SPECIMEN CASE PRESENTATION WRITE-UP Obstetrics Case Summary Ms.

X is a 28-year old secondagravida Rhesus negative woman who presented to the emergency department with painless moderate vaginal bleeding at 34 weeks of gestation. History of Present Pregnancy Mrs. X had her last menstrual period on the 14th January 2008, computing her expected date of delivery to the 21st October 2008; her cycles having been previously normal and regular every 28-30 days. She did not give a history of any menstrual problems. Mrs. X had no problems during the first trimester other than slight nausea and occasional vomiting. This she accepted as normal, since it did not particularly distress her. The pregnancy was planned and she had started folic acid two months previous to conception. She continued to take folic acid throughout the first trimester. She did not give any history of vaginal bleeding during the first three months of pregnancy. She attended her family doctor at eight weeks of pregnancy, when a clinical examination was reported as normal. She attended the antenatal clinic and booked her confinement at Mater Dei Hospital during the second trimester at 14 weeks of gestation. All routine investigations taken [complete blood count; TORCH-Syphilis-Hepatitis C-HIV screen; blood glucose] at that

visit were normal. Her blood group was A Rhesus negative; antibody titre for anti-D was negative. A general clinical examination was normal. Uterine size corresponded to dates; fetal heart was audible using a doptone stethoscope. She had her first ultrasound scan at 18 weeks of gestation. She was told that while the fetus was normal, the placenta was low-lying and that she will need a further scan in the third trimester to correctly assess the significance of this. She had no problems during the second trimester and gave no history of any episodes of vaginal bleeding. She was started on haematinics at 14 weeks of gestation.

Mrs. X had no problems during the early part of the third trimester until 32 weeks of pregnancy. All routine antenatal visits were reportedly normal with adequate fetal growth and blood pressure. She was given a prophylactic anti-D injection [500 IU] at 28 weeks of pregnancy. Ultrasound scan done at 32 weeks of gestation confirmed the persistence of a low placentation; fetal growth and well being was normal; fetal presentation was transverse. In retrospect she mentioned that at about 31 weeks, she had an episode of mild vaginal spotting the morning after having had sexual intercourse. The bleeding was slight lasting only one morning and she did not particularly alarm herself. She was

advised to refrain from having sexual intercourse. History of presenting complaint She presented at 34 weeks of gestation with painless vaginal bleeding of sudden onset. The present episode of bleeding was sudden in onset and severe enough for the blood to trickle down her thighs. There were no associated features such as pain or any discomfort. On admission, the bleeding had settled to only a slight vaginal loss. The fetus was easily palpable; presentation was cephalic oblique with the back to the left. Fetal heart was audible and of normal rate. Symphyseal-fundal height was about 34 cm corresponding to the gestational age. There was no tenderness over the uterus. There were no signs of maternal cardiovascular shock; the patients pulse was 80 beats per minute, blood pressure 110/70 mmHg. An ultrasound scan confirmed the clinical findings; the placenta was praevia, apparently marginal and posterior (Type 2 placenta praevia). Fetal growth corresponded to gestation.

An intravenous infusion was set up, while blood was taken for haemoglobin estimation and cross-match. An anti-D injection was administered. Regular monitoring of vaginal blood loss, pulse and blood pressure were carried out; while fetal heart rate monitoring was also carried out intermittently. The mother also received two doses of

dexamethasone [12 mg every 12 hours] to assist fetal lung maturity.

The patient was reviewed after 24 hours. The vaginal bleeding had stopped completely, there being only a slight browning staining on the vaginal pad. All parameters had remained normal. The intravenous infusion was stopped. She was transferred to the Antenatal Ward and told that she needed to remain in hospital throughout the remaining antenatal period. She had a repeat episode of slight bleeding at 35 weeks of gestation, which was managed conservatively. Fetal monitoring with cardiotocography and ultrasound showed no abnormality. An anti-D immunoglobulin dose [500 IU] was repeated.

Past Obstetric History The patient had had a previous pregnancy four years earlier. The antenatal period had run a normal course. Onset of labour was induced since the patients pregnancy had run to over a week past her estimated dates. Labour had progressed effectively, but fetal distress was diagnosed at about 5 cm cervical dilatation. An Emergency Caesarean section was thus performed. A live born male infant, weighing 3400 gm was delivered. She gave no history of miscarriages.

Past Medical & Surgical History The patient gave no history of any significant medical events. She had had an appendectomy performed at the age of 15 years.

Past Gynaecological History The patient had no relevant gynaecological events. Her menarche occurred around the age of 10 years; her cycles stabilising within about a year. She had had regular smear tests after she became sexually active; these having been always normal. Her last smear test was performed about six months before embarking on this current pregnancy. During the inter-pregnancy period she used the oral contraceptive pill [Yasmine] for contraception.

Drug History The patient was on no long-term medication, except for the haematinics received during her pregnancy. She did not report any drug allergies. She did not smoke cigarettes and did not abuse alcohol at any time during her pregnancy.

Social History The patient was in a stable relationship. She married at the age of 20 years; and lived with her husband and child. She worked as a clerk in an industrial manufacturing setting. She intended to apply for parental leave to care for her children.

Examination at 36 weeks of pregnancy The patient was examined at 36 weeks of pregnancy. At this point in time, she was an inpatient in the hospital. There were no acute symptoms.

On examination the patient was in good general health. She did not appear anaemic and was not distressed in any way. Cardiovascular system was normal; her blood pressure and pulse being 110/60 mmHg and 70 beats/min respectively. There was no lower limb oedema. Abdominal examination conformed to a 36 weeks of pregnancy. On visual examination there was a distended abdomen with a faint linea nigra and some striae gravidarum. On palpation, the symphysis-fundal height measured 37 cm; the fetal lie appeared to be oblique with a cephalic presentation and the back to the left side. The fetal heart was audible on the left lower quadrant.

Follow up of this pregnancy At 37 weeks of pregnancy, the patient suffered a sudden onset of severe vaginal bleeding while having a shower. She was transferred to the Central Delivery Suite. Assessment at this stage, showed a persisting unstable lie of the fetus. In view of the severity of bleeding and the maturity of the infant, a decision was made to undertake delivery by urgent

Caesarean section. This was carried out under spinal anaesthesia. At surgery, the placenta was confirmed to be a posterior Type 2 placenta praevia. A female infant, weighing 3540 gm, was born with an Apgar score of 8 at 1 minute. The infant required no resuscitation. The Caesarean section proceeded without any complications.

The patient was treated with a syntocinon infusion (40 units in 500 mls infusion) during the first 24-hours post-operatively. She also received intra-operative prophylactic antibiotics - three eight-hourly doses of intravenous Augmentin (amoxycillin 250 mg and clavulanic acid 125 mg) on induction has been compared with three 8 hourly doses in 900 patients. The fetus blood group was reported as Group O Rhesus negative; Coombs test was negative. No anti-D prophylaxis was thus administered to the mother. She was discharged with her child four days after surgery with a post-operative haemoglobin level of 10.5 g/dl; she was advised to continue her haematinics for a further six weeks.

Case Discussion This case involved a pregnancy in a secondagravida woman complicated by Type 2 Placenta praevia. The situation was further complicated by a Rhesus negative blood group.

The patient was noted to have a possible abnormal placentation at her first ultrasound scan at 18 weeks of gestation when the placenta was noted to be low-lying. While this observation is suggestive of an eventual placenta praevia at term, not all cases of lowlying placentae discovered in the second trimester remain so in the third trimester when the lower segment actually develops. The patient, by virtue of her previous caesarean section, was at high risk of abnormal placentation.

The clinical course was typical of the condition with warning bleeding occurring at 32 weeks of gestation [after sexual intercourse], followed by more severe bleeding at 34 weeks and subsequently. The initial management followed in this case included an expectant regimen awaiting fetal maturity. In anticipation of the possible need for a premature birth, fetal lung maturity was augmented by the administration of dexamethasone. Blood was cross-matched and kept in reserve to enable timely transfusion should the need arise. At 37 weeks of gestation, the bleeding increased significantly, and in view of the degree of fetal maturity, a decision to terminate the pregnancy was taken. Because of the persisting unstable lie, a Caesarean section was decided upon.

The case was further complicated by a maternal Rhesus negative blood group. To obviate

the possibility of subsequent immunization, a prophylactic dose of anti-D immunoglobulin was administered at 28 weeks is line with current guidelines. In anticipation of possible feto-maternal transfusion, a further dose was given whenever the patient experienced episodes of bleeding. These prophylactic measures proved needless since the fetus was eventually found to have been Rhesus negative.