Professional Documents
Culture Documents
Case
HOPI:Mrs NMO, 29 y/o, Malay lady, G2P1
with POG of 33w, presented with painless
vaginal bleed on the day of admission. The
bleed was spontaneous and happened whilst
patient was sleeping and it soaked the back
of her sarong. This is her first episode. The
blood was red in colour and there was no clot
or mucus present. There was no contraction,
history of trauma, lethargy, palpitation, SOB
fever, vaginal discharge or passage of fluid.
Menstrual Hx
Menarche at 12 y/o
Regular period with 7 days bleed and
cycle of 28 days
No dysmenorrhoea, menorrhagia,
intermenstrual bleed and post coital
bleed
Last pap smear: 2010 normal
Drug Hx
NKDA, NKFA
Iron tablets, Folic Acid, Multivitamin
No significant FHx
SHx
Teacher, live in Seri Manjung. Husband
works with MPSM. Her baby sitter is
taking care of her son.
Never smoke and non drinker
Examination
On examination, patient is alert,
conscious, lying comfortably and not in
distress.
No conjunctival pallor and CRT < 2sec.
Vitals : PR 90, BP 130/95, RR 20, T
36.1oC
Abdomen is distended with gravid
uterus (straie gravidarum and linea
nigra). No dilated veins or scars. The
SFH is 32cm which correspond to
gestation date. There is a singleton with
longitudinal lie, cephalic presentation.
The head is not engaged and FHR was
Investigations
Diagnostic Tests:Transabdominal
Ultrasound
Number of Gestations: 1
Lie: Longitudinal
Presentation: Cephalic
Position: Right
Fetal Heart Rate: 144 x minute
Fetal Movements: Present
Placenta: Placenta edge lies approximately
2cm from margin of internal os
Differential Diagnosis
Placenta Previa
Placental abruption
Vasa Previa
Show
Local causes: infection of
cervix/vagina, trauma to
cervix/vagina
Antepartum Hemorrhage
Bleeding from the genital
tract > 24 weeks of gestation
before onset of labor
Causes of APH
Unexplained (97%)
Placenta previa (1%)
Placenta abruptio (1%)
others
Maternal
Fetal
Show
Vasa previa
Infection of cervix/
vagina
Trauma of cervix/ vagina
Cervical erosion
Genital tract tumor
Assessment of APH
Initial assessment (maternal & fetal condition)
History
Maternal assessment (vital signs, abdominal
examination)
*never perform VE in per vaginal bleed without excluding placenta
previa first.
Management of APH
Placenta previa
Placenta abruptio
Abnormal implantation of
placenta, partially or entirely in
lower uterine segment after 24
weeks
Painless
Painful
Patient is distressed
Soft abdomen
CTG normal
CTG abnormal
Placenta previa
Placenta abruptio
Types:
Types:
Concealed
-no external bleeding evident
-has uterine pain,
Possibly with maternal shock or
fetal distress without obvious
bleeding
Major (ELSCS)
-type IIb: edge of placental at
margin of internal os but not
cover it - posterior
Type III: placenta completely
covers internal os when os
closed, partially covers when
cervix dilate
Type IV: placenta covers internal
os completely
Revealed
-has vaginal bleeding
-has minimal or no pain
Management of placenta
previa
those with major previa who have
previously bled should be admitted from
approximately 34 weeks of gestation.
while outpatient care can be considered
for those with minor previa or those
who are asymptomatic.
Management of placenta
previa
Maternal
Fetal
Labor
Management of placenta
previa
Delivery
ELSCS at 38 weeks of POG if placental
edge is <2cm from internal os and the
placenta is thick.
Allow SVD at term in minor PP unless
there is fetal or maternal compromised.
contraction
beat +/contraction
Active Phase
ARM and pitocin
SVD
SVD/LSCS
decided by
specialist
Latent Phase
SVD/LSCS
Management of Local
Causes
Infections Treat with
antibiotics/antifungal accordingly
Trauma stop any active bleeding
and reassure patient. However, if
bleeding doesnt stop a surgical
intervention may be necessary.