Addis Ababa University

Faculty of Medicine
Department of gynecology and obstetrics
Case Report I

Name: Mekdes Berhan

ID: MDR/3516/02
Submitted to: Dr.Dawit

Identification
Name:Ayelu belayneh Age: 31 Sex: F
Orthodox

Occupation: House Wife

Religion:

Address: Holleta Oromia Date of Admission: 13/03/04 Date of Clerking: 13/03/04

Marital Status: Married
Ward: east
Bed No:07

Ethnicity: Oromo

Department:obstetrics

Historian: The Patient

Chief Complaint
Vaginal bleeding of 10 minutes duration
History of Present Illness
This is a gavida 03 para 02 women whose LNMP is unknown but she claims she
had spotting b/n Tikimit 05 and tikimit 20 and on Tikimit 20 she took her last
dose of depo injection.since then she claims she has never seen any bleeding
since 10 days back.
Before 03 months she had abdominal discomfort and back pain so that she
went to a health center around her area of residency where she was told she
was 05 months pregnant on physical examination and after a week ultrasound
confirmed she was 06 months pregnant and was referred to st Paul Hospital for
further follow-up because six years ago she had twins with c/s after a failed
vaginal delivery.
Until the day she went to the health center for a complaint of abdominal
discomfort she claims she did not suspect herself becoming pregnant at all
even though she intentionally missed the last dose of inject able contraceptive
she used take for 09 years because she wanted to become pregnant. She
claims this is because she had irregular menstrual cycle b/c of the
contraceptive she takes. During her visits for follow up she was given tetanus
vaccine and iron supplement for one month, blood test was also performed and
she was found to be non reactive for RVI, VDRL, HBSAG and her blood group is
0+ve .
Since the pregnancy was uneventful untiL she was awakened by a sudden gush
of vaginal bleeding which lasts 10 minutes and amounted half a liter. the blood

was non clotted type, bright red in color and not associated with any type of
pain. Early in the next morning she was taken to st. Paul hospital
There is no history of offensive vaginal discharge
No history of abdominal trauma
No history of hypertension
No history of bleeding disorder or anticoagulant treatment
No history of decrease fetal movement after bleeding
No history of sudden abdominal fullness or rapid increase in size
No history of nasal bleeding
No history of severe headache , abnormal body movement, loss of
consciousness or vision disturbance
No history of epigastric or right upper quadrant pain , yellowish discoloration
No history of water hunger or diaphoresis
No history of leg swelling
No history of pushing down pain or sudden gush of fluid
No history of cough, fever, nightsweats, weightloss or loss of appetite
No self or family history of DM, HTN or asthma
She has gained a significant amount of weight through the course of
pregnancy .she eats 03 major diets daily and has frequent snacks in between.
Menarche started at the age of 15 years, menstruation was regular coming
every 21 days and lasting 5-7 days, the bleeding was usually dark in color and
not associated with clot. She was marred 12 years back her husband being her
first coital experience after she was married.Pregnaccy was planned, wanted
and supported.
past obstetric history
She was pregnant for the first time before 12 years where she gave birth to a
girl at home with unknown date of gestation but she claims she had ANC
follow-up. There were no post term complications and she has breastfed her,
the child is healthy and 6th grade student now.

Before six years she was pregnant for the second time and gave birth thru c/s
after a failed vaginal delivery with the outcome of live twins but she was unwell
by the time and she did not breast feed them at all and they passed away the
1st at 04 months of age and the 2nd at 08 monthss of age.
Gynecologic history
She has been using injectable contraceptive since 09 years which she has
stopped in b/n before six years for about a year she has no history of STD and
has been married for 12 years with her husband for being her first coital
experience . she has been tested and found to be non reactive for RVI.she has
no history of gynecologic operations.
Menstrual history
Her menarche started at the age of 15 with average of 21 days interval 5-7
days duration of flow , non clotting and no degree of pain.
Past medical history
None
Personal and family history
She was born and raised in holeta , she was never involved in formal education
. She is the 5th child for her parents who are not alive. she has no habit of
smoking or illicit drug use, she does not drink alcohol except
occasional,Tella.she is a housewife and lives supported by her husband who
is a daily laborer. She lives with her husband and daughter. There is no family
history of HTN, DM,allergies and mental disorders.
Review of systems
H.E.E.N.T
Head:no headache, no head injury , no dizziness
Ears:I. No loss of hearing, discharge or earache
Eyes:No pan, strain, lacrimation, photophobia or itching
Nose: No epistaxis or discharge
Mouse and throat:No dental pain, bleeding from the gums or sore throat.
Intact tonsils.

GlandsI. No mass in the neck, axilla,or groins, there is breast enlargement and
tenderness associated with the pregnancy, no discharge from the nipples . no heat or
cold intolerance.
Respiratory System:, no cough,No expectoration, hemoptysis, shortness of breath,
wheezing or stridor.
Cardiovascular system:No dyspnea, palpitation, orthopnea or syncope.
Gastrointestinal system:no nausea or vomiting,no deahrrea, on constipation, no
abdominalpain, or no change in stool color.
Genitourinary system:. No frequency , no dysuria, no urgency , no hesitancy,no
dribbling, no reddish discoloration
Integumentary system: Moist skin, no rashes or ulcers, no changes in hair
distribution or pigmentation.
Allergy:none
Locomotory system: No bony deformities, no joint pain.
Central nervous system: no history of numbness, no paralysis, urine incontinence,
seizures or speech defect.

Physical Examination

General Appearance
The patient is lying in right lateral position. She is conscious, doesnnot appear sick
looking. she is not in respiratory distress, no gross dismorphic features.
Vital signs
BP: 100/70mmHg, right arm sitting
PR: 96/min right radial artery, full in volume and regular rhythm
Weight: 62kg
Height: 165cm

H.E.E.N.T
Head: Normal size, shape and hair distribution, No scar.
Ears: Normal contour of pinna.Clear external ear canal.
Eyes: Normal eyebrows. No per-orbital edema, ptosis, exophthalmoses or strabismus.
The conjunctivae are pink. The sclera are not icteric. No funduscopic examination was
done.
Nose: The nasal septum is not deviated. There is no polyp or unusual discharge.
Mouse and throat: The lips show no fissure, ulceration or herpes. The gums
areintact and show no ulceration. There are no carious teeth. There are no extractions,
dentures or filling. The tongue is pink, doesnt show any atrophy. The tonsils arent
inflamed and the uvula is intact.

Lymphatic and glandularr system

No palpable lymph nodes. the breasts are engorged . they are soft. They are
not tender there is no lump. There is no discharge or inflammation over the
nipple. Thyroid is not palpable.
Respiratory System
Inspection: There is no cyanosis or clubbing or the finger nails.The palms are not
pale. Breathing is deepand is of regular rate. The chest is symmetrical. There
are no deformities, surgical scars, visible pulsation or dilated vessels.
Palpation: Thetrachea is central. There is no tenderness over theentire chest. The
total circumferential chest expansion is 3 cm along the nipple line on deep
inspiration. Tactile fremitus is normal overthe entire lung field. Chest expansion
is symmetrical.
Percussion: Both the right and left chest are resonant. Diaphragmatic excursion is
3cm.
Auscultation:The breath sounds are vesicular over the entire lung field. No wheezing,
stridor crepitation or pleural friction rub.
GUS

There is no costovertebral angle tenderness.

pelvic
sexual maturity rating of 5/5 .there is no visible vaginal discharge. There is no visible
mass at introitus. There is no swelling ove the labia, no ulcer.
Cardiovascular system
Arteries: BP and pulse (see under vital signs). The pulse volume is normal, the
rhythm is regular and there was no abnormal character or unusual condition of vessel
wall. Pulse volume can be tabulated as follow:

Right
Left

Caroti

Axillar

Brachi

al

+++
+++

++
++

++
++

Radial

Femor

poplit

++
++

al
+++
+++

eal
++
++

PT
++
++

DP
++
++

No radio-femoral delay detected.

Veins: There are no distended veins over the neck, chest wall, or leg.
The JVP at an inclination of 450 is 2 cm above the angle of louis.
No hepato-jugular reflex.
Precordium
Inspection: There is no abnormality in shape (no precordial bulge). The precordium is
Quiet. The apical impulse is visible at the fifth intercostal space along the mid
clavicular line.
Palpation: The point of maximum impulse is felt where it is visible. There is also no
parasternal or apical heave. There is also no thrill.
Auscultation: The heart sounds are normal over the valvular areas. There is no gallop
or murmur.
Abdomen

Inspection: The abdomen is distended and symmetrical and moves with respiration.
Flanks are full, no distended veins . no visible peristalysesbut fetal movment is
encountered.
Hernia sites are free, umbilicus is everted, there is linea nigra but no stria gravidarum.
There is midline surgical scar starting from above the umbilicus down to the
symmphysis pubis
Auscultation: The bowel sound is normo-active no vascular bruits are heard.
Palpation:no superficial mass or tenderness
Percussion: abdomen is tympanic above the ara of uterus.
Obstetric physical examinati
Leopold 1 fundus palpated 9 fingers above umbilicus, 38 old uterus, hard rounded and
ballotable mass occupying fundus.
Leopold 2 smooth regular sides ,flat structure on left lower and on on right side
irregular , longitudinal lie
Leopold 3 not done
Leopold4 not done
Integumentary System
No rash , no striagravedarum but linea nigra is present, no palmar pallor, no
jaundice , warm skin , normal hair distribution, soft textur and strengh , pink
nail beds,no inflammation aound nails , no clubbing.
Locomotory System
Theres no muscle or bone tenderness. The joints are normal and theres no bony
deformity.
Nervous system
Mental Status:

The patient is conscious with a GCS of 15/15. She is fully cooperative and doesnt
seem to be depressed.
She knows what day it is, where she is and what her name is. Orientation
She remembers what she ate for breakfast. She also remembers where she used to
live. Memory
She speaks in a low voice tone. There is no hesitancy and gap in the flow and rhythm
of her words. Speech
She denies any hallucinations or delusions.
Cranial Nerves:
N-I: Smells mango via each nostril.
N-II: She can differentiate 2 fingers at about 5 meters by both eyes. (Visual Acuity)
She sees waggling of finger approximately 100 0 from axis of the eye.(Visual Fields)
She differentiates green and red colors. (Color Appreciation)
N-III, IV & VI: The eyes can move in all directions. There is no nystagmus or diplopia.
The pupils are round, regular in outline and equal in size. They react to light directly
and consensually.
N-V: Sheidentifies light touch and pin prick over the mandibular, maxillary and
ophthalmic areas of the face. She closes her eyes at the touch of the cornea with a
cotton swab. Contraction of the temporal and masseter muscles is symmetrical and
strong.
N-VII: The face is symmetrical at rest and during voluntary movements (smiling,
raising the eye brows). She can close both eyes equally and forcefully.
N-VIII: She hears rubbing of the fingers on both ears.
N-IX & X:The soft palate rises in the midline when saying ah!
N-XI:The Sternocleidomastoid and trapezius muscles contract on turning the head and
on shrugging the shoulder against resistance, respectively.

N-XII:The tongue protrudes in the midline and shows no fasciculation or atrophy.

Motor:

Musclebulk: There is no muscle bulk reduction in all extremities and there is

also no bulk difference between the left and the right sides. There is no

spontaneous as well as induced fasciculation.

Muscle tone and power.

Right
Left

TONE
Upper
Normo-tonic
Normo-tonic

Lower

POWER
Upper

Lower

Normo-tonic
Normo-tonic

5
5

5
5

0 no active contraction 1 - flickering movements 2 - movement in

horizontal axis
3movement against gravity only 4 - movement against gravity + mild
resistance 5 - normal power
Coordination:
Finger to nose, heal to shin and rapid alternating movement of the arm were done
without any abnormalities.
Pronator Drift test was negative.
Reflexes:

Superficial reflexes:.Corneal reflex is intact in both eyes .Plantar reflex is

down going on both sides.

Deep tendon reflexes:

Right
Left

Biceps
++
++

Triceps
++
++

Supinator
+
+

Patellar
++
++

Ankle
+
+

Clonus: No clonus

Sensory:

She identifies light touch and pin prick over the extremities and trunk.
She appreciates the form of a key by means of only touch (Stereognosis)
She recognizes writings of different numbers on his palm (Graphesthesia)
She is able to differentiate 2 pin pricks upto 4 mm apart over the finger tips (2
pt discrimination).

She is able to recognizedifferent movements of the toes with his eyes closed.
(Position sense)
Vibration sense was not assessed due to lack of Tuning Fork.

Meningeal Sign:

There is no neck stiffness.

Kernig's Sign is negative.
Brudzinski's Sign is negative.

Summary of problems

Subjective summary

31 years old multigravida

Antepartum hemorrhage
Planned ,wanted, supported pregnancy
Stable, conscious

Objective Summary

38 wk size gravid uterus

Longituidanal lie

Positive FHB
Differential diagnosis
APH secondary to placenta previa
APH secondary to placenta abruption

Discussion of the differential diagnosis

Hemorrhage is so far the most common cause of maternal morbidity and mortality.
Serious hemorrhage can occur any time through out the course of pregnancy and
timing of bleeding is used to classify obstetrical hemorrhage. obstetrical hemorrhage
can be classified as an ante partum and postpartum hemorrhage

Ante partum hemorrhage is bleeding from the genital tract that takes place after fetal
viability and before delivery of the fetus. it is an important cause of maternal and
perinatal mortality complicating4% of pregnancies. It may be a result of obstetric or
non obstetric causes. Obstetric causes such as placenta previa , abruptioplacenta,
uterine rupture carry a poor maternal fetal outcome and are of great concern than
those, of the non obstetric causes such as genital tract laceration and anatomic
defects which are solved before causing disastrous consequences.

APH secondary to placenta previa

Placenta previa is used to describe a placenta that is implanted over or very
near the internal cervical os.
It may be total , partial , marginal or low lying. Digital palpation in an attempt
to assess changing conditions of the placenta in relation to the internal os due
to the dilating cervix usually results in severe hemorrhage .so it should be
avoided if placenta previa is suspected.
Risk factors associated with placenta previa include advanced maternal age,
multiparty, prior CS , multiple gestation , prior placenta previa and smoking.
The most characteristic event is painless hemorrhage usually at the end or
after the second trimester. This bleeding results from small disruption in
placental attachment during normal development and thinning of the lower
uterine segment. Bleeding is usually transient and mild but ultimately recurs.
The source of bleeding is maternal blood or choriodecidual space and the cause
is mechanical separation of a portion from its uterine attachment as the lower
segment lengthens during late pregnancy subsequent bleeding becomes
progressively heavier until finally they cause profuse hemorrhage.
Diagnosis is made by either transabdominal ultrasonography or
transvaginalsonography once diagnose, total and partial placenta previa should
not be allowed a trial of labor. CS is mandatory.
APH secondary to placental abruption
Placental abruption is the premature separation of a normally implanted
placenta. It is the commonest cause of death from APH premature separation
of the placenta if sever enough will lead to perinatal asphyxia and maternal
DIC. Abruption is a self perpetuating process as hemorrhage into the deciduas
basalis leads to the formation of a small retroperitoneal clot resulting in more
pronounced clot formation. These cascade of events ultimately end up

compromising maternal fetal oxygen and nutrient transfer and onset of early
uterine contractions . The bleeding is usually evident as separation involves the
periphery of the placenta but may also by conceal when separation is central.
Concealed bleeding carries a poorer prognosis as the extent of bleeding will not
be appreciated and there will be delay in diagnosis.
Even though the primary cause of placental abruption is unknown, several risk
factors involved have been identified and this include increased age and parity,
preeclampsia, previous history of abruption, sudden drop in intrauterine
pressure as in rupture of membranes in polyhydraminos or delivery of 1st twin,
abdominal trauma, chronic hypertension, smoking, cocaine use, thrombopjilia,
uterine leiomyoma.
Typical manifestation of abruption is pain which may range from mild cramping
or the more acute severe type. This may or may not be associated with
bleeding. The uterus will be firm, tender and sudden increase in fundal height
may be appreciated on physical examination. Fetal distress is present In 60% of
cases.
Complications include preeclampsia, maternal shock, renal failure, Sheehan
syndrome, DIC and PPH due to couvelair uterus. Feral complications are short
and long term complications of asphyxia.
This patient has none of the above mentioned risk factors. However it should
be noted that the primary cause of abruption is unknown and it is the most
common cause of maternal mortality due to APH. Even with the help of
laboratory and ultrasound it cannot be ruled out at completely this stage.
Investigation
CBC
Coagulation studies like PT, PTT, serum fibrinogen, bleeding time, platelet
count
Trans abdominal ultrasound
Blood typing
Indirect coombs test
Urine analysis