JOSE C.

FELICIANO COLLEGE
INSTITUTE OF NURSING, MIDWIFE AND NURSING AIDE
DAU EXIT, DAU EXPRESSWAY DAU MABALACAT PAMPANGA

THREATENED ABORTION
(A CASE STUDY IN OBSTETRIC WARD)
BSN II – A (GROUP 1)

SUBMITTED BY:

ABIAN, IVYLYNN
AGUIRRE, ROXANNE
ARCILLA, CHRISTIAN ROI
BACANTE, CIELITO JOHN
CABRERA, JEFFREY
CANIEL, JOSEPH
LIWANAG, JEEANNE
NAVARRO, JOEL
PANGASIAN, CRYSTAL MAY

SUBMITTED TO:
MRS. FLORENCE AWKIT RMT, RN
CLINICAL INSTRUCTOR (OB WARD)
ACKNOWLEDGEMENT

This project would not be made possible without the help and guidance of our Almighty
Father, who conveyed our group adequate knowledge, sufficient vigor and bravery to
face innovative and peculiar defy during the entire course of this project. Our never-
ending thanks to Almighty Father the most High for the love and care he showered upon
us.

Our genuine gratitude to our beloved parents for always supporting us physically,
mentally, emotionally and financially in regards to this venture. Warmth thanks for
entrusting to us their confidence and understanding not only in times of need but in
everyday of our lives. They used to complain that we are getting too sovereign and
matured; however we live in the ideology that letting go of their children is the hardest
part of being a parent. Though it is not easy for us to acknowledge the fact that we are
getting old bit by bit, we have to separate from them in order to understand the true
essence of being a human, and still our love for them remains the same. To our dear
parents, rest guaranteed that what we are doing right now will serve as a stepping stone
towards a philosophical future and sagacious life, and that is being a nurse.

INTRODUCTION

Pregnancy is an exciting time in any parent's life. It's a time of change, growth, discovery
and a lot of questions. One of the most important factors of having a healthy baby is the
mother’s health especially during the 9 months where the child’s development has
already started. The mother’s nutrition, activity etc. greatly affect the developing fetus
inside her womb such that any move could put the child at risk resulting to
abnormalities, poor health or even death to the precious being anytime or even during
pregnancy if mother’s health is being taken for granted.

Complications may occur at any time during pregnancy and can result from pre-existing
maternal medical problems or from the pregnancy itself. Early and consistent prenatal
care results in improved fetal and maternal outcomes, regardless of complications that
may occur. One of these complications, threatened abortion is a condition of pregnancy,
occurring before the 20th week of gestation, that suggests potential miscarriage may
take place.

Approximately 20% of pregnant women experience some vaginal bleeding, with or

without abdominal cramping, during the first trimester. This is known as a threatened
abortion. However, most of these pregnancies go on to term with or without treatment.
Spontaneous abortion occurs in less than 30% of the women who experience vaginal
bleeding during pregnancy.

In the cases that result in spontaneous abortion, the usual cause is fetal death. Such
death is typically the result of a chromosomal or developmental abnormality. Other
potential causes include infection, maternal anatomic defects, endocrine factors,
immunologic factors, and maternal systemic disease.

Estimates report that up to 50% of all fertilized eggs abort spontaneously, usually before
the woman knows she is pregnant. Among known pregnancies, the rate is approximately
10%. These usually occur between 7 and 12 weeks of gestation. Increased risk is
associated with women over age 35, women with systemic disease (such as diabetes or
thyroid dysfunction), and those with a history of 3 or more prior spontaneous abortions.

During our duty in the Ob ward at Ospital Ning Angeles (ONA) , we decided to take the
case of Mrs. X in which she was diagnosed with threatened abortion v/s incomplete
abortion because we would like to have a deeper understanding about this condition so
that we could render the care the patient needed to arrive with a good prognosis.
Management should therefore always be based on appropriate clinical judgment. We
would like to apply all the things that we’ve learned through our lectures for the benefit
of our patient and to enhance our skills as well.

We hope that this case study will enable us, student nurses to better understanding
about the disease process and that we will be more sensitive in attending to our patient’s
need. For the community, we hope that this will increase the level of awareness among
the members of the community so that it could help in the prevention of further
pregnancy complications.

OBJECTIVES

General
This case study aims that the students and the readers will gain knowledge and further
understanding about Threatened Abortion

Specific to be able to:

1. Establish rapport with our client including her family members
2. Gather all necessary information regarding her and her family members as may be
related to our case study
3. Ascertain client’s past and present health history
4. Trace her genogram or family tree
5. Trace the development data of the client
6. Perform physical assessment on client’s condition so as to attain baseline data
7. Present the definitions of the complete diagnosis that would explain the illness of our
client
8. Study the anatomy and physiology of female reproductive system
9. Trace the Pathophysiology of Threatened Abortion
10. Determine the diagnostic tests our client has undergone including their implications
and nursing responsibilities
11. Identify the drugs prescribed to our client, their action, side effects, indications,
contraindications and nursing responsibilities
12. Identify and prioritize the need of our patient
13. Formulate an appropriate nursing care plan based on the assessment
identify needs and problems of the patient
14. Render health teachings as part of our holistic care to alleviate problems identified
15. Evaluate complications to nursing practice, education and research
 PATIENT’S DATA
Name: Mrs. X
Address: Mt. View Balibago Angeles City
Age: 27 y/o.
Birthday: July 09, 1982
Birthplace: Angeles City
Civil Status: Single
Religion: Iglesia Ni Cristo
Nationality: Filipino
Educational Attainment: High School Graduate
Occupation: Housewife
Date Admitted: February 08, 2010
Time Admitted: 11:00 PM
Ward: OB
Bed no.: 22
Admitting Diagnosis: Pregnancy uterine 8 weeks 3 days AOG G2P1 (1001)
Threatened Abortion v/s Incomplete Abortion

Student Nurse Centered:

After the completion of the case study, the student nurse shall be able to:

• Present a comprehensive and detailed report regarding the patient’s illness

• Have a complete picture of the patient’s physical, psychosocial and mental status
through daily assessment
• Have a well-structured nursing diagnosis of the client’s status based from an
integration of data gathered
• Understand the factors that might have contributed to the development of the
disease
• Provide organized and structured nursing interventions as a response to the patient’s
anticipated needs
• Provide relevant information on available alternative therapies and management

III. Nursing Process

A. Assessment

1. Personal History

a. Demographic Data

Mrs. X is a 27 years old Single Mother. She was born on July 09, 1982 in Mt. View
Balibago Angeles City, she is a Filipino Citizen and a Iglesia Ni Cristo. She is the 4 th
child among the 8 children. This is her 2nd Pregnancy on her G2P1 8 weeks and 3 days
Age of Gestation. She has a 1 daughter 7 years of age. During my initial assessment to
her she told me that they living in a good and peaceful community, there surroundings
are clean and she has a good knowledge about what happening to her.

b. Socio Economic and Cultural Factors

Mrs. X is a plain housewife, they are residing at Mt. View, Balibago Angeles City her
husband is currently working as a welder at Ben Side Car earning P 250 a day. They
lived in a commuted place together with her daughter and niece, during her first time
pregnancy she is always submitting herself for pre natal check up. Including her 2nd
pregnancy because she has experience in her first pregnancy that she always
experiencing vaginal bleeding during her 1st trimester. She is always aware what
happening to her that’s why she never miss to consult the health center near at her
place.

Mrs. X blaming her daily activity that all the household choir she is doing that,
causing her to bleed. All her activity in everyday to washing dishes, clothes, cleaning the
house, cooking and walking about 2 kms just to bring her daughter in school at the Don
Gueco Elementary School. She believes that she really needed a bed rest during her
pregnancy but because of what there is status right now that they having difficulty
financially that there only source of income is that her husband salary. Sometimes those
meds has been prescribed during her pre natal check up is difficult for her to buy
because of lack of resources in their family.

2. Family Health – Illness History

Mrs. X diseases has a direct connection with the past illnesses. Her 1st pregnancy she
has experience a vaginal bleeding during the 1st trimester, and also diagnosed
Threatened abortion is a vaginal bleeding other than spotting during early pregnancy is
considered a threatened miscarriage. (A miscarriage may also be referred to as a
spontaneous abortion.) Vaginal bleeding is common in early pregnancy. About 1 of every
4 pregnant women has some bleeding during the first few months. About half of these
women stop bleeding and have a normal pregnancy.

Father Mother

(Arthritis) (Ovarian Cysts

1st 2nd 3rd Sister Mrs. X 4th 3rd 2nd 1st

Sister
Brothe Sister (Ovarian Brothe Brothe Sister
r Cysts) r r (Diseas
3. History of Past Illness

Mrs. X has a previous operation via C/S her two ovaries has been removed and
diagnosed with Ovarian Cysts at Angeles Medical Center. Her family has a history of
having an ovarian cysts.

4. History of Present Illness

According to the Client in the evening of January 20, 2010, 10pm she just finish
washing her husband clothes and preparing herself to sleep, she suddenly just feel
something coming out on her vaginal part and having pain in her abdomen. She just
noticed that she having a bleeding which she think it will just diminish for the following
days. But the days gone by the bleeding still not stopping and accompanied with pain on
her abdominal part on the day of January 23 2010 she consulted Dr. Romero Clinic at
Burgos Angeles City and later was ordered to take a UTZ and was seen in Ultrasound
that she has a minimal subchorionic hemorrhage.

In February 08,2010 at 11:00 pm she submitted herself at ONA and upon assessing
her upon admission she has a minimal vaginal bleeding prior to admission and the UTZ
confirm that it has presence of blood cloth in her intrauterine segment. She was
diagnosed with Threatened Abortion v/s Incomplete Abortion.
 5. Physical Examination

PHYSICAL EXAMINATION

February 08, 2010

Upon Admission

Appearance and Behavior: Appears well when not moving but shows slight facial
grimaces upon movement and approachable

Mental Status: Conscious and Coherent

Language: Kapampangan

Posture: On a Semi Fowlers position

Vital Signs:

T: 36.6 OC

PR: 80 BPM

RR: 20 CPM

BP: 100/70 mmhg

Skin: with no pallor; no jaundice

Head: No lesions noted, no palpable nodules, symmetrical

Hair: Shoulder length, black and curly hair. No presence of dandruff

Eyes: Anictenic Sclerae, Pink Conjunctiva

Abdomen: Flabby, soft & non tender

Genitalia: dosed cervix x 1(4) Spotting

February 09, 2010

Actual Physical Examination

Appearance and Behavior: Appears well when not moving but shows slight facial
grimaces upon movement and approachable

Mental Status: Conscious and Coherent

Language: Kapampangan

Posture: On a Semi Fowlers position

Vital Signs:

T: 37.3 OC

PR: 85 BPM

RR: 18 CPM

BP: 90/70 mmhg

Skin: with no pallor; no jaundice

Head: No lesions noted, no palpable nodules, symmetrical

Hair: Shoulder length, black and curly hair. No presence of dandruff

Eyes: Anictenic Sclerae, Pink Conjunctiva

Chest & Lungs: SCE, with retractions

Abdomen: Flabby, soft & non tender

Genitalia: Minimal Vaginal Bleeding

Extremities: full and equal pulses

Diagnostics and Laboratory Tests:

A.)Urinalysis:
Examination Actual Values Normal Implication Rationale
Values
Color Light yellow straw yellow to Normal
amber in color
Transparency/ clear clear Normal

Appearance
pH 7.5 4.5-8 Normal
Specific 1.005 1.005-1.025 Normal >To examine
gravity the patient’s
Albumin Negative In normal Normal urine for sign of
condition there renal or urinary
should be no tract disease.
protein that
can be
detected.
Sugar Negative Blood glucose Presence of
levels should sugar in
be 160mg/dL urine may
indicate
diabetes, > To help
chronic discover disease
kidney that is not
disease. related to renal
RBC/HPF 0.1 Blood in the disorders.
urine may
sometimes
indicate
serious
urinary tract
problems.
Pus cells/HPF 0.2 May be a sign
Epithelial cells Rare >To
of swelling in
A . phosphate Rare Pus cells and demonstrate the
the kidney
bacteria should concentrating
and pelvic
be absent in and diluting
region,
urine. ability of the
urethral
kidneys.
ulceration
and chronic
specific
inflammatory
of the
bladder.

>To identify
drugs or
substances that
has been taken.
Nursing Responsibilities:

Tell the patient that the test is for the detection of renal and urinary tract disorders and
assessment for body function.
Notify the patient that the procedure requires a urine sample. Urine must be acquired
most likely on the first void in the morning.
Notify the laboratory and physician of any drugs that the patient has taken that may
affect the results.

Physical tests

The physical tests measure the color, transparency (clarity), and specific gravity of a
urine sample.

 COLOR. Normal urine is straw yellow to amber in color. Abnormal colors

include bright yellow, brown, black (gray), red, and green. These pigments may
result from medications, dietary sources, or diseases. For example, red urine may
be caused by blood or hemoglobin, beets, medications, and some porphyrias.
Black-gray urine may result from melanin (melanoma) or homogentisic acid
(alkaptonuria, a result of a metabolic disorder). Bright yellow urine may be
caused by bilirubin (a bile pigment). Green urine may be caused by biliverdin or
certain medications. Orange urine may be caused by some medications or
excessive urobilinogen (chemical relatives of urobilinogen). Brown urine may be
caused by excessive amounts of prophobilin or urobilin (a chemical produced in
the intestines).

 TRANSPARENCY. Normal urine is transparent. Turbid (cloudy) urine may be

caused by either normal or abnormal processes. Normal conditions giving rise to
turbid urine include precipitation of crystals, mucus, or vaginal discharge.
Abnormal causes of turbidity include the presence of blood cells, yeast, and
bacteria.

 SPECIFIC GRAVITY. The specific gravity of urine is a measure of the

concentration of dissolved solutes (substances in a solution), and it reflects the
ability of the kidneys to concentrate the urine (conserve water). Specific gravity
varies with fluid and solute intake. It will be increased (above 1.035) in persons
with diabetes mellitus and persons taking large amounts of medication. It will
also be increased after radiologic studies of the kidney owing to the excretion of x
ray contrast dye. Consistently low specific gravity (1.003 or less) is seen in
persons with diabetes insipidus. In renal (kidney) failure, the specific gravity
 remains equal to that of blood plasma (1.008–1.010) regardless of changes in the
patient's salt and water intake.

Biochemical tests

 pH: A combination of pH indicators (methyl red and bromthymol blue) react

with hydrogen ions (H + ) to produce a color change over a pH range of 5.0 to 8.5.
pH measurements are useful in determining metabolic or respiratory
disturbances in acid-base balance. For example, kidney disease often results in
retention of H + (reduced acid excretion). pH varies with a person's diet, tending
to be acidic in people who eat meat but more alkaline in vegetarians. pH testing is
also useful for the classification of urine crystals.

 Protein: Albumin is important in determining the presence of glomerular

damage. The glomerulus is the network of capillaries in the kidneys that filters
low molecular weight solutes such as urea, glucose, and salts, but normally
prevents passage of protein or cells from blood into filtrate. Albuminuria occurs
when the glomerular membrane is damaged, a condition called
glomerulonephritis.

 Glucose (sugar): The glucose test is used to monitor persons with diabetes.
When blood glucose levels rise above 160 mg/dL, the glucose will be detected in
urine. Consequently, glycosuria (glucose in the urine) may be the first indicator
that diabetes or another hyperglycemic condition is present.

 Blood: Red cells and hemoglobin may enter the urine from the kidney or lower
urinary tract. Testing for blood in the urine detects abnormal levels of either red
cells or hemoglobin, which may be caused by excessive red cell destruction,
glomerular disease, kidney or urinary tract infection, malignancy, or urinary tract
injury.

Microscopic examination

 The presence of bacteria or yeast and white blood cells helps to distinguish
between a urinary tract infection and a contaminated urine sample. White blood
cells are not seen if the sample has been contaminated. The presence of cellular
casts (casts containing RBCs, WBCs, or epithelial cells) identifies the kidneys,
 rather than the lower urinary tract, as the source of such cells. Cellular casts and
renal epithelial (kidney lining) cells are signs of kidney disease.

B.)Hematology:

Examination Result Normal Implication Rationale

Range
WBC 11.3 5-10 Bacterial >To verify
infection infection or
(White blood inflammation
cells) in the body and
observe its
responses to
specific
therapies.
RBC 3.83 4.20-6.10 Low RBC is due >To know the
to enormous amount of RBC
(Red blood cells) blood loss in the blood.
which results to
anemia.
Hemoglobin 120 g/dL 115-155g/dL Normal >To recognize
(Hgb) the amount of
O2 carrying
protein
contained
within RBC.
Hematocrit(Hct) 0.36 0.36-0.48 Normal >To identify the
percentage of
blood volume
occupied by red
blood cells.

ESR

Bleeding time 1’30’ Seg. 0.53

Clotting time 3’45” Lymph 0.47

ABO Type ‘A’

 WBC (White Blood Cell): Also referred to as leukocytes, a fluctuation in the

number of these types of cells may indicate the presence of infections and disease
states dealing with impaired immune system status (cancer, excess
stress/catabolism)

 RBC (Red Blood Cell): called erythrocytes, their primary function is to carry
oxygen (via the hemoglobin contained in each RBC) to various tissues as well as
giving our blood that cool "red" color. A decrease in the number of these cells can
result in anemia which could stem from dietary insufficiencies. An increase in
number can occur when androgens are used. This is because androgens increase
EPO (erythropoietin) production and red blood cell division, increasing RBC
count. This can increase blood pressure and result in stroke (called a
cardiovascular accident, or CVA).

 Hemoglobin: Hemoglobin is a carrier of dissolved gases, oxygen and carbon

dioxide, in blood, an important part of each red blood cell surface. An increase in
hemoglobin can be an indicator of congenital heart disease, congestive heart
failure, sever burns, or dehydration. Being at high altitudes, or the use of
androgens, can cause an increase as well. A decrease in number can be a sign of
anemia, lymphoma, kidney disease, sever hemorrhage, cancer, sickle cell anemia,
etc.

 Hematocrit: The hematocrit is used to measure the percentage of the total

blood volume that's made up of red blood cells. An increase in percentage may be
indicative of congenital heart disease, dehydration, diarrhea, burns, etc. A
decrease may be indicative of anemia, hyperthyroidism, cirrhosis, hemorrhage,
leukemia, rheumatoid arthritis, pregnancy, malnutrition, a sucking knife wound
to the chest, etc.

Nursing Responsibilities:
 1.) Explain to the patient the necessity of undergoing the test that it helps detect
occurrence of anemia and polycythemia.

2.) Notify the patient that the test requires blood samples as well as the person
who will perform the venipucture and time.

3.) Inform the patient that the procedure is slight discomfort and he/she may feel
a little pain.

4.) After the procedure, apply direct pressure to the venipuncture until bleeding
stops.

5.) Refer if venipuncture develops hematoma and monitor the pulses distal to
sites.

IV infusion/Blood transfusion:

Date Ordered No. of Infusion Name of Infusion Remarks

Date Consumed
02/08/10 #1 D5LRS 1L x TS: 10:50 am
30gtts/min. with
side drip D5 water
500ml + 3 amps.
Isoxilan x TS: 11pm
30gtts/min with
increasing.

Ultrasound Report:

10-18910

Baluyot, Erlinda 27/ R

January 23, 2010 Dr. Mandal

TRANSVAGINAL ULTRASOUND

Within an enlarged uterus is a single live embryo exhibiting good cardiac contractions
during time scanning of about 177 beats/ min. The crown rump length measures about
0.53cm equivalent to 6 weeks and 2 days age of gestation. EDD in this scan 09-16-10

Minimal sub chorionic hemorrhage is evident. Right ovary is normal in size with few
small follicles. No fecal mass seen. It measures 2.19 x 1.59cm. left ovary is not
demonstrated.

Cervix measures 2.35 x 2.29cm with homogenous echo pattern.

Adnexae are unremarkable. Negative cul-de-sac fluid.

IMPRESSION:

 Single, live, intrauterine, pregnancy, 6 weeks and 2 days age of gestation.

 EDD in this scan 09-16-10
 Minimal subchorionic hemorrhage
 Unremarkable right ovary, cervix and adnexae sonographically.
 THE FEMALE REPRODUCTIVE SYSTEM

 GENERAL
The organs of the reproductive systems are concerned with the general process of
reproduction, and each is adapted for specialized tasks. These organs are unique in that
their functions are not necessary for the survival of each individual. Instead, their
functions are vital to the continuation of the human species. In providing maternity
gynecologic health care to women, you will find that it is vital to your career as a
practical nurse and to the patient that you will require a greater depth and breadth of
knowledge of the female anatomy and physiology than usual. The female reproductive
system consists of internal organs and external organs. The internal organs are located
in the pelvic cavity and are supported by the pelvic floor. The external organs are located
from the lower margin of the pubis to the
perineum. The appearance of the external
genitals varies greatly from woman to woman,
since age, heredity, race, and the number of
children a woman has borne determines the
size, shape, and color. See figure 1-1 for the
female reproductive organs.
  TERMS AND DEFINITIONS

These are only a few terms and definitions that will be used in this lesson. Other
terms and definitions will be dispersed throughout the lesson.

A. Broad Ligaments. Two wing-like structures that extend from the lateral
margins of the uterus to the pelvic walls and divide the pelvic cavity into an
anterior and a posterior compartment.

B. Corpus Luteum. The yellow mass found in the graafian follicle after the ovum
has been expelled.

C. Estrogen. The generic term for the female sex hormones. It is a steroid
hormone produced primarily by the ovaries but also by the adrenal cortex.

D. Fimbriae. Fringes; especially the finger-like ends of the fallopian tube.

E. Follicle. A pouch like depression or cavity.

F. Follicle Stimulating Hormone. The follicle stimulating hormone (FSH) is a

hormone produced by the anterior pituitary during the first half of the menstrual
cycle. It stimulates development of the graafian follicle.

G. Graafian Follicle. A mature, fully developed ovarian cyst containing the ripe
ovum.

H. Hormone. A chemical substance produced in an organ, which, being carried to

an associated organ by the bloodstream excites in the latter organ, a functional
activity.

I. Lactation. The production of milk by the mammary glands.

J. Luteinizing Hormone. A hormone produced by the anterior pituitary that

stimulates ovulation and the development of the corpus luteum.
K. Oocyte. A developing egg in one of two stages.

L. Ovum. The female reproductive cell.

M. Progesterone. The pure hormone contained in the corpora lutea whose

function is to prepare the endometrium for the reception and development of the
fertilized ovum.

N. Reproduction. The process by which an off- spring is formed.

Anterior view of the uterus and related structures

 Wall of the uterus

 INTERNAL FEMALE ORGANS

The internal organs of the female consist of the uterus, vagina, fallopian tubes,
and the ovaries.

A. Uterus. The uterus is a hollow organ about the size and shape of a pear. It
serves two important functions: it is the organ of menstruation and during
pregnancy it receives the fertilized ovum, retains and nourishes it until it expels
the fetus during labor.

(1) Location. The uterus is located between the urinary bladder and the rectum. It
is suspended in the pelvis by broad ligaments.

(2) Divisions of the uterus. The uterus consists of the body or corpus, fundus,
cervix, and the isthmus. The major portion of the uterus is called the body or
corpus. The fundus is the superior, rounded region above the entrance of the
fallopian tubes. The cervix is the narrow, inferior outlet that protrudes into the
vagina. The isthmus is the slightly constricted portion that joins the corpus to the
cervix.

(3) Walls of the uterus (see figure 1-3). The walls are thick and are composed of
three layers: the endometrium, the myometrium, and the perimetrium. The
endometrium is the inner layer or mucosa. A fertilized egg burrows into the
endometrium (implantation) and resides there for the rest of its development.
When the female is not pregnant, the endometrial lining sloughs off about every
28 days in response to changes in levels of hormones in the blood. This process is
called menses. The myometrium is the smooth muscle component of the wall.
These smooth muscle fibers are arranged. In longitudinal, circular, and spiral
patterns, and are interlaced with connective tissues. During the monthly female
cycles and during pregnancy, these layers undergo extensive changes. The
perimetrium is a strong, serous membrane that coats the entire uterine corpus
except the lower one fourth and anterior surface where the bladder is attached.

B. Vagina.

(1) Location. The vagina is the thin in walled muscular tube about 6 inches long
leading from the uterus to the external genitalia. It is located between the bladder
and the rectum.
(2) Function. The vagina provides the passageway for childbirth and menstrual
flow; it receives the penis and semen during sexual intercourse.

C. Fallopian Tubes (Two).

(1) Location. Each tube is about 4 inches long and extends medially from each
ovary to empty into the superior region of the uterus.

(2) Function. The fallopian tubes transport ovum from the ovaries to the uterus.
There is no contact of fallopian tubes with the ovaries.

(3) Description. The distal end of each fallopian tube is expanded and has finger-
like projections called fimbriae, which partially surround each ovary. When an
oocyte is expelled from the ovary, fimbriae create fluid currents that act to carry
the oocyte into the fallopian tube. Oocyte is carried toward the uterus by
combination of tube peristalsis and cilia, which propel the oocyte forward. The
most desirable place for fertilization is the fallopian tube.

D. Ovaries (2) (see figure 1-4).

(1) Functions. The ovaries are for oogenesis-the production of eggs (female sex
cells) and for hormone production (estrogen and progesterone).

(2) Location and gross anatomy. The ovaries are

about the size and shape of almonds. They lie against the lateral walls of the
pelvis, one on each side. They are enclosed and held in place by the broad
ligament. There are compact like tissues on the ovaries, which are called ovarian
follicles. The follicles are tiny sac-like structures that consist of an immature egg
surrounded by one or more layers of follicle cells. As the developing egg begins to
ripen or mature, follicle enlarges and develops a fluid filled central region. When
the egg is matured, it is called a graafian follicle, and is ready to be ejected from
the ovary.

(3) Process of egg production--oogenesis (see figure 1-5).

(a) The total supply of eggs that a female can release has been determined by the
time she is born. The eggs are referred to as "oogonia" in the developing fetus. At
the time the female is born, oogonia have divided into primary oocytes, which
contain 46 chromosomes and are surrounded by a layer of follicle cells.

(b) Primary oocytes remain in the state of suspended animation through

childhood until the female reaches puberty (ages 10 to 14 years). At puberty, the
anterior pituitary gland secretes follicle-stimulating hormone (FSH), which
stimulates a small number of primary follicles to mature each month.

(c) As a primary oocyte begins dividing, two different cells are produced, each
containing 23 unpaired chromosomes. One of the cells is called a secondary
oocyte and the other is called the first polar body. The secondary oocyte is the
larger cell and is capable of being fertilized. The first polar body is very small, is
nonfunctional, and incapable of being fertilized.

(d) By the time follicles have matured to the graafian follicle stage, they contain
secondary oocytes and can be seen bulging from the surface of the ovary. Follicle
development to this stage takes about 14 days. Ovulation (ejection of the mature
egg from the ovary) occurs at this 14-day point in response to the luteinizing
hormone (LH), which is released by the anterior pituitary gland.

(e) The follicle at the proper stage of maturity when the LH is secreted will
rupture and release its oocyte into the peritoneal cavity. The motion of the
fimbriae draws the oocyte into the fallopian tube. The luteinizing hormone also
causes the ruptured follicle to change into a granular structure called corpus
luteum, which secretes estrogen and progesterone.

(f) If the secondary oocyte is penetrated by a sperm, a secondary division occurs

that produces another polar body and an ovum, which combines its 23
chromosomes with those of the sperm to form the fertilized egg, which contains
46 chromosomes.

(4) Process of hormone production by the ovaries.

(a) Estrogen is produced by the follicle cells, which are responsible secondary sex
characteristics and for the maintenance of these traits. These secondary sex
characteristics include the enlargement of fallopian tubes, uterus, vagina, and
external genitals; breast development; increased deposits of fat in hips and
breasts; widening of the pelvis; and onset of menses or menstrual cycle.

(b) Progesterone is produced by the corpus luteum in presence of in the blood. It

works with estrogen to produce a normal menstrual cycle. Progesterone is
important during pregnancy and in preparing the breasts for milk production.

 EXTERNAL FEMALE GENITALIA

The external organs of the female reproductive system include the mons pubis,

labia majora, labia minora, vestibule, perineum, and the Bartholin's glands. As a
group, these structures that surround the openings of the urethra and vagina
compose the vulva, from the Latin word meaning covering. See Figure 1-6.

a. Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and
covered with thick coarse hair.

b. Labia Majora. The labia majora run posteriorly from the mons pubis. They are
the 2 elongated hair covered skin folds. They enclose and protect other external
reproductive organs.

c. Labia Minora. The labia minora are 2 smaller folds enclosed by the labia
majora. They protect the opening of the vagina and urethra.

d. Vestibule. The vestibule consists of the clitoris, urethral meatus, and the
vaginal introitus.

(1) The clitoris is a short erectile organ at the top of the vaginal vestibule whose
function is sexual excitation.
(2) The urethral meatus is the mouth or opening of the urethra. The urethra is a
small tubular structure that drains urine from the bladder.

(3) T e. Perineum. This is the skin covered muscular area between the vaginal
opening (introitus) and the anus. It aids in constricting the urinary, vaginal, and
anal opening. It also helps support the pelvic contents.

f. Bartholin's Glands (Vulvovaginal or Vestibular Glands). The Bartholin's glands

lie on either side of the vaginal opening. They produce a mucoid substance, which
provides lubrication for intercourse.

 BLOOD SUPPLY

The blood supply is derived from the uterine and ovarian arteries that extend
from the internal iliac arteries and the aorta. The increased demands of
pregnancy necessitate a rich supply of blood to the uterus. New, larger blood
vessels develop to accommodate the need of the growing uterus. The venous
circulation is accomplished via the internal iliac and common iliac vein.

 FACTS ABOUT THE MENSTRUAL CYCLE

Menstruation is the periodic discharge of blood, mucus, and epithelial cells from
the uterus. It usually occurs at monthly intervals throughout the reproductive
period, except during pregnancy and lactation, when it is usually suppressed.

 The menstrual cycle is controlled by the cyclic activity of follicle

stimulating hormone (FSH) and LH from the anterior pituitary and
progesterone and estrogen from the ovaries. In other words, FSH
acts upon the ovary to stimulate the maturation of a follicle, and
during this development, the follicular cells secrete increasing
amounts of estrogen (see figure 1-7).
  Hormonal interaction of the female cycle is as follows:

(1) Days 1-5. This is known as the menses phase. A lack of signal from a fertilized
egg influences the drop in estrogen and progesterone production. A drop in
progesterone results in the sloughing off of the thick endometrial lining which is
the menstrual flow. This occurs for 3 to 5 days.

(2) Days 6-14. This is known as the proliferative phase. A drop in progesterone
and estrogen stimulates the release of FSH from the anterior pituitary. FSH
stimulates the maturation of an ovum with graafian follicle. Near the end of this
phase, the release of LH increases causing a sudden burst like release of the
ovum, which is known as ovulation.

(3) Days 15-28. This is known as the secretory phase. High levels of LH cause the
empty graafian follicle to develop into the corpus luteum. The corpus luteum
releases progesterone, which increases the endometrial blood supply.
Endometrial arrival of the fertilized egg. If the egg is fertilized, the embryo
produces human chorionic gonadotropin (HCG). Thehuman chorionic
gonadotropin signals the corpus luteum to continue to supply progesterone to
maintain the uterine lining. Continuous levels of progesterone prevent the release
of FSH and ovulation ceases.

 Additional Information.

(1) The length of the menstrual cycle is highly variable. It may be as short as 21
days or as long as 39 days.

(2) Only one interval is fairly constant in all females, the time from ovulation to
the beginning of menses, which is almost always 14-15 days.
(3) The menstrual cycle usually ends when or before a woman reaches her fifties.
This is known as menopause.

 Ovulation

Ovulation is the release of an egg cell from a mature ovarian follicle (see figure 1-
5 for ovulation). Ovulation is stimulated by hormones from the anterior pituitary
gland, which apparently causes the mature follicle to swell rapidly and eventually
rupture. When this happens, the follicular fluid, accompanied by the egg cell,
oozes outward from the surface of the ovary and enters the peritoneal cavity.
After it is expelled from the ovary, the egg cell and one or two layers of follicular
cells surrounding it are usually propelled to the opening of a nearby uterine tube.
If the cell is not fertilized by union of a sperm cell within a relatively short time, it
will degenerate.
  MENOPAUSE

As mentioned in paragraph 1-6c (3), menopause is the cessation of menstruation.

This usually occurs in women between the ages of 45 and 50. Some women may
reach menopause before the age of 45 and some after the age of 50. In common
use, menopause generally means cessation of regular menstruation. Ovulation
may occur sporadically or may cease abruptly. Periods may end suddenly, may
become scanty or irregular, or may be intermittently heavy before ceasing
altogether. Markedly diminished ovarian activity, that is, significantly decreased
estrogen production and cessation of ovulation, causes menopause.
 Description of the Disease

A threatened miscarriage is a condition that suggests a miscarriage might take place

before the 20th week of pregnancy.

A small number of pregnant women have some vaginal bleeding, with or without
abdominal cramps, during the first trimester of pregnancy. When the symptoms
indicate a miscarriage is possible, the condition is called a "threatened abortion." (This
refers to a naturally occurring event, not medical abortions or surgical abortions.)

Miscarriage occurs in just a small percentage of women who have vaginal bleeding
during pregnancy.

A miscarriage is the spontaneous loss of a fetus before the 20th week of pregnancy.
(Pregnancy losses after the 20th week are called preterm deliveries.)

A miscarriage may also be called a "spontaneous abortion." This refers to naturally

occurring events, not medical abortions or surgical abortions.

Other terms for the early loss of pregnancy include:

• Complete abortion: All of the products of conception exit the body

• Incomplete abortion: Only some of the products of conception exit the body
• Inevitable abortion: The symptoms cannot be stopped, and a miscarriage will
happen
• Infected abortion: The lining of the womb, or uterus, and any remaining products
of conception become infected
• Missed abortion: The pregnancy is lost and the products of conception do not exit
the body

Most miscarriages are caused by chromosome problems that make it impossible for the
baby to develop. Usually, these problems are unrelated to the mother or father's genes.

Other possible causes for miscarriage include:

• Hormone problems
• Infection
• Physical problems with the mother's reproductive organs
• Problem with the body's immune response
• Serious body-wide ( systemic) diseases in the mother (such as uncontrolled
diabetes)

It is estimated that up to half of all fertilized eggs die and are lost (aborted)
spontaneously, usually before the woman knows she is pregnant. Among those women
who know they are pregnant, the miscarriage rate is about 15-20%. Most miscarriages
occur during the first 7 weeks of pregnancy. The rate of miscarriage drops after the
baby's heart beat is detected.

The risk for miscarriage is higher in women:

• Older than 35
• Who have had previous miscarriages
PATHOPHYSIOLOGY
(Client Based)

Precipitating fx: No Predisposing fx:

>8 weeks AOG(occurs during first > Age- common among women over

trimester of pregnancy) 35y/o

> Race- No significant racial differences

During egg implantation, egg slightly separates or tears from the uterus

Blood collects between the chorionic membrane(a membrane that develops

around a fertilized egg) and the wall of the uterus

Blood leaks in the cervix

Mild uterine cramping Minimal vaginal spotting/bleeding

(lower abdomen) Date: (3-4 days) Dates: January 20, 2010

SUBCHORIONIC HEMORRHAGE

(determine by UTZ) Date: January 23, 2010

*Severe SC bleeding can lead to rupture of
the subchorionic membrane

Risk for Miscarriage &

Stillbirth(THREATENED ABORTION)
 DRUGS

Client response
Date to the
Route of
Name of drug Ordered/Date General Action Indication medication
administration with actual
Started
side effects.

GenericName: DO: 02/08/10 >10mg/tab,2 >Dydrogesterone > Treatment of >Patient

tabs TIDe is an orally active progesterone response
dydrogesterone progestogen deficiencies effectively with
which acts (eg, threatened no side effect
directly on the and habitual noted.
DS: uterus, producing abortion
a complete associated with
Trade Name: 02/09/10 secretory proven
endometrium in progesterone
Duphaston 1:00AM an estrogen- deficiency,
primed uterus. dysfunctional
uterine
bleeding,
dysmenorrhea,
endometriosis,
secondary
amenorrhea,
irregular
cycles,
premenstrual
syndrome,
infertility due
to luteal
insufficiency
and to
counteract the
effects of
unopposed
estrogen on the
endometrium
in HRT for
women with
disorders due
to natural- or
surgical-
induced
menopause
with an intact
uterus
Name of drug Date Route of General Indication Client
Ordered/Date administratio Action response to
Started n the
medication
with actual
side effects.

GenericName: DO: 02/08/10 >1amp side drip > Stimulates > Uterine >Patient
IVF skeletal beta hypermotility response
Isoxsuprine receptors to disorders: effectively
HCl produce Threatened with no side
vasodilation; abortion, effect noted.
DS: 02/09/10 stimulates premature
Trade Name: cardiac labor &
8:00AM function dysmenorrhea.
Duvadilan, (increased An adjunct
Vasodilan contractility, therapy in the
heart rate, treatment of
and cardiac arteriosclerosis
output) and obliterans,
relaxes thromboangitis
uterus. At obliterans
higher doses, (Buerger's
inhibits disease) &
platelet Raynaud's
aggregation disease.
and
decreases
blood
viscosity
DIET

Date Ordered: Indication / Client’s Response /

Type of Diet General Description
Date Started: Purpose reaction to the diet

DAT DO: 02/08/10 There is a dietary sodium To facilitate reduction of The patient is eating at
restriction on patient sodium in the body, thus regular diet.
DS: 02/08/10 reducing edema and
ascites.

It also aide in the

reduction of conjunction
of vascular fluids since
sodium attracts water.

Nursing Responsibilities:

• Explain the purpose.

• Assess for patient condition, how he respond diet.
• Provide variety of choices of foods low sodium.
• Be sure patient is taking / eating foods he can tolerate.
• Explain importance of compliance.
PATIENT TEACHINGS:

1. Avoid alcohol, cigarettes, and illegal drugs,

2. Limit caffeine intake
3. Avoid contact with toxin (ex. Arsenic, lead, heavy metals, and organic
solvents).
4. Control any medical conditions, such as diabetes and
hyperthyroidism..
5. Avoid or restricts some forms of activity, or advise a complete bed
rest.
6. Avoid having sexual intercourse is usually recommended until the
warning signs have disappeared.
7. Advise patients to return upon occurrence of symptoms such as:
 profuse vaginal bleeding
 severe pelvic pain
 temperature above 38 degree C (100.4 degree F).

8. Advise the patient to avoid intake of highly seasoned and fatty foods.
9. Talk with any physicians before taking medications to ensure they
are safe during pregnancy.
10. Advise the patient to take the full course of medications.
DISCHARGE PLAN

Medications:
· Teach patient and her family or significant others the proper dosage and
the right time to take the medication.
· Emphasize to the patient the importance of obediently taking the
prescribed medications and the disadvantages or complications that may
arise if these are not taken properly.
· Inform and discuss the possible side effects and reactions that these
drugs might produce and seek medical attention immediately is these
arise
· Discourage to use of OTC medications or at least inform the physician if
she’s taking other OTC medications. This is essential to prevent any
occurrence of drug interactions.
Exercise:
· Tell client to refrain from straining activities
· Encourage ambulation as a form of light exercise that would help in the
progression of her recovery and wound healing.
· Range of motion. Encouraging the patient to do some exercises would
allow good blood circulation as well as the prevention of the occurrence of
bed sores.
· Encourage patient to do some stretching exercise to prevent stiffness of

the bone due to less activity performed.

· Encourage patient to first sit up and dangle feet before standing from a
lying position to prevent orthostatic hypotention

Treatment
· Discussing the purpose of treatments to be done and continued at home
and report to the health professional when there is bleeding to alleviate
symptoms of the patient’s condition and monitor for her recovery.
· Encourage patient to have a sufficient rest and sleep to maintain internal
equilibrium
· . Provide a safe and comfortable environment because it could make the
patient more relaxed which is also needed to arrived with a good
prognosis
Hygiene:
· Discuss the significance of personal hygiene and proper hand washing in
preventing infections
· Give client some lectures about proper wound care through changing the

dressing as often as possible so as to protect the wound from invasion of

microorganisms as well as to reduce the risk of microorganism
transmission to others.
Outpatient Care:
· A follow up check-up is necessary for wound evaluation and to assess the
progression of wound healing.

Diet:
· Encourage the patient to increased fluid intake and to include fruits and
vegetables rich in vitamin C for the production of milk needed for lactation.
· Taking food rich in protein is also helpful for tissue repair.