|



By:
Dr. Meyzadel L. Bergado
O Labrado, Jamela a 21 y.o female married,
housewife, Roman Catholic presently living in
Lila, Bohol was admitted for the second time
in GCGMH for vaginal bleeding
 |




O No history of any allergies as to food or meds
O Non--asthmatic, non
Non non--diabetic, non-
non-hypertensive
O No history of any recent hospitalizations or
illnesses
 |

 



O High school graduate
O Non smoker
O Non alcoholic beverage drinker
 m



O No known heredofamilial diseases
 x


O Menarche @ 10 y.o
O Menses are at regular monthly interval that
lasted 3 days
O Consumed 2-3 napkins/day
O No dysmenorrhea
O No use of any form of contraceptions
O No history of any STI
O G1 = 2006
2006,, FT, NSD, GCGM
= 6.7 lbs
O G2 = present pregnancy
= LMP ± 12 12//6/07
= EDC ± 10/ 10/13/
13/08
= AOG ± 37 22//7 wks
Prenatal care started at 3 mos AOG with regular monthly
visits at the local health unit.
Good compliance to supplemental meds
BP ranges 110
110--120
120//80-
80-90 mmHg during PNC
UTI at 7 mos AOG and was given an unrecalled
antimicrobials to be taken 3x a day for 1 week
 Ä|
Two hours PTA, sudden onset moderate
vaginal bleeding without any associated
symptoms like hypogastric and lumbosacral
pains were noted. This prompted the patient to
be brought to GCGMH to seek medical help.
At the ER, one episode of profuse vaginal
bleeding was noted, thus admitted.
 |
O General Survey
O Conscious, coherent, ambulatory, NIRD
O Vital signs
O BP = 120
120//80 mmHg RR = 18 bpm
O HR = 82 T = 37.
37.1 C
O HEENT
O Anicteric sclerae, pinkish palpebral conjunctiva
O Neck
O (-) LAD, ((--) neck muscles retractions
O C/L
O CBS, (-
(-) adventitious sounds
O Cardiovasc
O Adynamic precordium, (-
(-) murmur, RRNR
O Abdomen
O Globular , FH = 29 cm, FHT = 141 bpm, ((--)
tenderness
O Speculum exam
O (-) active bleeding,
O Extremeties
O (-) edema, ((--) varicosities
 

Pregnancy Uterine 37 2/
2/7 wks AOG, CNIL, R/I
Placenta Previa
 2






 


|




O Frequent association of O No association with preeclampsia
preeclampsia or hypertension
from any cause O Repeated warning hemorrhages
O A single attack of vaginal often occurring over a period of
bleeding, which usually continues weeks
until delivery
O Local uterine tenderness,
hypertonic ³woody´ uterus in a O Usually no abdominal pain
concealed abruption O Normal uterine tone and usually
O patient usually in labor no tenderness
O Patient rarely in labor
O Presenting part often engaged O Presenting part above brim,
malpresentation usually found
O Presenting part maybe difficult to O Fetal parts usually palpable
palpate
O placenta demonstrated O Placenta demonstrated
in upper uterine in lower uterine
segment by ultrasound segment by ultrasound
O Double set-up reveals O Double set-up reveals
no placenta within 5 cm placenta implanted in
of internal os the lower uterine
segment
 þ


O Venoclysis was started with D5
D5LR 1 L @ 30
gtts/min
O Labs: CBC typing, HBS-
HBS-Ag det stat
UA
O Baseline CTG
O FHT monitoring q 4 hrs
O CBR w/o TP
O For transabdominal UTZ
O HBS-Ag ± nonreactive
HBS-
O Baseline CTG ± reactive NST
O CBC
O WBC ± 11 K/uL
O RBC ± 4.02 M/uL
O Hgb ± 11
11..2 g/dL
O Hct ± 33.
33.8 %
O Platelet ± 246 K/uL
O Bld Type ± B+
O UTZ
O Single live intrauterine pregnancy, cephalic
presentation
O Sonar age 34 weeks and 0 day by fetal biometry
O Placenta Previa Totalis Posterior, Grade III
O AFI = 9.7 cm
O EDC = 11/
11/06/
06/08
O EFW = 2390 gms
 r  



11:25 a.m
11:
O 2 units of FWB of patient¶s bloodtype properly
screened and crossmatched were on standby
O Monitored for any signs of profuse vaginal
bleeding or any other unusualities
O FHT monitoring was continued q 4 hrs
3:20 pm
O (+) vaginal bleeding, minimal with mild uterine
contractions
O Active FM
O Scheduled for emergency CS
O Consent
O OR and anesthesiologist informed
O Pedia informed
O Cefazolin 1 gm IVTT (ANST) on call to OR
O Abdominoperineal prep
O VS, FHT and UC were monitored q 15 min
9:15 pm
O Post
Post--op
O Cefazolin 1 gm IVTT q 8 hrs
O Ranitidine 50 mg IVTT q 8 hrs
O Tramadol HCl 50 mg IVTT q 8 hrs x 4 doses
O Ketorolac 30 mg IVTT q 8 hrs
O 2 units of PRBC properly screened and
crossmatched were transfused
O Pre--op dx
Pre
O G2P1(1001
1001)) PU 37 33//7 wks AOG, CILL, Placenta
previa totalis, posterior

O Post--op Dx
Post
O G2P2(2002
2002)) PU 37 33//7 wks AOG, Cephalic,
Placenta Previa Totalis, posterior
 ½  



O S
O (+) flatus
O Minimal vaginal bleeding
O Afebrile
O (-) dizziness
O O
O BP = 120
120//70
O Pale palpebral conjunctiva
O Post--op wound : dry, non erythematous
Post
O Abdomen: NABS
O A
O S/P primary LSTCS PU 37 wks AOG CILL, P. Previa totalis, post x 13 hrs post
post--op
O P
O Cont IVTT meds
O For repeat Hct
O General liquid diet
O Wound dressing
 [  



O S
O (+) BM
O Afebrile
O Scanty vaginal bleeding
O No dysuria
O O
O BP ± 110
110//70 mmHg Hct -27 %
O Pale palpebral conjunctiva
O Uterine size: 3 FB below umbilicus
O post--op wound : dry, non erythematous
post
O A
O Anemia Severe
O P
O For BT 1 unit PRBC screened and crossmatched
O P.O meds
O DAT
O Wound dressing
O Encourage ambulation
 ·  



O S
O No subjective complaints
O Afebrile
O No dysuria
O Scanty vaginal bleeding
O O
O BP ± 110
110..70 Hct ± 36%
36%
O BPE : I- parous A ± (-) tenderness,
U- 4 fb below umbilicus (-) mass
C ± 1 cm dil, soft D ± minimal lochial
discharges
O A
O improved
O P
O MGH with homemeds
O advised
 2


O Placenta previa
O Abnormal implantation of the placenta
O Implantation is in the lower uterine segment
 ë
O Total Placenta previa
O Partial placenta previa
O Marginal placenta previa
O Low--lying placenta
Low
O Incidence :
O 1 of 167 1 of 327 pregnancies
O Etiology:
O unknown
O Risk factors:
O Hx of prior C/S
O Hx of uterine curettage
O Increasing maternal age
O Increase parity
O Closely spaced pregnancies
O Tumors distorting the contour of uterus
O Endometritis
O smoking
 

 
term/onset of labor

retraction of lower uterine segment

Spontaneous premature rupture of the placenta from the spongy layer of the
decidua

Tearing into the maternal blood sinuses

Hge of the spiral arterioles in the decidua

bleeding
O Signs and symptoms
O Painless vaginal bleeding
O Diagnosis
O Placental localization of transabdominal UTZ
 @






Severe bleeding C/S

> 36 wks or
mature L/S ratio
Moderate bleeding AOG PT unstable
<36 wks
immature L/S ratio intensive care
beta mimetics
corticoids
BT
PT stable
>36 wks
mature L/S ratio
Mild bleeding AOG

<36 wks
immature L/S ratio expectant mgt
þ















O Inpatient observation for 72 hrs without vaginal
bleeding
O Stable serial hct > 35%
35%
O Reactive NST at the time of discharge
O Telephone--available 24-
Telephone 24-hr transportation between
home and hospital
O Patient¶s and family¶s comprehension of potential
complications
O Weekly clinical ff-
ff-up until delivery including serial
hgb and repeat UTZ