1. CASE REPORT April 2010

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

3. Chief Complaint
Scheduled for CS

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

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

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

7. 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)

8. 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

9. 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

10. 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 , (-) albumin, sugar; 2-5 pus cells, 0-2 rbc/hpf
Multivitamins + ferrous sulfate

11. 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

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

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

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

15. 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

16. 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

17. 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

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

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

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

21. 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

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

24. 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

25. Total placenta previa
The internal cervical os is covered completely by placenta

26. Partial placenta previa
The internal os is partially covered by placenta

27. Marginal placenta previa
The edge of the placenta is at the margin of the internal os

28. 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

29. 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

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

31. 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

32. 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.

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