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DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
CLINICO-PATHOLOGICAL CONFERENCE
IN
OBSTETRTICS
Francisco, Jeff-rayFrancisco, ReinardGarcia, JenniferGarcia, Maria ReginaGarcia, Marla MarieGarcia, Roman Karlo
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CASE
32 year old female G4P2 (2012) AOG of 38th 2/7 weeks married, housewife, Roman Catholic, high school graduate LMP: November 6, 2008EDC: August 13, 2009
Chief Complaint: vaginal bleeding
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HISTORY OF PRESENT ILLNESS
Three hours PTA- Brownish discharge soiling her underwear- Vaginal bleeding of bright red blood- 4 fully soaked pads- Irregular contractions
frequency: 3-4 times/hrduration: 20-40 secondsintensity: moderate
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OBSTETRIC HISTORY
• G1- NSD; fullterm• G2- Spontaneous abortion; S/P completion curettage• G3- Emergency CS for chromioamnionitis; fullterm no feto-maternal complications G4 (present pregnancy)- With prenatal care- UTI at 30 wks AOG; treated with cefalexin
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PAST HISTORY
- Coitarche at 24; (-) coital bleed/pain, STI- OCP use for 2 years (2005-2007) - (-) allergies, family history of HTN, DM,
lung/cardiovascular diseases, cancer, - (+) asthma, dysmenorrhea- Non-smoker; non alcoholic beverage
drinker
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PHYSICAL EXAMINATIONGeneral Survey: -Conscious, coherent, ambulatory, NIRD.Conscious, coherent, ambulatory, NIRD.
Vital Signs: BP- 110/70 mmHg, BP- 110/70 mmHg, HR- 96 bpm, HR- 96 bpm, RR- 28 cpm, RR- 28 cpm, T- 36.5°CT- 36.5°C
HEENT: -Anicetric sclerae, pink conjunctivae; No Anicetric sclerae, pink conjunctivae; No tonsillopharyngeal congestion and cervical tonsillopharyngeal congestion and cervical lymphadenopathy.lymphadenopathy.-Breasts: Symetric, no masses, tenderness, or Breasts: Symetric, no masses, tenderness, or nipple discharge.nipple discharge.
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CVS: - Adynamic precordium, normal rate, regular rhythm,
distinct S1 and S2, no murmurs.Chest and Lungs: - Equal chest expansion, clear breath sounds.Abdomen:- Globular, prsence of linea nigra,
FH= 33cm, FHT= 140’s. Leopolds-
I=breech II= fetal back maternal leftIII= Vertex, unenganged.
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Pelvic Exam:
Inspection- Normal looking external genitalia, with continuous trickling of blood.
Speculum and internal exam both not done.
Extremities: - With Grade 2 bipedal edema, pinkish nailbeds.
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8/1/09 8/3/09
Hgb 103 124
Hct 31 36
RBC 3.7
RBC morphology
Slightly hypochromic, normocytic
CBC result
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ADMITTING DIAGNOSIS
Uterine pregnancy at 38 and 2/7 weeks AOG by LMP, Cephalic presentation but not in
labor, G4P2 (2012) with 1 previous CS for chorioamnionitis in 2007;
Placenta previa, in hemorrhage.
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COURSE IN THE WARDS
- on admission; underwent emergency classical cesarean section 1 with hysterectomy
- Delivery of a live full term baby girl (birth weight of 3.335 kg, Birth length of 52 cm and APGAR score of 9 and 9)
- Blood loss of approximately 2,100 cc and blood transfusion with 3 units of PRBC
- The patient had stable VS at the Recovery Room, and first post-operative day.
- The patient recuperated well until her discharge on the 4th post-operative day.
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SUBJECTIVE DATA- 32 y/o female- G4P2 (2012); AOG of 38 2/7 weeks- Vaginal bleeding- Irregular contractions of moderate intensity- Good fetal movement- History of spontaneous abortion; S/P completion
curettage- Emergency CS- Non-smoker; non-alcolic beverage drinker
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OBJECTIVE DATA
- Normal VS
- Continuous trickling of blood on pelvic exam
- FH of 33cm; FHT of 140s (normal)
- Bipedal edema, grade 2
- CBC:
low Hgb, Hct and RBC count
slightly hypochromic, normocytic
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DIFFERENTIAL DIAGNOSIS:Abruptio placenta
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ABRUPTIO PLACENTARULED IN: Risk factors:- increasing maternal age, - multiparity Clinical presentation:- Uterine bleeding Initially brownish discharge followed by bright red
blood bleed- Presence of Uterine contractions
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ABRUTIO PLACENTARULED OUT- absence of unremitting abdominal/back pain- Absence of uterine tenderness, often hypertonic
uterus - Absence of other risk factors;
(hydramnios, diabetes mellitus, thrombophilias, uterine tumors like leiomyoma, nephropathy, fibroids, cigarette smoking, alcohol consumption of at least 14 drinks per week, cocaine use, abdominal trauma and maternal type O blood)
- (-) signs of fetal distress
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PRIMARY IMPRESSION:Placenta previa
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PLACENTA PREVIARULED IN: Risk factors- Increasing maternal age- Multiparity- History of abortion, S/P completion curettage- History of CS, chorioamnionitis Clinical presentation- Painless, persistent vaginal bleeding; bright red
blood- Presence of contractions- (-) signs of fetal distress; unangaged fetal head
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Placenta Previa
- Condition in which the placenta implanted in the lower uterine segment within the zone of effacement and dilatation of the cervix
- Leading cause of 3rd trimester bleeding
- Occurs in 1:200 live births
- often associated with placenta accreta.
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Diagnosis and Plan of Management
Diagnosis: Clinical presentation:- Painless, persistent vaginal bleeding- (-) signs of fetal distress; unengaged fetal head- (-/+) uterine contractions Presence of Risk Factors:- Increasing maternal age, Multiparity, multiple gestation,
abnormal vascularization of the endometrium caused by scarring or atrophy from previous trauma, surgery or infection, smoking, alcoholic beverages drinking…
definitive diagnosis can be made via a- transabdominal UTZ, or - transvaginal ultrasound
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Diagnosis and Plan of Management
Management: 2 possible approaches:
1. cautious surveillance (watchful waiting)
2. active approach
- Delivery of the baby Management prior to delivery:
- correction of blood loss with intravenous fluids
- Blood transfusion
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References1Kainer F, Hasbergen U. Emergencies Associated With Pregnancy and Delivery: Peripartum
Hemorrhage. Dtsch Arztebl Int. 2008 September; 105(37): 629–638.
2Lala ABH, Rutherford JM. Massive or recurrent ante partum haemorrhage. Current Obstetrics and Gynaecology. 2002; 12: 226–230.
3Kiondo P, Wandabwa J, Doyle P. Risk factors for placenta praevia presenting with severe vaginal bleeding in Mulago hospital, Kampala, Uganda. Afr Health Sci. 2008 March; 8(1): 44–49.
4Neilson JP. In: Ante partum Haemorrhage. Dewhurst text book of Obstetrics and Gynaecology for post graduate students. 6th Ed. Dewhurst , editor. London: Blackwell; 1999.
5Cunningham FG, et al. Williams Obstetrics. 22nd ed. USA: McGraw-Hill Companies, Inc. 2005.
Sakornbut E, et al. Late pregnancy bleeding. American Family Physician. 2007;75:1199.
The Merck Manual, 18th Edition. Abnormalities of Pregnancy: Abruptio placentae; Placenta previa. 2006:2191-2; 2196-7
Current Diagnosis and Treatment: Obstetrics and Gynecology, 10th edition
Robbins Pathologic Basis of Disease. 7th edition.
Board Review Series Pathology. Schneider 3rd edition.
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