Placental infarction in teenage pregnancy

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+6 2+' 5 ') ')+ * 20 '.# % Abstract .&%  #7+1+ 8 % 7+#. 9&0 * .:( &#'# $ + *+# A- 16  year-old primigravida woman had ') 28 '.#  9&+ * 36 '.# ' the first visit antenatal care at the health station '="  #$% & !&  #>  near home, when the gestational age was 20 +6 week 71+ 7+#++!+ +#& %$ *+'? #  by certained date, bood serology all negative. There  9+9# 1.3 ?   9>  was a problem of the fundal height less than the #= 9+ 7)+"# @ &9+& gestational age at 32 week of pregnancy but early  1#'# )  1 >+ ' 9>'= detection and further investigation was not done. " * & # %A %8'# At 36 weeks of pregnancy, she came to +#  7)+ .B  >  A1= the Taphanhin Crown Prince Hospital with the chief 9+  ' 250 ' >8C complain of abnormal vaginal bleeding and labor pain +9# 1 ?   35 ?  )  1  and the ultrasound findings were abnormal placenta >+%D $)   C (9  APGAR score (thickness 1.5 cm. and focal hypoechogenicity = 0, 3, 4 )  ' 1,260 ' Maturity Score 34 especially at the placental margin and the maternal '.#  %@'  %( "!>= *&#' floor ) and oligohydramnios. while she was being &* &9#++? %=&#' admitted to the labor room, the fetal distress was '=+!  =%&! >!  D#>2 ' detected so the cesarean section was done. The

*   7   ! "  #$% & !&   %' '# %

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  intraoperative findings were wide placental infarction  9>1  7+". += 7+=>8  (more than 1/3 of the placenta), 250 grams by weight, * & 7)+ D#>>+& 25 9+ (') * umbilical cord diameter is 1 cm., with average length   #1D* &?>+=#o (3) +D$ of 35 cm., severe oligohydramnios and the female 2>  7)+  A1=9+ 7)+ newborn (APGAR score = 0, 3, 4 ) 1,260 grams by %&8+ 7+#1%&D. ) ?A1 = > #* & weight, breech presentation and Maturity score was  %( "!>= * 7+= *D#>(4,5) 34 weeks. The diagnosis was severe IUGR and severe birth asphyxia. After birth the newborn was intubated
  and resuscitated, and then transferred to the Phichit 8>.p  (D  * + 16 ./  Hospital, 4 day later she was dead due to severe %'qCA./1 3 +! '%>'1 D. *   sepsis. +  *+' >+ %' '# %


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 %A % 50 g 1 hr 9&+ * 28 +3 - HEENT : not pale conjunctivae, no '.#  D#> 130 mg% icteric sclera , no thyroid enlargement 2. 9## $ + *') - Heart and Lung : . 28 '.# = >.& '#)# DD#> +'>? # - Abdomen : FH 2 >
(29 cm.) , 4 7+7 > 1  FHR positive, irregular uterine contraction Interval
4  6 , Duration 30 , severity 1  2 +  

- .s q" .&% ' .s q > &  D!'#  >+  .s q 1 #71 7+=!>  # - Speculum exam : bloody discharge

- '+C''&# 2 cc at post fornix, no active bleeding

,
 - Extremities : no deformities, no edema

- #+ 40 ./ .B   5 ./ 

5 56- 7,
'1  +   D#>#  1 10 ?++ ' CBC : Hb 12.3 mg/dl, Hct 39%, wbc  '  > 10 ./ 20,000 neutrophil 89%, lymphocyte 7% normal rbc

- + 18 ./ %'qCA./1 3 morphology, platelet smear 253,000, M.C.V. 81, +! 9'2'%> .s q" .&% '  1 2  M.C.H 26, M.C.H.C 32 3  + ' D1  + UA : sp.gr. 1010, albumin negative, 8>.p ''1"  sugar negative, ketone negative, rbc 30  50, epith  #$% & !&   '1 13   2550 cell 10

9&+ * 36 '.#  #>  71+. #>+o ') Coaglulogram : PT ., PTT . & 7+#. $>+++%!+ +# LFT : SGOT 32, SGPT 14 3 !'1 "+"  .s q# %$ 7+ FBS : 80 mg% BUN : 6 mg% +'  Triglyceride : 170 Creatinin : 0.9 mg% 
5
 Cholesterol : 207

- Vital sign : BP 120/80 mmHg, PR ANA : negative y 88/min, RR 18/min, BT 37.1 C CXR : .

- General appearance : a young EKG : . pregnant, good intelligent, BW 76 kg.

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* 1 1 NST * & Late decelelation, baseline 150 bpm, moderate variability &+++&> ( 71+ C)

* 1 2 +'? # : Single viable fetus, * 1 3 +'? ##  1.3 transverse lie, FHR positive, FM positive, AFI = 4 ?  +  posterior lower, '   fetal parameter   HC : ratio   1  9> #"# @ &9+& 1#

'#

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.28
 8>.p D#>' %@'  1. Primigravida teenage prenancy 2. IUGR with non reassuring FHR 3. R/O Abruptio placenta 9& 8') * * & progression of labor & FHR # (#'.)  %*= .# .„# 1 cm. effacement 75%, MI, station -2

* 1 4 Severe variation / late decelelation, FHR : baseline 120-140 bpm, moderate variability : no accelelation



9 - Set OR for : emergency cesarean section due to fetal distress. - Post operative diagnosis : Severe IGUR with fetal distress. - Operation : Low transverse cesarean section with Breech extraction. - Finding : Non gravid uterus, normal both adnexa, oligohydramnios. D $)  +# >+ #$"#D>+>  9# >8C 10 ?  . .B # 7)+?#&9$ .B  >   A1=9+ "# @ &#>#&+#9+, )  ' 250 ', no retroplacenta blood clot, >8C+ 1 ?  (A : V = 2 :1)

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 C (9 , APGAR 1  = 10 cc vein push, Dopamine 30 mg in 5% d/w 50 cc 0, 5  = 3, 10  = 4 ( HR = 2,  = 2 ) drip 1 cc/hr, Ampicillin 50 mg vein add Gentamycin )  ' 1,260 ' .. D =% ' 9 4 mg intravenous ' '+"  % ' )  ' =% >>+  80 ')/  D#>  '18+* +# 4 ' & ! >!  .B  15 &=+!  =% !  71+%# !7)+*=& 7+# + 3, A 7 ? , ON UVC line, DTX stat 27 mg% = > adrenaline (1 : 10,000) 0.2 cc %   7 dose, 0.9% NSS 10 cc/hr, 10% glucose

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:  9> 9+ 7)+# .B   >& 9# ') *= '  % '# 9+ NST  Late Decelelation ?A1#2A* & + +'" (WHO) 7+ ') *9&+ ++? % +1  D2A 20 ./ "#=.& C1 ' '    % 8#' 9>>%&+q= ') *= '.&>+& 15 - 20 9+ 8>.p )D#>  #* & uteroplacenta insufficiency +#&2A>+& 85 9++'') *=  = > # fetal decompensate .B IUGR %&'1 ''1 " (6) "#>+& 33 9+ '1') * #* &9#++? %=  = > 7+# )D =!>  # !#1  1= # # ..: &# #* & oligohydramnios * &?>++ (7)  +#)  ' ?A1 = >1 # Perinatal morbid & mortality +#>+= ' #%89+ +#+ D#>9A)   # 7+ '* & SGA "# )  '  * & uteroplacenta insufficiency.9+  +#>+ 19A).& 1.2 & SGA 8>.p )D#>7  =# ! #' 1 %( "!>= * 19A).& "  " & 7)+ 71+ 1 ' * &?# * & 1.3  (8,9,10,11) 8"#9++#' # !7)+= * & "*! ?A1D * & )  ' +#>+'D!'# % #' 9>> vasoactive agents (cocaine , nicotine) 8>.p 1 .B ( '') *1  %& .B %+C'+'#&1 .:(  %( "!> ')+ * 28  1 .& 10  / ' ?A1D#>' '1% '.#  DD#>'7 >&' 9&18>.p  8>+71%&* & 11%& #* &?>+o '1"  '1"# 1  5  / ' (') * + * 36 '.#  +'? #  1 1 %& +#)  '>+  ( + * 28 +2 '.#  ') *1D 1 .& 458 ' (12) & ( EFW 1,200 gram ?A1 < 10 percentile ') *1 # 1& ') * %& +# Body weight )  ' @1  1'D #.& 120 ' AFI = 4 ')o1 %& .B! 1)  1  %&' )  '>+ 1 #% ( # 7+ 36 '.#  ?A1'    * &)  1  ') *1D 1 .& 39 ' #'') >+$' 'q' 9#9+ )  '1 +#% (1 1%&% (1D  1.& 153 ' (13)

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= 1.&+  3,000 !# 9#9+%& 19A)+ *& nicotine .B1+'1#&8&+ 2   .D#> =.s' 7)+ 71+% .B1&D#>=D9'  = > '#  9+  71+%&# & 8D#> (14) &#' nicotine 19A)=& 7+#  # $ "#'1 D.%   9+  %& 9+#%&&>= > # 19A)9+ ''.# + * &>+1%&  4 - 5 catecholamine .B8= > #'" #9A) (16) ?  "#'1 D.> ' 23 '.# D  # 71+9+ 71+%  19A)9+ >+  1.5 ?  &D    5 %   collgen = chorionic villi & ' 9+ ? "#* &%& = > 7+#9+9# subtrophoblastic basement membrane # + &++? % ')9'2 9++  # #9A) 71+% 1%   +D#++D?#&9+ D#>>+ (22,23) 9+ syncytial buds &  9  apoptosis 9A)=9+8>1 1 & 71++ 4
   #9+ = ># .1+ &
 
   ++? %%# (15) 8 = > #* &
 

 

!"# )  ' #>+& IUGR (17)   $% 
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, '-   ./& % 71+%D.%'' $# 7+## (18)  = >

  
  $*+(
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* (&
0/      /  +# 7+# #' %A = > #* & hypoxia = 7)+ 
  ('1 + " & 9+8>1 1  D.#9+ placental 7)+ 71+ 1 ' * &?# * &# !7)+= * & hormone & # %$ *+  #D#>(19)  "*! 7+D#>'  #!# ! (') *1 1 %& = > # cocaine, nicotine #'') %@'  & * &?>++ !  &1  +' + '* & 7)+ ')7 >D#>')+   # 7)+ & #$)  '' >+ (20) & = *#%&! = > # perinatal outcome 1# * &?>++ ! .  #"  early neurodevelopmental impairment, behavioral (21) problem, ‡> >

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4
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