CASE REPORT April 2010
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CASE REPORTApril 2010
General DataME, 32y/o, G2P3 (2002), Filipino, married, from Tarlac
38 6/7 w AOG (by LMP)
Chief ComplaintScheduled for CS
Past Medical HistoryDenied hypertension, DM,
Bronchial asthma, thyroid diseaseNo previous surgeriesNo known allergies
Family HistoryDenied a family history of HTN,
DM, bronchial asthma, thyroid disease, cancer
Personal and Social HistoryNon- smokerNon- alcoholic beverage drinker
Gynecologic HistoryCoitarche: 26 y/o, 1 sexual
partnerNo vaginal discharge/symptoms
of STDUse of contraceptives for 1 year
after the birth of her second child (2005)
Menstrual History Menarche: 13 y/o Interval: 30 days, regular Duration: approx. 3-5 days No dysmenorrhea
LMP : July7, 2009 EDC: April 14, 2010
PMP: June 2009
Obstetric HistoryG1 (2002) delivered to a term,
live, baby boy; in QMMC via NSVD; BW 2.4kg; no recalled complications
G2 (2005) male, term, baby boy, at a lying-in clinic, via NSVD, no complications
G3 present pregnancy
Prenatal Check upFIRST TRIMESTER
◦(+) FPNCU ◦First ultrasound (15w AOG)◦CBC: HgB 13.6/Hct 0.4/WBC 9/RBC 4.28/
neutro 0.56/ lympho 0.33/eos 0.11◦Blood type B+◦HbsAg non-reactive◦UA: pale yellow, slightly turbid, pH6.5,
spec.grav. 1.015, (-) albumin, sugar; 2-5 pus cells, 0-2 rbc/hpf
◦Multivitamins + ferrous sulfate
Prenatal Check upSECOND TRIMESTER
◦(+) RPNCU◦(+) on Multivitamins and Ferrous
sulfate◦OGCT = 107 mg/dl (NV: 140)◦CBC: 12.5/36.6/12400/neutro
72/lymph19◦UA: light yellow, slightly hazy, (-)
glucose. WBC 13, casts 2◦Pap smear: benign cellular changes
Prenatal Check upTHIRD TRIMESTER
◦(+) RPNCU◦(+) on Multivitamins and Ferrous
sulfate◦USG: placenta previa totalis
History of Present Illness3 months PTA(~32 w AOG)
Sensation of pelvic fullnessDiagnosis of placenta previa
Schedule for elective CS
admission
Review of Systems
(-) dizziness, fainting spells, seizures
(-) fever(-) cough, colds, dyspnea, DOB(-) chest pain, palpitations(-) bipedal edema, no cyanosis
Physical ExaminationBP: 110/60mmHg HR: 94bpm, regular RR: 20/min,
regular T: 37.1 C
Eyes: pink palpebral conjunctivae, anicteric sclerae
Neck: supple neck, with no palpable neck mass, no neck vein engorgement
Breasts: appears engorged; no lesions or palpable masses
Lungs: symmetrical chest expansion, clear and equal breath sounds, no wheezing, rhonchi, or rales
Heart: adynamic precordium, normal rate, regular rhythm, no murmurs
Abdomen: globular, gravid, with prominent linea nigra, sparse striae albicans; FH 32 cm; FHT 150’s bpmL1 – breechL2 – right maternal side L3 – cephalic, unengagedL4
External pelvic examination: no lesions, redness, excoriations, hyper/hypopigmentations
IE: not done (c/i placenta previa)
Extremities: Full and equal pulses, no cyanosis, no edema
ASSESSMENT: Pregnancy uterine 38 6/7 weeks AOG, cephalic, not in labor; G3P2 (2002); placenta previa totalis for elective CS
The Placenta and Fetal Membranesthe development of the human
placenta is as uniquely intriguing as the embryology of the fetus
Links the mother and fetus by an indirect interaction with the maternal blood
blood bathes the outer syncytiotrophoblast, allowing exchange of gases and nutrients with fetal capillary blood within the connective tissue at the villous core
PLACENTA PREVIACondition wherein the placenta is
located over or very near the internal os
has four degrees:◦Total placenta previa◦Partial placenta previa◦Marginal placenta previa◦Low-lying placenta
Total placenta previaThe internal
cervical os is covered completely by placenta
Partial placenta previaThe internal os is
partially covered by placenta
Marginal placenta previaThe edge of the placenta is at the
margin of the internal os
Low lying placentaimplanted in the
lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it
The degree of placenta previa depends in large measure on the cervical dilatation at the time of examination.
Digital palpation to try to ascertain these changing relations between the edge of the placenta and the internal os as the cervix dilates can incite severe hemorrhage
EtiologyAdvancing maternal ageMultiparityPrior cesarian deliverySmoking = twice the risk
Pathophysiology:-scarring of placental site leading
to spread of implantation in subsequent pregnancies
-reason why placenta in placenta previa is more flat and occupies an area 20 to 40% larger
most characteristic event in placenta previa = painless hemorrhage,◦ near the end of the second trimester or after.◦ Abortions may result from such an abnormal
location of the developing placenta◦ Frequently has onset without warning, presenting
without pain in a woman who has had an uneventful prenatal course.
◦ In some women, particularly those with a placenta implanted near but not over the cervical os, bleeding does not appear until the onset of labor slight to profuse hemorrhage and clinically may mimic
placental abruption.
DDx: abruptio placenta vasa previa: velamentous
insertion of the umbilical cord
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