Patient’s Name: Pecaso, Miriam R.

Hospital: DLSU-MC
Informant: Patient Department: OB-GYN
Reliability: Good AP: Dr. Maria Concepcion Carlos
Historian: Rafanan, Lester John P. Date Admitted: December 26, 2010

CLINICAL HISTORY

General Data

M.P., a 36 year old, married G3P1 (1011), Filipino, Roman Catholic, born in Manila and
currently residing in San Manuel, Dasmarinas City, was admitted at DLSU-MC on December
26, 2010 at around 1:41pm.

Chief complaint

Vaginal bleeding

History of Present Pregnancy

LNMP April 10, 2010

PMP March 2010
EDC January 15, 2011
AOG 37 1/7 weeks by LNMP
Quickening August 2010

The patient had regular menstrual cycle until 8 months prior to admission (around 4
weeks AOG), when she became amenorrheic.

7 months prior to admission (around 8 weeks AOG), the patient experienced nausea
and vomiting. She also had episodes of spotting in small amounts. There were no dysuria,
flank pains and abdominal pain. Likewise, no history of trauma or taking any abortifacient was
reported. Pregnancy test was done using a home pregnancy test kit and resulted positive.
Patient sought consult and transvaginal ultrasound revealed positive pregnancy. She was
prescribed Isoxsuprine HCl (Duvadilan) three times a day for one month, Duphaston two times
a day for one month, multivitamins once a day, ferrous sulfate once a day and folic acid once
a day for one month. Complete bed rest was also advised. Patient took her medications with
good compliance and no recurrence of spotting was reported thereafter.

6 months prior to admission (around 12 weeks AOG), complete blood count and
urinalysis was done with unremarkable results.

5 months prior to admission (around 16 weeks AOG), patient had her HBsAg and VDRL
work-ups with normal results. Fetal movement was noted by the patient. Subsequent prenatal
checkups were done under her obstetrician.

2 months prior to admission (24 weeks AOG), patient had her routine prenatal check
up. 50g OGCT was requested which revealed normal result. Follow-ups were done at this
institution for the succeeding month and continued her bimonthly check-up.

4 days prior to admission (around 37 weeks AOG), patient had routine check up. Upon
internal examination, cervix was open and 1 cm dilated. There was no blood per examining
finger. Patient was sent home and advised to go to emergency room once labouring.

Few hours prior to admission, the patient decided to consult her neighbouring midwife
to know her cervical dilatation. Upon examination, sudden surge of bright red blood
1
amounting to 1 cup escaped from her vagina. Patient was immediately brought to this
institution where she was subsequently admitted.

Past Medical History

The patient has a history of allergy to mefenamic acid. She denied having history of
hypertension, diabetes mellitus, heart disease, hepatitis, goiter, asthma and urinary tract
infection.

Family History

The patient’s mother is a known hypertensive while her father is a diabetic. She denied
the presence of other heredo-familial disease such as asthma, allergies, tuberculosis, multiple
births and congenital anomalies.

Personal and Social History

The patient is a college graduate, who works as a quality inspector in a manufacturing

company. She is a non-smoker and non-alcoholic beverage drinker. She denies ever using any
illegal drugs

Her husband is a high school graduate, employed in a manufacturing company. He is a

smoker and alcoholic beverage drinker.

Menstrual History

The patient had her menarche at age of 12 years old with regular monthly cycle lasting
for 3 days. She uses 3 moderately soaked pads per day. She does experience dysmenorrhea
during her period and takes anti-analgesic which provides relief.

Obstetrical History

The patient is a G3P1 (1011)

No. Of Date of AOG Manner Place Sex Weigh Status Complications

Pregnanc Delivery of t
y Delivery

G1 2003 FT VSD Imus Male 2.5kg Alive none

Family
Hospita
l
G2 2009 Spontaneous abortion at 12 weeks
G3 Present pregnancy

Sexual History

The patient had her first sexual contact at the age of 28 years old. She has single
partner. Her last sexual contact was on April 2010. She does not experience dyspareunia or
post coital bleeding.

2
Contraceptive History

The patient has no history of contraceptive use.

Gynecologic History

The patient has no history of breast diseases. The patient did not have any history of
gynecologic surgery.

Review of Systems

General
(+) weight gain (-) loss of appetite (-) fever

(-) weakness (-) chills (-) easy

fatigability

Integument
(+) hyperpigmentation (-) erythema (-) wound
(-) pruritus (-) rashes (-) pallor

Head and Neck

(-) dizziness (-) lymphadenopathy (-) headache

Eyes
(-) pruritus (-) corrective lenses (-) redness
(-) discharge (-) pain (-) icteric sclera

Ears
(-) tinnitus (-) disturbance in hearing (-) vertigo

Nose and Sinuses

(-) watery discharge (-) epistaxis (-) obstruction

Mouth and Throat

(-) hoarseness (-) ulcers (-) dysphagia

Respiratory
(-) cough (-) chest pain (-) dyspnea

Cardiovascular
(-) chest pain (-) palpitations (-) dyspnea

Gastrointestinal
(+) vomiting (+) nausea (-)
constipation
(-) abdominal pain (-) diarrhea

Genito-Urinary Tract
3
(-) dysuria (-) flank pain (-) discharge

Hematologic
(-) easy bruising (-) prolonged bleeding (-)
pallor

Endocrine
(-) polyuria (-) polyphagia (-) polydypsia

Musculoskeletal/Extremities
(-) edema (-) muscle pain (-) joint
swelling

Neurologic
(-) loss of consciousness (-) tremors (-) numbness

PHYSICAL EXAMINATION

General Survey

The patient is mesomorph, conscious, coherent, oriented to time, place and person,
not in cardio-respiratory distress, ambulatory and appears her chronological age of 36.

Vital Signs

BP: 100/60 mmHg

HR: 68 bpm
PR: 68 bpm
RR: 20 cycles /min
Temp: 36.8oC

Regional Examination

Skin

There is no pallor, no jaundice, no erythema. The skin was neither warm or cool to
touch, no excessive moisture and dryness and has good skin turgor. The hair appeared to be
smooth, with no structural abnormality, no color change nor infestation. The nails have no
deformity, no change in shape or color.

Head and Neck

The head was symmetrical and normocephalic. There were masses, tenderness and
ulceration noted in the head and neck. Jugular venous pressure was not assessed.

Eyes

The patient had no corrective lenses. Both eyes were symmetrical, with pink
conjunctiva, with well distributed hair on the eyebrows, eyelids without lesions and lacrimal
glands without masses. Direct and consensual papillary reflex were present on both eyes.
Extraocular movements were intact and symmetrical.
4
Nose

The nose was symmetrical, found along the midline and without any mass, deformity
and tenderness. External nares were equal in size and shape. The nasal passages were
patent. Nasal septum was found along the midline. The mucosa was pale, smooth and without
ulceration, mass and discharge. Nasal turbinates were pinkish in color.

Ears

The external ears did not present any mass or lesion.

Lips and Oral Cavity

The lips were pinkish in color. No lesions and masses were noted. The gums were
pinkish in color and no lesion or any mass were noted.

Chest and Lungs

There was symmetrical chest expansion, no retractions. There was clear and equal
bronchovesicular breath sounds, without any adventitious breath sounds such as
crackles, wheezes or rales.

Cardiovascular

There were no precordial bulging, heaves or thrills. The patient had normal heart sound
with regular rhythm.

Abdomen

Inspection - The abdomen is globular and symmetrical. There were linea nigra and
striae gravidarum. There were no visible masses, veins, pulsations or peristalsis.

Auscultation - fetal heart tone was 145 bpm at maternal LLQ

Palpation - Fundic height was 32 cm

Leopold’s Maneuver
LM1: hard nodular mass
LM2: fetal back was palpated on maternal left and small parts were on
the left
LM3: not engaged
LM4: not assessed

Genitourinary (IE)

Upon speculum exam, the cervix was open, corpus enlarged to AOG, blood clots noted
at the external os.

Musculoskeletal

There were no edema, no cyanosis, and no gross deformities. Peripheral pulses were
full and equal.

5
Neurologic

The patient was very cooperative, attentive, and spoke in a normal conversing tone.
There were no signs of stuttering, mumbling, and no change in pitch and intensity of voice.
Each answer given was accompanied by appropriate amount of expressions and they were
goal-directed, relevant, and logical. The patient was alert during the interview. She was aware
of her environment, and was oriented to time, place and person.

CLINICAL DISCUSSION

Clinical Impression

Pregnancy, uterine, 37 1/7 weeks by LNMP

Cephalic in labor
Placenta Previa

Bases:

For pregnancy
Presumptive:
Amenorrhea
Nausea
Vomiting
Disturbance in urination
Quickening

Probable:
Positive pregnancy test
Abdominal enlargement
Physical outlining of the fetus

Positive:
Identification of fetal heart tones separately from the mother
Recognition of the fetus by ultrasonography

For Placenta Previa

Painless vaginal bleeding (preceded by internal examination)

Case Discussion

This is a case of M.P., a 36 years old, 37 1

/7 weeks uterine pregnancy, considered to be
at high risk because of placenta previa totalis.

Placenta previa is defined as a placenta implanted in the lower segment of the uterus,
presenting ahead of the leading pole of the fetus. It occurs in 2.8/1000 singleton pregnancies
and 3.9/1000 twin pregnancies and represents a significant clinical problem, because the
patient may need to be admitted to hospital for observation, she may need blood transfusion,
and she is at risk for premature delivery.

The incidence of hysterectomy after Caesarean section (CS) for placenta previa is 5.3%
(relative risk compared with those undergoing CS without placenta previa is 33). Perinatal
6
mortality rates are three to four times higher than in normal pregnancies. Unlike first trimester
bleeding, second and third trimester bleeding is usually secondary to abnormal placental
implantation.

The exact etiology of placenta previa is unknown. The condition may be multifactorial
and is postulated to be related to multiparity, multiple gestations, advanced maternal age,
previous cesarean delivery, previous abortion, and possibly, smoking.

Unlike first trimester bleeding, second and third trimester bleeding is usually
secondary to abnormal placental implantation.

Management and Treatment

Transvaginal sonography is now well established as the preferred method for the
accurate localization of a low-lying placenta. Sixty percent of women who undergo
transabdominal sonography (TAS) may have a reclassification of placental position when they
undergo TVS. With TAS, there is poor visualization of the posterior placenta, the fetal head can
interfere with the visualization of the lower segment, and obesity and underfilling or overfilling
of the bladder also interferes with accuracy. For these reasons, TAS is associated with a false
positive rate for the diagnosis of placenta previa of up to 25%. Accuracy rates for TVS are
high (sensitivity 87.5%, specificity 98.8%, positive predictive value 93.3%, negative predictive
value 97.6%), establishing TVS as the gold standard for the diagnosis of placenta previa. The
only randomized trial to date comparing TVS and TAS confirmed that TVS is more beneficial.
TVS has also been shown to be safe in the presence of placenta previa, even when there is
established vaginal bleeding.

Magnetic resonance imaging (MRI) will also accurately image the placenta and is
superior to TAS. It is unlikely that it confers any benefit over TVS for placental localization, but
this has not been properly evaluated. Furthermore, MRI is not readily available in most units.
Transvaginal sonography, if available, may be used to investigate placental location at any
time in pregnancy when the placenta is thought to be low-lying. It is significantly more
accurate than transabdominal sonography, and its safety is well established.

Because of the potential morbidity and mortality secondary to profuse bleeding, obtain
immediate gynecologic consultation, if available. Before gynecologic consultation or transfer,
the hemodynamic stability of the patient should be addressed. This includes the establishment
of 2 large-bore intravenous access lines with intravenous crystalloids or blood products, as
necessary. Obtain continuous fetal monitoring, if available. If the fetus is preterm and
immediate delivery is unnecessary (e.g., fetus <37 weeks' gestation and hemorrhage not
present), the patient may be treated expectantly on an outpatient basis. If the fetus is
reasonably mature (i.e., >37 weeks' gestation) and the patient is in labor or if severe
hemorrhage is present, therapy is directed at the delivery of the fetus. The patient should
receive crystalloids and/or blood, and the patient should be transferred to the operating room
with double set-up conditions. A trial of labor may be considered for anterior marginal previa,
including oxytocin (Pitocin) augmentation.

The goal should be directed at the hemodynamic stability of the patient. The primary
therapeutic agents should be intravenous crystalloids and/or transfusions. Recent studies are
now using prothrombin complex and recombinant factor VII to control hemorrhage associated
with obstetric complications and placenta previa.

7
 Steroids may be administered after consultation with a gynecologist, if vaginal
bleeding is mild and intermittent, if the patient is not in labor, and if gestation is less than 37
weeks.