Placenta previaPlacenta previa

By:By:

Dr. Meyzadel L. BergadoDr. Meyzadel L. Bergado

Labrado, Jamela a 21 y.o female married, Labrado, Jamela a 21 y.o female married, housewife, Roman Catholic presently living in housewife, Roman Catholic presently living in Lila, Bohol was admitted for the second time Lila, Bohol was admitted for the second time in GCGMH for vaginal bleedingin GCGMH for vaginal bleeding

Past medical historyPast medical history

No history of any allergies as to food or medsNo history of any allergies as to food or meds Non-asthmatic, non-diabetic, non-hypertensiveNon-asthmatic, non-diabetic, non-hypertensive No history of any recent hospitalizations or No history of any recent hospitalizations or

illnessesillnesses

Personal and Social historyPersonal and Social history

High school graduateHigh school graduate Non smokerNon smoker Non alcoholic beverage drinkerNon alcoholic beverage drinker

Family historyFamily history

No known heredofamilial diseasesNo known heredofamilial diseases

Ob-gyn historyOb-gyn history

Menarche @ 10 y.oMenarche @ 10 y.o Menses are at regular monthly interval that Menses are at regular monthly interval that

lasted 3 dayslasted 3 days Consumed 2-3 napkins/dayConsumed 2-3 napkins/day No dysmenorrheaNo dysmenorrhea No use of any form of contraceptionsNo use of any form of contraceptions No history of any STINo history of any STI

G1 = 2006, G1 = 2006, FT, FT, NSD, NSD, GCGMGCGM= 6.7 lbs= 6.7 lbs

G2G2 = present pregnancy= present pregnancy= LMP – 12/6/07= LMP – 12/6/07= EDC – 10/13/08= EDC – 10/13/08= AOG – 37 2/7 wks= AOG – 37 2/7 wks

Prenatal care started at 3 mos AOG with regular monthly Prenatal care started at 3 mos AOG with regular monthly visits at the local health unit.visits at the local health unit.

Good compliance to supplemental medsGood compliance to supplemental medsBP ranges 110-120/80-90 mmHg during PNC BP ranges 110-120/80-90 mmHg during PNC UTI at 7 mos AOG and was given an unrecalled UTI at 7 mos AOG and was given an unrecalled

antimicrobials to be taken 3x a day for 1 weekantimicrobials to be taken 3x a day for 1 week

HPIHPI

Two hours PTA, sudden onset moderate Two hours PTA, sudden onset moderate vaginal bleeding without any associated vaginal bleeding without any associated symptoms like hypogastric and lumbosacral symptoms like hypogastric and lumbosacral pains were noted. This prompted the patient to pains were noted. This prompted the patient to be brought to GCGMH to seek medical help. be brought to GCGMH to seek medical help.

At the ER, one episode of profuse At the ER, one episode of profuse vaginal bleeding was noted, thus admitted.vaginal bleeding was noted, thus admitted.

P.E.P.E.

General SurveyGeneral Survey Conscious, coherent, ambulatory, NIRDConscious, coherent, ambulatory, NIRD

Vital signsVital signs BP = 120/80 mmHgBP = 120/80 mmHg RR = 18 bpmRR = 18 bpm HR = 82HR = 82 T = 37.1 CT = 37.1 C

HEENTHEENT Anicteric sclerae, pinkish palpebral conjunctivaAnicteric sclerae, pinkish palpebral conjunctiva

NeckNeck (-) LAD, (-) neck muscles retractions(-) LAD, (-) neck muscles retractions

C/LC/L CBS, (-) adventitious soundsCBS, (-) adventitious sounds

CardiovascCardiovasc Adynamic precordium, (-) murmur, RRNRAdynamic precordium, (-) murmur, RRNR

AbdomenAbdomen Globular , FH = 29 cm, FHT = 141 bpm, (-) Globular , FH = 29 cm, FHT = 141 bpm, (-)

tendernesstenderness

Speculum examSpeculum exam (-) active bleeding, (-) active bleeding,

ExtremetiesExtremeties (-) edema, (-) varicosities(-) edema, (-) varicosities

Impression Impression

Pregnancy Uterine 37 2/7 wks AOG, CNIL, R/I Pregnancy Uterine 37 2/7 wks AOG, CNIL, R/I Placenta PreviaPlacenta Previa

Differential diagnosisDifferential diagnosis

Abruptio placentaAbruptio placenta Frequent association of

preeclampsia or hypertension from any cause

A single attack of vaginal bleeding, which usually continues until delivery

Local uterine tenderness, hypertonic “woody” uterus in a concealed abruption

patient usually in labor

Presenting part often engaged Presenting part maybe difficult to

palpate

Placenta previaPlacenta previa No association with preeclampsia

Repeated warning hemorrhages often occurring over a period of weeks

Usually no abdominal pain Normal uterine tone and usually

no tenderness Patient rarely in labor Presenting part above brim,

malpresentation usually found Fetal parts usually palpable

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

Course in the wardCourse in the ward

Venoclysis was started with D5LR 1 L @ 30 Venoclysis was started with D5LR 1 L @ 30 gtts/mingtts/min

Labs: CBC typing, HBS-Ag det Labs: CBC typing, HBS-Ag det stat statUA UA

Baseline CTG Baseline CTG FHT monitoring q 4 hrsFHT monitoring q 4 hrs CBR w/o TPCBR w/o TP For transabdominal UTZFor transabdominal UTZ

HBS-Ag – nonreactiveHBS-Ag – nonreactive Baseline CTG – reactive NST Baseline CTG – reactive NST CBC CBC

WBC – 11 K/uLWBC – 11 K/uL RBC – 4.02 M/uLRBC – 4.02 M/uL Hgb – 11.2 g/dLHgb – 11.2 g/dL Hct – 33.8 %Hct – 33.8 % Platelet – 246 K/uLPlatelet – 246 K/uL Bld Type – B+Bld Type – B+

UTZ UTZ Single live intrauterine pregnancy, cephalic Single live intrauterine pregnancy, cephalic

presentationpresentation Sonar age 34 weeks and 0 day by fetal biometrySonar age 34 weeks and 0 day by fetal biometry Placenta Previa Totalis Posterior, Grade IIIPlacenta Previa Totalis Posterior, Grade III AFI = 9.7 cmAFI = 9.7 cm EDC = 11/06/08EDC = 11/06/08 EFW = 2390 gmsEFW = 2390 gms

22ndnd hospital day hospital day

11:25 a.m11:25 a.m 2 units of FWB of patient’s bloodtype properly 2 units of FWB of patient’s bloodtype properly

screened and crossmatched were on standbyscreened and crossmatched were on standby Monitored for any signs of profuse vaginal Monitored for any signs of profuse vaginal

bleeding or any other unusualitiesbleeding or any other unusualities FHT monitoring was continued q 4 hrsFHT monitoring was continued q 4 hrs

3:20 pm3:20 pm (+) vaginal bleeding, minimal with mild uterine (+) vaginal bleeding, minimal with mild uterine

contractionscontractions Active FM Active FM

Scheduled for emergency CSScheduled for emergency CS Consent Consent OR and anesthesiologist informedOR and anesthesiologist informed Pedia informedPedia informed Cefazolin 1 gm IVTT (ANST) on call to ORCefazolin 1 gm IVTT (ANST) on call to OR Abdominoperineal prepAbdominoperineal prep VS, FHT and UC were monitored q 15 minVS, FHT and UC were monitored q 15 min

9:15 pm9:15 pm Post-opPost-op

Cefazolin 1 gm IVTT q 8 hrsCefazolin 1 gm IVTT q 8 hrs Ranitidine 50 mg IVTT q 8 hrsRanitidine 50 mg IVTT q 8 hrs Tramadol HCl 50 mg IVTT q 8 hrs x 4 dosesTramadol HCl 50 mg IVTT q 8 hrs x 4 doses Ketorolac 30 mg IVTT q 8 hrsKetorolac 30 mg IVTT q 8 hrs

2 units of PRBC properly screened and 2 units of PRBC properly screened and crossmatched were transfused crossmatched were transfused

Pre-op dxPre-op dx G2P1(1001) PU 37 3/7 wks AOG, CILL, Placenta G2P1(1001) PU 37 3/7 wks AOG, CILL, Placenta

previa totalis, posteriorprevia totalis, posterior

Post-op DxPost-op Dx G2P2(2002) PU 37 3/7 wks AOG, Cephalic, G2P2(2002) PU 37 3/7 wks AOG, Cephalic,

Placenta Previa Totalis, posterior Placenta Previa Totalis, posterior

33rdrd hospital day hospital day SS

(+) flatus(+) flatus Minimal vaginal bleedingMinimal vaginal bleeding AfebrileAfebrile (-) dizziness(-) dizziness

OO BP = 120/70BP = 120/70 Pale palpebral conjunctivaPale palpebral conjunctiva Post-op wound : dry, non erythematousPost-op wound : dry, non erythematous Abdomen: NABSAbdomen: NABS

AA S/P primary LSTCS PU 37 wks AOG CILL, P. Previa totalis, post x 13 hrs post-opS/P primary LSTCS PU 37 wks AOG CILL, P. Previa totalis, post x 13 hrs post-op

PP Cont IVTT medsCont IVTT meds For repeat HctFor repeat Hct General liquid dietGeneral liquid diet Wound dressingWound dressing

44thth hospital day hospital day S S

(+) BM(+) BM AfebrileAfebrile Scanty vaginal bleedingScanty vaginal bleeding No dysuriaNo dysuria

OO BP – 110/70 mmHgBP – 110/70 mmHg Hct -27 %Hct -27 % Pale palpebral conjunctiva Pale palpebral conjunctiva Uterine size: 3 FB below umbilicusUterine size: 3 FB below umbilicus post-op wound : dry, non erythematouspost-op wound : dry, non erythematous

A A Anemia SevereAnemia Severe

P P For BT 1 unit PRBC screened and crossmatchedFor BT 1 unit PRBC screened and crossmatched P.O medsP.O meds DATDAT Wound dressingWound dressing Encourage ambulationEncourage ambulation

55thth hospital day hospital day SS

No subjective complaintsNo subjective complaints AfebrileAfebrile No dysuriaNo dysuria Scanty vaginal bleedingScanty vaginal bleeding

OO BP – 110.70BP – 110.70 Hct – 36%Hct – 36% BPE : BPE : I- parousI- parous A – (-) tenderness, A – (-) tenderness,

U- 4 fb below umbilicusU- 4 fb below umbilicus (-) mass(-) massC – 1 cm dil, softC – 1 cm dil, soft D – minimal lochialD – minimal lochialdischargesdischarges

AA improvedimproved

PP MGH with homemeds MGH with homemeds advisedadvised

Discussion Discussion

Placenta previaPlacenta previa Abnormal implantation of the placentaAbnormal implantation of the placenta Implantation is in the lower uterine segmentImplantation is in the lower uterine segment

Types Types

Total Placenta previaTotal Placenta previa Partial placenta previaPartial placenta previa Marginal placenta previaMarginal placenta previa Low-lying placentaLow-lying placenta

Incidence :Incidence : 1 of 167 1 of 167 1 of 327 pregnancies 1 of 327 pregnancies

Etiology:Etiology: unknownunknown

Risk factors:Risk factors: Hx of prior C/S Hx of prior C/S Hx of uterine curettageHx of uterine curettage Increasing maternal ageIncreasing maternal age Increase parityIncrease parity Closely spaced pregnanciesClosely spaced pregnancies Tumors distorting the contour of uterusTumors distorting the contour of uterus EndometritisEndometritis smokingsmoking

pathophysiologypathophysiology

term/onset of laborterm/onset of labor

retraction of lower uterine segmentretraction of lower uterine segment

Spontaneous premature rupture of the placenta from the spongy layer of the Spontaneous premature rupture of the placenta from the spongy layer of the deciduadecidua

Tearing into the maternal blood sinusesTearing into the maternal blood sinuses

Hge of the spiral arterioles in the deciduaHge of the spiral arterioles in the decidua

bleedingbleeding

Signs and symptomsSigns and symptoms Painless vaginal bleedingPainless vaginal bleeding

DiagnosisDiagnosis Placental localization of transabdominal UTZPlacental localization of transabdominal UTZ

Management of placenta previaManagement of placenta previaSevere bleedingSevere bleeding C/SC/S

> 36 wks or> 36 wks or

mature L/S ratiomature L/S ratio

Moderate bleeding AOGModerate bleeding AOG PT unstablePT unstable

<36 wks<36 wks

immature L/S ratioimmature L/S ratio intensive careintensive care

beta mimeticsbeta mimetics

corticoidscorticoids

BTBT

PT stablePT stable

>36 wks>36 wks

mature L/S ratiomature L/S ratio

Mild bleedingMild bleeding AOG AOG

<36 wks <36 wks

immature L/S ratioimmature L/S ratio expectant mgt expectant mgt

Criteria for outpatient management Criteria for outpatient management of patients with placenta previaof patients with placenta previa

Inpatient observation for 72 hrs without vaginal Inpatient observation for 72 hrs without vaginal bleedingbleeding

Stable serial hct > 35%Stable serial hct > 35% Reactive NST at the time of dischargeReactive NST at the time of discharge Telephone-available 24-hr transportation between Telephone-available 24-hr transportation between

home and hospitalhome and hospital Patient’s and family’s comprehension of potential Patient’s and family’s comprehension of potential

complicationscomplications Weekly clinical ff-up until delivery including serial Weekly clinical ff-up until delivery including serial

hgb and repeat UTZhgb and repeat UTZ