Madam NTR is a 34 old ages old Malay lady with gravida 4 and para 3, presently at 37 hebdomads of gestations. She was admitted on 21st Nov 2010 at gestational age of 30 hebdomads and 1 twenty-four hours, due to referral from Health Clinic Sendayan in position of placenta previa based on ultrasound findings during a everyday prenatal visit. Her estimated day of the month of bringing was on 20th Jan 2011. She was symptomless with no ailments of per vaginal hemorrhage, contraction hurting, leaking spirits or show. Fetal motions were felt and were non reduced. She has no history of placenta previa in her old gestations.
The first twenty-four hours of her last normal catamenial period was on 15th Apr 2010. This was an unexpected gestation but both her and her hubby wanted it. She suspected she was pregnant when she missed her menstruations for 4 hebdomads. She confirmed her gestation after urine gestation trial done in a private clinic yielded positive consequence. Booking was done in Maternal and Child Health Clinic Gadong at 16 hebdomads of gestation and the dating scan at 16 hebdomads revealed parametric quantities matching to day of the month. However, placenta was noted to be low lying during that scan. Throughout her everyday prenatal visits, she was normotensive, non anemic and did non hold diabetes mellitus. HIV and VDRL trial were negative. Her blood group type is O Rh DA positive.
This is her 4th gestation. Her 3rd gestation was in the twelvemonth of 2007. She delivered a full term babe male child with birth weight of 2.6 kilograms via cesarean bringing due to breech presentation in Hospital Tuanku Jaafar Seremban. She delivered her foremost two kids who are both males in the twelvemonth of 2004 and 2005 via self-generated vaginal bringing, with birth weight of 4.26kg and 2.6kg severally. There was no history of shoulder dystocia. All her kids were born alive and good. Antenatal, natal and postpartum for all old gestations were uneventful.
She attained menarche at the age of 12. It is regular at 28 to 30 yearss rhythm with continuance of 5 to 7 yearss. There was neither dysmenorrhea nor hypermenorrhea. She practised sexual intercourse interuptus as prophylactic step. She ne’er had any PAP smear done antecedently.
Past surgical, medical and drug history were everyday. Family history was everyday. She and her hubby are married for 7 old ages. They are remaining together with their three kids in Gadong Jaya Village. She is a homemaker. She neither fumes nor drinks alcohol. On the other manus, her hubby works as a building worker. He is a tobacco user but non alcoholic. Family income is about RM2000 per month which is hardly equal for their life.
Physical scrutiny:
Madam NTR was watchful, witting and communicative. She was non in hurting or respiratory hurt. Her tallness and weight are 165cm and 76kg severally. Her blood force per unit area was 110/80 mmHg ; pulse rate was 86 beats per minute of regular beat and strong volume ; temperature was 37A° C ; respiratory rate was 19 breaths per minute. All critical marks were within normal scope. Upon general scrutiny, there was no conjunctival lividness, sclerotic coat icterus, palmar erythema or peripheral cyanosis. Thyroid secretory organs were non tangible and breast scrutiny was everyday. There was bilateral pedal edema up to mid-shin. Cardiopulmonary scrutiny was everyday.
Upon scrutiny of the venters, it was distended with a big womb. Linea nigra and striae gravidarum were seeable. There was a tranverse cicatrix, mensurating 12cm, located above pubic symphysis. Distention appeared to be matching to gestational age. The navel was flattened. On light tactual exploration, the venters was soft and non-tender. Uterus was non cranky. Symphysiofundal tallness was 38 centimeter which was matching to gestational age. It was a singleton gestation with cross prevarication and cephalic presentation. The spirits was equal. Estimated foetal weight was 3.0-3.2kg. Fetal bosom sound was 160 beats per minute.
Probes
Full Blood Count revealed normal haemoglobin degree ( 10.9g/dL ) .
Transabdominal Sonography ( TAS ) revealed cross prevarication foetus with the presence of foetal activity, estimated foetal weight of 3.19kg at 37 hebdomads of gestation, anterior placenta previa type 3 ( placenta previa major ) with grounds of placenta accreta at one country over bladder base. A The images besides demonstrated placental blank, gross addition in vascularity of neck which is implicative of placenta accreta.
Diagnosis
Anterior placenta previa type 3 with possible placenta accreta.
Management
Upon admittance, Madam NTR ‘s critical marks were taken. Cannula was inserted and blood was taken for full blood count probe and blood group cross-matching. Madam NTR was besides given the account to maintain her in ward until bringing and the status of her gestation. She was encouraged to rest in bed and lessening activity degree to avoid hemorrhage. Ultrasound was performed to corroborate the diagnosing of placenta previa.
She was so monitored for any contractions or shed blooding. Madam NTR ‘s pad chart, foetal kick chart and labour gestation chart were purely monitored. Fetal bosom rate was assessed 4 hourly with Daptone. Cardiotocography was done on a regular basis and it was normal. She was given a class of IM Decadron 12mg BD of 1 twenty-four hours continuance at 30 hebdomads of gestation. Full blood count probe was performed one time hebdomadal and transabdominal echography was carried out one time in every 2 hebdomads throughout admittance. Anemia should be corrected if present.
Madam NTR was besides prescribed ferric fumarate, folic acid, vitamin B composite every bit good as ascorbic acid. She was finally planned for an elected cesarean bringing on 5th Jan 2011 at 37 hebdomads of gestational age. Prior to that, she was counseled about hazard of bleeding and possibility of hysterectomy to be done during operation every bit good as option of conservative direction etc. Written informed consent was taken from both her hubby and her.
Progression
Throughout the admittance, she was comfy and her critical marks were all normal. She had no any episodes of vaginal bleed, leaking spirits, show, uterine contraction and hurting. She was non anemic as evidenced by normal values of her hemoglobin degrees. The most recent hemoglobin value was 10.9g/dl. Fetal wellbeing was assured as evidenced by normal CTG consequences. She and her foetus remained stable until the scheduled operation day of the month.
A twenty-four hours prior to that, she was kept nil by oral cavity. Packed cell blood was ready for transfusion if needed. After bringing of the foetus, manual remotion of the placenta was done and placenta accreta was found to be at the anterior bed of lower section of the womb. She developed a monolithic uterine bleeding and a hysterectomy was performed. 3 units of jammed cells ( 1 liter in entire ) were transfused intraoperatively. The operation lasted for 1 hr and 15 proceedingss.
She delivered a babe male child weighs 3.2kg with Apgar mark of 6 at first minute and 9 at 5th minute of life. After being assessed by paediatrician, he was discharged to the female parent. Estimated blood loss was 2.8 liters. Explanation about intraoperative findings and the determination of go toing physician to continue to hysterectomy was given to Madam NTR. Postoperatively, she remained hemodynamically stable. Post operative hemoglobin degree was 12g/dl. She was able to ambulate and digest orally on 3rd twenty-four hours after operation despite minimum hurting over operation site. She did non kick of shortness of breath, palpitation, chest hurting or calf hurting.
Baby was pink, active and good with no icterus. Breastfeeding was established. Both of the female parent and babe were discharged on 7th Jan 2011and subsequent followup was scheduled to be 2 months subsequently. She should be arranged for psychological reappraisal and direction as expiration of birthrate can sometimes do lay waste toing psychological impact to adult females.
Discussion
What other options that Madam NTR has other than hysterectomy in the instance of placenta accreta? Is hysterectomy perfectly indicated in Madam NTR?
Mainstay traditional direction has centred upon hysterectomy which has a high complication rate and terminates birthrate of a adult female. It can besides do lay waste toing psychological effects. While in huge bulk of instances hysterectomy will stay appropriate, there are other direction options available affecting conservative attacks. The chief nonsurgical conservative direction would be to go forth the placenta undisturbed in situ for it to be resorbed or to be passed spontaneously. It is expected that shed blooding will stay minimum with this attack. This enables birthrate to be preserved even though go forthing the placenta in situ has deductions for infection and return.
LoA?c Sentilhes et Al. ( 1 ) concludes thatA successful conservative direction for placenta accreta does non compromise the patients ‘ subsequent birthrate or obstetrical result but there is a high hazard that placenta accreta may repeat during future gestations. FlorenceA Bretelle et Al. ( 2 ) conducted a retrospective survey in which 50 instances of placenta accreta were studied and 26 patients ( 52 % ) were treated cautiously. 21 of them ( 80.7 % ) did non undergo hysterectomy and 3 adult females had successful gestation during follow-up. This farther proves that treated patient with placenta accreta selectively with conservative attack enables birthrate to be preserved without increasing morbidity.
However, conservative attack is normally considered merely when hemorrhage is minimum. In this instance of Madam NTR, there was terrible bleeding encountered after bringing of foetus. Conservative direction such as go forthing the placenta in situ will take to terrible postpartum bleeding or even maternal decease. Uterine compaction suturing to halt the hemorrhage was non able to be performed as her womb was excessively delicate to keep the suturas. Therefore, hysterectomy is perfectly indicated in the instance of Madam NTR for her safety. This is her 4th gestation ; therefore expiration of birthrate is non a major concern in her as discussed antecedently prior to obtaining her consent.
As Madam NTR was planned for a high hazard surgery with possibility of hysterectomy, reding and obtaining written informed consent prior to surgery play a critical function. After being counseled, Madam NTR stated that she had small understanding about her state of affairs and the surgery but non to the full apprehension due to inability to to the full grok medical nomenclatures used. The inquiry here would be: “ Has the go toing physician done his responsibilities good plenty and is patient ‘s liberty protected in this context? ”
Informed consent is the nucleus rule of modern medical pattern. The primary purpose of the consent procedure is to protect patient ‘s liberty. Patients have the right to decline medical attention, even when it means they will decease. This surgery is associated with high complication rate, expiration of birthrate and lay waste toing psychological effects to patient. Therefore, educating and informing her about her health care options, advantages and disadvantages associated with recommended direction every bit good as other options are really important.
The point is non simply to unwrap information, but to guarantee patient ‘s comprehension of relevant information. Unfortunately, really frequently that physician are unwraping information presuming that patients with different degree of adulthood, instruction degree, cultural background and native linguistic communication will be able to grok. On top of that, physicians are so used to medical nomenclatures and it is frequently found hard to unwrap medical information in layperson ‘s nomenclatures. Majority of patients whom I encounter were non aggressive in seeking chances to raise inquiries to go toing physicians, particularly during ward unit of ammunition whereby patient will be surrounded by specializer accompanied by medical officers, interns and medical pupils. All these farther jeopardize patient ‘s liberty to exert personal pick with entire comprehension of relevant medical issues.
In the instance of Madam NTR, she and her hubby should first of all be told what a placenta is before explicating to them about placenta praevia. Subsequently, go toing physician should explicate to her the ground vaginal bringing was non able to be carried out as the placenta covers the entryway to the uterus ( neck ) wholly, which is known as major placenta praevia. Therefore, cesarean bringing is perfectly indicated and it will be conducted by experient obstetrician and anesthesiologist on responsibility. If an exigency arises, a adviser will be present.
Hazard of terrible shed blooding from placenta praevia which can set the life of the female parent and babe in danger should be emphasized ; hence explicating the intent of blood group cross- matching for blood transfusion. She should besides be informed that seldom, placenta praevia may be complicated by a job known as placenta accreta, when the placenta is abnormally attached to the uterus, doing separation at the clip of birth hard. Most of the clip, it will go through out spontaneously. However, if the hemorrhage continues and can non be controlled, taking the uterus has to be done to command the hemorrhage after consideration of conservative attacks such as go forthing it in situ with possibility of return or infection fails.
She has to be told to fast anterior to operation. Choices of analgesia should be discussed with anesthetist in relation to hazards and advantages for each option. Last and most significantly is to guarantee her that the health care squad will urge the best manner for both her and her babe and at the same clip, she has the right to be to the full informed about her wellness attention and to portion in doing determinations about it.
Under the jurisprudence, the physician has a responsibility of medical attention to give ‘adequate ‘ information about the proposed medical intervention. The breach of informed consent in today ‘s legal scene is more normally interpreted as carelessness when the physician has non disclosed the hazard of process and when the hazard occurs, doing injury to patient. In the English instance of Wells v Surrey Area Health Authority ( 3 ) , a 36-year-old adult female with 2 kids, was advised to continue to caesarean bringing after prolonged labor. She was in dog-tired province when she was suggested to be sterilized during the surgery and consent was signed and sterilisation was done. When she recovered, she complained that consent was invalid as it was taken when she was mentally baffled. She sued the physician for assault and battery for operation was done without consent every bit good as for carelessness as information sing sterilisation was non given at all.
In decision, informed consent should be practiced in the right manner, particularly in OBs and gynecology, an country with high hazard of medico-legal positions, to supply best intervention and direction to patient and fetus every bit good as protecting physicians from being sued for carelessness.