CASE PRESENTATION
DR ANIKA TASNIM PROBHA
INTERN DOCTOR
GYNAE & OBS UNIT 1
JASHORE MEDICAL COLLEGE
HOSPITAL
Particulars of The Patient
Name: Mrs Shirina
Age: 32 years old
Marital status : Married
Husband’s name: Sentu Mia
Religion: Islam
Occupation: Housewife
Address: Mirzapur,Moheshpur,Jhenaidah
Ward no: G/W
Bed no: 3
Reg no: 36998/78
Date of admission: 19.7.22
Date of examination: 20.7.22
Chief complaints
History of Amenorrhea for 16 weeks
History of P/V bleeding for 15 days
History of Lower abdominal pain for 7
days
History of present Illness
According to the statement of the patient she was
amenorrheic for 16 weeks.She was having per
vaginal bleeding, which was irregular and scanty for 15 days.
There was no history of passing blood clot. She also
complained of lower abdominal pain which was cramping in
nature for 7 days.
With the complaints she went to Chowgacha Health
Complex. They referred to JMCH for better
management.
There is no history of fever, foul smelling per
vaginal discharge
Her bowel and bladder habits were normal.
History of past illness
She gave history of UTI 06 months back.
She has no H/O of Hypertension, Diabetes mellitus,
Bronchial Asthma.
Obstetric History
Married for: 15 years
Para: 4 (1 NVD+ 3 C/S) – 1(IUD)
Gravida : 5
ALC: 4 years
Gynecological history
Age of menarche : 13 years
Menstrual period: Irregular
Menstrual cycle : Irregular
Menstrual flow: Average
LMP: ?
EDD:?
Contraceptive History
She didn’t give any contraceptive history
Drug History
She took some medication for UTI but
couldn’t mention the name
Family History
Nothing contributory
Personal History
She is non smoker, non alcoholic. She doesn’t
take
beetle nut.
Socio-economic History
She belongs from a lower middle class family.
Immunization History
She is immunized as per EPI schedule
General Examination
Appearance : Looking ill
Body Built: Average
Nutritional status: Average
Cooperation : Cooperative
Anaemia: Mild
Jaundice: Absent
Oedema: Absent
Dehydration : Absent
Pulse: 76 b/min
BP: 110/70 mmhg
Respiratory rate: 16/ min
Temperature: 99°F
Per abdominal Examination
Inspection:
Abdomen was distended. Flank was full. Umbilicus
was centrally placed.
Linea nigra and striae gravida were present . There
was scar mark of previous C/S
Palpation:
Abdomen was tender in hypogastric, left and right iliac
region. Symphysio-fundal height was less than the period
of gestation. No fetal parts were palpable. No fetal
movement was present. Liver, spleen were palpable.
Kidney was not ballotable .
Percussion:
Percussion note was tympanic.
Auscultation:
There was no audible fetal heart sound
Bowel sound was present .
Other systemic Examination
Respiratory system examination:
Normal breath sound .Lung field was clear. No audible wheeze or crackle
was found
Cardiovascular system examination :
1st and 2nd heart sounds were audible. No other abnormities were found.
Nervous system examination :
No neurological deficit was found
Salient Feature :
Mrs. Shirina,32 years old, Married, Muslim, Housewife, non diabetic,
normotensive,5th gravida, Para 4 (1 NVD+3 C/S)- 1(IUD),hailing
from Mirazapur, Maheshpur, Jhenaidah admitted to JMCH with the
complaints of amenorrhea for 16wks; scanty irregular P/V bleeding
for 15days & cramping lower abdominal pain for a week. She gave no H/O
passing blood clot, fever & foul smelling discharge. Her bowel & bladder
were normal. She didn’t take anything for contraception.
She gave H/O UTI 5 months back for which she took some medication
But couldn’t mention the name.
On general examination I found the patient looking ill, average , built
& nutritional status and cooperative. She was mildly anemic, non
icteric, non oedematous, non dehydrated. During examination her
pulse was 76 b/min; BP 110/70 mmhg, R/R 16/min. On P/A/E I found
the abdomen distended, full flank, tender, soft. There were linea nigra,
striae gravida & scar mark of previous C/S .Symphysio-fundal height
didn’t correspond to the period of gestation. There were no fetal
movement, palpable fetal part & audible FHS. Other systemic
examination revealed no abnormalities.
Provisional Diagnosis
Missed Abortion
Differential Diagnosis
Septic Abortion
Incomplete Abortion
Initial Treatment
Diet: Normal
Tab. Cefuroxime 500mg 12 hourly
Tab. Metronidazole 400mg 8 hourly
Tab. Tiemonium Methylsulphate 500 mg 8 hourly
Cap. Esomeprazole 20mg 12 hourly
Tab Tranexamic Acid 500mg 8 hourly
Investigation
Confirmatory investigation:
Ultrasonography of pregnancy profile:
Uterus: gravid, contains single dead fetus
Fetus:
Presentation: cephalic
Fetal movement: Absent
Cardiac pulsation: Absent
Fetal heart rate: Absent
BPD: 35.00 mm
FL: 22.6 mm
F-maturity: 16 wks 06 days of gestation
Amniotic fluid: 14 cm
Placenta: Posterior fundal away from int. os
Maturity: Grade 0
Impression: Missed abortion
Associated investigation :
Blood grouping: O (+ve)
HB% : 10.5 mg/dl
HbsAg: Negative
BT: 03 min 10 sec
CT: 06 min 20 sec
Urine R/M/E : no abnormalities detected
Confirmatory Diagnosis :
MISSED ABORTION
Management Plan:
Expectant management:
We kept the patient under observation for 3 days for spontaneous
expulsion
Medical management:
For dilation of cervix prostaglandin analogue MISOPROSTOL was
used
From 22.7.22 we added Tab. Cytomis 200mcg 1/4th sublingually
6 hourly upto 24hr
Mechanical management:
To speed up the procedure on 23.7.22 we add intracervical
catheterization with 40 c/c distilled water.
Surgical management:
When above procedures failed to expel the product of conception ;with
written consent D&C was done under SAB.
Thank you !
