Placenta Previa

[ Case Reflection ]

Nurul Izyan Rahmat 07 / 251654 / KU / 12245

Patients Identity

Name Age

: Mrs N (163 717) : 35 y.o

Address : Kajoran, Banjaroyo, Kalibawang Date of Admission : 19th Feb 2012

Parity LMP

: G2 P1 A0 : 3rd June 2011

EDC
GA

: 10th March 2012

: 37 weeks

History Taking (19th Feb 2012)

Patient, 35y.o referred by midwife due to ante partum hemorrhage. Vaginal bleeding (bright red blood) since 17:30pm. Changed pad 3 times. Trauma (-), History of vaginal bleeding (-)

History
ANC Obstetric Past Medical Marriage Family Planning Midwife, Routine Check up I Girl, 9 y.o, 2900gm, Normal, Midwife II This Pregnancy Hypertension (-), Asthma (-), DM (-), Heart Disease (-) 10 y.o Injectable Contraceptive every 3 month (5 and years)

Physical Examination

General Condition; CM, non-anemia

Vital Sign;

BP : 130/90 HR : 78x/min RR : 20x/min t: Afebris

Palpation;
Singleton pregnancy, longitudinal, cephalic presentation, fetal movement (+),

Fundal Height

: 27 cm,

Laboratory (Pre-Op)
Hb WBC Hct PLT RBC BT 12.5 g/dL 10.83 x 10/ul 35.6 % 239 x 10/ul 4.13x 10^6/ul 2 min Ureum Creatinine SGOT SGPT HbsAg CT 22 mg% 0.6 mg% 21 u/l 14 u/l Negative 5 min

USG

Single fetus, Cephalic Presentation, FHR (+), Placenta located at posterior part of uterus, closed Os.

BPD

: 8.9 cm

AC : 29.9 cm EFW : 2526.4 g

Diagnosis

Ante Partum Hemorrhage due to Total Placenta Previa, Sekundigravida, Aterm

Plan

FHR and His observation Elective Cesarean Section

Cesarean Section Report

In narkose stage, antisepsis is done at the operation field. Incision is done at the abdominal wall, and extended bluntly until reached uterus. Incision is done at lower uterine segment, and extended bluntly.

The infant head was delivered.

Baby boy delivered perabdominal at 8:40am. BW:2200gm A/S 7/9.

Placenta completely delivered spontaneously perabdominal. The uterine incision was closed.

21st Feb (Day 1)

S : Lochia (+) Rubra, Fundal height : Same level of umbilical, Breast Milk (+)

O : CM, CA (-/-)
BP : 148/73 HR : 57

T : 36.3
Hb Post Op : 12.9g/dl

A : Post C-Sect due to Total Placenta Previa, D1

P : Ceftazidine 2 x 1 Amp
: Metronidazole 3 x 1 Amp

22nd Feb (Day 2)

S : Lochia (+) Rubra, Fundal height : 2 fingers below umbilical, Breast Milk (+), Mobilization (+)

O : CM, CA (-/-)
BP : 135/73 HR : 67

T : 36.5

A : Post C-Sect due to Total Placenta Previa, D2 P : Ceftazidine 2 x 1 Amp : Metronidazole 3 x 1 Amp : Ketorolac 3 x 1 Amp

23rd Feb (Day 3)

S : Lochia (+) Rubra, Fundal height : 2 fingers below umbilical, Breast Milk (+), Mobilization (+)

O : CM, CA (-/-)
BP : 133/85 HR : 72

T : 36.7

A : Post C-Sect due to Total Placenta Previa, D3 P : Ceftazidine 2 x 1 Amp : Metronidazole 3 x 1 Amp : Ketorolac 3 x 1 Amp

24th Feb (Day 4)

S : Lochia (+) Rubra, Fundal height : 3 fingers below umbilical, Mobilization (+), Breast Milk (+)

O : CM, CA (-/-)
BP : 133/93 HR : 84

T : 36

A : Post C-Sect due to Total Placenta Previa, D4 P : Cefadroxyl 2 x 500 mg : Metronidazole 3 x 500 mg : Mefenamat Acid 3 x 500 mg

25th Feb (Day 5)

S : Lochia (+) Rubra, Fundal height : 3 fingers below umbilical, Mobilization (+), Breast Milk (+)

O : CM, CA (-/-)
BP : 130/84 HR : 80

T : 36.5

A : Post C-Sect due to Total Placenta Previa, D5 P : Cefadroxyl 2 x 500 mg : Metronidazole 3 x 500 mg : Mefenamat Acid 3 x 500 mg

Summary

20th Feb, 08:40 19th am Feb, : Baby !7:30pm 19th boy Feb, : (2200 Vaginal 20:00pm 25th gm) Bleeding was Feb : Admit born : Patient 20th perabdominal at RSU Feb, wasMuntilan 08:25 discharged 20th am Feb, : Cesarean with 08:42 good : Place Sec co

Discussion

Ante Partum Hemorrhage

Ante Partum Hemorrhage is vaginal bleeding which occurs after fetal viability

Incidence : 2-6%
Placenta Previa

Differential Diagnosis

Vasa Previa

Placenta Abruption Uterine Rupture

Placenta Previa

Placenta Previa is a condition in which the placental tissue lies abnormally close to the internal cervical os.

Commonly diagnosed on routine ultrasonography before 20 weeks gestation.

It occurs in 2.8/1000 singleton pregnancies and 3.9/1000 twin pregnancies (Lawrence O., et al, 2007). Significant clinical problem because the patient may need to be admitted to hospital for observation.

Classification

Total Placenta Previa The internal cervical os is covered completely by placenta.

Partial Placenta Previa The internal os is partially covered by placenta.

Marginal Placenta Previa

The edge of the placenta is at the margin of the internal os.

Risk Factors

Increasing parity: Incidence 0.2% in nulliparas versus up to 5% in grand multipara.

Maternal age : Incidence 0.03% in nulliparous women aged 20-29 versus 0.25% in nulliparous women 40 years of age.

Number of cesarean deliveries incidence 10% after 4 or more.

Number of curettages for spontaneous or induced abortions.

Clinical Manifestation

Painless vaginal bleeding without any reason and usually bright red blood.

Always found abnormal lie of fetus. Fetus are usually float.

First bleeding in small amount and not fatal, but recurrent bleeding usually profuse.

Fetus in good condition

Diagnosis

The diagnosis is based upon results of ultrasound examination. Clinical findings are used to support the sonographic diagnosis. Placenta previa should be suspected in any women beyond 24 weeks of gestation who presents with painless vaginal bleeding. Such examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean delivery, because even the gentlest examination of this sort can cause torrential hemorrhage.

Transvaginal vs Transabdominal

TVS has several advantages over TAS imaging in localization of the placenta.

The shorter distance from the vaginal probe transducer to the cervix and lower uterine segment allows the use of higherfrequency ultrasound waves, with improved resolution; therefore the relationship between the placental edge and the internal os can be determined more accurately.
With TAS, there is poor visualization of the posterior placenta, the fetal head can interfere with the visualization of the lower segment and obesity and overfilling of the bladder also interfere with accuracy.

Management
Gestational age 37 weeks, fetal body weight 2500 gm. Less bleeding. Does Mothers not general have sign less apparent of than delivery. 37 with not weeks. good. good condition.

Active Management

Expectant Management

Bleeding 500 ml.

Have sign of delivery.

Expectant Management
1.

Total bed rest. D 5% and electrolyte infusion. Tocolytic (eg. Magnesium Sulphate). Check Hb, Hct, blood group.

2.

3.

4.

5.

USG.
Observe for continuously bleeding, BP, HR and FHR.

6.

Indication for Cesarean Section

1.

Total Placenta Previa

2.

Placenta previa in primigravida Placenta previa in transverse lie or breech presentation fetal Fetal distress

3.

4.

5.

Profuse bleeding

Prognosis

50% of women with placenta previa have preterm delivery. Those case complicated with vaginal bleeding and extreme prematurity are at an increased risk at perinatal death. A greater incidence of fetal malformations and growth restriction is noted with placenta previa.

Neonates are more likely to have low birth weight, respiratory distress, jaundice, NICU admission and longer hospital stay.

Conclusion

From the anamnesis (painless vaginal bleeding) and USG (Placenta located at posterior part of uterus, closed Os), I agreed this patient was diagnosed as Total Placenta Previa. Since patient have profuse bleeding (3 times changed of pad) and it was total placenta previa, the active management should be taken. Thus, elective cesarean section was the best for that.

Recommendation

Transvaginal sonography, if available, may be used to investigate placental location at any time in pregnancy when the placenta is thought to be low-lying. The os-placental edge distance on TVS after 35 weeks gestation is valuable in planning route of delivery. When the placental edge lies >20 mm away from the internal cervical os, women can be offered a trial of labour with a high expectation of success. A distance of 20 to 0 mm away from the os is associated with a higher CS rate.

SOGC Clinical Practice Guidelines, No 189, March 2007

References
1.

Late Pregnancy Bleeding. Ellen S., Lawrence L. and Patrica F., American Family Physician, Volume 75, no 8; April 2007

2.

The Diagnosis and Management of Placenta Previa. Mekawi S., ASJOG, Volume 3; February 2006
Diagnosis and Management of Placenta Previa. Lawrence O. et al, SOGC Clinical Practice Guidelines, No 189, March 2007 Placenta Previa : Distance to Internal Os and Mode of Delivery. Patrizia V. et al, American Journal of O&G; September 2009

3.

4.

5.

Plasenta Previa. T.M.Hanafiah, 2004.

William Obstetrics 23rd Edition E-book

6.