MS

34, filipino
Married
Tuao, Cagayan
Feb 20, 2016
Cc: vaginal bleeding

HPI
1 day PTA(+) vaginal spotting
not accompanied by abdominal pain
and fever.
no consult and no medications
taken.

Few hours PTC,

(+) vaginal bleeding
2 pads fully soaked
accompanied by uterine contractions,

Hence decided to seek consult to CVMC.

Past medical history:

No previous confinement nor surgery
No hypertension
No Diabetes mellitus
No Bronchial asthma
No allergies
No history of STI
Family History:
No hypertension
No cardiac disease
No Renal disease

Personal and social history

highschool graduate
housewife
Non smoker
Non alcoholic
Denies illicit drug use

Menstrual history:
Menarche- 12y/o
Interval- every 30 days
Duration- 4-5 days
Amount- 3 pads per day
No dysmenorrhea
Coitarche- 26yo to husband
1 sexual partner- no history of STI
No contraception
(-) dyspareunia

OB History:
G2P1 (1001)
LMP: JUNE 17, 2015
AOG: 35 3/7 DAYS
G1- 2007, term, NSD, CVMC, 3000g,
male, no complications of delivery,
living
G2- present pregnancy

PNCU: local health center 6x

MVS: ferrous sulfate tab OD
No maternal illness
No BP elevations

Physical exam

GENERAL APPEARANCE:
Conscious, coherent, not in

cardiorespiratory distress
VITAL SIGNS:
BP: 120/80
PR: 72 bpm
RR: 21 cpm
T: 36.1 C

SKIN: No jaundice, no cyanosis, no

pallor
HEENT: Anicteric sclerae, pinkish
palpebral conjunctivae, no nasoaural
discharge, no cervical
lymphadenopathy
CHEST/ LUNGS: Symmetrical chest wall
expansion, no retractions, clear breath
sounds
HEART: Adynamic precordium, normal
rate, regular rhythm, no murmurs, PMI
heard at 5th ICS LMCL

Abdomen:
Globular, Normoactive bowel sounds, soft,
nontender, (+) striae gravidarum,
Fundic height: 28 cm, EFW= 2635g
FHT: 140 BPM
LM1: buttocks occupy the fundus
LM2: fetal back is on the left maternal side
LM3: fetal head not engaged
LM4: head occupies the lower pole
Genitalia: grossly female, normal external
genitalia
Internal examination not done
Extremities: no deformities, no edema, full and
equal pulses

Review of systems:
No headache
No dizziness
No chest pain, no DOB

COURSE IN THE WARD

DAY OF
ADMISSIO
N
FEB 21,
2016
1:50 AM
Cc:
vaginal
bleeding

BP: 120/80
CR: 72 bpm
RR: 21cpm
T: 36.1 C
Conscious
coherent, no
jaundice,
nopallor,
AS, PPC, SCE,
Clear breath
sounds, AP,
NRRR,
globular,
NABS,
nontender,
FH:28,
FHT=140
IE: not done

ASSESSMENT

PLANS

G2 P1 (1001),
PU, Term, 35
3/7 weeks
AOG, Preterm
in Labor,
Placenta Previa
with
hemorrhage

Admit to LR-DR
NPO
Dxtics: CBC, BT, UA
Txtics:
IVF: PLRS 1L X 8h,
Ampicillin- Sulbactam 1.5g/
IV ANST as SD 30 mins
prior to OR
For E Primary LSCS
VS & FHT q 15 mins
Secure 2 units PRBC,
properly typed for
standby OR use

COURSE IN THE WARD

5TH HOUR
POST OP
FEB 21,
2016
7:50 AM
no flatus
no BM
no fever

BP: 100/60
CR: 61 bpm
RR: 20cpm
T: 37.1 C
(-)pallor, pink
palpebral
conjunctiva,
Symmetric
chest
expansion,
clear BS,
AP,NRRR, no
murmur
Flabby, (+)
bowel sounds,
soft,
nontender

ASSESSMENT

PLANS

G2P1(1102)
PU, term,
cephalic
delivered,
Placenta
Previa totalis
with
hemorrhage,
Emergency
LSCS for
placenta
previa totalis
with
hemorrhage

May have sips of water,

then soft diet once with
flatus
Continue IVF D5LRS 1L
X 12h
Meds:
Fe fumarate + Vit B
complex tab, 1 tab BID x
30 days
Ascorbic Acid tab, 1 tab
OD x 30 days
Mefenamic Acid
500mg/cap, 1 capsule TID
Ampicillin- Sulbactam
750mg/tab, 1 tab q 8h
Encourage ambulation
Vs q 1

COURSE IN THE WARD

2nd POST
OP DAY
FEB 22,
2016
7:50 AM
no flatus
no BM
no fever

BP: 100/60
CR: 61 bpm
RR: 20cpm
T: 37.1 C
(-)pallor, pink
palpebral
conjunctiva,
Symmetric
chest
expansion,
clear BS,
AP,NRRR, no
murmur
Flabby, (+)
bowel sounds,
soft,
nontender,

ASSESSMENT

PLANS

G2P1(1102)
PU, term,
cephalic
delivered,
Placenta
Previa totalis
with
hemorrhage,
Emergency
LSCS for
placenta
previa totalis
with
hemorrhage

May have sips of water,

then soft diet once with
flatus
Continue IVF D5LRS 1L
X 12h
Meds:
Fe fumarate + Vit B
complex tab, 1 tab BID x
30 days
Ascorbic Acid tab, 1 tab
OD x 30 days
Mefenamic Acid
500mg/cap, 1 capsule TID
Ampicillin- Sulbactam
750mg/tab, 1 tab q 8h
For rpt CBC
Encourage ambulation
Vs q 1

COURSE IN THE WARD

ASSESSMENT

PLANS

3rd POST OP
DAY
FEB 23, 2016
7:50 AM

BP: 120/90
CR: 86 bpm
RR: 22cpm
T: 37.1 C

(+) BM,
flatus
no fever

(-)pallor, anicteric
sclerae, pink
palpebral
conjunctiva,
Symmetric chest
expansion, clear
BS,
AP,NRRR, no
murmur
Flabby,
normoactive bowel
sounds, soft,
nontender
(+) dry and well
coaptated wound,
no discharge

MGH today
Continue oral meds at home
OPD follow up
Daily wound care

Placenta Previa
placenta that is
implanted
somewhere in
the lower uterine
segment, either
over or very near
the internal cervical
os.

Placental migration- trophotropism

a low-lying placenta is less likely to migrate within a

uterus with a prior cesarean hysterotomy scar

approximately 40 percent of placentas that

covered the os at midpregnancy continued to do
so until delivery.

placentas that lie close to but not over the

internal os up to the early third trimester are
unlikely to persist as a previa by term

Placenta previa

the internal os is
covered partially or completely by placenta.

Low-lying placenta implantation in

the lower uterine segment is such that the
placental edge does not reach the internal
os and remains outside a 2-cm wide
perimeter around the os.
-marginal previa

Digital palpation in an attempt to

ascertain these changing relations
between the placental edge and
internal os as the cervix dilates
usually causes severe hemorrhage!

vasa previa- fetal vessels course

through membranes and present at
the cervical os

Incidence and risk factors

average 0.3 percent or 1 case per 300 to 400 deliveries

multifetal gestation- larger placental area

twin pregnancy- increased by 30 to 40 percent compared with that of

singletons

Multiparity

Previous abortion

1.3 percent for those with only one prior cesarean delivery, but it was
3.4 percent if there were six or more prior cesarean deliveries.

Increased maternal age

<19yo = 1 in 1660
>35 yo= 1 in 100

cesarean delivery for the first pregnancy had a

significant 1.6-fold increased risk for previa in the
second pregnancy

increased at least twofold in women who smoke carbon monoxide hypoxemia causes
compensatory placental hypertrophy and more
surface area

may also be related to decidual vasculopathy that

has been implicated in the genesis of previa.

Clinical features
Painless bleeding10 percent of women, particularly those
with a placenta implanted near but not over
the cervical os, there is no bleeding until
labor onset. Bleeding at this time varies
from slight to profuse, and it may clinically
mimic placental abruption
-begins without warning and without pain or
contractions

uterine
body
remodels to
form the
lower
uterine
segment

internal os
dilates

implanted
placenta
inevitably
separates

inability of myometrial fibers in the lower uterine segment to

contract and thereby constrict avulsed vessels
lacerations in the friable cervix and lower segment

Placenta previa vs Abruptio placenta

PLACENTA PREVIA

Nature of bleeding

ABRUPTIO PLACENTA

Painless, appareently
causeless and
recurrent
Usually revealed

General condition and

anemia

Proportionate to visible
blood loss

Ht of uterus

Proportionate to AOG

Feel of uterus
malpresentation

Soft, relaxed
common

Painful often attributed

to preeclampsia or
trauma
Revealed, concealed or
usually mixed
Out of proportion to
the visible blood loss in
concealed or mixed
variety
May be disportionate,
enlarged in concealed
type
Tense, tender, and rigid
unrelated

placentography

Placenta in lower
segment

Placenta in upper
segment

Vaginal exam

Placenta is felt on lower

segment

Placenta is not felt on

lower segment, blood
clots should not be
mistaken as placenta

Abruptio placenta- the premature separation of

a placenta from its implantation in the uterus.

Within the placenta are many blood vessels

that allow the transfer of nutrients to the fetus
from the mother. If the placenta begins to
detach during pregnancy, there is bleeding
from these vessels. The larger the area that
detaches, the greater the amount of bleeding.
Placental abruption occurs about once in
every 120 births

Speculum examination

Ultrasonography Transabdominal
Transvaginal

Clinical examination- double set up,

should not be done unless delivery is
planned

MRI

MANAGEMENT
3 factors:
fetal age and thus maturity; labor; and bleeding and its
severity

If the fetus is preterm and there is no persistent active

bleeding, management favors close observation

If tocolytics are given, they be limited to 48 hours of

administration

near term and who are not bleeding, plans are made for
scheduled cesarean delivery
- elective delivery at 36 to 37 completed weeks (NIH)

DELIVERY

Practically all women with placenta previa

undergo cesarean delivery
VERTICAL INCISION

low transverse hysterotomy is usually

possible, this may cause fetal bleeding if
there is an anterior placenta and the
placenta is cut through

for women whose placenta previa is implanted anteriorly at the site of a

prior uterine incision, there is an increased likelihood of associated placenta
accrete syndrome and need for hysterectomy

Maternal and Perinatal Outcomes

Preterm delivery continues to be a major cause of

perinatal death

Threefold increased neonatal mortality rate with

placenta previa that was caused primarily from
preterm delivery

increased risk of neonatal death even for

fetuses delivered at term. This is at least partially
related to fetal anomalies, which are increased twoto threefold in pregnancies
with placenta previa

Risk of placenta previa in second birth after

first birth cesarean section

Vaginal 1st births- 4.4 per 1000 births

Cs at 1st births- 8.7 per 1000