Inunlan

OB/GYNE CASE
P R E S E N TAT I O N
A D R A L E S , B I O N G , E N C L U N A , FA M I L G A N ,
G E S T O S O , G U P I TA , L A H AY L A H AY, L O Z A N O ,
M A N L O Z A , TA B A N A G , T H O TA , Z O E
 1 Objectives
.
CONTENTS
2 History of Present Illness

3 Physical Examination

4 Impression
 Differentials and Final
5
Diagnosis
CONTENTS

6 Course in the Wards

7 Case Discussion
 01
PART

Objectives
Objectives
At the end of this case presentation, we will be able to:

1. Discuss a case of placenta previa with ann initial presentation of watery vaginal discharge
2. Discuss differential diagnosis and highlight pathophysiology and causes of the disease
entity.
3. To be able to differentiate types placental abnormalities and risk factors.
4. To discuss medical and surgical management and potential maternal and fetal morbidity and
mortality outcomes.
5. Apply knowledge in the discussion of clinical case scenarios.
 02
PART

General Data
General Data
• A case of A.M. watery vaginal discharge.
• 40 years old
• Female
• Single
• Filipino
• Roman Catholic
• Born on August 08, 1979
• Residing at Argao, Cebu
• Admitted in Vicente Sotto
Memorial Medical Center
for the first time due to
Chief Complaint
• Watery Vaginal Discharge
Obstetric History

• G4P2 (2012)
• LMP – April 15, 2019
• PMP – March 03, 2019
Obstetric History

No.of Year Outcome Gestation Complications

Pregnancy Completed
G1 2010 NSD FT None
G2 2013 NSD FT none
G3 2013 abortion (no 12 weeks none
consult done,
no D&C done)
G4 Present pregnancy
Menstrual History

• Menarche at 16 years old

• Interval: regular
• Duration: usually lasting 3 days
• Amount: consuming 2-3 pads/day
• No associated symptoms
Sexual History

• Coitarche at 29 years old

• 1 sexual partner
• No history of contraceptive use
• No papsmear done
• No history of STI
Prenatal History

• First prenatal visit at 3 months AOG followed by

monthly prenatal visits (total of 5) in Argao, Cebu by
a Midwife
• Supplements given: Ferrous sulfate, Calcium
• No ultrasound done
• No laboratories done
Past Medical History

• Abortion at 3rd pregnancy (2013)

• Previously non-hypertensive; noted increase in BP
(140/100) at 7 months AOG, with maintenance meds of
Methyldopa 250 mg, compliant as claimed
• (-) DM
• (-) BA
• Allergies: shrimps
Family History

• (+) HTN-maternal side

• (-) DM
• No known heredofamilial disease
Personal and Social History

• Works as a server at a restaurant

• Non-smoker
• Drinks occasionally
• Denies use of illicit drugs
3 HISTORY OF PRESENT ILLNESS

Patient noted watery Patient sought consult at

vaginal discharge Carcar CPH, IE was done
associated with and showed dilatation at 4 Patient was given one
hypogastric pain with a
cm, 50% effaced, RBOW, dose of Dexamethasone
scale of 6/10, reported no
(+) placental tissues at and Ampicillin, patient
active bleeding, fever, or
recent trauma. the cervical margin, no was then referred.
active bleeding. VSM M C

10 hours In t e r im R e f e rred
PTA
 03
PART

Physical
Examination
 Physical Examination

• General survey:
• Patient was seen awake, conscious, oriented,
coherent, cooperative and not in respiratory
distress.
Vital Signs:

• BP:120/80mmHg Ht: 162.5cm

• PR: 89bpm Wt: 68kg
• RR: 18cpm BMI: 25.75kg/m²
• Temp: 36.5°C
• SPO2: 98%
Physical Examination

• SKIN:
• Good skin turgor, warm to touch, no pallor, no cyanosis
• HEENT:
• No visible masses seen, pink conjunctiva, anicteric
sclerae, no abnormal discharges and no visible masses
in ears and nose, no lymphadenopathies, trachea in the
midline and moves with deglutition, no bruits heard
Physical Examination

• CHEST/LUNGS:
• No use of accessory muscles, equal chest expansion, no
palpable masses, resonant, clear breath sounds on both
lung fields
• BREAST:
• No visible masses, no palpable masses, no abnormal
discharges, no abnormal dimpling, no color changes
Physical Examination

• CARDIOVASCULAR:
• Adynamic precordium, PMI at 5th ICS, dull,
distinct S1 and S2
Physical Examination

• ABDOMEN:
• Globular abdomen, with normoactive bowel sounds
(12clicks/min) ,FHT:140s, dull on percussion,
• non-tender upon palpation
• Fundal height: 28 cm
• L1: breech, L2: fetal back at left maternal side, L3:
non-engaged, L4: cephalic
Physical Examination

• GENITOURINARY:
• (-) KPS bilaterally
• Speculum exam:
• (-) Active Vaginal Bleeding
• (+) Blood Clots (approximately 30cc)
Physical Examination

• MUSCULOSKELETAL:
• Full range of motion, 5/5 on all extremities

• CENTRAL NERVOUS SYSTEM

• CNI-XII intact
• GCS 15
 04
PART

Impression
IMPRESSION
• G4P2 (2012) PREGNANCY UTERINE 34 1/7 WEEKS AGE
OF GESTATION BY LAST MENSTRUAL PERIOD,
CEPHALIC, IN PRETERM LABOR, PLACENTA PREVIA
MARGINALIS, PREMATURE RUPTURE OF MEMBRANE,
ADVANCED MATERNAL AGE
 05
PART

Differential
and Final
Diagnosis
DIFFERENTIAL DIAGNOSIS
1. CHORIOAMNIONITIS (Intrauterine Infection)
2. URINARY TRACT INFECTION
3. PLACENTAL ABRUPTION
Chorioamnionitis (Intrauterine Infection)
RULE IN RULE OUT
+ WATERY VAGINAL DISCHARGE No maternal fever
+ HYPOGASTRIC PAIN No fundal tenderness
No fetal tachycardia
The most common cause of:
+ Uterine Dysfunction (Premature
Labor)
 URINARY TRACT INFECTION
RULE IN RULE OUT

+ WATERY VAGINAL DISCHARGE NO DYSURIA

+ HYPOGASTRIC PAIN NO INCREASED FREQUENCY OF
URINATION
PLACENTAL ABRUPTION
RULE IN RULE OUT
WATERY VAGINAL DISCHARGE NO SIGNS OF FETAL DISTRESS
+ HYPOGASTRIC PAIN
+/- VAGINAL BLEEDING
(CONCEALED ABRUPTION)
 06
PART

Course in the
Wards
ADMISSION DAY

S O A P
12-10-19 Alert, coherent, oriented to time, G4P2 (2012) Pregnancy For 1’ LSTCS + BTL
• Watery vaginal date and person Uterine 34 1/7 weeks Complete Bed Rest
discharge T: 36.5’C AOG/LMP cephalic in preterm Routine Labs
PR: 89 bpm labor, Placenta Previa Meds:
RR: 18 cpm Marginalis, preterm premature Ampicillin 2g IVTT q 6 hours
BP: 120/80 mmHg rupture of membranes x 1 Dexamethasone 6mg
SP02: 98 % hour; Advanced maternal age Hydralazine 5mg IV q 15 mins
Abdomen: gravid, + striae, Secure 2 units of PRBC
normoactive bowel sounds, dull,
non-tender
FHT:140,
Fundal Height: 28cm,
EFW:2325 gm
L1:breech, L2: Fetal back, L3:
non-engaged, L4: cephalic

Genito-urinary:
+ watery vaginal discharge
 HOSPITAL DAY 1; POST-OP DAY 1

S O A P

12-11-19 Cooperative and alert upon G4P3 (2113) Pregnancy -Give10 ‘u’ oxytocin 30qtts
examination Uterine delivered, cephalic, IM
• Pain in post-operative T: 37.1’C preterm, livebirth via 1’ -Repeat CBC at 1pm
site PS:4/10 PR: 72 bpm LSTCS + BTL -Monitor vital signs q15 mins
• No flatus RR: 16 cpm Secondary to bleeding x1 hr, q30mins x1hr then q
• No bowel movement BP: 120/ 80 mmHg placenta previa, a live baby hourly
• Adequate urine output SP02: 99 % boy with AS: 7,9; BW: 2030g; -Monitor urine output
Abdomen: BS: 35wks,
+ 6cm post-surgical incision, dry
intact dressing, hypoactive bowel
sounds, soft, flabby, non-tender

CBC result at 4pm:

WBC=16.74 (H)
RBC= 3.68 (L)
HB= 104 (L)
HCT= 31.30 (L)
MCHC= 33.20 (L)
S O A P

Neutrophil= 84.90 (H)

Lymphocyte= 9.60 (L)
Eosinophil= 0.00 (L)

Intraoperative findings:
HOSPITAL DAY 2; POST-OP DAY 2

S O A P
12-12-19 Cooperative and alert upon G4P3 (2013) Pregnancy Uterine Meds:
• Pain in post-operative site examination delivered, cephalic, preterm, • Co-amoxiclav 625mg/tab BID
PS:3/10 T: 36.4’C livebirth via 1’ LSTCS + BTL PO
• flatus x 2 PR: 82 bpm Secondary to bleeding placenta • Celecoxib 200g/tab BID PO,
• No bowel movement RR: 19 cpm previa, a live baby boy with AS: PRN for pain
• Adequate urine output BP: 120/80 mmHg 7,9; BW: 2030g; BS: 35wks • MV+ FeSO4 tab OD
SP02: 98% • Amlodipine 10mg/tab OD PO if
Abdomen: BP >140/90 as needed
+ 6cm dry post-surgical incision,
normoactive bowel sounds, soft, -low salt, low fat diet
flabby, non-tend -remove FBC
- encourage ambulation
- wear abdominal binder
- daily wound dressing
-perineal care BID
HOSPITAL DAY 3; POST-OP DAY 3
S O
12-13-19 Cooperative and alert upon
• No significant subjective examination
complaints T: 36.6’C
• Positive flatus PR: 74 bpm
• positive bowel movement RR: 16 cpm
• Positive urine output BP: 120/80 mmHg
SP02: 99 %
Abdomen:
+ 6cm dry post-surgical
incision, normoactive bowel
sounds, soft, flabby, non-
tender
A P
G4P3 (2013) Pregnancy
Uterine delivered, cephalic,
preterm, livebirth via 1’
LSTCS + BTL
Secondary to bleeding
placenta previa, a live baby
boy with AS: 7,9; BW:
2030g; BS: 35wks
take home meds:
• Co-amoxiclav 625g 1tab
BID PO for 7 days
• Celecoxib 200g/tab BID
PO, PRN for pain
• .MV+ FeSO4 tab OD for 3
months
-daily wound dressing
- follow-up at OPD 1 week
after discharge
FINAL DIAGNOSIS
G4P3 (2013) Pregnancy Uterine delivered,
cephalic, preterm, livebirth via primary low
segment transverse cesarean section + bilateral
tubal ligation secondary to bleeding placenta
previa, a live baby boy with AS: 7,9; BW: 2030g;
BS: 35wks
 07
PART

Case
Discussion
Anatomy and
Histology
ANATOMY OF THE FEMALE
INTERNAL ORGANS
PLACENTA PREVIA
• A placenta that is implanted somewhere in the lower
uterine segment, either over or very near the internal
cervical OS.
• Noted more often in the second trimester, and
frequently resolves as the pregnancy progresses

• INCIDENCE RATE: average 0.3% or 1 case per 300-

400 deliveries
Demographic Factors:

• Maternal age
• Multiparity
• Cigarette smoking
• Uterine leiomyomas
Clinical Factors:

• One or more prior cesarean deliveries

• Prior uterine incision and placenta previa
• Maternal serum alpha-fetoprotein (MSAFP)
levels
• Assisted reproductive technology (ART)
TYPES/CLASSIFICATIONS
TYPES/CLASSIFICATIONS
Signs & Symptoms:

• Begin during late pregnancy (Third

Trimester)
• sudden, painless vaginal bleeding with
bright red blood (after 20 wks AOG)
• Sentinel bleed: bleeding without pain or
contractions
Complications
• MATERNAL: • FETAL:
• hemorrhage • fetal growth restriction

• fetal malpresentation • major congenital anomalies

• preterm premature rupture of the • respiratory distress syndrome

membranes (secondary to premature
delivery)
• vasa previa
• anemia
• velamentous insertion of the
umbilical cord
Pathophysiolog
y
RISK FACTORS
• Multiparity

• Prior cesarean delivery

• Uterine abnormalities that inhibit normal implantation ( eg, fibroids, prior curettage)

• Prior uterine surgery ( eg, myomec tomy) or procedure ( eg, multiple dilation and
curettage [D and C] procedures )

• Smoking

• Multifetal pregnanc y

• Older maternal age

• Trophectoder m

• Trophoblas t

• Placental Implantation on lower uterine segment

• Attachment and growth of the developing placenta

• Cover the cervical os

• Lower unterine segment remodeling and Cervical dilatation

• Spontaneous placental separation

• Hemorrhage
Diagnostic
Modalities
 Diagnostic Modalities

• All of the exams should be done with the following

precautions:
• In the operating room
• Under general anesthesia
• Cross-matched blood prepared
• Operating theater is ready for immediate CS
Diagnostic Modalities

• Physical Examination
• Radiologic
• Laboratory
 Diagnostic Modalities

• Speculum exam
• Exclude local lesions is only permissible
when placenta previa has been excluded by
UTZ
 • IE

• Placenta can be felt as a tough fibrous mass

• A cervical digital examination is done with the
patient in an operating room and with preparations
for immediate cesarean delivery. Even the gentlest
examination can cause torrential hemorrhage.
Transvaginal Sonography (TVS)

• Gold standard
• Accurate, cost-effective, safe and well
tolerated
• More superior than TAS
Transabdominal Sonography (TAS)

• Simple, precise and safe method

• Alternative to TVS
• Less accurate
Transabdominal Sonography (TAS)
• According to Leerentveld et.al and Sherman et.al.,
false-positive and false-negative rates of TVS were
1% and 2%, respectively, and rates of 7% and 8% for
TAS, respectively.
 Transperineal
Sonography
• Also accurate to localize
placenta previa (Hertzberg,
1992)

• Often deferred to the

accuracy, safety and
tolerability of TVS

• May compliment TAS and to

help eliminate false-positive
results using the TAS
method alone
Translabial
Sonography
• Effective and
accepted method
for assessing the
low-lying
placenta in the
third trimester
Magnetic
Resonance
Imaging (MRI)
• Excellent method
to identify
different types of
placental
abnormalities
• Unlikely to be use
as routine
evaluation and
replace
sonography
• Useful for
 LABORATORY TESTS

• Levels of fibrin split products (FSP) and fibrinogen

• PT/APTT
• Blood type and crossmatching
• CBC count
Management
3 factors to be
considered
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 Fetal age and maturity

 Labor
 Bleeding Severity
Surgical Intervention
Cesarean Delivery

Vertical Laparotomy
Incision
- rapid entry in cases with torrential
bleeding or operating space if
hysterectomy is required

Low transverse
Hysterotomy
- usually possible
- may cause fetal bleeding if placenta is
implanted anteriorly and is incised.
 Controlling Blood Loss
follwing placental removal
Interrupted 0-chromic suture
- if hemostasis at placental implantation site
cannot be obtained by adequate uterotonic
administration and pressure.
- 1 cm interval to form circle around the
bleeding portion of lower segment.
Others:
 Compression suture
 traversed and compressed the anterior
and posterior uterine wall
 Bakri or Fooley balloon tamponade alone or
coupled with compression suture
 Hemostatic Gel
 Bilateral uterine or iliac artery ligation
 Pelvic artery embolization
Hysterectomy

• done if conser vative methods fail

• Placenta previa—especially with an abnormally adherent placenta

• most frequent indication for peripar tum hysterectomy

Medical Management
TOCOLYTICS
• MgSO4
• May be used to administer antenatal
corticosteroids
• 48H-Bose and Collegues
CORTICOSTEROIDS

• Dexamethasone or Betamethasone
-promote the development of the lungs in
the fetus
ADRENERGIC AGONIST
• Terbutaline
-acts on beta2-receptors to relax uterine
contractions
-sympathomimetic vasopressor activity
THANK YOU
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