Placenta Previa With Breech
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Transcript of Placenta Previa With Breech
CASE PRESENTATION Lopez, Julianne
Ramos, Iso
General Objectives: To discuss a case of placenta previa To discuss the management of placenta
previa
General Data: 29 yo G2P1(1001) Married Roman Catholic 1st avenue, East rembo, Makati Admitted for the first time (Mar 6, 2012) AOG: 37 3/7 weeks
Chief complaint: Irregular uterine contractions
History of present Illness: LMP: June 17, 2011 AOG: 37 3/7 weeks AOG by LMP
36 5/7 by UTZ (24 5/7 weeks on 12/12/11) First trimester check up:
1st PNCU done at 2 months AOG at East Rembo health center
CBC and urinalysis done (normal) Regular intake of multivitamins, folic acid and
milk Denies history of illnesses, exposure to radiation
and viral exanthem
History of present Illness: 2nd trimester check up:
Regular visits with same health center Quickening at 4 months AOG (October,
2011) No tetanus toxoid given Regular intake of multivitamins and ferrous
sulfate
History of present Illness: 2nd trimester check up:
Pelvic UTZ (done on 12/12/11): Single, live, intrauterine pregnancy, cephalic,
24.6 weeks AOG by BPD and PL, placenta previa marginalis, grade I (left posterolateral area extending to the margin of the internal cervical os)
Denies vaginal bleeding
History of present Illness: 3rd trimester check up:
Regular visits at same health center Regular intake of multivitamins and ferrous
sulfate
History of present Illness: 3rd trimester check up:
Pelvic UTZ (done on 2/22/12): Single live intrauterine pregnancy, cephalic,
35.1 weeks AOG by BPD and FL, low lying placenta, grade 2-3 (left posterolateral area, extending to the lower uterine segment), Normohydramnios (19.1 cm)
Referred to OB OSMAK further evaluation of low lying placenta
Denies vaginal bleeding
History of present Illness: Irregular uterine
contractions No watery or
bloody vaginal discharge
Good fetal movement
Persistence of symptoms consult
1 hour prior to admission
Past Medical History: No history of hypertension, diabetes
mellitus, asthma, heart disease, cancer, thyroid disease
No previous surgery No previous hospitalization
Family History: Denies history of heredofamilial diseases
such as hypertension, diabetes mellitus, asthma, heart disease, cancer, thyroid disease
Personal and Social History: College graduate (BS Communication Arts) Securities clerk Married Resides with her husband and daughter non smoker non alcoholic beverage drinker Denies illicit drug use
Menstrual History: Menarche: 12 yo Interval: every 28-30 days Duration: 5 days Amount: 4 moderately soaked pads/day No Dysmennorhea
Contraceptive history:- No intake of oral contraceptive pills- No IUD- No injectables- No natural family planning method- (+) withdrawal method
Sexual History: Age of 1st coitus: 15 yo 1 sexual partner, monogamous Works as a security guard No post coital bleeding No dyspareunia No leukorrhea Pap smear: November 2011
unremarkable
OB History: G1 (2003)
Previous CS for CPD Outcome: term female, BW=2925 g Complications: treated for sepsis for 1 week
G2 (2011) Present pregnancy
Review of Systems:No loss of consciousness, weakness, feverNo difficulty of breathing, chest pain,
coughNo constipation, loose bowel movementNo dysuria, hematuria
Physical Examination: General survey: alert, coherent, not in
cardiorespiratory distress Vital signs: BP 100/60 CR 89 RR 21 T
37.1oC Anthropometrics:
BMI: 22.31 Weight: 60 kg Height: 164 cm
Physical Examination: HEENT: anicteric sclerae, pink palpebral
conjunctivae, (-) tonsillopharyngeal congestion Chest: symmetric chest explansion, clear and
equal breath sounds, no rales/crackles, no wheezes
Cardiac: adynamic precordium, apex beat at 5th intercostal space, left mid clavicular line, normal rate, regular rhythm, no murmurs
Extremities: no cyanosis, no edema, good skin turgor, full and equal pulses
Physical Examination: Abdominal examination:
Globular Fundic height: 31 cm Fetal heart tone: 140bpm, right EFW: 2900-3100 grams Leopold’s maneuver:
Fundus occupied by the fetal head Fetal back at right, fetal small parts on the left Fetal breech at the level of pubis symphysis
Physical Examination: Normal looking external genitalia,
nulliparous introitus Speculum examination: cervix
violaceous, smooth, no mass, erosions, polyps, no pooling of amniotic fluid, no bleeding per os
Internal examination: not done
Admitting Impression:G2P1(1001) PU 37 3/7 weeks age of
gestationBreech, not in laborLow lying placentaPrevious CS I for CPD
Plan: Diagnostics and Therapeutic For admission For CBC with PC, HbsAg urinalysis, ABO
typing For LTCS II for low lying placenta Secure 2 units of blood for possible blood
transfusion
Intra-operative findings:
The uterus is enlarged to AOG The lower uterine segment was formed Delivered a live baby boy AS 999, 38 weeks by
pediatric aging, AGA Placenta was implanted posteriorly with its edge
partially covering the internal os and appeared grossly normal with 3 vessel umbilical cord
The rest of the pelvic organs were grossly normal Estimated blood loss of 700cc
Outcome and Final diagnosisG2P2(2002) PU 37 3/7 weeks age of
gestation by LMP delivered by LTCS II to a term live baby boy AS 9,9 BW 2.95 kg BL=47cm 38 weeks AGA
Placenta previa marginalisPrevious CS I for CPD
CASE DISCUSSION: PLACENTA PREVIA
030612 Lopez, Julianne YL9-OBGYNECOLOGY
Placenta Previa Placenta that is implanted over or very
near the internal cervical os Normal: placenta implanted in the
fundus 1 in 300 deliveries (US) 1 in 360 deliveries (Philippines_
Abnormalities in placental location
Risk factors: Advanced maternal age Multiparity Multifetal gestation Multiple induced abortions Puerperal endometritis Prior CS Smoking Elevated maternal alpha feto protein
Significance of Placenta Previa 0.3-0.5% of all pregnancies (US) Perinatal mortality 2-3% (US) Maternal morbidities:
Antepartum bleeding Need for hysterectomy Need for blood transfusion Septicemia Thrombophlebitis
Causes of Obstetric hemorrhage:
Pathophysiology At term or during labor:
Retraction of lower uterine segment + dilatation of cervix
Spontaneous premature separation of placenta from the spongy layer of decidua
Hemorrhage
Pathophysiology 1st theory:
Primary implantation is at the isthmus Expansion of implantation site may occupy
lower uterine segment including nternal cervical os
2nd theory: Implantation site at the fundus but because of
damage done from previous pregnancies, there is unidirectional growth towards the isthmus
Signs and Symptoms
Placenta Previa
Placenta Abruptio
Hemorrhage Painless
Ceases spontaneously
May be painfulMay be concealedDoes not cease spontaneously
Abdominal pain
None May be present
Uterine contractions
None Frequent
Uterine hypertonus
None None
Why does it bleed? Dilatation of the internal os result inevitably
in tearing of placental attachments Inherent inability of myometrial fibers of
the lower uterine segment to contract and constrict the avulsed vessels
“Placental Migration” Relative upward shift of the placenta due
to differential growth of the lower segment that is continuous into the late trimester Placenta in the 2nd trimester are low lying in
45% of cases By term less than 1% remains low lying 88% of TPP will resolve by term and only
12% will remain at high risk
Management - diagnostics: Transvaginal/transabdominal UTZ
Sensitivity is >95% Transvaginal more accurate than
transabdominal Look for an abnormally positioned placenta
(accreta, increta, percreta)
Ultrasound Placental edge exactly reaching the internal
os is described as 0 mm Placental edge may extend 0-20mm away
from the os
Ultrasound Placental edge my extend from 0-20 mm
beyond the os and maybe reported as mm overlap
Management Do not do internal exam!
May cause severe hemorrhage Serial UTZ to assess fetal growth and
document resolution (can convert to a normally positioned placenta)
Management Preterm
If no active bleeding observation If with MINIMAL BLEEDING
Administer tocolytics Administer corticosteroids if still under 37
weeks Replacement of blood loss Bed rest
If with moderate to profuse bleeding CS
Management Term
Cesarean delivery – Delivery method of choice >2cm away can be offered a trial of labor with
high expectation of success <2cm is associated with higher CS rate – 80-
90% Any degree of overlap (>0 mm) after 35 weeks
is an indication for CS
Management Term
Cesarean delivery – Delivery method of choice Classical cesarean
section --> atraumatic extraction of fetus
Low transverse incision – as long as longitudinal fetal lie, placenta not anterior
Complications• Placenta accreta – due to the thin,
poorly formed deciduas of the LUS• Postpartum hemorrhage – the LUS is
only weakly contractile and maybe ineffective in hemostasis• Risk factors: advanced maternal age,
previous Cs, sponge-like sonographic findings in cervix
Intrauterine growth restriction Abruptio placenta
Breech presentation Buttocks of fetus enters the pelvis before the head
Risk factors: Hydramnios High parity with uterine relaxation Multiple fetuses Oligohydramnios Hydrocephaly and anencephaly Previous breech delivery Uterine anomalies Placenta previa Fundal placental implantation Pelvic tumors
Definitions Frank breech – lower extremities flexed
at the hips and extended at the knees Complete breech – one or both knees
are flexed
Incomplete breech – one or both hips are not flexed, and one or both feet or knees lie below the breech
Footling breech – incomplete breech with one or both feet below the breech
Abdominal Examination Leopold’s maneuver – to ascertain fetal
palpation Accuracy varies Must confirm with sonography LM 1 – Hard, round, ballotable fetal head occupying
the fundus LM 2 – Fetal back on one side of the abdomen, small
parts on the other LM 3 – If not engaged, breech is movable above the
pelvic inlet LM 4 – If engaged, shows firm breech beneath the
symphysis pubus
Vaginal Examination Frank breech
Both ischial tuberosities, sacrum, anus palpable
Complete breech Feet felt alongside buttocks
Footling One or both feet are inferior to the buttocks
Prognosis Maternal morbidity and mortality
Genital tract laceration Rupture of the uterus Uterine atony Post partum hemorrhage Infection (manual manipulations)
Prognosis Perinatal morbidity and mortality
Preterm delivery Congenital anomalies – 6.3% of breech
presenting fetuses Birth trauma
Fracture of humerus and vaginal delivery Upper extremity palsies – brachial plexus