This document presents a case study of a 34-year-old woman admitted to the hospital with heavy vaginal bleeding and weakness. On examination, she was found to have a bulky uterus and vaginal bleeding. Tests showed low hemoglobin and a positive pregnancy test. Ultrasound revealed retained products of conception in the uterus. She was diagnosed with incomplete abortion and shock. Treatment included blood transfusion, antibiotics, and misoprostol to complete the abortion. Her condition improved and she was discharged with medications and advice to rest and use contraception.

1. Department of Obstetrics & Gynaecology
Welcome

2. Case presentation
Presented by:
• Dr. Fatihatul Jannat Mou
• Dr. Jannatul Nayeem
• Dr. Najmul Islam

3. Name: Mrs.Lipi akter
Age: 34 years
Sex: Female
Marital Status: Married
Occupation: Housewife
Religion: Islam
Nationality: Bangladeshi
Address: South Begunbari,
Tejgaon,Dhaka.
Date & time of admission:
30.04.23 at 7.30 pm
Date & time of examination:
30.04.23 at 7.40 pm
Bed no.:L9

4. 01
02 Dizziness and weakness for 1 day
Heavy per vaginal bleeding for 2 days

5. According to the statement of the patient,she was an
irregularly menstruating woman for last 7 years with
average flow and duration and her menstruation occurs
average 2-3 months interval and to regularize her
menstruation she started taking Oral contraceptive pill.
There after she didn’t have withdrawal bleeding and she did
urine strip test which was negative.

6. Then she started taking Oral Contraceptive Pill again.
But unfortunately she started per vaginal bleeding while
she was taking Oral contraceptive pill.Then it became
very heavy clotted,blackish per vaginal bleeding and
lower abdominal pain for last 2-3 days for which she
wasn’t feeling well, she feels dizziness and weakness for
this she immediately came to this hospital for better
management.

7. ● Menstrual cycle: Irregular (2-3 months interval)
● Menstrual period:5-7 days
● Menstrual flow: Average
● LMP: 05.03.23

8. Married for: 20 years
Para: 3(NVD)
gravida:Nill
MR:Nill
Abortion:Nill
ALC: 7 years

9. Nothing contributory
There is no family H/O DM,HTN,BA etc.All the
family members are apparently healthy.

10. No known allergic history
No known drug history

11. Non Smoker
Non Alcoholic
No history of substance abuse
She belongs to a middle class family

12. She was immunized as per EPI schedule
Immunized against tetanus & COVID-19
Oral contraceptive pill for last 2 years
(irregularly)

13. Appearance: Ill looking
Body built:Average
Cooperation: co-operative
Decubitus: on choice
Anemia: moderate
Jaundice: absent
Cyanosis: absent
Edema: absent
Dehydration: present
Pulse: 110 bpm(low volume)
BP: 70/60 mmHg
Temp: 98° F
Respiratory rate: 24breaths/min
Breast : Narmal change acc. To
her age.
Thyroid gland: not palpable

14. * 1st & 2nd heart sound audible no other added sound present.
*Vesicular breath sound present.

15. Shape: Normal
Flank: Not full
Umbilicus: Inverted and centrally placed
Striae albicans present
Superficial and deep palpation revealed no tenderness
Tympanic on percussion note
Bowel sound present

16.  Cervix was soft and Os was open
 Vagina was full of clotted blood
 Uterus was bulky in size

17.  Incomplete Abortion with shock.

18.  Complete Abortion
 Inevitable abortion
 Ectopic pregnancy

19.  Emergency USG of L/A was done at
night(9.00PM) on 30-4-23 that
reveals-Small amount of retained
product of conception.

20. ● CBC
● B.HCG
4633.8 mlU/mL (01.05.23)
236.9 mlU/mL (02.05.23)
● HbsAg--------- (negative)
● Blood grouping- (A positive)
• Hb
• ESR
• Total WBC
• Neutrophil
• Lymphocyte
• Platelet
9.1 gm/dl
31 mm in 1st hour
13270/cumm
82%
12%
196000/cumm
• Hb
• ESR
• Total WBC
• Neutrophil
• Lymphocyte
• Platelet
9.6 gm/dl
31 mm in 1st hour
7760/cumm
85%
09%
150000/cumm
After 2 unit
whole blood
transfusion
• S.Creatinine-------(0.7 mg/dl)
• RBS------------------(6.7mmol/L)

21.  USG
On 02-05-23:
 Uterus is bulky in size(9.2*4.6)cm and anteverted in
position.Myometrium is homogeneous
 Cavity is filled with mixed echogenic
structures(Vol-30.4cc) which suggest retained
products of conception
● Review on 03-05-23:
 Small echogenic structure (Vol-3.5cc) is seen
within the endometrial cavity.

22. Mrs. Lipi akter,34 years old, Muslim housewife,Normotensive
,Non diabetic, hailing from South Begunbari,Tejgaon, Dhaka
.admitted in this hospital on 30.04.23 at 7:20 pm with the
complaints of heavy clotted, blackish per vaginal bleeding
and lower abdominal pain for last 2-3 days for which she
feels dizziness and weakness ,for this she immediately came
to this hospital for better management.

23. On her general examination she was ill looking, average body
built, cooperative, decubitus on choice, moderately anemic, non
icteric, non cyanotic, dehydration was present and there
wasn’t any edema. Her pulse rate was 110 bpm, BP was 70/60
mmHg, temp was 98° F, respiratory rate was 24 breaths/min.
Her breast was normal change acc. To her age. Her bowel and
bladder habits are normal.

24. On abdominal examination there was striae albicans present,
umbilicus was inverted and centrally placed, Abdomen was soft and
non tender .
On her vaginal examination,Cervix was soft and Os was open,Vagina
was full of clotted blood,Uterus was bulky in size.
Her investigation shows Hb 9.1 gm/dl.After 2 unit whole blood
transfusion Hb 9.6gm/dl.B.HCG level-0n (01.05.23)-4633.8 mlU/ml
and then on (02.05.23)-236.9 mlU/ml.

25. On USG of L/A-Uterus is bulky in size(9.2*4.6)cm and
anteverted in position . Myometrium is homogeneous. Cavity is
filled with mixed echogenic structures(Vol-30.40cc) which
suggest retained products of conception.
On repeated USG -Small echogenic structure (Vol-3.5cc) is
seen within the endometrial cavity.
Other investigations report was within normal ranges.

26.  Incomplete Abortion with shock.

27. As it is a Gynaecological emergency so to Resuscitate the
patient,treatment was given-
General management:
 Call for help
 O2 inhalation
 Inf. Lactoride (1L)+Normal Saline(1L)___I/V __ running then Normal
Saline __I/V__30 drops/min
 Inj. Tranexamic acid (500mg)__1amp__I/V__ stat & 8 hourly
 Inj. Medroxyprogesterone acetate__2amp__I/M ___ stat
 Inj. Ondansetron(8mg)___I/V----stat
 Inj. Pantoprazole (40mg)__I/V----stat
 Continuous Catheterization in an aseptic way.

28.  Inj. Ceftriaxone (1 gm)___ 1 vial I/V __ Stat & 12 hourly
 Inj. Metronidazole (500 mg)__ 1 bottle I/V__ Stat & 12 hourly
 Tab.Norethisterone (5mg)_____2 tab stat
 Two unit whole Blood transfution

29. Inj. Tranexamic acid (500mg)__1amp__I/V__ 8 hourly
Inj. Esomeprazole (40 mg)____1 vial I/V___ 12 hourly
Inj.Calcium gluconate (10%)___1Vial__I/V(slowly)__after blood transfution
Tab.Misoprostol(200mcg)__1.5Tab in each buccal region & keep it for 30 mins
then swallow with water____(01-05-23)
Tab.Misoprostol(200mcg)__2Tab in each buccal region & keep it for 30 mins then
swallow with water____(02-05-23)
Susp.Magnesium Hydroxyde__2TSF___TDS
Supp.Glycerol(2.3mg)___3 stick __P/R___stat

30.  P/C:
• Per-vaginal Bleeding
(Decreasing)
 O/E
• Pulse:84 bpm
• BP: 110/60 mmHg
• Temp:98*F
• H/L: NAD
• Abdomen: soft and non-tender.

31. 1. Tab.Levofloxacin (500 mg) __0+1+0__(7 days)
2.Cap.Cefexim (400 mg)__1+0+1__(7 days)
3. Tab.Metronidazole (500 mg)__1+0+1__ (5 days)
4. Tab.Esomeprazole(20mg)__1+0+1__(Before meal)_ (15days)
5. Tab.Ferrous Ascorbate __ 0+1+0__( 1 month)
6. Tab.Calcium Carbonate(500mg)__0+0+1__(After meal_1 month)
7. Tab.Misoprostol (200 mcg)__1+0+1__(after meal)_(5 days)
8. Tab.Paracetamol__1+1+1__( 5days)
9.Syp.Magnesium Hydroxide__2 TSF_3 times daily__( 1 File)

32. ● Take medicine regularly
● Take adequate rest, nutritious food
● Drink water adequately
● Abstinence for 14 days
● Avoid heavy work 14 days
● Use contraceptive method .
● If any of these symptoms occur- heavy bleeding,
foul smelling vaginal discharge, high grade fever
visit nearest hospital immediately

33. THANK YOU

34. Question and Answer session….