A 32-year-old woman, gravida 5,Para1 ,Living 1 And abortion 3 presented to emergency department for bleeding per vagina at 33 weeks and 3 days,have GDM that is controlled by diet and previous LCSC 7 years ago. She is not in labor.

1. OBG Case Review
Demographic data of the patient:
Name:ABC
Age:32
Occupation:Housewife
Nationality: Egypt
Marital status:Married , for 9 years
Blood group:A+ve
Husband:
Name:XYZ
Age:36
Nationality: Egypt
Consanguinity:Not related
Blood group:A+ve
Parity Index:G5P1L1A3
LMP:15th
May 2020
EDD:19th
Feb 2021
GA: 33 weeks 3days
CHIEF COMPLAINT& DURATION:Bleeding per vagina since 1 day
H/O PRESENT ILLNESS:The patient was feeling all fine in the morning on the other day and she said
that she had a slight dull pain in the lower abdomen as she worked around the house .the pain was
intermittent coming every 10 minutes with no radiation. and noticed vaginal spotting when she went to
use the washroom later that day .The bleeding was scant without any clots.She doesn’t complaint of any
associated nausea,vomiting or headache.She is a known case of placenta previa centralis .She was bought
to emergency department in Fujairah hospital the same day by evening.
HISTORY OF PRESENT ILLNESS-
1ST TRIMESTER
 It is a Planned pregnancy , conceived naturally
 Confirmation via home test followed by admission in Kalba hospital
 tiredness, malaise was present
 Regular Bookingsand Imaging (crown rump length) done
2nd TRIMESTER
 Active foetal movements
 Mild Symptoms of anemia was noted
 Routine Imaging (head circumference), Anomaly scanning and Blood pressure check ups

2. done
 Changes in weight was noted
3rd TRIMESTER
 Currently diagnosed with GDM, controlled by diet
 No History of UTI or vaginal discarges
PAST OBSTETRIC HISTORY
 First Pregnancy :- Boy child of 41 weeks GA born in 2013 via C-section Breastfeeding
started immediately ,Exclusive breastfeeding for 6months, Developmental milestones
reached on time
 Second Pregnancy :- Misscarriage at 6th week in 2015
 Third Pregnancy:- Miscarriage at 7th week in 2016
 Fourth Pregnancy :- Miscarriage at 6th week in 2018
Parity Index: G5P1L1A3
LMP:15th May 2020
EDD:19th Feb 2021
GA: 33 weeks 3days
MENSTRUAL HISTORY
 Menarche attained at 11 years of age
 Cycle duration and frequency - ( 27 +/- 2 days)
 Regularity of previous cycles - Regular
 Amount of bleeding and associated clots - 2-3 pads per day, moderately soaked
GYNAECOLOGICAL HISTORY
• Age of menarche at 11 years with Regular cycles
• LMP on 15th May 2020,
• No history of Cervical smear or fibroids or other utrerine pathology
• Methods of contraception – Barrier method
PAST MEDICAL HISTORY
•No history of HTN, DM or epilepsy
PAST SURGICAL HISTORY
• C-section for first pregnancy in 2013
• 2 ERCPs in 2010
• No associated complications or reaction to anaesthesia.

3. FAMILY HISTORY
• Father a known case of HTN
• No Genetic disorder runs within family
• No History of twin.
DRUG HISTORY
• Calcium carbonate 500mg tab q24hr
• Ferrous sulphate 200mg Oral q12hr
• other Pregnancy related medication (folic acid,antiemetic) ,vitamins and nutritional
supplements.
SOCIAL HISTORY
• Doesn’t smoke nor takes alcohol, No recent travel history
PERSONAL HISRTORY
• Lives with her husband and child in villa , No pets in the house.
EXAMINATION
Vital signs
 Temp –36.8
 HR-102
 RR - 18
 BP -103/62
 SpO2- 98%
 Weight -72.5 Kg
Gernral examination:- Alert and oriented, well nourished, no acute distress.
Systemic Examination
- Eye: PERRL, EOMI, normal conjunctiva.
- HENT: Normocephalic, clear tympanic membranes, normal hearing, moist oral mucosa,
no scleral icterus, no sinus tenderness.
- Neck: Supple, non-tender, no carotid bruits orJVD, no lymphadenopathy.
- Lungs: Clear on auscultation and percussion, no labored respiration.
- Heart: Normal rate, regular rhythm, no murmur, gallop or edema.
- Abdomen: Soft, non-tender, normal bowel sounds, no mass.
- Musculoskeletal: Normal range of motion and strength, no tenderness or swelling.

4. - Neurologic: Awake, alert, and oriented with CN II to XII intact.
- Psychiatric: Cooperative, appropriate mood and affect
INSPECTION - Distention andomen with previous pregnancy Scar (in the event of previous C section)
with Striae Gravidarum .
Leopold maneuver 1 - FUNDAL GRIP
- A softer triangular pole continuous with the foetal body indicating the foetal buttocks
Leopoldsmaneuver 2 - LATERAL GRIP
- A firm, regular surface on the left side indicating foetal back and lumpy and irregular
knob like projectionnth eright side for foetal limbs
Leopolds maneuver 3 - PAWLIK’S GRIP
- A hard, smooth, round pole indicates the foetal head.
DIAGNOSIS: Placenta previa
MANAGEMENT:
 Initially asked to take bed rest and limitation of activity as she was not in labour yet.
 Tocolytic medications given to buy time inorder to avoid preterm labour.
 blood transfusions may be required depending upon the severity of the condition.
 Cesarean delivery is required for complete placenta previa.
RECENT ADVANCES IN DIAGNOSIS AND MANAGEMENT:
 Ultrasound is both sensitive and specific for the diagnosis of PP, although this is operator
dependent. It may be performed by a transvaginal, transabdominal, and there is concern
regarding significant bleeding and possible cervical dilatationin TVS approach, although
transvaginal ultrasound is preferred as it helps in in accurate position of the placenta
placement.
 A course of steroid injections between 34 and 36 weeks of pregnancy to help your baby
to become more mature
 If you go into labour early, you may be offered a type of medication (known as tocolysis)
that is given to try to stop your contractions and to allow you to receive a course of
steroids.
Case summary
A 32-year-old woman, gravida 5,Para1 ,Living 1 And abortion 3 presented to emergency department for
bleeding per vagina at 33 weeks and 3 days,have GDM that is controlled by diet and previous LCSC 7
years ago. She is not in labor.
DISCUSSION

5. When the placenta continues to lie in the lower part of the uterus as the pregnancy continues it is
termed as placenta previa , It is known as low-lying placenta if the placenta is less than 20mm
from the cervix or as placenta praevia if the placenta completely covers the cervix.
Risk factors include uterine scarring (most commonly due to prior cesarian section), advanced
maternal age, smoking, previous multiple pregnancies/short interpregnancy intervals or
miscarriages/induced abortions, prior PP etc.Usually the previa is marginal or partial. In the
absence of bleeding, this should be followed by serial ultrasounds at 28 to 32 weeks to ensure the
previa has resolved. In the current case Complete PP, however, does not usually resolve,
therefore monitoring by serial ultrasound is necessary.
FOLLOW UP
• Patient monitored by serial ultrasound and CTG checked regularly
• Patient is counselled about Emergency C section in any case of APH,risk of prematurity
fully explained
• All risks including APH and PPH explained
• Cross matching for blood transfusion done