This case presentation summarizes the management of a 26-year-old pregnant woman for antepartum hemorrhage secondary to placenta previa. She presented at 34 weeks gestation with vaginal bleeding and was found to have a complete placenta previa covering the cervical os. She underwent an emergency cesarean section to deliver a stillborn fetus. Post-operatively, she developed features of preeclampsia and was managed accordingly. She recovered well and was discharged on post-operative day four.

1. 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)

2. CONTENT
• Case summary
• Discussion
• Scientific discussion
• Comment
• Take home message
• Reference
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3. IDENTIFICATION
• Name: W/T
• Age: 26 years
• Marital status: married
• Address :O/Nada
• DOA :19/05/14
• DOD:23/05/14
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4. 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
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5. • Has easy fatigability, palpitation, light headedness
and dizziness
• Has no headache, blurring of vision or epigastric pain
• No known medical or surgical illness
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6. 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
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7. • Abdomen: -
• 34 week sized
gravid uterus
• Longtitudinal lie
• Breech
• Has contraction
• FHB: negative
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U/S:- SIUPX
-FHB: negative
-Breech
-Placenta covers cervical os
totally and bulk is anterior
-FL:31+4 wks
Index:3rd TM PX +
PPT+IUFD
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8. • GUS: -There is active vaginal bleeding
• MSK: NAD
• INTEG:NAD
• CNS: COTTPP with GCS 15/15
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9. • 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
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10. 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
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11. • 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
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12. • 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
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13. 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
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14. • 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.
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15. 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 bleeding
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16. 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
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17. • 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
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18. 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%
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19. 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
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20. 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
DBP:85-100
82-84 22-24 36.9-37.3 UOP
1000/16Hr
21/5/14 SBP:140-150
DBP:90-95
80-96 20-22 36.2-37.3
22/5/14 SBP:130-150
DBP:80-100
86-104 20-24 34-37.6
23/5/14 SBP:120-135
DBP:70-86
80-100 22-24 36.7-37.3
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21. 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
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22. 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
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23. • 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
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24. DISCUSSION
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25. Problems identified
• Bilobed placenta
• IUGR
• Breech presentation
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26. 7/30/2022 26
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27. 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
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28. ETIOPATHOGENESIS
• 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
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29. RISK
FACTORS
Previous history
Previous uterine surgery
large placenta
Parity
Age
Intrauterine procedure
Race
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30. MECHANISM OF BLEEDING
last months of pregnancy lower
uterine segment persistently increase
while placental growth is lower.
Opening up of uteroplacental vessels
and leads to an episode of bleeding.
Physiological phenomenon which
leads to the separation of the
placenta
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31. COMMON BLEEDING TIMES
• Development of lower uterine segment
• Fetal engagement
• Onset of labor
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32. RESPONSE TO HEMORRHAGE
10% of the circulatory blood volume is lost,
vasoconstriction in order to maintain blood
pressure
As blood loss reaches 20%, systemic vascular
resistance can no longer compensate and
blood pressure and Cardiac output decreases.
In severe preeclampsia, these physiologic
adaptations are altered.
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33. 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
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34. 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
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35. PHYSICAL EXAMINATION
• V/S
• HEENT
• Appropriate for date uterus
• Relaxed uterus without tenderness.
• Malpresentation
• Fetal heart sound is usually present
• Vaginal examination: absolutely contraindicated
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36. ULTRASOUND
• Localization of placenta
• Assessment of invasive placentation
• Prediction of bleeding
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37. LOCALIZATION OF PLACENTA
• Trans-abdominal
• Trans-vaginal
• Trans-labial
• Color Doppler
• MRI
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38. • 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.
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39. PREDICTORS OF BLEEDING
• Placental edge
• Cervical length
• Extension over the internal os
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40. 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
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41. Expectant
Immediate
delivery
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42. Indications for immediate delivery
• Term pregnancy
• IUFD
• NRFS
• Heavy bleeding
• Lethal congenital anomaly
• labor
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43. 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
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44. Maternal complication
• PPH
• Shock
• Anemia
• AKI
• Increased operative intervention
• Maternal death
• Recurrence with adherence
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45. Fetal and newborn complications
• Prematurity and Low birth weight
• Congenital Malformations
• Neonatal Anemia
• ?IUGR
• Malpresentation
• NICU admission
• Perinatal mortality
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46. Perinatal mortality
• Decreasing, but still ranges from 10-15%
• Possible causes:
• Preterm delivery
• Asphyxia
• Malformation
• Cord accidents
• Fetal exsanguination
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47. MATERNAL AND PERINATAL OUTCOME OF ANTEPARTUM
HEMORRHAGE AT THREE TEACHING HOSPITALS IN ADDIS
ABABA, ETHIOPIA
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48. Prevention of Perinatal mortality
• Early registration and regular ANC
• Early detection
• Early referral to higher center
• NICU care
• Expectant management
• Elective c/s
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49. 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
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50. 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
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51. 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
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