A CASE PRESENTATION

SEVILLA, LOREANNE NOVEM

SILIM, MIRIAM GRACE D.
Identifying Data
This is the case of C.H., 27 years old, G3P1(1011) 39 weeks AOG by eUTZ, married, Filipino, born
on June 27, 1994, from Banilad Dumaguete City, who came in due to a scheduled repeat
cesarean section.
History of Present Illness
3 days PTA, patient had onset of generalized abdominal pain with PS 7/10 radiating to the
hypogastric area with associated uterine contractions every 10-15 mins with 1-3 minutes
duration, not associated with vaginal discharges. Patient sough consult to OB AP and an IE was
done which showed 3 cm cervical dilatation. Patient opted to undergo TOLAC.
1 day PTA, uterine contractions and abdominal pain subsided. Sought consult with OB AP and an
ultrasound was done which showed estimated fetal weight of 3.1 kg, she was advised for a
scheduled repeat cesarean section, thus this admission.
OBSTETRICS HISTORY
OB score: G3P1(1011)
Current pregnancy
LMP: November 2020
EDC: October 21, 2021 by Eutz
AOG: 39 weeks AOG by eUTZ
PRENATAL HISTORY
Pregnancy detected thru PT; confirmed thru TVS at 9 wks AOG
Prenatal vitamins:
• Calci-Vit
• Molvite-OB

Regular prenatal check-up

1st prenatal visit at 9 weeks AOG with an ObGyn
• Once a month until 28 weeks AOG
• Twice a month until 32 weeks AOG
• Weekly thereafter
Regular laboratory results upon prenatal check-ups were normal. No gestational comorbidities.
PREVIOUS PREGNACIES
NO. YEAR DURATION TYPE OF DELIVERY PLACE OF BIRTH COMPLICATIONS
DELIVERY WEIGHT
G1 January 2019 8 weeks Abortion
G2 November Term 1 LSTCS SUMC 3.06kg NRFHBP
2019 (recurrent late
decelerations)
G3 2021 Current pregnancy
GYNECOLOGIC HISTORY
Menarche: 12 years old Coitarche: 21 years old
Interval: Irregular (every 1-3 months) Sexual partners: 1
Duration: 4-5 days Contraceptives: condom
Amount: 5 moderately soaked pads/day Pap smear: none
Symptoms: dysmenorrhea (tolerated without meds) STIs: none
Past Medical History
Adult Illness:
o (-) HPN
o (-) DM
o (-) Bronchial Asthma
o (-) Malignancy

Previous hospitalizations:
o Hyperthyroidism (2016): Ultrasound showed Functional Nodules, was prescribed with Methimazole
(Unrecalled dose and duration of treatment)

Previous surgeries: 1 LSTCS (2019)

Food and Drug Allergies: Egg, chicken, sea food
Personal and Social History
Non-smoker
Non-alcoholic beverage drinker
No history of illicit drug use
She is a DTI employee.
Family History
(+) HPN - maternal side
(+) Goiter - maternal side
(+) Parkinson’s disease – paternal side
(-) Malignancy
(-) Diabetes Mellitus
(-) Bronchial Asthma
Review of Systems
UNREMARKABLE (-) loss of appetite
(-) fever, chills
(-) nausea, vomiting
(-) anosmia (-) fatigue
(-) diarrhea, constipation (-) dyspnea
(-) headache (-) blurring of vision
(-) dizziness
Physical Examination
Gen: conscious, coherent, oriented to time and place, not in respiratory distress
VS:
o BP: 100/70 mmHg
o T: 36.8 C
o PR: 83 bpm
o RR: 14 cpm
o O2 sat: 98 %
o Ht: 163 cm
o Wt:74.7 kg
o BMI: 28.1 kg/m2
Physical Examination
Skin: no lesions, no pallor, no jaundice, warm, good skin turgor
HEENT: anicteric sclerae, pink palpebral conjunctiva, no exophthalmos, no nasoaural discharges, no cervical
lymphadenopathy
C/L: equal chest expansion, no retractions, resonant upon percussion, clear breath sounds
CVS: Heart sounds best hest heard at 5 th ICS LMCL, distinct heart sounds, no murmurs
ABD: Gravid, (+) Linea nigra, (+) striae
FH:32 cm EFW: 3100g FHT: 150s UC: none
Leopold’s Maneuver:
L1: Breech
L2: R: Fetal back L: Fetal small parts
L3: Floating
L4: Cephalic
Physical Examination
GUT: IE:
Dilation: 2-3 cm
Effacement: 50%
Station: -4
Presentation: Cephalic
Consistency: Firm
Position: Posterior

EXT: No gross deformities, (-) edema, strong peripheral pulses, CRT <2 secs
CNS: (-) Convulsions, within normal limits
Primary Working Impression
G3P1 (1011) PU 39 weeks AOG by eUTZ, cephalic, NIL; S/P 1 LSTCS 2 to NRFHBP (2019);
Hyperthyroidism - euthyroid state
THERAPEUTIC PLAN
Supportive Management:
Antibiotic prophylaxis prior to OR.
Monitor FHT and uterine contractions.
Monitor VS q 4 hours
Monitor I and O q shift

Definitive Management:
Cesarean Delivery
COURSE IN THE WARDS
ON ADMISSION:
 Secure consent for care.
 DAT then NPO post-midnight.
 Start venoclysis: D5LR 1L @ 33 gtts/min
 AP prep
 Monitor FHT and VS q 4 hrs
 Monitor Intake and Output q shift
 Medications:
 Omeprazole (OMEPRON) 40 mg IV at 6am
 Cefuroxime (ZEGEN) 750 mg IVTT (-) ANST at 1 hour prior to OR
Laboratory and Diagnostic Tests
Hgb 12.80%
Hct 39. 00%
WBC 10610/cumm
• Segmenters 69%
• Lymphocyte 24%
• Eosinophil 1%
• Monocyte 6% Within the normal range.
• Basophil 0% Taken: 10/14/21 (Hospital Day 1)
Platelet count 150 T/cumm
RBC 4.7 M/cumm
M 83 fl
MCH 27.20 pg
MCHC 32.8 %
 Urinalysis CHEMICAL EXAMINATION
Taken: 10/16/21 (Hospital Day 3)
GLUCOSE Negative
PHYSICAL EXAMINATION
BLOOD Negative
COLOR DARK YELLOW
TRANSPARENCY HAZY UROBILINOGEN Normal
SPECIFIC GRAVITY 1.020 BILIRUBIN Negative
pH 6.5
URINE FLOW CYTOMETRY NITRITE Negative
RBC 6 KETONE Negative
WBC 28
PROTEIN Trace
EPITHELIAL CELLS 27
LEUKOCYTES Negative
HYALINE CASTS 1
BACTERIA 742 Mucus threads: Abundant

Leukocytosis may be attributed to contamination with vaginal discharge.

Increased epithelial cells also suggest contamination of the specimen. The urine sample submitted was a poor catch urine.
Laboratory and Diagnostic Tests
PROTHROMBIN TIME
Patient Test 10.60
Within the normal range.
% Activity 120.60
Taken: 10/14/21 (Hospital Day 1)
INR 0.90
Control 11.6

BLOOD TYPE: O+

Chest X-ray (PA): Normal findings

COVID-19 RAT: Negative

 SURGICAL MANAGEMENT
1st Repeat LSTCS with TAH
Performed: 10/15/21 (Hospital Day 2)
Intraoperative findings:
Gravid uterus with thickened out LUS, extracted a live male neonate, 38 weeks AOG
by BS, ASS9,9 BW 3.46kg, L50 cm, in cephalic presentation, LOT position
Placenta densely implanted unto the endometrium-myometrium located on the fundal
region, manually extracted.
Bilateral ovaries and fallopian tubes are grossly normal.
Boggy uterus, not well contracted with active blood loss.
Thinned out myometrium at the left cornual region.
Positive endometrial implants at posterior LUS.
Estimated blood loss: 1700 cc.
POST-PARTUM MANAGEMENT
O2 inhalation @ 3Lpm via face mask
Monitor v/s q 15 mins until stable
Diet: NPO
IVF: L arm: D5LR 1L @ 33 gtts/min
R arm: PNSS 1L @ KVO rate
Labs: Repeat CBC 6H post BT of 2nd unit
Medications:
Ketorolac (KORTEZOR) 30 mg IV q 6 hours, ANST(-) then shift to SKUDEXA ½ tab PO q 8hrs once on general
liquids with 6am-2pm-10pm timing
Tramadol Hcl (PEPTRAD) 50 mg + 9cc PNSS to be given very slowly q 8hrs then D/C once on general liquids
Metoclopromide (PLASIL) 10 mg IV q 8 hours x 6 doses
Omeprazole (OMEPRON) 40 mg IV, OD while on NPO
Cefuroxime (ZEGEN) 750 mg IV q 8hrs
Flat on bed, then encourage to move once able
Morphine precaution
Transfuse 1 unit of blood to run 4hrs immediately once available (2 nd unit)
Hospital Day 2 10/15/21
7 Hours post-op
S O A P
(-) febrile episode FBC in place, patent, UO: 30 cc/hr G3P2(2012) PU 38 • NPO
(-) flatus • T: 37.4 weeks AOG by BS, del • Medications:
(-) BM • HR: 84 via 1st repeat LSTCS to a Ketorolac (KORTEZOR) 30 mg IV q
(+) Complained of • RR: 19 live male neonate, AS 6 hours, ANST(-) then shift to
pain on the incision • BP: 110/70 9,9 BW 3.46 kg L50cm SKUDEXA ½ tab PO q 8hrs
site (PS 3/10) • SpO2: 96% (10/15/21 @ 10:11AM, once on general liquids with
Postpartum 6am-2pm-10pm timing
• HEENT: pale palpebral hemorrhage 2° to t/c Tramadol Hcl (PEPTRAD) 50 mg +
conjunctivae, anicteric sclerae, Placenta Accreta, 9cc PNSS to be given very
no nasoaural discharges, pale Uterine atony, S/P slowly q 8hrs then D/C once
moist oral mucosa, trachea at Hysterectomy; S/P 1st on general liquids
midline LSTCS 2 to NRFHBP Metoclopromide (PLASIL) 10 mg IV
• C/L: equal chest expansion, clear (recurrent variable q 8 hours x 6 doses
breath sounds, NIRD decelerations) Nov Omeprazole (OMEPRON) 40 mg IV,
• CVS: distinct S1 and S2, no 2019; Hyperthyroidism- OD while on NPO
murmurs Euthyroid state Cefuroxime (ZEGEN) 750 mg IV q
• Abd: post-op dressing dry and 8hrs May have sips of
intact, hypoactive bowel water/general liquids with
sounds, tympanitic on most crackers in AM
areas, pain on incision site • May apply abdominal binder in AM
• Ext: No edema, strong • Transfuse 3rd unit PRBC tomorrow AM
peripheral pulse, CRT <2sec as side drip to mainline
Laboratory and Diagnostic Tests
Hgb 9.50%
Hct 28.20%
WBC 18030/cumm
• Segmenters 82%
Hemoglobin and hematocrit were
• Lymphocyte 13%
decreased due to blood loss from the
• Eosinophil 0% surgical operation (1st repeat LSTCS
• Monocyte 5% with TAH), estimated blood loss was
• Basophil 0% 1700cc.
Platelet count 128 T/cumm Elevated leukocyte might be
RBC 3.4 M/cumm secondary an ongoing infection.
M 84 fl Taken: 10/16/21 (Hospital Day 3)

MCH 28.40 pg
MCHC 33.7 %
Hospital Day 3 10/16/21
Post-op Day 1
S O A P
(+) chills FBC in place, patent, UO: 30 cc/hr G3P2(2012) PU 38 • Encourage oral fluids
(+) flatus • T: 37.2 weeks AOG by BS, del • Soft diet for lunch
(-) BM • HR: 90 via 1st repeat LSTCS to • DAT for dinner
(+) Dark yellow • RR: 24 a live male neonate, • Dulcolax (BISACODYL) 2 rectal
urine • BP: 130/80 AS 9,9 BW 3.46 kg suppositories if still without BM
• SpO2: 98% L50cm (10/15/21 @ • Remove FBC, due to void by 3:00am.
10:11AM, Postpartum Refer if unable to do so.
• HEENT: pink palpebral hemorrhage 2° to t/c • Encourage ambulation
conjunctivae, anicteric sclerae, Placenta Accreta, • Shift IV Cefuroxime to Cefuroxime
no nasoaural discharges, pale Uterine atony, S/P (ZEGEN) 500 mg/tab 1 tab BID after
moist oral mucosa, trachea at Hysterectomy; S/P 1st 12nn dose
midline LSTCS 2 to NRFHBP • IVFTF: PNSS 1L @ KVO rate
• C/L: equal chest expansion, (recurrent variable
clear breath sounds, NIRD decelerations) Nov
• CVS: distinct S1 and S2, no 2019;
murmurs Hyperthyroidism-
• Abd: Abdominal binder in Euthyroid state
place, normoactive bowel
sounds, tympanitic on most
areas
• Ext: No edema, strong
peripheral pulse, CRT <2sec
Hospital Day 4 10/17/21
Post-op Day 2
S O
(-) febrile episode FBC in place, patent, UO: 30 cc/hr
(+) BM • T: 36.8
(+) Pain on incision • HR: 80
site (PS2 1/10) • RR: 20
• BP: 100/70
• SpO2: 99%
• HEENT: pink palpebral
conjunctivae, anicteric sclerae,
no nasoaural discharges, pink
moist oral mucosa, trachea at
midline
• C/L: equal chest expansion,
clear breath sounds, NIRD
• CVS: distinct S1 and S2, no
murmurs
• Abd: Abdominal binder in
place, normoactive bowel
sounds, tympanitic on most
areas, pain on incision site
• Ext: No edema, strong
peripheral pulse, CRT <2sec
A P
G3P2(2012) PU 38 • DAT
weeks AOG by BS, del • Take home pain medications:
via 1st repeat LSTCS to - Cefuroxime (ZEGEN) 500mg/tab
a live male neonate, 1 tab BID to complete 7 days
AS 9,9 BW 3.46 kg - Hemarate 1 tab BID for one
L50cm (10/15/21 @ month
10:11AM, Postpartum - Tramadol + Dexketoprofen
hemorrhage 2° to t/c (SKUDEXA) 75/25mg/tab ½ tab PO q
Placenta Accreta, 8hrs (6am-2pm-10pm) until
Uterine atony, S/P 10/22/2021 then prn for pain
Hysterectomy; S/P 1st
LSTCS 2 to NRFHBP  Possible discharge tomorrow
(recurrent variable  RTC: 10/25/21, for dressing prior to
decelerations) Nov discharge
2019;
Hyperthyroidism-
Euthyroid state
FINAL DIAGNOSIS
G3P2(2012) PU 38 weeks AOG by BS, del via 1st repeat LSTCS to a live male neonate, AS 9,9
BW 3.46 kg L 50cm (10/15/21 @ 10:11AM, Postpartum hemorrhage 2° to t/c Placenta Accreta,
Uterine atony, S/P Hysterectomy; S/P 1st LSTCS 2 to NRFHBP (recurrent variable decelerations)
November 2019; Hyperthyroidism-Euthyroid state
Placenta
Accreta
 • Formerly known as Morbidly
Placenta Adherent Accreta

Accreta • Also known as accrete syndromes

• aberrant placentation characterized
Spectrum by abnormally implanted, invasive,
or adhered placenta
Accrete Syndromes

• occurs when a defect of the decidua basalis and Nitabuch’s layer allow the
trophoblasts to break the barrier and invade the myometrium resulting in
abnormally invasive placental implantation
• Etiopathogenesis: microscopically placental villi are anchored to muscle fibers
rather than to decidual cells
• recent data now suggest that accrete syndromes are not solely caused by
anatomical layer deficiency but that the cytotrophoblasts may control decidual
invasion through factors such as angiogenesis and growth expression
• Increased risk conveyed by previous uterine trauma as in cesarean delivery
may be partially explained by an increased vulnerability of the decidua to
trophoblast invasion
Types depending on depth
of invasion

• Placenta Accreta (75%) -

attached to myometrium
• Placenta Increta (15%) -
invade myometrium
• Placenta Percreta (5%) -
penetrate through
myometrium
Incidence

• 13% of 5367 pregnancy-related maternal deaths in the US from 2006 to

2013
• One of the most formidable problems in obstetrics
• leading cause of hemorrhage and emergency peripartum hysterectomy
• 20% recurrence risks in subsequent pregnancies following placenta
accreta
Risk Factors

• Placenta previa
• Previous cesarean delivery
• Prior uterine surgery (myomectomy)
• prior uterine currettage – Asherman’s syndrome
• uterine irradiation for intra-abdominal cancer
Treatment
• after endometrial ablation
• Multiparity
• Advanced maternal age
 • 1st and 2nd trimester
o hemorrhage that is the
consequence of coexisting
placenta previa
o prompts evaluation and
Clinical management
Presentation • 3rd stage labor
o Abnormally adherent placenta
that requires manual removal
o postpartum hemorrhage
secondary to partial placental
separation
Diagnosis

• Transvaginal Sonography
o Placenta previa (A)
o Multiple vascular lacunae within the
placenta
o Loss of the normal hypoechoic zone
between the placenta and myometrium
o Decreased retroplacental myometrial
thickness (less than 1 mm)
o Abnormalities of the uterine serosa–
bladder interface
o Extension of placenta into
myometrium, serosa, or bladder 
Diagnosis

• Color flow Doppler imaging

o Turbulent lacunar blood
flow - most common
finding
o increased subplacental
vascularity
o gaps in myometrial blood
flow
o vessels bridging the
placenta to the uterine
margin
 Management
• Build up hemoglobin and
prepare crossmatched blood
• delivery in a tertiary care
center
• intrapartal prophylactic
antibiotics
• active management of the 3rd
stage of labor
• difficult placental delivery - do
hysterectomy
• conservative surgery if fertility
preservation is desired
NO ANTENATAL DIAGNOSIS OF
PLACENTA ACCRETA

• Undelivered placenta > 30 minutes check cervix

• for trapped placenta
• If negative do manual evaluation and extraction
• under anesthesia
• Absence of cleavage plane and presence of hemorrhage –
do HYSTERECTOMY
Complications

• Hemorrhage
• urinary tract injury
• intensive care unit admission
• secondary surgical procedures
REFERENCE

Williams Obstetrics 25th ed