CASE REPORTApril 2010

General DataME, 32y/o, G2P3 (2002), Filipino, married, from Tarlac

38 6/7 w AOG (by LMP)

Chief ComplaintScheduled for CS

Past Medical HistoryDenied hypertension, DM,

Bronchial asthma, thyroid diseaseNo previous surgeriesNo known allergies

Family HistoryDenied a family history of HTN,

DM, bronchial asthma, thyroid disease, cancer

Personal and Social HistoryNon- smokerNon- alcoholic beverage drinker

Gynecologic HistoryCoitarche: 26 y/o, 1 sexual

partnerNo vaginal discharge/symptoms

of STDUse of contraceptives for 1 year

after the birth of her second child (2005)

Menstrual History Menarche: 13 y/o Interval: 30 days, regular Duration: approx. 3-5 days No dysmenorrhea

LMP : July7, 2009 EDC: April 14, 2010

PMP: June 2009

Obstetric HistoryG1 (2002) delivered to a term,

live, baby boy; in QMMC via NSVD; BW 2.4kg; no recalled complications

G2 (2005) male, term, baby boy, at a lying-in clinic, via NSVD, no complications

G3 present pregnancy

Prenatal Check upFIRST TRIMESTER

◦(+) FPNCU ◦First ultrasound (15w AOG)◦CBC: HgB 13.6/Hct 0.4/WBC 9/RBC 4.28/

neutro 0.56/ lympho 0.33/eos 0.11◦Blood type B+◦HbsAg non-reactive◦UA: pale yellow, slightly turbid, pH6.5,

spec.grav. 1.015, (-) albumin, sugar; 2-5 pus cells, 0-2 rbc/hpf

◦Multivitamins + ferrous sulfate

Prenatal Check upSECOND TRIMESTER

◦(+) RPNCU◦(+) on Multivitamins and Ferrous

sulfate◦OGCT = 107 mg/dl (NV: 140)◦CBC: 12.5/36.6/12400/neutro

72/lymph19◦UA: light yellow, slightly hazy, (-)

glucose. WBC 13, casts 2◦Pap smear: benign cellular changes

Prenatal Check upTHIRD TRIMESTER

◦(+) RPNCU◦(+) on Multivitamins and Ferrous

sulfate◦USG: placenta previa totalis

History of Present Illness3 months PTA(~32 w AOG)

Sensation of pelvic fullnessDiagnosis of placenta previa

Schedule for elective CS

admission

Review of Systems

(-) dizziness, fainting spells, seizures

(-) fever(-) cough, colds, dyspnea, DOB(-) chest pain, palpitations(-) bipedal edema, no cyanosis

Physical ExaminationBP: 110/60mmHg HR: 94bpm, regular RR: 20/min,

regular T: 37.1 C

Eyes: pink palpebral conjunctivae, anicteric sclerae

Neck: supple neck, with no palpable neck mass, no neck vein engorgement

Breasts: appears engorged; no lesions or palpable masses

Lungs: symmetrical chest expansion, clear and equal breath sounds, no wheezing, rhonchi, or rales

Heart: adynamic precordium, normal rate, regular rhythm, no murmurs

Abdomen: globular, gravid, with prominent linea nigra, sparse striae albicans; FH 32 cm; FHT 150’s bpmL1 – breechL2 – right maternal side L3 – cephalic, unengagedL4

External pelvic examination: no lesions, redness, excoriations, hyper/hypopigmentations

IE: not done (c/i placenta previa)

Extremities: Full and equal pulses, no cyanosis, no edema

ASSESSMENT: Pregnancy uterine 38 6/7 weeks AOG, cephalic, not in labor; G3P2 (2002); placenta previa totalis for elective CS

The Placenta and Fetal Membranesthe development of the human

placenta is as uniquely intriguing as the embryology of the fetus

Links the mother and fetus by an indirect interaction with the maternal blood

blood bathes the outer syncytiotrophoblast, allowing exchange of gases and nutrients with fetal capillary blood within the connective tissue at the villous core

PLACENTA PREVIACondition wherein the placenta is

located over or very near the internal os

has four degrees:◦Total placenta previa◦Partial placenta previa◦Marginal placenta previa◦Low-lying placenta

Total placenta previaThe internal

cervical os is covered completely by placenta

Partial placenta previaThe internal os is

partially covered by placenta

Marginal placenta previaThe edge of the placenta is at the

margin of the internal os

Low lying placentaimplanted in the

lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it

The degree of placenta previa depends in large measure on the cervical dilatation at the time of examination.

Digital palpation to try to ascertain these changing relations between the edge of the placenta and the internal os as the cervix dilates can incite severe hemorrhage

EtiologyAdvancing maternal ageMultiparityPrior cesarian deliverySmoking = twice the risk

Pathophysiology:-scarring of placental site leading

to spread of implantation in subsequent pregnancies

-reason why placenta in placenta previa is more flat and occupies an area 20 to 40% larger

most characteristic event in placenta previa = painless hemorrhage,◦ near the end of the second trimester or after.◦ Abortions may result from such an abnormal

location of the developing placenta◦ Frequently has onset without warning, presenting

without pain in a woman who has had an uneventful prenatal course.

◦ In some women, particularly those with a placenta implanted near but not over the cervical os, bleeding does not appear until the onset of labor slight to profuse hemorrhage and clinically may mimic

placental abruption.

DDx: abruptio placenta vasa previa: velamentous

insertion of the umbilical cord