# Clinical Cases: Second and Third Trimester Complications

## Case 1: Preterm Premature Rupture of Membranes (PPROM)

### Patient Demographics
- **Age:** 29 years
- **Sex:** Female
- **Occupation:** Bank teller

### Chief Complaint
"I felt a gush of fluid and I think my water broke. I'm only 31 weeks pregnant."

### History of Present Illness
The patient is G2P1 at 31 weeks 2 days gestation who reports an acute gush of clear fluid from her vagina 4 hours ago while at work. She has had persistent leaking since then. She denies uterine contractions, vaginal bleeding, fever, or foul-smelling discharge. She reports normal fetal movement.

### Past Medical History
- Asthma (well-controlled, uses albuterol inhaler rarely)
- No prior preterm births

### Obstetric History
- G2P1001
- Prior term uncomplicated vaginal delivery at 39 weeks

### Physical Examination Findings
- **Vital Signs:** BP 112/68 mmHg, HR 78 bpm, Temperature 98.4F
- **Abdomen:** Gravid, soft, non-tender, fundal height 30 cm, vertex presentation by Leopold
- **Sterile Speculum Examination:**
  - Pooling of clear fluid in posterior vaginal fornix
  - Positive nitrazine test (fluid turns paper blue, pH >6.5)
  - Ferning pattern present on microscopy
  - Cervix appears 1 cm dilated, no prolapsed cord
- **NO digital cervical exam performed** (increases infection risk with ruptured membranes)

### Fetal Assessment
- **Fetal Heart Rate:** Baseline 140 bpm, moderate variability, accelerations present
- **Ultrasound:** Vertex presentation, AFI 4 cm (oligohydramnios), EFW 1,600 grams

### Diagnosis
**Preterm Premature Rupture of Membranes** at 31 weeks 2 days
- Confirmed by pooling, positive nitrazine, positive ferning
- No evidence of chorioamnionitis
- No active labor

### Management Plan

**Admission and Monitoring:**
- Continuous fetal monitoring initially, then daily NST
- Maternal temperature and vital signs every 4 hours
- Monitor for signs of infection or labor

**Latency Antibiotics (to prolong latency and reduce infection):**
- Ampicillin 2 g IV every 6 hours for 48 hours
- Azithromycin 1 g PO once
- Then Amoxicillin 500 mg PO every 8 hours for 5 days

**Antenatal Corticosteroids (for fetal lung maturity):**
- Betamethasone 12 mg IM x 2 doses, 24 hours apart
- Administered at 31 weeks - within recommended window (24-34 weeks)

**Magnesium Sulfate for Neuroprotection:**
- Indicated because <32 weeks and delivery anticipated within 24 hours is possible
- 4 g IV loading dose, then 1 g/hour maintenance

**GBS Prophylaxis:**
- GBS culture obtained
- Will receive intrapartum prophylaxis regardless of culture result (prolonged ROM)

### Hospital Course

**Day 1-2:**
- Received both betamethasone doses
- Completed magnesium sulfate (24 hours)
- No contractions, afebrile
- Transitioned to oral antibiotics

**Day 3-7:**
- Stable, afebrile
- Minimal fluid leaking
- AFI 3 cm (persistent oligohydramnios expected)
- Daily NST reactive
- No signs of chorioamnionitis

**Day 8 (32 weeks 3 days):**
- Patient developed temperature 38.2C, maternal tachycardia (110 bpm), fetal tachycardia (170 bpm)
- Uterine tenderness on palpation
- WBC 18,000 with left shift

### Diagnosis of Chorioamnionitis
Clinical chorioamnionitis diagnosed based on:
- Maternal fever (>38C)
- Maternal and fetal tachycardia
- Uterine tenderness
- Elevated WBC

### Delivery Decision
**Indication for delivery:** Chorioamnionitis (infection mandates delivery regardless of gestational age)

**Delivery:**
- Ampicillin and gentamicin started for broader coverage
- Induction of labor initiated with oxytocin
- Vaginal delivery after 6 hours of labor
- Female infant, 1,720 grams, Apgar 7/8
- Admitted to NICU for prematurity and sepsis evaluation

### Clinical Image
![PPROM Management](case_01_image.jpg)

**Image Description:** Algorithm diagram showing the management of preterm premature rupture of membranes, including gestational age-based decision making, latency antibiotics protocol, and criteria for chorioamnionitis diagnosis.

**Attribution:** Educational illustration adapted from ACOG guidelines. Used for medical education purposes.

---

## Case 2: Placenta Previa with Third Trimester Bleeding

### Patient Demographics
- **Age:** 36 years
- **Sex:** Female
- **Occupation:** Restaurant manager

### Chief Complaint
"I woke up to bright red bleeding. I'm soaking through pads."

### History of Present Illness
The patient is G4P2012 at 32 weeks gestation. She woke from sleep with sudden painless bright red vaginal bleeding. She has soaked through 3 pads in the past 2 hours. She denies abdominal pain, contractions, or trauma. She was told at her 20-week ultrasound that she had a "low-lying placenta" and was scheduled for a repeat ultrasound next week.

### Past Medical History
- Two prior cesarean deliveries (low transverse incisions)
- One first-trimester miscarriage

### Risk Factors for Placenta Previa
- Prior cesarean deliveries (strongest risk factor)
- Multiparity
- Advanced maternal age

### Physical Examination Findings
- **Vital Signs:** BP 105/68 mmHg, HR 102 bpm, Temperature 98.2F
- **General:** Anxious, pale
- **Abdomen:** Soft, non-tender, uterus non-tender, no contractions palpated
- **EXTERNAL exam only:** Active bright red bleeding from vaginal introitus
- **NO speculum or digital exam** (contraindicated until placenta previa ruled out)

### Initial Management
- Two large-bore IVs placed
- Type and crossmatch for 4 units PRBCs
- IV fluid resuscitation initiated
- Continuous fetal monitoring

### Fetal Assessment
- **Fetal Heart Rate:** Baseline 150 bpm, moderate variability, no decelerations
- Fetus tolerating bleeding episode

### Diagnostic Workup
- **Hemoglobin:** 9.8 g/dL (was 11.2 at last prenatal visit)
- **Platelets:** 210,000
- **Type and Screen:** B positive, antibody negative
- **Coagulation studies:** Normal
- **Transvaginal Ultrasound (safe in previa - does not touch cervix):**
  - Complete placenta previa - placenta completely covering internal cervical os
  - Placenta appears to be invading into lower uterine segment (concern for accreta)
  - No evidence of abruption
  - AFI normal, EFW 1,950 grams

### Diagnosis
**Complete Placenta Previa** with:
- Third trimester hemorrhage
- Possible placenta accreta spectrum (given prior cesareans)

### Management Plan

**Immediate Stabilization:**
- Continued IV fluids
- Blood available at bedside
- Transfused 2 units PRBCs (Hgb was 9.8 and actively bleeding)
- Anesthesia notified
- OR on standby

**Bleeding Management:**
- Bleeding slowed spontaneously over 2 hours
- Total estimated blood loss ~800 mL

**Expectant Management Protocol (if stable):**
- Inpatient observation until delivery
- Bed rest with bathroom privileges
- Serial hemoglobin monitoring
- Antenatal corticosteroids (betamethasone x 2 doses given)
- No pelvic rest (already maintained)
- Type and screen always current

**MRI for Accreta Evaluation:**
- Performed on hospital day 3
- Demonstrated loss of retroplacental clear zone
- Bladder wall irregularity
- Findings concerning for placenta accreta

### Delivery Planning

**Multidisciplinary Team:**
- Maternal-fetal medicine
- Gynecologic oncology (accreta expertise)
- Urology (bladder involvement possible)
- Blood bank (massive transfusion protocol prepared)

**Planned Cesarean Hysterectomy:**
- Scheduled at 34 weeks if stable (balances prematurity vs. hemorrhage risk)
- If recurrent significant bleeding: emergent delivery regardless of gestational age

### Hospital Course
- Remained stable with no further bleeding episodes
- Repeat betamethasone at 34 weeks not indicated (single course)
- Delivered by cesarean hysterectomy at 34 weeks 2 days
- Placenta accreta confirmed at surgery
- EBL 2,500 mL, received 4 units PRBCs
- No bladder injury
- Infant: 2,180 grams, Apgar 8/9, NICU for prematurity

### Clinical Image
![Placenta Previa Ultrasound](case_02_image.jpg)

**Image Description:** Transvaginal ultrasound image demonstrating complete placenta previa with the placenta completely covering the internal cervical os. The lower image shows normal placental position for comparison.

**Attribution:** Image from Radiopaedia. Case courtesy of Dr. Ian Bickle. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/placenta-praevia

---

## Case 3: Intrauterine Growth Restriction with Abnormal Dopplers

### Patient Demographics
- **Age:** 33 years
- **Sex:** Female
- **Occupation:** Accountant

### Chief Complaint
"My doctor said the baby is too small and the blood flow is abnormal."

### History of Present Illness
The patient is G1P0 at 28 weeks gestation. She was noted to have a fundal height measuring 3 cm below expected for dates. Growth ultrasound revealed estimated fetal weight below the 5th percentile. She was referred for maternal-fetal medicine consultation and Doppler evaluation. She feels fetal movement daily. She denies vaginal bleeding, leakage of fluid, or contractions.

### Past Medical History
- Chronic hypertension diagnosed 2 years ago, on labetalol
- No diabetes

### Prenatal Course
- Chronic hypertension controlled on labetalol 200 mg twice daily
- BP range 120-135/75-85 throughout pregnancy
- No proteinuria to date
- Anatomy ultrasound at 20 weeks was normal

### Physical Examination Findings
- **Vital Signs:** BP 138/88 mmHg, HR 72 bpm
- **Abdomen:** Fundal height 25 cm (3 cm below expected 28 cm)
- **Lower extremities:** Trace edema bilaterally

### Diagnostic Workup

**Growth Ultrasound:**
- EFW 780 grams (<3rd percentile for 28 weeks)
- Abdominal circumference <3rd percentile
- Head circumference 15th percentile
- Femur length 12th percentile
- **Pattern:** Asymmetric IUGR (head-sparing) - suggests placental insufficiency
- AFI 6 cm (low-normal)

**Umbilical Artery Doppler:**
- Elevated systolic/diastolic ratio (>95th percentile)
- End-diastolic flow PRESENT but reduced
- **Interpretation:** Increased placental vascular resistance

**Middle Cerebral Artery Doppler:**
- Pulsatility index decreased (<5th percentile)
- **Interpretation:** Cerebral redistribution (brain-sparing)

**Ductus Venosus Doppler:**
- A-wave present (forward flow during atrial contraction)
- Currently normal

### Diagnosis
**Severe Early-Onset Intrauterine Growth Restriction**
- EFW <3rd percentile at 28 weeks
- Asymmetric pattern (placental insufficiency)
- Abnormal umbilical artery Doppler (elevated resistance)
- Evidence of fetal compensation (brain-sparing on MCA)
- Associated with chronic hypertension

### Risk Assessment
- High risk for adverse outcomes
- Currently compensated (positive end-diastolic flow, normal ductus venosus)
- Risk of progression to absent/reversed end-diastolic flow

### Management Plan

**Antenatal Corticosteroids:**
- Betamethasone 12 mg IM x 2 doses given (for potential preterm delivery)

**Fetal Surveillance (Intensive Protocol):**
- Twice-weekly NST and biophysical profile
- Umbilical artery Doppler twice weekly
- If absent end-diastolic flow develops: daily Doppler, consider delivery
- If reversed end-diastolic flow: delivery recommended at viable gestational age

**Maternal Monitoring:**
- Blood pressure monitoring for superimposed preeclampsia
- Weekly labs: CBC, CMP, LFTs, uric acid
- 24-hour urine protein (baseline for preeclampsia surveillance)

**Delivery Timing:**
- Current status (abnormal UA Doppler with present end-diastolic flow): aim for 34-37 weeks
- If absent end-diastolic flow develops: 32-34 weeks
- If reversed end-diastolic flow: 30-32 weeks with ductus venosus assessment
- If abnormal ductus venosus or BPP <6: delivery regardless of gestational age

### Hospital Course

**Weeks 28-30:**
- Twice-weekly testing with NSTs reactive
- Umbilical artery Doppler persistently abnormal but end-diastolic flow present
- EFW at 30 weeks: 950 grams (<3rd percentile, minimal interval growth)

**Week 31:**
- Developed absent end-diastolic flow on umbilical artery Doppler
- Admitted for daily monitoring
- Ductus venosus remained normal
- Magnesium sulfate for neuroprotection initiated

**Delivery at 32 weeks 1 day:**
- Indication: Persistent absent end-diastolic flow with declining biophysical profile (6/10)
- Cesarean delivery (failed induction at this gestational age, IUGR)
- Male infant: 1,020 grams, Apgar 6/8
- Admitted to NICU: required initial respiratory support, otherwise stable

### Clinical Image
![Umbilical Artery Doppler](case_03_image.jpg)

**Image Description:** Umbilical artery Doppler waveforms comparing normal flow pattern (with positive end-diastolic flow), elevated S/D ratio, absent end-diastolic velocity (AEDV), and reversed end-diastolic velocity (REDV). These patterns indicate progressive placental vascular resistance.

**Attribution:** Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/articles/umbilical-artery-doppler