A 36 years old multigravida at 34 weeks, with previous 2 LSCS now presented with unstable lie. The most likely diagnosis in this case is:
Ans. b. Placenta previa (Ref: Dutta 6/e p244, 251)Oligohydraminos does not present with unstable lie.History of previous cesarean section or any scar on uterus is a predisposing factor for Placenta previa.Placenta PreviaDefinition: When placenta is attached partly or completely in lower uterine segmentPrevia means in front ofPredisposing FactorsMultiparous womenQAge >35 yearsQHistory of previous cesarean section or any scar on uterusQLarge placenta sizeQ Types/Degree of Placenta Previa (PP) (Norman and White)I* Low lying (Lateral)QII* Marginal (Dangerous PP)QIII* Partial (Incomplete central)QIV* Total (Complete central)QClinical Features:Bleeding in PP is always maternalQ.Sudden ''painless" vaginal bleeding, causeless, recurrentQOn abdominal examination:Malpresentation is more commonQHead floating in contrast to period of gestationQUterus feel: Soft, relaxed, no tendernessQStall-Worthy's SignSlowing of heart rate on pressing the head down into the pelvis which soon recovers promptly as pressure is released, is suggestive of low lying placenta specially posterior typeQ.Diagnosis:USG: Most accurate method for localization of placentaQExpectant Management for Placenta Previa (Johnson's and Macafee Regimen):\Suitable cases for expectant management:Mother is in good condition, patient not in labour and should be hemodynamically stableQHb 10 gm% or morePregnancy <37 weeksQFHS: goodActive bleeding absentInitial bout of bleeding <600 mlExpectant treatment carried up to 37 weeks i,e. Baby becomes maturePremature termination of expectant treatment may be doneRecurrence of brisk hemorrhageQFetus is deadQFetus is found congenitally malformed on investigationsQExpectant Management for Placenta Previa (Johnson's and Macafee Regimen)Suitable cases for expectant management:Mother is in good condition, patient not in labour and should be hemodynamically stableQHb 10 gm% or morePregnancy <37 weeksQFHS: goodActive bleeding absentQInitial bout of bleeding <600 mlExpectant treatment carried upto 37 weeks i.e. Baby becomes mature Premature termination of expectant treatment may be done:Recurrence of brisk hemorrhageQFetus is deadQFetus is found congenitally malformed on investigationsQ
Oligohydramnios
Placenta previa
Pelvic tumor
Uterine anomalies