Addis Ababa University

School of Medicine
Department of Gynecology &
Obstetrics

Obstetrics Case
Report #2
Submitted to: Dr. Eyasu Mesfin

Prepared by: Gedle Mulugeta

MDR/0415/03

Ginbot, 2005
Identification
Name: Zeituna Kedir Age: 28 Occupation: Housewife

Marital Status: Married Religion: Muslim Address: Addis Ababa around ‘Alem Bank’

Ward: 2nd Obstetrics Ward Bed No. – 18/1

Date of Admission: 9/9/2005 Date of Clerking: 14/9/2005

Chief Compliant
Vaginal bleeding of 3 hours duration

History of Present Pregnancy

This is a 28 year old, gravida 4 para 3 abortion 0 mother who doesn’t remember her LNMP but claims to
be amenorrhic for 8 months. She felt the first fetal movements at gestational age of four months.

She suspected that she might be pregnant when she missed one menstrual cycle. So she went to a local
health center and her pregnancy was confirmed by urine test on the first month of pregnancy.

She started her ANC follow up in a different health center on the sixth week of gestational age. There,
Blood pressure, Height & weight measurements, abdominal examination, vaccination & blood and urine
tests were done. She was given mixed iron and folate supplements which she took once a day. She has
had only 2 visits so far. She was also given two doses of TT during her pregnancy first on the 6 th and
second on the 7th month of gestational age. She was also given a councling on family planning and
danger signs of pregnancy.

Bleeding started around 2 PM on 9/9/05 and continued for about 3 hours until her admission to GMH. It
started suddenly when she was taking a break from washing clothes but there was no direct trauma. It
was profuse and painless. She claims that the amount was of about 3 tea cups and that it soaked her
underwear and also her dress. Its color was bright red initially but it became a little darker and clotted
later on. The bleeding was not associated with any vaginal discharge. She had a ‘lightheadedness’ feeling
right after the bleeding.

Fetal movements are of kicking type and they are currently felt over the lower abdomen [below the
umbilicus]. The fetal kicks increase especially after meal intake. She also told me that there has been no
decrement in the frequency of fetal kick after the bleeding, neither has been no change in the pattern of
fetal movement.

On the third day of her admission she experienced an abdominal pain together with pushing-down pain,
diarrhea and vomiting. The abdominal pain was severe and located on the lower abdomen. It was of a
crampy type and it radiates to the sides and the back. Nausea, vomiting, bloating and heart burn are also
associated with the pain. It has a timing of 1 hour. The pain exacerbates when she sits down and she gets
some relief upon supination. On the next day stool sample was taken and she is currently on Tinidazole.
 She has urinary frequency, urgency and burning sensation during urination.

Otherwise she has no history of trauma or coitus prior to the onset of bleeding.

No history of previous bleeding tendencies

No history of previous C/S scar

No history of Fever

No history of vaginal discharge or leakage of liquor

No headache, blurring of vision or epigastric pain.

Her appetite is slightly increased. She eats 3 times a day with slight increase in amount. She usually eats
‘injera’ with ‘misir’ ‘shiro’ or vegetables and drinks Vimto.

Pregnancy was unplanned but wanted and supported.

Past Obstetric History

Year GA Place Mode of W Complications Duration of Did baby cry Cong Breast
of Delivery t labor immediately? Malf. feeding
Deliver .
y
1998 38 Health Vaginally - - 7 hrs. Yes None Yes
wks. center
2001 40 Health Vaginally - - 7 hrs. Yes None Yes
wks. center
2003 38 Health Vaginally - PPH 20 to 12 hrs. Yes None Yes
wks. center retained
placenta

Gynecologic History
Contraceptive History: She was on oral contraceptives [Progesterone only pills] two days prior
to her last normal menstrual period, but she stopped taking it because she experienced nausea and
vomiting.

Sexual History: Her first coitus was when she was 25 years old. She is married and in a
monogamous relationship and she didn’t have previous partners other than her husband. She is HIV
negative and she has no history of sexually transmitted infections. She has had no foul smelling vaginal
discharge, No history of pain during coitus, No itching or ulceration over the genital area.

Menstrual History: She experienced menarche when she was 10 years old. Her menstrual cycle
was regular, coming every 30 days and lasting for 3 or 4 days. She uses one traditional cloth per day,
especially on the first day, but on the next days she doesn’t even use any cloth as the amount decreases.
The flow was dark red and of a non-clotting type. She doesn’t feel any discomfort or pain during menses.

She has female genital cutting and she has never went under any gynecologic operations prior to her
pregnancy.

Past Medical/Surgical History

She has no history of Diabetes Mellitus, Hypertension, Thyrotoxicosis, Childhood diseases, blood
transfusion or HSR to drugs.

She has had no surgeries.

Personal/Family History
She was born in ‘Selte’ and when she was 7 years old, her family moved to Addis Ababa. She has two
sisters, both are alive and healthy. She attended school up to 3 rd grade. She now lives with her husband
and their three children in a 3 room and well ventilated house with a separated kitchen. She has no habit
of smoking or drinking alcohol or chewing chat. She is a house wife and supported by her husband, who
is a merchant. She doesn’t know exactly how much he earns per month but she claims that it is no less
than 1000 birr.

Both her parents are dead. Her father died of DM 6 months ago and she doesn’t remember when or due
to what cause her mother died as she was a child at the time.

There is family history of DM and HTN. There is no history of TB or twinning.

Review of Systems
HEENT
Head: No headache, No injury

Ear: No pain, No deafness, No discharge, No tinnitus, No vertigo

Eye: No itching sensation, No disturbance of vision, No photophobia

Nose: No discharge, No epistaxis

Mouth & Throat: No dental caries, No bleeding gums, No hyperplasia of the gums, No sore throat or
sore tongue

Glands
Lymph Nodes: No enlargement

Thyroid: No enlargement, No heat/cold intolerance

Breast: There is breast tenderness and enlargement that is normally associated with pregnancy. No
retraction, No discharge, No mass
Respiratory system:
No cough, No hemoptysis, No shortness of breath, No chest pain, No cyanosis

Cardiovascular system:
No palpitation, No dyspnea, No orthopnea, No Paroxysmal Nocturnal Dyspnea, No syncope

Gastrointestinal System:
No dysphagia, No bloody stool [Other GI symptoms are mentioned in the HPP]

Genitourinary system:
No flank pain, No Hesitance, No Hematuria, No incontinence [Other GU symptoms are mentioned in the
HPP]

Integumentary System:
No rashes, No Ulcers

Locomotor System:
No bone deformities, No joint pain, No muscle weakness,

Central Nervous System:

Well oriented, good memory, No seizures, No insomnia.

Physical Examination
General Appearance:
The patient was sitting comfortably and she was in no respiratory or cardiac distress

Vital Signs:

PR: 92 per minute over the right radial artery of a regular rhythm and of a full volume

BP 110/75 mmHg over the right brachial artery in a sitting position

T o – 35.50C over the right axilla

RR: 20 per minute

H.E.E.N.T
Head: Normal size and shape. No scar, No Scalp Infection. Normal hair distribution
Ears: Normal contour of pinna. Normal Position, Clear external ear canal. Good equal hearing.
Eyes: Normal eyebrows. No periorbital edema, ptosis, exophthalmos, excessive lacrimation or
strabismus. The conjunctiva are whitish. The sclerae are not icteric. The pupils are equal in size.

Nose: Nasal septum is in the mid line. There is no polyp or unusual discharge
Mouth & Throat: Normal breath odor, the lips have no fissure, ulceration. The gums are intact and
clean. There is no carious tooth,no artificial denture. The uvula is central.

Lymphoglandular System:
The occipital, pre and postauricular, submandibular, submental, supraclavicular, epitrochlear, axillary and
inguinal areas are free of palpable lymph nodes. The thyroid is not enlarged. The breasts are of a
symmetrical size. There is no palpable mass, no discharge from the nipples or any retraction or
ulceration of the skin. The nipples are everted. The areola are black are the Montgomery glands are not
palpable.

Chest Examination:
Inspection: No scar, no use of accessory muscle while breathing, symmetrical chest movement, no
cyanosis and no clubbing.

Palpation: Trachea is central, no tenderness, and there is symmetrical chest expansion [2.5 cm]. There is
symmetrical tactile fremitus.

Percussion: Symmetrical resonant notes, Diaphragmatic excursion is 4.5 cm

Auscultation: Good air entry, Bronchial, intrascapular and vesicular breath sounds are well heard. No
Rhonchi, No Wheezes, No pleural friction rub.

Cardiovascular System:
General: No clubbing or cyanosis, no pallor of the palms. Her legs are edematous.
Arteries: BP and pulse (see under vital signs)
Precordium
Inspection: The precordium is quite. There are no chest deformities. The apical impulse is visible on the
left fifth interspace, medial to the midclavicular line.
Palpation: The point of maximum impulse is palpable over the same area. There is no thrill, parasternal
or apical heave
Auscultation: S1 and S2 are well heard. No murmur, No gallop, No pericardial friction rub.
Abdominal Examination:

Inspection: The abdomen is grossly distended with no dextrorotation. She has inverted, slit like
umbilicus. The abdomen moves with respiration. There are no scars or distended veins. There are white
striae gravidarum and linea nigra. No flank fullness. No herniations at any of the likely sites. No visible
peristalsis, No visible fetal movement.

Palpation:Superficial: No tenderness, No mass, No rigidity

Deep: Tenderness on deep palpation over the left lower quadrant. No hepatosplenomegally.No rebound
tenderness

Leopold Maneuver
1st: Fundal height measurement: 36 weeks size by finger method [ 37 cm of symphysis fundal height]

2nd: Fundal presentation: Cephalic [Hard, round, regular, balottable mass occupies the fundus]

3rd and 4th Leopold Maneuver are not done because placenta previa has not been ruled out.

Percussion: There is no flank dullness. There is no fluid thrill.

Auscultation: There is no bruit or friction rub over the liver. The bowel sounds are active. Fetal heart
beat are well heard

Pelvic Examination
Inspection of External Genitalia:Pubic hair has normal distribution with an inverted triangle
appearance. She has had female genital cutting of grade 2.

Bartholin’s glands are not visible,

Labia minora and majora: No discharge, ulcers, swelling or mass

Urethral Orifice: No inflammation

Perineum: Smooth, Episiotomy scars are visible.

Digital Vaginal examination and Speculum examinations are not done because placenta previa has not
been ruled out yet.

Genitourinary System
The Kidneys are not palpable. There is no costo-vertebral angle tenderness or mass.
Central Nervous System
Mental Status: The patient is conscious, oriented in person, place and time. Her memory status is good.

Cranial Nerves:
N-I: The patient was able to smell scented hand sanitizer.
N-II: Normal visual acuity, good visual fields and color appreciation
N-III, IV & VI: The eyes can move in all directions. There is no nystagmus. The pupils are round and
regular in outline.
N-V: She responded for light touch. There is contraction of the temporal and masseter muscles
N-VII: The face is symmetrical at rest, and during voluntary movement. Intact nasolabial folds.
N-VIII: Hears ticking of watch bilaterally
N-IX & X: Soft palate rises in the midline when saying ‘ah’. Uvula is central.
N-XI: There is turning of head and shrugging against resistance.
N-XII: No deviation of the tongue. There is also no fasciculation or atrophy.

Motor

Normal muscle size,tone, bulk and power. No spontaneous or induced fasciculation.

Sensory

Light touch, pain, temperature, deep pressure, position sense, vibrations and passive movements are
well appreciated.

Reflexes

 Superficial
Corneal Abdomen Plantar
Right ++ +  (down going)
Left ++ (down going)

 Deep
Biceps Triceps Supinator Patellar Ankle
Right + + + + +
Left + + + + +
 Assessment
 24 years old
 Multipara
 Anemic
 APH of 3 hours duration
 Unreliable LNMP

Differential Diagnosis
1. Placenta Previa
2. Abruptio Placenta
3. Vasa Previa
4. Bloody show
5. Uterine Rupture
6. Coagulation Disorders
7. Cervicitis
8. Cervical Ca
9. Uterine Leiomyoma
Discussion of the differential diagnoses
1. Placenta previa: It is defined as an abnormal placentation of placenta especially in the lower
uterine segment close to the internal cervical os.
The typical features of placenta previa are sudden, profuse, painless & bright red bleeding which
are all apparent in this patient.
The risk factors include multiparity, advancing maternal age, previous history of placenta previa,
of which one, multiparity is apparent in this patient, making placenta previa a likely diagnosis.

2. Abruptio placentae: Refers to the premature separation of a normally implanted placenta after
28th week of gestation, attributing to 1/3 of ante partum hemorrhage.
Risk factors include previous abruptio placentae, hypertensive conditions, advanced maternal age,
DM, uterine over distension as in the case of polyhydraminos and multiple gestation. Though the
most common precipitating factor is trauma
The signs and symptoms of abruptio placenta include abdominal/back pain, sudden increment in
fundal height. Uterus will be firm and tender.
The risk factors are not of much importance in this patient. History and P/E especially
abdominal/obstetric palpation and the absence of direct trauma prior to the onset of bleeding do
not support placental abruption as a likely diagnosis.

3. Vasa Previa: It has similar clinical manifestations as placenta previa, like sudden onset and
profuse bleeding but its rare incidence in the general population make it an unlikely diagnosis.
4. Bloody show: It is a pink, brownish or red tingled mucous that is usually apparent at the onset
of the first stage of labor. It is an unlikely diagnosis in this particular patient provided that the
bleeding she experienced is profuse and bright red.

5. Uterine Rupture: It is one of the most feared and fatal complications of delivery, especially
following myomectomy or previous C/S. Its signs and symptoms include abdominal pain, vaginal
bleeding, increased pulse rate & shock. The absence of symptoms such as abdominal pain and
increased pulse rate rule out uterine rupture as a likely diagnosis.

6. Coagulation Disorder: It could present as abnormal vaginal bleeding with a history of

bleeding tendency. Its non-obstetrical symptoms include bleeding into joints, excessive bleeding
and epistaxis. The absence of the above mentioned symptoms in this patient make coagulation
disorder an unlikely diagnosis.

7. Cervicitis: It is easily defined as the inflammation of the cervical mucosa, mainly secondary to
microbial infections, for example trichimonas vaginalis, N. Gonorrhea and Herpes simplex virus.
Its signs and symptoms includeabnormal bleeding per vaginum, dyspareunia, grayish/yellowish
vaginal discharge with an offensive odor. But these signs and symptoms may not be sufficient for
diagnosis, so we need to use other methods such as vaginal examination [PV], Pap smear & close
inspection of the vaginal discharge under a microscope
Only vaginal bleeding is favored as a diagnosis for this patient, the inability to do further tests
makes cervicitis a less likely but a possible diagnosis.

8. Cervical Ca: It is one of the most common gynecologic malignancies. Its signs and symptoms
are bleeding per vaginum, vaginal discharge, change in menstrual cycle with no explanation,
dyspareunia. Also pelvic or back pain, urinary incontinence, hematuria, weight loss, loss of
appetite, Shortness of breath, constipation and anemia are among the late onset symptoms none of
which except vaginal bleeding are seen here.

9. Uterine Leiomyoma: Benign clonal neoplasms arising from the myometrial cells of the uterus.
They are usually asymptomatic but when symptomatic, their most common symptom is vaginal
bleeding.
Associated symptoms include bloating, abdominal discomfort, painful defecation, urinary
incontinence & backache & in some cases infertility.
Diagnosis can be made by bimanual palpation, ultrasound and MRI
It is an unlikely diagnosis because most of the signs and symptoms are no apparent in this patient
except for vaginal bleeding.

Final Diagnosis: Placenta Previa

Investigations
1. CBC, Hgb, Hct
2. Blood group & Rh
3. LFT
4. RFT
5. U/S [to differentiate the type of placenta previa]
6. Urinalysis