REPUBLIC OF THE PHILIPPINES

ISABELA STATE UNIVERSITY

ECHAGUE CAMPUS
SAN FABIAN, ECHAGUE, ISABELA

A CASE STUDY OF MISCARRIAGE

PRESENTED TO:
MAAM DOTHA MUNDO
MAY 12,2020
PRESENTED BY:
ANGELICA CARL MAE P. CAUILAN
 
 

 
 Introduction
 Abortion is the loss or termination of pregnancy less than the age of viability which is 20-24 weeks of gestation or if the
fetus weighs less than 500 grams.
 Early abortion – happens before 12 weeks of gestation
 Late Abortion – happens 12-20 weeks of gestation.
 Abortus – a fetus that weighs less than 500 grams or expelled from uterus before age of viability
  
 Types
  
 Complete abortion- complete expulsion of all the products of conception.
  
 Criminal abortion - termination of pregnancy by illegal interference, usually undertaken when legal induced abortion is
unavailable. The most frequent complications are severe hemorrhage
 and sepsis, and for those who delay seeking medical attention the mortality rate is high.
  
 Habitual abortion - in three or more consecutive pregnancies before the 20th week of gestation.
  
 Incomplete abortion- abortion in which parts of the products of conception are retained in the uterus.
  
 Induced abortion -abortion brought on intentionally by medication or instrumentation.
 Inevitable abortion- a condition in which vaginal bleeding has been profuse, membranes usually
show gross rupturing, the cervix has become dilated, and abortion is almost certain.
  
 Missed abortion- retention of dead products of conception in utero for more than 8 weeks.
  
 Septic abortion - abortion associated with serious infection of the products of conception and
endometrial lining of the uterus, leading to generalized infection; it is usually caused by pathogenic
organisms of the bowel or vagina.
  
 Spontaneous abortion - termination of pregnancy before the fetus is sufficiently developed to
survive; called miscarriage .Chromosomal abnormalities cause at least half of spontaneous abortions.
  
  
 Therapeutic abortion - abortion induced legally by a qualified physician to safeguard the health of
the mother.
  
 Threatened abortion- a condition in which vaginal bleeding is less than in inevitable abortion, the
cervix is not dilated, and abortion may or may not occur; this is the presumed diagnosis when any
bloody vaginal discharge or vaginal bleeding occurs in the first half of pregnancy
 Sign and symptoms
  
 • vaginal bleeding
 • cramping and pain in your lower tummy.
 • a discharge of fluid from your vagina.
 • a discharge of tissue from your vagina.
 • no longer experiencing the symptoms of pregnancy, such as feeling sick and breast tenderness.
 • heavy spotting.
 • discharge of tissue or fluid from your vagina.
 • severe abdominal pain or cramping.
 • mild to severe back pain.

CAUSES
 Infection
 Medical conditions in the mother, such as diabetes or thyroid disease
 Hormone problems
 Immune system responses
 Physical problems in the mother
 Uterine abnormalities
 A woman has a higher risk
 s over age 35
 Has certain diseases, such as diabetes or thyroid problems
 Has had three or more miscarriages
ANATOMY AND PHYSIOLOGY
 The Female Reproductive System
 The female reproductive system is designed to carry out several functions. It
produces the female egg cells necessary for reproduction, called the ova or
oocytes. The system is designed to transport the ova to the site of fertilization.
Conception, the fertilization of an egg by a sperm, normally occurs in the
fallopian tubes.
  
 After conception, the uterus offers a safe and favorable environment for a baby to
develop before it is time for it to make its way into the outside world. If
fertilization does not take place, the system is designed to menstruate (the
monthly shedding of the uterine lining). In addition, the
 female reproductive system produces female sex hormones that maintain the reproductive cycle.
  
 During menopause the female reproductive system gradually stops making the female hormones necessary for the
reproductive cycle to work. When the body no longer produces these hormones a woman is considered to be
menopausal.
  
 What parts make-up the female anatomy?
The female reproductive anatomy includes internal and external structures.
  
 The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body
and to protect the internal genital organs from infectious organisms.
 The main external structures of the female reproductive system include:
  
 Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as
"large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia
majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair.
 Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie
just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus
to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body).
 Bartholin’s glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion.
 Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The
clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the
clitoris is very sensitive to stimulation and can become erect.
  
 The internal reproductive organs include:
  
 Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth
canal.
 Cervix: the lower one-third of the uterus is the tubular "cervix," which extends downward into the upper portion of the vagina. The
cervix surrounds the opening called the "cervical orifice," through which the uterus communicates with the vagina.
 Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two
parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus
can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit.
 The Wall of the Uterus (3 Layers)
 The outer serous coat called the perimetrium, consists of peritoneum supported by a thin layer of connective tissue;
 The middle muscular coat called the myometrium consists of 12 to 15 mm of smooth muscle. The myometrium increases
greatlyduring pregnancy. The main branches of the blood vessels and nerves of the uterus are located in this layer;
 The inner mucous coat called endometrium is firmly adherent to the underlying myometrium.
 The endometrium is partly sloughed off each month during menstruation.
 It lines only the body of the uterus.
 The Ligaments of the Uterus
 a. Transverse Cervical Ligament (Cardinal Ligament)
 This extends from the cervix and lateral parts of the vaginal fornix to the lateral walls of the pelvis.
 b. Uterosacral Ligaments
 These pass superiorly and slightly posteriorly from the sides of the cervix to the middle of the sacrum.
 They are deep to the peritoneum and superior to the levator ani muscles.
 The uterosacral ligaments tend to hold the cervix in its normal relationship to the sacrum.
 c. Round Ligament of the Uterus
 These ligaments are 10 to 12 cm long and extend for the lateral aspect of the uterus, passing anteriorly between
the layers of the broad ligament.
 They leave the abdominal cavity through the inguinal canal and insert into the labia majora.
 The Broad Ligament
 This is a fold of peritoneum with mesothelium on its anterior and posterior surfaces.
 It extends from the sides of the uterus to the lateral walls and floor of the pelvis.
 The broad ligament holds the uterus in its normal position.
 The 2 layers of the broad ligament are continuous with each other at a free edge.
 This is directed anteriorly and superiorly to surround the uterine tube.
 Laterally, the broad ligament is prolonged superiorly over the ovarian vessels as the suspensory ligament of the
ovary.
 The ovarian ligament lies posterosuperiorly and the round ligament of the uterus lies anteroinferiorly within
the broad ligament.
 The broad ligament contains extraperitoneal tissue (connective tissue and smooth muscle) called parametrium.
 It gives attachment to the ovary through the mesovarium.
 The mesosalpinx is a mesentery supporting the uterine tube.
 Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries
produce eggs and hormones.
  
 9
 Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels
for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a
sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to
the uterine wall.
  
 What happens during the menstrual cycle?

Females of reproductive age (anywhere from 11-16 years) experience cycles of hormonal activity that repeat at
about one-month intervals. (Menstru means "monthly"; hence the term menstrual cycle.) With every cycle, a
woman’s body prepares for a potential pregnancy, whether or
 not that is the woman’s intention. The termmenstruation refers to the periodic shedding of the uterine lining.
  
 The average menstrual cycle takes about 28 days and occurs in phases: the follicular phase, the ovulatory
phase (ovulation), and the luteal phase.
  
 There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs) involved in
the menstrual cycle: follicle-stimulating hormone, luteinizing hormone, estrogen, and progesterone.
  
 Follicular phase
This phase starts on the first day of your period. During the follicular phase of the menstrual cycle, the
following events occur:
 Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH) are released from the brain
and travel in the blood to the ovaries.
 The hormones stimulate the growth of about 15-20 eggs in the ovaries each in its own "shell," called a follicle.
 These hormones (FSH and LH) also trigger an increase in the production of the female hormone estrogen.
 As estrogen levels rise, like a switch, it turns off the production of follicle-stimulating hormone. This careful
balance of hormones allows the body to limit the number of follicles that complete maturation, or growth.
 As the follicular phase progresses, one follicle in one ovary becomes dominant and continues to mature. This
dominant follicle suppresses all of the other follicles in the group. As a result, they stop growing and die. The
dominant follicle continues to produce estrogen.
 Ovulatory phase
The ovulatory phase, or ovulation, starts about 14 days after the follicular phase started. The ovulatory
phase is the midpoint of the menstrual cycle, with the next menstrual period starting about 2 weeks later.
During this phase, the following events occur:
 The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing hormone that is
produced by the brain.
 This causes the dominant follicle to release its egg from the ovary.
 As the egg is released (a process called ovulation) it is captured by finger-like projections on the end of the
fallopian tubes (fimbriae). The fimbriae sweep the egg into the tube.
 Also during this phase, there is an increase in the amount and thickness of mucus produced by the cervix
(lower part of the uterus.) If a woman were to have intercourse during this time, the thick mucus captures
the man's sperm, nourishes it, and helps it to move towards the egg for fertilization.
 Luteal phase
The luteal phase begins right after ovulation and involves the following processes:
 Once it releases its egg, the empty follicle develops into a new structure called the corpus luteum.
 The corpus luteum secretes the hormones estrogen and progesterone. Progesterone prepares the uterus for a
fertilized egg to implant.
 If intercourse has taken place and a man's sperm has fertilized the egg (a process called conception), the
fertilized egg (embryo) will travel through the fallopian tube to implant in the uterus. The woman is now
considered pregnant.
 If the egg is not fertilized, it passes through the uterus. Not needed to support a pregnancy, the lining of the uterus breaks
down and sheds, and the next menstrual period begins.
  
  
 How many eggs does a woman have?
  
 During fetal life, there are about 6 million to 7 million eggs. From this time, no new eggs are produced.
  
 The vast majority of the eggs within the ovaries steadily die, until they are depleted at menopause. At birth, there are
approximately 1 million eggs; and by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will be
ovulated during a woman's reproductive lifetime. The eggs continue to degenerate during pregnancy, with the use of
birth control pills, and in the presence or absence of regular menstrual cycles.
  
  
 Embryonic development
  
 Chromosome characteristics determine the genetic sex of a child at conception. This is specifically based on the 23rd
pair of chromosomes that is inherited. Since the mother's egg contains an X chromosome and the father's sperm contains
either an X or Y chromosome, it is the male who determines the baby's sex. If the baby inherits the X chromosome from
the father, the baby will be a female. In such case, testosterone is not made, but the Wolffian duct will degrade and the
Müllerian duct will develop into female sex organs. In this case, the female clitoris is the remnants of the Wolffian duct.
On the other hand, if the baby inherits the Y chromosome from the father, the baby will be a male. In such case,
 testosterone will be in charge of stimulating the Wolffian duct in order to develop
male sex organs, and the Müllerian duct will degrade.
PATHOPYSIOLOGY
 Predisposing Factors
Precipitating Factors
Age: 35 years old
 
Gender: Female
Works 5 days in a week
Previous abortion
Work-related stressor
Medical Condition
Genetic issues
 

Abdominal
contraction

Abdominal pain

Cervical Dilatation

Vaginal bleeding
for weeks
Passing of small pieces of
pregnancy tissue

Passing of small pieces of

pregnancy tissue

Dilatation and Curettage

Nursing Care Plan
Assessment Diagnosis Planning Intervention Rationale Evaluation
  •Risk of infection •After 4 hours of •assess for sign and •To monitor if the patient is high risk for After 4hours
•

infection
Objective: due to nursing intervention symptoms •A first
Of nursing intervention the patient
•Red bleeding from miscarriage   Of sepsis Line of defense adopted new information on how to
Vagina Or abortion •the patient verbalize Fever, chills and Against infections prevent herself for infection
•To increase the immune system to fight
•improper hygine Understanding diaphoresis against infection
  Of individual •advice patient for •To increase awareness
Risk factor proper hygiene Of and to prevent
Communicable Disease
•Identify interventions  
To prevent •Review individual
Risk infection nutritional needs and
•Demonstrate appropriate exercise
Techniques  
Lifestyle changes  
To promote •Provide info. In
Safe appropriate community
Environment And national education
  Programs
   
Assessment Diagnosis Planing Intervention Rationale Evaluation
Objective: Deficient fluid volume After 4hours of *Monitor vital sign and *Changes in blood After 4hours of nursing
*Delayed capillary refill related to excessive nursing compare it to previous normal pressure may use for intervention the patient
*Restless- blood loss intervention findings estimate of blood was able to
ness   the patient will: *Note patients individual *Symptomatology may demonstrate improved
*Vaginal spotting   physiological responses be useful in gauging fluid balance as evidence
*demonstrate to bleeding such as changes in severity of length of by stable v/s, good skin
improve mentation, bleeding turgor and prompt
fluid weakness, restlessness and   capillary refill
balance as evidence pallor  
by stable vital sign, *measure central venous  
good skin turgor pressure, if available  
and prompt *maintain bed rest  
capillary refill *provide guidelines for
fluid re-
placement
*Fluid re-
placement
with isotonic solution
depends on the degree
and duration of bleeding
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: *Antici- *After 8hours of nursing inter- *Assess the reaction of the patient *To deter- The women and her partner begin
“Nalu- patory grieving r/t vention and support person mine verba-
lungkot loss of pregnancy the mother and her partner   the feelings of the client lizing
ako sa pagka wala ng anak ko” as cause of abortion ang future will verba-   and of the sig- their grief and acknow-
verbalized by the patient child lize grieve and acknow-   nificant other ledge that the grieving process last
  bearing ledge that the grieving process lasts   *To lessen confu- several months
    several months *Provide infor- sion
Objective: mation of patient regar-
  regarding ding the loss, to clarify and to avoid
*Appears sad current status blame
  as needed  
  *encourage patient to discuss feeling  
  about  
the loss of the baby and include effect  
on relationship with the father  
*Acknow-  
ledge the loss and allow grieving *to relive emo-
  tions
  sharing of feelings
  to father may encou-
  rage support
  from each other
  *The grie-
  ving
  period
following a mis-
carriage usually last 6-24 months
DRUG STUDY
Medications Dosage Route Indications Application to the patient

Oxytocin 10 unit IM To improve and stimulate the uterine To facilitate and stimulate of the uterine
    contractions contraction of the woman and control
  postpartum bleeding

D5LR’s 1 liter regulated of 30 drops per Parenteral A type of hypertonic solution that is To replace and replenish the electrolytes
minute source of water electrolytes and calories mainly glucose of the woman.

PNSS 500 cc regulated KVO Parenteral A type of isotonic solution , and prevent A solution for fluid and electrolyte
  for hypocvolemic shock replenishment. And used to woman for
prevention of shock

Diazepam 10mg IM A sedation that provides light Used to sedate the woman during the
anesthesia and muscle relaxant procedure
Medications Dosage Route Indications Application to the patient

Fortifier FA 125mg/tab Oral To prevent and treat iron deficiency Because the patient had a lot of blood
anemia loss so she needs to regain by taking this
and she is prone to anemia

Mefenamic acid 500mg/tab with meals Oral Relief of pain during post op and Because postpartum women had a
postpartum traumatic experience and pain during
procedure

Co-amoxiclav 625 mg/cap BID x 7 days Oral Used to prevent an infection Mother who have been for completion
curettage can be at risk of getting
infection, example: the patient has a poor
perineal hygiene