Michelle S.

Pitpit
• To present a case of 34 year old presenting vaginal bleeding
on her 2nd trimester pregnancy
• To present algorithm and come up with a diagnosis based on
clinical symptomatology and laboratory results
• To discuss clinical manifestations, management and treatment of
the case
• Vaginal bleeding
• J.P., 34 year old, single, Filipino, Roman Catholic, vendor
• 12/23/1983 at Manila
• Currently residing at #32 Damayan Maypajo, Caloocan City
• Admitted last May 25, 2018
• 89% reliabilty
• 5 hours PTA
• Had sudden vaginal bleeding amounting to approximately 250mL with
associated blood clots and meaty materials
• No associated fever, hypogastric pain, dysuria, nausea and vomiting
• No history of trauma or any strenuous activities
• No medications were taken
• Consult was done at the ER of DJRMH, surgical intervention was advice
hence subsequent ADMISSION
• PMP: 8/2017
• LMP: 9/22/2017
• AOG: 35 WEEKS
• EDC: 6/29/2018

• Pregnancy was confirmed with (+) pregnancy test after 1 month of

amenorrhea
• Had 1 PNCU at Lawton Health Center, started at 23 weeks AOG
• Ultrasound done revealed: Pregnancy Uterine 23 4/7 weeks AOG based by
Fetal biometry. Live sinlgleton, in transverse presentation. Anteroposterior
placenta Gr I, totally covering the os. Adequate amniotic fluid. EFW: 614
grams, EDD: 6/29/2018
• 14 year old, 28 days cycle, with 3-5 days duration, consuming
4 moderately soaked regular pads, no associated
dysmenorrhea
• OB SCORE : G7P5 (5-0-1-5)
G1 2000 FT ALIVE NSD Jose reyes hospital
(-) complications
G2 2002 FT ALIVE NSD Jose abad Santos Hosp
(-) complications
G3 2004 5 MONS D&C
G4 2007 FT ALIVE NSD Jose reyes hospital
(-) complications
G5 2009 FT ALIVE NSD Jose reyes hospital
(-) complications
G6 2014 FT ALIVE NSD Jose reyes hospital
(-) complications
G7 PRESENT PREGNANCY
• 1st sexual contact: 15 year old
• 2 sexual partners
• Last sexual contact: April 2018
• No history of STD, bleeding
• No pap smear
• No family planning done
 (+) Asthma last attack 15 years ago
No known history of Hypertension, DM, heart disease,
cancer, Blood-related disease, immunologic disease

No known allergies No previous history of fall,

to food and drugs trauma and/or accident
 Parents : Both died due to Heart attack

(-) Diabetes Mellitus

(+) Heart Disease- (-) Hypertension
Paternal (-) Cerebrovascular Disease
(+) Asthma- Maternal (-) Pulmonary Tuberculosis
(-) Blood Dyscrasia
(-) Cancer
Highshool graduate, smoker
since 15 y/o consuming 4 Youngest among 4
sticks/ day, non-alcoholic siblings
beverage drinker
(-) weakness
(-) easy fatigability
(-) dyspnea
(-) chest pain
(-) headache
(-) dizziness
GENERAL SURVEY:
Awake, conscious, afebrile and not in cardiopulmonary distress

VITAL SIGNS:
BP: 120/70mmHg RR: 17 cpm
CR: 94 bpm Temp: 36.5°C

SKIN:
no pallor, no jaundice, warm to touch with good skin turgor;

HEENT:
anicteric sclerae, pinkish palpebral conjunctiva, moist lips and
buccal mucosa, no TPWC
CHEST and LUNGS:
Symmetrical chest wall expansion, no lagging, no retractions, clear
breath sounds
HEART:
PMI at 5th ICS LMCL, normal rate, regular rhythm, no murmur

ABDOMEN:
Globular, FH: 29cm, FHT: 145bpm EPW: 2947gm

SPECULUM EXAMINATION:
Not done

INTERNAL EXAMINATION:
Not done

EXTREMITIES:
No cyanosis, non-pitting edema
• 34 y/o, G7P5 (5-0-1-5)
• Complaint of sudden profuse vaginal bleeding amounting to
approximately 250ml, with associated blood clots and meaty
material
• No associated hypogastric pain, fever, dysuria, history of
trauma or any strenuous activities
• LMP: 9/25/2017
• 1st PNCU done at Lawton HC, Ultrasound done revealed: Pregnancy Uterine
23 4/7 weeks AOG based by Fetal biometry. Live sinlgleton, in transverse
presentation. Anteroposterior placenta Gr I, totally covering the os.Adequate
amniotic fluid. EFW: 614 grams, EDD: 6/29/2018
Patient with painless, sudden, profuse vaginal bleeding on her 3rd
trimester pregnancy
History
Ultrasound
Physical Examination

Placenta previa
Abruptio placenta
Vasa previa
Preterm Labor
PLACENTA PREVIA ABRUPTIO VASA PREVIA PRETERM LABOR
PLACENTA
RULED IN RULED OUT RULED OUT RULED OUT
- Presentation of - Abruptly, persistent - Vaginal discharge (
painless, profuse, abdominal pain watery, mucus or
with vaginal
sudden vaginal bleeding bloody)
bleeding - With history of - (+) hypogastric
- UTZ finding: trauma pain
Anteroposterior - No UTZ findings - (+) regular
like hematoma,
placenta Gr I, Increased placental contractions
totally covering thickness or
the os subchorionic
collection
• Remain one of the major causes of maternal death in
developing countries and 50% of the estimated 500,000
maternal deaths that occur globally each year
• Causes of antepartum hemorrhage:
• Placenta previa
• Placental abruption
• Vasa previa
• Local causes: bleeding from the vulva, vagina or cervix
• Placenta that is implanted somewhere in the lower uterine
segment, either over or very near the internal cervical os
• Suspected in any woman beyond 20 weeks AGE who present
with painless vaginal bleeding
• 80% cases it is found in multiparous women.
• increased beyond the age of 35
• with high birth order pregnancies and in multiple pregnancy
• incidences approximately 4-5 per thousand pregnancies
• Multiparity
• Increased maternal age
• Higher altitude
• History of previous scar in the uterus
• Smoking
 LOW LYING MARGINAL INCOMPLETE CENTRAL OR
OR PARTIAL TOTAL
• major part • placenta • placenta • placenta
of placenta reaches the covers the completely
iattached to margin of internal os covers the
the US and internal os partially ( internal os
only the but does cover the even after
lower not cover it internal os it is fully
margin when closed dilated
encroaches but does
onto the not entirely
lower do so when
segment but fully
not to the os dilated)
• Painless vaginal bleeding – 70-80%
• 1/3 prior to 30 weeks
• Uterine contraction – 10-20%
Individualized based on (not much evidence):
• Gestational age
• Amount of bleeding
• Fetal condition and presentation
Preterm with minimal or resolved
bleeding
 Expectant management – bed rest with bathroom
privilege
 Periodic maternal hematocrit
 Prophylactic transfusion to maintain hematocrit >
30% only with continuous low-grade bleeding with
falling hematocrit unresponsive to iron therapy
Preterm with minimal or resolved
bleeding
 Fetal heart rate monitoring only with active
bleeding
 Ultrasound every 3 weeks – fetal growth, AFI,
placenta location
 Rhogam for RhD-negative mother
Active bleeding
 Stabilize mother hemodynamically
 Deliver by Cesarean section
 Rhogam in Rh-negative mother
 Betamethasone or dexamethasone between 24 –
34 weeks’ gestation to enhance lung maturity
Management of placenta previa
 No large clinical trials for the recommendations
 Consider hospitalization in third-trimester
 Antepartum fetal surveillance
 Corticosteroid for lung maturity
 Delivery at 36-37 weeks’ gestation
Preterm with minimal or resolved
bleeding
 Amniocentesis weekly starting at 36 weeks to
assess lung maturity – delivered when lungs reach
maturity
 Betamethasone or dexamethasone between 24 –
34 weeks’ gestation to enhance lung maturity
 Tocolysis
• GRAVIDA 7 PARA 5 (5-0-1-5) PREGNANCY UTERINE 35
WEEKS AGE OF GESTATION BY LAST MENSTRUAL PERIOD,
PLACENTA PREVIA IN HEMORRHAGE, S/P CURETTAGE 2004
• Admit patient
• Secure consent for Emergency CS + BTL
• Diagnostics: CBCP, UA, Blood typing
• Treatment:
• IVF: D5LR 1 Li X 8 hours
PNSS 1 Li X KVO
• Cefazolin 2gm IV ( ) ANST 1 hour prior to anesthesia
• Dexamethasone 5mg
• Prepare 2 units PRBC properly typed and cross-matched
• Insert IFC
• Inform PROD, AROD, ROD
• Monitor VS, FHT every hour and record
Hemoglobin 72 g/L
Prothrombin Time PTT
Hematocrit 0.24 PT: 12.7 secs PT: 33.1 secs
WBC 8.4 Control: 13.1 secs Control: 26.2
INR: 1.10
Neutrophils 0.68
% activity: 86
lymphocytes 0.25
Platelets 485.0
Blood type A+ RBS 167.64
BUN 4.51 (L)
Color Yellow Creatinine 0.46 (L)
Specific gravity 1.13 SGPT 8.83
Glucose (-) SGOT 17.71
Protein (-) Na 134.71 (L)
RBC 46 K 3.45 (L)
WBC 5
Epithelial Cells 1
Bacteria 19
• No complications noted during and after the operation
• Estimated blood loss: 1200cc
• Hence 2 Units PRBC properly typed and cross-matched was
ordered
Hemoglobin 107.0 g/L
Hematocrit 0.34
WBC 14.6
Neutrophils 0.80
lymphocytes 0.15
Platelets 395.0
Blood type A+
 (-) profuse vaginal bleeding, (+) tolerated post-
S operative pain, (+) adequate UO, (+) flatus, (-) BM,
Subjective able to ambulate
GS: awake, conscious, afebrile and not in distress
Vital Signs: BP: 130/80; CR: 80 bpm;

O
Objective
RR: 19 cpm; Temp: 36.7ºC
Skin: no pallor, no jaundice
HEENT: pinkish palpebral conjunctiva, anicteric sclera, (-) TPWC
Abdomen: (+) dry & well coaptated surgical wound, (-) bleeding, (-)
discharge, (-) hematoma, (-) swelling, NABS, soft, (-) tenderness
IE: cervix soft, admits tips, uterus well-contrated, minimal non-foul smelling
lochiall discharge
Extremities: (+) Gr II, pitting edema, (-) cyanosis, full and equal pulses
Tea and cereals then Low salt low fat diet, increased oral fluid

P intake
MEDS: Co-amoxiclav 625mg 1 tab 3x a day (1/3)
Plan Paracetamol 500mg 1 tab every 6 hrs for pain
FeSO4 1 tab 2x a day,
Amlodipine 5mg 1 tab once a day,
Clonidine 75mg 1 tab as needed for BP >/= to 150/100
 (-) profuse vaginal bleeding, (+) tolerated post-
S operative pain, (+) adequate UO, (+) flatus, (-) BM,
Subjective able to ambulate
GS: awake, conscious, afebrile and not in distress
Vital Signs: BP: 100/60; CR: 92 bpm;

O
Objective
RR: 19 cpm; Temp: 36.7ºC
Skin: no pallor, no jaundice
HEENT: pinkish palbebral conjunctiva, anicteric sclera, (-) TPWC
Abdomen: (+) dry & well coaptated surgical wound, (-) bleeding, (-)
discharge, (-) hematoma, (-) swelling, NABS, soft, (-) tenderness
IE: cervix soft, admits tips, uterus well-contrated, minimal non-foul smelling
lochiall discharge
Extremities: (+) Gr II, pitting edema, (-) cyanosis, full and equal pulses
Low salt low fat diet, increased oral fluid intake, 2 bananas/meal
P
Plan
MEDS: Co-amoxiclav 625mg 1 tab 3x a day (1/3)
Paracetamol 500mg 1 tab every 6 hrs for pain
FeSO4 1 tab 2x a day,
Amlodipine 5mg 1 tab once a day,
Clonidine 75mg 1 tab as needed for BP >/= to 150/100