A 23-year-old woman, gravida 3 para 2, at 35 weeks gestation comes to the emergency department due to vaginal bleeding that started after intercourse, 2 hours prior to arrival, and has soaked through 3 perineal pads. The patient reports normal fetal movement and mild intermittent cramping but no leakage of amniotic fluid. Her only prenatal visit was at 7 weeks gestation, when an ultrasound was normal. The patient has a history of 2 prior cesarean deliveries at term. The first delivery was performed for a category III fetal heart rate tracing; the second was an elective repeat. The patient has a history of intravenous drug use and smokes a pack of cigarettes a day. She has no known drug allergies. Blood pressure is 130/70 mm Hg and pulse is 98/min. The fetal heart rate tracing is 140/min with moderate variability, accelerations, and no decelerations. The tocometer shows contractions every 5 minutes. On examination, the patient is in no distress. The abdomen is gravid, soft, and nontender. There is frank blood on the patient's perineal pad. Item 1 of 2 Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c01d_7903_8f63_7b1af32d07b3_MD0005_00 This patient has painless vaginal bleeding at >20 weeks gestation, a presentation consistent with placenta previa. Placenta previa, the extension of the placenta over the internal cervical os, is associated with an increased risk of obstetrical hemorrhage and preterm delivery. Because the bleeding from placenta previa is maternal in origin, the fetal heart rate tracing is typically normal. Risk factors include prior cesarean delivery, multiparity, multiple gestation, and tobacco use. Placenta previa Placenta previa is typically diagnosed at the 18- to 20-week prenatal anatomy ultrasound, when the placental location is determined. Patients with vaginal bleeding at >20 weeks gestation and no previous anatomy ultrasound require a transvaginal ultrasound to exclude placenta previa. Transvaginal ultrasound and speculum examination are safe in placenta previa as neither the transvaginal probe nor the speculum enters the endocervical canal. However, a digital cervical examination is contraindicated due to entrance into the endocervical canal, which can disturb the placenta and result in hemorrhage (Choice B). Placenta previa is an absolute contraindication to vaginal delivery; patients require cesarean delivery. speculum examination (Choice A) A biophysical profile, an ultrasound examination of fetal movement, tone, breathing, and amniotic fluid volume, evaluates for fetal hypoxia after an abnormal nonstress test (eg, decelerations, no accelerations). Because this patient has a normal fetal heart rate tracing, a biophysical profile is not indicated. (Choice C) Fetal fibronectin (FFN) in the cervicovaginal discharge of patients at <34 weeks gestation with preterm contractions correlates with a high risk for preterm delivery. However, blood can cause a false positive FFN test result and is not indicated in this patient due to the gestational age. (Choice E) Although this patient has a history of intravenous drug abuse, the priority is to determine the cause of her bleeding via ultrasound. A urine drug screen can be performed later. Educational objective: Patients with vaginal bleeding at >20 weeks gestation and no previous anatomy ultrasound require a transvaginal ultrasound to exclude placenta previa. Digital cervical examination is contraindicated in patients with placenta previa. References: Abnormal placentation: placenta previa, vasa previa, and placenta accreta. (http://www.ncbi.nlm.nih.gov/pubmed/26244528)

A 23-Year-Old Woman, Gravida 3 Para 2, at 35 Weeks