University of Santo Tomas

Department of Obstetrics and Gynecology

Section of Obstetrics

Bioethics Conference

Clinical Clerk
March 2, 2018
 20 y/o,G1P0
7-8 weeks AOG
LMP: January 13-17, 2018

Chief Complaint:
Vaginal bleeding
 History of Present Illness
3 days
PTA • Missed menses
• (+) nausea and vomiting
• (+) breast tenderness
• Positive pregnancy test
• Consult with a traditional birth
attendant
– Inserted 3 tablets of Misoprostol
intravaginally
 History of Present Illness
2 days
PTA
• Intermittent, crampy, hypogastric
pain radiating to the lumbosacral
area
• Vaginal bleeding
• No consult done
 History of Present Illness
1 day
• Intermittent, crampy, hypogastric pain
PTA
• Increase in amount of vaginal
bleeding
• (+) passage of meaty tissues
• Consult with the traditional birth
attendant
 History of Present Illness
5 hours
PTA
• Progression of crampy, hypogastric
pain
• Increase in amount of vaginal
bleeding
• Dizziness and generalized weakness

ADMISSION
 Review of Systems
No weight loss
No dyspnea, orthopnea
No chest pain, no cough, no colds
No diarrhea, no constipation
No dysuria, no hematuria, no urgency
No easy bruisability
 Past Medical History
No Hypertension
No Diabetes mellitus
No Asthma
No Thyroid disorder
No known allergies
No previous surgeries
 Family History
(+) Diabetes Mellitus – father
(+) Hypertension – mother
No Bronchial asthma
No Thyroid disease
No Cancer
 Personal and Social History
Non-smoker
Not an alcoholic beverage drinker
No illicit drug use
 Menstrual History
Menarche : 12 years old
Interval : 28-30 days
Duration : 3-5 days
Amount : 3 to 4 pads/day, moderately
soaked
Symptoms : No dysmenorrhea
LMP : January 13-17, 2018
PMP : December 15-18, 2017
 Sexual History
Coitarche: 15 y/o
2 sexual partners
No post-coital bleeding
No dyspareunia

Family planning method: Withdrawal method

 Physical Examination
Conscious, coherent, wheel-chair borne
BP 80/50 mmHg, PR 122 bpm RR 24 cpm, T 36.8˚C
Wt 110 lbs Ht 155 cm
Cold & clammy skin, (-) dermatoses, (+) pallor,
(-) jaundice
Anicteric sclerae, pale palpebral conjunctivae
Neck not rigid, thyroid not enlarged, no palpable
cervical lymph nodes
 Physical Examination
Breasts symmetric, no masses, no tenderness, no
nipple discharge
Symmetrical chest expansion, no retractions, clear
breath sounds
Adynamic precordium, apex beat at 5th left
intercostal space mid-clavicular line, S1 louder at the
apex, S2 louder at the base, no murmurs
Abdomen flat, soft, no masses, non-tender
 Physical Examination
External Genitalia: No gross lesions
Speculum Exam: cervix violaceous, smooth, with
moderate bleeding and placental tissues plugging the
os
Internal examination: cervix soft, long, 1 cm dilated,
with placental tissues plugging the os, uterus slightly
enlarged, anteverted, movable, non-tender, no adnexal
mass nor tenderness
No cyanosis, no edema, pulses weak
 ADMITTING DIAGNOSIS
G1P0 Incomplete abortion 7-8 weeks
AOG, induced, non-septic
Hypovolemic shock secondary to acute
blood loss
Anemia, severe
 PLANS
Run 200 cc PNSS now then 30 gtts/min
Request for
- Complete blood count
- Blood typing
Transfuse 2 units Fresh whole blood properly-typed and
cross-matched
Reserve 1 u pRBC, properly-typed and cross-matched
For Completion curettage
Ampicillin 2 g/SIVP after negative skin test
Refer to Anesthesiology
 Complete Blood Count
Ref Range Result
Hemoglobin 120-170 g/L 68
Hematocrit 0.37-0.54 0.29
Platelet 150-450 x109/L 228
WBC 4.5-10.0x109/L 12
Segmenters 0.80 0.83
Bands 0.00
Lymphocytes 0.19 0.16
Eosinophils 0.01 0.01
Monocytes -
 Procedure Done

• Completion curettage under

general intravenous anesthesia
 Complete Blood Count
Ref Range Result
Hemoglobin 120-170 g/L 92
Hematocrit 0.37-0.54 0.31
Platelet 150-450 x109/L 228
WBC 4.5-10.0x109/L 11
Segmenters 0.80 0.85
Bands 0.00
Lymphocytes 0.19 0.14
Eosinophils 0.01 0.01
Monocytes -
 Final Diagnosis
G1P0 (0010) Induced Abortion 7-8 weeks,
non-septic, completed by curettage
Hypovolemic shock secondary to acute
blood loss, corrected
Mild Anemia, on correction
Abortion

Spontaneous or
induced termination
of pregnancy before
20 weeks AOG or
birthweight <500 g

William’s Obstetrics 24th Edition

 Pathogenesis
Bleeding into the decidua basalis

Necrosis of adjacent tissues

Uterine contractions initiated

Expulsion

William’s Obstetrics 24th Edition

Spontaneous abortion
Threatened, inevitable, incomplete, complete, and missed abortion.

Recurrent abortion
With repetitive spontaneous abortions

Induced abortion
Surgical or medical termination of a live fetus that has not reached
viability

William’s Obstetrics 24th Edition

 Epidemiology
● 27 abortions per 1,000 women of reproductive
age in 2000, with lower and upper estimates of
22 and 31 abortions per 1,000 women.
● Abortion methods:
○ 22% of poor women used massage or a

catheter while no nonpoor women employed

such methods.

Unintended Pregnancy and Unsafe Abortion in The Philippines: Context and Consequences, Guttmacher Institute, 2013
 Direct Abortion
vs
Indirect Abortion
 Direct Abortion
Abortion willed as an end or as a means

1. Vacuum Aspiration or Suction Termination

2. Saline Injection (Salt Poisoning)
3. Partial Birth Abortion
4. Drug-induced

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 Vacuum Aspiration
or Suction Termination

• Usually
done at 7-
15 weeks
Saline Injection (Salt Poisoning)
• Outer layer of
skin is burned off
• Poisoned when
swallowed
• 1 hr to die
• Birth to dead or
dying baby
• before 24 hours
Partial Birth Abortion
• Fetus is turned into
breech
• Clamp is inserted into
the base of the fetal
skull
• Head contents are
destroyed
• Collapsed head is then
delivered
 Drug-induced
MIFEPRISTONE
• Progesterone antagonist
• Prostaglandin is taken 2 days
later
• Preventing implantation and
causing abortion
MISOPROSTROL
• Synthetic PGE1
• Used for NSAID induced gastric
ulcers
• Causes uterine contraction and
cervical effacement
 Ethical
Principles
 The Principle of Well-Formed
Conscience
• Conscience is a judgment of reason whereby the
human person recognizes the moral quality of a
concrete act
• Moral conscience: continuous, habitual judgment
of acts as being morally good or bad
• Freedom of conscience – freedom to seek out the
truth, NOT the freedom to personally declare
certain acts as moral or not according to one’s
own values
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 The Principle of Cooperation
• Working with another to perform an action
• Formal – act of evil, with intent; equal guilt
• Material – no intent, but act is evil
- Immediate – performance of act, equal guilt
- Mediate – act is indifferent or good, but assists
in the occasion of sin; context is important
- Remote – distant relation to evil act
• Negative cooperation – neglecting to stop a sin

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 Principle of Human Dignity
• Human dignity originates from God and is of God
because we are made in God’s own image and
likeness (Gn 1:26-27)
• Human life is sacred - most central and clearest
reflection of God among us.
• individuals have an inherent and immeasurable
worth and dignity
Virtues of a Catholic
Health Care Giver
 Catholic health care
• Commitment to promote and defend human
dignity
• Respects the sacredness of every human life from
the moment of conception until death
• The right to life entails a right to the means for
the proper development of life, such as adequate
health care

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 Core Values of a Medical
Professional
1. Commitment to Professional Duty

2. Commitment to Competence and Commitment

to Excellence

3. Commitment to a Code of Conduct

4. Commitment to Altruism

5. Compassion/Caring
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 References
• Kockler, NJ. The Principle of Double Effect and Proportionate Reason
• Manlangit, J. 2010. Fundamental concepts: Principles and issues in
Bioethics (Vol. 1). University of Santo Tomas Publishing House.
Manila, Philippines
• Solomon, D. Double Effect. The Encyclopedia of Ethics.
• http://www.catholic.com/quickquestions/whats-the-difference-
between-direct-and-indirect-abortion
• http://www.catholicculture.org/culture/library/dictionary/index.cfm
?id=31582
• http://www.nhsdirect.wales.nhs.uk/encyclopaedia/ch/article/aborti
on/
• http://www.lifenews.com/2013/01/02/abortion-methods-and-
abortion-procedures-used-to-kill-unborn-babies/

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THANK YOU