Identification

Name: Gelano Mamo Age: 34 Sex: female

Address: Awash area

Occupation: housewife Marital status: Married Religion: Orthodox Christian

Date of admission: 15/03/05 Ward: East Bed no 205

Chief complaint:
Vaginal bleeding of 1 day duration

HPP:
This is a 34 year old gravida 4 para lll mother. Her LNMP was 25/01/04 E.C which makes her EDD on
07/05/05E.C , and gestational age 34 weeks. The cycle was regular coming every 4 weeks and she has
never used contraception for 8 month before her LMNP.

She suspected her pregnancy after she missed one menstrual cycle.

She has no any ANC follow up in the current pregnancy as well as in the previous pregnancy.

After admission , she was having blood and urine examination but her blood group ,HIV status HbsAg,
VDRL are not known by her .

She does not remember exactly when quickening happened but she tried to guess that it was started after
5 month of her LNMP. Fetal movements were kicking in type. Fetal kicks had not decreased.she had no
loss of appetite she had 2- 3 meals per day consisting of injera with wot sometimes vegetables .

She claims about 7 kilograms weight gain. The pregnancy is planned, wanted and supported by
the family.

She started to experience vaginal bleeding on 14/03/05 E.C in the after noon after she has finished her
routine home activity . The blood was bright red, with no clots and amounted to 2 Arabian coffee cup. It
was spontaneous and happened 3x so far. There was no associated pain, pruritus, discharge or leakage of
liquor. during this time She immediately went to Awash health station where She was referred to St.
Paul Hospital for better evaluation and treatment.

She has 3 chidren , All are delivered at term, through spontanous vaginal dwlivery without any
maternal or fetal complication even though the delivery was at home by traditional birth
attendant. She doesn’t remember their birth weight but they are all healthy and alive .

She used to take oral and injectable contraceptives for three years but discontinued due to epigastric
discomfort.
 She has no history of sexually transmitted diseases. She is sexually active. She started coitus by the age
of 17. She has coitus at an average of 2x/wk and she is monogamous. She had her last coitus 4 months
ago . She has no history of gynecologic operations or instrumentation but, She had undergone
circumcision.

After one week of her admission she started to have global head ache and profuse sweating that makes
her cloths wetting.
She has also history of increased urinary frequency (3/2 D:N ratio)

Other wise : -
There is no history of offensive vaginal discharge
No history of abdominal or pelvic trauma.
No history of coitus near term
No history of hypertension
No history of decreased fetal movements after bleeding
No history of dysuria , incontinence or dribbling of urine no haematuria.
No history of abdominal pain
No history of sudden abdominal fullness or rapid increase in size
No past history of antepartum hemorrhage in the previous pregnancies.
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 other sites
no hx of blood transfussion
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

Past obstetric history: see HPI

Gynecologic history: see HPI

Menstrual history:
She doesn't remember the age menarch . her menses was regular. Duration of flow is 3 days. She uses 2
pad per day during menses. The flow is dark, with no clots. She experiences mild headache and
abdominal discomfort associated with flow of menses.

Past medical history : see hpI

Family/personal history
The patient was born and raised in Awash and married at about the age of 17. she lives with her husband
and three children She is the 2nd child for her parents. She has never sent to school. she is a house wife
and has a duty of taking care of the children and cooking food for the family. her husband is a farmer
who engaged in subsistence farming. She has no habit of smoking drinking or any drug use. she has
three sister and two brother allare healthy and alive. her father is 70 and healthy but her mother is dead
when she was achild with unknown cause.

There is no family history , hypertension, diabetes mellitus, asthma , tuberculosis or allergies.

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.
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

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: 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: 130/90 mmHg right arm in supine position
Pulse rate: 90/min right radial artery, full in volume and regular rhythm
RR: 20breath/min normal
Temperature: 36.5⁰c
Weight: 69kg
Height: 174cm BMI 23kg/m2
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: slightly pale 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.

Respiratory system:
Inspection: slight cyanosis of the palm , no 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 not raised

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 5 th 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 flank fullness and distended veins. The
abdomen moves with respiration. Epigastric pulsations are not visible. Inguinal, epigastric, umbilical and
femoral sites are free of hernia. The umbilicus is everted. 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: normo active bowel sound, no renal or aortic arterial bruits.

Obstetric physical examination:

Leopold 1: fundus palpated 7 fingers above umbilicus, 34 week gravid 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&4: are not done because placenta previa is not ruled out yet i.e thre is high suspiction of
placenta previa from the history.
Auscultation: Fetal heart rate is positive (148beats/min)

GUS:
There is no costo-vertebral angle tenderness

Pelvic:
Inspection: 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, but striae gravidarum and linea nigra are present , there is mild palmar pallor, no finger
clubbing, no jaundice, skin is warm
normal hair distribution, hard texture and strength.

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 RLL LUL LLL
L
POWE 5/5 5/5 5/5 5/5
R

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-

-34 years old

-multigravida mother

-third trimester pregnancy

-presented with painless and bright red antepartum hemorrhage

-Reassuring fetal condition

Objective- Blood pressure: 130/90 mmHg right arm in supine position

Pulse rate: 90/min right radial artery, full in volume and regular rhythm
RR: 20 breath/min normal
Temperature: 36.5⁰c
Weight: 69kg
Height: 174cm

-34weeks gravid uterus

-longitudinal lie

-breech occupying the fundus

-FHR:148/Min

Differential Diagnosis

Placental Non placental

1.Placenta Previa 1.uterine rupture

2 Abruptio Placentae 2.local lesions of

cervix,vagina ,and vulva
3.Vasa previa 3.indeterminate

4.Bloody show

Discussion of Differential diagnosis

• Bloody Show

This is due to detachment of the mucus plugs in the cervix and rupture of small vessels during
cervical effacement and dilatation. But she doesn’t have signs of labour .
• Vasa Previa
Vasa previa is defined as the velamentous insertion of fetal vessels over the cervical os, after
rupture of fetal membranes. BecauseIt is a rare condition & the patient has no leakage of
liquor. Not likely
3.Abruptio placenta
- is a premature separation of a normally implanted placenta. It normally presents with dark
red bleeding and has pain associated with it, due to contraction and irritation of the uterus.
The uterus appears rigid, tetanic and tender due to the contraction and inflammation. There
could be fetal distress or fetal death. Its risk factors could be over distension, trauma, HTN,
amniocentesis, or renal disease. This patient has none of those signs and risks . She has soft
and non tender uterus. Fetal condition is safe, as she was told after and normal heart rate .
4.Local causes-are also under the list of differential diagnosis and could be ruled out after
speculum examination, but because the history is sufficient to make the diagnosis
5.Placenta Praveia
Implantation of the placenta in to the lower uterine segment. Bleeding results from
disruptions of the placental attachment, during formation and thinning of the lower uterine
segment. It presents with causeless,bright red, painless bleeding that stops by it self. Abdomen
is relaxed and non tender. Risk factors include:large placenta (twinning), multiparity, and
increased maternal age. This lady has all those symptoms mentioned above; making placenta
previa the most likely diagnosis.

Risk Assessment
This is a high risk pregnancy because of spontaneous bleeding, increased maternal age,
possibly recurring severe hemorrhage.

Investigations
 CBC with differential to rule out anemia due to concealed hemorrhage
to check for thrombocytopenia and rule out DIC

 Trans abdominal U/S to localize placenta or detect a retroplacental clot

 Blood typing for possible transfusion & identifying Rh setup

Urine analysis to detect proteinuria (preeclampsia) and to detect asymptomatic.

bacteruria.
 LFT & RFT

Case report # 2
NAME Mekonen Asrese
ID NUMBER MDR/3806/02

SUMBMITTED TO
DR.DAWIT DESALEIGN

DEPARTMENT OF
OBSTETRICS AN GYNECOLOGY