Expectant Management for a patient with PPROM with Placenta and Vasa Praevia plus Velamentous Cord Insertion.
Mena Abdalla
King’s College Hospital NHS Foundation Trust  - London

Objective:

To share a case of high risk pregnancy with PPROM, Placenta and vasa praevia plus velamintous cord insertion, as extending gestational weeks significantly decrease the rates of neonatal respiratory distress syndrome, immature brain, and electrolyte imbalance, while simultaneously increasing neonatal weight and enhancing the neonatal Apgar score .

Case report:

 a 28 years old, G6 P 2+3, low BMI, (GBS positive). 3 Miscarriages,  1 Stillbirth, and 1 forceps delivery.

The patient’s timelines during this pregnancy: 

At 13 weeks, the patient had a cervix scan of 33.9mm long, opted for cervical cerclage. The patient had a cervical suture inserted at 14 weeks. At 20 weeks + 5 days, she had PPROM, the patient attended to MAU with a history of non-provoked spontaneous rupture of membranes with pink-coloured liquor and amnio-sure was positive. (With normal inflammatory markers and normal Liquor volume (LV). The patient has been admitted to the maternity ward for 3 days.

During her hospital admission, and after being discharged home, she had a follow-up regular blood test done. On the first day of her attendance, the patient had WCC = 9.3, CRP 2. Repeated after 2 days and found that WCC = 8.6. CRP = 2. Then repeated after another 2 days and found: WCC = 2. CRP = 3. Furthermore, the inflammatory markers have been repeated every week till the end of pregnancy and were all within normal range. 

The Patient has been prescribed oral erythromycin 250 mg 4 times a day for a period of 10 days.

ultrasound scan at 31+5 weeks: The placenta was: posterior low-lying placenta 12 mm far away from the internal os. The cord insertion is velamentous at the anterior uterine wall 20 mm away from the internal os on the right uterine wall, Fetal vessel could be seen communicating between the cord and the lower edge of the placenta, less than 20mm away from the internal os. The baby was found to be SGA baby < third centile with normal dopplers/LV. Normal Fetal movement. 

The recommendation was to opt for the patient for admission as an inpatient from 32 weeks and a Caesarean section at 35-36 weeks.

At 31+6 patient attended the hospital with her first episode of non-provoked PV painless bleeding, which eventually settled. The next day,  she had a spot of blood, unprovoked, No abdominal pain,  No SROM or urinary symptoms. Good fetal movements. The patient has been admitted since that time. The patient has been given steroids at (32+0 weeks). With daily follow-ups and monitoring with serial bedside scans, CTGs and daily reviews. At 35 weeks +5 days, while she was admitted, the emergency buzzer was pulled due to fetal bradycardia with quick recovery happened and after observation, she had normal FHR and normal variability. The patient had a successful elective caesarean section (ELCS) at 36+0 weeks with 300 mls Estimated blood loss. No complications happened either to the baby or to the mother. 

Discussion: