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APH Secondary To Placenta Previa 2
APH Secondary To Placenta Previa 2
APH Secondary To Placenta Previa 2
This is a 35 years old Gravida5 Para4 Abortus 0 lady whose last LNMP is
unknown,because she was amenorrhic for the last 9 years due to use of
Depo Provera.On Megabit 23,2004 E.C she started to experience
painless, bright red ,non clotting vaginal bleeding that woke up her from
sleep. The blood soaked her underwear,clothes, linen and stopped after
30 minutes. According to her,the bleeding is about half a liter and not
associated with vginal discharge. Before that, she never experienced any
bleeding during the pregnancy. The next day she went to Fitche
Hospital ,where she had ANC follow ups.After blood tests and ultrasound
was done she was told that the baby’s head is covered by the placenta
facing downwards & referred to Tikur Anbessa hospital. She had five
regular ANC follow ups(every month) after experiencing nausea &
vomiting at the 12th week of gestation. Blood pressure, Height & weight
measurements, abdominal examination, vaccination & blood tests were
done repeatedly. She was told that everything was fine. But she does not
remember any of the results. She was also given Iron supplements &
counseling about danger signs of pregnancy. The first time she heard
fetal movement is 4 months a ago (both rolling and kicking type).Now, it
is becoming much more stronger than ever, and more felt at night & after
meal. After admission here at Tikur Anbessa Hospital, an ultrasound and
blood test was done, advised not to allow any lower abdominal
examination & per virginal examination & also to report if any
bleeding .She eat 4 meals per day (injera, fruits, meat, vegetables and
cereals)as the pre pregnancy time. She claims about 7 kilograms weight
gain. She has no history of any type of drug use, during the whole
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Gynecologic History
parents are alive and relatively healthy. She has 6 brothers and 5
sisters; all first degree family are relatively healthy and have no history of
HTN,DM,TB,mental disorders and twinning. She is happy in her
marriage. They live in a house with 2 rooms that has a toilet ,have 2 oxen
,10 sheep’s and 1 TV, they have no car.
FUNCTIONAL INQUIRY
H.E.E.N.T
Glands
Respiratory
Cardiovascular system
Gastrointestinal system
Genitourinary system
Integumentary system
Locomotor System
Physical Examination
GENERAL APPEARANCE
she looks older than her stated age and comfortable with no signs of
distress.
VITAL SIGNs
RR: 19breaths/min
H.E.E.N.T.
Chest Examination
CardioVascularSystem
Veins
The jugular venous pressure observed at one pillow elevation (45 o couch
was not available) has a measurement of 7cm,no hepatojugular reflux,
no distended veins over the neck, chest wall, no varices or phlebitis in
the legs.
Precordium
Abdomen
Palpation:
Obstetric(Leopold’s):
Pelvic examination
Mental Status
The patient is well oriented to person, place and time. normal speech,good
memory,attention ,no halucination
Cranial Nerves:
Motor:
Normal muscle ,size,tone, bulk and power. No spontaneous or induced
fasciculation.
Sensory
Reflexes
Superficial
Corneal Abdomen Plantar
Right ++ + (down going)
Left ++ (down going)
Deep
Biceps Triceps Supinator Patellar Ankle
Right + + + + +
Left + + + + +
Summary
Subjective-
-multigravida mother
-longitudinal lie
-FHR:140/Min
Differential Diagnosis
4.Bloody show
1. Bloody Show
This is due to detachment of the mucus plugs in the cervix and rupture
of small vessels during cervical effacement and dilatation. But she
doesn’t have signs of labour.
2. Vasa Previa
Vasa previa is defined as the velamentous insertion of fetal vessels over
the cervical os, after rupture of fetal membranes. BecauseIt is a rare
condition & the patient has no leakage of liquor. Not likely
3.Abruptio placenta
- is a premature separation of a normally implanted placenta. It
normally presents with dark red bleeding and has pain associated with
it, due to contraction and irritation of the uterus. The uterus appears
rigid, tetanic and tender due to the contraction and inflammation. There
could be fetal distress or fetal death. Its risk factors could be over
distension, trauma, HTN, amniocentesis, or renal disease. This patient
has none of those signs and risks. She has soft and non tender uterus.
Fetal condition is safe, as she was told after and normal heart rate .
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4.Local causes-are also under the list of differential diagnosis and could
be ruled out after speculum examination, but because the history is
sufficient to make the diagnosis
5.Placenta Praveia
Implantation of the placenta in to the lower uterine segment. Bleeding
results from disruptions of the placental attachment, during formation
and thinning of the lower uterine segment. It presents with
causeless,bright red, painless bleeding that stops by it self. Abdomen is
relaxed and non tender. Risk factors include:large placenta (twinning),
multiparity, and increased maternal age. This lady has all those
symptoms mentioned above; making placenta previa the most likely
diagnosis.
Investigations
CBC,Hgb,Hct
LFT & RFT
Urine unalysis
(obstetric)Abdomino pelvic ultrasound
BPP
MRI
Risk Assessment
This is a high risk pregnancy because of spontaneous bleeding,
increased maternal age, possibly recurring severe hemorrhage.
Management Plan
Conserative:
follow her with: -APH CHART
-KICK CHART
Give Iron Supplement
Follow her with Hct,BPP
Advice family to stay near,& immediately report if any bleeding
Definitive:
-Delivery of the child in this patient could be considerd,
after fetal maturity is confirmed.