This is a case of a 35 yr pregnant lady presenting with painless PV bleeding. The case was presented by Shadman Shakib, 5th yr med student of DMC.

1. 35 yr Old Pregnant
Lady With
Painless Per Vaginal
Bleeding
Md Shadman Shakib
Student of K-71
Dhaka Medical College

2. Particulars of the patient
 Name- Mrs Maleka
 Age – 35 yrs
 Sex: Female
 Religion: Islam
 Marital Status : Married
 Occupation: Housewife
 Present Address: Saturia, Manikganj
 Permanent Address: Saturia, Manikganj
 Route of Entry -Emergency
 Date & time of Admission: 24.05.18 , 4.00 AM
 Date & time of Examination: 24.05.18 , 9.00 AM

3. Chief complaints
 Pregnancy for 34 wks
 Recurrent per vaginal bleeding for 10 days
 Generalized weakness for 24 hrs

4. History of present illness
According to the statement of the patient she was a regularly
menstruating women. Her LMP was 21.09.17 & accordingly her EDD
28.06.18.Her pregnancy was confirmed by urinary beta hcg test at 3rd
week of gestation and farther by ultrasound . This is her 3rd conception
& a planned pregnancy. She was on regular antenatal check-up & she
was a booked case of the local UHC . She was properly immunized by
TT vaccine & her antenatal period was uneventful till 10 days ago

5. when she noticed sudden per vaginal bleeding which was
moderate in amount
bright red in colour
not associated with abdominal pain
no history of passage of any blood clot

6. ,She had 3 episodes of bleeding, 2 of them persisting 1-2 days
when she did not consult with any doctor but the last episode
continued for 3 days.Her perception of fetal movement was
normal.On query she denied any history of trauma or fall . She
also complained of generalized weakness for last 24 hrs . She
had no complaints of fever, burning sensation or increased
frequency or urgency during micturition or leg pain. Her bowel

7. habit is normal . She is normotensive & non diabetic.
With this complaints she was admitted in local UHC & was
referred to DMCH & was duly admitted for better
management.

8. Obstetric history
 Married for- 10 yrs
 Para-2
1 NVD , 1 C/S
 Gravida – 3rd
 Abortions/MR- Nil
 Age of last child – 4 yrs

9. OBSTETRIC CHART
Serialno
YearofPregnancy
Durationof
pregnancy
ANC
Complications
duringpregnancy
Mode&placeof
delivery
Complicationduring
delivery
Puerperium
Infant
01 2009 38 wk Regular No NVD at
hospital
No Normal Alive
Wt : 2.8 kg,
Female
No
congenital
Anomaly
Exclusively
breastfed
02 2014 36 wk Regular APH at 36th
week
C/S due to
placenta
praevia at
hospital
No Normal Alive
Wt : 3 kg,
Male
No
congenital
Anomaly
Exclusively
breastfed

10. Menstrual history
 Age at menarche- 13 yr
 Menstrual cycle – 28-30 days
 Period – 4-5 days
 Flow- Average
 LMP- 21.09.17
 EDD- 28.06.18

11. Contraceptive history
She has not taken any contraceptive method so far.

12. History of past illness
She has no past history of DM, HTN, MI,TB,SLE,
asthma, jaundice or thyroid disorder & no history of any
surgical intervention.

13. Family history
Father died 5 yrs ago at the age of 70 due to stroke. He
had DM & HTN.
Mother is alive & is in good health.
She has 4 siblings, all are in good health .

14. Personal history
She has habit of taking Gul. She takes normal Bangali
diet rich in protein & carbohydrate.No history of smoking,
alcoholism or taking cocaine or other recreational drugs.

15. Drug history
She took iron & folic acid supplementation , dose &
duration she cannot mention. Now she is on some
medications ,names & doses could not be mentioned by
her.

16. Immunisation history
She has got TT vaccines as per EPI schedule.

17. Socioeconomic history
Monthly family income – Taka 50000+
Lives in a brickbuilt house
Drinks safe drinking water.
Uses sanitary latrine.

18. General examination
 Appearance – Ill looking
 Body built- Average
 Co-operation – Co-operative
 Decubitus – On choice
 Nutritional status – Well nourished
 Anemia- Moderate
 Jaundice - Abesnt

19.  Edema - Absent
 Dehydration –Mild
 Cyanosis -Absent
 Pulse - 65 /min
 Blood pressure - 110/70 mm Hg
 Respiratory rate - 18 /min
 Temperature - 99◦F

20.  Heart : 1st and 2nd heart sound was audible in all 4 areas , no added
sound
 Lungs: Both lung fields were clear with vesicular breath sound
 Skin condition- Normal
 Breast examination –Not done
 Thyroid gland –Not palpable
 JVP- Not raised

21. Abdominal examination
Inspection
Abdomen is uniformly distended with umbilicus
centrally placed & everted
Abdominal skin is tense
Linea nigra & striae gravidarum was present
Previous scar mark of Pfannenstiel incision present,
no engorged vein.

22. Palpation
SFH 34 cm corresponding to the age of gestation
Uterus is felt as relaxed ,soft & elastic without any localized
tenderness
Fundal grip- hard globular structure which represents foetal
head, head is ballotable
Lateral grip- smooth curved structure which represents foetal
back was felt on left side & irregular knob like structure which

23. represent foetal limbs were felt on right side.
First pelvic grip- Soft broad irregular mass representing
breech
Second pelvic grip- Breech is not engaged
Abdominal girth- 94.5 cm
Percussion
No evidence of ascites

24. Auscultation
Foetal heart sound was heard & FHR was 140 at that
minute & was regular.
Per Vaginal Examination:
Inspection revealed bright red bleeding

25. Salient features
Mrs. Maleka 35 yrs female , married muslim housewife of middle
class family ,para-2 ( 1 NVD 1 C/S) , 3rd gravida & ALC-4 yrs, was
admitted into DMCH on 24/05 /2018 at the 34 weeks of
gestation with complaints of recurrent per vaginal bleeding for 3
days & generalized weakness for 24 hrs . According to the
satatement of the patient she was a regularly menstruating
woman. Her LMP was 21.09.17 & accordingly EDD 26.06.18.Her

26. pregnancy was cofirmed by urinary β-hcg test & farther by ultrasound.
She was a booked case & took her ANC irregularly.She was immunized by
TT vaccine according to EPI schedule.Her antenatal period was
uneventful till 10 days ago when she noticed moderate amount of
painless bright red per vaginal bleeding with no abdominal pain & no
history of passage of any blood clot per vagina. She had 3 events of
bleeding, 2 of them persisting 1-2 days & she did not

27. consult with any doctor then . But the last episode is continued
for 3 days. She had no history of any trauma or fall. She had no
complaints of fever, burning sensation or increased frequency
or urgency during micturition or leg pain.Her bowel habit was
normal.She was normotensive & nondiabetic. Her obstetric
history revealed that her 2nd baby was delivered preterm at 36th
week by LSCS due to APH due to placenta praevia.

28. With due consent she was examined & on general
examination she was found ill looking with average body built,
co operative, decubitus on choice , moderately anemic ,
anicteric, no edema, mildly dehydrated, non cyanosed . Pulse
rate was 65/min, BP 110 /70 mm Hg , respiratory rate 18/ min
& temperature 99◦F.

29. Abdominal examination revealed SFH 34 cm corresponding to
the age of gestation , hard globular ballotable foetal head on
fundal grip ,smooth curved foetal back on left side & irregular
knob like foetal limb on right side . Soft broad irregular mass
representing breech in 1st pelvic grip & breech was not engaged
as evidenced by 2nd pelvic grip . FHR was 140 at that minute &
was regular. PV examination revealed bright red bleeding on
inspection.Examination of other systems were normal.

30. PROVISIONAL
DIAGNOSIS ?

31. A case of 3rd gravida with 34 wk
pregnancy with Antepartam
Hemorrhage due to placenta praevia
with breech presentation

32. Differential diagnosis
APH due to Abruptio placenta
Morbidly adherent placenta
Vaginal or Cervical trauma
Local malignancy

33. Investigations
For Dx purpose – Placentography for localization of placenta by
Sonography
-TAS
-TVS
-colour doppler study
MRI

34. Clinical
-Double set up examination
-Direct visualization during caesarean delivery.
-Examination of placenta following VD

35. For management purpose
Hb% , Hct
Blood grouping & Rh typing

36. TREATMENT
Expectant management (As her bleeding was light & stopped
now)
Bed rest with bathroom privileges.
Blood samples for grouping & Rh typing ,cross matching,
Hb% estimation.
IV access , to correct dehydration.
Blood transfusion ,if needed.

37. Fetal surveillance by USG at 2-3 weeks interval
Gentle speculum examination after 1 week of cessation of
bleeding to exclude local malignancy.
*Continued till 37 wk of gestation

38. Definite management
As it is her post caesarean pregnancy, Caesarean
section at 37th completed week is the definite management
irrespective of type of placenta praevia.