Case presentation on a patient managed for late

term pregnancy+ LFSOL+ breech presentation+

+ IUGR + Bilobed placenta

By Dr. Wondmeneh(R2)
Moderator: Dr.lammi(R4)
CONTENT

• Case summary

• Discussion
• Scientific discussion
• Comment

• Take home message

• Reference

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 IDENTIFICATION

• Name: A/A
• Age: 26 years
• Marital status: married
• Address :Jimma
• DOA :21/11/14
• DOD:25/11/14

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Senior resident evaluation ANC on
22/9/14
• G2A1(@2 ½ months, spontaneously) lady

• GA:33weeks from R.LNMP(01/02/14)

• ANC follow up at this hospital, uneventful

• She feels fetal movement as usual

• Has no headache, blurring of vision or epigastric pain

• No passage of liquor or vaginal bleeding

• No hx of DM,HTN or other chronic medical illness

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 P/E

• G/A: well looking

• V/S: BP: 100/70 PR:70 RR: 20 T: 36.4
• HEENT: Pink conjunctiva, non icteric sclera
• LGS: No anterior neck mass
• Chest: clear chest and good air entry
• CVS: S1 and S2 well heared, no murmur no S3 gallop

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Abdomen: U/S:-
• 32week sized gravid • SIUPX, FHB: +,Breech
uterus • EFW:1.7kg
• Longitudinal lie • AGA:31+3wks
• SDP:2.4cm
• Breech • Fundal anterior placenta and
• no contraction there is another placenta on
• FHB: 144 posterior with lacune
• GBM,BM&FT seen
• Index:3rd TM PX + RBPP+
bilobulate placenta

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• MSK & INTEG:NAD
• CNS: COTTPP
• Assessment: early preterm pregnancy+ breech + RBPP
+ bilobed placenta
• Plan:-advice on danger signs
• Ferrous sulphate 325mg po daily
• Consult senior

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Senior resident evaluation labor ward on
21/11/14

• G2A1(spontaneously@2 ½ )

• GA:41+3 weeks from R.LNMP

• ANC follow up at this hospital2x and FGA 2x

• Told to have breech presentation

• Presented with pushing down pain of 2 hours ,but no

passage of liquor
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• Has no headache, blurring of vision or epigastric pain

• No pushing down pain, passage of liquor or vaginal

bleeding

• No known chronic medical illness

• Feels fetal movement as usual

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 P/E

• G/A: in labor pain

• V/S: BP: 120/80 PR:96 RR: 22 T:
• HEENT: Pink conjunctiva
• LGS: NSLAP
• Chest: NAD

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Abdomen: U/S:-

• 34week sized gravid • SIUPX, FHB: +, Breech

uterus • EFW:2.5kg ,FL/AC:26%

• Fundal Placenta, bilobed
• Longitudinal lie, Breech
• GBM,BM&FT seen
Presentation
• Index:3rd TM PX +?IUGR
• FHB: 148

• Cont:2/10’/30-35’’

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• GUS: cervix is 3 cm dilated,70%effaced,M-itact
• Fetal foot is palpable in the cervical canal past the
buttock
• MSK & INTEG:NAD
• CNS: COTTPP
• Assessment: late term pregnancy+ breech
presentation(footling)+ ?IUGR
• Plan:-prepare for emergency CS
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Operation note
• After informed written consent taken patient prepared
and transferred to OR

• Under SA abdomen cleaned and draped

• Abdomen entered via pfannesteil incision

• Finding:
• Intact gravid uterus
• Healthy looking tubes, ovaries and urinary bladder
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• Done:
• Vesicouterine peritoneum reflected down and LUST incision
made to effect delivery of alive male neonate weighting 2.1KG
with APGAR score of 7/9 at 1st and 5th minutes respectively
• Pitocin 10IU IM stat given, placenta delivered by CT.
• There is separate lobe of placenta connected with
membranous blood vessel crossing over
• Uterus exteriorized, mopped and closed in 2 layers using vicryl
no 2
• Hemostasis secured, Correct counts reported
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• Fascia and skin closed using vicryl no 2 and 3/0
respectively

• Mother and neonate transferred to recovery room with

stable V/S

• EBL-400ML

• TOLAC possible in next pregnancy

• Newborn has features of IUGR

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 Post op Order

• P: Immediate postop day after LUST C/S done for

LFSOL+ Footling breech
• C: subcritical
• A: encourage ambulation

• D: start SIPS after 8hrs

• Ix: Determine post op hct after 8hrs

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• Treatment:
• Put on maintenance fluid(3L of NS,DNS and RL) every 8
hours/24hour
• Check uterine tone intermittently
• Watch for vaginal bleeding
• V/S every 15min for first 1hrs then then every 1
hour/4hours then QID.
• Tramadol 50mg IV TID
• Remove foley catheter after 8hrs.
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Investigation chart
date investigation result
21-11-14 CBC WBC- 11.39 NE-85.2%
HGB- 15.8 HCT-46.4%
PLT-142000

TSH 6.53

B/F NO H/P Seen

BG/RH A+
VDRL Negative
HBsAg Negative
U/A Blood +1
Others negative

Postop HCT 46.4%

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 POST OP V/S FOLLOW UP
date Time BP PR RR TEMP Medication
21-11-14 10:40AM 124/60 96 24 36.2
10:55AM 125/64 96 24 36.1
11:10AM 124/62 94 24 36.2
11:25AM 126/60 96 22 36.4
11:40AM 120/66 92 22 36.6
11:55AM 119/75 84 22 36.5
100-110/70 80-87 20-22 36-36.9

22/11/14 SBP-100-120 90-120 20-24 36.6-37.7

DBP-70-80
23/11/14 SBP-90-110 104-108 22-24 36.6-36.8
DBP-60-70
24/11/14 SBP-100-110 104-116 20-24 36.7-37
DBP-60-70
25/11/14 SBP-100-110 96-112 20-24 36.5-36.8
DBP-60

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Plan upon discharge

• Advised on danger symptoms, newborn care ,EBF

• Counseled on FP, Opted for implanon

• TOLAC possible

• Advised on interpregnancy interval

• Next ANC should be at hospital and early U/S

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 DISCUSSION

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PROBLEMS IDENTIFIED

• Bilobed placenta

• IUGR

• Breech presentation

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INTRODUCTION

• Placenta is a feto-maternal organ that develops in uterus

during pregnancy.

• consisting of umbilical cord, membranes and

parenchyma

• Provides oxygen and nutrients to fetus and removes

waste products from fetus.

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PLACENTA AT TERM

• Oval

• Diameter : 22 cm

• Thickness : 2.5 cm

• weights : approximately 470 g

• Two surfaces- Maternal and fetal

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• Abnormal Shape or Implantation

• Degenerative Lesions

• Circulatory Disturbances

• Inflammatory

• Tumors
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MORPHOLOGIC ABNORMALITIES
• Fenestrated Placenta

• Placenta Extrachorialis

• Placenta Membranacea

• Placenta succenturiata

• Duplex placenta

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BILOBED PLACENTA

• Also known as bipartrite or duplex placenta

• 2-8% of placentas

• Roughly equal size lobes are separated by a segment of

membranes

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PLACENTA SUCCENTURIATA
• Refers to a placenta with an additional lobe or lobes of
placental tissue located a few centimeters away.

• Called placenta spuria if no vascular communication

• 3% of pregnancies

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Bilobed placenta vs succenturate

Bilobed succenturate

• Different size lobes

• Equal size
• Eccentric and
• Central cord insertion velamintous cord
insertion
• Lobes are attached by • Lobes are attached by
membranes
chorionic tissue
• RPOC more common,
• Primary PPH late PPH
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10/09/2022 PA BY WK 30
RISK Age
FACTORS
Infertility treatment

smoking

Diabetes

Multifetal gestation

Uterine scar

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ETIOPATHOGENESIS

• localized atrophy as a result of poor decidualization

and vascularization in a part of the uterus

• Implantation in areas of decreased uterine perfusion

• Other local factors :

• Implantation over leiomyomas,Area of previous
surgeries and Over the cervical os

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ANTENATAL DIAGNOSIS
• most important, in preventing adverse outcomes

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CLINICAL SIGNIFICANCE

Maternal Fetal

• 1st trimester bleeding • Fetal demise

• APH(Placenta previa, • IUGR

vasa previa) • Malpresentation
• Retained placenta • AFV abnormalities

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IUGR vs abnormal placental shapes

• Lateral wall implantation/Placenta previa

• Vascular thrombosis

• Battledore placenta

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 Comments
STRENGTH PITFAIL
• Diagnosed antenatal • ECV not planned
• Maternal tachycardia not
explained
• ?Left shift in WBC
• Stayed for 5 days

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Take home message
• Prenatal diagnosis of the bilobed placenta in scans
alerts the obstetrician and helps appropriate planning,
prompt recognition, and treatment of complications
associated with it.

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REFERRENCES
• Williams obstetrics 26th edition

• Uptodate 2021

• Benirschke Pathology of the Human Placenta 6th Edition

• Suzuki S, Igarashi M. Clinical significance of pregnancies

with succenturiate lobes of placenta.

• Sumisti S (2019) Antenatal Discovery of Bilobed Placenta

Helped Manage Third Stage of Labor: A CasenReport
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