Case Report

Supervised by:
dr. M. Arief Solehudin, Sp.OG

Presented by:
Arya Pradipa Adrianto Putra 2014-061-080

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

RSUD R. SYAMSUDIN, S.H., KOTA SUKABUMI
ATMA JAYA FACULTY OF MEDICINE
2016
 CHAPTER I
INTRODUCTION

Placenta previa is described as a placenta that is implanted somewhere in the

lower uterine segment, either over or very near the internal cervical os. It is one of the
differential diagnosis that should be considered in antepartum hemorrhage as about
one third cases of antepartum hemorrhage belong to placenta previa.
Reported incidences for placenta previa average 0.3 percent or 1 case per 300
to 400 deliveries. With greater upper uterine blood flow, placental growth more likely
will be toward the fundus trophotropism. Many of those placentas that migrate
most likely never were circumferentially implanted with true villous invasion that
reached the internal cervical os. Prior caesarean delivery may less likely cause the
low-lying placenta to migrate within a uterus as there is lesser blood flow within it.
Several other factors may also increase the likelihood of having placenta previa, such
as increased maternal age, multifetal gestation, prior curettage, cigarette smoking and
multiparity. Third trimester cervical length < 30 mm may also increase the risk for
hemorrhage, uterine activity and preterm birth.
Placenta previa should always be considered whenever there is uterine
bleeding after midpregnancy. Management of patient with placenta previa such as
adequate antenatal care, antenatal diagnosis with routine ultrasound examination and
being aware of the present of warning hemorrhage should be done early in the
pregnancy to improve the patients prognosis. Maternal prognosis can also be
improved with increasing availability of blood transfusion facilities while inadequate
antenatal care, delay in referral caused by transport difficulties may contribute to the
poor outcome in whice hemorrhage and shock is the ultimate causes of death. Fetal
prognosis itself can be reduced by expectant treatment thereby decreasing the loss
from prematurity. The definitive treatment itself such as expectant management or
active management, depends upon the duration of pregnancy, fetal and maternal status
and the extent of the hemorrhage.

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 CHAPTER II
CASE

2.1. Patients Identity

Name : Mrs. D
Date of birth / Age : December 5th, 1993 / 22 year-old
Nationality : Indonesian
Address : Kp. Tegal Tugu RT 04/01, Campaka, Cianjur
Marital status : Married
Occupation : Housewife
Religion : Moslem
Date of visit : September 26th, 2016
Date of examination : September 28th, 2016

2.2. History Taking

Chief Complaint
Pervaginam bleeding since 1 day prior to hospital visit.

History of Present Illness

Patient came to RSUD R. Syamsuddin, admitting that she is seven months
pregnant and said that there were blood from her vagina that suddenly burst as
was lying down 1 day prior to hospital visit. The bleeding was quite heavy,
sudden and painless as patient did not feel any pain in the abdomen. Patient
described the blood as bright red and there are some coaugulate. The patient
had to change her tampon per two hours after the first bleeding occurs. There
were no abdominal trauma before the bleeding occurs. It was the first time the
bleeding occurred during this gestation. Patient can still feel the fetal
movement and denies any other complaints.

History of Past Illnesses

History of surgery : denied
History of currettage : denied

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 History of hypertension : patient was diagnosed with hypertension at the
age of 15 ( 7 years ). Patient consumed Nifedipine 1x10 mg regularly.
History of stroke : January 2016, patient couldnt feel half of her
face and body. Was diagnosed with stroke, patient said it was an ischemic
stroke.
History of diabetes mellitus : denied
History of allergy : denied
History of asthma : denied

Menstruation History
Menarche : 12 years old
Menstrual cycle : regularly happens every 28 days, 7 days
duration and no history of dysmenorrhea.
Amount of menstrual blood : 2-3 normal pads / day ( 60 cc )
First day of last menstruation: 6th February 2016

Contraception History
History of using injected and contraception. Patient last used oral
contraception around 3 months before last menstrual period.

Marital History
Married once, has been going on for 6 years.

Gestational History
No Date Gestational Age Labor History Sex Birth Weight
1. 2011 7 months Vaginal delivery - -
2. 2012 4 months (died) Vaginal delivery - -
3. 2013 6 months (died) Vaginal delivery - -
4. This pregnancy

2.3. Physical Examination

General condition : mildly ill appearance
Consciousness : compos mentis

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Blood pressure : 140/90 mmHg
Heart rate : 88 bpm
Respiratory rate : 23 x/minute
Temperature : 36,6C
Weight : 53 kg
Height : 155 cm
BMI : 22,06 kg/m2

General Examination
Eyes : anemic conjunctiva -/-, icteric sclera -/-
Mouth : wet oral mucosa membrane
Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
Lung
Inspection : symmetric chest expansion in breathing
Percussion : resonant on both lungs
Auscultation : vesicular breath sounds +/+, rhonchi -/-, wheezing -/-
Mammae : Hiperpigmentation of aerola +/+, nipple retraction -/-
Abdomen
Inspection : rounded shape
Palpation : supple in all abdominal region, tenderness -
Auscultation : bowel sound +
Extremities : warm, edema -/-/-/-, CRT < 2 seconds

Obstetric Examination
Inspection : Convex
Palpation : Leopold I: soft and not fully rounded part was palpated
Leopold II: wide and flat part is at the maternal right side
Leopold III: hard and round part was palpated
Leopold IV: convergent as the lowest part of the fetus has
not enter the pelvic inlet
Fundal height : 24cm
Fetal heart rate : 148x / min
His : (-)
Internal vaginal examination : not performed

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 Inspeculo : not performed

Laboratory Examination (October 26th, 2016)

Hemoglobin : 12,8 g/dL
Hematocrit : 38 %
Erythrocyte : 4,6 millions/L
Leucocyte : 18.800/L
Platelets : 252.000/L
Erythrocyte index
o MCV : 82 fL
o MCH : 28 pg
o MCHC : 34 g/dL
HEMOSTASIS
Bleeding Time : 2.00 minutes
Clotting Time : 8.00 minutes
BLOOD GLUCOSE
Random Blood Glucose : 74 mg/dL
LIVER FUNCTION TEST
SGOT : 32 U/L
SGPT : 21 U/L
Albumin : 3.0 g/dL
KIDNEY FUNCTION TEST
Ureum : 14 mg/dL
Creatinine : 0.73 mg/dL
ELECTROLYTES
Natrium : 142 mmol/L
Potassium : 3.0 mmol/L
Calcium : 8.8 mg/dL
Chloride : 109 mmol/L
URINE
Color : yellow
Transparency : slightly mudded

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 pH : 5.5
Density : 1.010
Leukocyte : negative
Nitrite : negative
Protein : +++
Glucose : negative
Keton : negative
Urobilinogen : negative
Bilirubin : negative
Erythrocyte : negative
URINE MICROSCOPIC TEST
Leukocyte : 1-2 cells/ visual field
Erythrocyte : 15-20 cells/ visual field
Epithelial cells :+
Cylinder cells : negative
Crystal : negative
Bacteria : negative

Laboratory Examination (October 27th 2016)

URINE
Color : yellow
Transparency : cloudy
pH : 6.0
Density : 1.015
Leukocyte : negative
Nitrite :+
Protein : +++
Glucose : negative
Keton : negative
Urobilinogen : negative
Bilirubin : negative
Erythrocyte : negative

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 URINE MICROSCOPIC TEST
Leukocyte : 15-20 cells/ visual field
Erythrocyte : 40-50 cells/ visual field
Epithelial cells :+
Cylinder cells : negative
Crystal : negative
Bacteria :+

USG Examination

Interpretation:
Single live intrauterine fetus, head presentation, positive pulsation of the fetus,
placenta covered all the internal uterine ostium.

CTG examination

Interpretation:
Reactive NST

2.4. Diagnosis
G4P0A3, 22 years-old, gravid 24-25 weeks according to first day of last
menstruation with pervaginam bleeding et causa placenta previa and chronic
hypertension with superimposed preeclampsia.

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2.5. Management
IVFD Ringer Lactate 500c/24 hours
MgSO4 loading dose 4 gr in 15 minutes continued with maintenance dose 1 gr
/hour
Observe vital signs
Observe amount of vaginal bleeding
Observe uterine contraction and fetal heart rate
Nifedipine 2 x10 mg
Dopamet 2 x 250 mg
Educate the patient to bed rest

2.6. Follow Up

Date Subjective Objective Assessment Planning

26/10/2016 Vaginal General condition : G4P1A2, 22 Observe vital

bleeding moderate ill years old, signs
22.00
has Level of gravid 24-25 Observe amount
stopped, consciousness: CM weeks of vaginal
slightly Vital Sign : according to bleeding
dizzy Blood Pressure : first day of last Observe uterine
150/100 mm/hg menstruation, contraction and
Heart Rate : with fetal heart rate
88x/minute pervaginam Educate the
Respiratory Rate : bleeding et patient to bed
24x/ minute causa placenta rest
Body Temperature previa and Nifedipine 3x10
: 36,6C chronic mg p.o.
Eyes: anemic hypertension Dopamet 3 x
conjungtiva -/-, with 250 mg p.o.
superimposed
icteric sclera -/- Dexamethasone
Mouth : wet oral preeclampsia. 2x5 mg (2 days)

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 mucose
Cor : regular 1st and
2nd heart sound,
murmur -, gallop -
Pulmo : vesicular
breath sound +/+,
wh -, rh-
Abdomen :
I : convex
A: bowel sounds
(+), 4x/minutes
P : supple, pain
with palpation (-)
P : tympanic in all
quadrant
Obstetric
examination
Fundal height : 24
cm
Uterine
contraction: (-)
Fetal movement:
(+)
Fetal heart rate:
139 bpm
Vaginal bleeding:
0 cc
27/10/2016 No General condition: G4P1A2, 22 Observe vital
bleeding moderate ill years old, signs
06.30
from Level of gravid 24-25 Observe amount
vagina. consciousness: CM weeks of vaginal
Headache. Vital Sign: according to bleeding
Blood Pressure: first day of last Observe uterine

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 160/100 mmHg menstruation, contraction and
Heart Rate: with fetal heart rate
82x/minute pervaginam Educate the
Respiratory Rate : bleeding et patient to bed
21x/ minute causa placenta rest
Body previa and Dexamethasone
Temperature: chronic 2x1 IM
36,2C hypertension
Eyes: anemic with
conjungtiva -/-, superimposed
icteric sclera -/- preeclampsia.
Mouth: wet oral
mucose
Cor: regular 1st and
2nd heart sound,
murmur -, gallop -
Pulmo: vesicular
breath sound +/+,
wh -, rh-
Abdomen:
I: convex
A: bowel sounds
(+), 4x/minutes
P: supple, pain
with palpation (-)
P: tympanic in all
quadrant
Obstetric
examination
Fundal height: 24
cm
Uterine
contraction: (-)

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 Fetal movement:
(+)
Fetal heart rate:
146 bpm
Vaginal bleeding:
0 cc
28/10/2016 No General condition: G4P1A2, 22 Observe vital
bleeding mildly ill years old, signs
from the Level of gravid 24-25 Observe amount
vagina. consciousness: CM weeks of vaginal
Headache. Vital Sign: according to bleeding
Blood Pressure: first day of last Observe uterine
180/110 mm/hg menstruation, contraction and
Heart Rate: with fetal heart rate
79x/minute pervaginam Educate the
Respiratory Rate: bleeding et patient to do bed
20x/ minute causa placenta rest
Body previa and Educate patient
Temperature: chronic about vulva
36,4C hypertension hygiene
Eyes: anemic with Dexamethasone
conjungtiva -/-, superimposed 2x1 IM
icteric sclera -/- preeclampsia.

Mouth: wet oral .

mucose
Cor: regular 1st and
2nd heart sound,
murmur -, gallop -
Pulmo: vesicular
breath sound +/+,
wh -, rh-
Abdomen:
I: convex

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 A: bowel sounds
(+), 4x/minutes
P: supple, pain
with palpation (-)
P: tympanic in all
quadrant
Obstetric
examination
Fundal height: 24
cm
Uterine
contraction: (-)
Fetal movement:
(+)
Fetal heart rate:
152 bpm
Vaginal bleeding:
0 cc

2.7. Prognosis
Quo ad vitam : bonam
Quo ad functionam : bonam
Quo ad sanationam : bonam

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 CHAPTER III
CASE ANALYSIS
3.1. Diagnosis
Theory
History Patient complains about
sudden onset of vaginal
bleeding in the third
trimester of pregnancy.
Bleeding is bright red in
colour, unrelated with
activity and often occurs
during sleep, it is also
causeless and may reoccur.
The bleeding is also
described as painless and
the patient did not feel any
contraction. Fetal movement 33-34 weeks and therefore
can usually still be felt in
patient with placenta previa
Risk factors - Prior caesarean delivery
- Prior currettage
- Maternal age
- Cigarette smoking
- Multiparity
- Multifetal gestation
- Placental size and
Case
The chief complaint of this
case is vaginal bleeding as
the patient was sleeping.
Patient has similar
symptoms which is
described as painless
bleeding that is unrelated
with any activities. Patients
first day of last menstruation
is on 6th February 2016
which indicates that her
present gestational age is
the bleeding also occurs at
the third trimester of the
pregnancy. Fetal movement
can still be felt and there is
no history of vaginal
bleeding.
Patient in this case is
present with prior caesarean
delivery and prior curettage,
is in a increased maternal
age group (>35 years old )
and multiparity.
Other risk factors described
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 abnormality in theory are not found in
this patient.
Physical General physical General physical
examinations examinations may reveal examinations are on normal
anemic condition that is range, patient is not anemic
directly proportionate to the and has a stable
visible blood loss. hemodynamic status. There
Obstetrical examination are no signs of
shows that uterus feels malpresentation and fetal
relaxed and soft without any heart sound is present.
localized area of tenderness Inspection and vaginal
and there might be examination are not done in
malpresentation. The head is this patient although
floating and fetal heart inspection should have be
sound is usually present. done to assess if the
Only inspection of vulva bleeding is still occurring,
should be done revealing character of the blood and
bright red coloured blood to exclude local cervical or
and vaginal examination vaginal lesion.
should not be done as it
increases risk of major
hemorrhage.
Laboratory In lab examination patient Patient is anemic with
studies may be anemic if theres a hemoglobin level of
massive bleeding and 10.7g/dL. Ultrasonography
ultrasonography is the initial examination is done in this
procedure either to confirm patient revealing that the
or to rule out the diagnosis. placenta is located in the
It provides the most simple, marginal of the internal
precise and safest method ostium uteri.
for placental localization.

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3.2. Management
Management of placenta previa should be done by prevention which is by
doing a routine antenatal care, antenatal diagnosis of low lying placenta at 20
weeks needs repeat ultrasound examination to confirm the diagnosis, warning
hemorrhage should not be ignored and color flow Doppler USG might also be
done to detect any placenta accreta. All patient present with antepartum
bleeding should be admitted to the hospital for further observation as the
bleeding may recur and the amount of bleeding could not be predicted.
Definitive treatment of placenta previa depends upon the duration of
pregnancy, fetal and maternal status and extent of hemorrhage.
Management could be done by expectant management which has aim to
continue pregnancy for fetal maturity without compromising maternal health.
Mother should be in stable hemodynamic status, duration of pregnancy is less
than 37 weeks, active vaginal bleeding is absent and fetal well being is assured
by CTG and USG. Patient is put to bed rest, investigations such as laboratory
test for hemoglobin level, hematocrite and blood grouping, observation of the
bleeding and fetal surveillance with USG, supplementary hematinics and
gentle speculum to exclude local cervical or vaginal lesions can be done.
Tocolysis can also be used in case where vaginal bleeding is associated with
uterine contractions. Preterm delivery can be done before 37 weeks if there is
recurrence of brisk hemorrhage, the fetus is dead or congenitally malformed
on investigation. In preterm delivery steroid therapy should be given to reduce
the risk of respiratory distress. Active management can be done only if the
bleeding occurs at or after 37 weeks of gestation, patient is in labor, bleeding
is continuing and of moderate degree and baby is in nonreassuring cardiac
status, dead or congenitally deformed. Caesarean delivery is done for patient
in which the placental edge is within 2 cm from the internal os and is
especially indicated if it is posterior or thick. Caesarean delivery is mostly
done to reduce the maternal risk and improve fetal salvage. Vaginal delivery
may be considered when placental edge is clearly 2-3 cm away from the
internal cervical os based on sonography examination. Management of

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 placenta previa can also be done by assessing the characteristics of bleeding.
Figure 1 presents the scheme of management of placenta previa in a hospital.

Figure 1.

Figure 1

3.4. Complications
There are various complications of placenta previa that includes
antepartum hemorrhage with varying degree of shock, malpresentation,
premature labor or even death due to hemorrhage. There might also be
premature rupture of membrane, cord prolapse, slow dilatation due to
attachment of placenta on the lower segment of uterus and intrapartum
hemorrhage as there is a further separation of placenta with dilatation of the
cervix. Postpartum hemorrhage might also be present as a complication due to

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imperfect retraction of lower uterine segment upon which placenta is
implanted, large surface area of placenta with atonic uterus due to preexisting
anemia, trauma to the cervix and lower segment because of extreme softness
and vascularity. Adherent placenta on the lower segment of uterus and may
cause maternal death. There might also be risk of retained placenta.
Fetal complications include low birth weight, asphyxia, intrauterine death
and congenital malformation are more common in placenta previa. Maternal
and fetal morbidity and mortality from placenta previa are significantly high in
patients that did not undergo effective management.

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 REFERENCES

1. Cunningham FWilliams J. Williams obstetrics. New York: McGraw-Hill

Medical; 2010.
2. Dutta DKonar H. DC Dutta's textbook of obstetrics.
3. Arias F. Arias' Practical Guide to High-Risk Pregnancy and Delivery. Elsevier
Health Sciences APAC; 2008
4. Diagnosis and management of placenta previa. International Journal of
Gynecology & Obstetrics. 2008;103(1):89-94.

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