UNIVERSITY OF THE GAMBIA

SCHOOL OF MEDICINE AND ALLIED HEALTH SCIENCES

DEPARTMENT OF NURSING AND REPRODUCTIVE HEALTH

REPRODUCTIVE HEALTH

CASE STUDY ON

MISSED ABORTION

Tobiloba A. Omotosho 2130019

DECEMBER, 2015
INTRODUCTION

The following is a case study of a female client, Naffie Sambou (fictitious name), suffering
from a condition diagnosed as “Missed Abortion”. A missed abortion occurs when a fetus
dies, but the body does not recognize the pregnancy loss or expel the pregnancy tissue. As a
result, the placenta may still continue to release hormones, so the woman may continue to
experience signs of pregnancy (Elena, A., 2015). Missed abortion also called missed
miscarriage is only one of the numerous forms of abortion and is caused by chromosomal
abnormalities in the fetus, which do not allow the pregnancy to develop (Elena, A., 2015).
The patient was reviewed on account of profuse PV bleeding being one of the complications
for this condition alongside abdominal pain.

Through induction and surgery, this patient showed successful recovery and was discharged
six days after admission.

PATIENT HISTORY

This section presents a brief history of the patient considered in this study. Naffie is a 32year
old Business woman and Gambian national. She is a Muslim and she resides in Lamin with
her husband, Karamo Tamba and her children. She has had six previous pregnancies, one of
which ended as a spontaneous abortion at 24weeks gestation and two were complicated by
Pregnancy Induced Hypertension but carried to term and delivered via Safe Vaginal Delivery.
All other pregnancies including this last one were uneventful. She had an Intra-Uterine
Device inserted 3years ago and has no previous history of sexually transmitted infection.

She was admitted at the Gamtel ward of Edward Francis Small Teaching Hospital (EFSTH)
on the 24th November, 2015 by quarter past five in the evening. The pregnancy was at
13weeks gestation and the expected delivery date was March, 2016. She presented with
abdominal pain of 6days, not pale and afebrile. Vaginal examination revealed moderate
bleeding with some clots, and membranes bulging through the cervix.

Vital Signs on admission – Respiratory Rate: 20breaths per min; Temperature: 35.10C;

Blood Pressure: 110/80mmHg; Pulse rate: 70beats per min

SYMPTOMS AND DIAGNOSIS

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This section presents an overview of the symptoms associated with this condition and the
diagnosis as noted by literatures as well as symptoms exhibited by patient and their diagnosis.

A missed abortion is often known as a silent miscarriage because women generally do not
have common miscarriage symptoms, such as vaginal bleeding, heavy cramping or expulsion
of fetal tissue. With a missed miscarriage, the placenta may still release hormones, which can
continue the signs of pregnancy. However some women may notice that their pregnancy
symptoms, like breast tenderness, nausea or fatigue may disappear. Some may also have
brownish or red vaginal discharge (Elena, A., 2015)

A missed miscarriage is usually diagnosed during a routine checkup, where the doctor will
fail to detect the fetal heartbeat and an ultrasound that will show an underdeveloped fetus
(Elena, A., 2015).

Naffie had abdominal pain for six days, vaginal bleeding and abdominal cramps. There was
moderate bleeding with some clots and membranes bulging through the cervix. A pelvic
ultrasound was conducted on the 24th November, 2016 and result revealed presence of single
fetus, no fetal movement, no heart activity, Crown Rump Length – 13weeks and conclusion
was ‘Fetal Death’. Hemoglobin level was found to be 12.0g/dl and 10.7g/dl on the 24 th and
28th respectively.

PLAN

This section presents the treatment plan for this patient as well as the results and outcome of
the treatment.

If a missed abortion has occurred early in pregnancy, a woman will usually be able to expel
the pregnancy tissue naturally. However, if the fetal tissue remains in the body for a longer
time, a D&C procedure is usually recommended. In this procedure, the cervix is opened and
the contents of pregnancy are removed. After a missed miscarriage, couples are encouraged
to wait between one to three menstrual cycles before trying to conceive again (Elena, A.,
2015).

Patient was given 10 IU Pitocin in drip and transferred to the labor ward for expulsion of
products of conception. Patient expelled products of conception but the placenta was not
expelled. Therefore, IV Pitocin was continued. Vaginal examination done, showed no active
bleeding and plan was to allow pitocin drip to progress then await expulsion of placenta.

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Six hours later, patient was reviewed again and placenta was still not out. Another ultrasound
was done which confirmed the presence of placenta in the uterus separated from the uterine
wall. This prompted the need for evacuation and cross match was ordered to prepare 2pints of
whole blood.

APPLICATION & RESULT/OUTCOME

Evacuation was done on the 28th November, 2015. Pre-op vital signs included:

Blood Pressure: 129/69mmHg; Pulse Rate: 114beats per min; SPO2: 100%

IV Fentanyl 100mg was given as analgesic, IV Normal Saline Stat was given and IV
Ephedrine 15mg was given. Under mild sedation with thiopentanal with patient in lithotomy
position, routine cleaning was done and then patient was draped under aseptic technique.
Two Sims Speculum were used to hold the cliteric lip of the cervix. A sponge holding forceps
was used to hold on the membrane of the placenta and it was gently pulled. The placenta
came out and suction evac was done to suck remaining products. Estimated blood loss was
200mls and the immediate post-op vital signs were – BP: 130/79mmHg; PR: 105bpm; SPO 2:
100%.

Further plan was to admit at Gamtel ward. Iv Pitocin 10 IU in %00mls of Normal Saline was
given over 4hours at 12 drops per minute. Patient was placed on the following drugs:

Tabs Ampiclox 500mg QDS 5/7; Tabs Flagyl 500mg TDS 5/7; Tabs Diclofenac 50mg TDS
1/7; Tabs Fefa ½; and Tabs Cloxacillin 100mg BD 5/7.

On the 30th November, 2015, patient was reviewed and plan was to discharge patient. She
was given appointment for 10th December, 2015 at the Gynea Clinic. She was given the
following medications to go home with:

PO Ampiclox 500mg QDS and PO Flagyl 500mg TDS.

CONCLUSION

The author hopes that the case study presented here has communicated some of the issues
associated with missed abortion. Naffie’s abortion was the second one and this last one was
complicated by retention of placenta after other pregnancy products were expelled. With
evacuation and suction, the retained products were removed and patient was given hospital
bed rest for 2days after the evacuation before discharge.

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REFERENCES

Elena A. (2015). Missed Miscarriage. Fertility Authority: USA, New York. Accessed on 30 th
November, 2015. Retrieved from: https://www.fertilityauthority.com/fertility-
issues/miscarriage/missed-miscarriage