University of Medicine (1) Yangon

Community Medicine Program

Community Oriented Case Presentation

Obstetrics and Gynecology - Miscarriage

Presented by
House Officers of UM (1)
Public Health Field Training
1st posting 2nd group
(20.1.2020 – 3.2.2020)
 Contributors

• HS. Dr. Thiha Min Thein (Leader)

• HS. Dr. Eaint Thazin Maung (Presenter)
• HS. Dr. T Zaw San Aung Hkum
• HS. Dr. Tet Naing Phyar Ko
• HS. Dr. Ingyin Hmwe
• HS. Dr. Aung Myo Min
• HS. Dr. Aung Thu Phyo

2
 History Taking

Personal Identification
• Name – Daw YYL
• Age – 42 years
• Parity – P 3+1
• Race & Religion – Burmese/Buddhist
• Address –Minn Village, Mhaw Bi Township
• Occupation – Manual worker
• Husband’s Name – U WA
• Date & Time of Admission – 21.1.2020 (8pm)

3
Chief complaint
- Bleeding per Vagina for 1 day
- Amenorrhea for 1 month
 

4
Menstrual History

- Age of Menarche – 17 years

- Regular, 3/30 days cycle
- Amount – moderate (3 pads per day)
- History of Dysmenorrhea – Absent
- LMP – 1.12.2019 (not sure)
- EDD – 8.9.2020
- MBD at the time of Miscarriage – 3 weeks

5
Marital History
- Age of marriage – 21 years
- Single marriage
- Parity – P 3+1

 
Past Obstetrics History

- First child is 18 years old.

- Second child is 16 years old.
- Third child is 4 years old.
- All are born by NSVD at hospital without complications.

6
Contraceptive History
- She took OC pill for 1 year between 2nd and 3rd child

- No history of contraception after 3rd child

History of Present Pregnancy

- It is an unplanned pregnancy.

- After amenorrhea for one month, she took UCG test (at January) and the result was positive.
She did not take AN care.

7
History of Present Illness

• After amenorrhea for one month, there was a bleeding per vagina due to fall from 3 feet height.
• Amount – soaked 1 longyi
• Color – Reddish in color
• Odor - no foul smell
• Contents – Passage of tissues present, no vesicles
• History of induced abortion is denied.
• History of palpitation (+)

8
History of Present Illness

• No history of reduced urine output and cold & clammy extremities

• No history of blood transfusion
• No history of fever, abdominal pain, shoulder tip pain
• No history of excessive vomiting and metastasis
• On admission to hospital, blood test were done and MVA was done at 21.1.2020 under LA and aseptic
conditions.
• Today is the second day of hospitalization and her condition is stable.

9
Past Gynecological History
• No history of genital warts, foul smelling discharge, ulcers
• No history of taking Pap smear
• No history of HPV vaccine

Past Medical and Surgical History

• Not relevant
 
Drug History
• No history of Regular taking drugs
• No known drug allergy

10
Personal History
• History of betel chewing (+) for 15 years
• No history of Smoking and Alcohol dinking

Family History
• No history of Hypertension, DM, Heart diseases and Gynecological diseases
 
Social History
• Patient’s education - Basic Primary School
• Husband’s education – Basic High school
• Financially stable

11
Environmental History

• Type of House – wooden house

• Water – drinking purified water
• Latrine – Back pit (Fly proof)
• Refuse disposal – sanitary disposal

12
 Physical Examination

 
General Examination
• GCS – 15/15
• Temperature – normal
• Slight pallor (+)
• Blood Pressure – 110/70 mmHg
• PR – 90/min
• Heart and Lungs – NAD

13
Abdominal Examination

Inspection
• Abdomen is slightly distended.
• Old striae (+)
• No scar, No dilated veins
• Hernia orifices are intact.

Palpation
• On light palpation, abdomen is soft, no guarding, no rigidity and no tenderness. Temperature is normal.
There is no palpable mass
• On deep palpation, Liver and spleen are not palpable. Kidneys are not ballotable.

Percussion
• No Free Fluid is detected.

14
Auscultation
• Normal bowel sound is intact.
 
Pelvic Examination
Inspection
• Normal female type of Pubic hair distribution.
• Labia majora and minora are seen and normal.
• On separation of labia minora, clitoris and external urethral orifice are seen and normal.
• Active bleeding (-)
• No growth, No ulcer
• Second degree perineal tear (+)
• Anus is intact and no piles.
• On coughing, there is no demonstrable stress incontinence.
• On straining, there is no cystocele, urethrocele and rectocele.

15
Speculum Examination
• Cervix is pinkish in color, multip os, os is open.
• No growth, No ulcers, No blood stain discharge on speculum blades
• Lateral Vaginal walls are healthy.

Bimanual Examination
• Cervix is directed downward and backward.
• Soft in consistency, No cervical motion tenderness, No growth and no ulcers
• Uterus is normal size, anteverted position
• Firm in consistency, No tenderness
• Lateral Culs and POD are clear.
• No discharge on VE finger.

16
 Diagnosis

42 yrs. old, Parity 3+1 at post-MVA day 1 due to incomplete

miscarriage

17
Investigations
• UCG (+)
• Hb% - 12 g/dl
• Bleeding Time – 2 mins 30s (N)
• Clotting Time – 4 mins (N)
• Infection screening are all NR.
• Blood for G&M – O (+)

Suggestive Investigations – CP (auto), TVS

18
Treatment
• IM ATT 1cc stat
• IV N/s 1 bot. 20dpm
• IV Ceftriaxone 1g 12Hrly
• IV metro 1 bottle 8Hrly

Problem Analysis
• Low socioeconomic status
• High risk pregnancy
• Low level of education
• Little knowledge of contraception
• Lack of AN care

19
 Fish Bone Diagram of Problem Analysis
Low Knowledge of
No AN care
Contraception

Pregnancy at
Reproductive Abortion Hospitalization
42 year
Age woman
( High Risk )

Low level of Low level of education Financial burden

Education
Psychological Problem
Interference with work
20
 Impact
Individual and Family Level
• Abortion can cause psychological trauma to mother and also her family.
• Lack of knowledge of contraception can cause fear of unwanted pregnancy in reproductive age
women.
• It can cause financial burden to family.
 
Community Level
• Lack of awareness of taking AN care and usage of contraception.
• Increase Infant Mortality Rate and Maternal Mortality Rate.

 National Level
• Increase Infant Mortality Rate and Maternal Mortality Rate.
• Decrease health status of the country

21
 Problem Solving
Individual Level
• Health Education about the importance of contraception and the proper use of appropriate
contraceptive method
• HE about Pre pregnancy counselling such as methods of contraception, family planning,
reproductive health knowledge, birth spacing, AN care, obstetric care, postnatal care, post
abortion care.

Family Level
• Health Education about reproductive health and family planning
• Physical and Psychological support to the patient
• Involvement of husband’s decision in usage of different kind of contraception for family
planning and birth spacing

22
Community Level
• Health Education about family planning and reproductive health
• Community awareness about danger of High-Risk Pregnancy and how to prevent unwanted
pregnancy
• Easy Accessibility to AN care service
• Health education by mass media

National Level
• Health Education should be given by mass media
• Continuous training of Basic Health Staff for comprehensive maternal and child care
• Prioritization of Effective Family planning method in National Health plan
• Strengthening the capability of basic health workers in RH program especially emergency
obstetric care
• To reinforce health care facility in hospitals

23
 References:
- Gynecology by Ten Teachers 20th edition

24
Thank You