plasenta previa

Placenta Previa[ Case Reflection ]

Nurul Izyan Rahmat07 / 251654 / KU /

12245Gadjah Mada University

Patient’s Identity

• Name : Mrs N (163 717)

• Age : 35 y.o

• Address : Kajoran, Banjaroyo, Kalibawang

• Date of Admission : 19th Feb 2012

• Parity : G2 P1 A0

• LMP : 3rd June 2011

• EDC : 10th March 2012

• GA : 37 weeks

History Taking (19th Feb 2012)

• Patient, 35y.o referred by midwife due to ante partum hemorrhage.

• Vaginal bleeding (bright red blood) since 17:30pm.

• Changed pad 3 times.

• Trauma (-), History of vaginal bleeding (-)

History

ANC Midwife, Routine Check up

Obstetric I – Girl, 9 y.o, 2900gm, Normal, MidwifeII – This Pregnancy

Past Medical Hypertension (-), Asthma (-), DM (-), Heart Disease (-)

Marriage ± 10 y.o

Family Planning Injectable Contraceptive every 3 month (5 and ½ years)

Physical Examination

• General Condition;

CM, non-anemia

• Vital Sign;

BP : 130/90 HR : 78x/min RR : 20x/min t: Afebris

• Palpation;

Singleton pregnancy, longitudinal, cephalic presentation, fetal movement (+),

Fundal Height : 27 cm,

Estimated Fetal Weight: 2325 g,

Fetal Heart Rate (+) : 145 bpm

Laboratory (Pre-Op)

Hb 12.5 g/dL Ureum 22 mg%

WBC 10.83 x 10³/ul Creatinine 0.6 mg%

Hct 35.6 % SGOT 21 u/l

PLT 239 x 10³/ul SGPT 14 u/l

RBC 4.13x 10^6/ul HbsAg Negative

BT 2 min CT 5 min

USG

• Single fetus, Cephalic Presentation, FHR (+), Placenta located at posterior part of uterus, closed Os.

• BPD : 8.9 cm

• AC : 29.9 cm

• EFW : 2526.4 g

Diagnosis

• Ante Partum Hemorrhage due to Total Placenta Previa, Sekundigravida, Aterm

Plan• FHR and His observation• Elective Cesarean Section

Cesarean Section Report

• In narkose stage, antisepsis is done at the operation field.

• Incision is done at the abdominal wall, and extended bluntly until reached uterus.

• Incision is done at lower uterine segment, and extended bluntly.

• The infant head was delivered.

• Baby boy delivered perabdominal at 8:40am.

BW:2200gm A/S 7/9.

• Placenta completely delivered spontaneously perabdominal.

• The uterine incision was closed.

• Abdominal wall was closed.

• Skin was stitched subcutaneously.

• End of operation.

21st Feb (Day 1)

• S : Lochia (+) Rubra, Fundal height : Same level of umbilical, Breast Milk (+)

• O : CM, CA (-/-)

BP : 148/73

HR : 57

T : 36.3

Hb Post Op : 12.9g/dl

• A : Post C-Sect due to Total Placenta Previa, D1

• P : Ceftazidine 2 x 1 Amp

: Metronidazole 3 x 1 Amp

: Ketorolac 3 x 1 Amp

: Mobilization after 24 hours

22nd Feb (Day 2)

• S : Lochia (+) Rubra, Fundal height : 2 fingers below umbilical, Breast Milk (+), Mobilization (+)

• O : CM, CA (-/-)

BP : 135/73

HR : 67

T : 36.5





23rd Feb (Day 3)

• S : Lochia (+) Rubra, Fundal height : 2 fingers below umbilical, Breast Milk (+), Mobilization (+)

• O : CM, CA (-/-)

BP : 133/85

HR : 72

T : 36.7





: Remove IV line

: Remove Dwelling Catheter

24th Feb (Day 4)

• S : Lochia (+) Rubra, Fundal height : 3 fingers below umbilical, Mobilization (+), Breast Milk (+)

• O : CM, CA (-/-)

BP : 133/93

HR : 84

T : 36


• P : Cefadroxyl 2 x 500 mg

: Metronidazole 3 x 500 mg

: Mefenamat Acid 3 x 500 mg

25th Feb (Day 5)

• S : Lochia (+) Rubra, Fundal height : 3 fingers below umbilical, Mobilization (+), Breast Milk (+)

• O : CM, CA (-/-)

BP : 130/84

HR : 80

T : 36.5


• P : Cefadroxyl 2 x 500 mg

: Metronidazole 3 x 500 mg

: Mefenamat Acid 3 x 500 mg

: Discharged

Summary

19th Feb, !7:30pm : Vaginal Bleeding19th Feb, 20:00pm : Admit at RSU Muntilan20th Feb, 08:25 am : Cesarean Section20th Feb, 08:40 am : Baby boy (2200 gm) was born perabdominal20th Feb, 08:42 : Placenta delivered spontaneously perabdominal25th Feb : Patient was discharged with good condition

Discussion

Ante Partum Hemorrhage

• Ante Partum Hemorrhage is vaginal bleeding which occurs after fetal viability

• Incidence : 2-6%

Differential Diagnosis

Placenta Previa

Placenta AbruptionVasa Previa Uterine Rupture

Placenta Previa

• Placenta Previa is a condition in which the placental tissue lies abnormally close to the internal cervical os.

• Commonly diagnosed on routine ultrasonography before 20 weeks’ gestation.

• It occurs in 2.8/1000 singleton pregnancies and 3.9/1000 twin pregnancies (Lawrence O., et al, 2007).

• Significant clinical problem because the patient may need to be admitted to hospital for observation.

Classification• Total Placenta Previa

The internal cervical os is covered completely by placenta.

• Partial Placenta Previa

The internal os is partially covered by placenta.

• Marginal Placenta Previa

The edge of the placenta is at the margin of the internal os.

• Low Lying Placenta

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

William Obstetric 23rd Edition

Risk Factors• Increasing parity: Incidence 0.2% in nulliparas versus up to 5%

in grand multipara.

• Maternal age : Incidence 0.03% in nulliparous women aged 20-29 versus 0.25% in nulliparous women 40 years of age.

• Number of cesarean deliveries incidence 10% after 4 or more.

• Number of curettages for spontaneous or induced abortions.

• Smokers : Increased 2-fold in smoking. Hypoxemia due to smokes cause hypertrophy of the placenta.

Clinical Manifestation

• Painless vaginal bleeding without any reason and usually bright red blood.

• Always found abnormal lie of fetus. Fetus are usually float.

• First bleeding in small amount and not fatal, but recurrent bleeding usually profuse.

• Fetus in good condition

Diagnosis

• The diagnosis is based upon results of ultrasound examination.

• Clinical findings are used to support the sonographic diagnosis.

• Placenta previa should be suspected in any women beyond 24 weeks of gestation who presents with painless vaginal bleeding.

• Such examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean delivery, because even the gentlest examination of this sort can cause torrential hemorrhage.

Transvaginal vs Transabdominal

• TVS has several advantages over TAS imaging in localization of the placenta.

• The shorter distance from the vaginal probe transducer to the cervix and lower uterine segment allows the use of higher-frequency ultrasound waves, with improved resolution; therefore the relationship between the placental edge and the internal os can be determined more accurately.

• With TAS, there is poor visualization of the posterior placenta, the fetal head can interfere with the visualization of the lower segment and obesity and overfilling of the bladder also interfere with accuracy.

Management

ExpectantManagement

Gestational age less than 37 weeks.Less bleeding.

Active Management

Gestational age ≥37 weeks, fetal body weight ≥ 2500 gm.

Bleeding ≥500 ml.

Does not have sign of delivery.Mother’s general apparent with good condition.

Have sign of delivery.

Mother’s general apparent not good.

Expectant Management

1. Total bed rest.

2. D 5% and electrolyte infusion.

3. Tocolytic (eg. Magnesium Sulphate).

4. Check Hb, Hct, blood group.

5. USG.

6. Observe for continuously bleeding, BP, HR and FHR.

Indication for Cesarean Section

1. Total Placenta Previa

2. Placenta previa in primigravida

3. Placenta previa in transverse lie or breech presentation fetal

4. Fetal distress

5. Profuse bleeding

Prognosis

• 50% of women with placenta previa have preterm delivery.

• Those case complicated with vaginal bleeding and extreme prematurity are at an increased risk at perinatal death.

• A greater incidence of fetal malformations and growth restriction is noted with placenta previa.

• Neonates are more likely to have low birth weight, respiratory distress, jaundice, NICU admission and longer hospital stay.

Conclusion

• From the anamnesis (painless vaginal bleeding) and USG (Placenta located at posterior part of uterus, closed Os), I agreed this patient was diagnosed as Total Placenta Previa.

• Since patient have profuse bleeding (3 times changed of pad) and it was total placenta previa, the active management should be taken. Thus, elective cesarean section was the best for that.

Recommendation

• Transvaginal sonography, if available, may be used to investigate placental location at any time in pregnancy when the placenta is thought to be low-lying.

• The os-placental edge distance on TVS after 35 weeks’ gestation is valuable in planning route of delivery. When the placental edge lies >20 mm away from the internal cervical os, women can be offered a trial of labour with a high expectation of success. A distance of 20 to 0 mm away from the os is associated with a higher CS rate.

SOGC Clinical Practice Guidelines,

No 189, March 2007

References

1. Late Pregnancy Bleeding. Ellen S., Lawrence L. and Patrica F., American Family Physician, Volume 75, no 8; April 2007

2. The Diagnosis and Management of Placenta Previa. Mekawi S., ASJOG, Volume 3; February 2006

3. Diagnosis and Management of Placenta Previa. Lawrence O. et al, SOGC Clinical Practice Guidelines, No 189, March 2007

4. Placenta Previa : Distance to Internal Os and Mode of Delivery. Patrizia V. et al, American Journal of O&G; September 2009

5. Plasenta Previa. T.M.Hanafiah, 2004.

6. William Obstetrics 23rd Edition E-book

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