Identification

Name: Wudinesh Mitiku Walelgn

Age: 35 Date of Admission:23/08/04 E.C

Address: Oromia,Fitche ,kebele 02 H.no1016

Occupation: House wife Ward: Obstetrics

Marital Status: Married Educational status:9th complete

Religion: Christian, Orthodox Bed no:25/4

Previous admission :None

Chief Complaint: vaginal Bleeding of 30 minutes duration.

History of present pregnancy

This is a 35 years old Gravida5 Para4 Abortus 0 lady whose last LNMP is
unknown,because she was amenorrhic for the last 9 years due to use of
Depo Provera.On Megabit 23,2004 E.C she started to experience
painless, bright red ,non clotting vaginal bleeding that woke up her from
sleep. The blood soaked her underwear,clothes, linen and stopped after
30 minutes. According to her,the bleeding is about half a liter and not
associated with vginal discharge. Before that, she never experienced any
bleeding during the pregnancy. The next day she went to Fitche
Hospital ,where she had ANC follow ups.After blood tests and ultrasound
was done she was told that the baby’s head is covered by the placenta
facing downwards & referred to Tikur Anbessa hospital. She had five
regular ANC follow ups(every month) after experiencing nausea &
vomiting at the 12th week of gestation. Blood pressure, Height & weight
measurements, abdominal examination, vaccination & blood tests were
done repeatedly. She was told that everything was fine. But she does not
remember any of the results. She was also given Iron supplements &
counseling about danger signs of pregnancy. The first time she heard
fetal movement is 4 months a ago (both rolling and kicking type).Now, it
is becoming much more stronger than ever, and more felt at night & after
meal. After admission here at Tikur Anbessa Hospital, an ultrasound and
blood test was done, advised not to allow any lower abdominal
examination & per virginal examination & also to report if any
bleeding .She eat 4 meals per day (injera, fruits, meat, vegetables and
cereals)as the pre pregnancy time. She claims about 7 kilograms weight
gain. She has no history of any type of drug use, during the whole
l

pregnancy. The pregnancy is planned, wanted and supported by the

family. She was also told to give birth at Tikur Anbessa Hospital .She has
no known self or family history of hypertension, Diabetes mellitus or
goiter.
She has no pushing down pain, No leakage of liquor. No history of
trauma, post coital bleeding, abortion or still birth; no fever, itching
sensation of the genitalia, no urinary or gastrointestinal complaints.

Past Obstetric history

She has 4 chidren who were born in 1986,1988,1991and 1995.the first
child was female but all others are males. All are delivered at term,
vaginally without any maternal or fetal complication even though the
delivery was at home by untrained person. She doesn’t remember their
birth weight but they are all healthy.

Gynecologic History

She used Depo-Provera for the last 9 years, by withdrawing it in

between(when she want to be pregnant).The last time she skipped the
injection she was supposed to take was on Nehassie 26,2003 E.C
because she wanted to be pregnant. Otherwise she is satisfied by the
Depo-Provera,& has no history of oral contraceptive use. She was in
stable monogamous marriage since 1985, which was the time of her first
coitus(17years of age).Her husband is the only sexual partner she ever
had. She believes that her husband has no other sexual partner than
herself. For this reason they never used condom during intercourse. She
does not remember any time that could predispose her to STIs.

Past Medical and Surgical History

No history of UTIs or any other infections, liver disease, hormonal

replacement therapy, immunosuppressive therapy or chemotherapy
diabetes mellitus ,hypertension, renal or cardiac disorders. No history of
C/S, no any medical or gynecological surgery.

Personal/ Family history

She was born and raised in Fitche. She attended school until grade 9
and stopped because she repeated the year two times. She has history of
measles when she was 5-9years of age, but relieved by traditional
religious therapy. She has also history of Intramuscular vaccination,
when she was10-13 years of age. Otherwise, no history of other
childhood illnesses, smoking, Chat addiction or alcohol use. Both her
l

parents are alive and relatively healthy. She has 6 brothers and 5
sisters; all first degree family are relatively healthy and have no history of
HTN,DM,TB,mental disorders and twinning. She is happy in her
marriage. They live in a house with 2 rooms that has a toilet ,have 2 oxen
,10 sheep’s and 1 TV, they have no car.

FUNCTIONAL INQUIRY

H.E.E.N.T

Head: No headache or trauma.

Ears: no loss of hearing, discharge, earache, deafness, tinnitus or

vertigo.

Eyes: Good vision, no pain, strain, lacrimation or photophobia.

Nose: No epistaxis or unusual discharge

Mouth and throat: No dental pain or bleeding from gums no artificial

denture.

Glands

No mass in the neck, axillae, groin or lump in the breast. No discharge

from the nipples. No heat or cold intolerance.

Respiratory

No cough, expectoration, no hemoptysis, chest pain, shortnesss of

breath, Wheezing or cyanosis, no night sweats,

Cardiovascular system

Has palpitation sometimes, but no fatigue, no orthopnea, no PND, no

chest pain, no dysnea. No leg swelling, syncope or history of
hypertension.

Gastrointestinal system

No nausea, vomiting, darkening of stool, constipation or diarrhea. She

has regular bowel habits, no heart burn.
l

Genitourinary system

No frequency of urination, dysuria, urgency, hesitancy, dribbling,

hematuria or pyuria. No history of STIs.

Integumentary system

Hyperpigmentation in both sides of zygomatic bones, moist skin, full

hair distribution, or no color changes in fingernails.No known allergy or
drug sensitivity.

Locomotor System

No bony deformities, no chest pain, no joint pain or swelling, no loss of

function of limbs, muscle wasting or weakness.

Central Nervous System

No seizure, syncope, no blackouts, no spasms or involuntary movements.

Physical Examination
GENERAL APPEARANCE

she looks older than her stated age and comfortable with no signs of
distress.

VITAL SIGNs

PR: 90beats/min; regular, not full in vol.(left radial artery)

RR: 19breaths/min

BP: 110/70mmHg; left hand in a sitting position

To: 36.2OC, left axilla
Weight: 74kg
Height: 1.64m
BMI: 27.51
 l

H.E.E.N.T.

Head: Normal size and shape. No scar. Normal hair

distribution.
Ears: Normal contour of pinna. Clear external ear canal. Good
equal hearing.
Eyes: Normal eyebrows. No periorbital edema, ptosis,
exophthalmos, excessive lacrimation or strabismus. The
conjunctiva are pink. The sclerae are not icteric. The
pupil are equal in size.
Nose: Central nasal septum. There is no polyp or unusual
discharge
Mouth The lips show no fissure, ulceration or herpes. The gums
&Throat: are intact and clean. There is no carious tooth., artificial
denture

Lymphatic and glandular System:

The occipital, pre and postauricular, submandibular, submental,

supraclavicular, epitrochlear, axillary and inguinal areas are free of
palpable lymph nodes. The thyroid gland is not enlarged. Breasts has no
mass, no lump or nodule, no retraction of skin, wider areola bilaterally.
There is no nipple discharge or retraction.

Chest Examination

Inspection: Symmetrical,no scar, no use of accessory muscle while breathing,

symmetrical chest movement, no cyanosis and no clubbing.

Palpation: central trachea, symmetrical chest expansion and symmetrical tactile

fremitus both anteriorly and posteriorly.

Percussion:, resonant notes, diaphragmatic excursion =3.5cms

Auscultation: normal bronchial breath sounds

 l

CardioVascularSystem

Arterial pulse volume is tabulated as follows:

Carotid Brachial Radial Femo- Poplit- Dorsalis Posterior

ral eal Pedis Tibialis
R +++ ++ + ++ + ++ +
L +++ ++ + ++ + ++ +

Veins

The jugular venous pressure observed at one pillow elevation (45 o couch
was not available) has a measurement of 7cm,no hepatojugular reflux,
no distended veins over the neck, chest wall, no varices or phlebitis in
the legs.

Precordium

Inspection: quite precordium, no scar, no deformity, no bulging.

Palpation: The point of maximum impulse is felt at the 5 th intercostals

space medial to midclavicular line no palpable heart sounds, no
parasternal heave or thrill.

Auscultation: Normal S1 & S2 heart sounds ,no murmur ,no gallop

Abdomen

Inspection: Abdomen is grossly distended and is symmetrical. Flanks are

full. There is striae gravidarum in the lower quadrant of the abdomen,the
umbilicus is inverted. There are no distended veins, visible peristalisis, or
palpations. No visible hernia while coughing.

Auscultation: Bowel sound hard to appreciate. Positive fetal heart

rate(140/min), heard over the right side of the abdomen.

Palpation:

Superficial palpation: No tenderness, rigidity or superficial mass..

Deep & palpation: No palpable liver or spleen. No deep mass.

 l

Obstetric(Leopold’s):

1. Fundus occupied by breech it is soft, irregular, bulky and non

ballotable structure.
34cm uterus,above the symphsis pubis giving gestational age of
34weeks.
2. Back felt on the right side, giving a longitudinal lie.
 Leopold maneuvers 3&4 was not done because placenta
previa was not ruled out (possible risk of bleeding)
Percussion: No shifting dullness or fluid thrill.

Pelvic examination

Was not done, except inspection of External genitallia:

-shape of pubic hair: Inverted triangle

-Bartholin’s gland:not visible

-Labia majora and minora: no discharge ulcers, swelling, or mass

-Urethral Orifice: no inflammation

-Perineum : smooth and unbroken, no episiotomy scars, swelling

Central Nervous System

Mental Status

The patient is well oriented to person, place and time. normal speech,good
memory,attention ,no halucination

Cranial Nerves:

1. Smells alcohol via each nostril

2. Good visual field,acuity and colour sense
3, 4 & 6. The eyes can move in all directions. No nystagmus or diplopia.good
Pupilary reflex and accommodation.
5..Trigeminal: Positive corneal reflex,touch and pain sensation over the face.
Normal contraction of temporalis and,masseter,muscles.
7.Facial: symmetrical face both at rest and during voluntary movement,identiferd
orange taste.
8. Vestibulocochlear: no hearing loss ,good balance
 l

9, 10 Glossopharyngeal and Vagus: symmetrical soft palate and good phonation

11.Spinal accessory: Sternocledomastoid and Trapezius muscles contract with
full power
12.Hypoglossal: tongue can move to all directions,no tremor, no atrophy,
protrusion of the tongue

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 + + + + +

Summary

Subjective-

-35 years old

-multigravida mother

-third trimester pregnancy

l

-presented with painless and bright red antepartum hemorrhage

-Reassuring fetal condition

Objective- PR:90beats/min RR:19breaths/min ,BP: 110/70mmHg; T o:

36.2OC, Weight: 74kg,Height: 1.64m,BMI: 27.5,

-34weeks gravid uterus

-longitudinal lie

-breech occupying the fundus

-FHR:140/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

1. 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.
2. 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 .
l

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.

Investigations
 CBC,Hgb,Hct
 LFT & RFT
 Urine unalysis
 (obstetric)Abdomino pelvic ultrasound
 BPP
 MRI
Risk Assessment
This is a high risk pregnancy because of spontaneous bleeding,
increased maternal age, possibly recurring severe hemorrhage.

Management Plan
Conserative:
 follow her with: -APH CHART
-KICK CHART
 Give Iron Supplement
 Follow her with Hct,BPP
 Advice family to stay near,& immediately report if any bleeding
Definitive:
-Delivery of the child in this patient could be considerd,
after fetal maturity is confirmed.