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Final case protocol 'abortion'

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  • Ate Abie, please edit the type of vaginal bleeding noted by the patient (if there are any clots, meaty material noted).
  • No loss of consciousness (LOC)
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    • 1. UPH – Dr. Jose G. Tamayo Medical University DEPARTMENT OF OBSTETRICS & GYNECOLOGY OB-GYNE CASE PRESENTATION ABEGAIL M. ATIENZA OB-GYNE CLERK
    • 2. single G3P2 (1112) 26y/o Filipino Catholic Residing at Pacita, Laguna
    • 3. (-) Diabetes Mellitus (-) Hypertension (-) Previous hospitalization (-) Previous surgical operation (+) Bronchial Asthma, Mild Intermittent Last Attack: 12 years old
    • 4. (+) Hypertension – Both Parents (-) Diabetes Mellitus (-) Asthma (-) Cancer (-) Pulmonary Tuberculosis
    • 5. (+) waitress (+) single (+) living in with a 27 year old laborer (-) smoker (-) alcoholic drinker (-) allergy to food/drugs
    • 6.  12 years old, lasting for 5 days 28-30 days interval  5 days duration  3-4 regular napkin pads/day, fully-soaked  (-) dysmenorrhea
    • 7. (+) 1st coitus at 18 years old (+) with single partner (-) post-coital bleeding (-) dyspareunia
    • 8. (-) history of contraceptive use
    • 9. (-) leukorrhea (-) vaginal pruritus (-) pap smear
    • 10. 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
    • 11.  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
    • 12. 3 DAYS PTA  consuming 3 fully-soaked regular napkin pads  with episodes of blood clots NO MEDICATIONS TAKEN. NO CONSULTATION DONE.
    • 13. • Vaginal bleeding • Consuming 1 fully-soaked regular napkin pad • sought consult at the ER • advised for admission 1 DAY PTA (JULY 10, 2013) ADMITTED
    • 14. CNS: (-) loss of consciousness, (-) headache, (-) dizziness CVS: (-) chest pain, (-) palpitation, (-) easy fatigability RESP: (-) dyspnea, (-) cough/colds, (-) wheezing GIT: (-) vomiting, (-) nausea (-) heartburn, (-) diarrhea/constipation GUT: (-) dysuria, (-) polyuria, (-) hematuria HEMA: (-) bleeding tendencies, (-) easy bruisability MS: (-) limitation of movements
    • 15. 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
    • 16. • 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
    • 17. 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
    • 18.  Ectopic Pregnancy  Hydatidiform Mole  Threatened Abortion  Inevitable Abortion  Complete Abortion
    • 19. 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
    • 20. 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%).
    • 21. 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.
    • 22. 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
    • 23. 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
    • 24. ABO and RH Typing: “O” Rh (D) Positive HBSAg Screening : Non Reactive
    • 25. CBC with Platelet Count WBC: 15.4 RBC: 1.77 RDW: 12.5 Neutrophils: 12.2 HGB: 85 MCV: 98.9 Lymphocyte: 15.6% Hct: .175 MCH: 32.3 Monocytes: 4.41% Eosinophils: .282% MCHC: 327. Basophils: .705% Platelet: 473
    • 26. 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
    • 27. Internal Examination: Open Uterus slightly enlarged Minimal bleeding per os With blood clots No adnexal mass
    • 28. Intraoperative Findings: Obtained 1 tablespoon of placental tissues admixed with blood Non friable  Non foul smelling  Estimated blood loss approximately 80cc
    • 29. 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
    • 30. 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
    • 31. 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
    • 32. 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.
    • 33. 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
    • 34. • Increases with parity • Associated with paternal and maternal age • Incidence of abortion increases if a woman conceives within 3 months following a term birth
    • 35. • 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.
    • 36. 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
    • 37. Infections Chronic Debilitating Diseases Nutrition Drug Use and Environmental Factors Immunological Factors Inherited Thrombophilia Uterine Defects Incompetent Cervix
    • 38. Infections Uncommon causes of abortion in human: Listeria monocytogenes Clamydia trachomatis Mycoplasma hominis Ureaplasma urealyticum Toxoplasma gondii
    • 39. Chronic debilitating diseases • In early pregnancy, fetuses seldom abort secondary to chronic wasting disease such as tuberculosis or carcinomatosis • Celiac sprue
    • 40. 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↑
    • 41. 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
    • 42. 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
    • 43. • abnormalities in sperm have been associated with abortion
    • 44. • Hemorrhage into the decidua basalis, followed by necrosis of tissues adjacent to the bleeding
    • 45. 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.
    • 46. 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
    • 47.  Threatened Abortion  Inevitable Abortion  Complete and Incomplete Abortion  Missed Abortion
    • 48. 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
    • 49. Treatment after death of conceptus Uterus should be emptied → examination of all passed tissue whether the abortion is complete
    • 50. 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
    • 51. 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
    • 52. 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
    • 53. • 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
    • 54. • 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
    • 55. • No increase in fundic height • Absence of FHT • Regression of changes in pregnancy • Loss of weight
    • 56. • 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
    • 57. • 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.
    • 58. • 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
    • 59. • 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
    • 60. • 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
    • 61. • Pathology results from specimen sent from an early pregnancy should reveal chorionic villi.
    • 62. 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
    • 63. • 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
    • 64. 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
    • 65. 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
    • 66. 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

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