CASE REPORT April 2010

General Data ME, 32y/o, G2P3 (2002), Filipino, married, from Tarlac 38 6/7 w AOG (by LMP)

Chief Complaint Scheduled for CS

Past Medical History Denied hypertension, DM, Bronchial asthma, thyroid disease No previous surgeries No known allergies

Family History Denied a family history of HTN, DM, bronchial asthma, thyroid disease, cancer

Personal and Social History Non- smoker Non- alcoholic beverage drinker

Gynecologic History Coitarche: 26 y/o, 1 sexual partner No vaginal discharge/symptoms of STD Use of contraceptives for 1 year after the birth of her second child (2005)

Menstrual History Menarche: 13 y/o Interval: 30 days, regular Duration: approx. 3-5 days No dysmenorrhea LMP : July7, 2009 EDC: April 14, 2010 PMP: June 2009

Obstetric History G1 (2002) delivered to a term, live, baby boy; in QMMC via NSVD; BW 2.4kg; no recalled complications G2 (2005) male, term, baby boy, at a lying-in clinic, via NSVD, no complications G3 present pregnancy

Prenatal Check up FIRST TRIMESTER (+) FPNCU First ultrasound (15w AOG) CBC: HgB 13.6/Hct 0.4/WBC 9/RBC 4.28/ neutro 0.56/ lympho 0.33/eos 0.11 Blood type B+ HbsAg non-reactive UA: pale yellow, slightly turbid, pH6.5, spec.grav. 1.015, (-) albumin, sugar; 2-5 pus cells, 0-2 rbc/hpf Multivitamins + ferrous sulfate

Prenatal Check up SECOND TRIMESTER (+) RPNCU (+) on Multivitamins and Ferrous sulfate OGCT = 107 mg/dl (NV: 140) CBC: 12.5/36.6/12400/neutro 72/lymph19 UA: light yellow, slightly hazy, (-) glucose. WBC 13, casts 2 Pap smear: benign cellular changes

Prenatal Check up THIRD TRIMESTER (+) RPNCU (+) on Multivitamins and Ferrous sulfate USG: placenta previa totalis

History of Present Illness 3 months PTA (~32 w AOG) Sensation of pelvic fullness Diagnosis of placenta previa Schedule for elective CS admission

Review of Systems (-) dizziness, fainting spells, seizures (-) fever (-) cough, colds, dyspnea, DOB (-) chest pain, palpitations (-) bipedal edema, no cyanosis

Physical Examination BP: 110/60mmHg HR: 94bpm, regular RR: 20/min, regular T: 37.1 C Eyes: pink palpebral conjunctivae, anicteric sclerae Neck: supple neck, with no palpable neck mass, no neck vein engorgement

Breasts: appears engorged; no lesions or palpable masses Lungs: symmetrical chest expansion, clear and equal breath sounds, no wheezing, rhonchi, or rales Heart: adynamic precordium, normal rate, regular rhythm, no murmurs

Abdomen: globular, gravid, with prominent linea nigra, sparse striae albicans; FH 32 cm; FHT 150’s bpm L1 – breech L2 – right maternal side L3 – cephalic, unengaged L4

External pelvic examination: no lesions, redness, excoriations, hyper/hypopigmentations IE: not done (c/i placenta previa)

Extremities: Full and equal pulses, no cyanosis, no edema

ASSESSMENT: Pregnancy uterine 38 6/7 weeks AOG, cephalic, not in labor; G3P2 (2002); placenta previa totalis for elective CS

The Placenta and Fetal Membranes the development of the human placenta is as uniquely intriguing as the embryology of the fetus Links the mother and fetus by an indirect interaction with the maternal blood

blood bathes the outer syncytiotrophoblast, allowing exchange of gases and nutrients with fetal capillary blood within the connective tissue at the villous core

PLACENTA PREVIA Condition wherein the placenta is located over or very near the internal os has four degrees: Total placenta previa Partial placenta previa Marginal placenta previa Low-lying placenta

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

Low lying placenta implanted in the lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it

The degree of placenta previa depends in large measure on the cervical dilatation at the time of examination. Digital palpation to try to ascertain these changing relations between the edge of the placenta and the internal os as the cervix dilates can incite severe hemorrhage

Etiology Advancing maternal age Multiparity Prior cesarian delivery Smoking = twice the risk

Pathophysiology: -scarring of placental site leading to spread of implantation in subsequent pregnancies -reason why placenta in placenta previa is more flat and occupies an area 20 to 40% larger

most characteristic event in placenta previa = painless hemorrhage, near the end of the second trimester or after. Abortions may result from such an abnormal location of the developing placenta Frequently has onset without warning, presenting without pain in a woman who has had an uneventful prenatal course. In some women, particularly those with a placenta implanted near but not over the cervical os, bleeding does not appear until the onset of labor slight to profuse hemorrhage and clinically may mimic placental abruption.

DDx: abruptio placenta vasa previa: velamentous insertion of the umbilical cord