Case presentation on a patient managed for 3rd

TM pregnancy+ APH 2ry to PPT in labor with

active bleeding + severe anemia 2ry to ABL +
IUFD + preeclampsia with severity feature

By Dr. Wondmeneh(R1)
Moderator: Dr.Getaneh(R4)
CONTENT

• Case summary
• Discussion
• Scientific discussion
• Comment
• Take home message
• Reference

10/09/2022 PP BY WK 2
 IDENTIFICATION

• Name: W/T
• Age: 26 years
• Marital status: married
• Address :O/Nada
• DOA :19/05/14
• DOD:23/05/14

10/09/2022 PP BY WK 3
Senior resident evaluation at labor ward
on 19/5/14 at 5:50AM

• A primigravida lady

• Amenorrhic for the past 8 months

• ANC follow up at Baso HC 3 times and uneventful

• Presented with bright red vaginal bleeding of 12hours

duration

10/09/2022 PP BY WK 4
• Has easy fatigability, palpitation, light headedness
and dizziness

• Has no headache, blurring of vision or epigastric pain

• No known medical or surgical illness

10/09/2022 PP BY WK 5
 P/E

• G/A: ASL
• V/S: BP: 120/70 PR:120 RR: 20 T: ATT
• HEENT: Pale conjunctiva, non icteric sclera
• LGS: No LAP
• Chest: clear chest and good air entry
• CVS: S1 and S2 well heared, no murmur no S3 gallop

10/09/2022 PP BY WK 6
• Abdomen: - U/S:- SIUPX
• 34 week sized gravid -FHB: negative
uterus -Breech
-Placenta covers cervical os
• Longtitudinal lie totally and bulk is anterior
• Breech -FL:31+4 wks
Index:3rd TM PX +
• Has contraction
PPT+IUFD
• FHB: negative

10/09/2022 PP BY WK 7
• GUS: -There is active vaginal bleeding
• MSK: NAD
• INTEG:NAD
• CNS: COTTPP with GCS 15/15

10/09/2022 PP BY WK 8
• Assessment: 3rd TM pregnancy+ APH 2ry to PPT in labor
with active bleeding + severe anemia 2ry to ABL + IUFD

• Plan: CBC, BG/RH, RFT, U/A,VDRL, HBsAg

• Prepare for emergency c/s
• Prepare x-matched blood

10/09/2022 PP BY WK 9
Operation note
• After informed written consent taken patient prepared
and transferred to OR

• Under GA abdomen cleaned and draped

• Abdomen entered via pfannesteil incision

• Finding:
• Intact gravid uterus
• Healthy looking tubes, ovaries and urinary bladder
10/09/2022 PP BY WK 10
• Done:
• Vesicouterine peritoneum reflected down and LUST
incision made to effect delivery of freshly dead 2.4KG
female SB
• Pitocin 10IU IM stat given, placenta delivered by CT.
• Uterus exteriorized, mopped and closed in 2 layers
using vicryl no 2
• Hemostasis secured, Correct counts reported

10/09/2022 PP BY WK 11
• Fascia and skin closed using vicryl no 2 and 3/0
respectively

• Patient extubated and transferred to recovery room with

stable V/S

• EBL-500ML

• TOLAC possible in next pregnancy

• Duration of surgery : 40 minutes

10/09/2022 PP BY WK 12
 Post op Order

• P: Immediate postop day after LUST C/S done for 3rd

TM pregnancy+ APH 2ry to PPT in labor with active
bleeding + severe anemia 2ry to ABL + IUFD
• C: critical
• A: encourage early ambulation
• D: start SIPS when bowel sound is active
• Ix: Determine post op hct after 8hrs
10/09/2022 PP BY WK 13
• Treatment:
• Put on maintenance fluid(3L of NS,DNS and RL) every 8
hours/24hour
• Check uterine tone every 15 min/2hours
• V/S every 15min for first 2hrs then every 30min/2hours
the every 1 hour/4hours then every 4 hour.
• Tramadol 50mg IV TID
• Remove foley catheter after 8hrs.

10/09/2022 PP BY WK 14
Progress note ON 19/5/14 at 8:00AM

• P: she is on her Immediate postop day after LUST C/S done

for 3rd TM pregnancy+ APH 2ry to PPT in labor with active
bleeding + severe anemia 2ry to ABL + IUFD

• Done: transfused with 1 unit of X matched blood

• on maintenance fluid
• Tramadol 50mg IV TID

• S: no headache, blurring of vision, or epigasteric pain, No

vaginal
10/09/2022
bleeding PP BY WK 15
 P/E:
• G/A: ASL

• V/S: BP: 160/100 PR:116 RR: 20 T: 36.9

• HEENT: slightly Pale conjunctiva, non icteric sclera

• LGS: No LAP

• Chest: clear and resonant chest

• CVS: S1 and S2 well heared

• ABD: 18week sized well contracted uterus

• No sign of fluid collection
10/09/2022 PP BY WK 16
• GUS: no CVAT, no vaginal bleeding

• Dx: same + R/O PE with severity feature

• RX: start magnesium sulfate as per protocol

• Hydralazine 5mg if BP>=160/110mmHg every 20min
–maximum 5 doses
• Nifedipine 10mg po BID
• Ferrous sulfate 325mg PO TID

10/09/2022 PP BY WK 17
Investigation chart
date investigation result
19-5-14 CBC WBC-13800 NE-83.4%
HGB-11.5 HCT-34.3%
PLT-231000
RFT CR-0.45
UREA-6.4
LFT AST-33.2
ALT-17.4
ALP:123
BG/RH A+
VDRL Negative
HBsAg Negative
U/A protein:+2
Blood: +3
Full of RBC
Many pus cells
Few epithelilal cells
Postop HCT 30%

10/09/2022 PP BY WK 18
POST OP V/S FOLLOW UP
date Time Time PR RR TEMP Medication
19-5-14 7:00AM 147/110 92 20 35.5
7:15 152/109 100 20 35.3
7:30 150/106 96 20 35.4
7:45 156/108 88 20 35.5
8:50AM 162/118 92 - - Hydralazine 5mg
9:10AM 154/103 90 - -
9:25AM 152/108 96 - -
9:45AM 150/105 90 22 35.7
10:00AM 150/100 90 22 35.6
10:15AM 162/105 92 22 35.4 Hydralazine 5mg
10:30AM 143/92 90 22 36.2
11:00AM 160/110 92 20 35.6
11:30AM 155/90 96 22 36.4
11:45AM 160/100 92 20 37.1 Nifedipine 10mg
12:00PM 155/100 92 22 37
10/09/2022 PP BY WK 19
Date TIME BP PR RR TEMP MEDIcation
19/5/14 3:00pm 155/95 92 24 -

8:00pm 160/100 94 21 - Hydralazine

5mg

8:20PM 155/100 78-92 20-23 -

10:30PM 155/100 - - -

20/5/14 SBP:130-155 82-84 22-24 36.9-37.3 UOP

DBP:85-100 1000/16Hr

21/5/14 SBP:140-150 80-96 20-22 36.2-37.3

DBP:90-95

22/5/14 SBP:130-150 86-104 20-24 34-37.6

DBP:80-100

23/5/14 SBP:120-135 80-100 22-24 36.7-37.3

DBP:70-86
10/09/2022 PP BY WK 20
Discharge summary

• 4th postop day after LUST C/S done for 3rd TM

pregnancy+ APH 2ry to PPT in labor with active
bleeding + severe anemia 2ry to ABL + IUFD

• Passes flatus, started SIPS

• v/s: BP:130/80 PR:80 RR: 23 T: 36.3

• Ass’t : smooth 4th post op day + mild anemia + 1 C/S

scar + UTI
10/09/2022 PP BY WK 21
Plan at discharge

• Ferrous sulphate 325mg po TID/3months

• Cephalexin 500mg po TID/1week

• Advised on breast care

• Ibuprofen 400mg po PRN

• Check BP at HC 2x/week

• Counseled on family planning repeatedly, but insisted to take

at near by HC
10/09/2022 PP BY WK 22
• Advised to have prenatal follow-up in tertiary facility

• Counseled on next mode of delivery

• TOLAC possible

• C/s certificate given

• Advised the family on psychological support

10/09/2022 PP BY WK 23
 DISCUSSION

10/09/2022 PP BY WK 24
Problems identified

• APH 2ry to PPT

• Severe anemia 2ry to ABL

• IUFD

• Preeclampsia with severity feature

10/09/2022 PP BY WK 25
INTRODUCTION

• APH is vaginal bleeding after fetal viability but

before delivery of the fetus

• Complicates 6% of pregnancies

• Placenta previa accounts for 7% of cases

10/09/2022 PP BY WK 26
PLACENTA PREVIA

• Presence of placental tissue over or adjacent to the

cervical OS.

• Incidence at delivery is 0.5%, but higher in early

gestation(4-6% in 2nd TM)

• Placental migration explains resolution near term

10/09/2022 PP BY WK 27
ETIOPATHOGENE
SIS
• The pathogenesis of placenta previa is unknown.

• There are hypothesis:

• Suboptimal endometrium in the upper
uterine cavity due to previous surgery
• Big surface area of the placenta

10/09/2022 PP BY WK 28
RISK FACTORS Previous history
Previous uterine
surgery
large placenta
Parity
Age
Intrauterine
procedure
Race

10/09/2022 PP BY WK 29
 MECHANISM OF BLEEDING
P
h
y
s
i
o
l
o
g
i
c
a
l

p
h
e
n
o
m
e
n
o
n

w
h
i
c
h

l
e
a
d
s

t
o

t
h
e

s
e
p
a
r
a
t
i
o
n

o
f

t
h
e

p
l
a
c
e
n
t
a

10/09/2022 PP BY WK 30
COMMON BLEEDING TIMES

• Development of lower uterine segment

• Fetal engagement

• Onset of labor

10/09/2022 PP BY WK 31
 RESPONSE TO HEMORRHAGE
I
n

s
e
v
e
r
e

p
r
e
e
c
l
a
m
p
s
i
a
,

t
h
e
s
e

p
h
y
s
i
o
l
o
g
i
c

a
d
a
p
t
a
t
i
o
n
s

a
r
e

a
l
t
e
r
e
d
.

10/09/2022 PP BY WK 32
AIUM new classification of
Placentation

• Placenta previa: placenta covers the internal OS

• Low lying : when placental edge <20mm from

internal OS without covering it

• Normally located placenta: placental edge located

>20mm away from internal OS

10/09/2022 PP BY WK 33
CLINICAL PRESENTATION

• Sudden onset, Painless, causeless and recurrent 3rd

TM bleeding

• Bleeding occurs before 38 weeks in majority of case

• In 10% of cases no bleeding until onset of labor,

especially in primigravids

10/09/2022 PP BY WK 34
PHYSICAL EXAMINATION

• V/S

• HEENT

• Appropriate for date uterus

• Relaxed uterus without tenderness.

• Malpresentation

• Fetal heart sound is usually present

• Vaginal examination: absolutely contraindicated

10/09/2022 PP BY WK 35
ULTRASOUND

• Localization of placenta

• Assessment of invasive placentation

• Prediction of bleeding

10/09/2022 PP BY WK 36
LOCALIZATION OF PLACENTA

• Trans-abdominal

• Trans-vaginal

• Trans-labial

• Color Doppler

• MRI

10/09/2022 PP BY WK 37
• The mid-trimester routine fetal anomaly scan should
include placental localization.

• If a placenta previa is diagnosed repeat sonography

should be obtained in the early third trimester at 32
weeks.

10/09/2022 PP BY WK 38
PREDICTORS OF BLEEDING

• Placental edge

• Cervical length

• Extension over the internal os

10/09/2022 PP BY WK 39
MANAGEMENT

• Admit all ladies with APH secondary to placenta previa

• Resuscitation based on clinical condition.

• Monitor closely maternal & fetal conditions.

• HCT, BG & Rh, cross-match

• Anti D for RH negative

10/09/2022 PP BY WK 40
 Expectant

Immediate delivery

10/09/2022 PP BY WK 41
Indications for immediate delivery

• Term pregnancy

• IUFD

• NRFS

• Heavy bleeding

• Lethal congenital anomaly

• labor

10/09/2022 PP BY WK 42
MODE OF DELIVERY

• Low lying : Vaginal delivery can be allowed cautiously

• Cesarean delivery: Placenta previa, excessive bleeding,

NRFHR or other obstetric indications in low-lying
placenta

10/09/2022 PP BY WK 43
Maternal complication

• PPH
• Shock
• Anemia
• AKI
• Increased operative intervention
• Maternal death
10/09/2022 PP BY WK 44
Fetal and newborn complications

• Prematurity and Low birth weight

• Congenital Malformations
• Neonatal Anemia
• ?IUGR
• Malpresentation
• NICU admission
• Perinatal mortality

10/09/2022 PP BY WK 45
Perinatal mortality
• Decreasing, but still ranges from 10-15%

• Possible causes:
• Preterm delivery
• Asphyxia
• Malformation
• Cord accidents
• Fetal exsanguination

10/09/2022 PP BY WK 46
MATERNAL AND PERINATAL OUTCOME OF
ANTEPARTUM
HEMORRHAGE AT THREE TEACHING
HOSPITALS IN ADDIS ABABA, ETHIOPIA

10/09/2022 PP BY WK 47
Prevention of Perinatal mortality

• Early registration and regular ANC

• Early detection

• Early referral to higher center

• NICU care

• Expectant management

• Elective c/s

10/09/2022 PP BY WK 48
Pitfalls
• Severe anemia diagnosed without evidence

• Severe range BP not managed properly

• ASA for next pregnancy not planned

• Post op fluid management

• U/S about morbidly adherent placenta not mentioned

10/09/2022 PP BY WK 49
Take home message
• Every pregnant women should have at least one
Ultrasound scanning during pregnancy ,placental
location should be seen and documented during
anatomic scanning

10/09/2022 PP BY WK 50
Referrence
•Gabbe obstetrics 7th edition,
•Williams 24th edition,
•RCOG Green-top Guidelines 2018
•Creasy Resniks’s maternal and fetal medicine 8th edition
•Uptodate 2021
•Maternal and perinatal outcome of antepartum hemorrhage
at three teaching hospitals in addis ababa, Ethiopia 2020
•MOH 2021
10/09/2022 PP BY WK 51