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CASE REPORT April 2010

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.

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CASE REPORT April 2010

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  1. CASE REPORTApril 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. 1.015, (-) 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 previatotalis

  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, anictericsclerae 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: adynamicprecordium, normal rate, regular rhythm, no murmurs

  17. Abdomen: globular, gravid, with prominent lineanigra, sparse striaealbicans; 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 previatotalis 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

  23. 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

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

  25. Partial placenta previa • The internal os is partially covered by placenta

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

  27. 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

  28. 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

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

  30. 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

  31. 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.

  32. DDx: abruptio placenta vasaprevia: velamentous insertion of the umbilical cord

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