case study on incomplete abortion.docx

case study

1. CARE STUDY ON INCOMPLETE ABORTION
GENERAL HISTORY
Name of Patient: Mrs. Narayani w/o Ghanshyam
Age/sex: 27years/female
Marital status: Married
Hospital registration no.: 2789
Address: Milk man colony, Jodhpur.
Religion: Hindu
Education: B.A. Graduate
Admission date: 23.06.21
Occupation of husband and patient: Patient’s husband is an Engineer and patient is a house
wife.
Monthly family income: Rs. 30,000 per month
Chief complaints with duration: Patient was admitted in the hospital with chief complaints of
mild pain in the abdomen and expulsion of fleshy mass per vaginum.
History of past medical illness: Patient has no history of past medical illness.
History of present medical illness: Patient is admitted in Gynecology ward with chief
complaints of vaginal bleeding .
History of surgical illness: Patient has no history of any surgery.

FAMILY HISTORY:
 Type of family: Nuclear

2. Name of
family
member
Relation
with
patient
Age/sex Occupation education Health
status
Mrs . Savitri Mother in
law
54yrs/female House wife 10
th

standard
Healthy
Mr.Rajiv Husband 30yrs/male Engineer B.tech Healthy
Mrs. Preeti Self 27yrs/female House
wife
B.A Healthy

 Family history of illness: All members in patients family are healthy and do not have
any history of illness.
 Housing: Pucca house
 Toilet: Closed drainage system
 Electricity: Present
 Drinking water: Tap water
GRAVIDA PARA ABORTION METHOD OF
DELIVERY
PUERPERIUM
G1 P0 Incomplete
abortion with
expulsion of
mass per
vaginum
Not delivered Nil

 PRESENT OBSTETRIC HISTORY :
 Weight: 52kg
 Height: 5feet 2 inches
 Period of gestation: 8weeks
 Height of fundus: 8cm
 Number of visits: 2 visits
 Immunization: Nil
 No. of living children: Nil
 Menstrual history: My patients menarche started at the age of 13.she had a normal
history of menstruation, with a cycle of 28days , lasting for 4-5days.
 LMP: 22/10/20
 EDD: 29/07/21

3.  PERSONAL HISTORY :
 Personal hygiene: Good
 Oral hygiene: 2 times per day
 Bath per day:1 time per day
 Diet: Non-Vegetarian
 No. of meals per day: 3 times
 Food preference: Rice and chapati
 Fluid: 8-10 glasses per day
 Tea and coffee: Tea-2 times daily
 Sleep and rest: 8 hours sleep/day
 Elimination: 1 time/day
 Urine frequency: Regular
 During day: 3-4 times
 During night: 1 time
 Other habits: No

 SEXUAL AND MARITAL HISTORY :
 Age of marriage: 25 years
 Relationship: Satisfactory
 Contraceptive: condom

OBSERVATION AND EXAMINATION
1. General appearance: Normal
 Sensorium: Conscious
 Build: Average
 Nutrition: Good
 Physical examination:
 Weight: 52 kg Height: 5 feet 2 inches
 Vitals:
 Temperature:98.7*F pulse: 82/min respiration:26/min BP: 110/70mm Hg

4.  Head: Normal
 Hair: Black, well nourished
 Eyes: Brown, reacts to light
 Skin color: Pale
 Teeth/gums: Normal
 Glands: Not Enlarged
 Chest: Normal
 Breast examination: slight tenderness was present.
 Abdomen: Normal no previous scar marks.
 Oedema of legs: No
 Toes and nails: Normal

 vaginal examination: The following were the findings of vaginal examination:
 Excessive bleeding was present
 There was partial expulsion of the products of conception per vaginum
 Mild uterine contraction was present

Operation room notes:
 Dilatation and curettage: The cervix was dilated and endometrium was scraped
away
 Along with the products of conception using an ovum forceps, under general
anesthesia. The entire inner uterine cavity was Scraped with an in and out motion
.All products of gestation was removed (a grating sound/feeling was noted).

5. SIGN AND SYMPTOMS
LISTED IN BOOK PRESENT IN PATIENT
History of partial expulsion of fleshy mass
per vaginum
Present
Heavy bleeding Present
Dilated cervix Present
The size of the uterus is smaller products of
Conception
Present
Cramping/lower abdominal pain Present
Incomplete expelled mass Present
Patulous cervical os admitting tip of the
finger
Present


INVESTIGATIONS
LISTED IN BOOK PRESENT IN PATIENT REMARK
Hemoglobin 11.5gm% Normal (11.5-16.5gm%),
W.B.C 11,500/cu mm Elevated value than
normal(4500-11000/cu mm),
eliciting the signs of infection
Neutrophils 72% Normal(40-75%)
Lymphocyte 24% Normal (20-45%)
Eosinophils 01% Normal(1-6%)
Monocytes 03% Normal(2-10%)
Basophils 00% Normal(0-1%)

6. DISEASE ASPECT

INTRODUCTION: Maternal mortality occurs due to various pregnancy-related complications,
childbirth or later during the puerperium due to hemorrhage, hypertensive disorders of
pregnancy, abortion, obstructed labour or puerperal sepsis. It is now well-recognized that
antenatal care alone, no matter how good the quality and the coverage, cannot alleviate the major
burden of suffering during and around childbirth. For reducing maternal mortality
and morbidity, skilled attendance at every birth and provision of emergency obstetric care are
essential. Countries that have been successful in bringing down the maternal mortality ratio are
those that have ensured that emergency obstetric care is accessible to all women.


DEFINITION:
According to D.C Dutta: Abortion is the expulsion or extraction from its mother of an embryo
or fetus weighing 500 gm or less when is not capable of independent survival.
INCOMPLETE ABORTION: Incomplete abortion: Uterus retains part or all of the placenta.
Before the 10th week of gestation, the fetus and placenta usually are expelled together; after the
10th week, separately. Because part of the placenta may adhere to the uterine wall, bleeding
continues. Hemorrhage is possible because the uterus doesn't contract and seal the large vessels
that fed the placenta.
ETIOLOGY:
LISTED IN BOOK PRESENT IN PATIENT
Genetic factors Absent
Endocrine disorders Absent
Maternal medical illness Absent
Rh incompatibility Absent
Bacterial or viral infections Present
Cigerratte smoking Absent
Alcohol consumption Absent

7. PATHOPHYSIOLOGY:
 In this variety of miscarriage, the cervix opens and there part of the product of conception
are expelled. Usually the fetus is passed, and the placenta and membranes are retained.

 The patient is often more than 12 weeks pregnant, so the placenta is firmly embedded and
the slender cord breaks.

 The bleeding continues and may become profuse, because of the presence of retained
products, does not allow for efficient contraction and retraction of the uterus and
therefore control of the bleeding.

 There is pain, as well as backache, the cervical OS is usually open and the uterus remains
bulky.


MANAGEMENT OF INCOMPLETE ABORTION:

o If the bleeding is light to moderate and the pregnancy is less than 12 weeks, use
your fingers or a pair of ring (or sponge) forceps to remove the products of
conception protruding through the dilated cervix.

o If the bleeding is heavy and the pregnancy is less than 12 weeks, evacuate the
uterus.

 Manual vacuum aspiration (MVA) is the preferred method of evacuation

 "Procedure for manual vacuum aspiration for incomplete abortion". Do not carry out
evacuation by sharp curettage.

 If evacuation is not immediately possible, give Tab. Misoprostol 400 mcg orally
(repeated once after 4 hours, if necessary)

o If the pregnancy is more than 12 weeks:

8.  Start an Oxytocin drip, i.e. 20 U of Oxytocin in 500 ml of R/L @ 40 drops/minute until
the
 products of conception are expelled.

 If necessary, give Tab. Misoprostol 200 mcg vaginally every 4 hours until the products of
 conception are expelled; do not administer more than a total of 800 mcg.

 Evacuate any remaining products of conception from the uterus.

 After 12 weeks of pregnancy the foetus is usually expelled in toto but the placenta may
be retained, which has to be expelled.

 If the placenta does not deliver normally, and there is no bleeding, start an Oxytocin drip
(as in the case of a delayed third stage of labour with retained placenta). You can keep the
patient at the PHC for about 2 hours after starting the Oxytocin drip, waiting for the
placenta to be expelled. However, if bleeding occurs, refer immediately to an FRU.

 If the placenta is still retained, and the woman is bleeding, she needs immediate referral
to the FRU. Establish an IV line, start the Oxytocin drip, and refer.


 In rare cases, even after expulsion of the placenta, the woman may bleed. Such patients
too need to be referred to an FRU.


 Ensure post-abortion follow up of the woman after treatment

9. MEDICATION CHART
S
N
Name of drug Dose/time Route Action Side effect Nursing
responsibility
1 Ceftriaxone 1gm/BD IV Interferes with
protein synthesis
in bacterial cell
wall by binding
ribosomal
subunits ,
causing
miscreation of
genetic code
Nausea, vomiting
fatigue, dizziness,
oliguria,
hematurea
Check infusion
site for redness,
swelling, abscess
2
.
Diclofenac 75mg/BD IM Inhibit
prostaglandin
synthesis by
decreasing the
enzyme needed
for biosynthesis
Nausea, vomiting
fatigue, dizziness
Avoid aspirin,
alcohol
beverages, report
if bleeding is
present.
3 Methergine 200-400
mcg/12hrly
IM Stimulates
uterine vascular
smooth muscle,
causing
contractions,
decreases
bleeding
Headache,
hypotension, or
hypertension,
sweating, nausea,
vomiting, rash
Assess vitals,
administer only
on 4
th
stage of
labour.
4 Gentamycin 80mg/BD IV/I
M
Interferes with
bacterial protein
synthesis
Rash, urticaria,
scaling, redness
Assess allergic
reaction, signs of
nephrotoxicity,
ototoxicity
5 Dextrose5% 5% in
500ml/mai
ntenance
IV Needed for
adequate
utilization of
amino acids,
decreases protein
Confusion, loss of
consciousness,
glycosuria
Assess
electrolytes,
blood glucose.
Monitor
temperature
4hrly.


COMPLICATIONS:
 Injuries : Uterine, vaginal, urinary bladder or bowel
 Retention of urine or dysuria
 Distended abdomen

10.  Rigid (tense and hard)abdomen
 Vaginal hematoma
 Infection/sepsis

NURSING MANAGEMENT : it includes the following guidelines to be carried out:
Guidelines for complete clinical assessment of a woman with spontaneous abortion
Complete clinical assessment

History (Ask about and record the • Period of amenorrhea (ask her the date of her LMP)
information)
• Bleeding (duration and amount)
• Abdominal cramping (duration and severity)
• Foul-smelling vaginal discharge
• Abdominal or shoulder pain
• Allergy to drugs
• H/o passage of the products of conception/foetus/blood clot
• H/o inserting something into the vagina (suggestive of an illegal abortion)
Routine physical examination • Check the vital signs (temperature, pulse, respiratory rate, blood
pressure)
• Examine the general condition of the woman (malnourished)
• Look for pallor
• Examine the respiratory system, cardiac system and extremities
Abdominal examination • Auscultate for bowel sounds (absent in peritonitis due to septic
abortion)
• Check whether the abdomen is distended (hydatidiform mole, ectopic
pregnancy)
• Assess the presence, location and severity of pain
• Palpate for abdominal rigidity (tense and hard) and guarding (peritonitis,
ectopic pregnancy)
• Palpate for rebound tenderness

11. • Assess the abdominal mass (molar/ectopic pregnancy)

Pelvic examination • External pelvic and vaginal examination:
* Look for lacerations outside the vagina, or over the external genitalia
* Assess the amount of bleeding (light/heavy)
* Look for protruding products of conception lying outside the vaginal
canal

• P/V examination
Look for:
* Any visible product of conception protruding from the cervical os or
visible in the vaginal canal
* Foul-smelling vaginal/cervical discharge
* Cervical lacerations (indicative of instrumentation; may be suggestive of
illegal abortion)
* Foreign bodies in the vagina
• P/V examination
* Assess the amount of bleeding (light/heavy)
* Check whether the cervical os is open or closed (to determine the stage of
abortion)
• Bimanual examination
* Estimate the size of the uterus
* Palpate for any pelvic masses
* Examine for pelvic pain (note severity, location, and what causes the pain: is it present at rest;
does it occur/increase with touch and pressure; does it occur/increase on moving of the cervix).

12. Investigations : The woman's blood group, especially her Rh status, should be a part of routine
investigations during the clinical assessment in cases of abortion.
APPLICATION OF THEORY: My patient is a case of incomplete abortion. She requires
intense psychological support along with physiological care in order to avoid abortion associated
complications. The theory well suited for this case is Orlando’s theory of Nursing Process
ORLANDO’S THEORY OF NURSING PROCESS: Orlando's theory was developed in the
late 1950s from observations she recorded between a nurse and patient.
MAJOR DIMENSIONS OF THE THEORY
• Discuss the experience of a patient whose need has not been met.
• Nursing role is to discover and meet the patient’s immediate need for help.
o Patient’s behavior may not represent the true need.
o The nurse validates his/her understanding of the need with the patient.
• Nursing actions directly or indirectly provide for the patient’s immediate need.
• An outcome is a change in the behavior of the patient indicating either a relief from
distress or an unmet need.
o Observable verbally and nonverbally.
• Function of professional nursing - organizing principle
• Presenting behavior - problematic situation
• Immediate reaction - internal response
• Nursing process discipline – investigation
• Improvement – resolution
DOMAIN CONCEPTS
1. Nursing – is responsive to individuals who suffer or anticipate a sense of helplessness
2. Process of care in an immediate experience….. for avoiding, relieving, diminishing or
curing the individuals sense of helplessness. Finding out meeting the patients immediate need for
help
3. Goal of nursing – increased sense of well being, increase in ability, adequacy in better
care of self and improvement in patients behavior

13. 4. Health – sense of adequacy or well being . Fulfilled needs. Sense of comfort
5. Environment – not defined directly but implicitly in the immediate context for a patient
6. Human being – developmental beings with needs, individuals have their own subjective
perceptions and feelings that may not be observable directly
7. Nursing client – patients who are under medical care and who cannot deal with their
needs or who cannot carry out medical treatment alone
8. Nursing problem – distress due to unmet needs due to physical limitations, adverse
reactions to the setting or experiences which prevent the patient from communicating his needs
9. Nursing process – the interaction of 1)the behavior of the patient, 2) the reaction of the
nurse and 3)the nursing actions which are assigned for the patients benefit
10. Nurse – patient relations – central in theory and not differentiated from nursing
therapeutics or nursing process
11. Nursing therapeutics – Direct function : initiates a process of helping the patient express
the specific meaning of his behavior in order to ascertain his distress and helps the patient
explore the distress in order to ascertain the help he requires so that his distress may be relieved.
12. Indirect function – calling for help of others , whatever help the patient may require for
his need to be met
13. Nursing therapeutics - Disciplined and professional activities – automatic activities plus
matching of verbal and nonverbal responses, validation of perceptions, matching of thoughts and
feelings with action
14. Automatic activities – perception by five senses, automatic thoughts, automatic feeling,
action

14. NURSING CARE PLAN
S.No Assessme
nt
Diagnos
is
Goal Planning Implementat
ion
rationale Evaluati
on
1 Subjectiv
e data:-
Patient
complaint
s of pain
in
surgical
site.
Objective
data:-
On
observati
on, the
patient
was
restless
Acute
pain
related
to
mechani
sm of
abortion
To
reduce
the pain
.Plan to
assess the
site of pain
plan to
provide
drugs
prescribed
by the
doctor

.Plan to
provide
hot
compressi
ons in
lower
abdomen
.abdominal
region was
assessed.
Slight
tenderness
was present
in lower
abdomen.




.injection
Diclofenac
75mg was
administered
intramuscular
ly, as adviced
by the doctor.

. hot
compression
was provided
in the lower
abdominal
region.



.
Assessmen
t provide a
baseline
informatio
n
regarding
patient




.it help to
reduce the
pain




.helps to
reduce the
pain
Patient’s
pain was
reduced
2 Subjective
data:
Patient
complains
of
excessive
thirst
Objective
data:
On
observing
the urine
output, it
was very
scanty
Fluid
volume
deficit
related
to
excessiv
e blood
loss
maintain
fluid
balance
. plan to
assess the
vitals.







.plan to
start
intravenous
infusion
with
.vitals were
checked:-
temperature-
97.6*F, pulse-
77/min,respirat
ion-
22/min,Blood
pressure-
100/70mmHg.

. intravenous
infusion of
ringer lactate
and oral
administration
. .provide a
baseline
data for
monitoring
change and
selecting
effective
interventio
ns

.helps in
maintainin
Fluid
balance
was
maintain
ed and
bleeding
was
reduced.

15. prescribed
drugs for
fluid
maintenanc
e and
control
bleeding.

of liquids were
given to the
patient.
g fluid
balance
3 Subjective
data:
Patient
complains
of nausea
and
anorexia.
Objective
data:
On
observatio
n, it was
found that
the patient
was not
taking
proper
diet.
Imbalanc
ed
nutrition
less than
body
requirem
ent
related to
anorexia,
nausea
and
vomiting
Maintain
adequate
nutrition
balance
. Plan to
assess the
dietary
pattern of
the patient.




. plan to
provide a
balanced
diet to the
patient.


. plan to
provide
small and
frequent
meals
. Assessed the
dietary pattern
of the patient.







. A balanced
diet rich in
iron,folic acid
and vitamin c
was given to
the patient.

.small frequent
meals were
provided to the
patient.
.provide a
baseline
data for
monitoring
change and
selecting
effective
intervention
s.

.promotes
early
recovery
from blood
loss.


.prevents
nausea and
promotes
effective
absorption
of meals
The
patients
nutritiona
l status is
improved
.
4 To
maintain
the body
temperat
ure
. plan to
assess the
vitals





. plan to
provide
measures to
reduce the
temperature
.
. vitals were
taken. The
temperature
was 102*F.




.cold sponging
was given to
the patient.
Tab.
Paracetamol
500 mg was
given to the
patient, as
prescribed by
the physician.
. helps to
identify
minute
variation in
body
mechanics


. helps to
reduce the
body
temperature
Patients
body
temperatu
re was
brought
to normal
i.e
98.8*F.

16. Subj
ective
data:
My
patient
complaint
s of hot
flushes
all over
body.
Objective
data:
On
observing
the vitals,
the patient
had
elevate
body
temperatu
re up to
102*F.
Hyperther
mia
related to
decreased
body
resistance
to
infection
To
reduce
the
anxiety
. plan to
assess the
knowledge
of the
patient

. plan to
provide
psychologi
cal support
to the
patient
. assessed the
knowledge
level of the
patient


. All doubts
of the patient
were cleared
with proper
explanation
before and
after each
procedure
.It helps to
find out
the
understand
ing level
of the
patient
.helps to
reduce the
anxiety
Anxiety
of the
patient
was
reduced.
Subjectiv
e data:
Patient
asks
many
questions
and
worries
regarding
treatment
regimen
Objective
data:
On
observati
on, it was
found
that the
patient
was very
anxious
Anxiety
related to
the
recovery
and
various
treatment
regimens

17. HEALTH EDUCATION :
• DIET: patient was advised to take nutritious diet including high protein, iron and folic
acid rich diet. She was encouraged to take plenty of water.

• REST: patient was advised to take proper rest and reduce heavy workload. She was
encouraged not to take stress and practice diversional therapies like music, art etc.


• PERSONAL HYGIENE: patient was asked to give specific importance to personal
hygiene, especially menstrual hygiene. She was also advised to observe the pattern of bleeding,
its color and duration, and to report any variation to the doctor immediately.

• MEDICATIONS: the patient was encouraged to take medicines regularly on time.

• FOLLOW UP CARE: The patient was advised to come to the hospital for follow up

check up. She was instructed to meet the physician if any complications occur.

18. CONCLUSION:
Patient was admitted in the ELR ward as a case of incomplete abortion. she was been treated
under Dr. Santosh. At the time of admission, she was having cramping abdominal pain and
vaginal bleeding. After the procedure – Dilatation and curettage, and administration of proper
medication, the condition of patient got stable.

19. BIBILIOGRAPHY:
 "Fear a factor in surgical births". The Sydney Morning Herald. 2007-10-07.
 Kiwi Caesarean rate continues to rise - New Zealand news on Stuff.co.nz
 “ Finger, C. (2003). "Caesarean section rates skyrocket in Brazil. Many women are
opting for Caesareans in the belief that it is a practical solution.". Lancet 362 (9384): 628.
doi:10.1016/S0140-6736(03)14204-3. PMID 12947949.
 "C-section rates around globe at ‘epidemic’ levels". AP / msnbc.com. Jan. 12, 2010.
http://www.msnbc.msn.com/id/34826186/. Retrieved February 21, 2010.
 “As there was a cultural taboo against burying an undelivered woman in Roman and
German societies, according to Lex Caesarea..." U Högberg, E Iregren, CH Siven,
"Maternal deaths in medieval sweden: an osteological and life table analysis", Journal of
Biosocial Science, 1987, 19: 495-503 Cambridge University Press
 “University of Virginia Health System, Claude Moore Sciences Health Library, Ancient
Gynecology: Caesarean Section
 Cesarean Section - A Brief History: Part 1". US National Institutes of Health. 2009-06-
25. http://www.nlm.nih.gov/exhibition/cesarean/part1.html. Retrieved 2010-11-27.