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June 22, 2012 G.C

Case report #3
Submitted to Dr Sisay Teklu

Submitted by Samuel Masresha

MDR 6812/02

Department of Obstetrics and Gynecology

Tikur Ambessa Specialized Hospital
Addis Ababa University

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Identification:
Name: Marta Belachew Age: 28 Sex: female

Address: Gulele, kebele 01, Addis Ababa

Occupation: Housewife Marital status: Married Religion: Christian Orthodox

Date of admission: 05/09/04 E.C Ward: C6, Obstetrics & Gynecology Bed no# 610/06

Chief complaint:
Vaginal bleeding of 8hrs duration

HPP:
This is a 28 year old gravida II abortion II para 0 mother. The abortion was induced at 1 1/2 month of
amenorrhea. Her LNMP was 25/01/04 E.C which makes her EDD on 05/11/04 E.C. and gestational age
355/7 weeks. The cycle was regular coming every 4 weeks and she has not used contraception before her
LNMP.

She suspected she was pregnant after she missed one menstrual cycle. Without informing her husband or
consulting a health professional, she took an emergency morning-after-pill one month after her LNMP
because she didn’t think she was ready to raise the child. However, her menses did not return. She then
told her husband and family; who convinced her to keep the baby. She then went to St. Amanuel private
clinic where diagnosis of the pregnancy was confirmed by urine pregnancy test.

She started ANC follow up at St. Medhanealem Health center on 15th week of GA. General physical
examination and laboratory tests were done. She gave blood and urine sample. Her blood type was
determined to be O+. She was screened for RVI, VDRL and HBsAg and found negative for all three. She
was given TT vaccination and iron supplement because she had mild anemia. She was told everything
else was normal and that she should continue her follow up.

She went to the health center for her second ANC follow up at 24th week GA. History was taken, physical
examination was done and laboratory tests were ordered. She was told everything was normal and that
she should come after 4 weeks. She was given the second TT vaccination and continued her iron
supplement. She was told her child was healthy.

She continued her ANC follow up at 32th week GA. After history was taken, general physical exam was
done and blood and urine sample was taken for analysis, she was told that everything was normal and that
she should continue her follow up.

She does not remember exactly when quickening happened but guesses it to be in ‘Tir’ of 2004 E.C. She
claims fetal movements are kicking in type. They happened 20 times per day. Fetal kicks have not
decreased. She did not have loss of appetite. She used to have 5 meals a day. She eats a loaf of wheat
bread (150g) with milk or tea (100ml) for breakfast during her mornings. She ate four ‘kurt’ of ‘Tef

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Injera’ (300g) with ‘Misir’(75g) or ‘Shiro’(75g) or ‘Ye’abesha gomen’(100g) or rarely, meat(75g) for
lunch and dinner. She usually took two extra meals consisting of a loaf of wheat bread (150g) or ‘Tef
Injera’ (300g) with ‘Misir’(50g). This amounts to an average total of 1894kcal/day. She claims to have
gained a total of 11 kg.

There were no significant events during the first or second trimesters.

She experienced vaginal bleeding on 05/10/04 E.C early in the morning. The blood was bright red, with
no clots and amounted to one Arabian coffee cup. It was spontaneous and happened once so far. There
was no associated pain, pruritus, discharge or leakage of liquor. She immediately went to the health center
of her ANC where they took an ultrasound and referred her to Tikur Ambessa Specialized Hospital. She
was told the reason for her referral was an abnormal positioning of the fetus.

There is history of gynecologic operation (abortion by MVA )

There is history of increased urinary frequency (5/4 D:N ratio) otherwise no history of dysuria or
incontinence
There is no history of offensive vaginal discharge
No history of abdominal trauma.
No history of coitus near term
No history of hypertension
No history of decreased fetal movements after bleeding
No history of abdominal pain
No history of sudden abdominal fullness or rapid increase in size
No past history of antepartum hemorrhage
No history of sexually transmitted disease
No history of nasal bleeding or excessive bleeding from minor injury sites
No history of severe headache, abnormal body movement, loss of consciousness or vision disturbance
No history of epigastric or right upper quadrant pain, yellowish discoloration or bleeding from gums
No history of leg swelling
No history of pushing down pain or sudden gush of fluid
No history of contact with a chronic cougher, fever, cough, night sweat, weight loss or loss of appetite
No history of DM or asthma
She is not from a malarious area and there is no history of recent travel to a malarious area

Pregnancy was unplanned but wanted and supported. Birth was planned to take place spontaneously &
vaginally at a health center and money for taxi transport and health expenses was prepared.

Past obstetric history:

Year GA Place Route outcome wt complications
2002 EC 06 wks Health center Induced abortion - None
vaginal

Gynecologic history:
The couple used condoms as contraception. The mother has never used hormonal contraceptives before
she was pregnant. She tried morning after pill at 2 weeks GA but it did not work. She has no history of
sexually transmitted diseases. She is sexually active. She started coitus by the age of 24. She has coitus at

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an average of 3x/wk and she is monogamous. She had her last coitus 4 months ago (at 9 weeks GA.) The
mother had one abortion two years ago. It was induced and done by MVA at a health center. She claims
the reason for it was that it was an unplanned pregnancy and her financial inadequacy. She has no history
of circumcision.

Menstrual history:
She had menarche at the age of 12. The menses were regular. Duration of flow is 5 days. She uses 1 pad
per day during menses. The flow is dark, with no clots. She experiences mild discomfort associated with
flow of menses.

Past medical history:

She has a history of gastritis 8 years ago. She was given several unspecified medications with no
improvement. The disease subsided on its own after 3 months. She has a history of UTI with
pyelonephritis 5 years back which was successfully treated with antibiotics. She has occasional common
cold. She has no history of medical disorders like DM, or hypertension before the pregnancy. She has had
no previous transfusions. She has not experienced hypersensitivity to drugs. She has no history of
infection with STD.

Family/personal history:
The patient was born and raised in Addis Ababa. She is the first child to her parents. She has a younger
sister who lives with the parents and is currently healthy. Her mother and father are currently healthy. The
patient is educated upto the level of 10th grade. She discontinued her education because she thought she
was unfit academically. She has no habit of smoking or illicit drug use. She does not drink alcohol. She is
a housewife supported by her husband with a monthly income of 1500br. The husband is a surveyor for a
road construction company. She lives with her husband in Gulele. Their house is located 100m away from
the nearest asphalt. Their house has 3 rooms with a separate kitchen and toilet. They have a clean water
supply. They have no car. There is no family history of hypertension, diabetes mellitus, tuberculosis,
allergies or mental disorders.

Review of systems:
H.E.E.N.T
Head: no headache, no head injury, no dizziness
Ears: no impaired hearing or discharge, no ringing in the ears
Eyes: no discharge, no redness, no blurred vision
Nose: no discharge, no stuffy nose, no runny nose, no sneezing
Mouth: no dental caries, no bleeding gums, no artificial dentures
Throat: no sore throat, no difficulty in swallowing, no hoarseness of voice

L/G: no mass in the neck, axillae, or groins. There is breast enlargement and tenderness associated with
the pregnancy. No discharge from the nipples. No heat or cold intolerance

Respiratory: no cough, no expectoration, no chest pain, no wheezing, no cyanosis

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Cardiovascular: palpitations, no shortness of breath, PND or orthopnea, no chest pain, fatigue

Gastrointestinal: one episode of nausea and vomiting and one episode of heart burn. No diarrhea, no
constipation, no abdominal pain or, no change in stool color.

Genitourinary: increased frequency (5:4.) No dysuria, no urgency, no hesitancy, no dribbling, no reddish

discoloration of urine.

Integumentary: no rash, moist skin, no discoloration, no hair changes, hyperpigmentation on abdomen

along the midline from the umbilicus downwards.

Locomotor system: no history of pain, weakness or swelling of the joints,

Central nervous system: no history of numbness, no paralysis, urine incontinence, seizures or speech
defect

Physical examination:
General appearance:
The patient is lying in right lateral position. She is conscious. She does not appear sick looking. She is not
in cardiorespiratory distress. There is no gross dysmorphic feature.

Vital signs:
Blood pressure: 100/60 mmHg right arm in supine position
Pulse rate: 74/min right radial artery, full in volume and regular rhythm
RR: 18 breath/min normal
Temperature: 36.5⁰c
Weight: 69kg
Height: 174cm

H.E.E.N.T
Head: no scar, no scalp infections, no tenderness, normal hair distribution, clean
Ears: normal contour, normal position, no discharge, no mastoid tenderness
Eyes: pink conjunctivae, non-icteric sclerae, no discharge, no conjunctival inflammation, no lid lag, no
proptosis, no peri-orbital edema, no strabismus, no nystagmus,
Nose: no discharge, central septum, no visible polyps or deformity
Mouth: non offensive breath order, wet buccal mucosa, no mucosal ulcers, no cyanosis, fissures on the
lips, no active gum bleeding or ulcers, no dental carries or fillings, tongue is not fissured or
coated,
Throat: tonsils not enlarged, non-tender

L/G:
No palpable lymph nodes. The breasts are engorged. They are soft. They are not tender there is no lump.
There is no discharge or inflammation over the nipple. Thyroid is not palpable.

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Respiratory system:
Inspection: rate 18/min, no peripheral or central cyanosis or digital clubbing, chest moves symmetrically
with respiration, no gross deformities, no use of accessory muscles, flaring of ala nasi or grunting
Palpation: central trachea, no chest tenderness, symmetrical expansion, comparable tactile fremitus
Percussion: resonant over the lung fields, diaphragmatic excursion 3 cm bilaterally
Auscultation: bilateral good air entry, vesicular breath sounds heard over the lung fields, no crepitation,
no wheeze, no pleural friction rub

CVS:
Arteries: the pulse is full and regular in rhythm

radial brachial Carotid femoral popliteal Dorsalis pedis Post tibial

Right ++ ++ +++ +++ + ++ +
Left ++ ++ +++ +++ + ++ +
Veins: JVP is 3 cm above sternal angle in 30⁰ inclination. No distended veins

Inspection: no palmar pallor, no cyanosis, clubbing, Janeway lesion, splinter hemorrhage or Osler’s nodes
Precordium is quiet, no bulge, apical impulse is visible in 5th left intercostal space, 1 cm lateral to mid-
clavicular line
Palpation: PMI is palpable where apical impulse is visible. It is tapping, and localized. There are no
palpable heart sounds
Auscultation: S1 and S2 are well heard. No murmur or gallop. No pericardial friction rub.

GIS:
Inspection: the abdomen is distended and symmetrical. There is no flank fullness. There are no distended
veins. The abdomen moves upwards with inspiration and down with expiration. Epigastric pulsations are
not visible. Inguinal, epigastric, umbilical and femoral sites are free of hernia. The umbilicus is inverted.
There is linea nigra and striae gravidarum. No surgical scar.

Palpation: there is no superficial mass. There is no tenderness. There is no hepatomegaly, no

splenomegaly. The kidneys are not palpable. No other deep mass.

Percussion: abdomen is tympanic above the area of uterus, shifting dullness not checked due to patient
discomfort. Total vertical liver span is 9 cm along the mid-clavicular line.

Auscultation: active bowel sounds of 14/min, no renal arterial bruits.

Obstetric physical examination:

Leopold 1: fundus palpated 8 fingers above umbilicus, 36 week old uterus. Bulky, non-ballotable mass
occupying fundus, breech occupying fundus
Leopold 2: smooth and regular right side, irregular small parts palpated on left side, longitudinal lie
Leopold 3: not done because placenta previa is not ruled out yet
Leopold 4: not done because placenta previa is not ruled out yet

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Auscultation: Fetal heart rate is positive (148beats/min)

GUS:
There is no costo-vertebral angle tenderness

Pelvic:
Inspection: Sexual maturity rating of 5/5. There is no visible vaginal discharge. There is no visible mass
at introitus. There is no swelling over the labia, no ulcer.

Digital vaginal exam: not done due to fear of placenta previa

Integumentary:
no rash, striae gravidarum and linea nigra present, no palmar pallor, no jaundice, warm skin
normal hair distribution, soft texture and strength
pink nail beds, no inflammation around nails, no clubbing

Musculoskeletal:
No asymmetry of limbs, no gross deformities, no joint swelling, redness or tenderness. No edema. No
limitation in movement.

CNS:
General: conscious, rates 15/15 on Glasgow scale, oriented to place, time & person

Cranial nerves: CN I smells alcohol via each nostril

CN II good visual field and acuity, direct and indirect pupillary light reflexes
are present
CN III, IV &VI patient looks in all directions with both eyes symmetrically, no
strabismus or nystagmus
CN V intact tactile sensation over the face, corneal reflex present, intact motor
part
CN VII face is symmetrical at rest and upon voluntary movements like smiling,
nasolabial folds are present bilaterally
CN VIII good hearing on both sides,
CN IX & X says “ah”, no hoarseness of voice
CN XI shoulders shrug against resistance, neck turns against resistance
CN XII no atrophy of the tongue, tongue is central upon protrusion
Motor: bilaterally comparable muscle bulk of limbs, no spontaneous or induced fasciculation,
Muscle power:
RU RL LU LL
L L L L
POWE 5/5 5/5 5/5 5/5
R

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superficial reflexes: abdominal normal

plantar down going
corneal normal
deep tendon reflex:
Right Left
Biceps 2/4 2/4
triceps 2/4 2/4
Brachioradialis 2/4 2/4
patellar 2/4 2/4
ankle 2/4 2/4
No clonus on both sides
sensory: pain sensation is intact over all extremeties
Meningeal signs: no nuchal rigidity, absent kernig’s and brudzinsky’s signs.

Summary
Subjective Objective
Primipara Stable, conscious
Preterm 36 weeks gravid uterus
Hx of Induced abortion Longitudinal lie
Antepartum hemorrhage Cephalic presentation (ROT)
Unplanned, wanted, supported px Positive feta heart beat
Regular ANC follow up
Adequate weight gain
Urinary frequency
Hx of treated gastritis & pyelonephritis
Incomplete education

Assessment
High risk due to APH
primipara,
previous abortion,
low socioeconomic status (incomplete education)
Potential complications
APH placental insufficiency  perinatal asphyxia, IUGR,
Preeclampsia  eclampsia, DIC
Oligohydramnios  cord prolapse, perinatal asphyxia, MAS
Preterm PROM prematurity
Surgical complications [of CS] anaesthesia, infection, dehiscence, TTN
DIC bleeding, thromboembolism, shock, renal failure,
couvelaire uterus PPH

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primipara untested pelvis potential CPD, arrested labor, obstructed labor, uterine rupture
post-term pregnancy  shoulder dystocia, placental insufficiency
fistula formation (rectovaginal & vesicovaginal)
perineal tear
induced abortion uterine scar uterine rupture, Asherman syndrome, ectopic pregnancy
low socioeconomic st. PROM, STI, puerperal sepsis, chorioamnionitis, preeclampsia

Differential diagnoses:
APH secondary to placenta previa
APH secondary to placental abruption

Discussion of the differential diagnoses:

Antepartum hemorrhage is bleeding from the genital tract that takes place after fetal viability and before
delivery of the fetus. It is an important cause of maternal and perinatal mortality complicating 4% of
pregnancies. It may be a result of obstetric or non-obstetric causes. Its management depends on etiology,
severity, GA, maturity, presence or absence of fetal compromise, maternal condition and presence of
labor. Its most common cause is bloody show, which is benign and heralds the onset of labor.

APH secondary to placental abruption

Placental abruption is the premature separation of a normally implanted placenta. It is the commonest
cause of death from APH (20-30%.) Premature separation of the placenta, if severe enough, will lead to
perinatal asphyxia and maternal DIC. Abruption is a self-perpetuating process as hemorrhage into the
decidua basalis leads to the formation of a small retroplacental clot resulting in more pronounced clot
formation. These cascade of events ultimately end up compromising maternal-fetal oxygen and nutrient
transfer and onset of [potentially early] uterine contractions. The bleeding is usually evident as separation
involves the periphery of the placenta but my also by concealed when separation is central. Concealed
bleeding carries a poorer prognosis as the extent of bleeding will not be appreciated and there will be
delay in diagnosis.
Even though the primary cause of placental abruption is not known, several risk factors involved have
been identified and these include increased age and parity, preeclampsia, previous history of abruption,
sudden drop in intrauterine pressure as in rupture of membranes in polyhydramnios or delivery of 1 st twin,
abdominal trauma, chronic hypertension, smoking, cocaine use, thrombophilia, uterine leiomyoma.
Typical manifestation of abruption is pain(66%) which may range from mild cramping or the more acute
and severe type. This may or may not be associated with bleeding(78%). The uterus will be firm, tender
and a sudden increase in fundal height may be appreciated on physical exam. Fetal distress s present in
60% of cases.
Complications include preeclampsia, maternal shock, renal failure, Sheehan syndrome, consumptive
coagulopathy (DIC) and PPH due to couvelaire uterus. Fetal complications are the short and long term
complications of perinatal asphyxia.

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This patient has none of the above mentioned risk factors for placental abruption. However, it should be
noted that the primary cause of abruption is unknown and it is the most common cause of maternal
mortality due to APH. Even with the help of laboratory (hypofibrinogenemia) ultrasound (retroplacental
clot) It cannot be completely ruled out at this stage.

APH secondary to placenta previa

Placenta previa is used to describe a placenta that is implanted over or very near the internal cervical os. It
may ne total, partial, marginal or low lying. Digital palpation in an attempt to assess changing conditions
of the placenta in relation to the internal os due to the dilating cervix usually results in severe hemorrhage.
So it should be avoided if placenta previa is suspected.
Risk factors associated with placenta previa include advanced maternal age, multiparity, prior CS,
multiple gestation, prior placenta previa and smoking.
The most characteristic event is painless hemorrhage usually at the end or after the second trimester. This
bleeding results from small disruptions in the placental attachment during normal development and
thinning of the lower uterine segment. Bleeding is usually transient and mild but ultimately recurs.
Diagnosis is made by either transabdominal ultrasonography (simple, safe) or transvaginal sonography
(sensitive.) once diagnosed, total and partial placenta previa should not be allowed a trial of labor. CS is
mandatory.
This patient most probably incurred a uterine scar from her abortion 2 yrs ago which increases the risk of
placenta previa the same way a previous CS does. She complains of third trimester bleeding without any
pain which is transient and mild. This is the most likely diagnosis.

Investigation
CBC with differential to rule out anemia due to concealed hemorrhage
to check for thrombocytopenia and rule out DIC
Transabdominal U/S to localize placenta or detect a retroplacental clot
Blood typing for possible transfusion & identifying Rh setup
Indirect coombs test to detect Rh alloimmunization from previous abortion
Urine analysis to detect proteinuria (preeclampsia)
to detect asymptomatic bacteruria

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