers
HEENT : (-) headache, (-) sleepy, (-) blurring of vision,(-) excessive lacrimation, (-)
hearing loss,(-) tinnitus (-) nasal congestion, (-) epistaxis, (-) bleeding gum, (-) dysphagia,
(-) hoarseness.
Respiratory : (-) dyspnea, (-) cough, (-) hemoptysis
Cardiovascular : (-) chest pain, (-) easy fatigability (-)orthopnea, (-) palpitations
Gastrointestinal : (-) diarrhea, (-) no constipation,(-) melena, (-) vomiting
Musculoskeletal: (-) myalgia, (-) arthralgia, (-) upper back pain
Nervous system : (-) vertigo, (-) dizziness, (-) loss of consciousness

 Physical Examination
General survey: Patient is awake, cooperative, oriented to time, place and person
Vital Signs: Temp: 36.6° C RR: 21 CPR BP: 120/90 mm Hg PR: 82 beats/min
Skin: Soft warm to touch with no any lesions. Nail beds pink with no cyanosis or
clubbing. No rashes.
Head: Head is round and symmetrical with no any scars and lesion. Hair is black color,
and symmetrical appearance
Eyes: Pupils equal, round and reactive to light, anicteric sclera with no redness or
exudates. Eyelids without lesions. Pink palpebral conjunctiva
Ear: Hearing intact. Auricles without lesions, (-) Discharge
Nose: No masses, deformities, tenderness, nasal septum midline, no discharge
Mouth: moist lips and oral mucosa, no masses or ulceration
Neck: Full range of motion. Trachea at midline. No lymphadenopathy, (-) sore throat, (-)
hoarseness
Chest and lungs: Chest symmetrical expansion, clear breath sounds, no wheezes
 Cardiovascular: AP, NRRR, (-) murmurs
  Gastrointestinal: soft, non-tender, flabby; FH: 10cm, FHT: 140s
Genitourinary: IE: Closed cervix, with minimal blood
Musculoskeletal: No gross deformities, no pain, edema, or deformity

 Diagnosis:
G4P3(3013) INCOMPLETE ABORTION; EARLY (8-9WEEKS AOG) NON-SEPTIC,
NON-INDUCED S/P COMPLETION CURETTAGE (2/13/20 EACMC)
 Discussion:

MISCARRIAGE
A miscarriage, or spontaneous abortion, is an event that results in the loss of a fetus
before 20 weeks of pregnancy. It typically happens during the first trimester, or first three months,
of the pregnancy.
Types of miscarriage:
 Inevitable miscarriage
Inevitable miscarriages can come after a threatened miscarriage or without warning.
There is usually a lot more vaginal bleeding and strong lower stomach cramps. During the
miscarriage your cervix opens and the developing fetus will come away in the bleeding.

 Threatened miscarriage
When your body is showing signs that you might miscarry, that is called a ‘threatened
miscarriage’. You may have a little vaginal bleeding or lower abdominal pain. It can last days
or weeks and the cervix is still closed.

The pain and bleeding may go away and you can continue to have a healthy
pregnancy and baby. Or things may get worse and you go on to have a miscarriage.

There is rarely anything a doctor, midwife or you can do to protect the pregnancy. In
the past bed rest was recommended, but there is no scientific proof that this helps at this
stage.

 Incomplete miscarriage
Sometimes, some pregnancy tissue will remain in the uterus. Vaginal bleeding and
lower abdominal cramping may continue as the uterus continues trying to empty itself. This is
known as an ‘incomplete miscarriage. Your doctor or midwife will need to assess whether or
not a short procedure called a ‘dilatation of the cervix and curettage of the uterus’ (often
known as a ‘D&C’) is necessary to remove any remaining pregnancy tissue. This is an
important medical procedure done in an operating theatre.

 Missed miscarriage
Sometimes, the baby has died but stayed in the uterus. This is known as a ‘missed
miscarriage. If you have a missed miscarriage, you may have a brownish discharge. Some of
the symptoms of pregnancy, such as nausea and tiredness, may have faded. You might have
noticed nothing unusual. You may be shocked to have a scan and find the baby has died. If
this happens, you should discuss treatment and support options with your doctor.
  Complete miscarriage
A complete miscarriage has taken place when all the pregnancy tissue has left your
uterus. Vaginal bleeding may continue for several days. Cramping pain much like labour or
strong period pain is common – this is the uterus contracting to empty. If you have miscarried
at home or somewhere else with no health workers present, you should have a check-up with
a doctor or midwife to make sure the miscarriage is complete.

 Recurrent miscarriage
A small number of women have repeated miscarriages. If this is your third or more
miscarriage in a row, it’s best to discuss this with your doctor who may be able to investigate
the causes, and refer you to a specialist.

Treatment:
 Observation for threatened abortion
 Uterine evacuation for inevitable, incomplete, or missed abortions
 Emotional support

For threatened abortion, treatment is observation. No evidence suggests that bed

rest decreases risk of subsequent completed abortion.

For inevitable, incomplete, or missed abortions, treatment is uterine evacuation

or waiting for spontaneous passage of the products of conception. Evacuation usually
involves suction curettage at < 12 weeks, dilation and evacuation at 12 to 23 weeks,
or medical induction at > 16 to 23 weeks (eg, with misoprostol). The later the uterus is
evacuated, the greater the likelihood of placental bleeding, uterine perforation by long bones
of the fetus, and difficulty dilating the cervix. These complications are reduced by
preoperative use of osmotic cervical dilators (eg, laminaria), misoprostol, or mifepristone.

If complete abortion is suspected, uterine evacuation need not be done routinely.

Uterine evacuation can be done if bleeding occurs and/or if other signs indicate that products
of conception may be retained.

After an induced or spontaneous abortion, parents may feel grief and guilt. They
should be given emotional support and, in the case of spontaneous abortions, reassured that
their actions were not the cause. Formal counseling is rarely indicated but should be made
available.