Case study from Hospital Antonio Lorena, within the obstetrical service.

HPI: 37 yo pregnant female of 32 weeks and 4 days gestation presents to the emergency
room because of significant vaginal bleeding over the past hour. The patient also reports
some contractions, but denies any continuing abdominal pain. She denies any recent
trauma.

Past Obsetrical History:

-G3 P2002 (3 gestations, 2 full term, 0 pre-term, 0 miscarriages, 2 currently living)
-2 previous SVDs (spontaneous vaginal delivery)
-Last birth was 9 years ago by SVD, weighed 3800 grams
-No previous obstetrical complications or morbidity

Past Medical History: None

Past Surgical History: None
Family History: Unremarkable, no history of twins or multiple gestations
Social History: Patient lives with her husband in the Santiago district of Cuzco. Denies
any smoking, alcohol or other drug use during her pregnancy. Denies any spousal abuse.
Completed elementary school, currently works as a housewife. Low economic status.

Current Gestational History:

-G3 P2002
-Date of Last Menstration: 4/11/11
-Estimated Date of Delivery: 1/22/12
-Estimated Gestational Age (based on dates): 32 4/7 weeks
-No prior antenatal care

Physical Exam:
Vital Signs: Stable (BP 110/70, P 72)
General Appearance: No apparent distress, appeared clinically stable
Skin: Elastic, capillary reflex < 2 seconds

Uterine Height: 30 cm
Fetal Lie: Longitudinal
Contractions: Present
Fetal Heart Tones: 144 x minute
 Cervical Exam: Deferred

Brief Differential Diagnosis:

Placenta Previa
Placental Abruption
Displacement of Cervical Mucous Plug
Premature Rupture of Membranes
Cervicitis
Vaginitis/Vulvovaginitis

Diagnostic Tests: Transabdominal Ultrasound (see below)

Number of Gestations: 1
Lie: Longitudinal
Presentation: Cephalic
Position: Right
Fetal Heart Tones: 144 x minute
Fetal Movements: Present
Placenta: Total occlusion of internal cervical os

Discussion: Based on this patients clinical presentation, placenta previa was suspected
and further confirmed by transvaginal ultrasound. Placenta previa is defined as the
presence of placental tissue over or adjacent to the cervical os, and can be described
within a variety of possibilities:

Total placenta previathe internal 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 placentathe placenta is implanted in the lower uterine segment such that the
placental edge does not reach the internal os, but is in close proximity to it
Vasa previathe fetal vessels course through membranes and present at the cervical os
Diagram showing different categorizations of placenta previa.
Classically, the clinical presentation of placenta previa is painless vaginal bleeding in the
second or third trimester. In contrast, placental abruption, classically presents
with painfulvaginal bleeding.
 Risk Factors:
Below is a list of several risk factors that are associated with placenta previa. Our patient
had several, including increased parity, increased maternal age, and residence in higher
altitude.

List of associated risk factors for placenta previa. From "Bates Obstetrics."

Diagnostics:
Transabdominal (96-98% sensitivity) or transvaginal (almost 100% sensitivity)
ultrasounds are the diagnostic methods of choice for confirming placenta previa.
Ultrasound can not only diagnose placenta previa, but further define it as complete,
partial, or marginal, which can have implication in how to manage the patient. Placenta
previa that is diagnosed before 24 weeks of gestation should be managed conservatively,
and a repeat sonogrophy should be done between 28 and 32 weeks gestation. Many
cases of placenta previa that are diagnosed in the second trimester will resolve by the
third trimester.

Cervical Examination:
A cervical examination was deferred in our patient, as appropriate management.
Because of the risk of provoking life-threatening hemorrhage, a digital examination
is absolutely contraindicated until placenta previa is excluded. Such digital cervical
examination is never permissible unless the woman is in an operating room with all
the preparations for immediate cesarean deliveryeven the gentlest digital
examination can cause torrential hemorrhage.

Management:
Women with a previa may be considered in one of the following categories:

The fetus is preterm and there are no other indications for delivery
The fetus is reasonably mature
Labor has ensued
Hemorrhage is so severe as to mandate delivery despite gestational age.
Although our patient was clinically stable, her bleeding could not be appropriately
controlled. It was also felt that her fetus was reasonably mature, and the decision was
made to do an emergency cesarean section.
Furthermore, as part of management, large-bore intravenous access and baseline
laboratory studies (hemoglobin, hematocrit, platelet count, blood type and screen, and
coagulation studies) should be obtained. If the patient is less than 34 weeks gestation,
administration of antenatal corticosteroids should be undertaken (as was done in our
patient) as well as an assessment of the facilitys emergency resources for both the mother
and the neonate.