Case presentation

Dr. Meyzadel L. Bergado

Patients Profile
Cortejos, Juliet 23 y.o. G2P1(1001), Filipino, single, Roman Catholic presently living in Baclayon, bohol was admitted for the first time in March 21, 08 at the GCGMH due to vaginal bleeding

Past medical history

No history of any allergies as to food or meds Non-asthmatic, non-diabetic, nonhypertensive No known cardiac, pulmonary, renal or hematologic problems No recent history of any illnesses or any hospitalizations

Personal and Social Hx

High school graduate Non-smoker Non alcoholic beverage drinker

Family Hx

No heredofamilial dses

OB-gyne Hx
Menarche @ 12 y.o Menses are at regular monthy interval that lasted at an average of 5 days duration consuming about 2-3 pads/day No dysmenorrhea No use of any form of contraceptions No history of any STDs

G2P1 (1001) G1 = 2006, FT, NSD, home delivery, 6 lbs. good fetal outcome G2 = present pregnancy LMP aug. 2nd week EDC - May 3rd week AOG 30-31 wks

PNC s @ LHC , started @ 5 wks AOG with regular monthly visits BP ranges from 100-110/70-80 mmHg Good compliance to the prenatal supplements No illnesses were incurred during her present pregnancy

HPI
One hour PTA, sudden onset of profuse vaginal bleeding without any associated symptoms. Sought consult at the GCGMH thus admitted

P.E.
G.S conscious, coherent, afebrile, NIRD

VS BP = 110/70 mmHg HR = 84bpm RR = 19 cpm

HEENT anicteric sclerae, pinkish palpebral conjunctiva C/L (-) IC retractions, CBS Heart (-) murmurs, RRNR

Abdomen globular, FH 26 cm, FHT 151 bpm, (-) tenderness Speculum Exam cervix cant be visualize due to profuse vaginal bleeding

Impression
G2P1(1001) PU 30-31 wks AOG, PT, NIL, R/I Placenta Previa

Orders
Venoclysis was started with D5LR 1L @ 30 gtts/min Emergency blood transfusion 1 unit FWB of patients bloodtype, properly screened and crossmatched was then requested Sched for emergency primary LTCS Meds: Cefazoline 1 gm IVTT (ANST) on call to OR Dexamethasone 8 mg IVTT (stat)

Post Partum Notes

Del spont a live preterm bb. Boy, NCC, NMS, AS 8-9, BW 1758, BL 38 cm Placenta was delivered spontaneously and complete BP- 100/80 Methylergometrine maleate 1 amp was given thru IM

Placenta Previa

Placenta is implanted in the lower uterine segment

Types:
1. 2.

3.
4.

Total Placenta previa Partial placenta previa Marginal placenta previa Low-lying placenta

incidence

1 in 250 births or 0.4%

Etiology

Unknown

Risk factors
Advancing Multiparity Previous

maternal age

cesarean section

Smoking
Large

placenta Puerperal endometritis

PATHOPHYSIOLOGY
Term/onset of labor Retraction of lower uterine segment Dilatation of the internal os Spontaneous premature rupture of the placenta From the spongy layer of the deciduas

Tearing into the maternal blood sinuses

Hemorrhage from the spiral arterioles in the decidua

Lower uterine segment not covered by well developed decidua No limitation in the invasion of the trophoblasts Deep penetration into the underlying tissues Pathologic entity Placenta accreta

Sign & symptom Painless Vaginal Bleeding

Diagnoses
Placental localization by transabdominal sonography

Placental Migration
low lying placentas in the second trimester Migrate upward towards the fundus No clinical obstruction to the descent of the fetal presenting part

Differential diagnosis
Abruptio

placenta

Local

pathologic lesions in the vagina and cervix

Vasa

previa

Vasa Previa
Anomaly of the umbilical cord resulting from velamentous insertion Separation of umbilical vessels in the membranes some distance from the edge of the placenta Fetal blood vessels cross the internal cervical os and presents ahead of the fetal presenting part Tearing of fetal vessels during membrane rupture or by pressure from the fetal head

Placenta previa vs. Abruptio placenta

Abruptio placenta
History Frequent association of preeclampsia or hypertension from any cause A single attack of vaginal bleeding, which usually continues until delivery Abdominal pain

Placenta previa
No association with preeclampsia Repeated warning hemorrhages often occurring over a period of weeks Usually no abdominal pain

Abdominal Examination

Local uterine tenderness, hypertonic woody uterus in a concealed abruption patient usually in labor Presenting part often engaged

Normal uterine tone and usually no tenderness Patient rarely in labor Presenting part above brim, malpresentation usually found

Abruptio placenta
Abdominal Examination Presenting part maybe difficult to palpate Fetal heart tones often absent

Placenta previa
Fetal parts usually palpable Fetal heart tones usually present

Ancillary aids

placenta demonstrated in upper uterine segment by ultrasound

Double set-up reveals no placenta within 5 cm of internal os

Placenta demonstrated in lower uterine segment by ultrasound

Double set-up reveals placenta implanted in the lower uterine segment

Vaginal examination

I.

Preterm Fetus with no indication for delivery

Expectant management : close observation Target date for delivery at the end of the 37th week Hospitalization, corticosteroid administration, replacement of blood loss, keeping available blood for emergency purposes, and bed rest Bleeding subsided: home management Patient understands the nature of her condition bed rest with no coitus Round-the-clock transportation and communication availability and live within 20-30mins driving distance from the hospital Hematocrit above 30 volume percent to allow some reserve in the face of significant bleeding

II.

Pregnancy with 37 weeks or more --- Cesarean section indicated

 As a general rule, the method of delivery of choice in a patient with any degree of placenta previa is CESAREAN SECTION
Low-lying or marginal placenta implanted posteriorly will warrant Cesarean delivery associated with significant incidence of intrapartum fetal asphyxia due to cord or placental compression against the sacrum by the presenting part
Exception : Marginal or low lying placenta implanted anteriorly with advanced cervical dilatation and an engaged head III. Severe hemorrhage --- blood transfusion promptly given--- Cesarean section

low transverse uterine incision is most often made

Classical Cesarean circumstances

section

all

other

If placenta cannot be avoided generally best to seek the edge quickly and gain access to the amniotic sac and the fetus

Complications:

Placenta accreta Intrauterine Growth restriction Congenital abnormalities Postpartum hemorrhage

Oversew the implantation site with Chromic O suture Bilateral uterine or internal iliac artery ligation Placing circular interrupted O-chromic sutures around the lower uterine segment, above and below the transverse incision Failure of these methods --- hysterectomy

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