Avian Loren T.

Co
ASMPH Yr Level 8

Patient: CI, 28 years old, female, Filipino, married, Catholic, from Quezon City.
Source of Information: attending physician and patient chart

Chief Complaint: bloody vaginal discharge of 2 days

History of Present Illness:

3 weeks PTA
The patient underwent a dilatation and curettage procedure for a missed abortion.
2 days PTA
Patient noted intermenstrual bleeding which was aggravated by movement and by
changing positions. The bleeding was described to be dark red clots and was accompanied
by hypogastric pain radiating to the back. She took Tranexamic Acid for the bleeding. There
was no fever, vomiting, or dysuria. Persistence of the problem prompted her to seek consult.

Review of Systems
General: (-) fever, weight loss
HEENT: (-) headache
Respiratory: (-) dyspnea, cough
Cardiovascular: (-) palpitations, chest pains
Gastrointestinal: (-) nausea/vomiting, change in bowel habits, rectal bleeding
Genitourinary: (-) nocturia, frequency

Obstetric-Gynecologic History:
• Onset of menarche was at 11 years old, occurring irregularly, lasting 7 days
• No accompanying symptoms
• LMP: Last week of July 2010
Pregnancy History
• Age of first pregnancy: 28
• Primigravid G1P0
Gravida Outcome Date AOG
1 Missed abortion 2010 6 and 6/7 weeks
Vaginal and Pelvic Infections
• Frequent UTI (>10 times)
• No vulvar pruritus, no leukorrhea
Gynecologic Surgical Procedures
• Dilatation and curettage (October 2010)
Sexual History
• Active sexual life, first coitus is at 22 years old
• Number of partners: 1
• No dyspareunia
Contraceptive History
• No contraceptive use

Past Medical History:

Medical History
• There is no other medical conditions (PTB, DM, HPN)
• (+) Bronchial asthma, no medications taken for the last attack (no date of last attack)
• No known food and drug allergies
Surgical History
• No history of surgery other than the d&c.
Personal and Social History:
The patient is a non-smoker, non-alcoholic beverage drinker, and denies use of illicit
drugs. She’s a college graduate and currently works as a researcher at Quintiles Philippines.

Family History:
No known diabetic, hypertensive, or stroke in the family. The only known illness is
Bronchial Asthma (not specified).

Physical Examination
General: alert, coherent, pain (2/10), afebrile, well-groomed
Ht: 163cm Wt: 70kg BMI: 23.5 (Normal)
Vital Signs:
- BP: 110/60 mmHg
- HR: 86/min
- RR: 18/min
- T: 36.0C
HEENT:
- Anicteric sclera, pink palpebral conjunctivae, (-) TPC, (-) CLAD, flat neck veins.
Cardiopulmonary:
- Equal chest expansion, clear breath sounds, (-) rales/crackles, (-) wheezes. Normal
rate, regular rhythm, with good S1S2 and (-) murmurs.
Abdomen:
- Soft and flabby with normoactive bowel sounds.
- (+) Tenderness (not noted on which side)
Pelvic:
Speculum Exam:
- Moderate to profuse bleeding per os, (-) polyps, (-) lesions
Internal Exam:
- Cervix is 1cm dilated, no tenderness
- Adnexae: no masses, no tenderness
- Uterus is not enlarged, no tenderness
Digital Rectal Exam:
- Not done.
Skin & Extremities:
- Full and equal pulses, (-) scar, (-) edema, (-) signs of cyanosis, (-) jaundice, (-)
rashes/lesions.

Primary Impression
Incomplete Abortion s/p D&C

An incomplete abortion may be thought of first thing since the patient presented with
bleeding several weeks after a dilatation and curettage procedure for a previously missed
abortion. The pregnant patient presenting with hypogastric pain and vaginal bleeding show
signs of abortion. If the speculum exam already ruled out lesions or polyps of the cervix, an
internal exam should be done next. Clinically, the patient would be presenting with
hypogastric pain (uterine contractions) and bleeding, as was with this case. An incomplete
abortion would present on internal examination with vaginal bleed, cervical dilatation, and
passage or remnants of products of conception on IE. If the bleeding presented early on
after a d&c procedure, it might have just been bleeding from the procedure just like how a
normal pregnancy would bleed after delivery. However, this patient presented weeks after.
The d&c procedure is a blind procedure, remnants of the contraceptive product would not be
100% sure to be expelled or extracted with the said procedure.
Diagnostic Work-up:
- CBC
- Urinalysis
- Transvaginal ultrasound

A complete blood count may reveal a diagnosis of anemia and therefore, the need for iron
supplementation and for close monitoring. Another routine laboratory diagnostic is a
urinalysis to detect any urinary tract infection. A transvaginal ultrasound will be confirming
the contents of the uterus.

Management Plan:
Evacuation of the uterus must be done for this patient. There are some studies saying that
waiting for a spontaneous abortion is something more natural. However, doing a dilatation
and curettage will be more effective since a more complete removal of the product of
conceptus can be removed as soon as possible. Methylergometrine Maleate (Methergine)
was given for the uterus to contract promoting passage of tissue remnants as well as
promote hemostasis. Pain relievers, Mefenamic Acid, were also given since the contraction
will be painful for the patient. Lastly, prophylactic antibiotics were also given since the
management done was a surgical procedure that may have resulted to lesions inside the
uterus, therefore, may be a cause for infection.

Prognosis:
The couple may wait for at least 1-3 regular menstrual cycle before trying to conceive again.
If preventive measures are taken into consideration (eg. a healthy lifetstyle, avoid stressors)
before a start of a pregnancy, it is more likely that the couple could have a normal
pregnancy after.

Preventive Measures:
Chromosomal abnormalities can be related to the lifestyle of the patient. For this case, the
patient is a researcher and may be exposed to a lot of stress. An expected healthy
pregnancy should always start earlier than the day of conception itself. The body of the
mother should be primed for the pregnancy.

References:
http://www.medterms.com/script/main/art.asp?articlekey=30956
http://www.americanpregnancy.org/pregnancycomplications/blightedovum.html
www.emedicine.com
Sumpaico, et al. Textbook of Obstetrics, 3rd ed.
Leveno, et al. Williams Manual of Obstetrics: Pregnancy Complications, 23rd ed.