By: Edwin John C. Limjuco Senior Clerk

Informant:Patient % Reliability: 90% General Data: A.M., 30 years old, G5P4004, LMP: July 25,2006, PMP: June 25, 2006, AOG: 9 4/7 weeks, EDC: April 30,2007 admitted for the first time at Sacred Heart Hospital due to vaginal bleeding.

Chief Complaint:
Vaginal Bleeding

History of Present Illness (HPI):
10 days prior to admission, the patient noted vaginal bleeding characterized as intermittent, scanty, bright red, non-foul smelling, using 2-3 pads a day, moderately soaked.

The condition is not aggravated by physical activity and emotional stress; however, this was associated with mild, crampy, intermittent hypogastric pain, non-radiating. No headache, no dizziness, no blurring of vision, no anorexia and no weakness noted. Since condition was tolerable, no consult was made and no medications were taken.

The said condition persisted until 18 hours prior to admission, patient had passage of meaty tissues associated with profuse vaginal bleeding and severe hypogastric pain, crampy, intermittent, non-radiating . This prompted the patient to seek consult at Toledo City Hospital, where a pregnancy test was done with positive result. She was then referred to Sacred Heart Hospital for further management and was advised admission.

Antenatal course:


Review of Systems:

Skin- no jaundice, no pallor, no rashes, no pruritus, no bruising HEENT- no migraine, no history of head trauma, no visual disturbances, no abnormal lacrimation, no difficulty of hearing, no epistaxis, no sinusitis, no nasal discharges, no gum bleeding, no mouth sores, no tongue sores, no hoarseness.

Neck- no history of lumps and masses, no stiffness. Breast- no history of trauma, no lumps, no discharges. Respiratory system- no shortness of breath, no chronic cough, no hemoptysis, no wheezing.

   

Cardiovascular system- no chest pain, no palpitations, no edema, no dizziness. Gastrointestinal tract- no change in bowel habits, no mass. Urinary tract- no dysuria, no urgency Genitalia- vaginal bleeding noted 10 days PTA, no dyspareunia, no post-coital bleeding, no pruritus. Nervous system- no paralysis, no disturbances in smell or vision, no history of loss of consciousness.

Metabolic- no weight loss, no weight gain, no fever.  Psychiatric- no nervousness, no memory loss, no hallucinations, no insomnia.

Menstrual history:
The patient had her first menstruation at the age of 13 years old, in approximately 28-30 day cycles with 3-4 days of duration noted to be moderate in flow. This was usually associated with dysmenorrhea. LMP: July 25, 2006, PMP: June 25, 2006.

Obstetrical History:
Birth order Year of delivery AOG Condition of the baby BW Place of delivery Sex Type Handled
Compli cations

1 2 3 4

1988 1989 1992 1995


Good cry Good cry Good cry Good cry

6.5 lbs Hospital M 6.1 lbs Hospital M 6.8 lbs Hospital M 6.3 lbs Hospital F


None None None None

Contraceptive History:
 The patient and her spouse used

condom as contraception.  No history of OCP use

Sexual History:
Her first sexual contact was at the age of 17 years old, single partner. No history of post-coital bleeding, no history of dyspareunia. Her last sexual contact was 2 weeks prior to admission.

Past Medical History:
M- hypertensive, non-asthmatic, nondiabetic, no thyroid dysfunction, no history of abnormal vaginal bleeding. M- None A- No food and drug allergy S- None H- acute gastroenteritis with mild dehydration in 2006 at Toledo City Hospital.

Family History:
Heredofamilial disease include hypertension, on both maternal and paternal side of the patient.

Personal and Social History:



The patient is a college graduate and is presently working as a teacher She resides at Toledo City She has been married for the last 15 years, a Roman Catholic and lives with her husband She has no history of alcohol ingestion, cigarette smoking or drug/substance abuse. Her husband is 36 years old, a businessman and is currently in good health with single sexual partner.

Nutritional History
Breakfast: 1 glass milk, 1 pc. Bread  Lunch: 1 cup rice, 1 serving fish “tinola”  Dinner: 1 cup rice, 1 serving vegetables

weight:55 kg  height:5’1” =61”  IBW = (61x2.5) – 104.75 = 48 kg  TCR= (IBWx30) + 300 = 1740 kcal  BMI= 55 / (1.52)2 = 24 kg / m2

She has no change in appetite, no dentures, chews food properly,  Has no allergy to food. She does not have preference to food.  Their budget per meal is P200.00


General Survey: Examined conscious, coherent, cooperative, ambulatory, afebrile, not in respiratory distress and with the following vital signs: BP: 130/70 mmHg RR: 18 CPM HR: 89 BPM Temp: 37° C

Skin: warm, good turgor  Head: normocephalic  Eyes: pinkish palpebral conjunctivae, anicteric sclerae, no periorbital edema  Ears: no discharges  Nose: no alar flaring,  Throat: moist lips and tongue

 Breast: asymmetrical, slightly

engorged, no nipple discharge

Chest and Lungs: I- symmetrical, equal chest expansion, no skin lesions P- equal tactile fremitus in all lung fields, no mass P- Resonance at both lung fields A- Vesicular sound in all areas, no abnormal breath sounds, no rales, no wheeze

CVS: I- symmetrical, no bulging of the precordium P- PMI at L 5th ICS, MCL, no tenderness P- cardiac dullness within normal limits A- No murmur and friction rub, normal rate (89 bpm) and regular rhythm

Abdomen: I- flabby, positive silvery striae gravidarum, no scar P- soft, nontender, no mass palpated, urinary bladder not distended P- dullness on uterine area A-normoactive bowel sounds

Genitalia: non-gaping with myrtiform caruncles, minimal vaginal bleeding Speculum Exam: – Cervix: smooth, pinkish, no erosions, no active bleeding, no mass. Bimanual Pelvic Examination: – Cervix: admits tip, movable, nontender – Uterus: slightly enlarged, anteverted, non-tender – Adnexae: no mass, nontender – Discharge: minimal vaginal bleeding, non-foul Extremities: no edema, no clubbing, strong pulses, no limitation of movement, no deformities.

Neurologic Examination:
– Cerebral function: conscious, coherent, oriented to time, place & person – Cerebellar function: no disturbances in gait or balance, no nystagmus – Motor Function: full motor strength (5/5), both upper and lower extremities – Sensory Function: intact pain and tactile sensation – Cranial Nerves: within the normal limits – Reflexes: Normoreflexia (++), no pathologic reflexes

Laboratory Examinations


 

CBC: – WBC = 11.6 K/uL – Hemoglobin = 13.0 g/dL – Hematocrit = 39.1% – Platelet count = 237K/uL BLOOD TYPING: “B POSITIVE” Urinalysis: – WBC = 0 – 2/ HPF


OLD 2 MONTHS AMENORRHEA 9 WEEKS AGE OF GESTATION VAGINAL BLEEDING (intermittent, scanty, bright red, non-foul smelling, using 2-3 pads a day, moderately soaked)  HYPOGASTRIC PAIN (severe,
crampy, intermittent, non-radiating)



Differential Diagnosis:
Submucous Myoma  Ectopic Pregnancy  Hydatiform Mole (Partial Molar Pregnancy)

Submucous Myoma:


The etiology of submucous myoma is incompletely understood. Genetic determinants definitely contribute to its development.


↑ estrogen and progesterone, epidermal growth factor, insulin-like growth factor-1, platelet-derived growth factor ↓ Somatic mutation of normal myometrium ↓ Growth of myoma

Leiomyomas are benign tumors of muscle cell origin. It is the most frequent pelvic tumor.  Initially, most myomas develop from the myometrium beginning as intramural myomas (only 5%-10% of myomas become submucosal).

As they grow, they remain attached to the myometrium with a pedicle of varying width and thickness. Continued growth in one direction determines which myomas will be located just below the endometrium (submucosal) and which will be found just beneath the serosa (subserosal).

The exact stimulus for growth of myomas is unclear, however the growth may be influenced by relative levels of estrogen and progesterone. Myomas often enlarge during pregnancy and occasionally enlarge secondary to oral contraceptive therapy.

Estrogen and progesterone receptors are found in higher concentration in myomas than in the surrounding myometrium The amount of fibrous tissue is proportional to the extent of atrophy and degeneration that has occurred overtime The eventual rate of some myomas is determined by their relatively poor vascular supply

Types of degeneration: – Hyaline: the most common type of degeneration, it is the mildest form – Myxomatous – Calcific – Cystic – Fatty – Red: the most acute form of degeneration

Clinical Characteristics

The incidence of intrauterine myoma is common in 20-44 years of age About 30% of women in the reproductive years may develop myoma of the uterus and accessory organs The highest prevalence occur during the 5th decade of a woman’s life

 

Myomas are prone to grow and become symptomatic in multiparous women Myomas may vary in size from small to large enough to fill the entire abdominal cavity Large myomas may put pressure on the bladder neck, causing acute urinary infection

The more common symptoms are the following: 1. Pressure from an enlarging mass 2. Abdominal pain including dysmenorrhea 3. Abdominal uterine bleeding – occurs in 30% of women with myomas

The most common symptoms is menorrhagia The diagnosis is usually confirmed by palpating an enlarged, firm, irregular uterus during pelvic exam The uterine cavity is generally enlarged and often irregular with myomas

Basis for inclusion
36 years old  Multiparous  Vaginal bleeding associated with hypogastric pain

Basis for Exclusion
 

No history of Oral contraceptive pills used Uterus slightly enlarged but not irregular, no mass palpated

Diagnostic Procedures

Vaginal ultrasound – serial ultrasound is used to evaluate the progression in size of myomas or its response to therapy. Hysteroscopy

Ectopic Pregnancy

Ectopic Pregnancy
 Implantation of the fertilized

ovum outside the endometrium, lining the uterine cavity.

 Tubal pathology

(acute salpingitis - major cause of ectopic pregnancy)  Contraception failure – occurs with tubal sterilization (1.85%)

 Hormonal alterations – 1.5%

ectopic pregnancy rate after ovulation has been reduced with clomiphene citrate  Previous abortion – prior abortion increases the risk of ectopic pregnancy


Transplantation of the blastocyst in the mucosa ↓ Blastocyst invade the lamina propria and subsequently the muscularis ↓ Blastocyst grows mainly between the lumen of the tube and mesosalpinx

↓  Trophoblast invades blood vessels ↓  Retroperitoneal tubal hemorrhage  Extrusion from the fimbriated end  Tubal rupture

Clinical Characteristics

A classic triad of symptoms is usually described by a patient with ectopic pregnancy, namely: 1. abdominal pain 2. amenorrhea 3. vaginal bleeding

The abdominal pain is described as colicky, unilateral or bilateral, and in most instances, it is on the same side of the ectopic gestation.  Subjective symptoms of pregnancy are seen in about half of patients

On pelvic exam, tenderness of the cervix is elicited Decidual casts can be noted plugging the cervical os The uterus is smaller than the AOG except in cases of cervical or interstitial pregnancies

The cul-de-sac may be full due to substantial hemo-peritoneum A discrete mass or fullness of the adnexa is noted in half of the cases

Basis for Inclusion
   

(+) abdominal pain (+) amenorrhea (+) vaginal bleeding Positive pregnancy test

Basis for Exclusion
  

Adnexae: nontender Cervix: nontender No history of OCP used and smoking

Diagnostic Procedures
 

hCG assays: hCG level in ectopic pregnancy is >6,500 mIU/mL Culdocentesis: the presence of nonclotting blood in the posterior cul-de-sac is indicative of hemoperitoneum. Laparoscopy: direct visualization of the pelvic organs is the gold standard in the diagnosis of ectopic pregnancy.


Hydatidiform Mole

Characterized histologically by abnormalities of the chorionic villi consisting of varying degrees of trophoblastic proliferation & edema of villous stroma. Types:
– Complete- fetus absent, diffuse villous edema, slight to severe trophoblastic proliferation – Incomplete (Partial)- fetus often present, focal villous edema, slight to moderate trophoblastic proliferation

Incomplete Mole: Etiology

Incomplete or partial moles are usually triploid and have 69 chromosomes of both maternal and paternal origin. The most common mechanism for the origin of a partial mole is a haploid egg being fertilized by two sperm, resulting in 3 sets of chromosomes alternatively, triploidy could result when an abnormal diploid sperm fertilizes the haploid egg.

It is also possible for an abnormal diploid egg to be fertilized by a haploid sperm, but this latter mechanism usually results in an abnormal conceptus with congenital abnormalities rather than a partial mole.

Clinical Characteristics

In incomplete mole, the uterus is usually small for date, and if there is a fetus, it has multiple congenital defects, is stunted and does not survive. The contents are usually expelled in 10 – 26 weeks. Normal signs and symptoms of pregnancy may be present. There may be evidence of a fetus in incomplete mole by ultrasonography.

Bleeding is the common sign, found in 86% of cases. There is disparity in the size of the uterus and the age of gestation. Grossly the mole appears like a bunch of grapes, they are smooth and transparent on the surface. The risk of malignancy in incomplete mole is low.

Basis for Inclusion
  

(+) vaginal bleeding (+) pregnancy test (+) History of hypertension

Basis for Exclusion

Normal signs and symptoms of pregnancy are absent. No history of Thyroid dysfuntion.

Diagnostic Procedures
B – HCG titer: In H – mole, the BHCG titer is higher to normal pregnancy and can even reach > 100,000 IU/L on the 100th day from the LMP.  Hysteroscopy through the cervix is a simple and rapid procedure to identify mole cysts easily when present.  Pelvic Ultrasonography- snowstorm appearance

Final Diagnosis: Incomplete Abortion Non-septic; non-induced


Termination of pregnancy before 20 weeks based upon the date of the first day of last normal menses. The delivery of a fetus-neonate that weighs less than 500 g. The fetus and placenta are likely to be expelled together before 10 weeks, but separately thereafter. When the placenta, in whole or in part, is retained in the uterus, bleeding ensues sooner or later incomplete abortion.

Incomplete Abortion: Etiology  Genetic – major cause of abortion – Cytogenetic studies indicate that incidence of chromosomal anomalies is about 50%. The most common type of anomaly is autosomal trisomy, followed by polyploidy. The rate of chromosomal abnormalities is highest when abortion occurs between 8 and 15 weeks AOG. The incidence increases markedly after 35 years old,rising to>30% after age 40.

Environmental- congenital uterine anomalies – About 20-25% of women with anomalies of uterine fusion have problems with reproduction’ – Bicornuate and septate uteri are the anomalies most frequently associated with abortion.

Uterine Anomalies after Diethylstilbestrol (DES) – The endometrial cavity of women exposed to DES in utero had a significantly smaller surface area than normal contributing to the increased rate of spontaneous abortion. – It is associated with uterine anomalies particularly uterus didelphys as well as anomalies produced by fetal DES exposure.

Cervical incompetence
– Characterized by an asymptomatic dilation of the internal cervical os, leading to dilation of the cervical canal and external os during the 2nd trimester of pregnancy. The consequent lack of support of the fetal membranes leads to their spontaneous rupture, which is usually followed by the expulsion of the fetus and placenta.

Acquired uterine defects – Leiomyomas: submucosal leiomyoma is associated with repetitive abortion. – Intrauterine adhesions can cause partial or complete obliteration of the endometrium and amenorrhea, as well as being a cause of abortion. On occasion, IUA’s develop after diagnostic curettage, as well as in women with genital tuberculosis.

Endocrine causes – Progesterone deficiency: thyroid disease (there is no definite evidence that hypothyroidism is a cause of spontaneous abortion); and diabetes mellitus (diabetes without good metabolic control is associated with an increased risk of early pregnancy loss, and a direct correlation exists between the level of hemoglobin A, and the rate of abortion. – Hypersecretion of LH: the incidence of spontaneous abortion was only increased in those women with polycystic ovarian syndrome who had elevations of follicular phase plasma LH levels.

Immunologic Factors – Lupus anticoagulant – the presence of either the lupus anticoagulant or the anticardiolipin antibodies has been found to be associated with an increased rate of spontaneous abortion and IUFD. – Increased activated protein C resistance – hyperhomocystenemia

Infectious – T. gondii may infect the embryo and cause abortion – Mycoplasma, U. urealyticum, M. hominis can cause abortion. – U. urealyticum was associated with recurrent abortions

Environmental Factors
– Cigarette smoking – women who smoked more than 14 cigarettes/day has 1:7 times greater risk of having abortion than for women who do not smoke. – Coffee, caffeine, and cocaine – there are some epidemiologic data suggesting that each of these substances may be an independent risk factor for abortion, but the data are inconsistent. – Irradiation- teratogenic effect is dose-related – Environmental toxins- little valid information exists concerning the effect of environmental toxins on human abortion.

Paternal Factors – Chromosomal translocation in sperm can lead to abortion – Adenovirus and Herpes simplex virus are found in semen samples of sterile men in nearly 40%

Hemorrhage into the decidua basalis and necrotic changes in the tissues adjacent to the bleeding ↓  The ovum becomes detached ↓  Stimulation of uterine contraction Expulsion

Clinical Characteristics

Incomplete abortion refers to the passage of some but not all fetal or placental tissue from the uterine cavity through the cervical canal before 20 weeks’ gestation. Most abortions that occur between 8-14 weeks AOG are incomplete.

If only a portion of the products of conception have been expelled and the cervix remains dilated, a diagnosis of incomplete abortion is made. In many cases, the retained placental tissue simply lies loose in the cervical canal and can be lifted from an exposed external os with ovum or ring forceps

 Hemorrhage from incomplete

abortion is occasionally severe but rarely fatal

Basis for inclusion
  

Vaginal bleeding (+) pregnancy test 18 hours prior to admission, had passage of meaty tissues Cervix admits tip



– Indicated if missing products of conception are evident – It is often unnecessary to dilate the cervix before curettage – In many cases, the retained placental tissue simply lies loose in the cervical canal and can be lifted form an exposed os with ovum or ring forceps


A woman with a more advanced pregnancy, or a woman who is bleeding heavily, should be hospitalized and the retained tissue removed without delay. Fever is not a contraindication to curettage once appropriate antibiotic treatment has been started.


Day 1 (Oct. 1 ,2006)
– Admitted due to vaginal bleeding – IVF: D5LR – DAT – Laboratory exams requested: CBC, UA, BT, TVS in am – No medications given


Day 2 (Oct. 2, 2006)
– TVS done with the following results:
Slightly enlarge-sized, anteverted uterus  Thickened & intact heterogenous endometrium (1.2 cm) with minimal mixed echoes suggestive of bloodclots  No gestational sac intra nor extrauterine

– Final diagnosis Complete Abortion
– Discharged with take home medications:
 

Cefalexin 500 mg 1 cap q8h x 7 days Ferrous sulfate 1 cap OD

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