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In Partial Fulfillment of the Requirements

of the Department of Obstetrics and Gynecology, College of Medicine


Davao Medical School Foundation, Inc.

A Case Presentation on
Threatened Abortion

Submitted by;

Liu, Cavannah Ariel C.


Lompot, Kim Adrian C.
Mama-o, Joharra M.
Martinez, Ryan Paul

Davao Doctors Hospital


Group 1

March 31, 2017, 2017


Hospital: Davao Doctors Hospital
Date & Time of Admission: March 21, 2017 11:00 PM
Date & Time of Interview: March 21, 2017 11:15 PM
Informant: Patient Reliability: 90%

GENERAL DATA:
Name: E.G
Age: 33 years old
OB Score:G2P1 (1001)
Status: Married
Religion: Roman Catholic
Address: Brgy. Cabantian, Davao City

CHIEF COMPLAINT: Vaginal Spotting


LMP: February 01, 2017
PMP: January 2017
AOG: 6 weeks and 6 days
EDC: November 8, 2017

HISTORY OF PRESENT ILLNESS:


4 days prior to admission, at her 6 weeks and 2 days AOG, patient complained of
hypogastric pain more on the left lower quadrant, characterized as crampy with pain scale of 5/10,
often radiating to the epigastric area. The condition was not associated with vaginal bleeding and
discharges. No any consultations nor medications taken since the pain was tolerable.

Interim, the patient has been having on and off hypogastric pain of the same character, until
3 hours prior to admission, at her 6 weeks and 6 days AOG, when she noted vaginal spotting
staining on her underwear. This prompted consult and was then advised admission
PAST MEDICAL HISTORY:
Patient is non-hypertensive, non-diabetic and non-asthmatic. She has no known thyroid,
liver, kidney, nor blood disorders. She has no known food nor drug allergies. She underwent one
surgery last 1999 for the removal of the left ovary due to mass.

PERSONAL-SOCIAL HISTORY:
The patient has been married for eight years. She works as a treasury assistant at a
government agency.
She is a non-smoker and non alcoholic beverage drinker. She eats three full meals per day
with snacks in between. She prefers to eat meat with less intake of vegetables and fruits.

FAMILY HISTORY:
Patient’s father has diabetes mellitus type 2, while her mother has a history of breast carcinoma.
There were no family history of hypertension, bronchial asthma, and thyroid disease.

OBSTETRIC HISTORY:
Obstetrical Score: G2P1
Pregnancy Pregnancy Year Gestation Sex Birth Present Complication
Order Outcome Completed Weight Status
G1 Livebirth 2013 Term F 2.7 kg live No complications
delivered
via NSVD
G2 Present
Pregnancy

Contraceptive History: Patient claimed she and her husband don’t use any contraceptive methods.

PRENATAL HISTORY

No prenatal visit was done as well as medications taken for this present pregnancy. Urine
pregnancy test kit at home was done last March 12, 2017 which revealed to be positive result.
GYNECOLOGIC HISTORY
Menarche: 11 years old
Menstrual cycle: Regular (28-33 days cycle) lasting 5-7 days, moderately soaked, 4-5 regular
napkins per day
With history of dysmenorrhea
Coitarche: 25 years old
Number of sexual partners: 1
Vaccines: none for HPV; 1 tetanus toxoid last 2014
No previous pap smears done.

REVIEW OF SYSTEMS:
General: No weight loss, no fever, no chills, no fatigability, no anorexia
Skin: No rashes, dryness, lumps and sores
Head: No headache or dizziness.
Eye: No defects in vision, itching, lacrimation, redness, or pain.
Ear: No deafness, tinnitus, or discharges.
Nose: No epistaxis, discharge, obstruction, sinusitis, or postnasal drip.
Mouth: No bleeding gums, swollen glands, tongue lesions, dental caries, sores, or fissures.
Throat: No sore throat.
Neck: No neck lesions or goiter. No stiffness or limited mobility.
Respiratory: No cough, wheezing, dyspnea and asthma.
Cardiovascular: No palpitations, chest pain, orthopnea, or syncope.
Vascular: No phlebitis, varicosities, or claudication.
Gastrointestinal: No nausea, no vomiting, no melena, no dysphagia, no change of bowel habits
Genitourinary: No flank pain. No dysuria, hematuria, or nocturia. No urinary urgency, frequency.
No genital lesions or purulent discharges.
Musculoskeletal: No muscle atrophy.
Hematologic: No pallor, easy bruising, or bleeding.
Endocrine: No hot or cold intolerance, excessive sweating, thirst or hunger.
Neurologic: No seizures, dizziness, headaches, or weakness.
Psychiatric: No nervousness, depression, and memory changes.
PHYSICAL EXAMINATION:
General:
Patient was examined awake, alert, coherent, cooperative and not in cardiopulmonary distress

Vital signs:
Vital Signs Reading Interpretation
Blood pressure 100/70 mmHg Normotensive
Temperature 36oC Afebrile
Respiratory Rate 19 cpm Normal
Cardiac Rate 78 bpm Normal

HEENT:
H – Head is atraumatic and normocephalic. Hair is short in length, black, and even in
distribution. Face is symmetrical, without tics, edema, or masses.
E – Pupils are equally round, and reactive to light and accommodation, constricting at 3mm.
Patient has pink palpebral conjunctiva with clear, moist bulbar conjunctiva. Sclera are anicteric.
Eyelids close completely.
E – The auricles are without deformities, lumps, or skin lesions. No lesions or discharges noted.
No tenderness upon palpation of the mastoid. Fast recoil of the pinna.
N – Nasal mucosa pink, septum midline. Nostrils patent, without nasal flaring. No nasal polyps,
ulcers, or bleeding noted. No sinus tenderness.
T – Lips are soft and pinkish. Oral mucosa are pink without lesions or ulcers. Tongue is pink and
midline. Uvula is midline. Patient has good dentition.
Neck: Neck is supple and symmetrical. Trachea is midline. Thyroid not palpable. No palpable
lymph nodes.
Breast:
I – Pendulous, no discoloration
P – Soft, non-tender, no masses
Respiratory:
I – Equal chest expansion with no use of accessory muscles.
P – No palpable mass noted. No tenderness with equal tactile fremitus on both lung fields.
P – Resonant on both lung fields.
A – Clear breath sounds on both lung fields.
Cardiovascular:
I – Anterior chest is symmetrical. No visible pulsations.
P – Adynamic precordium, no heaves or thrills.
A – Regular rate and rhythm with distinct heart sounds. PMI is at the left 5th intercostal space,
midclavicular line. No murmurs noted.
Abdomen:
I – Abdomen is slightly flabby. No scars or lesions noted.
A – Normoactive bowel sounds noted, 12 per minute.
P – Tympanitic.
P – Hypogastric tenderness noted upon light and deep palpation. Negative for kidney punch sign.
Negative for Rovsing’s, Obturator, and Psoas sign.
Pelvic:
External genitalia: Grossly normal external genitalia. No lesions, masses or tenderness.
Speculum exam: Minimal brownish vaginal discharge of approximately 5cc.
Bimanual exam: Closed cervix. Wriggling tenderness noted. Corpus is small and nontender. No
adnexal masses but tenderness noted at the left side.
Peripheral Vascular: Pulse
Radial Brachial Popliteal Dorsalis pedis
Right 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+

Extremities: No edema or deformities. Capillary refill time of less than 2 seconds on all
extremities. Pink nail beds.
Musculoskeletal: No atrophy, deformity, or crepitus noted.
Neurologic Examination
Mental status: The patient is awake, alert, and coherent. She is calm and cooperative, with good
eye contact. Responds fully and appropriately to stimuli. She is oriented to time, place, and
person.
Motor System
Gait: The patient is ambulatory, without difficulty in mobility.
Coordination: Able to perform rapid alternating movements without difficulty.
Muscle strength: 5/5 on all extremities
Cranial Nerves
CN I Able to smell the scent of hand soap
CN II Pupils equally round and reactive to light and accommodation
CN III, IV, VI Extra ocular muscle movements intact. No nystagmus or ptosis.
V Sensation on face intact. Able to clench teeth, equal strength on both sides.
VII Able to raise eyebrows, frown, close eyes, grin, smile, and puff cheeks
VIII Acuity good to whispered voice.
IX, X Swallows without difficulty
XI Able to raise shoulders symmetrically against resistance.
XII Tongue at midline, without fasciculation, deviations, or atrophy.

No pathologic reflexes

SALIENT FEATURES
 33 years old
 Vaginal spotting
 Crampy hypogastric pain
 Positive pregnancy test
 AOG: 6 6/7 weeks based on LMP
 ROS: (-) Fever, (-) Shaking chills, (-) Nausea, (-) Vomiting, (-) Anorexia, (-) Dysuria, (-)
Flank pain, (-) Urgency, (-) Frequency, (-) Gross hematuria,
 VS: T=36OC, RR= 19cpm, PR= 78bpm, BP= 100/70mmHg
 PE: negative kidney punch sign, positive hypogastric tenderness, negative Psoas sign,
negative Rovsing’s sign, negative Obturator sign
 External Genitalia: grossly normal external genitalia, no lesions, masses and tenderness
 Speculum Exam: minimal brownish vaginal discharges of approximately 5cc
 Bimanual Exam: closed cervix, wriggling tenderness noted, corpus is small and
nontender, no adnexal masses but tenderness noted at the left side

DIFFERENTIAL DIAGNOSIS
Diagnosis Rule In Rule Out
Vaginal spotting
Amenorrhea for 7 weeks
Positive pregnancy test
Crampy hypogastric pain
Positive hypogastric
(-) Adnexal mass
tenderness
Speculum Exam: minimal
1. Ectopic Pregnancy Cannot be totally ruled out;
brownish discharges
requires additional tests such
Bimanual Exam: closed
as serum Beta HCG and TVS
cervix, wriggling tenderness
noted, corpus is small and
nontender, no adnexal masses
but tenderness was noted at
the left
(-) Nausea
(-) Vomiting
AOG: 6 6/7 weeks
(-) Anorexia
Crampy, Hypogastric pain
2. Appendicitis (-) Right lower quadrant pain
Positive hypogastric
(-) Psoas sign
tenderness
(-) Rovsing’s sign
(-) Obturator sign
(-) Fever
(-) Shaking chills
(-) Nausea
(-) Vomiting
(-) Anorexia
(-) Dysuria
AOG: 6 6/7 weeks
(-) Flank pain
3. Urinary Tract Crampy, Hypogastric pain
(-) Urgency
Infection Positive hypogastric
(-) Frequency
tenderness
(-) Gross hematuria
(-) Kidney punch sign

Cannot be totally ruled out;


requires additional tests such
as urinalysis and urine culture

Impression: G2P1 (1001) Threatened Abortion, to rule out Ectopic Pregnancy, at 6 6/7 weeks
AOG, S/P Oophorectomy, left (1999)
COURSE IN THE WARD
HOSPITAL DAY 1
SOA Plan
S:  Patient was admitted. Complete bed rest without bathroom
(+) brownish vaginal privileges was ordered. IVF was started.
discharge  Vital signs were monitored every 4 hours.
(+) Hypogastric pain  Patient was monitored for: hypogastric pain, vaginal bleeding,
passage of meaty tissue.
O:  The following labs were requested: CBC, Urinalysis and TVS
Temp: 37.4°C 
PR: 80 bpm  Medication started:
RR: 20 cpm o Dydrogesterone (Duphaston) 10mg tab, 1 tab BID
BP: 104/70 mmHg
o Isoxuprine drip: D5LR 500 ml + 5 ampules isoxuprine at
20 ugtt/min to be titrated with 5 ugtt/min increments for 30
(+) hypogastric
tenderness (left) minutes until without hypogastric pain and vaginal
(+) minimal brownish spotting
vaginal discharge

IE:
Cervix closed, corpus
sl. Enlarged, no
adnexal masses,
(+)wriggling tenderness
(left)
(+)adnexal tenderness
(left)

CBC results:
Hemoglobin 92.0 L
Hematocrit 0.28 L
RBC count 4.32 L
WBC count 8.90
Neutrophil 0.59
Lymphocyte 0.28 L
Monocytes 0.08
Eosinophil 0.04
Platelet count 322
RH +
Urinalysis results:
Light, Clear
(-) Glucose
(-) Albumin
WBC: 1; RBC: 37H;
Epithelial cells:3;
Bacteria 18
TVS results:
FHR: 113 bpm
EDC: 03/21/2017
Cervix: 3.1x2.19 cm
long and closed
Adnexae: right ovary =
3.1 x 3.1 x 2.6 cm with
corpus luteum
surgically absent left
ovary
Early intrauterine
pregnancy 6weeks
1day by fetal pole
measurement with slow
cardiac activity. May
repeat scan after 1-2
weeks for reevaluation

A: t/c threatened
abortion r/o ectopic
pregnancy

SOA Plan
S: 6th hospital hour
Awake, not in
distress, comfortable  Perineal hygiene
(-) vaginal spotting  Started with:
(-) hypogastric pain o FeSO4 (Sorbifer) durule, 1 durule PO BID
o Lactulose 30 cc PO
O: o Isoxsupine 10 mg tab, 1tab TID PO once isoxsupine
Temp: 36.6 °C drip is at 100 cc
PR: 84 bpm
RR: 18 cpm
BP: 110/80 mmHg

Soft, non-tender
abdomen

A: G2P1(1001); PU 6
1/7 weeks AOG;
threatened abortion

HOSPITAL DAY 2
SOA Plan
S:  May go home orders given after AP’s rounds:
Awake, comfortable, o Home medications:
not in distress  Dydrogesterone (Duphaston) 10mg tab, 1 tab PO
(-) Hypogastric pain BID for 7 days
(-) vaginal spotting  FeSO4 (Sorbifer) durules, 1 tab BID daily
Voiding freely  Isoxilan 10 mg tab, 1 tab TID for 7 days
Adequate urine output o To repeat TVS after one week
at 2.1 cc/kg/hr
o To follow-up after one week with attending physician
O:
Temp: 37.1°C
PR: 82 bpm
RR: 21 cpm
BP: 110/70 mmHg

Clear breath sounds,


soft, nontender
abdomen

A: G2P1 (1001)
Pregnancy uterine, 6
2/7 weeks AOG,
threatened abortion

DISCUSSION
ABORTION

DEFINITION
The World Health Organization define abortion as pregnancy termination before 20 weeks
gestation or with a fetus born weighing < 500 g.
In the Clinical Practice Guidelines published by the Philippine Obstetrical and
Gynecological Society (2015), the lower limit of viability is presently recognized to be 24 weeks
age of gestation but this may well change with progress in maternal-fetal and neonatal care.
Termination prior to 13 weeks age of gestation (AOG) is first trimester or early pregnancy loss
and after 13 weeks but before 20-24 weeks, it is termed second trimester or late pregnancy loss.
Categories
Spontaneous abortion. This category includes threatened, inevitable, incomplete,
complete, and missed abortion. Septic abortion is used to further classify any of these that are
complicated further by infection.
Recurrent abortion. This term is variably defined, but it is meant to identify women with
repetitive spontaneous abortions so that an underlying factor(s) can be treated to achieve a viable
newborn.
Induced abortion. This term is used to describe surgical or medical termination of a live
fetus that has not reached viability.
The history of our patient reveals that she belongs to the spontaneous abortion category.
There was no history of induction to terminate her pregnancy. The patient is presently on her
second gestation hence cannot be classified as recurrent abortion.
The following table summarizes the characteristics of the different types of spontaneous
abortion.

Table 1. Characteristics of Different Types of Spontaneous Abortion


History

Vaginal Passage of Abdominal


Physical Findings Ultrasound
Bleeding Products Cramps
Imaging
of and other
conception symptoms

Threatened Light Absent Lower Closed Cervical Os Visualized


Bleeding Abdominal; Uterus softer than Fetal heart
Painful normal Activity
Uterus corresponds
to dates

Inevitable Heavy Absent Lower Open Cervical Os; FH Activity


Bleeding Abdominal; Ruptured Membrane may not be
very painful Tender Uterus visualized
Uterus corresponds
to dates

Incomplete Heavy Present; Lower Open Cervical Os Retained


Bleeding with Abdominal; Uterus softer than Products;
retained painful normal No Fetal Heart
tissues Uterus corresponds Activity
or smaller than dates

Complete Light Present; Present; Closed Cervical Os Empty Uterus


Bleeding complete Light Uterus softer than
passage cramping normal
/may not be Uterus smaller than
painful dates

Missed May be Absent Asymptomatic Closed Cervical Os No Fetal Heart


present at early weeks Uterus smaller than Activity
dates

Septic Bleeding May or Lower Open or Closed May or may


may not Abdominal Cervix not have fetal
be Cramping and heart activity
Fever

The patient’s signs and symptoms, along with the history and physical examination led us
to the conclusion that she went through a threatened abortion. There was no passage of the
products of conception, ultrasound revealed fetal heart activity and contractions and vaginal
spotting ceased on the 6th hour of medication.
RISK FACTORS
Spontaneous expulsion is typically preceded by embryonic or fetal demise in early
miscarriage so that determining the cause of death uncovers the cause of pregnancy loss. Most first
trimester miscarriages are due to chromosomal abnormality – fetal factor. For the maternal factors,
advanced maternal age, previous spontaneous abortion, and maternal smoking are the best
documented (POGS, 2015). In the case of our patient, there were no risk factors that would
contribute to the threatened abortion. Other maternal factors include the following:
1. Infections (Chlamydia trachomatis)
2. Medical Treatment
- A pregnancy with an intrauterinedevice (IUD) in situ has an increased risk
of abortion andspecifically of septic abortion; with the newerIUDs,
Moschos and Twickler (2011) reported that only 6 of 26intact pregnancies
aborted before 20 weeks
- Radiation/Chemotherapy
- Uncontrolled DM
- Thyroid Disorders
- Extremes of nutrition—severe dietary deficiency and morbidobesity—are
associated with increased miscarriage risks.
3. Uterine defects
4. Immunologic Factors – anti-phospholipid antibody syndrome
5. Heredofamilial Disease - Inherited Thrombophilias
6. Environmental Exposure –
- DDT—dichlorodiphenyltrichloroethane—may cause excessive
miscarriage rates
- arsenic, lead, formaldehyde, benzene, and ethylene oxide can also cause
early miscarriages
7. Social and Behavioral Factors
- Cigarette Smoking – can cause early pregnancy loss by a number of
mechanisms
- Excessive caffeine consumption—not well defined—has been associated
with an increased abortion risk. There are reports that heavy intake of
approximately five cups of coffee perday—about 500 mg of caffeine—
slightly increases the abortion risk
- Heavy and Regular consumption of alcohol

DIAGNOSIS
The diagnosis is usually made by correlating clinical with ultrasound findings. Abortion is
classified based upon the location of the products of conception and the degree of cervical dilation,
which is determined mainly by pelvic examination, although pelvic ultrasound helps the define the
location of the products of conception.
These findings on transvaginal ultrasound are diagnostic of pregnancy loss (except for
threatened abortion):
1. Crown-rump length ≥7mm and no cardiac activity.
2. Mean gestation sac diameter ≥25mm without embryo.
3. Absence of embryo with cardiac activity ≥ 2 weeks after a prior scan that found
gestational sac without yolk sac.
4. Absence of embryo with cardiac activity ≥11 days after a prior scan that found
gestational sac with yolk sac
In this case, we were able to visualize fetal heart activity through ultrasonography.
Management of Spontaneous Abortion

Expectant, medical or surgical management are reasonable options unless there is serious
bleeding or infection.

Surgical evacuation is acceptable as standard and traditional practice. Expectant


management is also an acceptable alternative but it carries a higher risk of incomplete miscarriage
and bleeding, and subsequent need for surgical emptying of the uterus. Expectant management of
spontaneous incomplete abortion has failure rates as high as 50 percent.

The basis for expectant management was demonstrated in a study that more than 80% of
women with a 1st trimester spontaneous abortion have complete natural passage of tissues within
2-6 weeks with no higher complication rate than that from surgical intervention. Obviously,
surgical evacuation is the management of choice in women experiencing spontaneous abortion
with unstable vital signs, heavy vaginal bleeding or uncontrolled bleeding, or evidence of
infection. Curettage usually results in a quick resolution that is 95-100 percent successful.
Gynecological infection after surgical, expectant, and medical management of 1st trimester
miscarriage is low (2-3%) and no evidence exists of a difference by the method of management as
evidenced by the miscarriage treatment trial. However, significantly curettage occurred after
expectant management and medical management than after surgical management.
Antibiotics are indicated management where these are signs of infection in a case of
incomplete abortion, especially when unsafe abortion is suspected.

Threatened Abortion
Analgesia will help relieve discomfort from cramping. If uterine evacuation is not
indicated, bed rest is often recommended but according to POGS CPG 2015, there is no evidence
to support the prevention of miscarriage. Progesterone on the other hand reduces the rate of
spontaneous miscarriage. In cases in which there is a live fetus, further observation is needed.

The patient was still advised bed rest without toilet privileges. Dihydrogesterone was
started along with isoxsuprine. 6 hours into the patient’s admission, the vaginal bleeding stopped
and there were no longer complaints of crampy abdominal pain.

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