CASE PRESENTATION Lopez, Julianne

Ramos, Iso

General Objectives: To discuss a case of placenta previa To discuss the management of placenta

previa

General Data: 29 yo G2P1(1001) Married Roman Catholic 1st avenue, East rembo, Makati Admitted for the first time (Mar 6, 2012) AOG: 37 3/7 weeks

Chief complaint: Irregular uterine contractions

History of present Illness: LMP: June 17, 2011 AOG: 37 3/7 weeks AOG by LMP

36 5/7 by UTZ (24 5/7 weeks on 12/12/11) First trimester check up:

1st PNCU done at 2 months AOG at East Rembo health center

CBC and urinalysis done (normal) Regular intake of multivitamins, folic acid and

milk Denies history of illnesses, exposure to radiation

and viral exanthem

History of present Illness: 2nd trimester check up:

Regular visits with same health center Quickening at 4 months AOG (October,

2011) No tetanus toxoid given Regular intake of multivitamins and ferrous

sulfate

History of present Illness: 2nd trimester check up:

Pelvic UTZ (done on 12/12/11): Single, live, intrauterine pregnancy, cephalic,

24.6 weeks AOG by BPD and PL, placenta previa marginalis, grade I (left posterolateral area extending to the margin of the internal cervical os)

Denies vaginal bleeding

History of present Illness: 3rd trimester check up:

Regular visits at same health center Regular intake of multivitamins and ferrous

sulfate

History of present Illness: 3rd trimester check up:

Pelvic UTZ (done on 2/22/12): Single live intrauterine pregnancy, cephalic,

35.1 weeks AOG by BPD and FL, low lying placenta, grade 2-3 (left posterolateral area, extending to the lower uterine segment), Normohydramnios (19.1 cm)

Referred to OB OSMAK further evaluation of low lying placenta

Denies vaginal bleeding

History of present Illness: Irregular uterine

contractions No watery or

bloody vaginal discharge

Good fetal movement

Persistence of symptoms consult

1 hour prior to admission

Past Medical History: No history of hypertension, diabetes

mellitus, asthma, heart disease, cancer, thyroid disease

No previous surgery No previous hospitalization

Family History: Denies history of heredofamilial diseases

such as hypertension, diabetes mellitus, asthma, heart disease, cancer, thyroid disease

Personal and Social History: College graduate (BS Communication Arts) Securities clerk Married Resides with her husband and daughter non smoker non alcoholic beverage drinker Denies illicit drug use

Menstrual History: Menarche: 12 yo Interval: every 28-30 days Duration: 5 days Amount: 4 moderately soaked pads/day No Dysmennorhea

Contraceptive history:- No intake of oral contraceptive pills- No IUD- No injectables- No natural family planning method- (+) withdrawal method

Sexual History: Age of 1st coitus: 15 yo 1 sexual partner, monogamous Works as a security guard No post coital bleeding No dyspareunia No leukorrhea Pap smear: November 2011

unremarkable

OB History: G1 (2003)

Previous CS for CPD Outcome: term female, BW=2925 g Complications: treated for sepsis for 1 week

G2 (2011) Present pregnancy

Review of Systems:No loss of consciousness, weakness, feverNo difficulty of breathing, chest pain,

coughNo constipation, loose bowel movementNo dysuria, hematuria

Physical Examination: General survey: alert, coherent, not in

cardiorespiratory distress Vital signs: BP 100/60 CR 89 RR 21 T

37.1oC Anthropometrics:

BMI: 22.31 Weight: 60 kg Height: 164 cm

Physical Examination: HEENT: anicteric sclerae, pink palpebral

conjunctivae, (-) tonsillopharyngeal congestion Chest: symmetric chest explansion, clear and

equal breath sounds, no rales/crackles, no wheezes

Cardiac: adynamic precordium, apex beat at 5th intercostal space, left mid clavicular line, normal rate, regular rhythm, no murmurs

Extremities: no cyanosis, no edema, good skin turgor, full and equal pulses

Physical Examination: Abdominal examination:

Globular Fundic height: 31 cm Fetal heart tone: 140bpm, right EFW: 2900-3100 grams Leopold’s maneuver:

Fundus occupied by the fetal head Fetal back at right, fetal small parts on the left Fetal breech at the level of pubis symphysis

Physical Examination: Normal looking external genitalia,

nulliparous introitus Speculum examination: cervix

violaceous, smooth, no mass, erosions, polyps, no pooling of amniotic fluid, no bleeding per os

Internal examination: not done

Admitting Impression:G2P1(1001) PU 37 3/7 weeks age of

gestationBreech, not in laborLow lying placentaPrevious CS I for CPD

Plan: Diagnostics and Therapeutic For admission For CBC with PC, HbsAg urinalysis, ABO

typing For LTCS II for low lying placenta Secure 2 units of blood for possible blood

transfusion

Intra-operative findings:

The uterus is enlarged to AOG The lower uterine segment was formed Delivered a live baby boy AS 999, 38 weeks by

pediatric aging, AGA Placenta was implanted posteriorly with its edge

partially covering the internal os and appeared grossly normal with 3 vessel umbilical cord

The rest of the pelvic organs were grossly normal Estimated blood loss of 700cc

Outcome and Final diagnosisG2P2(2002) PU 37 3/7 weeks age of

gestation by LMP delivered by LTCS II to a term live baby boy AS 9,9 BW 2.95 kg BL=47cm 38 weeks AGA

Placenta previa marginalisPrevious CS I for CPD

CASE DISCUSSION: PLACENTA PREVIA

030612 Lopez, Julianne YL9-OBGYNECOLOGY

Placenta Previa Placenta that is implanted over or very

near the internal cervical os Normal: placenta implanted in the

fundus 1 in 300 deliveries (US) 1 in 360 deliveries (Philippines_

Abnormalities in placental location

Risk factors: Advanced maternal age Multiparity Multifetal gestation Multiple induced abortions Puerperal endometritis Prior CS Smoking Elevated maternal alpha feto protein

Significance of Placenta Previa 0.3-0.5% of all pregnancies (US) Perinatal mortality 2-3% (US) Maternal morbidities:

Antepartum bleeding Need for hysterectomy Need for blood transfusion Septicemia Thrombophlebitis

Causes of Obstetric hemorrhage:

Pathophysiology At term or during labor:

Retraction of lower uterine segment + dilatation of cervix

Spontaneous premature separation of placenta from the spongy layer of decidua

Hemorrhage

Pathophysiology 1st theory:

Primary implantation is at the isthmus Expansion of implantation site may occupy

lower uterine segment including nternal cervical os

2nd theory: Implantation site at the fundus but because of

damage done from previous pregnancies, there is unidirectional growth towards the isthmus

Signs and Symptoms

Placenta Previa

Placenta Abruptio

Hemorrhage Painless

Ceases spontaneously

May be painfulMay be concealedDoes not cease spontaneously

Abdominal pain

None May be present

Uterine contractions

None Frequent

Uterine hypertonus

None None

Why does it bleed? Dilatation of the internal os result inevitably

in tearing of placental attachments Inherent inability of myometrial fibers of

the lower uterine segment to contract and constrict the avulsed vessels

“Placental Migration” Relative upward shift of the placenta due

to differential growth of the lower segment that is continuous into the late trimester Placenta in the 2nd trimester are low lying in

45% of cases By term less than 1% remains low lying 88% of TPP will resolve by term and only

12% will remain at high risk

Management - diagnostics: Transvaginal/transabdominal UTZ

Sensitivity is >95% Transvaginal more accurate than

transabdominal Look for an abnormally positioned placenta

(accreta, increta, percreta)

Ultrasound Placental edge exactly reaching the internal

os is described as 0 mm Placental edge may extend 0-20mm away

from the os

Ultrasound Placental edge my extend from 0-20 mm

beyond the os and maybe reported as mm overlap

Management Do not do internal exam!

May cause severe hemorrhage Serial UTZ to assess fetal growth and

document resolution (can convert to a normally positioned placenta)

Management Preterm

If no active bleeding observation If with MINIMAL BLEEDING

Administer tocolytics Administer corticosteroids if still under 37

weeks Replacement of blood loss Bed rest

If with moderate to profuse bleeding CS

Management Term

Cesarean delivery – Delivery method of choice >2cm away can be offered a trial of labor with

high expectation of success <2cm is associated with higher CS rate – 80-

90% Any degree of overlap (>0 mm) after 35 weeks

is an indication for CS

Management Term

Cesarean delivery – Delivery method of choice Classical cesarean

section --> atraumatic extraction of fetus

Low transverse incision – as long as longitudinal fetal lie, placenta not anterior

Complications• Placenta accreta – due to the thin,

poorly formed deciduas of the LUS• Postpartum hemorrhage – the LUS is

only weakly contractile and maybe ineffective in hemostasis• Risk factors: advanced maternal age,

previous Cs, sponge-like sonographic findings in cervix

Intrauterine growth restriction Abruptio placenta

Breech presentation Buttocks of fetus enters the pelvis before the head

Risk factors: Hydramnios High parity with uterine relaxation Multiple fetuses Oligohydramnios Hydrocephaly and anencephaly Previous breech delivery Uterine anomalies Placenta previa Fundal placental implantation Pelvic tumors

Definitions Frank breech – lower extremities flexed

at the hips and extended at the knees Complete breech – one or both knees

are flexed

Incomplete breech – one or both hips are not flexed, and one or both feet or knees lie below the breech

Footling breech – incomplete breech with one or both feet below the breech

Abdominal Examination Leopold’s maneuver – to ascertain fetal

palpation Accuracy varies Must confirm with sonography LM 1 – Hard, round, ballotable fetal head occupying

the fundus LM 2 – Fetal back on one side of the abdomen, small

parts on the other LM 3 – If not engaged, breech is movable above the

pelvic inlet LM 4 – If engaged, shows firm breech beneath the

symphysis pubus

Vaginal Examination Frank breech

Both ischial tuberosities, sacrum, anus palpable

Complete breech Feet felt alongside buttocks

Footling One or both feet are inferior to the buttocks

Prognosis Maternal morbidity and mortality

Genital tract laceration Rupture of the uterus Uterine atony Post partum hemorrhage Infection (manual manipulations)

Prognosis Perinatal morbidity and mortality

Preterm delivery Congenital anomalies – 6.3% of breech

presenting fetuses Birth trauma

Fracture of humerus and vaginal delivery Upper extremity palsies – brachial plexus