This document presents a case study of a 22-year-old pregnant woman, Rupa Serung, who is 38 weeks pregnant and was admitted to the hospital with bleeding per vagina. On examination, she was found to have a grade II placenta previa. Tests showed signs of anemia. An ultrasound confirmed a single fetus in longitudinal lie and cephalic presentation with a low-lying placenta. The diagnosis was grade II placenta previa. The options for management include either expectant management with bed rest or immediate termination of the pregnancy depending on the status of the mother and fetus.

1. Presented by :
Arindom Rajbonshi (14)
Prasanta Ghosh (15)
Arpita Gogoi (16)
Nibir Saikia (17)
CLINICAL CASE PRESENTATION

2. PATIENT PARTICULARS
Name : Rupa Serung
Age : 22 years
Sex : Female
Religion : Hindu
Occupation : Tea garden worker
Education : 5th standard
Marital Status : Married
Duration of marriage : 2 years
Husband’s name : Essak Serung
Husband’s occupation : Daily wage worker
Husband’s education : 5th standard
Address : Borjuli tea estate , Rangapara , Dist. : Sonitpur
LMP – 20/09/2022
EDD – 27/06/2023
Parity index : G1P0L0
Gestational age : 38 weeks
Date of Admission : 10/06/2023
Date of examination : 13/06/2023

3. CHIEF COMPLAINTS
1. Cessation of menstruation for the last 9 months
2. Bleeding per vagina since the last 3 days

4. HISTORY OF PRESENT ILLNESS
• On elaborating the chief complaints , my patient was apparently normal 3
days ago when she noticed bleeding per vagina while waking up from her
sleep. It was sudden in onset and soaked the bedsheet. The blood was bright
red in colour and was not associated with any mucus discharge.
• The bleeding stopped gradually and was not associated with any pain.
• No history of trauma.
• No history of headache, swelling of legs or blurring of eyes.
• No history of doing heavy work or exercise.
• No previous history of bleeding.

5. HISTORY OF PRESENT PREGNANCY :
1ST TRIMESTER :
After missing her normal menstrual period for 1 month, she confirmed her pregnancy by urine
test kit conducted by self at home which was provided by the ASHA worker. It was spontaneous
conception and she had 1 antenatal visit in the 1st trimester.
During this period, she experienced :
• Nausea , vomiting , decreased appetite and increased frequency of micturition .
• She was able to carry on her daily activities.
• There was no history of pain in the abdomen, trauma, discharge per vagina, swelling of legs,
epigastric pain, fever with rash, breathlessness, exposure to radiation or any toxic drugs and
any other illness.
• Her sleep and bowel habits were normal.
• She went to Borjuli tea estate hospital at around two months of her pregnancy for check up
and registration and was given folic acid tablets.

6. 2ND TRIMESTER :
• She had 2 antenatal visits in the 4th and 5th month of her pregnancy.
• Cessation of menstruation continued and she noticed gradual enlargement of abdomen.
• Her nausea and vomiting subsided and appetite returned to normal.
• She perceived fetal movements for the first time at around 5th month of pregnancy which she did not
record in the calendar.
• She received iron and folic acid tablets and calcium tablets and was immunised with 2 doses of tetanus
toxoid on the 4th and 5th month of pregnancy.
• Her sleep, bladder and bowel movements were normal.
• There was no history of pain in the abdomen, trauma, discharge per vagina, fever with rash, swelling of
legs, breathlessness, blurring of vision, exposure to radiation, any toxic drug intake or any other illness.

7. 3RD TRIMESTER :
• She had 2 antenatal visits ain the 7th and 8th month of her pregnancy .
• Cessation of menstruation continued and there was gradual increase in the size of the abdomen.
• Fetal movements have become more pronounced.
• Her sleep, bladder and bowel habits are normal.
• She is taking iron folic acid and calcium tablets regularly.
• There was no history of nausea, vomiting, fever, burning micturition, breathlessness, headache,
swelling of legs, trauma, radiation or any toxic drug intake.
• She has done the USG on 13/06/2023

8. PAST OBSTETRIC HISTORY
• There is no past obstetric history.

9. MENSTRUAL HISTORY
• LMP : 20/09/2023
• Age at menarche : 12 years.
• Cycle is regular.
• Duration of cycle : 28 +/- 2 days.
• Duration of flow : 3-4 days.
• Flow is moderate. She uses 2-3 pads per day.
• Associated with mild pain and passing of clots occasionally.

10. PAST MEDICALAND SURGICAL HISTORY
• Patient does not give any history of chronic disease like hypertension,
diabetes mellitus, tuberculosis, thyroid disorders or any bleeding
disorders.
• There is no history of any previous surgery.

11. FAMILY HISTORY
• There are 4 members in her family. She lives with her husband, mother in law and
father in law.
• There is no history of consanguineous marriage.
• There is no history of any congenital anomaly and genetic disease in the family.
• There is no history of diabetes mellitus, tuberculosis and hypertension in the
family.

12. PERSONAL HISTORY
• My patient consumes rice based mixed Assamese diet
consisting of 3 major meals and 2 minor meals.
• Her sleep in adequate , appetite is good , bowel and bladder
habits are regular .
• There is no history of any substance abuse.

13. SOCIOECONOMIC HISTORY
• She belongs to a lower socio-economic status according to modified
Kuppuswamy scale.
• She lives in a kutcha house with 3 rooms, kitchen is separate. Latrine is separate
and hygenic, ventilation and lighting is adequate and they consume water from a
tubewell after filtration.

14. • Patient and her husband has not taken any contraceptive till date.
CONTRACEPTIVE HISTORY
IMMUNISATION HISTORY
She was immunized with 2 doses of Tetanus toxoid vaccine .
1st dose was give in the 4th month and 2nd dose was given in the 5th month.
• She is immunised with one dose of Covid vaccine.

15. DRUG HISTORY
• She has taken folic acid tablets upto 3rd month and iron-folic acid
supplementation along with calcium supplementation from the 3rd month
onwards.
• Other than this , she is not taking any other drug for any illness.
ALLERGIC HISTORY
• The patient is not allergic to any known substance till date.

16. EXAMINATION
1) General Examination
2) Systemic Examination
3) Obstetric examination

17. 1) General Examination
• Appearance = Normal
• Height = 152 cm Weight = 53 kg
• Built = Average
• Nutrition = Good
• Pallor = Present
• Icterus, Cyanosis, Dehydration, Lymphadenopathy, Edema
= Absent. No engorged veins & Varicose veins.
• Pulse = 92 bpm
• RR = 22/min
• BP= 110/70 mm Hg

18. 2) Systemic Examination
1. CARDIOVASCULAR SYSTEM
• Inspection: Shape of precordium = normal. No scar mark present and no other significant
finding.
• Palpation Apex beat present at 1.25 cm lateral to the left mid-clavicular line at 4th ICS.
• Auscultation : S1 & S2 heard.
2. RESPIRATORY SYSTEM
• Inspection- Shape of chest = normal and bilaterally symmetrical, and moves equally with
respiration. No scar mark, pigmentation seen.
• Palpation- Trachea in midline.
• Percussion- Resonant note heard all over the chest.
• Auscultation- normal vesicular breath sounds.

19. • Nervous system – Alert, conscious,
cooperative & well-oriented to time, place and
person, No neurological deficit
• Gastrointestinal system – No significant
finding, Liver & spleen = Non palpable

20. 3) Obstetric Examination
• Examination of Breast
• Abdominal Examination
• Per vaginal Examination (IF INDICATED)
Contra-indicated

21. Examination of Breast
• INSPECTION
Both breasts are uniformly enlarged
Nipples = Everted, Secondary areola & Montgomery tubercles
• PALPATION
No local rise of temperature
No tenderness
No any palpable lump

22. Abdominal examination
• Inspection : Shape, Flanks, Umbilicus, Striae, Scar,
Pigmentations, Fetal movements, Engorged veins
• Palpation :
Uterus – Soft and Non tender
Fundal height – Corresponds to 32 weeks of
gestation with fullness of flanks
Symphysio-fundal height = 32 cm

23. • Fundal Grip – Soft, broad, irregular mass
• Lateral Grip - Right side – Multiple irregular knob like
structure
Left side – Smooth curved resistance feel.
• Pelvic Grip
1st – Hard, Globular, Ballotable
2nd – Finger tips = Approximating
Sinciput at higher level than occiput.
OBSTETRICAL GRIPS

24. • Auscultation
FHS – Present
Site – Left Spino-Umbilical line
Rate – 138 bpm
Rhythm - Regular
• PV Examination = Not done

25. Case Summary
• Mrs. Rupa Serung, 22 years , G1P0L0 , was admitted on
10/06/2023 to the Obstetrics ward of Tezpur Medical College and
Hospital with complain of bleeding per vagina. Her LMP was on
20/09/2022, making her EDD 27/06/2023. She is consuming IFA
and Calcium tablets and is immunized with 2 doses of Td
vaccine. She is non hypertensive and non diabetic with no history
of trauma, exposure to radiation or chemotherapeutic drugs.
• On general examination, she was found to be average built with
height of 152 cm and weight 53 kg .No other significant findings
were present except pallor.

26. • On obstetrical examination; height of the fundus
corresponds to 32 weeks of gestation with fullness of
flanks, with longitudinal lie & cephalic
presentation, with Non-engaged head. On
auscultation, fetal heart sounds were audible on left
spino-umbilical line which was 138 bpm and regular
in rhythm and clear in intensity .

27. Provisional Diagnosis
From history and examination, my patient Rupa
Serung of 22 years , G1P0L0,on 38 weeks of gestation
with Longitudinal Lie & Cephalic Presentation and
with head Non-Engaged present with Antepartum
hemorrhage and not in labour .

28. Differential Diagnosis
• Placental abruption
vaginal bleeding with pain,
tenderness of uterus.
• Vasa previa
• Abnormality of Cervix
cervical erosion or polyp or cancer.

29. MANAGEMENT
MATERNAL RESUSCITATION:-
• After admission of my patient, Airway, Breathing and
Circulation was maintained.
• Amount of blood loss is noted by general
condition,pallor,pulse rate and BP.
• 2 large bore IV cannulas (no. 14 : orange/ no. 16 : gray) were
inserted for infusion of normal saline and obtaining blood
samples for Group determination, Cross-matching,
Hemoglobin, Hematocrit and Platelet count and Oxygen was
given by mask.
• Gentle abdominal palpation and inspection of vulva
• For confirmation of the diagnosis, necessary Investigations
and Ultrasonography were done.

30. INVESTIGATIONS
BLOOD INVESTIGATIONS:-
• ABO grouping:- B
• Rh typing:- Positive
• Hemoglobin:- 9.1 g/dL
• Hematocrit:- 28.0%
• MCV:- 80 μm3
• MCH:- 26.1 pg
• MCHC:- 32.6 g/dL
• Platelet count:- 247× 103/mm3
URINE EXAMINATION:-
• Ketone Bodies:- Nil
• Albumin:- Absent

31. • Routine Blood Sugar(RBS) :- 71 mg/dL
• Serum TSH :- 2.09 mIU/L
• Serum Creatinine :- 0.4 mg/dL
• HBsAg Test :- Non reactive
• Anti HCV antibody test:- Non reactive
• VDRL :- Non reactive
• HIV I & II :- Non reactive

32. • According to the USG report dated 13/06/23 done at the
radiology department of Tezpur Medical College & Hospital, a
single viable fetus is noted in uterus with variable presentation at
time of examinaton.
• Fetus corresponds to gestational age of 38 weeks.
• Fetal Heart Rate is found to be 138 bpm at the time of
examination.
• Liquor volume is adequate at the time of examination
• Low Lying Placenta noted (Grade II- Marginal Placenta
previa ; Placental edge reached the margin of internal os but not
cover the os )
• Active fetal movements noted.
ULTRASONOGRAPHY

33. FINAL DIAGNOSIS
My patient Rupa Serung, 22 years old, G1 P0 L0 A0,
gestational age of 38 weeks with a single live fetus in
longitudinal lie and cephalic presentation, head is
non-engaged, well flexed with Fetal Heart Rate of 138
bpm, regular in rhythm and clear in intensity and not in
labour, presents with Grade II placenta previa.

36. ACTIVE(Definite) MANAGEMENT
• Pregnancy is immediately terminated.
The indications of definitive management (delivery) are :
• Bleeding continues .
• Pregnancy more than 37weeks.
• Patient is in labor.
• Patient is in exsanguinated state on admission.
• Baby with non-reassuring cardiac status or dead or known to be
congenitally deformed.

37. Mode of delivery

38. Expectant Management
(also called as Macaffe and Johnson regime)
• Goal is to carry pregnancy till term without putting mothers life at risk with an
aim to achieve fetal lung maturity.
Vital prerequisites :
• Availability of blood transfusion whenever required.
• Facilities for C- section should be available throughout 24hours.
Indications :
• Gestational age less than 37 weeks.
• No active bleeding
• Hemodynamically stable(Hb>10g%,hematocrit>30%).
• Fetall wellbeing is assured.

39. Conduct of treatment:
• Bed rest with bathroom and toilet privileges.
• Investigations— like hemoglobin estimation, blood grouping and urine
for protein are done.
• Periodic inspection of the vulval pads and fetal surveillance with USG
at interval of 2–3 weeks .
• Supplementary hematinics and blood loss is replaced by adequate
cross matched blood transfusion .
• Cusco’s vaginal speculum examination : when patient is allowed out
of the bed (2-3 days after the bleeding stops), a gentle vaginal
examination is made to exclude local cervical and vaginal lesions for
bleeding.
• Tocolysis like magnesium sulfate can be done if vaginal bleeding is
associated with uterine contractions.
• Rh immunoglobin should be given to all Rh negative (unsensitized)
women.

40. Expectant management is continued till 37weeks of pregnancy.
Conditions where pre term delivery have to be performed :
• Recurrence of brisk haemorrhage and which is continuing.
• Non reassuring fetal status
• Fetus is dead.