Placental infarction in teenage pregnancy ..* ,-. " % & 4 '+! #> #!7)+=&7+# (') *+ 16 ./ 0 *1 +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 &#7+9# 1 ? 35 ? ) 1 and the ultrasound findings were abnormal placenta >+%D $) C (9 APGAR score (thickness 1.5 cm. and focal hypoechogenicity = 0, 3, 4 ) ' 1,260 ' Maturity Score 34 especially at the placental margin and the maternal '.# %@' %("!>= *&#' floor ) and oligohydramnios. while she was being &* &9#++?%=&#' admitted to the labor room, the fetal distress was '=+! =%&! >! D#>2 ' detected so the cesarean section was done. The * 7 ! " #$% & !& %' '# % ./1 22 @'1 2 ' 2550 77 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. + *+' >+ %' '# % 3 ,-2 .&% #7+ ')#> '1 28 .B 1&D " 9+ 2 2549 (% D#>+&1 +) # #& ' "#%&!71++& +# '1 5 2550 .sq #& &#7+9+'#9+# >1 '( > 0 * ')9&+ * 20 +6 2 .& 7+ .B1.1+ & '.# 121+'# + *+' >+ ++?%%# ') >1> %' '# % '#% 5 ') 87+#. n+"1% .B& ') * 2 % ) '+') * 58 "' 156 D#>% 71 21') 7 8 '.# (1) "# ? #'! 23.7 "'+ 71+9>D1+%&2+ 9+ @##&' %'((! .&D D9 D#> "#%& $.B>+7)+71++#>=9+8' 9 7+) =.: & 8 % '#+ #& 9>%& >7)+# (2) &q'?. %'A0 * 9>9+7)+= *&&%&.B$# .:( &+#1 +& * D.%D1 1. ) '9A) 17 "'*= 4 9+') * 71++ *9A)'%#9> #7+9&+ * 20 +6 - 35 +3 '.# &#.B 7+ .%'9A) #'&+% 78 " % %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 + - .sq" .&% ' .sq > & D!'# >+ .sq 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'%> .sq" .&% ' 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 "+" .sq#%$ 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. ./1 22 @'1 2 ' 2550 79 * 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# '# 80 " % .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$.B > A1=9+ "#@ &#>#&+#9+, ) ' 250 ', no retroplacenta blood clot, >8C&#7+ 1 ? (A : v = 2 :1) ./1 22 @'1 2 ' 2550 81 * 1 5 #* 7)+.B > A1=9+7)+ #>?>##>#, * 9 #* ## * 1 6 #* '#9 * 1 7 #* ' +# 2 ' C (9 , APGAR 1 = 10 cc vein push, Dopamine 30 mg in 5% d/w 50 cc 0, 5 = 3, 10 = 4 ( HR = 2, = 2 ) drip 1 cc/hr, Ampicillin 50 mg vein add Gentamycin ) ' 1,260 ' .. D =% ' 9 4 mg intravenous ' '+" % ' ) ' =%>>+ 80 ')/ D#> '18+* +# 4 ' & ! >! .B 15 &=+! =% ! 71+%#!7)+*=&7+# + 3, A 7 ?, ON UvC line, DTX stat 27 mg% = > adrenaline (1 : 10,000) 0.2 cc % 7 dose, 0.9% NSS 10 cc/hr, 10% glucose 82 " % 5: 9>9+7)+#.B >& 9# ') *= ' % '# 9+ NST Late Decelelation ?A1#2A* & + +'" (WHO) 7+ ') *9&+ ++?% +1 D2A 20 ./ "#=.&C1 ' ' % 8#' 9>>%&+q= ') *= '.&>+& 15 - 20 9+ 8>.p )D#> #* & uteroplacenta insufficiency +#&2A>+& 85 9++'') *= = ># fetal decompensate .B IUGR %&'1 ''1 " (6) "#>+& 33 9+ '1') * #* &9#++?%= = >7+#)D =!> # !#1 1=# # ..: &##* & oligohydramnios * &?>++ (7) +#) ' ?A1= >1# Perinatal morbid & mortality +#>+= '#%89+ +#+ D#>9A) # 7+ '* & SGA "# ) ' * & uteroplacenta insufficiency.9+ +#>+ 19A).& 1.2 & SGA 8>.p )D#>7 =# ! #' 1%("!>= * 19A).& " " &7)+71+1 ' * &?# * & 1.3 (8,9,10,11) 8"#9++#' #!7)+= * & "*! ?A1D * & ) ' +#>+'D!'#% #' 9>> vasoactive agents (cocaine , nicotine) 8>.p 1.B ( '') *1 %&.B %+C'+'#&1 .:( %("!> ')+ * 28 1 .& 10 / ' ?A1D#>' '1% '.# DD#>'7 >&' 9&18>.p 8>+71%&* &11%&#* &?>+o '1" '1"# 1 5 / ' (') * + * 36 '.# +'? # 1 1 %& +#) '>+ ( + * 28 +2 '.# ') *1D 1 .& 458 ' (12) & ( EFW 1,200 gram ?A1 < 10 percentile ') *1 # 1& ') * %& +# Body weight ) '@1 1'D #.& 120 ' AFI = 4 ')o1 %&.B! 1) 1 %&' ) '>+ 1#% ( # 7+ 36 '.# ?A1' * &) 1 ') *1D 1 .& 39 ' #'') >+$' 'q' 9#9+ ) '1 +#% (1 1%&% (1D 1.& 153 ' (13) ./1 22 @'1 2 ' 2550 83 = 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) $% &'()' $ +++D?#%& = >#* &7+# ** +,) %, '- ./& % 71+%D.%''$#7+## (18) = > $*+(0 ++?%#&71+" $&>= >#* & * (& 0/ / +#7+# #' %A = >#* & hypoxia =7)+ ('1 + " & 9+8>1 1 D.#9+ placental 7)+71+1 ' * &?# * &#!7)+= * & hormone &#%$ *+ #D#>(19) "*! 7+D#>' #!# ! (') *1 1 %& = ># cocaine, nicotine #'') %@' & * &?>++ ! &1 +' + '* &7)+ ')7 >D#>')+ # 7)+ &#$) '' >+ (20) & = *#%&! = ># perinatal outcome 1# * &?>++ ! . #" early neurodevelopmental impairment, behavioral problem, > > (21) 84 " % 4 7. Julie AQ. Sharon FE. The impact of continuing, illegal drug use on teenage pregnancy 1. Kazzi GM, Evans MI, Sokol RJ, outcomes a prospective cohort study. Br J Sabbagha RE. Placental maturation and thickness. In : obstetric Gynecol 2002 ; 109 : 1148 - 53. Sabbagha RE, editor. Diagnostic ultrasound applied 8. Agustin CD, Juse MB, Cristing L. to Obstetrics and Gynecology . 3rd ed. Philadelphia : Maternal-perinatal morbidity and mortality associated JB Lippincott Company ; 1994 : 289 98. with adolescent pregnancy in Catin America: cross 2. Muller LMM . Ultrasound assessment of sectional study American Journal obstetric the placenta , and clinical assessment of the placenta Coynecol 2005 ; 192 : 342-9. growth. In : Redmann CWG, Sargent IL and Starkey 9. Chineta RE, Michael Kl, William LG. PM, editors. The human placenta. Oxford : Blackwell Risk of adverse pregnancy outcomes in young Scientific Publications ; 1993 : 155-89. adolescent parturients in an inner-city hospital. 3. Spirt BA, Gordon LP. The placenta and American journal obstetric Gynecol 2002 ; 186 : cervix. In : McGahan JP, Porto M , editors. Diagnostic 918-20. obstetrical ultrasound . 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