questions 7

Abruptio Placentae

Topic updated on 06/17/17 9:28pm

  • A 30-year-old, G1P0, female at 36 weeks gestation presents to the emergency room with sudden onset of severe back pain which has lasted for 2 hours. Thirty minutes prior to presentation she noted bright red vaginal bleeding. She has had no prenatal care. On physical exam she is afebrile; her blood pressure is 30/80 mmHg, pulse is 106/min, and respirations are 18/min. Abdominal palpation reveals a gravid hypertonic uterus and palpable uterine contractions. You observe blood in the vaginal vault. Results of transabdominal ultrasound are shown.
  • Clinical definition
    • premature separation of a normally implanted placenta
      • placenta abruptio and placenta previa are the two most common causes of third trimester bleeding
  • Epidemiology
    • incidence
      • 1% of all pregnancies
    • demographics
      • more common in African-American women
    • risk factors  
      • trauma (e.g., motor vehicle accident)
      • prior placental abruption
      • maternal smoking
      • cocaine use
      • hypertensive disorders of pregnancy such as
        • eclampsia
        • preeclampsia
      • premature rupture of membrane
      • hyperhomocystinemia
  • Pathophysiology
    • rupture of maternal vessels results in
      • bleeding into the decidual-placental interface that leads to
        • placental separation from the uterine wall
  • Associated conditions
    •  may be associated with cardiovascular disease
  • Prognosis
    • mother
      • prompt intervention decreases the incidence of maternal mortality
    • fetus
      • increased mortality rate
  • Symptoms 
    • abrupt third trimester vaginal bleeding
    • abdominal and/or back pain 
    • uterine contractions
  • Physical exam
    • gravid hypertonic uterus
    • blood/clots may be observed in the vaginal vault
    • fetal distress is present
  • Ultrasound 
    • indications
      • used to rule out placenta previa
      • to find a retroplacental hematoma which is
        • classic for placental abruption
  • Diagnostic criteria
    • a clinical diagnosis that can be confirmed with pathologic placental evaluation
  • Placenta previa
    • presents as painless vaginal bleeding
  • Uterine rupture
  • Normal or pre-term labor
  • Conservative
    • expectant management with continuous fetal monitoring
      • indications
        • when both the mother and fetus are stable and the fetus is < 34 weeks gestation
    • vaginal delivery
      • indications
        • in cases where the fetus is 36 weeks gestation, vaginal delivery is preferrable if there are no indications to cesarean delivery
          • if the patient is not in active labor then
            • amniotomy and oxytocin administration can be used
  • Operative
    • immediate delivery
      • indications
        • in cases of non-reassuring fetal status
        • in cases of hemodynamic instability in the mother
        • when the fetus is 34-36 weeks gestation; however, this is dependent on
          • patient specific factors
          • balancing risk and benefit
  • Complications
    • disseminated intravascular coagulation (DIC)
    • hemorrhagic shock
    • recurrence risk in future pregnancies
      • 3-15% have a recurrence
    • fetal anemia


Qbank (3 Questions)

(M2.OB.8) A 31-year-old G1P0 with a history of hypertension presents to the emergency department because she believes that she is in labor. She is in her 38th week of pregnancy and her course has thus far been uncomplicated. This morning she began feeling painful contractions and noted vaginal bleeding. She is experiencing lower abdominal and pelvic pain between contractions as well. On exam, she is afebrile, blood pressure is 145/85 mmHg, heart rate is 102 bpm, and respiratory rate is 16 rpm. You note a gravid, hypertonic uterus on exam and moderate blood in the vaginal vault. Ultrasound reveals no abnormalities. Which of the following is the most likely diagnosis? Topic Review Topic

1. Abruptio placentae
2. Vasa previa
3. Placenta previa
4. Chorioamnionitis
5. Onset of normal labor

(M2.OB.32) A 26-year-old G2P1 female at 34 weeks gestation presents to the emergency department with sudden onset of vaginal bleeding and abdominal pain. Her vital signs are as follows: T 37.5, HR 129, BP 92/60, RR 22, O2 Sat 98% RA. Physical exam is significant for palpable uterine contractions and uterine hypertonicity. An ultrasound is obtained and is normal, with no evidence of placenta previa. The patient is placed on a continuous external fetal monitor, with the tracing shown in Figure A. Which of the following is the most appropriate management of this patient? Topic Review Topic
FIGURES: A          

1. Expectant management with continued fetal monitoring
2. Amniotomy and induction of vaginal delivery
3. Emergent cesarean section
4. Administer prophylactic corticosteroids
5. Uterine artery embolization

(M2.OB.4727) A 36-year-old G3P2002 at 34 weeks gestation presents to the obstetric triage unit with acute abdominal pain that started this afternoon at an outdoor festival where she ate tacos from a food truck. She describes the pain as diffuse and nearly constant but denies vaginal bleeding and loss of fluid. Her husband who is accompanying her, states that he had one episode of diarrhea after arriving in the triage waiting room. The patient has no past medical history. She had one spontaneous vaginal delivery five years ago and a low transverse C-section three years ago for arrest of descent. Her fetal heart rate tracing is shown in Figure A. Temperature is 98.8°F (37.1°C), blood pressure is 104/58 mmHg, pulse is 99/min, and respirations are 15/min. The patient has dry skin that appears to be mildly sunburned. Cervical exam is fingertip dilated, long, and high. Which of the following is the most likely etiology of this patient’s condition? Topic Review Topic
FIGURES: A          

1. Abdominal trauma
2. Prior C-section
3. Dehydration
4. Contaminated food
5. None - this patient is in early labor

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