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wKcase on placenta abnormalities final.pptx
1. Case presentation on a patient managed for late
term pregnancy+ LFSOL+ breech presentation+
+ IUGR + Bilobed placenta
By Dr. Wondmeneh(R2)
Moderator: Dr.lammi(R4)
2. CONTENT
• Case summary
• Discussion
• Scientific discussion
• Comment
• Take home message
• Reference
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3. IDENTIFICATION
• Name: A/A
• Age: 26 years
• Marital status: married
• Address :Jimma
• DOA :21/11/14
• DOD:25/11/14
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4. Senior resident evaluation ANC on 22/9/14
• G2A1(@2 ½ months, spontaneously) lady
• GA:33weeks from R.LNMP(01/02/14)
• ANC follow up at this hospital, uneventful
• She feels fetal movement as usual
• Has no headache, blurring of vision or epigastric pain
• No passage of liquor or vaginal bleeding
• No hx of DM,HTN or other chronic medical illness
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5. P/E
• G/A: well looking
• V/S: BP: 100/70 PR:70 RR: 20 T: 36.4
• HEENT: Pink conjunctiva, non icteric sclera
• LGS: No anterior neck mass
• Chest: clear chest and good air entry
• CVS: S1 and S2 well heared, no murmur no S3 gallop
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6. Abdomen:
• 32week sized gravid
uterus
• Longitudinal lie
• Breech
• no contraction
• FHB: 144
U/S:-
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7. • MSK & INTEG:NAD
• CNS: COTTPP
• Assessment: early preterm pregnancy+ breech + RBPP
+ bilobed placenta
• Plan:-advice on danger signs
• Ferrous sulphate 325mg po daily
• Consult senior
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8. Senior resident evaluation labor ward on
21/11/14
• G2A1(spontaneously@2 ½ )
• GA:41+3 weeks from R.LNMP
• ANC follow up at this hospital2x and FGA 2x
• Told to have breech presentation
• Presented with pushing down pain of 2 hours ,but no
passage of liquor
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9. • Has no headache, blurring of vision or epigastric pain
• No pushing down pain, passage of liquor or vaginal
bleeding
• No known chronic medical illness
• Feels fetal movement as usual
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10. P/E
• G/A: in labor pain
• V/S: BP: 120/80 PR:96 RR: 22 T:
• HEENT: Pink conjunctiva
• LGS: NSLAP
• Chest: NAD
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12. • GUS: cervix is 3 cm dilated,70%effaced,M-itact
• Fetal foot is palpable in the cervical canal past the
buttock
• MSK & INTEG:NAD
• CNS: COTTPP
• Assessment: late term pregnancy+ breech
presentation(footling)+ ?IUGR
• Plan:-prepare for emergency CS
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13. Operation note
• After informed written consent taken patient prepared
and transferred to OR
• Under SA abdomen cleaned and draped
• Abdomen entered via pfannesteil incision
• Finding:
• Intact gravid uterus
• Healthy looking tubes, ovaries and urinary bladder
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14. • Done:
• Vesicouterine peritoneum reflected down and LUST
incision made to effect delivery of alive male neonate
weighting 2.1KG with APGAR score of 7/9 at 1st and 5th
minutes respectively
• Pitocin 10IU IM stat given, placenta delivered by CT.
• There is separate lobe of placenta connected with
membranous blood vessel crossing over
• Uterus exteriorized, mopped and closed in 2 layers using
vicryl no 2
• Hemostasis secured, Correct counts reported
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15. • Fascia and skin closed using vicryl no 2 and 3/0
respectively
• Mother and neonate transferred to recovery room with
stable V/S
• EBL-400ML
• TOLAC possible in next pregnancy
• Newborn has features of IUGR
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16. Post op Order
• P: Immediate postop day after LUST C/S done for
LFSOL+ Footling breech
• C: subcritical
• A: encourage ambulation
• D: start SIPS after 8hrs
• Ix: Determine post op hct after 8hrs
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17. • Treatment:
• Put on maintenance fluid(3L of NS,DNS and RL) every 8
hours/24hour
• Check uterine tone intermittently
• Watch for vaginal bleeding
• V/S every 15min for first 1hrs then then every 1
hour/4hours then QID.
• Tramadol 50mg IV TID
• Remove foley catheter after 8hrs.
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18. Investigation chart
date investigation result
21-11-14 CBC WBC- 11.39 NE-85.2%
HGB- 15.8 HCT-46.4%
PLT-142000
TSH 6.53
B/F NO H/P Seen
BG/RH A+
VDRL Negative
HBsAg Negative
U/A Blood +1
Others negative
Postop HCT 46.4%
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19. POST OP V/S FOLLOW UP
date Time BP PR RR TEMP Medication
21-11-14 10:40AM 124/60 96 24 36.2
10:55AM 125/64 96 24 36.1
11:10AM 124/62 94 24 36.2
11:25AM 126/60 96 22 36.4
11:40AM 120/66 92 22 36.6
11:55AM 119/75 84 22 36.5
100-110/70 80-87 20-22 36-36.9
22/11/14 SBP-100-120
DBP-70-80
90-120 20-24 36.6-37.7
23/11/14 SBP-90-110
DBP-60-70
104-108 22-24 36.6-36.8
24/11/14 SBP-100-110
DBP-60-70
104-116 20-24 36.7-37
25/11/14 SBP-100-110
DBP-60
96-112 20-24 36.5-36.8
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20. Plan upon discharge
• Advised on danger symptoms, newborn care ,EBF
• Counseled on FP, Opted for implanon
• TOLAC possible
• Advised on interpregnancy interval
• Next ANC should be at hospital and early U/S
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23. • Placenta is a feto-maternal organ that develops in
uterus during pregnancy.
• consisting of umbilical cord, membranes and
parenchyma
• Provides oxygen and nutrients to fetus and
removes waste products from fetus.
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24. • Oval
• Diameter : 22 cm
• Thickness : 2.5 cm
• weights : approximately 470 g
• Two surfaces- Maternal and fetal
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25. • Abnormal Shape or Implantation
• Degenerative Lesions
• Circulatory Disturbances
• Inflammatory
• Tumors
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27. • Also known as bipartrite or duplex placenta
• 2-8% of placentas
• Roughly equal size lobes are separated by a segment of
membranes
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28. • Refers to a placenta with an additional lobe or lobes of
placental tissue located a few centimeters away.
• Called placenta spuria if no vascular communication
• 3% of pregnancies
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29. Bilobed
• Equal size
• Central cord insertion
• Lobes are attached by
chorionic tissue
• Primary PPH
succenturate
• Different size lobes
• Eccentric and
velamintous cord
insertion
• Lobes are attached by
membranes
• RPOC more common,
late PPH
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32. • localized atrophy as a result of poor decidualization
and vascularization in a part of the uterus
• Implantation in areas of decreased uterine perfusion
• Other local factors :
• Implantation over leiomyomas,Area of previous
surgeries and Over the cervical os
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33. • most important, in preventing adverse outcomes
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37. Take home message
• Prenatal diagnosis of the bilobed placenta in scans
alerts the obstetrician and helps appropriate planning,
prompt recognition, and treatment of complications
associated with it.
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38. • Williams obstetrics 26th edition
• Uptodate 2021
• Benirschke Pathology of the Human Placenta 6th Edition
• Suzuki S, Igarashi M. Clinical significance of pregnancies
with succenturiate lobes of placenta.
• Sumisti S (2019) Antenatal Discovery of Bilobed Placenta
Helped Manage Third Stage of Labor: A CasenReport
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