THE CASE
Mrs O.I, was referred to our center, Alex Ekwueme Federal University Teaching Hospital Abakaliki on 2nd June 2017 at a gestational age of 32 weeks and 5 days with bleeding in pregnancy and was admitted into our antenatal ward through the Accident and Emergency unit of the hospital on account of recurrent painless unprovoked bright red vaginal bleeding of 9 hours duration. The bleeding was profuse with clots. She had changed two well-soaked pads. There was no dizziness or fainting attacks. She was referred from a private hospital where she booked. She had had 2 previous episodes of unprovoked vaginal bleeding at a gestational age of 25 weeks and 2 days and 5 days prior to presentation. On both occasions she was managed at the peripheral hospital where she booked. She came with an ultrasound scan result that showed type 4 placenta praevia.
In 2015 she had a term delivery of a 4.3kg male neonate with Apgar scores of 6 in one and 10 in 5 minutes through an emergency caesarean section at a peripheral mission hospital on account of cephalo-pelvic disproportion
Examination revealed an anxious young lady in no obvious distress who was afebrile to touch, mildly pale but not jaundiced. The pulse rate was 98 beats per minute, moderate volume and regular and blood pressure was 110/70 mmHg and she had no pedal oedema. The chest was clinically clear and the abdomen was uniformly enlarged with a symphisio-fundal height of 33 cm. the uterus haboured a singleton fetus in longitudinal lie with cephalic presentation and a high floating presenting part. The fetal heart rate was 150 beats per minute and regular.
Inspection of the vagina showed a perineal pad that was mildly soaked with bright red blood but no active vaginal bleeding was seen per vagina. There was no digital examination. A diagnosis of antepartum haemorrhage secondary to placenta praevia at 32wks 5 days gestation in a primipara was made.
Blood was collected for haemoglobin, grouping and crossmatching of 4 units of blood and other investigations, an abdominal ultrasound was asked for and an intravenous line was set up with one liter of ringers lactate solution started fast. She was admitted into the antennal ward for conservative management of her placenta praevia. Intra-muscular dexamethazone 12mg, 12 hourly for 2 doses was prescribed for her among other medications.
The packed cell volume was 25% and the obstetric ultrasound on 2/6/17 showed a single viable intra-uterine fetus in transverse lie with the head to the maternal left. There was good gross fetal body movement with a fetal heart rate of 130 beats per minute. Estimated gestational age was 33 weeks and 3 days and estimated fetal weight 2.7kg. There was no fetal anomaly noted. The placenta was sitting on the internal os completely covering it with mild bleed noted in the cervical os. There was no obvious retroplacental bleed seen. The liquor volume was adequate and the internal os was closed. There was no coexisting uterine mass. An impression of a viable 33 wks 3days old gestation with placenta praevia type 4 was made.
She was transfused with 2 units of blood, placed on haematinics and other drugs and managed conservatively for 12 days till 14/6/17 when she started bleeding profusely again and was taken to the theatre for emergency lower segment caesarean section.
The operation went well as a live 2.5kg male baby (length 40cm and had circumference of 32cm) with Apgar scores of 9 in one minute and 10 in 5 minutes was delivered. Haemostasis was controlled as per departmental protocol with under running sutures used over the placental bed which stopped the bleeding. But the uterine refused to contract despite starting high dose oxytocin, repeating. ergometrine 0.5mg, giving sublingual misoprostol 800microgramme etc. The bleeding persisted as the uterus was still atonic..Two units of blood was transfused intra-operatively. A decision was made to carry out peripartum hysterectomy before the Esike’s Technique was carried out and the bleeding stopped. The patient made uneventful recovery and was discharged home on the 6th postoperative day. She had done well and on her 6th week postnatal visit and was discharged from the clinic after being seen.
She presented to the hospital on 16th February 2020 with inability to see her menstrual period for 3 months. Her last menstrual period was or 27/14/19. Ultrasound confirmed an intrauterine pregnancy of 11 weeks and 3 days. She was booked for antenatal care, had an uneventful antenatal period and on 20th of August 2020, she gave birth to a life 3.7kg male baby with Apgar scores of 10 in one minute and 10 in 5 minutes through a repeat lower segment caesarean section. Estimated blood loss was 600ml, Mother and baby were fine.