POSTPARTUM HAEMORRHAGE

BLEEDING PLACENTA PRAEVIA + BTL

SITI AISHAH MOHD ZAMERI

PER ADMISSION21/4/15; 32y.o/ Indian/ G3P2 @40w7dANC: 1) 1 previous scar(2008) for breech

delivery (untested)@ HSAH, patient keen for VBAC2) Voluntary subfertility > 7 years3) h/o UTI-completed abx

E/A for IOL for postdatism-patient is keen for BTL, however, explained that BTL will be done only if patient went for EMLSCS. Counselled regarding LARC(Implanon) –pt say will d/w husband.

Latest scan (17/4/15)-S/C, FH+, placenta:AUS, AFI:20.6,

EFW:3.66kg, parameters- to date

Currently: no s/sx of labour FM good

no fever/UTI/URTI sx

Past obstetric hx: 1)2004/FT/VSD/3.25kg/male2)2008/FT/LSCS for breech/2.75kg/male

Past gynae hx: 13 (4-5 days) regular

Past med hx: uneventfulFamily hx: uneventfulAllergy: seafoodSocial hx: housewife, H-lorry driverO/E- alert, conscious, pinkAbdomen- soft, nontender, uterus@term,

EFW:3.4-3.6kgCTG:reactivePlan:1) for IOL as planned2) V/S monitoring3)Daily CTG4) FKC

1st prostin inserted21/4/15- 10.00amBishop score: 5/13Dilatation (1), effacement:40%,

station(2), consistency(medium), position(middle)

prostin (1.5mg) inserted @ posterior fornix

2nd prostin inserted21/4/15- 1700pmBishop score: 5/13Dilatation (2), effacement:50%,

station(2), consistency(medium), position(middle)

prostin (1.5mg) inserted @ posterior fornix

L/R progress22/4/15- t/o to labour room as BS this

morning is 7/13, Os:3cm, MI, vertex, for ARM

Currently, FM good, afebrile, irregular contraction, no LL, no UTI/ URTI sx.

O/E- pink not tachypnoiec, V/S stablePer abdomen: S/C, soft, non tender,

Uterus@ term, HPA:4/5, no scar tendernessVE: V/V-NAD, os:3cm, st:-2, MI, cx:40-50%

effaced.Plan: prop up pt, for MO to r/v, start

augmentation first.

Review by MO22/4/15; 12.55pmInformed by HO that checked upon ARM

noted head was floatingUpon VE noted: Os; 4cmCx: soft (50% effaced)St:-3 (floating)+ placenta bed over the os- PP type 2+liquor mixed with bloodCTG: reactiveCase d/w Dr. Muna- for EMLSCS

INTRAOP22/4/15; 1350- EMLSCS+BTL for bleeding

placenta praevia.Findings: peritoneal cavity: no adhesions;

engagement: cephalic, head not engaged; BTL done; placental site: PP type 2 posterior; Bleeding from placenta bed, secured with multiple suturing but still oozing from placenta bed.

Dr. Kamal was called inBlood loss: 2000mlIntraop- transfused 2 pint WB + IV lasix 20mg

statBaby girl delivered, AS-4 @1min, 9@5min,

BW:3.52kg

PROGRESSPost-op review: currently: comfortable,

tolerable pain, no fever, no s/sx of anaemia.

O/E- alert, conscious, not tachypnoeic.Per abdomen: soft, tender @ operation

site, uterus well contracted@ 20w size, dressing not soaked.

FBC & coag profile post op was taken and traced to be within normal value. (Hb:10.4)

24/4/15- Allow discharge